ISSUE 7 FREE January — April 2012
Fantastic GPs give you a glimpse into the world of general practice Meet your new GP Ambassadors A Top End PGPPP experience Brand new features ‘It takes two’ and ‘Chocolate box’ Plus, your regular favourites ‘Dr Fairytale’, ‘What’s your diagnosis’ and more!
Dr Anne Kleinitz
Crossing borders
Be everything to everyone...
Be a GP
If you want to train to become a GP, then you can apply for the Australian General Practice Training (AGPT) program. The AGPT program offers you a pathway to gain vocational recognition under Medicare Australia. Talk to your local regional training provider (RTP) or go to: www.agpt.com.au
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In this issue…
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On the cover... Dr Anne Kleinitz (Photography: Justin Sanson Photography)
Regulars 5 9 12 16 19 21 23 32 34 36 39 40 42 42
Meet your Going Places GP Ambassadors It takes two GP focus in the hospital Telehealth — what it means for GPs, specialists and patients Confessions of a 21st Century Junior Doctor Chocolate box General practice in the news What’s your diagnosis? Clinical corner GP myths Applying for GP training Strange medical products from animals Dr Fairytale Book review
Profiles 10 14 24 26 28 30
Dr Anne Kleinitz — Crossing borders Dr Lang Yii — The PGPPP and me Dr Andrew Pennington — Keeping the faith Dr Margaret Niemann — Healing the mind and body Dr Will Thornton — The best of both worlds Dr Mike Cross-Pitcher — GP gone wild!
Welcome
to our seventh issue of Going Places magazine, keeping you in touch with the vast array of opportunities available in general practice. I am excited to step into the role of Medical Editor and proud to share articles both practical and quirky. We have it all! There is a truly global flavour to this issue with stories from GPs from the four corners of the globe. Dr Sarah McEwan takes us to the far north of WA and reveals the connection between a lump on the hand and a pain in the belly, in two different patients! Dr Layla Ahmed and Dr Ali Al-Hadi share their journey from Baghdad, Iraq to Mildura, Victoria and the challenges they faced. Dr Anne Kleinitz takes us from the Kimberly to Ethiopia with her inspirational story, and I am your personal guide on an expedition into the chilly winter wilderness of Tasmania.
No matter what you’re looking for in your career, you can find it in general practice. GPs from all over Australia have shared their journeys to finding their particular niche. Dr Will Thornton takes us into his world of caring for the dying young, while Dr Andrew Pennington shares his model of holistic care in rural obstetrics. Meanwhile, Dr Margaret Niemann reveals how a focus on mental health has enabled her to better treat patients with drug addiction. We have the quirky... Dr Gil Myers takes us down the Yellow Brick Road and Dr Ben Chandler injects us with a salmon sperm derivative. Dr Peter Schindler spins us a yarn about a bike, a brick, a stop sign and a spurt. Along the way, we debunk a few myths. We have the practical... what does telehealth mean to your back pocket? Dr Joshua Crase has the answer. How do you apply for GP training? Just hear what Dr Kerrie Stewart has to say! What can you get out of a PGPPP? A great deal, according to Dr Lang Yii! Need a good read? Dr Nicole Hall may have it for you... Sit back, grab a drink, dive in... just like general practice, you never quite know what’s next! Heal (and have fun),
Produced with funding support from
Editorial: Editor/Writer, Laura McGeoch; Writer, Ruth Hyland. Graphic Design: Peter Fitzgerald. Going Places Network Manager: Emily Fox. Business Development Managers: Marie Treacy, FSC Logo Kate Marie, Naomi Sher. Print: Graphic Impressions
Dr Mike Cross-Pitcher Medical Editor Hospital Registrar – Central and Southern Queensland Training Consortium GP Ambassador – Nambour General Hospital, Sunshine Coast, Queensland ©2011 GPRA. All rights are reserved. All materials contained in this publication are protected by Australian copyright law and may not be reproduced, distributed, transmitted, displayed, published or broadcast without the prior permission of General Practice Registrars Australia Ltd (GPRA) or in the case of third party material, the owner of that content. No part of this publication may be produced without prior permission and full acknowledgement of the source: Going Places magazine, a publication of General Practice Registrars Australia. All efforts have been made to ensure that material presented in this publication was correct at the time of printing and is published in good faith.
Taking a fresh look at general practice 3
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Meet some of our GP Ambassadors
The Going Places Network is thrilled to have an energetic and knowledgeable team of GP Ambassadors on board for 2012. They bring a diversity of skills and experience to their roles but have a shared commitment to helping other junior doctors achieve their general practice career goals.
Full profiles and contact details for all of our GP Ambassadors can be found at gpaustralia.org.au/goingplaces
ACT/NSW Anita Dey
Jane George
Hospital —The Canberra Hospital Email — canberragp@gpra.org.au
Hospital — Bankstown Hospital Email — bankstowngp@gpra.org.au
I chose general practice because I wanted to be able to do everything from minor surgery to obstetrics and gynaecology to paediatrics, all in one day. I’m inspired by all of the fantastic GPs I have had the pleasure of knowing and working with.
The best things about general practice are the variety, the opportunity to provide patients with continuity of care and the work-life balance. As a GP, I’m looking forward to a rewarding and challenging career that will allow me to develop my areas of interest.
Donna Lau
Natalie Sancandi
Hospital — Gosford Hospital Email — gosfordgp@gpra.org.au
Hospital — St George Hospital Email — stgeorgegp@gpra.org.au My GP was a big inspiration to me. He showed me that general practice could be whatever you want it to be, that you can work as much or as little as you like, and that you can really incorporate other interests into your life. I’m looking forward to the variety of patients in general practice and the ability to treat patients when they are sick as well as when they are well.
I thoroughly enjoyed my general practice terms as a student and enjoy all that general practice has to offer in terms of different job opportunities. As a GP, I’m looking forward to engaging with the community, having lots of variety and flexibility and being able to travel with my job.
NT Nicole Hall Hospital — Bankstown Hospital Email — bankstowngp@gpra.org.au I love the variety of cases you see in general practice, and the diagnostic side of things — after all, it is a GP who takes the first steps in solving many patients’ problems. I love that I will deal with the same patients on an ongoing basis, and be able to tailor treatments to suit them. I am also looking forward to running my own practice one day!
Andrea Wilson Hospital — Darwin Hospital Email — darwingp@gpra.org.au I chose general practice because I have an interest in several areas of medicine and a desire to work in rural and remote Australia. I’m inspired by the dedicated procedural GPs who keep country towns in Australia functioning.
QLD Michael Cross-Pitcher
Scott Hahn
Hospital — Nambour Hospital Email — nambourgp@gpra.org.au
Hospital — Logan Hospital Email — logangp@gpra.org.au
General practice fits my lifestyle and need for variety. As a GP, I’m looking forward to the challenges of consulting all areas of medicine every day. Almost every dedicated doctor I meet inspires me.
I chose general practice as a career for all the right reasons — career decision-making and training supports, diversity of practice, and lifestyle ranking high among them. This year, I’m looking forward to starting my first year as a GP registrar, but before that I have a few more Going Places events planned for Logan!
Taking a fresh look at general practice 5
QLD continued Katya Groeneveld
Ann Arlott
Hospital — Gold Coast Hospital Email — goldcoastgp@gpra.org.au
Hospital — Rockhampton Hospital Email — rockhamptongp@gpra.org.au
As a GP I’m looking forward to the variety of presentations and the ongoing challenges. General practice is the career for me because of the opportunity to provide continuity of care and the endless learning in a fulfilling profession.
Among all the specialties, only general practice encompasses such a huge variety of presentations — it means you will never be bored. As a GP, I’m looking forward to looking after patients over the long term, rather than the short-term care we give people in hospital.
Brendon Thompson
Sara Le
Hospital — Ipswich Hospital Email — ipswichgp@gpra.org.au
Hospital — Lyall McEwin Hospital Email — lyallmcewingp@gpra.org.au
As a GP I’m looking forward to the challenges of a career as a general specialist. I was first attracted to general practice as a specialty because of the flexibility, the continuity of care, and the variety.
Of all the rotations I did as a medical student, I never felt more at home or fulfilled than when I was doing rural general practice. Now I actually get homesick for the country. I am inspired by the many rural GPs I’ve had the privilege of meeting and working with — their passion, competence, diversity and commitment to their community.
VIC Erwin Wong
Edward Skinner
Hospital — St Vincents Hospital Email — stvincentsgp@gpra.org.au
Hospital — Box Hill Hospital Email — boxhillgp@gpra.org.au
As a GP, I’m looking forward to working with a variety of people. I find the aspects of longitudinal care and the breadth of patient issues both daunting and exciting. The myriad of options for sub-specialising and the potential for flexible work, both in location and time, are also a big plus.
I chose general practice because I don’t want to work night shift, and one day I’d like to own my own practice. I love the undifferentiated nature of presentations in general practice and the flexible hours.
Melissa Cairns Hospital — Austin Hospital Email — austingp@gpra.org.au I chose general practice for the huge variety of patient presentations, the opportunity to practice preventative medicine, and the ability to work all over Australia. I appreciate the close ties you develop with the local community, and the flexible work arrangements.
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Meet more of our GP Ambassadors for 2012 at
gpaustralia.org.au/goingplaces
Name Anita Dey Jane George Donna Lau Natalie Sancandi Nicole Hall David Ford Craig Roberts-Thompson Nici Wilkinson Sumi Chadha Coming soon Coming soon Andrea Wilson Michael Cross-Pitcher Scott Hahn Katya Groeneveld Ann Arlott Brendan Thompson Coming soon Matt Tatkovi Coming soon Richard Hargreaves Coming soon Jamie-Lea Whyte Linda Maluish Stephanie Davis Fiona Simpson Sara Le Coming soon Sam Manger Adam Swalling Coming soon Coming soon Kaylee Barnett Rachael Foster Erwin Wong Edward Skinner Elizabeth Bond Edmund Siauw Melissa Cairns Coming soon Coming soon Coming soon Coming soon Coming soon Coming soon Coming soon Clark Maul Tamla Wilke Coming soon Coming soon
State NSW NSW NSW NSW NSW NSW NSW NSW NSW NSW NSW NT QLD QLD QLD QLD QLD QLD QLD QLD QLD QLD QLD QLD QLD QLD SA SA SA SA SA SA TAS TAS VIC VIC VIC VIC VIC VIC VIC VIC VIC VIC VIC VIC WA WA WA WA
Hospital The Canberra Hospital Bankstown and Campbelltown Hospital Gosford Hospital St George Hospital Bankstown and Campbelltown Hospital Royal Prince Alfred Hospital John Hunter Hospital Westmead Hospital Royal North Shore Hospital Wollongong Hospital Nepean Hospital Darwin Hospital Nambour Hospital Logan Hospital Gold Coast Hospital Rockhampton Hospital Ipswich Hospital Mater Hospital Redcliffe Hospital Royal Brisbane Women’s Hospital Toowoomba Hospital Redland Hospital Townsville Hospital Cairns Base Hospital Mackay Base Hospital Princess Alexandra Hospital Lyall McEwin Hospital Royal Adelaide Hospital Flinders Medical Centre Flinders Medical Centre Queen Elizabeth Hospital Modbury Hospital Launceston Hospital Royal Hobart Hospital St Vincents Hospital Box Hill Hospital Western Health Shepparton Hospital Austin Hospital Alfred Hospital Ballarat Hospital Southern Health Northern Hospital Geelong Hospital Gippsland Hospital Goulburn Valley Health Sir Charles Gairdner Hospital Joondalup Health Campus Royal Perth Hospital Fremantle Hospital
Email canberragp@gpra.org.au bankstowngp@gpra.org.au gosfordgp@gpra.org.au stgeorgegp@gpra.org.au bankstowngp@gpra.org.au royalprincealfredgp@gpra.org.au johnhuntergp@gpra.org.au westmeadgp@gpra.org.au royalnorthshorgp@gpra.org.au wollongonggp@gpra.org.au nepeangp@gpra.org.au darwingp@gpra.org.au nambourgp@gpra.org.au logangp@gpra.org.au goldcoastgp@gpra.org.au rockhamptongp@gpra.org.au ipswichgp@gpra.org.au matergp@gpra.org.au redcliffegp@gpra.org.au royalbrisbanegp@gpra.org.au toowoombagp@gpra.org.au redlandgp@gpra.org.au townsvillegp@gpra.org.au cairnsgp@gpra.org.au mackaygp@gpra.org.au princessalexandragp@gpra.org.au lyallmcewingp@gpra.org.au royaladelaidegp@gpra.org.au flindersgp@gpra.org.au flindersgp@gpra.org.au queenelizabethgp@gpra.org.au modburygp@gpra.org.au launcestongp@gpra.org.au royalhobartgp@gpra.org.au stvincentsgp@gpra.org.au boxhillgp@gpra.org.au westernhealthgp@gpra.org.au sheppartongp@gpra.org.au austingp@gpra.org.au alfredgp@gpra.org.au ballaratgp@gpra.org.au southernhealthgp@gpra.org.au northerngp@gpra.org.au geelonggp@gpra.org.au gippslandgp@gpra.org.au goulburnvalleygp@gpra.org.au charlesgairdnergp@gpra.org.au joondalupgp@gpra.org.au royalperthgp@gpra.org.au fremantlegp@gpra.org.au
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Taking a fresh look at general practice 7
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It takes22 Layla Ahmed, 45, and Ali Al-Hadi, 46, met when they were medical students in Baghdad, Iraq. They arrived in Australia in 2003 with their two small children and started working at Mildura Base Hospital in north-west Victoria. They now work as GPs together at Lime Medical Clinic, Mildura.
Layla:
I met my husband Ali at Medical School in Baghdad. Several years after graduation, we decided to come to Australia and sat the Australian Medical Council (AMC) examination in 2003. We found the health system here very different to Iraq. For example, in Iraq, about 90 per cent of the services were free, including general practice. Also, we don’t have nursing homes because the elderly are looked after by their families. Another difference is the working hours — we used to work from 9am – 3pm, but had only one day a week off. I like Mildura because the people are very nice and friendly. I feel that I know my patients and understand their needs. I don’t like the concept of ‘walk-in, walk-out’ patients. I feel that they miss out on the continuity of care that our regular patients receive. The biggest challenge about living in Australia is being away from our families. But I am lucky to have Ali. We often discuss medical issues together, and I get his opinion when faced with difficult cases. Ali is always supportive when it comes to looking after the family when I am away for training or conferences. If I had to describe Ali in five words, they would be: kind, loving, hard-working family man. His biggest strength is not giving up when times are tough. Although both of us can be very busy at times, and hardly see each other at work, it is always nice to know that I have the support when I need it. For example, Ali would see my patients if I had an emergency and had to leave early, and he’d check my patients’ reports when I am away and would cover most of my calls. A challenge we face is when we both go on holidays because that puts pressure on other colleagues. We had a difficult initial three to four years in Australia because we had to work very hard to prove ourselves. We had to go through a series of examinations to gain further qualifications and fellowships. I got a diploma in obstetrics and gynaecology and Ali did one in dermatology and cosmetic medicine. This study put our family under a lot of pressure. As with any female doctor I see more female patients, especially those with gynaecological or psychiatric problems. I want them to feel confident that I am treating them the same way that I would treat my family. I think my strength is being patient. I’m a bit quieter than Ali, and he seems to be more organised with time.
I respect and value my profession and my patients as well as my colleagues and aim to provide the best quality service to my patients. I’ve seen a lot of patients but there is one I’ll always remember. When I was in my final year at medical school, I saw an infant with a rare haematological cancer. He was a very cute and very cheerful child, but he died within a short period of time. After that, I decided not to become a paediatrician. It’s been a long journey, but I now consider Australia home for me and my family. My advice for other students is to come to the country — you will find very warm people and they will make you feel part of the community in no time.
Ali:
Layla and I met at medical school in Baghdad. In 2003, we came to Australia with our children, Omar and Sarah.
Since then we have lived and worked in Mildura, Victoria. I like Mildura because it is a quiet place, with nice people — and no traffic jams! I have found the Australian medical system to be a bit different from Iraq. Here, we need much more documentation for medico-legal issues, for example. However, in many ways it is similar. If I had to describe Layla in five words, they would be: supportive, caring, kind and charming. Layla has a quieter personality than mine, but she is a very strong person. We help and support each other emotionally — through demanding patients and difficult situations. We also help each other professionally. She has a sub-specialty in obstetrics and gynaecology, so I consult her on certain women’s health issues. I have done further study in dermatology and cosmetic medicine, so she will often come to me for advice on skin diseases and skin cancers. My advice for international medical graduates settling in Australia who want to become GPs is to study hard for your exams, always follow the guidelines in managing your patients, respect and listen to your patients and respect your community. Do you know a pair who could feature in the next ‘It takes two’? A supervisor and registrar? Your mentor? A GP who inspired you? Let the Going Places team know, email goingplaces@gpra.org.au
Taking a fresh look at general practice 9
G P registrar
X
Crossingborders From Darwin to the Kimberley and from Sudan to Ethiopia — Dr Anne Kleinitz has crossed many borders to get the most out of her general practice career.
With each border crossed, something is achieved both personally and professionally. But the most impressive part about Anne’s story is that her career is just getting started. So, where to start? Perhaps it’s best to start with Anne’s personal highlights. Topping the list are two tours to Africa with the Nobel Peace Prize-winning Médecins Sans Frontières (MSF), Doctors Without Borders. “I had always wanted to do this,” Anne says. “This is still a highlight of my life.” Anne’s first stint was for six months in 2007/08 to Darfur, Sudan, with MSF’s French arm. Anne found that her experience working in rural environments helped her to prepare for this challenging work. “From a medical perspective, there is a huge need for rural experience in these volunteer situations,” Anne says. “It was valuable in Africa because they like you to think on your feet and be flexible. You also need to be able to work as a team.” “We had a 60-bed hospital and had patients of all ages, but didn’t do surgery,” Anne said. “There were lots of kids suffering from malnutrition, gastro and chest infections, and a lot of vaccinepreventable illnesses.” Anne also saw many pregnant women. “Because we didn’t do surgery, if the women needed a caesarean, we had to put them on the back of a pick-up truck and drive them on a dirt road for two hours to a hospital.” Adding another level of difficulty for the women was that they could only travel during the day for security reasons. There were no ‘blood banks’ in camp, so patients had to bring their own donor in case they needed a transfer.
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In addition to treating the day-to-day cases — which could hardly be described as routine — Anne and her team had to respond to more immediate emergency situations. “We had an outbreak of meningitis and had to organise a World Health Organisation (WHO) vaccination,” Anne said. “We also had an outbreak of Hepatitis E due to contaminated water.” Once a camp is set up, one of MSF’s priorities is to vaccinate children against measles, which malnourished children are very susceptible to. Anne’s work with MSF affirmed her belief in the importance of vaccinations. “I’ve seen so many children die from preventable illnesses in Africa and see the enormous hardship that this pain can cause,” she said. “When I was taking histories of the mothers at the camp, I always asked how many children they had and how many had died. I was always surprised if they answered that ‘none’ had died.” Despite witnessing these developing-world hardships, Anne said the work was very rewarding. “I remember finishing a shift and often
(From left) Anne working at a malnutrition clinic for Somali refugees in Somaliland, Ethiopia; playing with local children in Darfur; working with World Health Organisation members during a meningitis outbreak at the Darfur clinic; caring for children in the Darfur clinic; visiting town during a mobile clinic trip to a local village, Darfur. (Top right) Anne at her Darwin clinic.
thinking, ‘gee, I’m glad I went to work today’ because there were really sick people who needed my help and who wouldn’t have got it if I wasn’t there.” “In Australia, there is always someone to cover you if you can’t get to work. But over there, if you are not there, a patient may not get treated.” During the second half of 2008, Anne went to Ethiopia with MSF’s Spanish arm to look after Somali refugees. “I was a locum at the time when I got the call from MSF,” Anne said. “I was on the plane 48 hours later.You’ve certainly got to be flexible!” Her work in Ethiopia focused on children in the camps, including looking after those who were HIV positive. Anne encourages doctors to go overseas, sooner rather than later, before other life commitments make it hard to leave the country. “After a couple of year’s clinical experience, doctors would be ready to work with organisations like MSF and be really valuable on their first mission,” Anne said. One of the best things about aid work, Anne says, is that doctors learn to trust their diagnosis skills and this helps them to gain confidence. “Over there, you don’t have X-ray machines, blood tests or a specialist to ask — it is just you,” Anne said. “I think we sometimes rely on technology too much. We need to go back to history and examinations.” From the start of her career, Anne has enjoyed working in rural and remote areas. “Working in the country always appealed because country GPs get to do more because they have to do more.” Anne, who was the first recipient of the John Flynn Scholarship, spent a year in the Kimberley’s, Western Australia, with an Aboriginal Medical Service. She was based in Broome, but would fly into a small
“From a medical perspective, there is a huge need for rural experience in these volunteer situations. It was valuable in Africa because they like you to think on your feet and be flexible.You also need to be able to work as a team.”
community to the south, called Balgo, where she worked with a GP caring for people with chronic kidney disease. “It doesn’t get more remote in Australia than Balgo,” Anne says of the community of around 400 people. “The plane only flew out to the community once a week. While in Balgo I’d go also to Mulan and Billilunea, which were about 50km away, for a day. We’d go by four-wheel drive and try not to hit any wild camels!” “As doctors, we know that the Aboriginal and Torres Strait Islander health statistics are far behind non-Indigenous health statistics,” Anne said. “It’s really good to see the communities first hand, and to use your skills to help, rather than reading about it from the city.” Anne is now working part-time in a Darwin super clinic as a GPT3 and also works for Flinders University coordinating their third year postgraduate students. To top it off, she is completing her academic post and is researching into how GP registrars in the Northern Territory feel teaching medical students. For Anne, 33, choosing general practice meant not having to give anything up. “I could still do obstetrics, paediatrics, geriatrics, emergency and mental health,” she said. “It is by far and away the career that you can be most creative with and the career that you can enjoy huge variety and flexibility — you can really find your niche.” “You can work anywhere in Australia and overseas,” Anne added. “Why would you choose anything else?” Coming right back to basics, Anne also says that general practice offers a unique chance to be part of a person’s life. “You can establish one-to-one relationships with patients and get to know the different aspects of their life,” Anne says. “You are always striving to understand the bigger picture.” And so what’s the next step in Anne’s story? The next border crossed, or goal achieved? “Darwin is home for a little while,” Anne says. “But if you look at my history, it says that variety is the spice of life and I’m always ready to take up a new challenge!” Anne has recently become a member of the General Practice Registrars Australia Board. — Laura McGeoch
Taking a fresh look at general practice 11
cus There are ways to keep focused on general practice while you are training in hospital. As a junior doctor in hospital, it’s easy to be occupied with the usual duties of caring for too many patients and constantly being paged. Often, little time is left to think about how your hospital experience can help you as a GP in the future. Here are a few points that will help you make the most of your hospital experience. Choose the right hospital and rotations — Choose rotations that will give you experience with common GP-managed conditions. General terms, such as general medicine and general surgery, may be more relevant than super-specialised placements. Accident and emergency terms are always a great opportunity to experience a wide range of presentations and to learn acute care skills, timely management and referral. Any experience with skin, ears and eyes will stand you in good stead.
Pick up useful procedural skills — Learn procedural skills that may be useful in general practice: joint aspirations and injections, excision of cysts and skin lesions. Learn the art of referrals — Think about what information is pertinent on a referral letter sent with a patient to emergency. Discuss the referral process with consultants. What do they like in a referral? What tests should be ordered prior to referral? How urgently do they need to see particular cases? Be curious about management decisions — In addition to the acute management decisions you will have made in the hospital setting, as a GP you will also be initiating and monitoring long term management of chronic conditions. Talk to your consultants and registrars about up-to-date guidelines and approaches to chronic disease management.
Learn procedural skills that may be useful in general practice: joint aspirations and injections, excision of cysts and skin lesions.
Do the PGPPP — During the prevocational years, doing a Prevocational General Practice Placements Program (PGPPP) term is a great asset (read about Lang Yii’s PGPPP experience in Darwin on pages 14-15).
Fine-tune your practical skills — Ask nurses to teach you skills, such as giving vaccinations, especially to children, and dressing wounds. Ensure you can place common types of plaster casts with confidence.
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Find out who’s who — Identify people who may be good information sources when you are working in the community; for example, hospital registrars, consultants, CNCs.
Practise your writing — Take particular notice of writing comprehensive and prompt discharge summaries, and don’t be afraid to call GPs to tell them their patients are coming home. Contributed by Dr Kate Beardmore, Dr Kate Kelso and Dr Kirsten Patterson
Choose the right hospital and rotations Choose a hospital and placements that will give you experience with common GP-managed conditions. There are rotations and experiences that are considered to be mandatory preparation for the Australian General Practice Training (AGPT) program. There are four compulsory rotations:
(preferably general medicine but as this is not • Medicine available in some hospitals, a rotation that offers broad
medical experience)
• General surgery • Accident and emergency • Paediatrics
In addition, each college (RACGP and ACRRM) requires certain other hospital terms and particular courses to be completed. For example, training in anaesthetics as well as obstetrics and gynaecology is mandatory in the ACRRM curriculum in addition to the rotations above. Refer to the college websites and discuss with your regional training provider (RTP). If you have completed some of these as a prevocational doctor, you may qualify for recognition of prior learning (RPL) so you can either reduce your training time or substitute terms that develop existing or new skills. Your RTP can provide further information about RPL, which you must apply for in the first year of training. Be sure to keep good records of your training experiences if you want to apply for RPL.
Taking a fresh look at general practice 13
PGPPP AND ME
PGPPPdiary Lang Yii, a junior doctor working in country Victoria, got a taste of the tropics when she trekked to Darwin for her Prevocational General Practice Placements Program (PGPPP). Going Places magazine spoke to Lang about her experience in the Top End, and the top tips she learned about general practice.
Where did you do your PGPPP? Jabiru Community Health Clinic, located in Kakadu National Park. I was there towards the end of 2011.
What was your supervisor like? My supervisor was Dr Renata Rams-Harvey. She has been working in Jabiru for nearly a year and is the only senior GP in the clinic. After my first day at work, she cooked me dinner and we had a long chat about our backgrounds and visions. To me, she is not only a great doctor and mentor, but also an adventurous, cheerful and easy-going friend.
Tell us about some of the work you have done?
Jabiru Clinic is also an emergency department and looks after the whole Kakadu community. Therefore, I got to do many procedures: insertion and removal of implanon and mirena IUDs skin lesion removal cryotherapy (liquid nitrogen freezing) on skin warts Pap smears foreign body removal ear syringing.
• • • • • •
Is there a patient who you will remember more than others?
I’ll remember my first patient. She was an Aboriginal lady in her mid-40s with several chronic diseases. The consultation was difficult because she was not managing her illnesses and medicine, and she challenged me with excuses. I knew that she would not take my advice home that first day.
The incident opened my eyes to some of the challenges of being a GP. With advice from my supervisor and other GPs, I followed up with her weekly and educated her about the consequences of not taking her medicine.
This worked remarkably well — she eventually took responsibility for her medicines. She later asked me to talk to her friends about the disease and taking medication correctly. That felt very rewarding.
What have you learned about patient care? 1) Do no harm. Always say “I don’t know” when you are unsure and get help from a senior GP. You are not only establishing trust with your patient, but also learning from your mentor. 2) Identify the main agenda with a patient for their consultation, and manage your time wisely. 3) Say “no” to patients who have inappropriate demands.
What have you learned about general practice? Too much! In short, I’ve learnt to live and practise like a GP now!
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Has the experience made you want to pursue general practice? Yes, it has inspired me to work as a GP in a rural area. I like the lifestyle and the challenges that this work offers.
What’s living in Darwin like? I love the natural beauty and weather! The extraordinary scenery and indigenous art have amazed me.
Lang’s diary... When the specialists are a hundred miles away… Unlike a hospital setting where specialists are readily available, I’ve found rural GPs have to do everything on their own. Good clinical judgment and knowledge are crucial to managing acute problems and emergencies. For example, we had a woman in her mid-20s who had sudden onset acute abdomen. We couldn’t rule out if she needed emergency surgery due to the limited tests available. Eventually, we transferred her to the nearest hospital. The next day, the specialist called to say she had improved after a few large bowel motions and was treated as acute gastroenteritis. This is the challenge of remote medicine — without adequate facilities and specialist support, we have to act according to what is available at the time.
GP TRaining 2013... If you want to train to become a GP, then you should apply for the Australian General Practice Training (AGPT) program for 2013. The AGPT program is a world-class vocational training program for medical graduates wishing to pursue a career in general practice in Australia.
Talk to your RTP or go to: www.agpt.com.au
When your patient does not do what you tell them to… Patient compliance is one of the biggest issues I’ve encountered in general practice. Patients give many excuses for not taking their medications “…ginger ants ate the medicine”, “…I was too busy shooting for geese and I forgot”, or “…I threw them out by accident”. It’s challenging when patients don’t take their illnesses seriously. When the patient is not happy about your plan… You will never please everybody. Some patients walk into your room expecting to be diagnosed with what they have in their minds. When you say, “no”, it’s like saying “goodbye” to them. However, I learnt to stand firm. A mother of a five month-old baby demanded medicine for reflux after making her ‘diagnosis’ via Google. I refused to prescribe the medicine, and explained her baby had infant colic. However, in the end she bought an infant anti-reflux medicine from over the counter. She hasn’t turned up at the clinic since. Leisure times… After work, I usually go for a run around Jabiru Lake. I can climb to the peak of Ubirr and see one of the most scenic sunsets in Kakadu. My fiancé and I also went on scenic flight around Kakadu — there is so much to do and see here!
Telehealth going places feature
— what it means for GPs, specialists and patients Dr Joshua Crase is a PGY2 at Ballarat Base Hospital and a Going Places GP Ambassador. A former computer systems engineer, Dr Crase provides Going Places magazine with an overview of the Australian Government’s telehealth initiative. Benefits for GPs Telehealth, a video consultation initiative, will make it easier for Australians living in rural, remote and outer metropolitan areas to access a specialist. Patients using telehealth services in general practices, eligible residential aged care facilities, eligible Aboriginal Medical Services and other facilities — even the patient’s home — will have access to a specialist without the time and expense needed to travel to major cities.
For the 2011–2012 financial year, each GP or specialist who uses the service will receive $6,000 as a one-off payment. There are also Medicare-funded payments for the ‘patient-end’ and ‘specialist-end’ parties (whether a practice nurse or GP at the patient-end). The patient-end practitioner must be co-located with the patient (ie. the same building) for the consultation, even if they are seeing other patients at the same time.
To this end, telehealth provides an important step to reduce the gap in life expectancy between rural, remote and outer metropolitan patients and their city counterparts.
Telehealth allows GPs to either sit in with the patient and interact with the specialist at the same time during the consultation, or continue to see other patients and have the patient attend their own telehealth appointment. Being with the patient during a telehealth consultation allows the GP to ask questions directly to the specialist, which helps them to treat or investigate the patient’s symptoms sooner. The GP is paid for the proportion of time they spend with the patient in the telehealth consultation. GPs can also bill Medicare for a separate face-to-face consultation on the same day as a telehealth consultation.
From 1 July 2011, the government’s telehealth funding will provide 495,000 consultations ($620 million) over four years, as well as training and incentives for GPs, specialists, and other health professionals to deliver telehealth services. Medicare rebates for specialist consultations are available across a range of medical specialties. GPs, nurse practitioners, midwives, practice nurses and Aboriginal health workers who provide services on behalf of a medical practitioner can access rebates.
Telehealth fosters cooperation between GPs and specialists by encouraging cross discipline education about patients and disease processes.
An example telehealth consultation
Benefits for patients
Mary lives on a dairy farm in NSW — a twenty-minute drive from Bega. Mary’s local GP is Dr Sharma, who detected Mary’s respiratory disorder in 2010. Dr Sharma referred her to Dr Brown, a specialist based in Sydney, and she has recently finished her treatment. She should now see Dr Brown every second month for a follow up consultation.
For rural and remote patients, telehealth enables specialist consultation without the travel, leading to time and cost savings. The service also provides immobile elderly or disabled patients in nursing homes with better access to specialists.
However, Mary finds it difficult to find the time and money to travel to Sydney. At Dr Sharma’s suggestion, and with Dr Brown’s agreement, Mary begins attending consultations via telehealth. A practice nurse attends each consultation, on Dr Sharma’s behalf, to provide clinical assistance. Mary is bulk billed by Dr Sharma and Dr Brown. In this case, each practitioner receives Medicare rebates and financial incentives. Source: Medicare Australia.
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Telehealth will help this group of patients to see a specialist sooner and to experience more efficient communication between their specialist and GP.
Potential negatives Accessing telehealth requires the cooperation of the patient, GP and specialist. Most rural and remote GPs would be very keen to have access to telehealth consultations, but specialists may need some convincing. Specialists often have a stable base of urban referrals and are not affected by the travel required by rural and remote patients (as the patient is going to them). However, the advantage for specialists is being able to tap into new patients, enjoy a different mode of consultation, and experience more efficient interactions with GPs and the financial incentives of telehealth consultations.
h
At this point, the technology for telehealth consultations is not standardised. Guidelines have been produced, however, there is no mandated technical solution for video consultations. The guidelines state that the telehealth technology must be capable of sufficient video quality and security to meet the normal privacy requirements. This could potentially lead to clinicians purchasing complex video-conferencing solutions that are expensive and not interoperable with other similar technologies. However, the guidelines imply that, provided the video stream is encrypted, practitioners can use solutions such as Skype (a free service) to facilitate the consultation, and expensive video conferencing systems may not need to be purchased. Many of these free solutions can be used on portable devices, such as iPads and iPhones, which can act as a third camera for use in physical examination.
Further information The colleges have been funded to develop telehealth guidelines, training and education modules for patients and GPs. Visit RACGP — racgp.org.au/telehealth ACRRM —acrrm.org.au/news/join-acrrm-national-telehealthinterest-group Medicare Australia — medicareaustralia.gov.au/provider/incentives/ telehealth.jsp
The rollout of the National Broadband Network will complement telehealth services. However, until then, remote GPs may find accessing telehealth consultations difficult due to inadequate computer/network infrastructure and insufficient bandwidth. Specialist billing for telehealth could be potentially complex. The specialist may have a delay in billing if the patient is invoiced for the consultation and must go through Medicare to facilitate payment. The patient may receive an invoice from the specialist and GP and a gap for each one. The GP could choose to facilitate the payment for the specialist, but may have to deal with different gap payments and accounts for each specialist. The specialist may choose to bulk bill, or use EFT/credit card payment at the time of consultation (in a similar way to telepsychiatry). For this process to work more efficiently, the government will need to create a straightforward system to allow the patient to be billed at the GP for their telehealth service with an automatic transfer to the appropriate specialist. If the billing is complex and left to clinicians to manage, some may become disinterested in the telehealth initiative. Writing specialist prescriptions is more complex with telehealth unless the GP is allowed to authorise a particular specialist medication via the specialist’s provider number. Otherwise, prescriptions may need to be posted to patients and result in slight treatment delays. This may be eliminated in the future with the introduction of electronic prescriptions.
Impact on the profession Aside from a few initial logistical and technical issues, telehealth will enable greater cooperation and more efficient meaningful interactions between patients, GPs and specialists. Ultimately, this will benefit the patient via timely and less costly treatment and ongoing care. Telehealth will help the profession grow closer together and try to break down the silos of general practice and specialist/hospital care. Rural, remote, outer metropolitan and Aboriginal and Torres Strait Islander patients can be some of the most disadvantaged people in Australia from a health perspective. Telehealth aims to reduce this health gap by providing better primary and specialist health care delivery through existing technologies.
Taking a fresh look at general practice 17
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gpaustralia.org.au — get on it! P tips on applying for general PNeed practice training? Want to calculate how much you P could earn as a GP? Like to hear first-hand from experienced GPs?
Visit gpaustralia.org.au for everything you need to know about general practice from a junior doctor perspective.
Go online to read fantastic blogs, including posts from one of our most popular bloggers — Confessions of a 21st Century Intern. Here’s a taster…read the full blog at gpaustralia.org.au
Confessions
of a 21st Century Intern
Confessions of a 21st Century Intern is the private blog of Dr Ernest Tecrin, on gpaustralia.org.au. Ernest is your junior doctor gyroscope, zeroing in on the latest dramas and happenings in the intern world. Read how he navigates his way — or at least tries to plot a steady course — through the sometimes murky waters of hospital rotations.
Cure sometimes, relieve often, comfort always “I’m in my new rotation, emergency. Emergency is a different beast — it’s often always full, never sleeps and is often the setting for organised chaos. It’s not as noisy as I thought — no one is yelling “STAT”, no one is running anywhere...in fact, one of the interns is reprimanded for running by the nurse in charge (she tells her that you only run in the most dire of emergencies...which in emergency, must be bad). Emergency is like a lottery.You might get someone who is really sick, or conversely, someone who could really have seen their GP but has the distorted view that they will get better medical care for a non-urgent problem in the emergency department (because their family doctor is “just a GP”). I remind this category of patient that those who are “just a GP” are often more experienced than most ED doctors. And they wouldn’t have had to wait six hours to see a doctor if they had just gone to their local clinic. My last patient for the day is a nice man called George. George, 70, lives alone after his wife passed away only a month ago.
George was presenting with four weeks of unexplained lethargy, shortness of breath and decreased appetite on a background of prostate cancer, treated four years ago. He tells me that he has had this ongoing “chest infection” that hasn’t responded to three courses of antibiotics. I groan internally because I think I know what’s going on. I don’t let on because it’s just a hunch, but a CXR and CT Scan confirm it. George has a recurrence of his prostate cancer. It’s everywhere and not likely to be amenable to surgery. I break the bad news to George. Like many patients, he had a feeling of what was going on. He takes it well. We talk for a while, he asks questions and sheds a few tears. I give him time without saying anything, just listening. I offer to call his son and tell him the news. He agrees and all of a sudden, reaches up to give me a hug. Stunned but understanding, I return the hug. His son, as nice as George, offers to come in and take him home to his house. My face must be giving away my internal conflict, as George places his hand on mine and says: “Thanks for comforting me Doc, it means everything. I know there’s nothing else that you can do medically, but as a person, I appreciate your efforts.” I nod, unable to say anything further and excuse myself to make arrangements for George. I bid him goodbye after his son arrives and on the way home, smile as the old saying springs to mind — ‘cure sometimes, relieve often, comfort always’.”
Rule #3: Comfort always. Taking a fresh look at general practice 19
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Dr Peter Schindler has been a GP for around 35 years and has worked overseas and in rural Australia. In this ‘Chocolate box’ story, Dr Schindler relates a tale involving an early morning cycle ride, a policeman, a pair of thongs and a haematoma.
“A miracle” I worked as a GP in Halls Creek, Western Australia, from 1979 to 1982 and I remember an interesting incident. It was early in the morning, the sun was just rising over the far horizon and I was wide-awake. I knew that in a few hours the temperature was going to be moving into the 36 degrees range so what better to do but to get some exercise by getting onto my bicycle and pedalling around the streets of the small town.
When you’re a GP, you never know what you’re going to get…
Picking up speed I scooted across the then empty highway, not bothering to come to a standstill at the stop sign at this sleepy time. Suddenly from my immediate left, about 100m away, I heard a shout pierce the morning silence. “Hey Doc! Come over here before you go anywhere else!” Looking around I saw it was the town’s police chief (who was also one of my patients) out in the station’s garden. He was out of uniform, dressed casually, and wearing a pair of thongs. My heart jumped as I was sure he had seen me speed through the stop sign. Quickly, I stopped, dismounted and walked the bicycle to his obviously agitated beckoning figure. “Hey what are you doing out so early speeding around on your bicycle?” I cringed, gave no response, and waited for him to go on. “You’re just the person I need right now,” he said. “I’ve just dropped a brick on my big toe. It hurts bad and doesn’t look good. Do you think it might be fractured?” By that time I had reached him and lay the bicycle aside. I got down on my knees and bowed my head to the ground to inspect his big toe. The right big toe looked swollen and the nail appeared black and blue and distended above its bed. I thought this may need a heated paperclip to burn a hole through the nail to relieve the pressure. Down on my knees, I casually but gently manipulated the toe and toenail, and was surprised by a sudden spurt of blood which shot out of the anterior aspect of the nail under considerable pressure. “Ahhh” he exclaimed. “That feels much better already — almost a miracle!” I reassured him that it did not appear to be fractured, and I stood to wait his further words. “Thanks so much, Doc,” he said. “I look forward to not having to see you again soon — carry on with your cycling,” he added, grasping my shoulder and then waving me on. I moved off quickly, rejoicing that the haematoma had virtually relieved itself spontaneously, but also that I had not collected a rebuke for not stopping at the stop sign. To a distant witness it may have appeared I had earnestly begged for mercy at his feet and been forgiven!
Dr Peter Sch at the en indler and family d of the in Halls C 70s reek
Do you have an interesting story to share — an unusual case, a miraculous recovery or an amusing anecdote? Let the Going Places team know, email goingplaces@gpra.org.au
Taking a fresh look at general practice 21
General Practice Training in Indigenous Health Victoria It is important
Is it for YOU?
It is challenging It is inspiring
What are you doing about Indigenous Health? Indigenous health is a national priority, with Aboriginal and Torres Strait Islander Australians still dying years earlier than other Australians and suffering from a wide range of preventable diseases and treatable illnesses. As a GP working in Indigenous health, you are likely to make a bigger difference to health outcomes than in any other area of medicine in Australia today! • Practice a holistic approach to primary health care in a cultural context by training at an Aboriginal Community Controlled Health Service (ACCHS). • Get an appetite for Indigenous health by negotiating part-time or sessional arrangements whilst doing your GP training. • Experience complex medicine including chronic disease, preventive health care, health promotion and public health management. • Train under inspirational GP Supervisors, who are ACRRM and/or RACGP Fellows with years of experience and in depth knowledge of the clinical status and cultural aspects of the community. • Enjoy complete flexibility with 9-5 daily hours, leave for release sessions, conferences, study and personal life.
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Are you interested in Indigenous Health? Contact the GP Education and Training Officer at VACCHO.
5-7 Smith St, Fitzroy VIC 3065 P: (03) 9419 3350 E: enquiries@vaccho.com.au W: www.vaccho.com.au
Victorian Aboriginal Community Controlled Health Organisation
GP in the news Free edition
Going Places - Taking a fresh look at general practice
Smart phone injuries on the rise
Gen Y replacing GPs with Internet
The generation that brought the world Facebook, Justin Bieber and planking has an even less impressive notch on its collective belt – being number one when it comes
A new repetitive strain injury presentation is on the rise in tandem with the increasing use of smart phones and tablet computers, health practitioners say. So-called “text neck” is becoming more prevalent as are injuries to the thumb caused by overuse, and it’s mainly because people are using high-tech gadgets for accessing the internet rather than making phone calls. Health experts in Britain have warned that the strain injuries stemming from long periods spent staring at small screens and tapping at tiny keys could be debilitating.
to online self-diagnosis and taking unprescribed medication. More than half of so-called Gen Y admitted to looking up symptoms on the internet instead of seeing a healthcare
GPs’ role in providing acute medical care is highlighted in a new report showing 18 per cent of patients who saw a GP in the last year did so for urgent treatment. Released by the Australian Bureau of Statistics, the report also shows that of patients who visited an ED in the last year for their own health, one fifth thought the care they received there could have been provided by a GP. Source: Australian Doctor
professional compared to 36 per cent of the rest of the population, according to a survey of 1,002 people by the Australian Medicines Industry. Source: Medical Observer
Patients satisfied with GP experience
Source: AFP (Agence FrancePresse)
GPs play key role in urgent care
Issue 7 - 2012
Money may be a sweetener but less effective long term Financial incentives for patients can be effective in modifying health behaviours but work best in encouraging simple and short-term changes such as undertaking immunisation, University of Newcastle researchers say. A review of recent literature showed
that incentives appear less effective when it comes to modifying complex entrenched behaviours like smoking, diet or exercise, they found. Source: International Journal of Behavioural Medicine (IJBM)
GPs are leading the way in measures of patient satisfaction, according to an Australian Bureau of Statistics report detailing patient experiences of health professionals. The report, Patient Experiences in Australia, revealed that four out of five people had visited a GP in the past 12 months and that 88 per cent of patients felt their GP had “always or often” spent enough time with them. Source: ABS
Popular doctors not always the best
Caution is needed when assessing a doctor’s professionalism by how popular they are among their patients and colleagues, because biases arise based on a doctor’s personality and country of origin, according to a UK study in the BMJ. Source: BMJ
Taking Taking aa fresh fresh look look at at general general practice practice 23 23
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For Dr Andrew Pennington, the skills that make a great GP have little to do with medical prowess, and everything to do with communication and empathy.
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Keeping the faith Dr Andrew Pennington knew something wasn’t right. Sure, this was a middle-aged man seeking advice on erectile dysfunction and asking for a prescription for Viagra … nothing particularly unusual there. But as Andrew tried to establish the likely cause of the problem, something told him this wasn’t a clear-cut case. “We talked for a while, and as I was listening to him, my instinct just told me that there was something else going on,” he says. His intuition was right. Blood tests and an MRI revealed a prolactinoma (a pituitary gland tumour) that, if left undiagnosed and untreated, could have left his patient permanently blind. “Every patient is an individual, but if you can connect with them as a person, really listen to them and take their concerns seriously, you’re more likely to be able to help,” he says. For Andrew, the chance to listen to, and even bond with his patients, is the most rewarding aspect of his job as a general practitioner. “Most doctors have the technical skills to be a good GP. But, if you are not truly interested in connecting with your patients, and you don’t actually like following up with people, and caring for people, then general practice is just not for you,” he says.
“It’s incredibly satisfying to be able to empower women to labour well, and give birth well. It’s so rewarding to see them become confident that they are capable, and that their bodies are capable of coping with childbirth,” he says.
Andrew grew up in Sydney, and studied medicine at the University of Newcastle. It was here that his eyes were opened to the possibilities of a career outside of the urban environment. As a John Flynn Scholar, he spent two weeks of each university year in a small town in southwest NSW. Working closely with an established rural general practitioner, he experienced the reality of life and work in a rural community.
It’s an approach Andrew says is guided by his strong Christian faith.
Despite being a “city boy”, he quickly realised that he enjoyed the lifestyle and the opportunity for varied procedural work available to rural GPs. “For me it was a few particular positive experiences seeing rural GPs in action in those early years that encouraged me to aspire to general practice,” he says. He also recognised that rural GPs have the opportunity to do a lot of practical medicine. “As a rural practitioner, your work really crosses over into hospitalbased, procedural practice. There are so many areas that you can focus on in rural general practice, and you can develop your skills in that area to a significant degree,” he says. Now based in the Kilmore region, about one hour north of Melbourne, Andrew has a varied working week, seeing patients at a clinic in the small town of Wallan, and spending part of his week on the obstetrics and emergency roster of the local hospital. Andrew undertook an advanced rural skills post in obstetrics in the middle of his general practice training, as he was “keen to offer the rural community a skill that it genuinely required”. His dedication to patient-centred care extends to his obstetric patients. “There are a lot of misconceptions out there about childbirth, and women often come to their GP scared by all the things they have been told. I focus on educating my patients, and giving them the facts. It’s like a coaching role, helping them on their way through that important journey they are on,” he says.
“My Christian faith does shape who I am as a doctor, it certainly impacts how I view the world, and how I see my job. As a Christian, I believe that I have a moral responsibility to demonstrate compassion and love. Working as a doctor is one major way of fulfilling that responsibility,” he says. He’s careful to point out that he would never force his faith onto his patients. But he’s not one to shy away from discussing spiritual issues, especially as they may impact on a patient’s health. “The area of spirituality is one that is often taboo, especially in the medical and scientific community. I don’t think it should be,” he says. “Everyone is guided by some moral philosophy, especially doctors. We’ve all chosen a career that’s all about helping people. It might not always be evident in my work, but in difficult cases, my faith gives me strength,” he says. One such case is the heartbreaking story of a woman in her mid-50’s who came to see Andrew at his clinic with nausea and mild abdominal pain. “I referred her for an ultrasound, and unfortunately it became clear she had metastatic pancreatic cancer,” says Andrew, “Giving bad news is part of every doctor’s working life, but it’s never easy.” Although this story did not have a happy ending, Andrew says it is still rewarding to provide “empathy, care and a listening ear to every patient”. “As a GP, just doing what you can, listening and supporting is often the best thing you can do. I try to operate by the philosophy ‘Do unto others as you’d have them do unto you,’ ” he says. Andrew was a GP Ambassador at Wodonga Hospital for the Going Places Network during 2010. — Ruth Hyland. Photography: Emily Lane Star News Group
Taking a fresh look at general practice 25
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Healing the mind body It’s often said that one of the unique skills GPs offer is that they invest time to understand the bigger picture of what’s happening in a patient’s life. For Dr Margaret Niemann, getting further qualifications in mental health, and gaining resilience through remote work, has helped her to treat patients whose ailments go beyond the physical. After first considering psychiatry as a career option, Margaret decided to study general practice because of all the options and benefits it offered — travel, experience and lifestyle. But since graduating from Melbourne University in 1978, she’s still been able to build on her initial interest in psychiatry by specialising in mental health and treating people who have been affected by trauma. “I’d always been interested in mental health and had been prepared to give people longer appointments so I could have a really good talk with them,” Margaret told Going Places magazine. Margaret had done some mental health training throughout her career, and in 2001 got her Masters in Psychological Medicine through the University of New South Wales. She recommends all GPs to do some mental health training so they can be prepared when a patient needs this expertise. “The common conditions, such as anxiety and depression that all GPs deal with can be dealt with more efficiently and effectively with more training. More training helps to pick up the less common presentations of mental health conditions,” Margaret says. Margaret recalled a period in the early 1990s where there was a public awareness campaign to encourage victims of sexual abuse to speak up. At the time, Margaret was working in a country Victorian town called Bairnsdale, which has a population of around 12,000. “I started to get about one patient a week revealing to me that they had been sexually abused. I was the first person they had ever told,” she said. “I started to help these people deal with their problems and did more mental health training to help me to cope and treat patients.” What are the first steps a GP takes when treating a victim of sexual abuse? “You listen. You check that they are safe now, as much as you can,” Margaret advises. “If someone has been abused as a child, they are often not good at protecting themselves as adults. Their protective instincts have been overwhelmed and they may still be being abused. One of the tasks is to help them to articulate the issues and find the right support,” Margaret says.
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Margaret has also worked with patients with drug addictions, and the subsequent psychological and physical conditions that arise from drug abuse. She ran a methadone program for nine years. “There is a real shortage of doctors who do the methadone program,” Margaret said. She says this could stem from the perception that the majority of patients on the program are very high maintenance and may cause a public disruption within a clinic environment. “More than 50 per cent of the people on the program are perfectly organised. They turn up on time, they are stable and looking after their program,” Margaret says. “They get on with things.”
“Another 25 per cent are a little bit unstable — they try to reduce too quickly. They get frustrated and then go back to using. They can be a little erratic.” “
“
“Then there are the small group who are disorganised, demanding, angry and distressed, and they are the ones the public see. They implode eventually.” Some doctors think, ‘I couldn’t deal with that all the time’, but it’s not a true reflection of the program.”
“Running the program is satisfying because you’ve actually got something constructive to do with these people instead of giving them a script, or not, and telling them to go away. On average, one person dies from illicit drug use every day in Australia — many of these deaths are preventable.” Margaret says this work, and in particular helping young people through mental health issues, is very rewarding. “I also worked with people with eating disorders for about 10–15 years,” Margaret said. “However, for the past two years I haven’t been working with anyone in a long-term way.” She credits this with the “tremendous” promotional work done with schools today about healthy eating. Solid clinical and practical experience in hospitals and rural and remote environments, including being the only GP in an Aboriginal community in Arnhem Land, has helped Margaret to gain the confidence and resilience to treat the often sensitive and complex cases of patients with psychological trauma.
She met her husband, Michael, who is also a GP, at medical school. In a ‘city girl meets country boy’ romance, they both moved to country Victoria after graduating. “We worked rural for two years in Ballarat and Bendigo, and then went to England for two years. I did my Diploma in Child Health and a Diploma in Obstetrics over there. Michael did anaesthetics and obstetrics — we were training ourselves up to work as rural GPs.” The pair came back to Bairnsdale, which had the “perfect job” for them. They worked in a hospital run by the GPs who also looked after the hospital patients. “There was a big range of work — as much responsibility as you wanted, as much variety as you wanted,” Margaret said. During their time there, Margaret had three children and worked part-time as they raised their family. But in 1997/98, they went from
“The common conditions, such as anxiety and depression that all GPs deal with can be dealt with more efficiently and effectively with more training. More training helps to pick up the less common presentations of mental health conditions.”
rural to remote and worked in Maningrida, Arnhem Land, in the Northern Territory. “We were the first resident doctors employed by the mostly Aboriginal community, which had about 2,000 people,” Margaret recalls. “It’s a great Aboriginal community and we really enjoyed being there on lots of different levels.” “I found my personal confidence increased enormously. We were forced to take on more responsibility, but we found we could rise to the challenge.” Margaret says one of the nicest aspects about working in a rural community was that “you live amongst” your patients. “We didn’t just see them when they were sick, when people are often grumpy or miserable. We’d see a fisherman hunting and looking after his family, doing the best he could do. You get a much more balanced view of your patients this way.” At the end of 2010, Margaret’s career took another turn when she left her mainstream practice and started working as a locum in the Northern Territory and Kununurra. “I go to remote communities for short-term stints, about four weeks, to cover doctors who are away,” Margaret says. Margaret, who also works as a casual tutor for registrars, has not looked back since choosing general practice. “I’ve had a very good life and I’ve had lots of variety. It’s extremely rewarding, challenging and interesting.” “Occasionally some people are not very responsive, but that’s one of the challenges of being a GP,” Margaret says. “You are working with people in their early stages of a problem, when you are more likely to be helpful. Unlike other professions, including psychiatry, you see them when the treatment is most likely to work and to be most effective.” — Laura McGeoch
Margaret (left) with Cindy, a friend from Maningrida, NT, during a visit to Victoria. (Inset photo) Margaret (middle) with Aboriginal health workers, Jeannie (left) and Margaret (right), in Maningrida, 1998.
Taking a fresh look at general practice 27
G P profile
The best Dr Will Thornton has discovered how to combine the ‘best of both worlds’ when it comes to carving out his general practice career. He has given his resume an international flavour by studying and working in England, from where his family originate. This overseas work gave him a unique experience of working within the sub-specialty of paediatric palliative care. Will currently works in a Perth Hills clinic, but mixes it up by “going bush” every few months. Going bush could see him fly in to work in a remote Western Australian community, or do health education at a major mining site. Will started a postgraduate medicine course when he was 27 at Flinders University in Adelaide, and completed it in Darwin getting tropical health experience and exposure to Aboriginal and Torres Strait Islander health. After graduating and finishing his hospital medicine, he went to the UK and completed his general practice training. Building on his “past life” as a high-school teacher, Will has worked as a medical educator with Western Australia General Practice Education and Training (WAGPET) to help mentor the next generation of GPs. Education has always been an area of interest to Will. “Before medicine, I was a maths and science teacher, so I always had the education slant on my career,” he said. Will has worked with GP registrars, supervising them and mentoring them through their training with WAGPET. He is also an examiner for the RACGP and an educator for the Australian Medical Council examination revision courses. And above all, Will combines the best of both worlds by getting home most nights for the bath, bed and story routine with his three young children.
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of both worlds “In general practice, particularly in Australia, the world is your oyster,” Will told Going Places magazine. “You can do anything here,” he said. “You can extend into emergency work, procedural general practice — surgical, obstetrics or anaesthetics, occupational health and education. And with a good work-life balance hopefully too!” He’s combined his educational experience with occupational health through his work at mining sites. “I visit some of the mines in the Pilbara to do some health promotion with the fly-in fly-out workers there. I talk to them about lifestyle changes such as stopping smoking, exercise, healthy eating and weight,” he says. “They are away from their family for a long time and can feel quite isolated, so we also look at depression and dealing with marital problems stemming from time apart from loved ones.” Will is currently working at the Stirk Medical Group in Kalamunda, which is derived from Aboriginal words meaning ‘home in the trees’. Upon negotiating his employment with the centre, Will asked to work seven or eight sessions per week (four days), to free up an extra day to spend with his family. “I also take a week off every couple of months and in that week I’ll do a locum stint out bush.”
“For a new GP looking to work different hours and take time out to do different things, you need to be clear about what you want, and what you can offer in terms of what will fit into your life. And be up front when negotiating your contract from the start.” During a typical month, Will flies up to remote areas in the Kimberley, and out to small Aboriginal communities as well as working as a district medical officer in the emergency department of the hospital. “The experience of working in these rural areas, where you need to deal with emergency situations, helps me to keep up-skilled and manage the acute presentations when working in an urban practice.” Will continues to build upon what he learned during time spent studying and working in the UK, particularly when it comes to paediatric palliative care. He has a Diploma of Palliative Medicine in Paediatrics from Cardiff University and worked at a hospice in Oxford, England, with life-limiting paediatric patients. He is using this experience to try and set up paediatric facilities in Australia that reflect those that have been developed in the UK. He is a board member of a developing children’s hospice, Hannah’s House (hannahshouse.org.au), in Perth. The hospice is named after Hannah Watson, who was born with the very rare Opitz trigonocephaly syndrome. Hannah’s House is a not-for-profit
initiative that helps families with children who suffer from life threatening conditions. He says there are significant differences between dealing with adult and child palliative care patients. “In adult palliative care, over 80 per cent of patients have cancer, so there is a focus on oncology, with the other roughly 20 per cent being non-malignant,” Will said. “However, paediatric palliative care is very different, especially with improved prognoses due to effective treatment protocols for paediatric cancer. Indeed, it is the reverse with the percentages, so the majority of paediatric palliative care patients have non-malignant conditions such as neurological, muscular diseases, metabolic disorders and organ failure.” “This means you are dealing with families who are living with sick children 24/7 and usually we have no respite care. Rather than dealing with death after intensive treatments or major operations, their children generally have a gradual but unpredictable death. Thus they can experience significant health difficulties during their child and teenage years, and even into their adulthoods.” “One hundred years ago, people were used to kids dying, but in 2011 we’re not used to that. Families with sick and dying children can be very isolated and so the whole family are an integral part of the patient’s care.” Will says his UK hospice experience gave him an insight into paediatric palliative care that he could not have got in Australia. “Some GPs may only manage one paediatric palliative care patient in their career,” Will says. “But it will be a relationship that stays with them forever.” And what’s his advice for the next generation of GPs, who are hoping to get the best of both worlds from their general practice career by incorporating travel, education and a niche area into their work? “For a new GP looking to work different hours and take time out to do different things, you need to be clear about what you want, and what you can offer in terms of what will fit into your life. And be up front when negotiating your contract from the start,” he advises. Will also noted that for the long term it is important to seek a suitable practice.“So for me that was having a teaching ethos, with a collegial philosophy, that fostered mentoring and reflective clinical practice and was also flexible.” And he says not to forget that with general practice, the world is your oyster. “General practice allows you to have a comfortable living and a good work-life balance — although sometimes I don’t always master that! The advantage of general practice compared to other specialties is that you really can do anything you want.” — Laura McGeoch
Taking a fresh look at general practice 29
! d l i w e n go
J U N I O R D O C T O R profile
GP Dr Mike Cross-Pitcher (Going Places Medical Editor) is a GP registrar undertaking the combined FACRRM and FARGP rural general practice pathways. He studied graduate-entry medicine at the University of Western Australia and is a PGY2 currently working as a Junior House Officer at Nambour Hospital on the Sunshine Coast, where he is also the GP Ambassador. As part of his general practice career, Mike did a short course in Expedition Medicine (Snow and Ice) with General Practice Training Tasmania (GPTT) last year. Mike tells Going Places magazine about his time in the wild.
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“Nothing is better than waking up on a frosty morning, snuggled in your sleeping bag in the middle of the remote wilderness with a day of hiking and adventure ahead of you. Unless, of course, you are awoken because someone is screaming: “Fire! Fire! We need a doctor! There’s been an accident!” Wiping the sleep from your eyes and rushing out of your tent, you are presented with a scene of chaos and mayhem. Four of the campers in your group have set their tent on fire with stove fuel and are writhing on the ground in agony. They need help. Now. You are in the middle of nowhere — a three-day hike from help. They need a doctor. All eyes turn to you... I was that doctor, and the emergency felt real. The difference was that I had asked for it to happen. This was one of the many simulated emergencies we experienced as part of the short course in expedition medicine. Anyone in the remarkable profession of medicine can be caught in a remote and resource-poor environment with the request (and responsibility) for medical help landing on his or her shoulders. An acute coronary syndrome in a commercial aircraft at cruising altitude can be just as lonely and difficult to manage as a broken ankle during a trek across Cradle Mountain, Tasmania. For those of us who enjoy getting away from it all, whether climbing K2 or sea kayaking around the west Canadian coastline, the risk of having to manage an emergency far from medical help is much higher. The key variable that we can control is how prepared we are for it. My lonely experience was this year as a trekker on the Kokoda Track, Papua New Guinea. I had been called to review a member of another
(Left) Mike cools down during his Kokoda Track trek, and is put through his paces during GPTT’s Ice and Snow course in Tasmania.
group late in the afternoon of the third day’s hike. He was experiencing palpitations, lethargy and dizziness, with a significant cardiac past medical history. The only help available was among my fellow trekkers (including a very experienced nurse) or via an extremely unreliable satellite phone connection to his travel insurance doctor. Evacuation was only possible by chopper... and not until morning. He was mine until daylight. A torch, oral fluids, a few antibiotics and other miscellaneous items were all that were at hand. Fortunately, he was stable through the night and able to be evacuated the following day. Returning to Australia, I wondered how to become more capable at managing this type of crisis. This is where General Practice Training Tasmania (GPTT) and their expedition medicine short courses came in. Expedition medicine is the branch of medicine concerned with the provision of health care to people journeying in remote and often hostile environments. The expedition doctor undertakes pre-expedition health care and related logistical planning, teaches advanced first aid skills to others, and provides health care while on expedition. Many expedition doctors are GPs who are following their passion for adventure. The unique ability to combine your passion with your vocation is just one more reason why general practice is such an outstanding career. GPTT run different short courses in expedition medicine each year. In 2011 they included: Ice and Snow (Arm River, Tasmania) Mountain Medicine (Freycinet - Tasmania)
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“Many exped who are follo ition doctors are GPs w adventure. Ting their passion for combine you he unique ability to rp vocation is juassion with your why general st one more reason pr outstanding actice is such an career.” The short courses provide training for people from a wide variety of backgrounds, and cater for both the novice and the experienced. All courses cover the following core topics: accident management plan search and rescue remote area communications navigation and other field skills leadership and team-work pre-expedition planning and medical kits improvisation of medical and rescue equipment.
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The courses are accredited as a Tier 2 emergency medicine course, contributing towards the ACRRM compulsory emergency training requirements. In addition, GPTT and the Australian Antarctic Division each fund one participant annually. In 2011, I was one of those fortunate two, having applied for, and been granted, a funded place with GPTT on the Snow and Ice course at the Arm River, Tasmania, approximately 35km south-west of Mole Creek in the state’s north. The course was convened by Dr Graham Denyer, a medical officer at the Australian Antarctic Division, and all facilitators had extensive experience in climbing, guiding, remote medicine and snow craft. The participants were doctors (ranging in experience from intern to senior registrar) and students undertaking their Certificate III in Wilderness Guiding. This diverse range of experience was essential for the cross-pollination of skills needed to meet many of the challenges thrown at us. As for the challenges, they tested us all mentally, physically and emotionally. An essential part of the learning experience is simply not knowing what will happen next. Without giving too much away, the emergencies took ‘simulation’ to an entirely new level. It is incredible just how many ways were found for us to manage ‘near-death’ experiences. But, with the practical wilderness skills we learnt and the Accident Management Plan to guide us, the task was far less daunting. The Short Course in Wilderness Medicine (Snow and Ice) was an outstanding experience, blending the passion for the outdoors with the majestic beauty of the Tasmanian wilderness and exceptional emergency training. I feel more prepared to tackle the challenges of the remote environment and highly recommend the course to any of my colleagues who have a hankering for the wild.” “Many thanks to GP Training Tasmania for sponsoring me on this incredible experience.” GPTT website: gptt.com.au Australian Antarctic Division website: antarctica.gov.au
Taking a fresh look at general practice 31
What’s your diagnosis? Dr Sarah McEwan writes about a recent diagnosis involving a young man and his girlfriend.
It’s a busy Monday morning in a rural emergency department in North West Western Australia. I had undertaken a short locum under the impression that the majority of presentations to the emergency department were in fact general practice type cases.
On examination of the swelling to his right second metacarpalphalangeal joint, I found a round lump to the dorsal aspect of the joint that measured approximately 2.5cm in diameter. It was firm to touch but not overly tender and non-fluctuant.
Relieved, I called for my next patient, by the name of Darrell.
His other clinical observations, blood pressure, pulse rate, respiratory rate and temperature were all within normal limits.
Darrell* is a 25-year-old healthy, fit-looking Aboriginal man from a community about 200km from town. He presented with a one-week history of a swollen and mildly tender right second metacarpalphalangeal joint. Darrell was very shy and was unsure about how this occurred. He denied trauma, denied drinking, denied fighting, had never suffered gout and had never previously fractured his hand.
Given that I was under immense time pressure and had minimal history, I decided to send Darrell for an X-ray on his right hand to further investigate the problem. I hoped that that it would turn up some answers and give me some thinking time... While waiting for the X-ray to be performed, I called for the next patient.
He was right-handed and played football, but had not played recently because his partner had delivered their second child just three weeks earlier.
The next patient was Krista*. She turned out to be Darrell’s partner who had recently delivered her second child by normal, spontaneous vaginal delivery. There were no post-partum complications to date.
Darrell was otherwise fit and well, took no regular medicines, had no allergies and did not smoke (cigarettes or marijuana). He admitted to binge drinking on the weekends, mostly during the football season, but denied any other illicit drug use.
Krista presented with bilateral lower abdominal and flank pain with fevers and chills, accompanied by nausea. She said that she had felt this way for about three days and had noted some vaginal discharge over the last week. When asked, Krista stated that her lochia post-delivery had settled completely and that the discharge was new. Krista denied dysuria. Further history demonstrated that Krista was also otherwise in good health. Has had no other medical issues, didn’t take medications, denied any allergies, was a non-smoker and had not been drinking as she was fully breast feeding her newborn baby. She said that she had never taken any illicit drugs. On examination, Krista’s observations were — blood pressure 112/76, respiratory rate 14, pulse rate 98 and her temperature 39.8. She looked unwell and was complaining of moderate lower abdominal pain. I decided to do a urine analysis which demonstrated positive leuks 3+ and also some blood 2+. There were no nitrites seen, and as expected her urine bHCG was also negative. Clinically, there were no other signs of note.
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Based on the above presentation I considered such things as a urinary tract infection or endometritis — or both — as a cause for Krista’s symptoms. Because she presented as unwell, I started her on broad-spectrum intravenous antibiotics and ordered a pelvic ultrasound scan to rule in or out retained products of conception with subsequent endometritis. I also sent her urine off for culture and some bloods to check on her white cell count, CRP and renal function. Meanwhile, Darrell’s X-ray showed no acute bony injury. Interesting...
What’s your thoughts? Make the diagnosis and read on to see if you are right!
I was slightly stumped at this stage and decided that reassurance was needed for Darrell knowing that there were no acute fractures and he was not in a great deal of pain. In my mind simple analgesia was in order with some safety netting of when to return should things worsen. Once again I returned to Krista to ensure the treatment plan was underway. It then dawned on me that I should consider an STI screen in both patients. Perhaps at a long shot, both presentations could be linked with a commonality — that being either a chlamydial or gonorrhoeal infection. Knowing that these tests would not be back for at least 48hours I decided to keep Krista in hospital for further investigation and treatment and follow up her test results. Fortuitously my hunch was right. There was in fact a commonality. Both patients returned positive PCR tests for gonorrhoea. Brilliant.
Timidly, I approached Krista to advise her of the diagnosis knowing that there would be endless questions that she would need to ask Darrell. Darrell returned to see a male doctor in the emergency for his results and treatment. The joint swelling had resolved when he was reviewed in the department three weeks later for an unrelated matter. Darrell’s diagnosis could be explained by Reiter’s Syndrome or post-infectious arthritis. This is a reactive arthritis classified as an autoimmune condition that develops in response to an infection in another part of the body. Coming into contact with bacteria and developing an infection can trigger the disease. *Names have been changed
Reactive arthritis is a group of inflammatory conditions that involves the joints, urethra, and eyes. There may also be sores (lesions) on the skin and mucus membranes. The exact cause of reactive arthritis is unknown. It occurs most commonly in men before the age of 40. It may follow an infection with chlamydia, campylobacter, salmonella, or yersinia and uncommonly gonorrhoea. Certain genes may make a person more prone to the syndrome. Urinary symptoms usually appear within days or weeks of an infection. Low-grade fever, conjunctivitis, and arthritis develop over the next several weeks. The arthritis may be mild or severe, and may affect only one side of the body, or more than one joint. The diagnosis is based on symptoms. Since the symptoms may occur at different times, the diagnosis may be delayed. A physical examination may reveal conjunctivitis or typical skin lesions. Tests that may be performed include: CRP, HLA-B27 antigen, joint X-rays, ESR, U/A and STI screens. The goal of treatment is to relieve symptoms and treat any underlying infection. In this case, antibiotics targeted for treatment of gonorrhoea were provided, along with simple analgesics for the joint pains for Darrell and appropriate antibiotic treatment was also provided to Krista. Reactive arthritis may go away in a few weeks, but can last for a few months. Symptoms may return over a period of several years in up to half of the people affected. The condition may become chronic. Preventing sexually transmitted diseases and gastrointestinal infection may help prevent this disease.
Dr Sarah McEwan
Taking a fresh look at general practice 33
Clinical
CORNER Medical Observer provides Going Places magazine with some interesting clinical case studies and helpful tips for dealing with patients that have been sent in by readers. Edited by Dr Justin Coleman.
Dermatology
Occupational hazard
An obvious weeping dermatitis confined to one hand should always raise the possibility of a localised allergic contact dermatitis.
This hand belonged to a postman. Close questioning revealed that he wrapped groups of letters in large thick elastic bands and then used other elastic bands to hold the bundles of letters in that hand when he was delivering from door to door. Patch testing showed an allergy to mercaptobenzothiazole, a rubber allergen found in elastic bands. Use of a strong topical steroid cream and changed work practices not involving the use of rubber bands led to disappearance of the problem. Patch testing is a very useful technique to determine the likely allergen in a situation like this.
GP tips Palpation by stealth In general practice, surgical acute abdomen comprises a fraction of all abdominal pain presentations. ‘Voluntary’ guarding is relatively common, particularly in children and anxious adults. So rather than diving straight in with palpation, try relaxing the patient with gentle auscultation, then gradually increase the pressure of the stethoscope head. You can often palpate deeply via the stethoscope before the anxious patient thinks about it and tightens up.
Saving the scalp Common skin conditions are often trickier to treat when they happen to affect the scalp. Steroid scalp lotions are significantly more expensive than their cream counterparts, presumably because the market is smaller. I advise my patients to first apply a cheap supermarket shampoo (or a low-irritant alternative if soaps affect the rash) and rinse. The hair, because it is now clean and wet, requires a considerably smaller quantity of the medicated formula.
MEDICAL
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Considering the road towards general practice?
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General practice
myths Boring? Badly paid? A second-rate specialty? We object! Our featured GPs debunk some of those nasty myths about general practice.
Dr Will Thornton (pages 28-29)
Dr Andrew Pennington (pages 24-25)
Myth: GPs failed at the other specialties
Myth: It’s all about coughs, colds and referrals to specialists
“GPs are specialists in family health and a whole range of areas. If you choose another specialty, that becomes your specialty and that is what you’ll do for the rest of your life. With general practice, the world is your oyster.”
“It’s simply untrue. Particularly in a rural setting, we do a lot of diagnosis. I see a lot of undifferentiated illness, I do caesarean sections, and I do a lot of hands-on work.”
Dr Margaret Niemann (pages 26-27)
Dr Mike Cross-Pitcher (pages 30-31)
Myth: GPs aren’t doing good medicine or have unreliable diagnoses
Myth: General practice is boring and predictable. Coughs and colds, tears and smears
“A lot of illnesses never get to the specialists because we are actually making the right diagnosis and providing the right treatment.”
“The best description of general practice that I have come across is that each day is like eight hours of “Thank God You’re Here” where you never know what is about to walk through your door. General practice is about the journey through life… from birth ‘til death, usually across a number of generations. It is filled with joy, grief, acceptance and despair. No other specialty encompasses the entirety of human experience as comprehensively as general practice, nor permits the medical professional to accompany their patients along that winding road. Every other vocational choice only samples points in time of the journey…the birth, the broken leg, the heart attack, the dying… general practice allows a doctor to improve a patient’s whole life, not just a portion of it.”
Dr Anne Kleinitz (pages 10-11) Myth: It’s boring! “It is by far and away the career that you can be most creative with and the career that you can enjoy huge variety and flexibility — you can really find your niche. You can work anywhere in Australia and overseas.”
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Applying for GP Training Decided general practice is your career choice? This guide will tell you what you need to know about the application process for general practice.
How do I become a GP?
One pathway into general practice in Australia is through the Australian General Practice Training (AGPT) program. Successful completion of all elements of this training program is a pathway to Fellowship to one of two Australian GP Colleges – the Royal Australian College of General Practitioners or the Australian College of Rural and Remote Medicine – depending upon which curriculum is selected. Both Fellowships are vocationally recognised under Medicare.
What is the AGPT?
The Australian General Practice Training (AGPT) program is a worldclass vocational training program for medical graduates wishing to pursue a career in general practice in Australia. The AGPT program is fully funded by the Australian Government.
What is involved?
The program involves a three or four year full-time (or part-time equivalent) commitment, which can be reduced with recognition of prior learning (RPL).
Who delivers the training?
The training is delivered by 17 regional training providers (RTPs) throughout Australia. Eligible applicants will be allocated to RTPs based on their application and assessment ranking, training preferences and availability of training places. Training is conducted within accredited medical practices and hospitals and is supervised and assessed by experienced medical educators. The training includes self-directed learning, regular face-to-face education activities and in-practice education. Visit www.agpt.com.au to see who the training providers are in your State or Territory.
Where do I do my training?
The AGPT program is based on an apprenticeship model. During training, registrars gain valuable practical experience in teaching hospitals, in rural and urban practices, in extended skills, procedural and academic posts. Registrars in general practices are supervised by experienced GPs.
How do I apply?
General Practice Education and Training Ltd manages the selection of applicants into the AGPT program. Opening and closing dates of application for 2013 entry will be available at www.agpt.com.au
Find out more at www.agpt.com.au
The inside scoop on GP Training Dr Kerrie Stewart is completing her residency at Dubbo Base Hospital, NSW, and has secured her place on the Australian General Practice Training (AGPT) program. She gives Going Places magazine some tips on the very first steps of applying for the AGPT program — mastering the paperwork! “As a medical student and junior medical officer (JMO), you know that one day you will have to make that big decision about which specialty to pursue. But, having made that all-important decision, how does one apply to the appropriate training program? More specifically, how does one apply for the AGPT program? Thankfully, the AGPT program application is easily accessible, user friendly and well supported by GPET. The application is completed online. To apply, you need a valid email address, as all correspondence is sent via email. Applicants are issued with a six digit ID number which is used to identify your application to GPET, and allows you to log in and out of your online application. The application form can be saved and accessed as many times as you need to add the required information. It is helpful to read the applicant guide prior to completing the application form, as this tells you all of the documentation and information you will need.
I’d advise you to start collating your personal information including registration, citizenship/ residency details, medical qualifications, prior work experience and referee details a few weeks in advance, as the application form is only accessible for one month and it may take weeks to get together all the documentation if you do not already have it.
Once completed, a full copy of the application form must be printed and sent to GPET, together with the required certified supporting documentation and three passport sized photos.
You need to provide two referees. The process involves giving their email address to GPET, which then emails the form to your referee who fills it out online and emails it back to GPET. You then receive an email confirming that the reference has been submitted. It is important to confirm that you have the correct email address for your referee and that they know to check their inbox for the form and fill it out and submit it to GPET in a timely fashion. While it all sounds quite complex, with a little forward preparation of required documents and information, the application form itself can take as little as half an hour to complete.”
Taking a fresh look at general practice 39
Strange medical products from animals Written by Dr Ben Chandler
Would you ever consider injecting a product taken from a pig’s intestine into a patient then reversing its effects with a syringe full of fish sperm?
Pig skin — Aside from being a key ingredient in pork scratching production, pig skin is also used in some special wound dressings.
Believe it or not these are just some of the wacky products we use in everyday medicine. We take a trip to the pharmaceutical zoo, to uncover some of the strangest uses of animal parts we can find.
Observers noted over a hundred years ago that maggots did a great job of cleaning wounds and that soldiers who had maggots in their wounds seemed to be more likely to survive. The invention of penicillin stifled interest for a while but with the advent of drug resistant bacteria maggots are back.
Pigs Pigs have the misfortune of having similar sized organs to humans and being readily available. Porcine tissues are already used throughout numerous fields of medicine and the humble pig is felt to be one of the best candidates for future production of organs for transplant into humans. The many porcine derived products include: Heparin — One of the oldest drugs still in current use, heparin was initially extracted from dogs liver. Controversy was sparked in the USA in 2008 when a number of patients suffered adverse effects from heparin, potentially associated with numerous deaths. When the drug was traced back to its sources, the Food and Drug Administration identified a contaminant in heparin sourced from pigs raised in China. Insulin — Although newer insulin formulations are human insulin, porcine insulin is still available. It only differs from human insulin by a single amino acid — another example of how genetically similar we are to pigs!
Maggots
Leeches Another medieval sounding treatment that is also making a comeback. Leeches have been used for over 3,000 years and modern medicine still finds them useful. Historically leeches were used to treat many ailments but today their use is mainly in plastic surgery to extract blood from swollen grafts. Unlocking the components of leech saliva has also given a new range of anticoagulant medications.
Salmon Possibly the most surreal use of an animal product. Protamine sulphate is derived from salmon sperm and it is used to reverse the effect of heparin. It is associated with some nasty side effects when injected.
Bees Honey has been used as a medicine for thousands of years, and recently has been shown to have antibacterial properties. It may even be a useful weapon against MRSA. This article first appeared in JuniorDr.
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With you on your journey At General Practice Registrars Australia (GPRA), we support our members throughout their general practice journey. We are with you through medical school and your hospital internship, right up until when you negotiate your first employment contract. We then provide resources to help you make the most out of your career and be a resilient GP.
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MEDICAL
Taking a fresh look at general practice 41
BOOK REVIEW Doctor Fairytale The Wizard of Oz Written by Dr Gil Myers
Consider this a group session. What with busy surgeries sometimes it’s easier to see a family together. It may not be best practice but you can’t just give patients magic beans and send them home anymore. Instead of journals, lately I have been getting medical information from the newspapers – a valuable source of the latest advancements in diagnosis and treatment options.
Dorothy A difficult set of symptoms to diagnose from: vertigo, euphoria, paranoia and visual hallucinations (“munchkins singing and dancing”). All these could clearly be put down to a number of causes including drugs, violent video games and Facebook. However, in this case I think the answer lies in Dorothy’s need to stay awake to avoid the “Wicked Witch” has meant her drinking too many energy drinks and overdosing on ginseng. As an active ingredient of these beverages, ginseng can cause all these and easily account for her erratic behaviour. Treatment should be given in the form of a “clip round the ear” and a period of National Service.
Lion His main complaint is of a generalised anxiety state with occasional “panic attacks” brought on without a known precipitant. Although it’s hard to rule out thyroid problems because of a large mane obscuring the neck, it would seem an unlikely. As it is impossible to determine the source of these worries, I would move straight onto a trial of propranolol to remove “the fear” completely. That would be just what the newspapers would suggest.
Scarecrow Although seemingly happy, it appears that the patient suffers from nihilistic delusions with the result that he has the firmly held belief he does not have a brain. Despite any arguments to the contrary this belief is unshakable and unrelenting. While further investigations – EEG, CT (head) – would be useful, it may be more efficient to consider placebo surgery, with a fake brain shown to him before being “implanted”. I would recommend using bran, pins and needles to construct such a pseudo-cerebellum.
Tinman On observation of his gait and body posture, I would assume that there are classic signs of Ankylosing Spondylitis. The “stiff neck turn” and odd movements are almost pathognomic. Ankylosing Spondylitis is a chronic, often painful, inflammatory arthritis. It affects joints in the spine and the sacroilium in the pelvis, causing eventual fusion of the spine. His grey skin could be an atypical side-effect of his previous pharmacological treatments, so I would therefore suggest frankincense as alternative remedy. This article first appeared in JuniorDr.
Sick Notes: True Stories from the Frontline of Medicine
by Dr Tony Copperfield Reviewed by Dr Nicole Hall GP Ambassador Bankstown-Campbelltown Hospital I’ll be honest; my first impression of Sick Notes was not great. The author of the book, GP Dr Tony Copperfield (the pseudonym of a British GP) began with what I felt was a non-specific rant about who a GP is, and what they do. I was not entertained. I put the book down for a few days, thinking, “I know all of this, I don’t need a book to tell me!” But, true to form, I persevered and picked the book up again for Round 2. This time I was more impressed. The best of humour often comes, not from jokes and stories, but from simple observation and comment on the frustrations and difficulties that afflict most of us. The things that happen to all of us are funny, as long as they’re happening to someone else. In the first of many such amusing anecdotes, Dr Copperfield describes an overweight man dragged to his office by his wife for being overweight, smoking, drinking, suffering from erectile dysfunction and smelly feet. The first thought of Dr Copperfield? That the wife consider trading the patient in for a “sleeker, more vibrant, less pungent model.” Copperfield provides not just a snapshot of his patients’ lives but often more of a story, describing the evolution of their conditions. One such case involves a diabetic insulin-dependant teenager with terrible compliance who drives Dr Copperfield mad, and eventually ends up in intensive care. Although essentially written for a lay audience, Dr Copperfield highlights the challenges every future GP will face — from the non-compliant patients, to the Google hypochondriacs, to the list bearers who see the GP once a decade with a list as long as their arm (“While I’m here, doc…”). We as GPs will have to be very patient with some people in our career and Sick Notes makes you realise we all deal with the same challenges, we’re in it together. This could also be a great book to give to family members so they have some idea about what we will be dealing with in our careers. I’ll admit, I did skip a few chapters that dealt with NHS bureaucracy (the British national health care system), but for the most part this book was a great way to empathise with another GP on the pros and cons of our chosen specialty.
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WHERE TO FROM NOW? So, you’ve read through Going Places magazine and now you are curious about general practice as a career. Or maybe you’ve already decided that being a ‘general specialist’ is your vocation! What’s next? Here are five ways to start going places in your career as a GP:
1 Join the Going Places Network Become part of the Going Places Network at your hospital. It’s a fun way to network with others who have an interest in general practice, while developing your professional knowledge and credentials! Looking for the Going Places Network at your hospital? Visit gpaustralia.org.au to find out more and join online.
2 Talk to your GP Ambassador Our GP Ambassadors are junior doctors who have a real passion and enthusiasm for general practice. They’ll be able to answer all your questions about general practice. If there are any questions they can’t answer, they’ll find the answers for you! Visit gpaustralia.org.au to meet the GP Ambassador in your hospital or area — or look out for posters on notice boards in your JMO lounge.
3 Test drive general practice with the PGPPP The Prevocational General Practice Placements Program (PGPPP) is a great opportunity to experience life as a GP during your hospital training years. When you participate in the program you rotate into a general practice training post for a minimum of one, and a maximum of two hospital terms. Throughout your placement you are well supervised by experienced GP supervisors. You have management of your own patients and are involved in varied areas of health care, such as sexual health, drug and alcohol, aged care, paediatrics, home visits, acute and chronic disease management. Visit gpet.com.au to find out more about the PGPPP program.
4 Get the A-Z on GP training Ask your GP Ambassador for a copy of the Going Places Prevocational Doctors Guide to General Practice Training — your comprehensive guide to becoming a GP. They’ll also be able to provide you with a copy of the AGPT (Australian General Practice Training) 2013 Handbook, which has full details about the AGPT program.
5 Visit gpaustralia.org.au To find out how general practice training works, visit the website! It will guide you through the pathways available, the organisations involved, the nuts and bolts of applying and more, helping you to plan your path into general practice.
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You’re training on the job every day and it isn’t easy. Let our national medico-legal team advise you . Your medical indemnity partner, Avant 1800 128 268 We’re with you all the way
IMPORTANT: Professional indemnity insurance policies available from Avant Mutual Group Limited ABN 58 123 154 898 are issued by Avant Insurance Limited, ABN 82 003 707 471, AFSL 238 765. The information provided here is general advice only. You should consider the appropriateness of the advice having regard to your objectives, financial situation and needs before deciding to purchase or continuing to hold a policy with us. Please read and consider the policy wording and PDS, which is available at avant.org.au or by contacting us on 1800 128 268.