ISSUE 8 FREE May — September 2012
Our city, country and international GPs put a new spin on general practice Junior doctor tips for surviving your internship Clinical case studies to test your diagnostic skills Going Places Network extends across Australia Plus, your regular features ‘It takes two’, ‘Chocolate box’ and more!
Dr George Forgan-Smith
GP blogger
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In this issue…
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On the cover... Dr George Forgan-Smith (Photography: Peter Leslie Photography)
Regulars 5 6 9 11 21 23 24 34 38 41 43 45 46 46
Going Places Network update Going Places Network across Australia It takes two Chocolate box GP in the news Clinical corner Feature article – Lifestyle medicine What’s your diagnosis? Recruitment special AGPT update The future of medicine General practice myths Dr Fairytale Book review
Profiles 12 Dr Tim Sullivan — The PGPPP and me
14 Dr Nici Williams — Out of Africa 16 Dr Danni Gitsham — Helping out our neighbours 26 Dr George Forgan-Smith — GP blogger 28 Dr Mary Belfrage — A home away from home 30 Dr Bruce Chater — Going with the flow 32 Dr Stuart Prosser — Delivering specialist skills Produced with funding support from
Welcome
back for another great journey into the world of general practice! Have you noticed the proliferation of GP Ambassadors throughout your hospitals? The Going Places Network continues to flourish and bring current and future GPs together around Australia. We have the pleasure of meeting Drs Comparti and Comparti, father and daughter, one of whom I have the honour of calling my good friend. Two generations of Western Australian country born and bred GPs in ‘It takes two’. We continue the rural theme with Dr Stuart Prosser, who will deliver your baby, put you to sleep and fix your skin — all in a day’s work! Speaking of skin, in the ‘Chocolate box’ section Dr Nick Demediuk’s patient delivers a mistaken dressing down for his management of her skin ulcers, and we delve into the urticarial world of rashes with Dr Adrian Lim. Meanwhile, Dr Sarah McEwan leads us by the nose in a horsey tale about knee pain and macular rashes. Feeling itchy yet? A great way to discover if general practice is for you is to undertake a Prevocational General Practice Placements Program (PGPPP) during your junior years. Dr Tim Sullivan shares his PGPPP experience, which turned his head and captured his heart. If you’ve already made the decision to become a GP, two of our recruitment sponsors give us some expert advice on how to score the job you’re after. As always, we have an international flavour. Dr Nici Williams brings Africa to our doorstep, and Dr Danni Gitsham takes us on 21-day patrols through the jungles of Papua New Guinea. These ladies prove that general practice can take you anywhere in the world! Dr George Forgan-Smith shows us why all bears should have an internet connection and we see why Dr Bruce Chater is moving furniture and riding his jet ski to rescue his patients. Once again, the world of general practice has its many facets. Sit back and dive in! Heal (and have fun), Dr Mike Cross-Pitcher Medical Editor Hospital Registrar – Central and Southern Queensland Training Consortium GP Ambassador – Nambour General Hospital, Sunshine Coast, Queensland
Editorial: Editor/Writer, Laura McGeoch; Writer, Jan Walker. Graphic Design: Peter Fitzgerald. Going Places Network Manager: Emily Fox. Business Development Managers: Marie Treacy, Kate Marie. Print: Graphic Impressions.
©2012 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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Going Places Network update
We’re well into 2012 and what a busy and exciting year it is shaping up to be.
Intern orientation
Going Places events
The Going Places team kicked off 2012 by attending 33 intern orientation days at hospitals around the country. The team signed up more than 336 new members, and the network’s membership now stands at more than 1,800 — and counting!
Going Places members have already enjoyed several networking and educational events. First up was a lunch in the Victorian city of Ballarat, where members listened to a local GP and did a practical session with a Welch Allyn otoscope. The team then travelled south to Tasmania. It held dinners in Launceston, where members heard from five local GPs, and in Hobart, where ACRRM past president Dr Jeff Ayton was a guest speaker.
Going Places prevocational doctors guide to GP training Jam-packed with all the information for junior doctors considering a general practice career, this guide is the essential go-to handbook on how to get there.
More events are planned all over the country for later on this year. Events will be promoted in your hospital, but you can also keep an eye on the Going Places Network website at gpaustralia.org.au/events
Get your copy from your GP Ambassador.
GP Companion This is a handy clinical pocket reference book. It contains a goldmine of accessible facts and figures on essential medical conditions, preventative medicine and clinical reasoning. Following positive feedback from junior doctors, this reference booklet is now available to Going Places members and is really handy for those on a PGPPP rotation. Get your copy at a Going Places event or download the e-book copy today at gpaustralia.org.au/ content/publications
Going Places reaches the Top End The Going Places Network has now officially reached every corner of Australia after appointing GP Ambassador Dr Andrea Wilson in Darwin, Northern Territory. This means our 44 GP Ambassadors have a presence in 65 per cent of the country’s teaching hospitals. Even the medical media thought this was a great achievement, with the Medical Observer writing a story about Andrea’s appointment.
In thiea! med
Health Minister recognises Going Places Network’s role to support future GPs Health Minister Tanya Plibersek has acknowledged the “important” role that the Going Places Network plays to promote general practice and improve primary health care. “The Going Places Network is doing a fantastic job encouraging prevocational doctors to consider general practice as a career choice,” she said. “We must not underestimate the importance of good guidance and support in the early stages of one’s professional career,” she added.
Ms Plibersek made her comments during GPRA’s ‘Breathing New Life (BNL) into general practice’ conference at Parliament House on 19 March. BNL brings current health industry leaders together with GPRA’s student, junior doctor and registrar members. The Going Places Network sent six of its members to take part in the conference.
Taking a fresh look at general practice 5
Hospital
Name
QLD 1
Cairns Base Hospital
Linda Maluish
cairnsgp@gpra.org.au
2
Gold Coast Hospital
Katya Groeneveld
goldcoastgp@gpra.org.au
3
Ipswich Hospital
Brendan Thompson
ipswichgp@gpra.org.au
4
Logan Hospital
Scott Hahn
logangp@gpra.org.au
5
Mackay Base Hospital
Stephanie Davis
mackaygp@gpra.org.au
6
Nambour Hospital
Michael Cross-Pitcher nambourgp@gpra.org.au
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Princess Alexandra Hospital Fiona Simpson
princessalexandragp@gpra.org.au
8
Redcliffe Hospital
Matt Tatkovic
redcliffegp@gpra.org.au
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Rockhampton Hospital
Rupert Jayraj
rockhamptongp@gpra.org.au
10 Toowoomba Hospital
Richard Hargreaves
toowoombagp@gpra.org.au
11 Townsville Hospital
Jamie-Lea Whyte
townsvillegp@gpra.org.au
Nicole Hall
campbelltowngp@gpra.org.au
Jane George
bankstowngp@gpra.org.au
NSW 12 Campbelltown Hospital
13 Bankstown Hospital
14 Royal North Shore Hospital Sumit Chadha
15 Westmead Hospital
16 Royal Prince Alfred Hospital David Ford
royalprincealfredgp@gpra.org.au
17 Gosford Hospital
Donna Lau
gosfordgp@gpra.org.au
18 St George Hospital
Nici Wilkinson
royalnorthshoregp@gpra.org.au
75 westmeadgp@gpra.org.au
Natalie Sancandi
stgeorgegp@gpra.org.au
19 John Hunter Hospital
Craig Roberts -Thomson
johnhuntergp@gpra.org.au
Marianne Moore
hornsbygp@gpra.or.au
ACT 21 The Canberra Hospital
Anita Dey
canberragp@gpra.org.au
VIC 22 Eastern Health
Edward Skinner
boxhillgp@gpra.org.au
20 Horsnby Hospital Network
23 St Vincent’s Hospital
Erwin Wong
stvincentsgp@gpra.org.au
24 Shepparton Hospital
Edmund Siauw
sheppartongp@gpra.org.au
25 Austin Health
Melissa Cairns
austingp@gpra.org.au
26 Ballarat Hospital
Garry Matthews
ballaratgp@gpra.org.au
27 Geelong Hospital
Ineke Woodhill
geelonggp@gpra.org.au
28 Peninsula Health
Michael Toolis
peninsulagp@gpra.org.au
29 Southern Health
Sara Tarafi
southernhealthgp@gpra.org.au
30 Western Health
Elizabeth Bond
westerngp@gpra.org.au
TAS 31 Launceston General Hospital Kaylee Barnett
launcestongp@gpra.org.au
32 Royal Hobart Hospital
Rachael Foster
royalhobartgp@gpra.org.au
SA
33 Flinders Medical Centre
Adam Swalling
flindersgp@gpra.org.au
34 Flinders Medical Centre
Sam Manger
flindersgp@gpra.org.au
35 Lyell McEwin Hospital
Sara Le
lyellmcewingp@gpra.org.au
36 Modbury Hospital
Sarah Maltby
modburygp@gpra.org.au
37 Royal Adelaide Hospital
Eliza Hannam
royaladelaidegp@gpra.org.au
38 Royal Adelaide Hospital
Adelaide Boylan
royaladelaidegp@gpra.org.au
39 Queen Elizabeth Hospital
Kerry Summerscales
queenelizabethgp@gpra.org.au
NT
40 Royal Darwin Hospital
Jasmine Banner
darwingp@gpra.org.au
Jemma Smith
royalperthgp@gpra.org.au
WA 41 Royal Perth Hospital
42 Sir Charles Gairdner Hosptial Clark Maul
charlesgairdnergp@gpra.org.au
43 Fremantle Hospital
Kate Reid-Milligan
fremantlegp@gpra.org.au
44 Joondalup Health Campus
Tamla Wilke
joondalupgp@gpra.org.au
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To find out more about these GP Ambassadors scan this or go to gpaustralia.org.au
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It takes
Dr Katherine Comparti is a PGY3 junior doctor at Princess Margaret Hospital in Perth. She has applied to the AGPT program and plans to follow the FACRRM pathway. Her father, Dr Michael Comparti, is a GP in the port city of Bunbury, 175km south of Perth. Kath says her father inspired her to choose a career in general practice.
Katherine:
I remember going into the hospital with dad on the weekends and mornings before school and waiting for him to do his ward rounds. I also remember the displays of snakes in bottles and jars in the treatment room. We spent a considerable amount of time at his surgery — playing with the liquid nitrogen was a highlight! The benefit of having dad as a GP was that everyone in town knew us. The country (Donnybrook, WA, population 3,000) was a great place to grow up. Although on the flipside, like many children from medical families, I did hear my share of “you’ll live” and “you’ve got Katherine Comparti-itis”. This translated as: “Who knows? But nothing significant!” As a GP, dad is well respected and liked by his patients. He’s cool and calm in a crisis. These qualities are something I’d like to emulate, as well as his excellent time management and professionalism. Dad has developed some long-term relationships with his patients — he is pretty proud to be now seeing, delivering and treating the children of the children he delivered. As a person, the five words I’d use to describe him are: fun, caring, wise, sensible and ‘dad’. He is very honest and trustworthy. He has a sensible, methodical approach to everything. There is quite a bit of medicine in my family — my mum is a registered nurse, my grandmother did part of a nursing certificate and my grandfather and aunty (and now cousin) are pharmacists. I want to be a country doctor, like dad, who is part of the community and liked and trusted by my patients. I have always known I wanted to go to the country to practise. I also really enjoy emergency medicine, which is why rural general practice appeals to me. For me, the wider benefits of general practice are the lifestyle, day-to-day variety and variability, and continuity of care. I think the most important qualities that GPs can offer their patients are reassurance and health promotion. I would consider working with dad, but only if he moved more rurally again. He is now in Bunbury, which has a population of 60,000 — that’s not rural enough for me! In ten years’ time I’d like be living in a small country town. Hopefully with a husband and family, and with a few farm animals and pets.
Michael:
I’ve now been a GP for 27 years — all of it in the country. For the last 13 years, I’ve been a GP obstetrician partner in an 18-doctor practice which dates back to the 1940s. Prior to that, I was in a two-doctor practice for 14 years in Donnybrook. I grew up in the country and the Perth Hills where the GPs were legends. I always wanted to follow their example. My dad was an old-
fashioned country chemist. He went out at all times of the night to fill a script when the GP had done a house call, so we lived and breathed it. My sister went on to do pharmacy, and I crossed to the other side. Being a GP today is very different from when I started, but I suspect less so the smaller the community is in which you work. There is more red tape for GPs now. Paperwork and the complexity (and idiocy) of having to do a care plan just to refer someone for allied health when even ‘blind Freddy’ can see they need it, is frustrating. When work becomes stressful or challenging, I find it best to talk with a colleague. And now I get to ring Katherine and let off steam. However, the wonderful variety of country GP work — and the interesting people you come to know well — remains the same. Delivering babies and then watching them grow up is very satisfying. More recently, going up to the Kimberley for ‘working holidays’ in the hospitals has re-invigorated me professionally. Initially, I was a little worried that Katherine may not find the fulfilment that I have. But I am immensely proud of her — and intimidated by how much she knows! I’m impressed by her calm approach to emergencies and that she never seems overwhelmed. She also has a great empathetic approach to people. Empathy is one of the most important qualities GPs can offer, alongside a degree of professional detachment. If I was to describe Kath in five words, they would be: intelligent, caring, competent, quirky and adventurous. A challenge for the profession is the quest for work-life balance that new GPs have — it does seem to take two people to fill the shoes of each ‘dinosaur’ like me who retires. That is not a criticism, just an observation. We didn’t feel we had any options other than to work what my generation calls ‘full-time’. In ten years’ time I’d like to be working in here Bunbury. But I might ease back to part-time (retire from obstetrics and only work five days per week!). I’d love to work alongside Katherine, but secretly fear she would show me up. My advice to Katherine is to find a community where you can belong, but far enough away from the city that you can practise the broadest possible range of medicine. And phone me when YOU want to let off steam!
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
Is general practice the specialty you have been looking for?
Scan this code for more information
Join the Going Places Network today and find out more about general practice. • More than 1,800 junior doctors have already joined us • Network with experienced GPs and meet other peers interested in becoming a GP
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• Attend free networking and educational lunches and dinners • Access free tools and resources • Get key information from your local GP Ambassador in your hospital
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“A dressing down” One of the biggest challenges facing general practitioners is keeping up to date and knowing ‘more and more’ about ‘more and more’. This is as opposed to our specialist colleagues who at times seem to just learn ‘more and more’ about ‘less and less’.
When you’re a GP, you never know what you’re going to get…
This is the case for the management of wound dressings, which has come a long way since I graduated. One of my middle-aged female patients suffers from Milroy’s disease (primary lymphoedema) and had many large ulcers over her lower limbs when she presented. After many months using the latest and greatest dressings and techniques (to be fair I had more than a little help from my practice nurses), I had conquered all but two of the lesions. These last two recalcitrant lesions were about 6cm and 10cm in diameter, however, the time had come for me to run up the white flag and refer her on for a specialist opinion. Not being one to give up without a fight, I thought that just for completeness and before she saw the professor in the ulcer clinic at the tertiary hospital, I should perform a biopsy to exclude both Bairnsdale ulcer and skin cancer. To my great surprise histology showed that both were basal cell carcinomas unlike any that I had seen before and identical in appearance to all the other lesions successfully treated on her lower limbs. I discussed my findings with the patient and also my recommendation that she still see the wound clinic for advice on management of her recurrent ulcers and lymphoedema. She duly presented to the professor, who was using the clinic patients to provide a tutorial for 10 or so medical students. The professor took a brief history and immediately cut to the chase and examined the ulcers, before launching into a 30-minute tirade around the inadequacies of GPs and their management of wound dressings, followed by a discourse on how to manage ulcers properly. My patient, seeing things that were going badly for me, and presumably for her as he was recommending exactly the types of dressings which we had been putting on for the last three months, decided to make her move. She loudly asked (mainly to the student audience): “Didn’t you read my doctor’s letter?” The professor took the hint and then took the next 20 minutes trying to retract what he had said. The patient took great delight in reporting back to me what had transpired. She was pleased to tell me that there was nothing new she could add to her management that we hadn’t already tried.
CHOCOLATE BOX
Dr Nick Demediuk has been a GP for more than 30 years and is the sole director of a multidisciplinary general practice. He developed an interest in procedural medicine early in his career and delivered babies for more than two decades. He is also known as ‘Dr Snip’, due to his creation of a micro-keyhole ‘no scalpel’ vasectomy technique, which uses the best of current procedures to minimise side effects.
Dr Deme diu Hailey (le k with two of his p ft) and K ylie (right) ractice nurses, .
Do you have a story to share — an unusual case, a miraculous recovery or an amusing anecdote? Let us know, email goingplaces@gpra.org.au
Taking a fresh look at general practice 11
PGPPP AND ME
PGPPP diary Dr Tim Sullivan completed his internship at Brisbane’s Princess Alexandra Hospital. Before becoming a GP registrar in his hometown of Toowoomba, he did a Prevocational General Practice Placements Program (PGPPP) in the multicultural suburb of Inala, about 20km south-west of Brisbane. He talks to Going Places magazine about seeing his first patients and becoming “their doctor”. Tell us a bit about Inala. I did my rotation at Inala Primary Care. Inala is a multicultural suburb — more than 40 per cent of its residents are born outside of Australia and 14 per cent are from Vietnam. A significant portion of people in Inala live in public housing. Historically, access to health care in Inala was limited. But since the development of government-supported facilities, locals have comprehensive and culturally appropriate health care on their doorstep. What was your supervisor like? Dr Sue Williams was an absolute pleasure. Contrasting to my experiences working in hospital, I had one-on-one teaching time and continuous supervision from her. I learnt something new every day and she introduced me to all aspects of life as a GP. She was always available to answer my questions and often went above and beyond to answer them. Were you always interested in general practice? During medical school I was very keen on surgery. Most of my electives were in surgical disciplines, but I also travelled to a remote Aboriginal community in the Northern Territory and worked with the sole GP in the area. This was the most memorable of all my rotations because I got to see the vast array of presentations and pathology that you simply would not be exposed to in the city. I worked for two years at the Princess Alexandra Hospital as an intern and JHO doing various surgical rotations including urology, vascular and plastic surgery. Up until completing my PGPPP, I was convinced that surgery was for me.
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Did you get some ‘hands on’ experience?
From the very first day at Inala Primary Care, I was seeing my own patients as “their doctor”. Before long I had my own group of patients who I got to know well. I participated in patients’ health care journeys from diagnosis, through their treatment and beyond. The experience was very much ‘hands on’ as there was a great deal of autonomy — something that you just don’t get as a hospital resident! Describe an average day during your PGPPP. My first patient was at 9am with half an hour prior for fixing up paperwork and checking pathology results. I saw about three to four patients an hour. With each consult presenting a different challenge, time tended to pass quickly and it became very obvious why GPs can often run late! Most days I was home for my lunch break and I was always home by 5pm. Is there a patient who you will remember more than others? I met a lady who had just arrived in Australia as a refugee from Africa. She had been diagnosed as a diabetic with evidence of end organ disease as part of a refugee health screen.
During my first consultation with her, she gave one word answers to my questions via a phone interpreter while she stared at the door. She didn’t make eye contact once. By the end of my rotation and seeing her on a weekly basis, I had learnt that she had been separated from her husband and two sons and subjected to physical abuse before escaping to Australia. She had only heard the word ‘diabetes’ for the first time when she arrived in Australia, but was now able to show me her daily blood sugar levels and showed joy in seeing them come under control. During my last consult with her she wished me luck in my next job, told me that she was sad to see me leave and thanked me for helping her. This brought a great sense of satisfaction unlike anything I’ve experienced.
What have you learned about patient care?
I was continually surprised by the complete lack of insight that some patients have regarding their health. It became obvious that the more a patient is educated about their illnesses the better they engage in treatment and prevention processes. In the GP setting I was able take the time to explain what was going on and this helped patients to manage their health. What have you learned about general practice? Before my PGPPP I had completely written off being a GP. I was indoctrinated into the hospital way of thinking that a GP deals with only
minor ailments and complaints. During my PGPPP rotation, it became obvious that every consult had potential to pose a significant medical problem and my diagnostic, interpersonal and technical skills were challenged.
Another challenge was dealing with the ‘just a GP’ stigma. Many hospital colleagues seemed surprised and almost expressed sympathy that I was doing a GP rotation. This became a non-issue after I experienced the great things about life as a GP.
I have learnt that general practice is flexible and sub-specialisation options are endless. I’ve also learnt how rewarding a healthy work-life balance can be. I had time to ‘improve’ my golf game and had every weekend free to be with family and friends.
Would you recommend a PGPPP to junior doctors? If you have ever thought of becoming a GP, then definitely try it out. No matter where you end up in medicine you will be dealing with GPs, so to know what it’s like to actually be one provides a great insight.
What has surprised you about this experience? I was so surprised at how rewarding providing continuity of care can be. During my hospital rotations, patients blurred into particular conditions, problems or bed numbers and I only got a snap shot of who that person really was. Seeing people regularly over a period of time allowed me to get involved in the ongoing health care of patients. This gave me fantastic job satisfaction. Has the experience made you want to pursue a general practice career? It certainly has. I’m really not sure what I would be doing now if I hadn’t of volunteered to do a PGPPP. One thing I do know is that I am a much happier and more fulfilled person after doing it. Were there any challenges? There are aspects of general practice that you can’t learn from a textbook — counselling technique, dealing with family issues, relationship problems. Being the person who people come to for advice about anything and everything was daunting.
Tim’s top tips
1 Realise that the practice you are at is not a hospital funded by the government. They are going over and above to provide you with this opportunity, so participate as best you can and show them your appreciation. 2 Be nice to your supervisor! They have their own patient load on top of supervising a junior doctor. They are responsible for your actions so pay them some respect for giving you their time and teachings. 3 Take the time to think about what you want out of life as a doctor. Make the most of the lifestyle it has to offer and take that into consideration when deciding on a career path.
Taking a fresh look at general practice 13
J U N I O R D O C T O R profile
Out of Africa
Dr Nici Williams is a junior resident doctor and Going Places GP Ambassador based at Westmead Hospital in Sydney. She grew up in Johannesburg, South Africa. Since then, she’s studied in Scotland, lived in London, volunteered in a refugee camp in Kenya, and completed overland trips through the Middle East and across Africa. And now, she calls Australia home. If there’s one word that describes Dr Nici Williams’ career, education and personal life, it would be ‘international’. Of course, words like ‘exciting’, ‘ambitious’ and ‘fulfilling’ also spring to mind, but there’s no denying the international element to Nici’s life. Medicine was the “last thing” on Nici’s mind when leaving high school. Travel and the big wide world were more appealing. She found a way to combine study and travel by doing her Masters (Hons) in International Relations at St Andrews University in Scotland. During her university summer breaks, she trekked the Inca Trail to Machu Picchu and took a Spanish immersion course. She ran a workshop in Japan, provided educational assistance in Malawi and gained a Diploma in International Socio-Cultural Israeli Studies in Jerusalem. After graduation, Nici spent a year travelling the length of Africa, from London to Cape Town. It was on this adventure that she met her now husband, Mathew, an environmental manager from country Western Australia. It wasn’t until 2003, when Nici volunteered for the International Rescue Committee (IRC) in Nairobi, Kenya, that she first considered a medical career. The IRC provides refugees escaping conflict and natural disaster in Sudan and neighbouring countries with essentials like clean water, health care and shelter. “I was based in Kakuma Refugee Camp in north-west Kenya, about 100km from the Kenya-Sudan border,” Nici tells Going Places magazine. “At the time there were about 100,000 refugees at the camp.” “It was an absolutely mind blowing place. It’s a thriving city in the middle of the desert. There are mud and thatched houses as far as you can see. I helped to monitor the IRC’s goals and how funding was being administered.” The major medical issues at the camp were malnutrition, malaria and cholera. “I started to see how much could be done in terms of providing basic health care,” Nici says. “I wished at the time that I had the skills to do more of the ‘hands on’ work, rather than just the program management.”
Above: Nici with an elephant, a favourite African animal. Right:With her husband Mathew. Far right:With supervisors at Kable Street Practice.
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Left: On her elective at Baragwanath Hospital, trauma ward. Far left: African travels.
Camp living conditions were very basic and often difficult. “It was very, very hot,” Nici recalls. “The average temperature was 40-plus degrees. It was very dusty and there was no electricity in the quarters I was staying in. There were lots of spiders and flies were everywhere.”
“Once I decided to study medicine, I knew I was going to be a GP”, Nici says. “I like the variety, the fact that you constantly have to access all areas of medicine and you’re treating all ages.”
Many of the non-governmental organisations (NGOs) were focused on preparing the refugees, both medically and emotionally, for their return to Sudan.
After graduating and moving into the hospital environment, Nici discovered it was hard to find out about becoming a GP. “Much of the focus in tertiary hospitals seems to be on physician training and other specialties.”
“What I really like is that you’re treating people, not problems.”
“What I really like is that you’re treating people, not problems.”
“Through a friend I heard about the Going Places Network. The network was a perfect source for all my questions and I put up my hand to be a GP Ambassador.”
“One NGO would drive a huge truck into the camp and slide a screen down the side of the truck to show footage about what Sudan would look like when they returned,” Nici says. “As soon as the screen was down there would be thousands of people craning their necks to see the footage. The ‘movie’ was in their language and was culturally relevant. It was such a fantastic way of reaching these people.”
When Going Places magazine spoke to Nici, she was halfway through her Prevocational General Practice Placements Program (PGPPP) at a multi-GP practice in Windsor on the Hawkesbury River. “The PGPPP is a fantastic opportunity to see if general practice is for you.”
“The whole experience planted the medical seed for me and also cemented the idea that I loved humanitarian work.”
“In general practice, you never know what is coming through the door. It’s a steep learning curve too, unlike some rotations where you learn what to expect from your specialty .”
Nici felt the pull towards medicine again when she worked as a Project Manager from 2004–2006 for Nurturing Orphans of AIDS for Humanity (NOAH). Based in Johannesburg, NOAH focuses on supporting South Africa’s 3.7 million orphans. It builds symbolic ‘arks’ that act as networks of care and enable orphans to be cared for within their own communities. “To date, Noah has set up 100 arks that support about 20,000 orphans,” Nici says. “I loved my job, but in the back of my mind I kept asking myself whether I’d still love what I’m doing in ten years’ time or could I be making more of a difference as a doctor?” She made the leap — and another international move — and applied for an undergraduate medicine program at the University of New South Wales. Within a week, she and her husband started making arrangements to move to Sydney.
“I’ve got two wonderful supervisors from whom I learn so much, and at the moment I’m seeing between 8-12 of my own patients each day.”
Nici says general practice is medically challenging. “You can’t solve everyone’s problems in one appointment. Sometimes you have to be comfortable with not knowing the answer and waiting for results.” So, what part of the world does Nici see herself living in 10 years’ time? “My goal is to base myself in a general practice in Australia, but to continue travelling and to get involved in humanitarian work where I can,” says Nici, who recently became an Australian citizen but is still subject to the 10-year moratorium. “At the moment my husband and I are getting excited for our move to tropical northern Queensland at the end of the year.” To find out more: NOAH — noahorphans.org.za, IRC — rescue.org — Laura McGeoch
Nici’s top tips for junior doctors Nici describes the first year in the hospital as “a year of learning the • Surround yourself with positive people — It can be draining when hard way”. “You’re being called ‘doctor’, but you don’t feel like you’ve earned that title,” she says. Here are Nici’s tips for getting through your internship.
• Keep a balance — It’s easy to let aspects of work permeate through
people are complaining about hours, patients and workloads. Make sure you have the right people around you.
• If you don’t do what you love, love what you do — Find doctors
other aspects of your life, so maintain a balanced life outside the hospital.
who inspire you with the way they treat patients and their bedside manner.
• Give everything a go! — It’s a huge leap from identifying yourself
• Don’t be too hard on yourself — We put so much pressure on
as a medical student to a doctor. Remind yourself that you’re under supervision, so just try things, get involved and have fun.
ourselves to do everything right the first time. We’re only human and we will make mistakes, so remember to be kind to yourself.
Taking a fresh look at general practice 15
G P registrar
Helping out our A six-month stint working in the rural area of Papua New Guinea (PNG), one of Australia’s closest neighbours, meant GP registrar Danni Gitsham had to do many things outside her comfort zone. From overcoming language and technical barriers so she could teach local health workers, to learning how to wash clothes in a running river — adaptability was the key. And general practice training, Danni says, gave her a great head start. Danni at Koko Village clinic in the Tabar Islands.
Treating a burns patient at Piliwa Sub Health Centre.
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Danni and nurse Lucy travelling around Djaul Island for village clinic visits.
Danni palpating a patient’s enlarged thyroid at Wang Village.
neighbours “In general practice, you need to be flexible,” says GP registrar Danni Gitsham, speaking to Going Places magazine from rural PNG. “This quality has certainly helped here!” Even her journey to PNG required a degree of flexibility. Danni and her husband Dan, a mechanical engineer, had been working in Karratha, Western Australia. They decided to venture to PNG in the first half of 2011. They resigned from their jobs and were set to go, but overnight the political situation in PNG became unsafe. “It was a setback, but instead we trekked off to Europe, South America and Asia for six months, with the intent to return to PNG when the country was more stable,” Danni says. The oceanic country with a population of around 7 million was always an interest to Danni, who is in her final year of training and working towards both the RACGP and ACRRM fellowships. “Papua New Guinea is one of our closet neighbours, and yet it has such poor health care statistics,” she says. “I had seen the work that Australian Doctors International (ADI) had done there and was inspired. I liked ADI’s approach to how it runs its programs — it looks at how it can work with the local government to make a sustainable difference.” After returning from Europe in July 2011, Danni successfully applied to ADI for a position as a volunteer doctor in the New Ireland Province in the north-east of the country. ADI had signed a Memorandum of Understanding (MOU) with the provincial government to work together to run a program aimed at improving health services and the skills of health professionals in rural areas. ADI saw that Danni would bring valuable skills to PNG — she had worked in rural WA, researched diabetes and health indicators within the Aboriginal and Torres Strait Islander communities during her research year, and had an Advanced Diploma of Obstetrics and Gynaecology with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Her ‘outback’ experience would be particularly helpful. As well as being one of the most culturally diverse countries on earth, PNG’s population is also one of the most remote — around 20 per cent of people live in rural areas. Danni’s job is to help health care services reach these people. Working within a team of 10, made up of ADI volunteers, local health professionals and volunteers, translators and government representatives, Danni goes out on 21-day ‘patrols’ and visits rural and remote health centres in New Ireland. There are 26 centres that the team visits. Most are staffed by nurses and community health professionals, due to a severe shortage of doctors. “There are no doctors in the New Ireland Province outside of the Provincial Centre of Kavieng,” Danni explains. “There is a regional referral hospital 270km south of Kavieng, but it hasn’t had a doctor there since August 2010.” “Our training and education focuses on improving the skills of the nurses and voluntary community health professionals. We do practical case-based teaching, which means we focus on whatever cases come through the door that day.”
During the sessions, Danni and her team will ask the staff if there are any areas on which they want or need more information. The sessions focus on assessment, basic management and then teaching the staff how to identify the right time to refer a patient for further care. There are constant — and at times, very stark — reminders of the barriers rural locals can face to accessing health care. “Part of our work is to encourage women to give birth in the hospital rather than the local village,” Danni says. “But it costs them the equivalent of AUD$9 to do this. Some women simply can’t afford that.” Transport is another barrier. Emirau is one of a string of islands off New Ireland. For Emirau’s residents, reaching a doctor in Kavieng is a nine-hour ferry journey or a trip on a ‘banana boat’, a fairly rudimentary and risky vessel for such a long journey. On the clinical side, Danni is learning the A–Z about tropical diseases. “I’ve seen more malaria and tuberculosis in a few months here than I have in my whole career!” Leprosy, respiratory infections and pneumonia are other common illnesses that she sees. HIV testing is not yet common in the province, but the numbers of HIV cases are increasing in the rest of the country. Diabetes and hypertension are also common health problems. A contributing factor, Danni says, could be limitations in diet due to recent drought in the area. “Since the drought, the staple food available has been pumpkin, paw paw, which is high in glucose, and seaweed, which is high in salt.” Danni hopes that with the work her ADI team is doing, and through continued co-operation with the local government, there may be a second doctor in New Ireland some time during 2012. As part of her work, Danni reports back to the provincial government on her team’s progress. She provides feedback and recommendations for how to improve health care, and also how to improve access to health care. “It’s a long process,” Danni says. “It can be frustrating and quite daunting, but the work is very rewarding. We see people who have not seen a doctor for more than 10 years, so it is great to be able to help them.” Getting to know and understand the local people and culture is personally rewarding. “When we are out on patrol, we live with locals in their communities. We eat what they eat and live how they live.” Fast forward several months and we caught up with Danni again. She is now back from PNG and working in a Gladstone GP super clinic, Qld. Danni plans to use her experience to eventually work as a GP in rural Australia. She has no regrets about making the decision to specialise in general practice. “I had decided on general practice early on, but then changed my mind a couple of times and considered paediatrics and also obstetrics and gynaecology,” Danni says. “But my husband’s work drew us to rural areas. So we made the lifestyle decision that general practice would give us the flexibility we needed.” And a return trip to PNG? “I definitely couldn’t rule that out. I’ve still got to master washing clothes in the river!” Find out more about Australian Doctors International (ADI) at adi.org.au — Laura McGeoch
Taking a fresh look at general practice 17
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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. Students
Junior doctors
Registrars
GPs
General Practice Students Network gpsn.org.au
Going Places Network gpaustralia.org.au
General Practice Registrars Australia gpra.org.au
R-cubed – wellbeing for doctors rcubed.org.au
GP in the news Free edition
Going Places - Taking a fresh look at general practice
Skin clinic GPs better at diagnosing melanoma
GPs who sub-specialise in skin cancer have a greater accuracy in diagnosing melanoma, mostly due to their use of dermatoscopy, a Queensland study suggests. Primary care practitioners with an interest in skin cancer excised about half the number of benign lesions for each melanoma detected compared to their generalist GP counterparts, according to research in the Journal of the American Academy of Dermatology.
GPs get top honour on Australia day
Eight GPs have been recognised on this year’s Australia Day
Source: 6 Minutes
honours list, with five receiving Australia (AO) while three the Officer of the Order of received the Member of the Order of Australia (AM). Those receiving the Officer of the Order of Australia (AO) were: Dr Les Woollard, Moree, NSW; Dr Kerry Moroney, Narrabri, NSW; Dr Ernest Cramond, Clayfield, Qld; Dr Kim Tee Ong, Dalkeith, WA; and Dr Appupillay Balasubramaniam, Homebush, NSW (for services to the Hindu community). Recipients of the Member of the Order of Australia (AM) were: Dr Graham Deane, Gunnedah, NSW; Dr Rod Pearce, Adelaide, SA; and Dr Jill Benson — Adelaide. Source: Australian Doctor
GPs the ‘missing link’ in palliative care provision
GPs have turned away from the ‘cradle to the grave’ ethos at the heart of general practice according to experts who say a lack of family doctors is forcing patients to die under stress and away from home. WA GP and Palliative Care Australia president Dr Scott Blackwell said research had previously shown 75-85% of all palliative care patients would prefer to die in their own home but to do so they needed the help of a willing GP in order to access late stage palliative care . Source: Medical Observer
Issue 8 - 2012
GPs encouraged to get flu jab
Record number of doctors start GP training
A record number of junior doctors have started GP training as part of a $150 million Federal Government program to boost GP numbers. Participants in the Australian General Practice Training (AGPT) program have increased from 700 in 2010, to 900 in 2011 and to 1,000 for 2012.
*Articles have been shortened from their original form.
“GPs are the front line of our health system, providing professional medical care to millions of Australians every year,” Health Minister Tanya Plibersek said. Source: Australian Government news release
GPs and frontline health care workers should get flu vaccinations as winter approaches, says the Influenza Specialist Group (ISG). ISG Director Professor Lou Irving said vaccination among health workers was too low and many continued to work when unwell. “There’s a long standing attitude among many doctors to keep battling on when they are unwell as they think their patients still need them,” he said. “It’s important to emphasise that if you’re sick, you shouldn’t be at work — viral infections can have serious consequences.” Source: Influenza Specialist Group news release
Taking a fresh look at general practice 21
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Clinical
CORNER
Medical Observer provides Going Places magazine with some interesting clinical case studies and tips for treating patients. This issue’s case study is by Dr Adrian Lim.
Rash is a great pretender
This rash can masquerade as many other illnesses.
A 45-year-old man presents with a scattered rash of red, scaly spots, 0.5–1 cm in diameter on both palms (see figure 1). The rash has been present over the last month and appears to be confined to the palms.
He migrated from Indonesia two years ago. He is married with two children but has occasional unprotected male-to-male sexual encounters.
What is the diagnosis that comes to mind?
Syphilis
Syphilis is a sexually acquired disease that has gained much notoriety throughout history. It has been suggested that the introduction of syphilis into Europe occurred upon Christopher Columbus’s return from the Americas. It has been known as the ‘great pox’. Syphilis is also regarded as the ‘great pretender’ for its ability to masquerade as many illnesses.
Three stages Syphilis results from Treponema pallidum bacteria infection and classically occurs in three stages: • First stage — development of a painless primary chancre (ulcer) in anogenital sites that subsequently heals. • Second stage — presents typically as a maculopapular (flat-raised) or papulosquamous (raised-scaly) rash that can last for several months. The onset of the rash is usually within the first two years of the infection. • Third stage — syphilis can go into a latent phase and a third of these cases will progress to tertiary syphilis affecting the internal organs, especially the cardiovascular and central nervous systems.
Presentation The manifestation of syphilis depends on its stage and which organ it subsequently targets. The secondary stage can mimic many diverse skin rashes — the most common being pityriasis rosea — a benign scaly rash of young adults. Tertiary stage syphilis can affect any organ ranging from the skin and bone (granulomatous gummas) to the heart and central nervous system (cardiovascular and neurosyphilis). Undiagnosed tertiary syphilis can present decades later as aortic aneurysms or seizures.
Management issues MEDICAL
(Figure 1) Palmar rash reminiscent of ‘copper pennies’ in secondary syphilis.
(Figure 2) Syphilis can also manifest in a rash on the upper body.
This patient has secondary syphilis that was confirmed with a positive RPR and TPHA. The RPR (or VDRL) is a screening test for syphilis, and when positive, is confirmed with TPHA test that is specific for T. pallidum. Following syphilis infection, TPHA remains positive for life, whereas RPR/ VDRL levels become positive soon after infection but tend to gradually decline with time and can be used to monitor responsiveness to therapy. Tissue microscopy (or chancre swabs) may reveal the spirochete (spiral-shaped) organisms and is confirmatory of active infection. The main treatment is intramuscular penicillin injections given as single-dose for most primary and secondary syphilis and multidose for latent and tertiary infections. Post-treatment follow-up extends to one to two years. Patients with neurosyphilis or HIV require additional CSF examination (lumbar puncture), more intensive treatment and closer and more prolonged follow-up. As with the diagnosis of any STI, the full gamut of communicable disease testing is mandatory, as is the need for thorough contact tracing. The related issues of extra-marital sexual encounters and sexual orientation may be as problematic for this patient (and family) as the disease itself. Effective handling of this sensitive aspect requires expertise that is every bit as important as skillful interpretation of complex syphilis serologies. Referral to a sexual health/ HIV physician or infectious disease specialist is recommended for ongoing expert management.
Taking a fresh look at general practice 23
F E AT U R E A RT I C L E
Lifestyle medicine Dr Joshua Crase is a PGY3 at Ballarat Base Hospital and a Going Places GP Ambassador. In this issue, he explores the developing area of lifestyle medicine which can add a new dimension to general practice work.
to obesity, and subsequently, Type 2 diabetes. The obesity further worsens sleep apnoea, reduces the likelihood or desire to exercise and may reinforce poor food choices through depression. By helping the patient in all of these areas rather than just treating the consequences of obesity-driven disease, the clinician can make some inroads into the causal factors fuelling the vicious cycle.
Lifestyle medicine and causal factors “The natural force Lifestyle medicine, like conventional medicine, uses risk factors to prevent and within each one treat disease. However, lifestyle medicine a few steps further to look at a much of us is the widergoesarray of causal factors. As the following table from the Eggers, Binns and Rossner greatest force in article shows, lifestyle medicine seeks to Governments have previously been very reactive by funding break-fix medicine strategies. the ‘proximal’, ‘medial’ and getting well. understand However, the creation of Medicare ‘distal’ factors impacting on the patient. Enhanced Primary Care (EPC) plans, be Lifestyle medicine clinicians can then Our food should general practice Super Clinics and possible develop appropriate treatments directed incentive payments for patient outcomes, each level of causality. Governments our medicine, our canat also is seeing a political move towards funding use this model to direct lifestyle-based preventable medicine in appropriate public health campaigns medicine should general practice. towards large groups of at-risk patients. be our food.” What is lifestyle medicine? In 2009, the Medical Journal of Australia (MJA) published an article about lifestyle medicine. In it, Egger, Binns and Rossner stated that: “Around 60–70 per cent of all primary health care visits in developed countries are for lifestyle-based (and therefore preventable) diseases”.
Egger, Binns and Rossner define lifestyle medicine - Hippocrates 400 as: “…the application of environmental, behavioural, medical and motivational principles to the management of Distal lifestyle-related health problems in a clinical setting”. causes
Industrialisation
Dr Wayne Dysinger, a leading lifestyle medicine clinician in the United States, describes lifestyle medicine as “…assisting clinicians to provide lifestyle change interventions and promote healthy behaviours for patients with or at risk of chronic diseases”. Lifestyle medicine uses established behavioural, motivational and learning theories to promote individual and public health disease prevention through the processes of education and behaviour change. In general practice, lifestyle medicine partners with modern pharmacological medicine to treat and prevent chronic disease. Lifestyle medicine and chronic disease Lifestyle medicine aims to help clinicians and patients to manage obesity, sleep, mood (anxiety and depression), addictions (smoking, alcohol and other substances), sexual behaviour, skin health, oral and auditory health, pain, iatrogenic illness (caused by surgery or medications) and many types of injury. Chronic diseases are usually based around vicious cycles with multiple variables contributing to the manifestation of the disease. For example, obstructive sleep apnoea, lack of exercise and poor food choices leading
24
BC
Modern lifestyle
g
Economic growth
(Figure 1) A hierarchy of causes of chronic disease.
Medical causes Stress Anxiety Depression Social/ peer pressure Psychological factors Occupation Boredom Technology change
Proximal causes
Risk factors/ Markers
Smoking Diet Inactivity Unsafe sex Obesity Sun exposure Alcohol/drugs Pollution
Blood pressure Lipids Apolipoproteins Tg LDL-C HDL-C High fasting plasma glucose Impaired glucose tolerance High glycated haemoglobin
Disease Coronary heart disease Diabetes Stroke Cancers Injury STDs PCOS Infertility COPD Gallstones Tg = triglycerides. LDL-C = low-density lipoprotein cholesterol. HDL-C = high density lipoprotein cholesterol. STD = sexually transmitted disease. PCOS = polycystic ovary syndrome. COPD = chronic obstructive pulmonary disease. * From Egger et al. Lifestyle medicine. Sydney: McGraw-Hill Australia, 2008: 16.
Lifestyle medicine and conventional medicine Egger, Binns and Rossner comment: “Medication, in the lifestyle medicine paradigm, is seen more as an adjunct than an end-treatment in care…”. They go on to say: “Exercise and nutrition are the penicillin of lifestyle medicine; psychology the ‘syringe’ through which these are delivered…”. For example, cognitive behavioural therapy and exercise can be used as first line treatments for non-melancholic depression instead of anti-depressant medications. The lifestyle approaches may be more time consuming than taking a tablet. However, in general, they have far less side effects and usually more long-lasting and wider benefits. Lifestyle medicine and the patient Lifestyle medicine involves patient co-operation at a much deeper level than traditional medicine. Lifestyle medicine helps to move the patient towards making behavioural change for the prevention and treatment of chronic disease. Due to this close relationship between clinician and patient, lifestyle medicine focuses on providing the clinician with the required skills and motivational techniques to assist patients with behavioural change. Motivational interviewing is one of the strategies used by lifestyle medicine to engage the patient in a patient-centred behavioural change. Lifestyle medicine, general practice and team-based care Lifestyle medicine focuses on delivering behavioural interventions to individuals (and often small groups) in a primary care setting. The scope of behavioural change may involve multiple clinicians, including a GP, psychologist, exercise physiologist, dietician, specialist, practice nurse and diabetes educator. Most chronic disease problems are too large for one clinician to manage — particularly in a few consultations in general practice. A co-ordinated team approach with a general practitioner at the centre helps the patient to navigate through a behavioural change to improve their overall health outcome. Lifestyle medicine and clinician skills Lifestyle medicine leads a clinician to acquire a certain skill set to implement sustained behavioural changes in their patient population. These skills include: being able to show leadership in promoting and demonstrating healthy lifestyle behaviours; demonstrating knowledge and an evidence-based approach to behavioural change; being able to assess a patient’s readiness to change; building effective relationships with patients and other clinicians involved in their care; and helping a patient maintain their behavioural change in the long term. These are all skills that general practitioners and registrars have in their possession.
the aim of keeping its working population healthier for longer, rather than waiting for them to become sick and require expensive health care services. Lifestyle medicine provides a suitable skillset for clinicians in this changing environment both now and into the future. It reinforces the need for clinicians with skills in lifestyle medicine — to create a paradigm shift in general practice to prevent the continuation of the Western chronic disease epidemic.
“The doctor of the future will give no medicine, but will instruct his patient in the care of the human frame, in diet and the cause and prevention of disease.” — Thomas Edison Learning about lifestyle medicine Lifestyle medicine was developed in the United States with the first textbook published in 1999 (Rippe). Specialist postgraduate courses are co-ordinated at three US universities (Harvard, University of Florida and Loma Linda) and one Australian university (Southern Cross, scu.edu.au). Australia has its own Lifestyle Medicine Association (ALMA — lifestylemedicine.com.au). There is an American College of Lifestyle Medicine (as well as the American College of Preventive Medicine) which produces the American Journal of Lifestyle Medicine. The current definitive (and Australian) textbook is Lifestyle medicine: second edition, by Egger G, Binns A, Rossner S and published by McGraw-Hill. References 1. Dysinger, W. (2011). Lifestyle Medicine in the USA: From Here to Where? ALMA Conference, Manly, Sydney. 2. Egger, G., A. Binns, et al. (2009). ‘The emergence of lifestyle medicine as a structured approach for management of chronic disease’. Medical Journal of Australia 190(3): 143-145.
Conclusion In Western countries, as well as rapidly growing developing countries, lifestyle-based chronic diseases are dominating current medical practice and will dominate future medical care. To minimise health care costs, the Australian government is progressively altering health care with
Taking a fresh look at general practice 25
G P profile
GP blogger Not content to help just one patient at a time, Dr George Forgan-Smith has embraced the internet to extend his reach and deliver important health information to a sub-group within the gay community. Going Places magazine talks to George about blogging, ‘bears’ and a Bahamas dream.
GP Profile George Forgan Smith George works on a blog post during his lunch break.
The internet is a never-ending vortex of information. If you want to find out about something — anything! — a few minutes online will get you started. Within an hour, you may be overwhelmed. But reliability of online information can be questionable, and health information isn’t always backed up by medical professionals or research. And if you want really specific health information, the web can become quite tangled. Enter Dr George Forgan-Smith, a Melbourne-based GP, writer and blogger. If you’re a gay man looking for a solid source of information about sexual, general and emotional health, George can help you. His blog ‘The Healthy Bear’ has close to 1,000 daily readers and around 5,000 ‘likes’ on Facebook. A half-hour consultation with George will reach one person. A blog post from him will reach thousands through Facebook and his direct followers. The blog will be stored on the web, becoming accessible to anyone who types in the related criteria in a search engine. But back to basics. Why did George start the blog and what is a ‘bear’? “A ‘bear’ is basically a big, hairy gay bloke,” George tells Going Places magazine. He says the bear community started as a reaction to the “body fascism movement” created by the “muscle men” of the gay community. “When HIV first came out one of the biggest moves was towards creating the body beautiful and muscles. There was the thought that if you were muscular and strong you couldn’t possibly have HIV,” he says. “Obviously that was a load of nonsense.”
George explains that your typical bear is approaching middle age and thus closer to reaching health problems, such as obesity and diabetes, common to that age group. He always had an interest in writing, but it was an incident in a nightclub that prompted him to combine it with his GP work. “About a year ago I resuscitated somebody who had overdosed on drugs in a nightclub,” he recalls. “No one had any idea about how to administer basic first aid. So, I wrote an article about how to look after your mates if they’ve overdosed. The article got picked up by a gay magazine.” The blog came a couple of months later after discussing with some fellow bears the need for better health information for this group. George’s blog covers the A–Z of gay men and bears’ health. From diabetes and anal cancer, to anal douching and weight loss; as long as it is relevant, no subject is taboo. “I’ve been able to blog about topics that other people don’t talk about,” George says. “These are often the things that need to be talked about.” He references male rape, anal cancer and men deliberately infecting others with HIV, known as ‘stealth seeding’. “I’m fairly unshockable these days, which is great for my patients,” George says. He adds that he is very “up front” with his patients because the health needs of gay and straight men are different. “I’ll ask them: ‘Are you sleeping with men, women or both?’ If they are sleeping with another man and engaging in oral sex, I need to know so I can swab the back of their throat.” “Yes, some of these questions are going to be uncomfortable, but I’m asking them for a good reason,” he says.
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George says he finds it difficult to write about “stigmatised” health topics, especially HIV. “I’ve agonised over what to write about this,” says George, who often seeks his partner’s opinion on these more sensitive pieces. “The highest population of people in Australia who are becoming HIV positive are those aged between 35 and 45,” George says. “This is group is often missed by HIV awareness campaigns… they need this information.”
life and donate it to doing something good. I get as much, if not more, out of it as the kids.” So, what’s next for the GP blogger? “Well, one day I’d like to be able to blog from the Bahamas!” “I’ll stick to men’s health because that’s what I know. I want to be the source of good information and to be aware of what’s ‘trending’ in the social media world.”
He adds that he’d like his blog to be syndicated in gay magazines. While having an informal and relaxed feel to them, George’s blogs are “The key to success in anything is how many people you can help and far from whimsical musings. He researches topics, backs them up with my blog lets me help more people. relevant data and research and As a solo GP, I can only help one George with a patient in his city-based clinic. taps into his network of medical person at a time.” colleagues. “As a GP, you need to “I don’t want a parade or anything ensure your patients have access to like that,” he says. “I just want good information,” he says. people to be healthy and don’t Importantly, George’s blog stretches want any more friends getting HIV.” beyond physical health. He blogs Visit George’s blog at — about emotional and social aspects thehealthybear.com of life as a bear, including gay marriage, relationships, depression — Laura McGeoch and suicide.
“I’ve been able to blog about topics that other people don’t talk about.”
This focus stems from his initial interest in psychiatry and his own experience with depression. “We know that gay men and women are 60 per cent more likely to suffer from depression than a straight man or woman,” he says.
He emphasises the importance of GPs being able to connect with their patients on an emotional level. “When you’re a busy doctor, it’s very easy to get overwhelmed and to just stop being a person. But you have to be a people person if you want to be a successful GP,” he says. “I used to get annoyed during my hospital rounds when the nurses or doctor would say: ‘Bed seven is a fractured hip’. I was like: ‘Sorry? What do you mean bed seven is a fractured hip? Maybe we should get the bed fixed?’” George encourages young doctors to keep on top of their own health. “You need to make an appointment to do something that you really like once a week,” he advises. George, who studied at the University of Queensland and did his training in Byron Bay, strikes the right balance by writing and working as a GP three days a week in Melbourne. He also volunteers each year with Camp Quality, working with children who have had cancer and their families. This year will be his fifth and in 2011 the camp presented him with the Volunteer of the Year award. “I’ve done everything at camp, from helping kids get costumes together …all the way through to resuscitating a child who was really unwell,” George says. “I think that every doctor should take a week out of their
Enjoying the “vibrant” city of Melbourne.
Taking a fresh look at general practice 27
G P profile
A home away from home Creating a welcoming environment that can feel like a “home away from home” is an essential ingredient for many Aboriginal people to be part of their own health care, says Dr Mary Belfrage.
I’m sitting in the waiting room of the Victorian Aboriginal Health Service (VAHS) in Fitzroy, a trendy inner-city suburb of Melbourne. It’s unlike any medical waiting room I’ve ever been in. Firstly, it doesn’t have that quiet ‘clinical’ feel. Instead, the echoes of children’s voices from a large indoor playground float down the corridor. Staff, some dressed in jeans and runners with VAHS-branded tee shirts, whisk by, their keys jangling. Secondly, it’s not decorated in the blue and grey hues that so often adorn waiting rooms. It’s colourful. A mural of a yellow serpent, decorated with green zig-zags, black stripes and white dots, winds its way down the corridor. Thirdly, I don’t see one copy of a Women’s Day magazine — or any gossip magazine. But there’s plenty to read. Walls are plastered with health information flyers and posters. A Kooris in the Kitchen flyer promotes healthy eating, another gives falls prevention advice for Aboriginal Elders. There are community notices too, including one promoting two young Aboriginal singers entering a competition. But the biggest difference is the relaxed and informal — yet professional — atmosphere in the room. Patients, who seem to know at least one other person there, chat with each other. Aboriginal staff members, who seem to know everyone there, chat with patients. They greet people with a hug or a handshake as they arrive. It’s no surprise that when I speak with Dr Mary Belfrage, GP and VAHS Medical Director, she tells me that this atmosphere is a key to good health care for the Aboriginal community. “This is an Aboriginal community controlled health service. It is a model where there are a lot of Aboriginal people on the staff and we try to always have non-Aboriginal clinicians working alongside an Aboriginal Health Worker. We aim for a blend of expert cultural knowledge and clinical excellence,” Mary tells Going Places magazine. “The role of the Aboriginal Health Worker is to provide an invaluable expertise and knowledge of culture, communities and often the individual,” Mary adds. “I go to Aboriginal Health Workers every day for advice.” Mary says this strengthens trust between patients and staff, creating safety and a feeling of safety for the patient. This prompts me to ask about the terms ‘cultural safety’ and ‘cultural awareness’ — often used when referring to working with Aboriginal people.
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“To me, cultural awareness means that someone might know about something, but they don’t necessarily do anything with that knowledge,” Mary says. “Cultural safety is what the patient experiences when measures have been put in place so they don’t feel that there is an assault on their identity. They feel comfortable being themselves in that place.” History — very recent history — underlines the importance of establishing this trust. Many of the patients who attend VAHS have been directly impacted by the Stolen Generation policies. They were either taken from their parents, had their children taken from them, or other family members were directly impacted. Many remember the scourge of being classified as ‘flora and fauna’ before Aboriginal people got citizenship rights in 1967 — less than 50 years go. Mary talks about patients who recall getting food handed to them through a side window in shops, because they weren’t allowed in the front doors. “You can understand why many Aboriginal people would find it extremely difficult to go to a health clinic and be seen by a health professional they don’t know,” Mary says. “And that’s a huge barrier to good health care.” Mary, who grew up in Melbourne and studied at Melbourne University, has been the VAHS Medical Director for nearly three years, but has been doing ‘stints’ as a GP at the clinic for the last 15 or 20 years. In 1989, she did her final year student clinical placement in Alice Springs and spent six weeks at Ernabella, part of the Pitjantjatjara community controlled health service, Nganampa Health Council. “It was just so exciting and had a drama about it, completely different to all my hospital-based experience. It was a completely different politic,” Mary says. “It was fantastic working with Aboriginal people and experiencing loads of other languages and cultures within Australia.” “I’d always had an interest in the social determinants of health and I loved the obvious public health dimension.” When asked what she means by this, Mary explains: “When you visit a town camp and seeing pus pouring out of a kid’s ear, you know that if you swab it you’ll grow something — but it’s so obviously not haemophilus that’s causing middle ear disease in these kids,” she says. “It’s about housing, hygiene, sanitation...” Mary says that many of the problems among Aboriginal people living in rural and inner-city areas are surprisingly similar. Diabetes, heart and kidney disease are major problems, despite city areas offering better access to good food and health services. But health problems also manifest at an emotional level, Mary says.
She says there’s often a lot of disconnect for Aboriginal people in inner city areas from language, land and culture. For those affected by the Stolen Generation policies, add in disrupted attachment to mother, family and community. “There is enormous resilience and optimism, but there is also a layer of grief and trauma and disrupted attachment that, for me, is the bedrock of a lot of health issues,” Mary says. “It shapes people’s will to live and, in terms of health, it manifests as a lot of things including addiction and mental health issues, violence and dysfunction.” Mary says that the Apology was an important step to improve Aboriginal health statistics, but that real inclusion is needed in the decision-making that affects Aboriginal people’s lives. “We need to make sure their story is part of our history by making sure it’s visible. We can’t fix what happened, but we can make sure that the story doesn’t get swept away.” Mary’s keen to point out that good health care for Aboriginal people is simply good health care. “It’s just the engagement and strategies that are different. It’s about what it takes for people to receive effective care.” “Aboriginal people have a higher risk of most health problems and of dying younger,” she says. “It’s a terrible health message. So we need to encourage healthy living in a way that is respectful and that’s not overwhelming.” Despite the challenges and complexities, there is a feeling in the clinic of real progress being made. “I’d love to do a study about the number of years of life we’ve saved. I think that’s what we are doing all the time.” “And we get a laugh every day,” she adds. “One of the really lovely things about working with Aboriginal people is that there is a lot of humour around.” The VAHS team is working hard to invite patients to be part of their own good healthcare. “We don’t want to do healthcare to someone, but to create a space that people step into to have a conversation about their own health.” “The community call this place a ‘home away from home’,” Mary says. The trick is to harness this feeling, while ensuring the clinic is a “centre of excellence” for primary healthcare. As I leave, a toddler and a male staff member play together. The little boy winds himself about the staff member’s feet, who tickles him while talking to his parents. It looks like the team is headed in the right direction. — Laura McGeoch
“We don’t want to ‘do’ health care to someone, but to create a space that people can step into to have a conversation about their own health.”
Taking a fresh look at general practice 29
G P profile
Going with the flow
Flashback to Christmas 2010. A doctor stands knee-deep in floodwater outside the medical centre he built in his small Queensland community. It’s taken a lifetime of work to build it and just a few days of nature’s fury to destroy it. Tens of thousands of dollars worth of expensive medical equipment — equipment he paid for out of his own pocket — is sodden beyond salvage. The doctor was Dr Bruce Chater of Theodore, a small central Queensland town hit hard by the infamous floods. His story was beamed into our living rooms during the rolling TV coverage and it personified the community spirit that emerged from the muddy mayhem.
of Queensland and as a past president of the Australian College of Rural and Remote Medicine (ACRRM). In the early days after the flood, Bruce encouraged locals to talk about their feelings with a sausage and beer in hand at a community barbecue. A doctor in a small town is a community leader — and the barbie debriefing says a lot about Bruce’s casual, laid-back leadership style. A believer in the hands-on, practical approach, Bruce is fond of telling this story. After a disaster, a psychologist arrives in town to offer counselling and says to a patient: “What can I do for you?” “Well, for a start you can help me shift the furniture,” the patient replies. You get the impression that Bruce has rolled up his sleeves and shifted a lot of furniture in his time. There is no doubt that Bruce inspires others, but Going Places magazine wanted to know who or what inspires him? “Country people inspire me,” he says. “I say to the medical students and registrars that often people who don’t have a lot can have very happy lives.” “The thing that inspires me is just how well a town like Theodore can pitch in and help. Everyone just got on with things. The simple human bit about helping your fellow man… I just find it inspiring being part of that.” Bruce grew up in St Lucia, Brisbane, close to Queensland University where he later studied medicine and is now a professor.
Putting his personal loss to one side, Bruce went on to rescue a stranded patient by jetski, direct a mass evacuation of the town by fleets of helicopters and was a rallying point for community morale.
Science was a family trade. “I always wanted to do science and I had a fairly good grounding in it. My mother was a physics lecturer, of all things, in 1938. That was pretty unusual for a woman in those days, especially in the science field.”
Bruce is the quintessential rural GP — multi-skilled, steadfast, able to overcome setbacks when nature turns feral in the Australian bush.
“I had an uncle who was a doctor in Nambour, which was fairly rural. So I suppose he inspired me a bit.”
The last quality has been roundly tested since the flood. The drawn-out rebuilding program is starting to get old. But for Bruce, it’s business as usual.
“I wanted to do science and I wanted to mix with people, so I decided medicine was a good thing to do.”
“I suppose when you’ve been a doctor for a while, you’ve seen most things and I’ve seen a lot more tragic things. There was no loss of life for us. I think what put it all into perspective was the Grantham experience where people tragically did lose their lives,” he reflects in a matter-offact drawl.
From the outset, Bruce was interested in being a generalist. “Back in those days we had our own de facto rural generalist program but it was very compressed and you were just thrown in the deep end. As an intern, I got to do appendectomies and anaesthetics and obstetrics and all sorts of things.”
“There was certainly loss of other things, but I’m a great believer in worrying about the things you can do something about and the rest you have to go with the flow a bit,” he adds.
When he was a young medical student, Bruce spent three months in Nepal. “We were sent there to see what really, really, really rural practice was like,” he laughs.
Now set up in a temporary donga next to the town’s 10-bed hospital while his new medical centre is being built, Bruce is going with the flow. He continues to see his patients in Theodore as he has for more than 30 years, much of this time as the town’s solo doctor.
Some time after returning to the relative comfort of medical practice in Australia, the fledgling doctor was posted to Theodore in Queensland’s north-west with his wife Anne. They went for a two-year posting and stayed for 30. Anne became practice manager, and she and Bruce are very much a team. Many of the Chaters’ patients are friends.
He is also mentoring his current registrar and medical students as Associate Professor and Head of Rural Remote Medicine at the University
Rural life suited them — interesting, diverse medicine, and the perfect place to give their four boys a freewheeling country upbringing.
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An aerial view of Bruce’s surgery and his house (with white car parked out the front).
Bruce bringing locals up to speed with evacuations to Moura and expected times and plans for returning to Theodore.
The Dawson River, which burst its banks so dramatically, has been the setting for many happy memories — fishing, boating and skiing. A typical working week may find Bruce delivering babies, performing minor surgery, attending accidents, liaising with the local Aboriginal and Torres Strait Islander community, doing routine GP consults. He runs the hospital and the dispensary (there is no pharmacy in town) and a radiology clinic, with X-rays and ultrasounds performed by Bruce and the practice nurses. Acupuncture? No problem! Bruce does that too. ‘Jack of all trades’ is a badge Bruce wears with pride. “The rhyme goes: ‘Jack of all trades and master of none’,” he recites. “If you look it up, there’s actually a second line that goes: ‘But oft-times better than master of one’. I think in rural areas that is the case that you’ve got to be a master of many things.”
“The thing that inspires me is just how well a town like Theodore can pitch in and help. Everyone just got on with things.”
— Jan Walker
Bruce back at work with medical students and an antenatal patient.
Preparing to fly from Moura to Theodore to meet with residents still in outlying areas of Theodore.The plane was owned by a local who was also evacuated.
G P profile
Delivering specialist skills As a GP obstetrician, delivering babies is just one of the hands-on procedural skills Dr Stuart Prosser brings to his Perth practice.
Google the name ‘Dr Stuart Prosser’ and you will find a cluster of comments from new mums eager to share their personal experiences of pregnancy over the digital back fence. “Dr Stuart Prosser delivered our first baby earlier this year and was amazing.” “He is very professional yet somehow maintains a relaxed demeanour.” “I don’t think you could find anyone who would recommend Dr Prosser as highly as I do. He is a very caring and supportive doctor.” Going by the patient praise, it’s no wonder this GP obstetrician has a full book of expectant mothers to care for. But delivering babies is just one of the special skills Stuart brings to his role as a GP in Kalamunda, nestled in the Perth Hills where the ’burbs meet the bush on the city fringe. He juggles sub-specialty work in obstetrics with anaesthetics and dermatology, and still manages to squeeze several sessions of routine general practice into his working week. Stuart acquired the hands-on disciplines of obstetrics, anaesthetics and minor surgery when training as a rural general practitioner in country Western Australia. Here the tyranny of distance requires GPs to wear many hats, including those worn by specialists in the city. When family circumstances forced a move to Perth — one of his children needs health services only available in the city — Stuart was keen to continue with his procedural skills, even though delivering babies and giving anaesthetics is somewhat unusual for an urban GP today. “I really enjoyed those aspects of my work and didn’t want to give it up when I came to the city,” Stuart says. He considers himself part of a growing band of GPs who are returning to the ‘all-rounder’ doctor model of earlier generations, when the family GP routinely delivered babies, did anaesthetics and performed minor surgery. “I think there’s a bit of a resurgence in GP obstetricians and the traditional GP role,” Stuart explains. “There’s increasingly a feeling from the population that it’s what they really want. Of course, I don’t do any of the high risk stuff — that’s why we have specialists.” So is there any hint from the specialist obstetricians that a GP obstetrician might be treading on their turf? Stuart is quick to rebut this theory. “Not at all. I was actually surprised. I’m very much respected within the obstetric community and environment. I’m involved in all the obstetric ongoing clinical meetings and they’ve even invited me to be part of the medical advisory committee at Mercy Hospital, so there’s no issue there.”
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Dr Stuart Prosser in theatre.
“I thoroughly enjoy doing everything so if I was to do just obstetrics all the time I think I’d go nuts. I think I would find it a little bit constricting. I really enjoy the challenge of doing lots of things.” “I think it’s also the fact that I trained with a lot of them. I was doing GP obstetrics and they were doing specialist but we’ve known each other for a long time and we’ve got a lot of mutual respect for each other.” Stuart says that with so many strings to his bow, time management is an ongoing challenge. “But we get there,” he laughs. He is based at Mead Medical, one of Perth’s largest privately owned GP practices with a staff of over 40, including 14 GPs and a couple of registrars. The practice encompasses Hills Obstetrics, Hills Anaesthetics and the Kalamunda Skin Clinic — and Stuart is active in all three. He says the dedicated clinics make it easier to divide his sub-specialties into mental compartments, and he and his colleagues can confer on difficult cases. In a typical week, he does three sessions of obstetrics including caesarean sections at Mercy and Bentley Hospitals, three hospital anaesthetic lists, a session of checking and removing skin lesions and three general practice sessions, with unscheduled baby deliveries in between. One advantage of working in a large group practice is that his colleagues can cover for him if he is called away. Other duties include teaching and supervising registrars at the practice, especially those interested in following his path as a GP obstetrician. ”Our practice is the only one in the Perth metro area that offers this,” he says. A question Stuart is often asked is why he didn’t become a specialist obstetrician, anaesthetist, dermatologist or surgeon rather than a GP with sub-specialties.
“I think I would find it a little bit constricting. I really enjoy the challenge of doing lots of things.” Stuart’s dream to be a GP was sparked at a young age. He grew up on a farm under the boundless blue skies of Kalannie in the Shire of Dalwallinu — ‘a Place of Wheat and Wattle’. His family later moved to Perth, where Stuart attended high school, but his grandparents remained in the country and their grandson became acutely aware of their community’s struggle to attract doctors. He set his mind on becoming a rural GP with the broad skills to serve isolated communities. To this end, he completed both the RACGP and ACRRM fellowships, with training stints in the Western Australian rural towns of Darkan and Narrogin where he stayed on as a GP for a number of years. For his sub-specialty qualifications, he gained a Diploma of the Royal Australian College of Obstetricians and Gynaecologists (Advanced), which required a six-month posting followed by an additional 12 months of training in caesarean sections. Anaesthetics training was covered as a sub-specialty in the ACRRM curriculum. Not content to rest on his laurels, Stuart is currently studying for the RACGP’s Certificate of Primary Care Dermatology when work and family commitments allow. Stuart and his wife Kay have three children and strive for work-life balance. “I have a really strict rule that when I’m working I’m really focused on it but when I’m off, I’m off,” he says. “Every morning I make sure I have breakfast with my kids and talk to them about their day. And I have early-finish afternoons, and make sure I’m home for dinner.”
His answer is simple: variety. “I thoroughly enjoy doing everything so if I was to do just obstetrics all the time I think I’d go nuts,” he says.
— Jan Walker Images courtesy of General Practice Education and Training (GPET). Photographed by Erik Williamson.
Smiles all round for this new arrival.
With a patient during an antenatal check-up.
Taking a fresh look at general practice 33
What’s your diagnosis? Dr Sarah McEwan explores the case of a young woman experiencing knee pain after starting a job on a farm working racehorses.
It is a Wednesday. I remember vividly that it had been unusually slow for me in general practice this particular week. It had been unseasonably warm, and the town had been experiencing greater amounts of rain than usual for the time of year. Maybe the patients were relishing the rainy weather and using it as an excuse to miss non-urgent appointments? I got a call from my receptionist to ask that I see a ‘walk in’. I was relieved to have something to drag my attention away from the mountain of paperwork that was piling up on my desk. It seems I too must have been enjoying the slower pace the wet weather was bringing. I had been asked to review Gemma*, a new patient to the practice. Gemma was an 18-year-old girl who had popped in to the surgery while she was in town getting supplies for her farm. She had been troubled by a two-day history of bilateral knee pain. Gemma revealed that only weeks previously, she had scored her dream job as a farm hand at the nearby race track. She had a passion for horse riding. Thanks to this passion, she had quickly been promoted to lead track worker, which meant she was responsible for working the racehorses every morning. She didn’t seem to mind the early starts but stated that she was finding it difficult to get herself up and moving of a morning, especially recently
with her progressive knee pain. Keen to prove herself to her employers, Gemma had been doing a little more work of late. But this had left her with extremely sore knees, even more so after training the horses. She had attempted to treat her symptoms with regular oral paracetamol, but was concerned that her knee pain was worsening. Gemma had no recollection of any acute injury that had occurred to the knees to coincide with the history of pain. Gemma was otherwise well, and a fit young lady. She had no other previous medical conditions, took no regular medications, and was a non-smoker and occasional drinker. She eventually felt comfortable enough to admit to binge drinking with her new colleagues of late, but only on the nights prior to her days off. She said she did not want to risk her job by turning up to work with a hangover, or worse, still drunk when arriving for her 4am start. I was thankful that I had the additional time to discuss safe drinking levels with Gemma, which hopefully will stand her in good stead for the future. Gemma had no significant family history. She stated that she was sexually active and was well aware that she was due for her first routine Pap smear and said she would arrange this at a later appointment. She had received all of her immunisations at school, including the Gardisil (human papillomavirus) vaccine. She had also in the recent past had a urine sexually transmitted infection (STI) screen which was negative for chlamydia and gonorrhea. Gemma had a slight build and weighed 55kg. She had a normal blood pressure. On examination of her knees, there was normal range of movement of both joints and no obvious signs of bruising. However, the joints were slightly warm to touch and there seemed to be a mild amount of swelling surrounding the knees bilaterally, but not enough to describe the finding as an effusion. On palpation there seemed to be non-specific mild joint line tenderness. The anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) seemed intact, as did the co-lateral ligaments.
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Perplexed, Gemma and I together contemplated that perhaps the sudden increase in horse riding had irritated her knees and led to her discomfort. Our plan of attack was to have her trial a week of regular anti-inflammatory medication in combination with the paracetamol and keep a pain diary to see if things worsened or improved. Gemma, intelligently suggested that she could start to wear some extra padded riding pants around the knee joint to see if this improved the situation. After much discussion, Gemma left the surgery, feeling comfortable with the proposed plan and had made a follow-up appointment with the receptionist for a week’s time. Gemma did return for a follow-up 10 days later. She initially cancelled her appointment because her knee swelling had dissipated, but then rescheduled only days later after she developed a fine macular rash to her body.
She was not so bothered by the rash, but more by the fatigue she was experiencing. Gemma stoically put this down to her early morning starts; however, I was suspicious enough at this stage to request some bloodwork. I requested the following tests: FBC, UECs, CRP and arbovirus serology. Gemma was happy enough to agree to this and again booked a follow-up appointment for a week’s time. Gemma kept her follow up appointment after the practice nurses kindly called her to ensure she attend after being alerted by our recall system, which I signalled on review of Gemma’s bloodwork. On return, I finally had a preliminary answer for Gemma’s unusual collection of symptoms and could in fact tie both presentations together, and also explain Gemma’s new found fatigue…
*Names have been changed
Do you know the diagnosis?
Go online and see if you are right! Visit gpaustralia.org.au/content/whats-your-diagnosisgoing-places-magazine-issue-8
You can also find out the diagnosis by scanning this code.
Dr Sarah McEwan
Taking a fresh look at general practice 35
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. 36
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
gpaustralia.org.au Your one-stop shop packed with essential information and resources for junior doctors considering a career in general practice. Want to calculate how much you could • earn as a GP? Like to get first-hand information from • experienced GPs through videos, case
studies and blogs? Need help understanding GP training? Want to get in touch with your Going Places GP Ambassador? Like to use our forum to get your burning general practice questions answered?
• • •
Go online to keep up to date with what’s happening with the Going Places Network!
Download the Going Places magazine
The Going Places magazine is published three times a year. It’s full of real-life stories about GPs from across Australia. It also includes helpful clinical information and case studies. Download it at gpaustralia.org.au/content/publications or look out for it in your JMO lounges.
Taking a fresh look at general practice 37
R ecruitment special
Job tips from our recruitment sponsors
Get a head start on your next doctor role Ochre Recruitment
Looking for a job can be a tedious task at the best of times. Looking for a medical job, in particular, can be downright painful. With so many things to consider — registration, credentialling, Medicare, travel, salary and a list of other bureaucratic hoops to jump through, it’s hard to work out where to begin! There are a lot of advantages, therefore, in using a recruitment agency. Whether it’s a permanent role in a different area that you’re looking for, or you want to enter the locum market, a medical recruitment agency can help take the pain out of those steps between looking for a job and actually starting in the practice. Most hospitals and practices will go through an agency when looking for a doctor to fill their vacancies. It therefore stands to reason, that by working with an agency, you’ll have a better chance at finding that ideal job to suit your lifestyle, needs and career goals. You also may get word of the vacancy ahead of others who are looking, giving you the edge on the competition when your CV winds up on the practice manager’s desk first. Furthermore, when it comes to the locum market, you may find out about vacancies that don’t even get advertised. Many locum jobs are filled so quickly, they don’t get advertised externally because agencies are able to fill them with doctors already on their database. The best way to make sure you have your finger on the pulse of this market is to be one of those doctors on that database. You can work as frequently or as sparingly as you wish — but you’ll need to be on that list to be in the hunt!
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The second major benefit of working with an agency comes down to one word: paperwork. Let’s ask you a few questions:
• Are you 19AA/19AB or otherwise? • Have you got access to the full Medicare rebate, dealing with
DoHA, ROMPS, etc?
• Can you arrange flights, a car, accommodation, travel allowance? • Do you have a provider number for the location you’re going to? • Are you confident in contract negotiation? • Are you aware of the schools, sports clubs and other facilities
if moving with family?
There is so much to be considered and arranged between the moment when you hear about that perfect job, and the moment you see your first patient. An agency like Ochre Recruitment is able to help you out when it comes to the bureaucracy, red tape and paperwork required to get there. A consultant will help you arrange travel and logistics, credentialling, negotiate the best contract outcome for you, and so much more.
So whether you’re looking for a new GP or hospital role, or wanting to keep your finger on the pulse of the locum market, and get some travel under your belt while still earning a crust, signing up with a medical recruitment agency like Ochre Recruitment will provide you with greater access to jobs, and an easier end-to-end process when it comes to actually starting in that next doctor role.
Please feel free to contact Ochre Recruitment today to discuss more details about using a medical recruitment agency!
Contact Ochre Recruitment Ph. (03) 6224 4399 ochrerecruitment.com
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Taking a fresh look at general practice 7
R ecruitment special c o n t i n u e d
Your brilliant medical career Health 24-7
By Sacha Etherington, Director, Health 24-7 The start of a medical career is exciting. After years of study, you’ve made it into the workforce. Hurrah! Real patients with real problems. You can start making a difference to patients’ health, and finally earn some money. Your GP training and junior years are an ideal opportunity to explore your career options before settling into a long-term position. Or you may have whet your appetite for particular types of work already. Many young doctors use the early years of their career to work in locum assignments, gaining insight into different specialties, work environments, patient groups and locations. Through locum work you can experiment with different job postings and you can make some excellent connections along the way.
Location, location Australia is a big and diverse country. Now is the time to see something of it. Short-term assignments allow you to work in places that you might not consider for longer periods. And, we all know rural and regional areas are screaming out for doctors. Talk to your recruitment agency about job opportunities in different locations, from coastal towns to wine regions to regional cities or the outback. Be open-minded and flexible. And, who knows, you might just change your mind about living in Alice Springs or Cairns.
Different locations, different patients and problems Australia’s varying climate and environment mean that you will see different health issues in different locations. For example, there are tropical diseases in far north Queensland that you won’t treat elsewhere. Patients differ too. Certain hospitals and clinics will have higher concentrations of patient groups, such as children, older people, Aboriginal or Torres Strait Islander people or particular ethnic groups.
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Hospital versus clinic The scope and variety of work will differ in not just hospitals versus clinics, but also depending on the size, location and whether it’s public or private. Try a few different settings as a locum – you may develop a preference or you may like the variety.
Enjoy your career If you have a clear idea of where you want to work, the early period of your career is a good opportunity to confirm or change your thinking. Or, if you’re not sure, it’s a great way to find out. Remember, your career is a journey. It doesn’t have to go in a straight line; it’s about accumulating interesting life experiences. The most important point is to enjoy it. Good luck with your decisions — and feel free to call Health 24-7 to discuss your career and job opportunities. Health 24-7 is a boutique medical recruitment agency owned and run by Sacha Etherington. It’s based in Mudgee in regional NSW, and provides long and short-term positions throughout Australia. Contact Health 24-7 Ph. 1800 005 915 health247.com.au
What’s new in GP training this year? This year applications for the Australian General Practice Training program (referred to as AGPT) open a month earlier than in previous years Applications open on 16 April and close on 18 May. Check your eligibility now and be ready to apply online at: agpt.com.au If you’re eligible for the AGPT program (you’ll be notified if you’re not eligible), you’ll need to get leave from the hospital for a day to attend a National Assessment Centre. Attendance at a National Assessment Centre is mandatory if you want to be considered for the AGPT program and GP training. At the National Assessment Centre you’ll go through two different types of assessments. • Situational Judgement Test The first, called a Situational Judgement Test, assesses your clinical knowledge, analytical problem solving skills and professional/ethical attributes. • Multiple Mini Interview The second is a Multiple Mini Interview which examines your communication/interpersonal skills, organisation/ management skills, personal attributes and your sense of vocation/motivation for general practice. After the National Assessment Centre, you’ll be emailed your score and the band into which your score falls. The higher your score, the more likely you are to receive your first preference. You’re then shortlisted by a regional training provider (RTP), and you may hear from them directly for an interview or referee check. They will then offer you a place in the AGPT program or not. Applications for the AGPT program are competitive. Go online now and look at the eligibility and application requirements through the Applicant Guide or talk to your local GP Ambassador for more information.
For more information, contact the AGPT Selection Team on (02) 6263 6776 or email: selection@gpet.com.au
If only drug interactions were as easy to spot! Of course you know that Warfarin goes with Diclofenac as badly as pink and orange stripes. But there are thousands more interactions that will do far worse than make you turn up your nose, yet often slip past the most experienced physician. MIMS can let you play it safe in no time at all. Tap into MIMS Drug Interactions for split second access to primary evidence-based information. It’s graded with levels of severity and probability to help you make the final decision.
Call 1800 800 629. Email clientservices@mims.com.au
mims.com.au 42
The physician’s medicine cabinet in 1950 was virtually bare and the only imaging available was a primitive X-ray. Today’s practice of medicine is incomparable and the speed of change isn’t likely to slow down. By Dr Steve Ginn Genetics and pharmaceuticals
When Dr Francis Collins of the Human Genome Research Institute said that the Human Genome Project provided a tool to “uncover the hereditary factors to virtually every disease” it was hard not to be impressed. Being able to obtain a unique DNA signature for each patient will enable identification of disease susceptibility and treatment. Because of the enormous genetic variability between individuals, this leads to a corresponding variability in responses of patients to modern medical treatments. In the future, instead of wasting time on trial-and-error treatment, physicians will be able to use a genetic test to identify patients with the most potential to respond to a drug. Professor Sikora, a leading cancer researcher, suggests that susceptible people may be able to be implanted with a ‘gene chip’ which would detect the earliest signs of genetic mutations that produce cancer. A patient could then check themselves with a home computer which could then contact the GP by email to arrange an appointment for review.
Nanorobots
Nanotechnology, the control of matter on an atomic and molecular scale, is another big hope. The field has its own journal Nanomedicine and the latest issue discusses futuristic topics such as the advances in using nanotubes to fight bacteria and nanoparticles for cancer diagnosis and therapeutics. Expectations for a sub-specialty of ‘Nanorobotics’ — the technology of creating machines or robots on a nanometer scale — are even higher. Once introduced to the body, these ‘nanomachines’ will be able to repair cellular structures, isolate cancer cells on an individual basis and deliver drugs directly to specific receptors. Nanotechnology may even make indefinite lifespans for humans possible if the potential is fully realised.
Sensors
We’re used to sensors being all around us. In the future, sensors will be embedded in the walls and ceilings of our homes or even woven into clothing to monitor our health.
Remote transmission of pulse rate and blood pressure from the homes of patients with chronic illness is already possible. New devices that can sense hypoglycaemia in diabetic patients and can differentiate between the odours produced by ear, nose and throat infections are nearly complete. This last technology has further applications in hospital infection control when combined with air monitors to detect and report any visitor who might transmit airborne infection.
Bionics
From the Cybermen in Doctor Who to the Borg in Star Trek, lovers of science fiction will already be well acquainted with part-machine alien races. This technology is now being developed and has already found some impressive applications. The most widely reported example is Mr Nagle, a man from Massachusetts, who was left paraplegic following a knife attack. He was fitted with a 4mm-square chip or ‘Braingate’ that reads signals from the primary motor cortex of his brain allowing him to open emails, play computer games and operate a prosthetic limb. The possibilities of ‘cyborg technologies’ appear almost limitless. As well as providing prosthetic limbs or restoring sight we could be seeing applications with the intent of enhancing the human body beyond its natural capabilities
Robots in surgery
Researchers at the University of Nebraska have developed a machine about the size of a lipstick which is able to drive around a patient’s body and act as the eyes and hands of a surgeon who could be many miles away. London doctors have begun pioneering the first fully robotic heart catheter ablation and angioplasty. The cardiologist sits at a console outside the operating theatre and uses a joystick or mouse to guide the magnets. It’s also possible to pre-program the computer so the entire operation is automatic.
The challenges of technology
Over the coming decades it is a certainty that technology will play an increasing role in the provision of health care. It is possible that with advances the doctor’s role will become obsolete — or perhaps we will find that our patients need our help more than ever to provide a friendly human face and a guide to the technologies on offer. This article first appeared in JuniorDr.
Taking a fresh look at general practice 43
i
my GP
Know an amazing GP? Tell us why you love ‘em! The Going Places Network is celebrating GPs on World Family Doctor Day, 19 May 2012. We want to raise the profile of GPs across Australia and acknowledge the important work they do.
Visit iheartmygp.com.au on 19 May 2012 and share your GP story.
iheartmygp.com.au
General practice
myths Dr Danni Gitsham (pages 16-17)
Myth: General practice is an easy job “This is the hardest job I’ve ever done because you are expected to know everything about everything. People think general practice is an easy specialty, but it’s not. With O&G, you focus on mainly the pelvis. With ear, nose and throat, it’s the head area. But with GP, it’s the whole body and also lifestyle.”
Dr George Forgan-Smith (pages 26-27) Myth: That it’s all about coughs and colds “I’m happy if I get a patient with a cough or a cold. It means I can relax for five minutes!”
Dr Mary Belfrage
(pages 28-29)
Myth: It’s boring! “In terms of general practice and particularly Aboriginal health, the work is medically really challenging and interesting. We see a lot of pathology, we practise holistic care and we work in a multi-disciplinary team. So for people who are team players, it’s great. You have to be meticulous, because people die from preventable diseases if you’re not. You make a difference — you really make a difference.”
Dr Bruce Chater (pages 30-31) Myth: Rural-remote GPs have to be ‘super docs’ “I get annoyed with people saying you have to be a ‘super doc’ to be a rural-remote GP in a very disparaging way. They imply that we’re over-stressed. It’s as if it’s
Boring? Badly paid? A second-rate specialty? We object! Our featured GPs debunk some of those nasty myths about general practice. unattainable, and I don’t think that’s true. Where I work, the on-call is divided between the registrar and myself. People will ring the hospital and get triaged. If it’s not an emergency and I’m in the middle of dinner with friends they will wait. You can be super in a nice way — you can have a super-interesting career with a super range of skills. The rural generalist program (in Queensland) is producing some great docs.”
Dr Stuart Prosser (pages 32-33) Myth: General practice is not as exciting and challenging as other specialties “I actually think it’s more exciting and challenging because you have to be across so many different things. You go to work and you never know what your day is going to bring you. You’re always learning and developing — it’s one of the thrills of being a GP. And seeing your patients get better and being able to follow them up and continue to look after them is very rewarding. I think it’s lovely that I look after a grandparent, a parent and a newborn from the same family. That’s one of those wonderful things; you’ve got a real sense of being part of that family. It’s a really important part of general practice that sometimes gets lost.” Taking a fresh look at general practice 45
Classic
BOOK REVIEW
Doctor Fairytale Alice in Wonderland
Written by Dr Gil Myers
Our own Dr Fairytale pays a home visit to his celebrity client in Wonderland for a diagnosis. Here’s his medical report.
Multiple drug use Despite her protestations it is clear that Alice has a drug problem. Given any opportunity she ingests potions, wafers and mushrooms without concern for her personal safety. She reports bizarre variation in her height, changes in her perspective, loses track of time and space — even her own identity. She also refers on a number of occasions to a hookah-smoking caterpillar which suggests that her social network is that of drug users. More worryingly, Alice displays a total lack of insight into her problem and has created a fantasy to justify her drug-induced hallucinations.
EBV infectious mononucleosis Infectious mononucleosis is a diffuse disorder which, especially in adolescents and young adults, is characterised by fever, sore throat and fatigue. It can cause encephalopathies, which may include visual imbalance symptoms. Alice reports all sorts of odd things: talking white rabbits, morbidly obese twins and a mad hatter obsessed by tea parties. It would seem more likely that Alice’s symptoms are the result of this infectious symptomatology rather than simply ‘magical’. We know that IM is also known as the ‘kissing disease’ suggesting that Alice has probably not been as innocent as she claims.
Migraine with benign paroxysmal vertigo of childhood Alice may well be suffering from severe recurring vascular headaches. A migraine is a neurological syndrome characterised by altered bodily perceptions, severe headaches and nausea. These could explain how a young girl would start to talk about falling down a rabbit hole into a weird world full of odd things making her ill. In addition, several studies have found some migraines are triggered by changes in weather. The worst conditions for this are a high temperature mixed with humidity and we know that Alice was most affected during a mid-summer picnic.
Alice in Wonderland syndrome I should probably mention Alice in Wonderland syndrome (AIWS) — a neurological condition. The symptoms are the result of cells in the brain firing inappropriately, giving rise to unusual perceptions and experiences. Patients report visual distortions where things seem to be closer or further away, disturbances of time and delusions of their own bodies — for example, their head growing larger. In fact, AIWS or Todd’s syndrome to give its dull name, is clearly a medicalisation of Alice’s attention-seeking behaviour. By claiming to have experienced such changes Alice is making sure she is the focus of interest to everyone around her. I would strongly recommend avoiding giving her reported symptomatology any credence by allowing this term to be used. This article first appeared in JuniorDr.
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The House of God:
by Samuel Shem Reviewed by Dr Mike Cross-Pitcher Going Places magazine Medical Editor and GP Ambassador at Nambour Hospital
Does God’s house still have a place in modern medicine? Have you experienced it yet? That moment during your internship (or beyond) where you are (either literally or metaphorically) sitting in a stairwell in the middle of the night, rocking back and forth muttering: “There’s no place like home... there’s no place like home...”. We like to think we’re superhuman and we can handle the heavy responsibilities that are placed on our shoulders so early in our careers, but the reality is that sometimes we come close to breaking. At these times, it is important to have a guardian angel looking over your shoulder. My angel was a close friend, who gave me The House of God. First...the disclaimers. This book is in your face, politically incorrect, occasionally rude and offensive, contains material of a sexual nature and people die. It is also heart-warming, caring, tragic and wonderful. I suppose all of this means that it is an accurate reflection of life. Long before TV shows like Scrubs, Grey’s Anatomy or House there was The House of God. It is a mesmerising and provocative journey that documents the internship of Dr Roy Basch and five of his fellow graduates at the most renowned teaching hospital in the country. If you have a sensitive nature and are offended by a little frankness, do not read this book! If, on the other hand, you can sift through the sands of humour and find the pearls of wisdom, this is for you. You will discover the benefits of Dr Jung’s Anal Mirror, how to identify a LOL in NAD, and learn the difference between a SIEVE and a WALL. For me, The House of God was like a little bit of Internship Cognitive Behavioural Therapy. My angel hit me with it at just the right time, and all of a sudden I knew that everything would be ok. I knew that even when I felt completely isolated, I wasn’t alone. This book was a masterpiece of its time and stands up just as well in today’s era of modern medicine.
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.
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.
Taking a fresh look at general practice 47
If you’re a doctor in training interested in a research placement, would $25,000 or $50,000 help? Avant is delighted to announce the launch of the Avant Doctor in Training Research Scholarships Program. Each year we will award two full-time scholarships to the value of $50,000 each and four part-time scholarships of $25,000 each. Let us help turn your dream of that elusive research placement into a reality.
As a recipient of grants in the past, I would encourage you to put as much detail as possible into the application, it’s worth the time and effort to get it right. Dr Gareth Crouch Cardiothoracic Registrar (SA) Member, Avant’s Doctor in Training Advisory Council
Applications open at 9am on 13 February 2012 and must be received by 5pm on 31 May 2012. For more information or to download the application form, please visit www.avant.org.au/scholarship 6
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