Australian Doctor Top50 by Health and Life

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50 THINGS GPs SHOULD KNOW

Before prescribing, please review Product Information and PBS Information in the primary advertisement in this publication. Further information is available on request from AstraZeneca Pty Ltd. ABN 54 009 682 311. Alma Road, North Ryde NSW 2113. CRESTOR is a trademark of the AstraZeneca Group. Licensed from Shionogi & Co. Ltd, Osaka, Japan. 04/08 AST1730/AD/CJB Print Post Approved PP255003/00320

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THINGS GPs SHOULD KNOW Editor MARGE OVERS Writer JANE McCREDIE Art director JULIE COUGHLAN Sub-editor SHAHIRON SAHARI Photo editor LIZ HIND Australian Doctor editor-in-chief DR KERRI PARNELL Publisher JEREMY KNIBBS Commercial director SUZANNE COUTINHO Sales director LYNETTE ROCHFORD Sales managers SARAH WYLIE, TIM YOUNG Production manager RAY GIBBS

Getting of wisdom

e’ve all heard the joke about specialists – they know more and more about less and less – while it feels as if general practitioners need to be across an ever-increasing body of knowledge. And like most professionals, GPs are bombarded by information from all quarters and, with our in-trays and inboxes overflowing, it can be tricky deciding what to try to absorb and what to put straight in the bin. So with our tongues only partly in our cheeks, for the latest in our Top 50 series, Australian Doctor took on the almost impossible challenge of putting together a list of the top 50 things a GP needs to know. We’re not talking just simple tips, but sharing a variety of real-life advice among the profession, ranging from the serious to the practical, and from inside and outside the surgery. We began with experienced journalists, a hand-picked panel (see below), some good food and fine wine, and after a hilarious evening were well on our way. Along with suggestions from the Australian Doctor GP and specialist advisory panels, discussions with colleagues and much soul searching, we chose the top 50 you see today. We’ve grouped the list into four categories: patients, medicine, life and practice – with icons to match (see below). Clearly it was a subjective process and we’d love to hear your ideas about what we’ve missed, what you disagree with and what you think is invaluable. (Please email your feedback to mail@australiandoctor.com.au) We also hope you’ll find it useful and entertaining.

An Australian Doctor publication Reed Business Information Tower 2, 475 Victoria Avenue Locked Bag 2999, Chatswood DC, NSW 2067 Ph: (02) 9422 2797 Fax: (02) 9422 2800 E-mail: mail@australiandoctor.com.au

Dr Kerri Parnell Editor-in-chief Australian Doctor

Patients

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50 THINGS GPs SHOULD KNOW

Further information is available on request from AstraZeneca Pty Ltd. ABN 54 009 682 311. Alma Road, North Ryde NSW 2113. CRESTOR is a trademark of the AstraZeneca Group. Licensed from Shionogi & Co. Ltd, Osaka, Japan. 04/08 AST1730/AD/CJB

Life

Practice

The panel DR GILLIAN DEAKIN GP in Bondi, NSW, and author of 101 Things your GP would tell you if only there was time

DR ANNETTE KATELARIS Australian Doctor Medical editor

DR JON FOGARTY GP on the NSW Central Coast and Australian Doctor columnist

DR MARK O’REILLY GP registrar in Darlinghurst, NSW.

DR GED FOLEY GP in Mosman, NSW

DR VLAD MATIC GP in Walgett, western NSW, and a columnist with Australian Rural Doctor

MARINA FULCHER National president of the Australian Association of Practice Managers

PROFESSOR SIMON WILLCOCK Associate professor, discipline of general practice, University Of Sydney Medical Program

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Five ways to find art and soul 1

There are ways to earn more money. YOU CAN dress up in funny hats and slice people up in courtrooms as a barrister, or be funded to sleep through the same cases as a judge, or move theoretical money around in virtual worlds until the whole delusional complex crashes as stock traders do each day. Yet after two decades of general practice it is my ﬁrm opinion that no occupation can supply this level of satisfaction, excitement, disappointment, fear, human contact, joy, exhilaration, obsession, independence and challenge yet still feed a family, prevent poverty and allow employment mobility. I’ve never met a GP worried about unemployment or competing for a clinical job, or about how to attract patients. General practice non-monetary rewards are unparalleled – and you can still make a decent living.

You’re paid to treat and help patients, not like them or make them like you. A GOOD rapport is a tool and not an

outcome; a likeable patient is a boon and their liking you an absolute bonus. Always remind yourself they are the ones with the problems and the diseases, that empathy is a short distance from inappropriate involvement, and most of all to leave them and their problems at the surgery. Your partner and family want to have a happy home, not some general practice focus group or post-traumatic stress disorder drop-in centre.

Now it’s your turn...

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No occupation can supply this level of satisfaction, excitement, disappointment, fear, human contact, joy ... and challenge.

Say no to professional masochism.

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BY DR VLAD MATIC

FIFTY TOP tips for general practice? What if 50,000 tips wouldn’t cover every possible situation? Maybe it’s best to share ﬁve ideas and leave the rest to you.

Matt Clare

When all is said and done, our profession can be as fulﬁlling as we want it to be.

THERE MAY be a ﬂu outbreak, but it’s not exactly bubonic plaque. Yes, many patients want an appointment, but sometimes in life one has to wait. Look at the rest of society: even police stations in many towns close overnight, as do pharmacies, community health centres, divisions and health departments, and ministers’ ofﬁces. Unlike them, we have an emergency access system called hospitals, so no one really misses out.

Ignore the media headlines.

You don’t need to solve every puzzle. SOME questions have no answer and not all questions need an answer. Be frugal with the community’s dollar and understand that in many cases you can be 90% sure for $90 spent, and 92% sure for $9000; that the most expensive drug is rarely the best and the rarer the test the less likely it will provide a useful result. Beware the patient whose real disorder is that of seeking an illness, and don’t be afraid to say: “I’m conﬁdent there’s nothing wrong physically” (see heartsink patients, next page).

IT WOULD be lethal to believe every piece of nonsense created by the press, especially on Sundays. We are not about to be replaced by robots, computers, nurses or iridologists. Doctors have a special place in the community’s hearts and minds, not so much for our science but because of the caring, the conﬁdentiality and the continuity of our involvement throughout the human lifespan and throughout the ages. I believe we are an art masquerading as, and on occasions incorporating, a science, and with very few exceptions beneﬁt the lives of those who seek us out for help. DR VLAD MATIC is a GP in Walgett in far-west NSW and a columnist for Australian Rural Doctor.

Share your wisdom Fifty is not near enough to cover all the gems a GP needs to know. We’ve declared our top 50, but now we want to hear from you, so our 50 turns into 100 or more. What do you think are the 50 most useful bits of information that make a GP’s life easier or more rewarding or most help their patients? Please send your ideas about patients, medicine, life and practice to mail@australiandoctor.com.au

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HOW TO LOVE YOUR HEART-SINK PATIENTS

That extra step It’s worth pursuing the psychological in parallel with the physical when patients present again and again. BY DR KERRI PARNELL

Arrange a meeting on your terms SOME GPs say the easiest option is not to see them at all, while others ﬁnd the drug rep a useful source of information – not to mention the samples for patients. But the main thing is to make sure encounters with reps are on your terms. If you usher them into your consulting room, offering them a seat and a drink of water, you could ﬁnd you’re in for the long haul. “Don’t sit down,” is the advice one GP gives. “If you stay on your feet, they’ll have to too and it’s amazing how much swifter and to the point people are when they don’t have a comfortable chair to relax into.” Develop a practice policy on rep visits so that the receptionist can head unwanted visitors off at the pass, saying, for example: “Dr Bloggs only sees reps at 12 on Thursdays and the next available slot is in three weeks. Would you like that?” And, of course, remember the information given comes with spin – the rep’s primary job is to sell a product, not to provide unbiased information. They may have the answers to your questions about a drug, but don’t be afraid to ask for, and critically evaluate, the evidence behind what they say.

WHEN NOT TO SAY YOU’RE A GP

1. Make the patient feel understood. Spend time understanding their fears, acknowledging the reality of the symptoms. The last thing the patient wants to hear at this stage is “it’s all in your head”.

Time to keep quiet WHILE honesty is the best policy, sometimes GPs can be forgiven for not telling the whole truth. Just as patients often assume the GP owns the swanky car in the carpark (usually it’s the practice manager), tradepeople may up the fee if they know you’re a doctor. And an MBBS can hurt your bargaining powers too.

2. Broaden the agenda. By now you’ve probably uncovered an element of anxiety or depression, so gently ﬂoat the idea that this may be linked to their symptoms. 3. Make the link. Expand on the relationship of their symptoms to their anxiety or depression. Give speciﬁc and common examples of the mind causing physical symptoms – for example, diarrhoea before an exam. 4. Reassure. Explain that the symptoms will resolve when their anxiety and depression

Australian Doctor | Top 50 Things GPs Should Know

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A negative test is only temporary reassurance and reinforces the perception that a physical solution will be found if we just look hard enough.

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HOW TO HANDLE DRUG R REPS E

MANY PATIENTS we secretly think of as “heart sinks” cause our myocardium to plunge, not because we don’t like them, but because we don’t feel we’re doing them much good. In my experience, the patients most likely to engender such feelings are those who somatise their symptoms; in other words, they present again and again with physical symptoms not explained by physical disease. To state the obvious, even if we suspect a patient falls into this category, a good history and physical exam, plus judicious tests, are needed to convince ourselves and the patient we’re not missing a serious physical illness. But it also pays to pursue the psychological in parallel with the physical, and remember two things: that in general practice up to 30% of physical symptoms are not explained by physical disease, and that anxiety and depression are common in patients who somatise their symptoms, which frequently include dizziness, intermittent dyspnoea, chronic chest pain and abdominal pain. The ﬁrst trick, after establishing that physical disease is unlikely, is to avoid the trap of “one more test” or “one more referral”. The deﬁning feature of somatisation is illness conviction – these patients are convinced they have a serious malady. A negative test is only temporary reassurance and reinforces the perception that a physical solution will be found if we just look hard enough. After one or two focused sessions, you’ll probably suspect that anxiety and/or depression are major factors. Initially, reassure the patient that you’re just as keen as they are to help them recover, and that the chance of a life-threatening event is very low. Below is a summary of how to proceed from this point, adapted from an excellent Australian text, General Practice Psychiatry, beginning with the important phase of reattribution:

are dealt with, and let them know you’ll stay with them throughout the process. This also tells the patient they don’t need a physical problem or a “ticket” to see you. Sometimes, after this process, the patient’s symptoms will begin to fade, and at others, they’ll need speciﬁc psychological treatments, but you’ll be on your way. Like everything in general practice, this approach won’t work all the time, but for an intervention that can take surprisingly few consults, it can bring great rewards to both patient and doctor. Blashki G, Judd F, and Piterman L. General Practice Psychiatry. McGraw-Hill, Sydney, 2006.

DR KERRI PARNELL is editor-in-chief of Australian Doctor and is studying for a Masters in General Practice Psychiatry.

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IF THERE’S ONE FEAR GPs SHARE, IT IS MISSING A SERIOUS TREATABLE CONDITION. THESE ARE THREE OF THE SCARIEST. THAT NOT ALL MELANOMAS ARE UGLY DUCKLINGS

Guilty until proven otherwise you should remove it within a week.” The problem is that these cancers don’t generally match the ABCDE criteria that will successfully identify other melanomas. In fact, on cursory examination, many of them could be mistaken for an inflamed pimple as most are not pigmented. Closer inspection, however, will reveal that they are firmer and without a pusfilled head. They are often mistaken for

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You only get one chance with nodular melanoma – if you suspect one, you should remove it within a week.

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IT MIGHT seem like a malicious quirk of fate that the hardest melanomas to diagnose – the ones that don’t conform to the standard criteria – are also the most lethal. Although they account for only 10% of all melanomas, the nodular variety are responsible for a much higher percentage of fatal outcomes, says the head of the Victorian Melanoma Service, Associate Professor John Kelly. This is partly because they are often missed by GPs – and sometimes dermatologists too – but also because they grow at a phenomenal rate, ﬁve times as fast as other melanomas, meaning they can become life-threatening within weeks. “GPs are pretty good at ordinary melanomas, but they miss these ones,” Professor Kelly says. “You only get one chance with a nodular melanoma – if you suspect one,

non-melanoma skin cancers, despite not having the pearliness or telangiectasia of basal cell carcinomas or the hyperkeratosis often seen in squamous cell carcinomas. Any ﬁrm and enlarging nodule without features of BCC or SCC should be considered a possible nodular melanoma, Professor Kelly says, stressing that patients may be more likely to notice them than doctors. “Some of us are a little bit cocky about what we think we know about the appearances of melanoma. Too often, the patient points it out to the doctor and is reassured,” he says. “When the diagnosis eventually becomes clear, some of these patients feel angry, because they found the melanoma but the doctor missed it. Those are the situations that see doctors end up in court.” The bottom line is that red nodules are melanomas until proven otherwise, Professor Kelly says, and should be removed in their entirety – not punch biopsied – immediately.

Characteristics of nodular melanoma The features of nodular melanoma can be summarised as EFG: elevated, ﬁrm and growing progressively. They are also: - similar to a nodular non-melanoma skin cancer - ﬁrm to palpate - dome-shaped and discrete - often reddish, though can be pigmented - sometimes ulcerated.

Nodular melanomas can be fast growing and lethal. 1. 2.1mm thick, level IV nodular melanoma, showing only focal pigmentation and ulceration. This appeared as a new lesion two months earlier. 2. 1.75mm thick, level III nodular melanoma. The patient felt the lesion had been present for 1-2 months. 3. 1.75mm thick, level IV nodular melanoma. In spite of a history of change over six months, medical practitioners repeatedly reassured the patient. Photos courtesy of Professor John Kelly.

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HOW TO RECOGNISE THE SERIOUSLY ILL CHILD

It’s as easy as A B C IT’S THE stuff of nightmares. Among the legion of febrile kids who pass through your doors might be one with a life-threatening illness, but how do you know which child it is? Commonsense is generally a pretty reliable guide, says Dr Matthew O’Meara, director of emergency at Sydney Children’s Hospital, Randwick. If a child looks really sick, they probably are. Dr O’Meara also relies on an assessment tool developed by Victorian researchers based on data from hundreds of infants presenting to emergency. Called ‘ABC fluids in – fluids out’ (see box), the tool is a good generic way of stratifying risk based on the severity of the child’s illness, he says. And, although it was developed and validated in infants, the principles apply across the age spectrum. The researchers found that infants with frequent drowsiness, generalised pallor or decreased activity had a risk of serious illness of between 45% and 59%. Those with fever, pallor and drowsiness had a 70%-75% risk of serious illness, a finding the researchers described as “one of the most useful paradigms of infant sickness assessment”. They concluded that the presence of drowsiness,

pallor or chest wall recession in febrile infants “virtually necessitates either admission to hospital or at least aggressive investigation and treatment as an outpatient because of the risk of serious illness”. The triage system by itself identiﬁed about 80% of infants with serious illness. Performing urinalysis in febrile babies and adding those with convulsions raised the proportion to about 90%. Dr O’Meara says the tool can help to identify meningitis, although the classic signs – rash, photophobia, irritability and neck stiffness – are also important. He says: “How do you reliably pick up meningitis? You listen to the story, how things have changed, and the speed at which things have changed. “Take a decent history and examine them well. The features are more subtle in younger children and infants, so you need to be even more careful.” Febrile children with a non-blanching rash should be immediately started on antibiotics and sent to hospital, Dr O’Meara says. A patient handout on recognition of serious illness in children based on the ABC system is available at www.sch.edu.au/health/factsheets

ABC – FLUIDS IN, FLUIDS OUT The triage system at a glance A = Arousal, alertness and activity Warning signs: listlessness, apathy, lack of interest in people or toys B = Breathing problems Warning signs: fast rates, effort in breathing, grunting C = Circulation Warning signs: mottling or, most importantly, pallor

Fluids in Warning sign: intake less than half of normal Fluids out Warning sign: less than four wet nappies per day

DEALING WITH ACUTE VISUAL LOSS

Eyes wide open John Downie, a vitreoretinal surgeon at the Sydney Eye Hospital. “Otherwise, the patient could end up losing the sight in both eyes,” he says. “And the drugs are not going to do any harm in the short term if the diagnosis turns out to be disproved.” ESR and CRP tests also need to be ordered immediately in such cases so that the results will be available to the ophthalmologist on referral. The loss of vision with temporal arteritis will generally be sudden, severe and persisting. Patients may also experience systemic symptoms such as headache, jaw claudication, fever and anorexia, aches and pains or sweats. Acute visual loss can be caused by a range of other conditions, including glaucoma, retinal vascular occlusions, optic

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High-dose steroids should be started straight away if temporal arteritis is suspected, without waiting for the diagnosis to be conﬁrmed.

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THE 74-year-old patient presented with neck pain, headache and an itchy left eye. Both temporal arteries were prominent and the GP noted visual acuity in the left eye was 6/60, compared with 6/9 in the right. Suspecting temporal arteritis, he contacted an ophthalmologist to conﬁrm the diagnosis. Unfortunately, the ophthalmologist disagreed and the GP instead initiated treatment for retinal vein thrombosis – a decision that cost the patient’s sight in one eye and led to the GP being successfully sued. So even the experts can get it so tragically wrong, there are some simple rules of thumb to keep in mind. One of those is that high-dose steroids must be started straight away if temporal arteritis is suspected, without waiting for the diagnosis to be conﬁrmed, says Dr

nerve conditions and ‘mechanical’ problems such as retinal detachment or vitreous haemorrhage. While all cases require urgent – generally same-day – referral to an ophthalmologist, GPs can generally make a preliminary diagnosis based on a careful history and simple examination, including testing visual acuity and visual ﬁelds and checking any pupillary reactions. The likely cause of visual loss will inﬂuence the referral path. Patients with transient visual loss – amaurosis fugax – need urgent referral to a neurologist for management of stroke risk, as well as being referred to an ophthalmologist, Dr Downie says. “These patients may have effectively had a transient ischaemic attack in the eye and there’s a growing consensus that all TIAs should be treated as emergencies.”

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TIPS FOR COMPLIANCE

Don’t stick to the script BY JANE MCCREDIE THERE’S the woman who forgets her contraceptive pill for days at a time, then takes three at once to bring herself up to date. Or the elderly couple who happily swap medications when it suits them. He’ll have one of her “pink ones” when he runs out of his – never mind that hers are bisphosphonates and his are antihypertensives.

Not to mention the baby boomer who doesn’t bother to tell you about the joint he smokes each night “for relaxation”, the ginkgo he believes will prevent Alzheimer’s, or the St John’s wort he’s taking for his depression. Helping patients to manage their medication can be challenging at best. Initiating a home medicines review can be useful in those at high risk of mixing up their medicines, as can occasionally asking patients

to bring everything they’re taking into the surgery. “It’s amazing how many are doubling up, taking two lots of the same things under different brand names,” one GP says. You can also ask practice staff to give selected patients a simple questionnaire based on the Morisky scale to assess their compliance with medications (for one version of this scale, see box).

Patient compliance questionnaire

TARKA® - recommended as second line BP therapy 1

The combined power of an ACEi plus a CCB • TARKA: effective control irrespective of baseline BP 2

1. Do you ever forget to take your medication? 2. Are you ever irregular or inconsistent about taking your medication? 3. When you feel better, do you sometimes stop taking your medication? 4. If you feel worse when you take your medication, do you sometimes stop taking it? Patients who answer yes to any of these questions are considered to have inadequate adherence to medication. Source: National Prescribing Service

THE GENOME

• TARKA: 8 out of 10 patients achieve BP target 3 • TARKA: the power to help maintain BP control 2,3

All in the genes

PBS Information: Restricted Benefit Hypertension in a patient who is stabilised on treatment with trandolapril 4 mg and verapamil hydrochloride sustained release 240 mg. TARKA 2/180 is not listed on the PBS. PLEASE REVIEW APPROVED PRODUCT INFORMATION BEFORE PRESCRIBING. Full Product Information is available on request from Abbott Australasia Pty Ltd. ABN 95 000 180 389. 32-34 Lord Street, Botany NSW 2019, or by calling the Medical Information Service on 1800 225 311. Indications: Tarka is indicated for the treatment of hypertension. Treatment should not be initiated with this fixed dose combination. Contraindications: Hypersensitivity to trandolapril, any other ACE inhibitor, verapamil hydrochloride or any of the inactive ingredients; history of hereditary and/or idiopathic angioedema or angioedema associated with previous treatment with an ACE inhibitor; high flux haemodialysis low-density lipoprotein apheresis; severe left ventricular dysfunction; hypotension or cardiogenic shock; sick sinus syndrome; second- or third-degree AV block (except in patients with a functioning artificial ventricular pacemaker); patients with atrial flutter or atrial fibrillation and an accessory bypass tract; use in pregnancy, lactation or in children. Precautions: Renal impairment; hepatic impairment; desensitisation therapy; hypotension; hyperkalaemia; neutropenia/agranulocytosis; surgery/anaesthesia; dialysis; valvular stenosis; heart failure; periodic monitoring liver function; accessory bypass tract; first degree atrioventricular block; hypertrophic cardiomyopathy; attenuated neuromuscular transmission e.g. Duchenne’s muscular dystrophy. Adverse Effects: Hyperkalaemia, angioedema, hypotension, taste disturbances, upper respiratory tract infections; hyperlipidaemia; headache; dizziness; atrioventricular block first degree; cough; dyspnoea; constipation; nausea; back pain; asthenia/weakness; chest pain; increased alanine aminotransferase. See full PI. Interactions: Antihypertensives; alpha blockers; antiarrhythmics; theophylline; carbamazepine; phenytoin; antidiabetics; rifampicin; phenobarbitone; midazolam; beta blockers; digoxin; cyclosporin; inhalation anaesthetics; HMG CoA reductase inhibitors; lithium; HIV antiviral agents; sulfinpyrazone; neuromuscular blocking agents; aspirin; doxorubicin; alcohol; grapefruit juice. Presentation, Dosage Regimen and Route of Administration: Available in blister packs of 28 film coated tablets containing 2 mg trandolapril and 180 mg verapamil or 4mg trandolapril and 240 mg verapamil. Adults: 1 tablet daily, swallowed whole with water in the morning with or after food. Date of Preparation: 18 April 2008. PBS Dispensed Price: 4/240mg $41.61, 2/180mg is a private prescription. References: 1. Guide to management of hypertension 2008, Quick reference guide for health professionals, accessed at www.heartfoundation.org.au/Professional_Information/Clinical_Practice/Hypertension on 29 June 2008. 2. Messerli F, et al. Blood Pressure 2007; 16 (suppl 1); 6-9. 3. Data on file. 4. Tarka Approved Product Information. ® Registered Trademark. TAR061-0708-1. Abbott Australasia Pty Ltd. ABN 95 000 180 389. 32-34 Lord Street, Botany NSW 2019 Australia.

WITH THE human genome finally revealing its secrets, the era of personalised medicine is upon us – or so we’re told. New genetic markers and tests are appearing pretty much on a weekly basis, making it impossible for any busy clinician to stay fully abreast. So what to do? The Federal Government last year set up an online genetic resource specifically designed for GPs: www.gpgenetics.edu.au Although ongoing funding to keep the site up to date has yet to be confirmed, it does provide detailed practical information covering a broad range of inherited conditions, as well as testing, ethical issues and links to available services. Another good source is the University of Washington-sponsored www.genetests.org, which offers a wealth of information including a genetics tools section that is specifically aimed at GPs.

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TO LOOK A GIFT HORSE IN THE MOUTH

THE SECRETS OF TIME MANAGEMENT

Present tense A JAR OF home-made jam or a box of chocolates at Christmas are harmless enough, but sometimes it’s wise to be wary of patients bearing gifts. That expensive bottle of ﬁne malt whisky might go down well at the time, but you could live to regret it when the patient turns up a few weeks later waving an application for a disabled parking sticker. “It just needs a signature here, Doc.” Requests for priority appointments, a reference, even help with a court appearance … suddenly it’s looking like an expensive bottle of whisky indeed. So, the general advice is to accept only small tokens of appreciation, tactfully refusing anything more substantial. If refusal is difﬁcult, you can always tell the patient you don’t accept substantial gifts for yourself but would be happy to pass the item on to a local charity.

THAT NOTES LAST A LONG TIME

Indelible record THE 18-YEAR-OLD student came in because she was having difﬁculty with exam stress and the GP noted her anxiety in the notes. More than a decade later, the doctor was horriﬁed to learn that her patient had been refused life insurance because of a pre-existing “anxiety disorder”. It’s a useful reminder that comments in notes can have unintended consequences for patients and doctors if they are later revealed in an insurance report or in legal proceedings. In the absence of a clinical diagnosis, trigger words, such as “anxiety” and “depression”, are best avoided as they can come back to haunt the patient even years later.

Action stations Conquering the time bandits of procrastination, paperwork and emails. BY MARGE OVERS

Dealing with paperwork While the mountain of paperwork in general practice grows, many GPs pretend it’s not work, and tack it onto the end of the working day as if it’s a hobby. But it’s important to acknowledge paperwork as part of the job and schedule time for it. A doctor’s paperwork can be overwhelming and it can be easy to dither. We all know how it works – you sit at the desk covered with paper, pick up the ﬁrst piece of paper, don’t know what to do with it, put it down and pick up another. Eventually you touch all the pieces of paper on the desk and it makes you feel like you’ve actually done some work. One of the keys with paperwork is that you should handle each piece of paper only once, using one of the three Ds: do it now, diarise it or ditch it. For those for whom ‘ditching’ seems too ﬁnal, there is a fourth option: the just-in-case pile, which you can turf every few months.

Managing e-mails

HOW TO SAY NO WITH STYLE

The ‘corridor’ consult

The electronic version of paperwork, e-mail, is also increasing but unlike paper, which sits silently on your desk, e-mail beeps and often distracts your train of thought. Some people ﬁnd e-mails addictive and get anxious if they don’t check them regularly. The solution is to have set times to check e-mail. It also helps to set aside time for e-mail that is just before an appointment – so that if you have a deadline you’re likely to be quicker in responding. It can also help to have someone in the practice screen and prioritise your e-mails to reduce the number of e-mails that land in your inbox. The ‘three D’ rule applies to e-mail as well. Once you open it you have to deal

YOU’RE JUST picking up your fork to tuck into the terrine when it starts: “So you’re a doctor?” It’s a heart-sink moment. You wonder what it THAT IT’S OKAY TO SACK A PATIENT will be this time. A suspicious-looking mole? A strange feeling in the chest? Whether it’s the acquaintance at a dinner party or the regular patient at your local café, every GP THE DRUNK who throws up in the waiting room, needs a strategy to deal with the person seeking a the woman who makes racist comments to the free after-hours consult. receptionist, the businessman who regularly There’s always the polite but ﬁrm refusal, of asks for a new script to be faxed to his golf club course, but if you have the chutzpah you can go because he doesn’t have time to come in … one step further. Perhaps not as far as the rural Which, if any, of these patients would you be GP who tells us his response to a request for test prepared to inform that you can no longer be their results in the supermarket queue is to say at the doctor? top of his voice: “Oh, I haven’t got the cholesterol The AMA code of ethics makes it clear that back yet, but I have got your HIV results.” doctors can decline to continue a therapeutic relaBut there is a middle way. “Oh yes, I’d love to tionship, provided it is not an emergency and the take a look,” you can say to your fellow dinner patient is informed of the decision and has access guest. “Just take off all your clothes so I can do a to an alternative source of care. full examination.” . 12 | Australian Doctor | Top 50 Things GPs Should Know

with it straight away – do something, plan to so something or delete it. If you’re not ready to take action, don’t open the e-mail.

Beating procrastination Procrastination is a double whammy – not only are you avoiding a task, you have a black cloud over your head because you know you should be doing it. These strategies can help: • Set speciﬁc times for tasks – and write those times in your diary. • For big or difﬁcult tasks, break it down into smaller bits. • If you do something that you’ve been dreading, have a reward afterwards. (That

means, having the cup of tea after you complete the difﬁcult report, not before.) A surprisingly simple way to combat procrastination is based on the motivating effect of action, which means that even a little action leads to motivation, which leads to more action, and you’ll ﬁnish the job before you know it.

This is an edited version of a story that ﬁrst appeared in Australian Rural Doctor. These time management ideas come from SA psychologists Hugh Kearns and Maria Gardiner, who run workshops for doctors, helping them to create a better balance between work and home. For more information, www.ithinkwell.com.au

End of the line

But, despite that, GPs often feel obliged to treat all comers, says Dr Ray Seidler, a GP in Sydney’s Kings Cross. Dr Seidler ﬁnds he has to set very clear parameters about the behaviour that is acceptable in patients. Patients who continually seek free advice by phone or e-mail but rarely come in for a consult may be candidates for dismissal. As may those who present drunk or ﬁlthy, are rude to practice staff, or who refuse to accept that they do not have the obscure cardiac condition they found on the Internet, despite all evidence to the contrary.

“Patients who continually rub you up the wrong way are not good for your psyche or your longevity in medicine,” Dr Seidler says. Before you actually do the deed, it is worth checking any legal requirements with your medical board. At the ﬁnal consult, be prepared for pleading and promises of reform. It may be best to keep it simple, making it clear that you do not believe this is a useful therapeutic relationship and handing your soon-to-beex-patient a list of other local doctors.

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HOW TO MANAGE LOW BACK PAIN

Going back to basics Ten tips to take the sting out of low back pain for both doctor and patient. BY PROFESSOR SIMON WILLCOCK LOW BACK pain (LBP) consistently appears in the top 10 list of conditions managed by Australian GPs, yet many GPs lack conﬁdence in their diagnostic and management skills when confronted with this problem.

1. LBP is mechanical in origin. Less than 10% of LBP seen in general practice will be due to other causes, so know how to assess mechanical pain (see point 5) and the ﬂags for other uncommon causes (signs of cauda equina involvement, weight loss or other systemic symptoms, age <20 or >50, and failure to respond to initial treatment).

2. The most common source of LBP is the intervertebral disc.

3. The next most common cause of LBP is facet joint dysfunction. Facet pain usually comes on suddenly, like a wry neck, or if associated with chronic facet pathology is only mild-moderate in severity.

4. Remember the sacroiliac joints. Sacroiliac joint pain is also common, especially in women. It is often less severe, but persists over days to weeks and is usually experienced in the gluteal region.

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Only use imaging to conﬁrm your clinical diagnosis, and never use it to “ﬁsh” for a diagnosis – you will catch too many red herrings.

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Most injuries are associated with an incomplete radial disc tear (internal disc derangement) with no herniation or prolapse. This will lead to a relatively slow onset of pain as an inﬂammatory response develops, with subsequent local muscle spasm (6-12 hours).

5. Use your hands. Examine from T11 to L5 to define the side and level of the problem. Examine the patient in a prone position to eliminate the action of postural muscles. Even though disc pathology is most common in the lower lumbar spine, facet joint problems occur at all levels. Document your findings and share them with the patient and other practitioners who are sharing management of the patient – for example, “Based on your history and my examination I think that you have an internal disc injury at L4/5 on the right side”. This enhances patient confidence and promotes respect from those whom you refer to.

6. Remember the thoracic spine. Thoracic stiffness and dysfunction is common and often asymptomatic. In patients with recurrent LBP (or neck pain), examine the thoracic spine to exclude stiffness, which may increase the load on the

and is due to direct trauma to unprotected neural tissue. Other pains in the lower limb are due to somatic referred pain, which is caused by irritation of a peripheral nerve (usually due to muscle spasm).

8. Investigations are not usually indicated in the assessment of acute uncomplicated LBP. Plain X-rays are rarely helpful. If you order imaging (CT or MRI) to confirm bony or soft tissue pathology, tell the radiologist where you think the pathology is. Only use imaging to confirm your clinical diagnosis, and never use it to “fish” for a diagnosis – you will catch too many red herrings (such as non-specific disc bulges, mild structural anomalies).

9. Avoid excessive immobilisation. It is essential to maintain core stability of multifidis muscles (small intrinsic muscles wrapped around each facet joint), abdominal musculature, pelvic floor. Exercises should start within 48 hours of the onset of symptoms. Failure to maintain multifidis function correlates directly with the development of chronic pain syndromes. lumbar and cervical spines, and contribute to recurrent injury.

7. Radicular pain signiﬁes direct neural compression and inﬂammation. Radicular pain arises from within the spinal canal or intervertebral foramina

10. Be optimistic in your prognosis. If you follow steps 1-9, your optimism will be well placed and your patients will share that optimism. PROFESSOR SIMON WILLCOCK is Associate Professor, Discipline Of General Practice, University Of Sydney Medical Program

HOW TO DEAL WITH NEEDLE PHOBIA

Blood and distraction NEEDLE PHOBIA is a hereditary condition but few patients fear the needle prick – what they cannot tolerate is their excessive vasovagal reaction, with its faintness, nausea and other bodily failings that can bring down the strongest individual. So the trick is to do whatever it takes to maintain cerebral blood ﬂow: have the patient lie down, tense their muscles (rather than relax, which is the usual advice proffered) and elevate their legs if they still have a marked vasovagal response. Next, distract the patient: draw up vaccines out of view of the patient, engage them in stimulating conversation or ask a penetrating question (ha ha), especially just before the needle plunge. Alternatively, ask the patient to do absurd actions such as cross their big toes over their second toes or to cough (amazing how few realise what you are up to). Finally, avoid alcohol wipes for vaccines unless the skin is obviously infected as there is no evidence the smear of alcohol reduces infection rates, but it will increase local pain. Instead, use ﬁrm pressure with a cotton ball immediately before the needle prick, to exploit the gate theory of pain and further distract the patient. Maintain your banter until the ordeal is over and you will have successfully cured your needle phobe. – Dr Gillian Deakin

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THE BEST WAYS TO RECRUIT

The right fit IF YOU’RE NOT HAPPY, CHANGE

Don’t settle for less “LOCUM WANTED – one month. Tropical beachside location. Excellent remuneration.” If you’re a city GP battling through yet another winter of coughs and colds, such an offer might sound attractive, but would you actually pick up the phone and do something about it? It’s tempting to think there’s nothing you can do about the aspects of your work that drive you mad. But it’s also generally wrong. The ﬁrst step can be to work out exactly what the problem is. If the computer is your bugbear, maybe you need some expert advice on your software – or just a quick typing course. Changes can be that small, or they can be huge. For one former practice principal who decided to go back to being a contractor, improving his quality of life meant cutting back his hours and accepting the associated reduction in income. For others, it may mean developing a special interest, teaching, starting a research project, moving practices, or even towns ... General practice has many faces – you just have to choose the one that suits you best.

HOW TO NEGOTIATE A CONTRACT

Get it in writing IT’S A FRAUGHT issue for many employee GPs, particularly if they have a personal friendship as well as a professional relationship with the practice principals. But just as good fences make for good neighbours, good contracts make for a good working environment. The ﬁrst rule is to be very clear about the conditions you want, including remuneration, hours of work and the support to be provided by the practice. Get as much information as you can about other people’s arrangements to ensure you are getting a fair deal, but also that your expectations are realistic. AMA guidelines say all agreements must be clearly documented in a written contract and recommend that you seek advice from your accountant or lawyer before signing. Whether you are a contractor or an employee, key issues to cover in the contract include: • the nature and hours of your work • what you will be paid and how it will be calculated • regular remuneration review dates and factors that will be considered • a provision to vary the contract if both parties agree in writing • the process for resolving any disputes. The AMA’s Guidelines on Service Contracts between Doctors and Medical Practice Principals is available at: www.ama.com.au/web.nsf/doc/SHED5G3DTH

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GPs who’ve appointed the wrong practice staff or doctor know how much it can affect their practice. Practice manager Marina Fulcher sets out a plan to find the best person to fill the vacant chair. SO YOUR favourite receptionist has told you she is leaving after nine years of dedicated service and you think your practice will fall apart without her. It is a loss, but it’s also an opportunity to review the needs of the practice and look at how things have changed since she was employed so you can find the right person to fill her shoes.

Step 1: Review the duties A duty statement/job description is the foundation stone of good employment. If there’s already a document, dig it out and dust it off. Does it still meet the needs of the practice? Probably not. The job description should include: 1. Position title 2. Employment conditions (full time, part time, casual) 3. Employment agreement (the award or other agreement that sets out the terms of employment) 4. Reporting relationships 5. Summary of position responsibilities 6. Selection criteria, essential and desirable 7. List and brieﬂy outline tasks/duties/ responsibilities (don’t forget to include “other duties as directed”) 8. Key result areas (this will form the foundation of future performance management)

Step 2: Advertise the job It’s vital to advertise a job, and resist the easy option of appointing someone you know, or the friend of a friend. If Mrs Smith recommends her daughter (“she’s a lovely girl doctor and she’s done a computer course”), ask her to apply when the job is advertised. Your advertisement is now easy to write based on the job description. Look at it as an investment and an opportunity to appeal to the kind of person you want. Set out the core skills and characteristics and ask for names of referees. Local newspapers are cost effective, as they’re inexpensive and your small ad will stand out. The Internet is also a good option, with a comprehensive ad costing less than $200.

Step 3: Review the applications Look at the standard of the application. If it’s poorly set out and badly written, is this the standard of work you want for your practice? Take the time to gather a few applications to get a feel for who’s out there. Sometimes you can be lucky and other times there is no one suitable. Don’t be afraid to wait or to re-advertise.

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Review applications against the essential and desirable criteria. Draw up a table with the criteria across the top and the names down the side, and then decide who you will interview based on the applicants who meet the essential criteria.

Step 4: The interview Don’t be tempted to squeeze interviews between patients. Set aside time when you won’t be interrupted and try to involve a couple of people at the practice. Prepare a standard list of questions so you ask each applicant the same or similar questions and end up comparing apples with apples. Look at the way each candidate presents – this shows how seriously they take the interview and how they are likely to present themselves for work.

Step 5: The decision Once you’ve shortlisted candidates who are the right ﬁt for your practice, the next and very important step is to speak to referees. Whether you’ve chosen one candidate or two or three, always speak to their

referees – don’t rely on written references. You should talk to a previous employer and preferably someone from their current employer. Again, a standard set of questions is useful and should include “would you reemploy this person?”. I always talk to at least two people. If you’re not happy with what they tell you, move on to another applicant and follow up their references. Some people scoff at the suggestion that gut instincts are important when employing staff. Some of us, however, have learnt the hard way when we have ignored our instincts when employing staff. I know I have. Gut instincts can be an indicator of whether the applicant has a suitable personality for your practice.

MARINA FULCHER is the national president of the Australian Association of Practice Managers.

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WHAT GOMERS* ARE

HOW TO READ A CLINICAL PAPER

House rules IF YOU don’t know that the first procedure at a cardiac arrest is to take your own pulse, you clearly haven’t been doing your homework. Along with the axiom that there is no body cavity that cannot be reached with a #14 needle and a good strong arm, this is one of the 13 laws of the House of God, the fictional Boston hospital immortalised in Samuel Shem’s 1978 satirical novel of the same name. Some of the medicine and attitudes may seem a bit dated now, but the adventures of junior hospital resident Dr Roy Basch still provide an entertaining, and sometimes enlightening, read. Many medical readers have pointed out the wisdom lurking in the book’s 13th and final law: “The delivery of good medicine is to do as much nothing as possible.” *For the uninitiated, GOMERS are elderly patients who refuse to die despite a huge burden of illness and low quality of life (GOMER = Get Out of My Emergency Room). THAT SMALL GESTURES MATTER

Sweat the small stuff YOU KNOW how you like it when the barista remembers the way you take your coffee without being told? Similarly, we should know that patients like it when we remember things about them. A simple question such as “How was the holiday?” means a lot. Even better if you can remember to ask young Holly how the netball game went. But how do you remember that much detail about your patients’ lives when you see 30 patients a day, and often the risk of saying the wrong thing can deter you from saying anything? Simple answer – cheat. Add small reminders to the notes so you know what to ask about next time they come in. It’s amazing how the therapeutic relationship can beneﬁt from other simple courtesies, such as apologising if you’re running late or saying goodbye again if you’re in the waiting room when a patient’s leaving.

Finding the truth Don’t believe a study’s conclusions without knowing how they were arrived at. BY JANE MCCREDIE

DO YOU know your case controls from your cohorts, your confidence intervals from your confounders? If the answer is no, it could be time for a quick refresher course in how to read a clinical paper. Claims don’t have to be untruthful to be seriously misleading. You might be told, for example, that a whiz bang new medication is five times as likely as the conventional treatment to benefit patients. That’s a 400% increase in likelihood of a positive outcome. Sounds good. But whether it’s risk or benefit, that kind of relative increase is not meaningful without absolute numbers. Are we talking an increase from one patient in 10 to five in 10, or from one patient in a milion to five in a million? That’s where the ‘number needed to treat’ comes in: how many patients would need to receive the new drug for one person to benefit?

And, of course, the likelihood of beneﬁt needs to be weighed against the risk of harm before a decision to prescribe can be made. The number needed to treat’s evil twin – the number needed to harm – also needs to be factored into the equation. Here again, a lack of understanding of the difference between absolute and relative risk can cause trouble. Alarmist claims in the general media about a “tripling of cancer risk” with a particular treatment are often a result of this confusion. Has the risk tripled from one in a billion to three in a billion, or from one in 10 to three in 10? If it’s the ﬁrst, you may be able to reassure your patient that they should not believe everything they read. If it’s the second, it could be time to make some urgent phone calls. For a useful summary, see this BMJ series on critical appraisal of clinical papers: BMJ 1997; 315:305-08, 364-66, 422-25.

Taking a closer look: the key questions

THAT A HOLIDAY WITH CME IS NOT A HOLIDAY

Make the break real IT CAN be tempting to Google your next holiday destination “plus medical conferences” in the search for a tax deduction – but stop to think before you do it. Do you really want to spend your week in Japan with a thousand endocrinologists or focus on haematology when you’re in Samoa? Real holidays are the ones where you have a complete change of pace and that means you don’t spend your days at clinical workshops and your nights at industry-sponsored drinks. Whether you climb a mountain or just lie on the beach, make sure your break away from it all really is away from it all.

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What type of study is this and what level of evidence does it provide? Double-blinded randomised controlled trials are the gold standard of research and can provide evidence of a causal relationship between a treatment and its effects. A systematic review of such trials provides the highest level of evidence. Observational studies provide evidence of an association but do not prove a causal relationship.

How many participants dropped out of the study before the end? A high drop-out rate makes the ﬁndings less reliable, as patients who had side effects or who didn’t receive a beneﬁt may have been more likely to discontinue. Check whether the researchers have done an intention-to-treat analysis; that is, one that includes all patients enrolled in the study and not just those who completed the treatment.

How many people were studied and how were they selected? Small studies are usually less reliable. As well, you may not be able to generalise the results of studies done in a population that is substantially different from your own patients – in age, sex or race – or that does not represent those likely to receive this treatment.

Have the researchers adjusted for relevant confounders? Have the researchers adjusted for other factors that could have affected the outcome, such as smoking, diet, exercise and age?

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Are the findings statistically significant? Make sure the p values are below 0.05 and check that the confidence intervals are not

too wide and do not cross 1. For example, a confidence interval of 1.2-1.4 is significant, but an interval of 0.9-1.1 is not. How many people would need to receive the intervention for one person to benefit? Look to see whether the authors have given a number needed to treat or – in relation to adverse effects – a number needed to harm. Do the conclusions match their findings? Are the findings mentioned in the conclusion statistically significant and have the researchers adequately acknowledge any limitations? Who paid for the study? Notice whether the authors are affiliated with major academic institutions or with industry, and consider the effects of any potential commercial interest.

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THAT GENERATION Y HAS A POINT

Dr Trinh Tran: “If I’m happier at work then I’m treating my patients better.”

Talkin ’bout their generation BY BIANCA NOGRADY HIGH MAINTENANCE, brash, cocky, selfcentred, demanding, ambitious and endowed with an overly healthy self-esteem – it’s hardly a ﬂattering portrait of generation Y. It’s easy to be dismissive of the under-30s – slagging off generation Y is almost a national sport but could it be that underlying that over-eager condemnation is a niggling feeling this cohort might actually have got it right? “They’re aware of themselves and where they ﬁt into life,” says Dr Ian Pryor, 61, a GP at the Tuggeranong Square Medical Centre in Canberra. “They have an understanding that life is more than just medicine.” The news that there’s more to life than just medicine might come as a shock to ‘old-school’ GPs – the ones Dr Pryor says began their working lives with the expectation of hanging up their shingle on day one and “them putting it on your box when you die”. Dr Trinh Tran, 29, remembers one such GP at a workshop she attended, a retired, country GP. “He was very much of the generation where you worked and you stayed behind late and your family accepted that,” says Dr Tran, a GP registrar in Gumeracha, SA. “I think he was a little bit disappointed

that our generation weren’t of that opinion.” And why should they be? Such a commitment, particularly in rural practice, entails long hours and being drafted into extra-curricular activities such as board meetings and town committees, not to mention the expectation that you are the doctor 24/7. All of which effectively means you can kiss goodbye to a social life until you kiss goodbye to medicine – something generation Y is not buying into. “Myself and colleagues, we just feel as if it’s something we want to maintain throughout life rather than something to look forward to at retirement,” Dr Tran says. And happier GPs make better doctors, she says. “I enjoy my work more if I have a work-life balance, and if I’m happier at work then I’m treating my patients better.” But there’s more to gen Y’s attitude than simply work-life balance. Peter Sheahan, a consultant in workforce trends and generational change, says there are three key things that gen Y needs from a job to stay excited and motivated: control, respect and contribution. “Do I feel like I have control over where my career is going, do I have control over my workload?” says Mr Sheahan, who has written widely about generation Y.

“Respect: do I feel like I’m fairly compensated for the work I’ve done?” Respect is also about their future, he says, do they feel that their future is being invested in? “The third idea is contribution – am I making a contribution where I work and does what I do make a broader contribution?” Not that any of this differs enormously from the expectations of generations before them, but with their greater conﬁdence and assertiveness, gen Y are better at demanding those expectations be satisﬁed – and walking away if they’re not. Dr Pryor, while acknowledging that the gen Y attitude might generate some

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They’re aware of themselves and where they ﬁt into life. They have an understanding that life is more DR IAN PRYOR than just medicine.”

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Old-school GPs can a lot from younger doctors making their way in medicine.

headaches for workforce suppliers, thinks it’s about time GPs took a little back for themselves. “I think GPs and particularly teachers are groups that society has preyed upon to do everything for as little as possible,” he says. So if gen Y want to reclaim a bit of ﬂexibility, who are we to argue? “My view is [that] as long as they come along, say what they’re going to do, work efﬁciently in the time so they’re not ripping off the system by having a bludge at your expense, I’m comfortable with that.” Top 50 Things GPs Should Know | Australian Doctor |

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Perfect practice Rural Victorian GP and practice management advisor, Dr Neville Steer, thinks many of his colleagues could run their practices more effectively. Here are three things he believes GPs need to know. BY JANE MCCREDIE

PAYING OTHER PEOPLE CAN SAVE YOU MONEY YOU HAVE to spend money to make money. It applies just as much to general practice as it does to any other business, though it’s not always easy to convince GPs of that. Dr Neville Steer puts GPs’ common reluctance to invest in the development of their practice down to the fact that many have not seen the difference that really good staff and systems can make to their own quality of life, the profitability of the practice and health outcomes for their patients. “It’s difficult to know what you’re missing out on,” says Dr Steer, who practises in Traralgon in Victoria’s La Trobe Valley. “If you haven’t worked in a practice that has got really good business systems, you just think what you’ve experienced is the norm.” Getting expert advice and hiring staff who can free you of some routine tasks – such as a practice manager and practice nurse – are among investments that can return more than they cost. Good practice managers will ensure revenue is maximised and the practice runs as efficiently as possible. They will also free doctors from administrative tasks, so they can do more clinical work. Similarly, nurses can contribute to the efficient running of the practice by carrying out tasks on behalf of doctors, such as triage and ringing patients with test results. Nurses are key to successful chronic disease management programs, and Medicare item numbers allow them to take over some routine clinical tasks, such as wound care and immunisations (see Secrets of the MBS, page 28). But they can also generate income for the practice through non-Medicare activities, such as occupational health and safety work. “Not everything has to revolve around Medicare,” Dr Steer says. Bringing in an expert to look at how your practice works can help to ensure you are making the most of your staff, facilities and expertise. A practice management consultant – or perhaps a business advisor recommended by your accountant – can help you put together a business plan as well as examining issues such as staffing, risk management and financial information. You can also employ a practice manager for enough time to suit your practice. A large group practice may need a full-time practice manager while a smaller practice may only need a practice manager one day a week or even just one day a month.

ALL PATIENT RECORDS SHOULD BE ELECTRONIC IF YOU use your computer for prescribing and to look up information, if you write the odd patient note on it but keep a paper ﬁle as well, you might just be the typical Australian GP. But that doesn’t mean you’re doing the best you can for your patients. The hybrid paper-electronic records kept by so many GPs are the worst of all possible worlds, Dr Neville Steer says. “There’s a risk of patient information getting missed because it’s in two different systems,” he explains. “GPs should be aware that a hybrid system is not best practice.” The use of patient data to improve health outcomes through initiatives such as the Australian Primary Care Collaboratives program has highlighted the need for fully electronic records. “We have now moved one step beyond just collecting data and storing it electronically,” Dr Steer says. “We are now using it to look at the way we practise – for example, am I achieving best practice in diabetes care?” Such questions can be difﬁcult to answer without crunching the numbers, he says. “There are now software tools that can analyse your performance against a number of clinical indicators. Electronic records allow you to compare yourself to the national average. If it’s there in writing and you have got measures, such as your patients’ HbA1c levels, it carries weight.” Although almost all GPs now use computers, Australian research suggests many have not fully embraced their potential. For example, one survey found that, while 80% of GPs with a computer kept some data electronically, only one-third kept all their patient information in an electronic format. A second survey found uptake of electronic prescribing was near universal, but GPs were far less likely to be taking advantage of the potential of electronic records to improve clinical outcomes by, for example, generating lists of patients needing immunisation or with particular chronic conditions. While the situation may have improved since the results of these two large national surveys were published in 2006, Dr Steer believes there is still a way to go. “In 2009, GP uptake of computer records should be 100%,” he says.

EVERY PRACTICE NEEDS A WRITTEN BUSINESS PLAN “I DON’T need a business plan because I already know what I want to achieve” is the attitude of many GPs. But preparing a written plan forces you to focus on where you really want to be and how you are going to get there, Dr Steer says. “The psychology is that if you put things in writing you gain commitment – if you just talk about it, it’s easy to get distracted,” he explains. “It’s easy to get caught up in the day-to-day things and not look at the big picture.” Written plans are also an effective communication tool, helping to ensure the practice principals share the same goals and that these are communicated to all members of the practice team.

But there’s no point in writing a business plan if you then leave it to gather dust in a drawer. The three essential qualities of the goals in a plan are that they are specific, measurable and achievable, Dr Steer says. This makes the plan a living document that can be used to measure progress along the way and alert you to any obstacles that emerge. For example, a plan might aim for 10% of practice income to come from nurse-run clinics within two years. If the figure is only 1% after the first six months, that is a signal that further changes need to be made. The take-home message? Have clear goals. Communicate them to all members of the practice team. And, most importantly, write it all down.

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YOUR LIMITS

Mere mortals The sooner GPs realise we are not superheroes and are just like everyone else, the healthier we will be.

“IF ALL else fails and you don’t have a clue what’s wrong, do a dipstick,” is the advice one GP would like to pass on to his colleagues. “Or a swab,” chimes in another. It’s a reminder that, despite all the genetic tests, the PET scanners and the MRIs, sometimes the simplest tests are the best. There’s no going past a good physical examination and a thorough history, of course, but if that leaves you ﬂummoxed, a brainstorming session with colleagues will often provide the clue. As one GP puts it: “A problem shared is a problem halved – and a new perspective usually helps.” And if you’re still uncertain? Just remember that you don’t always have to know what it is, as long as you know what it isn’t.

THE VALUE OF HAND-OUTS

Take-home messages IT MUST be something about us humans. When we’ve paid our money, we expect to walk away with something in our hot little hands. It’s one reason patients are often so anxious to have a script, any script. But there is an alternative to doling out antibiotics on demand – the patient handout. Having a list of instructions for common conditions ready to print out provides a tidy end to the appointment and helps the patient to leave satisﬁed, even if it doesn’t say much more than “rest and keep up your ﬂuids”. Another parting gift that can prove useful is a brief written summary of the consult. It’s a good rule of thumb that patients will have forgotten half of what you told them before they reach the car park – and most of what’s left by the next day. “What did the doctor say?” asks the spouse, waiting in the car. “Aw, not much. Could be my heart.” There goes 15 minutes’ detailed explanation of risk reduction. A simple sheet of paper with a brief summary of the presenting problem and a list of the actions the patient needs to take can help to overcome this. You can include medications, tests, lifestyle changes and specialist appointments to be made.

Where to get good patient handouts • Professor John Murtagh’s classic patient handouts are at www.australiandoctor.com. au/cmi.asp • The major children’s hospitals have excellent factsheets for parents. Try the Sydney Children’s Hospital at www.sch.edu.au/health/factsheets or Melbourne’s Royal Children’s Hospital at www.rch.org.au/kidsinfo/factsheets.cfm • Disease advocacy bodies often have good patient information.

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OKAY, WE’RE not only telling you the top 50 things you need to know, but we want to know the top 50 doctors, so hands up if you have never made a mistake. Keep your hand up if you’re always polite, patient and professional with your patients, never keep them waiting, always see them when they wish, always carry out preventive health checks in a timely fashion and base all your treatment on carefully researched best practice, evidence-based, of course. Wonderful, but all you with your hands still up should be scheduled for delusional disorder. The nature of our work is doing the impossible with far too little resources, skills, time and facilities. If we are going to maintain our work levels for decades, we GPs need to know how to stay within our limits and how to recognise the ways in which an unhealthy work ethic may push us beyond them. The Ancient Greek myth of Zeus and Semele contains a truth that we doctors would do well to heed if we wish to live our mortal lives with any degree of equanimity. When the mortal, Semele, calls on her lover, the god Zeus, to appear to her in his true archetypal form, she is immediately burnt to a crisp. Whenever we lose sight of our humanness and seek to identify too completely with some archetypal form, we too will suffer. In over-identifying with our professional persona – omniscient, omnipresent and omnipotent – we risk not being burnt up but burnt out. We doctors sometimes seem to forget that we are human and prone to the same frailties we are accustomed to seeing in our patients. Ask yourself how often you ﬁnd yourself working without the usual amount of sleep, meals, rest and social support that we recommend for other mortals. We may come to believe we are indispensable to our patients and end up failing in our other roles of partners, friends or family members. Every working GP is at risk of burnout and we need to have a high index of suspicion, as one of the early signs is loss of perspective – the burnt-out person is often the last to recognise it. But how do we conduct ourselves professionally while also maintaining our own wellbeing? Keep a very watchful eye on our own good selves during our working day (and after, for that matter). We need to be able to recognise when we are becoming too tired, hungry, overloaded, fed up or annoyed to continue a good level of care and STOP! Remember we are no different from other humans and need to take a break, have a stretch, have something to drink or eat, catch up with colleagues or make that personal call.

Australian Doctor | Top 50 Things GPs Should Know

Matt Clare

Simple is best

BY DR GILLIAN DEAKIN

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YOUR OWN GP’S PHONE NUMBER

Becoming a doctor doesn’t mean we have to start wearing our underpants on the outside.

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WHAT TO DO WHEN THERE’S NO CLUE

Becoming a doctor doesn’t mean we have to start wearing our underpants on the outside. And it is the recognition of our own frailty, our hopes and fears that we can better understand what our patients are experiencing. DR GILLIAN DEAKIN is a GP in Bondi, NSW, and the author of 101 things your GP would tell you if only there was time.

Don’t heal yourself IT CAN be tempting to try to look after your own health, but one of the best protections against burnout is to develop an open relationship with your own GP and make a point of seeing them regularly. Keep in mind the old adage: the doctor who treats himself has a fool for a patient. – Dr Gillian Deakin

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THE BEST WEB SITES

The wheat among the chaff It’s not all rubbish on the Internet – the trick is to know where to look. BY JANE MCCREDIE

THE PATIENT sitting opposite you is like a kid at a birthday party. He’s just found out there’s a new miracle cure for his type 1 diabetes and, even better, it’s all “herbal” and therefore “risk free”. Yes, you could be forgiven for thinking that the Internet has a lot to answer for. But while quack remedies and dangerous half-truths proliferate in cyberspace, there is also a huge amount of quality information online for doctors and patients. Sunshine Coast GP Dr Bryan Palmer, who reviews web sites for Australian Doctor, says sensitive antennae are needed to tell the online treasures from the trash.

“There is so much rubbish out there,” Dr Palmer says, citing patients who turn up with reams of articles downloaded from obscure journal sites or promotional material about various miracle cures. “Chelation’s a big one. I get that all the time.” Questions that can help you to evaluate the reliability of a clinical site include: • Who runs the site? • Who is paying for it? • Is the information peer reviewed? • Is it up to date? • Are authoritative sources cited? • Are contact details given?

Of the sites that have passed Dr Palmer’s personal test (see below), his favourite is www.gpnotebook.co.uk/. Designed for clinicians, the site boasts that it is the largest source of medical information on the web, with 27,000 pages, 65,000 links and 15,000 users. Another site Dr Palmer recommends as a good entry point is eMedicine (www. emedicine.com). And, of course, there’s always Google, which one study found provided the correct diagnosis more than half the time when doctors entered a list of symptoms into the search engine.

Top sites for your favourites list GENERAL GP notebook www.gpnotebook.co.uk eMedicine www.emedicine.com

SPECIFIC CONDITIONS Beyondblue www.beyondblue.org.au Excellent patient information on depression, anxiety, postnatal depression and bipolar disorder

Cancer Council Australia www.cancer.org.au Quality information for patients and doctors, including easy-to-use GP guidelines Diabetes Australia www.diabetesaustralia.com.au Clinical guidelines and a downloadable guide to managing type 2 diabetes in general practice Heart Foundation www.heartfoundation.org.au Answers to common patient questions plus fact sheets for GPs

THAT A SPOONFUL OF SUGAR REALLY DOES HELP

Sweet blessings SHE MAY have had a strange taste in hats, but Mary Poppins was no fool when it came to managing a sick child. When you’re looking for a procedural analgesic in infants, it’s hard to go past good old-fashioned sucrose solution. There’s plenty of hard evidence from studies in neonatal intensive care that dipping a baby’s dummy in the sweet stuff substantially lowers the level of distress associated with procedures. A Cochrane review found neonates given sucrose solution before a procedure had signiﬁcant decreases in crying, grimacing, heart rate and pain scores, compared with those given water. Repeating the dose every three minutes, up to three times in total, increased the effect.

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Australian Doctor | Top 50 Things GPs Should Know

MoodGYM www.moodgym.anu.edu.au Free program teaching CBT skills to overcome depression and anxiety National Asthma Council www.nationalasthma.org.au Fact sheets, statistics and asthma management tools National Breast and Ovarian Cancer Centre www.nbocc.org.au Includes an excellent breast cancer risk assessment tool for patients

Osteoporosis Australia www.osteoporosis.org.au Information for doctors and patients, including exercise and fracture prevention guides

National Stroke Foundation www.strokefoundation.com.au Clinical guidelines and online learning for doctors, plus patient information

Raising Children Network www.raisingchildren.net.au Excellent government-supported resource for parents of children aged 0-8

KNOW IF YOUR BREATH SMELLS

Frank friends JUST SPENT the day with a speck of spinach stuck between your front teeth and wondered why nobody pointed it out? Every GP needs a straightforward colleague who can tell you when your ﬂy’s undone or your skirt’s tucked into the back of your undies. Not to mention quietly offers you a mint when you’ve had garlic prawns for lunch ...

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Why I am a GP

Grahem Schumann

“I am a GP because I love the variety in my work. General practice gives me an ‘in’ into people’s lives. They share their thoughts, problems and lives with me. Looking after a number of generations gives me a lot of satisfaction. There is nothing like it – except holidays.” Dr Gavan Mackey, of Orange, NSW, with practice nurse Val McKenzie and Father Harley McKillop.

THAT WHAT YOU DO IS IMPORTANT

Why it’s all worthwhile BY JANE MCCREDIE ONE PHRASE that should never cross the lips of anyone working in general practice is made up of the three words “just a GP”. “What’s that about?” one GP asks in frustration. “Which is more demanding, spending your whole life looking at knees? Or working across the whole breadth and depth of medicine, never knowing what’s going to walk into your surgery next, and dealing with a hundred different problems a week?” A colleague agrees: “It’s an absolute privilege to be a GP – to have such access to our patients’ lives and to be able to have so much impact on the quality of them.” A third GP stresses the proud lineage of the profession. “We need to be aware that we belong to a healing tradition that goes back to Hippocrates – and even further in Aboriginal culture. We are the custodians of that for a time and it’s our responsibility to value it and pass it on.”

History of general practice THE CONCEPT of the general medical practitioner is as old as the first European settlement of the continent, yet Australia was one of the last developed nations to recognise general practice as a defined discipline of medicine. Up to the 1950s, most Australian medical graduates spent a period working in family practice and those who later chose to move to specialist practice generally had to train overseas. Post-war population growth and the expansion of hospitals saw the development of local specialist training, leading to fewer new graduates entering general practice and greater exclusion of GPs from hospital work, particularly in the procedural specialties. General practice came to be seen by some as the fallback option for those without the inclination or ability to follow the specialist path. By the late 1950s, doctors around the world had become concerned that the increasing focus on hospitals was leading to the disappearance of the traditional family doctor and the depersonalisation of care. Following similar moves in the US and UK, the Australian College of General Practitioners was founded in 1958, with these aims: • to promote a scientific approach to problems of disease at the level of the individual and the family • to promote the prevention of disease and guard the nation’s health and the welfare of the community by every means available to the general practitioner • to foster and maintain high standards of general practice

State Library of Queensland

GPs have a proud heritage. Don’t let anyone tell you otherwise.

A GP at work in Brisbane in 1941. • to encourage and assist young men and women in preparing for, qualifying in and establishing themselves in general practice • to stimulate postgraduate education of general practitioners by providing facilities applicable to general practice • to conduct clinical research into conditions most frequently seen and appropriately studied in general practice It was the beginning of a process that led to the establishment of formal GP training in the 1970s and to the recognition of general practice as a specialty in 1989. Source: Dr Michael Bollen and Professor Deborah Saltman. A history of general practice in Australia, Federal Department of Health 2000, www.health.gov.au

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HOW TO MANAGE THE PRESCRIPTION SHOPPER

Beware slick tactics Doctor shoppers hope that ﬂattery will get them everywhere in their quest for the next script. BY JANE MCCREDIE

Dr Ray Seidler: “They’ll elevate you to a status you’ve never even dreamt of.”

Shopper’s list Patients seeking medicines in excess of medical need often: • have a detailed knowledge of key medical conditions that can only be treated with certain types of drugs • present at the end of the day and try to get medication quickly before the surgery closes • repeatedly claim to have lost prescriptions or medications • claim to have a high tolerance of drugs and to have run out of scripts early • appear to have no ongoing relationship with any one doctor and may have travelled some distance to see you • have a supporting letter from another doctor about a condition that requires a particular medication.

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You prescribe on Friday night and, by Monday, your waiting room is full. It’s faster than sending out a group SMS.

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“HEY DOC, is that your family?” the patient says, picking up a photo from your desk. “Is that your wife? Jeez, she’s beautiful, isn’t she? And those are your kids. Aren’t you a lucky man?” If you’ve never seen this patient before, and he’s travelled from a distant suburb just because he’s heard what a great doctor you are, chances are what he’s really after is a script for opioids or benzodiazepines. Kings Cross GP Dr Raymond Seidler is well used to the machinations of such “boundary-transgressing” patients, who he says will use any form of flattery or manipulation to get what they want. “They’ll piss in your pocket and give you a nice warm feeling,” he says. “They’ll elevate you to a status you’ve never even dreamt of.” But Dr Seidler also knows the consequences of giving in to such demands. “You prescribe on Friday night and, by Monday, your waiting room is full,” he explains. “It’s faster than sending out a group SMS.” It’s an increasingly common problem. Medicare Australia’s prescription-shopping hotline now has almost 14,000 doctors registered with it, most of them GPs. The service took more than 18,000 calls from concerned doctors last financial year (up on 14,500 the previous year) and met more than 8000 doctors to discuss patients suspected of prescription shopping. So, if being told you look half your age or offers of unpaid help in your garden aren’t enough to ring alarm bells, what other signs can alert you to a drug-seeking agenda? Based on the experience of doctors registered with the prescription shopping program, Medicare Australia has compiled a list of common traits of patients who may be seeking drugs in excess of medical need (see box). A new patient turning up late in the day with an elaborate medical history is definitely a candidate. Watch out for an

Source: Medicare Australia prescription shopping program

encyclopaedic knowledge of symptoms or a catalogue of catastrophes, including convoluted explanations of why the patient is unable to go to their usual GP for the medication. A tattered 2003 letter from a pain clinic on the other side of the country may also be produced to back up the demands. At Dr Seidler’s busy Kings Cross practice, his receptionist is skilled at identifying “problem patients” before they even get into the consulting room, allowing the GP to emerge and take them aside for a quiet word. Leading the patient out into the street

can help to defuse a potentially threatening situation, he says. If a drug-seeking patient does get past the receptionist, the key thing is stop them before they get started on their wellpractised spiel. “They are extraordinarily adept at recounting their history,” Dr Seidler explains. “They give you every hospital admission, every injury – a litany of disasters. I put up my hand and I say, ‘Stop!’. And then I say it again, because they don’t normally listen the ﬁrst time. “Then I say, ‘What do you really want

today?’ And I tell them I can’t do that for them, I am terribly sorry, and I stand up straight away.” Of course, safely getting rid of the drug seeker is only part of the story. As one Sydney GP puts it: “We have to remember that these patients are going to die if they don’t get help.” But while GPs can offer advice on tackling addiction, and treatment for comorbidities, support services for these patients are often woefully inadequate. And that’s one problem for which nobody has yet found an easy solution.

WHAT JUNIOR DOCTORS NEED

Be a wise old head Imagine this scenario. A trainee pilot is ushered into the cockpit and waved off with a plane full of passengers and an “Off you go, see you at 5 o’clock!”. The trainee is under supervision, of course, from a more experienced colleague ﬂying the same route. Only problem is the supervisor is in a different plane. Sound ridiculous? Well, yes, but is it really all that different from what sometimes happens in general practice when junior doctors are put in a room on their own and left to cope as best they can? The AMA code of ethics says doctors have an

obligation to pass on their professional knowledge and skill, but ﬁnding the time to do that amid the demands of general practice can be a challenge. And that means the less assertive juniors can slip through the cracks. “GPs need to remember that not all junior doctors will ask for help when they need it,” one registrar says. Some may not even realise they need it without the prompting of an alert supervisor. While junior doctors need supervisors who can answer their clinical questions, the issues are

broader than that, says Dr Hilton Koppe, a medical educator with North Coast GP Training in NSW. “What I do is teach people the short cuts I have learnt over the years,” he explains. “It is not about the dose of ACE-inhibitors in hypertension. It is about the approach to people and listening.” Junior doctors need inspiring role models, Dr Koppe. “They need to be kept away from grumpy, whinging GPs, and exposed to people who are enthusiastic about what they do – not in a Pollyanna way, but realistically enthusiastic.”

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WHAT YOU’RE COSTING YOUR PATIENTS

THE FINER POINTS OF THE MBS

The bottom line YOU MAY think about the cost to your patient before referring for an expensive procedure or a private MRI, but it’s easy to forget about the cumulative effect of all the smaller health care expenses they face. It can be tempting to order a battery of tests just to make sure all bases are covered and nothing is missed. But are the extra tests really worth what they are costing the patient? And is the more expensive drug clearly better? Patients often feel embarrassed about raising ﬁnancial issues with their doctor, so the issue may never come up unless you take the ﬁrst step. And some people will just quietly discontinue treatments they are struggling to afford. A good start is to ask patients how much they’re spending on medications and services each month – and how they’re coping with that.

THE WEEKEND’S SPORTS RESULTS

Game theory WHEN A patient presents with chest pain on a Monday morning, it could be a good idea to ask: “Did you watch the big game yesterday?” Earlier this year, German researchers reported that the number of cardiac emergencies in their country more than doubled on days when the national soccer team was playing a World Cup match, with most of the impact seen in men. The ﬁnding prompted the researchers to suggest preventive measures were urgently needed. No, not cancelling the World Cup, but prophylactic medication and behavioural therapy ahead of stressful games. One Sydney GP, who has observed the cardiovascular impact of major sporting events in her patients, says knowing the latest sports results is all part of knowing what makes your patients tick. “We need to know about all those external things that affect our patients’ health,” she says. “The big local issues, the unemployment rate in the area and, yes, who won on the weekend.”

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Secrets of the book BY HEATHER FERGUSON

It’s not exactly light reading, but getting acquainted with the MBS can lead to a tidy increase in income.

Australian Doctor | Top 50 Things GPs Should Know

IT’S PROBABLY the dullest looking item on your desk, but if you look closely enough you’ll see the gleam of money. We’re talking about the Medicare Beneﬁts Schedule, a book so dry it could cure the worst insomniac. But wily GPs have found that getting to know it can lead to a satisfying income boost. A good starting point is the section on enhanced primary care (EPC) items, which all attract meaty rebates. Practice manager Jan Chaffey says EPC items for health assessments, team care plans, GP management plans and diabetes cycle of care are the most under-utilised of the MBS. In Ms Chaffey’s practice, Camp Hill Medical Centre in Brisbane, a community nurse does most of the work for a 75-plus health assessment in the patient’s home. The GP initiates and signs off on the assessment and organises referrals. “The GP contractor gets the same percentage as if they had seen the patient for a normal consultation,” says Ms Chaffey, the immediate past president of the Australian Association of Practice Managers. “It can lead to a big increase in their income.” Mr David Dahm, CEO of Health and Life, a practice management consultancy, calculates GPs can make $300-$500 an hour seeing other patients if they pass on most of the care plan work to their practice nurse. Don’t stop reading if you’re already doing this. It seems most practices are failing to make full use of their nurses, which is costing them a chunk of Practice Incentives Program income. Mr Dahm says that too often practices use their nurses to provide care around one item – for example, cervical cancer screening – and ignore all the other rebates on offer. “I recently reviewed the PIP status of 40 practices and the clear majority – 90% – were not picking up basic rebates yet are employing practice nurses

who are supposed to do help them take advantage of these items,” he says. One reason for this is that practice nurses can feel overwhelmed by the need to keep up with the requirements for so many items. In practices where there is more than one nurse, dividing up responsibility can work well. Among the newer items, one that is begging to be used is the health check item for patients aged 45-49 who are at risk of developing a chronic disease. GPs who are on to this item tend to use it opportunistically, organising the tests required when a patient comes in for another reason – travel vaccinations, for instance. The difference between this item and the level C rebate is almost $90. Practice management consultant Dr Neville Steer believes GPs could also take better advantage of level C items for routine consultations. One option is to time consultations using computer software. The difference between the end of a standard consultation and the beginning of a long one passes very quickly, he says, and in most situations the complexity required for a level C consultation is there. There are ways to make the task of getting to know the MBS less odious. MBS Online provides an easy way of identifying relevant item numbers – type in “removal of a foreign body”, for example, and 34 different procedures pop up. If you prefer working with hard copy, the RACGP has produced a summary of all of the relevant GP items, up until November 2006, which is available on its web site (www.racgp.org.au). An updated version is in the pipeline; MBS supplements can ﬁll in the gaps in the meantime. RACGP president-elect Dr Chris Mitchell says there are countless computer-based templates GPs can use to reduce the paperwork burden of EPC items. Try the RACGP, divisions, the AGPN and the Rural Doctors Association of Australia.

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THE GOLDEN RULES OF WEALTH

Slowly and surely These basic principles of money management hold true for everyone. BY NOEL WHITTAKER

1. Use compound interest EINSTEIN called compound interest the eighth wonder of the world because its effects are miraculous. Investing is like a health program or a diet – you seldom see results immediately. This is why people often start an investment program and quit after a few years because they think they’re not making much headway. With compounding, you earn interest each year on the previous year’s interest and your investment grows exponentially. Compound interest takes a while to get started. The secret is to start now and stick with it. Shares are good investments for compounding because dividends can be reinvested. Superannuation is good too because the money can’t be withdrawn until you reach preservation age.

2. Understand the importance of growth investments It’s a good feeling to have plenty of cash in the bank, especially when you can get a safe 8% as you can right now, but the problem with cash is that it has no tax benefits, gives you no chance of any capital gain and is eroded by inflation. A return of $8000 on a deposit of $100,000 sounds attractive, but tax could take $3200, leaving you with a net return of $4800 or 4.8%. Take off 3% for inflation and you’re left with a net return of just 1.8%. This is why holding cash over the long term is one of the worst investment strategies.

3. Appreciate the risk-return trade-off A general rule of investment is that the greater the risk, the greater the potential return. Greater risk may not mean the total loss of capital, but merely the volatility of returns over the investment period. Therefore, if you’re prepared to invest for the longer term, you should be prepared for some volatility in expectation of higher returns. Think about a person aged 65, who has $600,000 in super and wants to draw $40,000 a year. If their fund is diversiﬁed enough to earn 9% per annum, their money will last to age 95 if inﬂation averages 3% per annum. However, if they opt for a “safe” 5% return, their money will be gone at 82. In an age where most retirees can expect to live to 90, that’s a sobering thought.

4. Don’t invest solely for tax benefits Doctors are targets for those offering taxeffective investments and each year, as June approaches, you will find a host of investments offering 100% tax deductibility. They can be useful in certain cases, but anybody who uses them as a Band-aid solution because they haven’t budgeted for their tax may well find themselves in serious trouble. All they are doing is exchanging a debt to the tax office for a bigger debt to the bank. Remember, an investment should be

judged on its overall growth potential, not solely its tax deductibility. If you were to lose $10,000-$20,000, the tax deductibility would offer you little consolation.

5. Be an investor not a speculator Share traders are a lot like punters: they tend to overstate their winnings and understate their losses. If you’re going to try and time the market, you’re not investing, you’re speculating. There’s nothing wrong with this, provided you speculate with money you can afford to lose. Serious investors understand that the secret is time, not timing. So start early, stay focused and don’t try to jump in and out of the market.

6. Pay off non-deductible debt ﬁrst There are two types of debt: non deductible debt, where the interest is not tax deductible, and deductible debt, where it can be claimed as a tax deduction. One of the secrets of ﬁnancial success is to maximise your deductible debt and minimise your non-deductible debt. This is why all your deductible loans should be on an interestonly basis until your non-deductible debt has been paid off. Noel Whittaker is one of Australia’s leading investment advisers.

NOT TO TAKE NO FOR AN ANSWER

Try and try again EVER RUNG the authority prescribing hotline and been told your patient doesn’t qualify? Well, here’s a hot tip: pick up the phone and try again. Medicare Australia says its training and monitoring programs are designed to ensure a nationally consistent approach, but that is not always the experience of GPs on the ground. “Just keep trying,” one experienced GP tells us. “The ﬁrst operator may turn you down, but the next one might say yes.” Medicare does not record data on the approval rate for authority scripts, although about 97% of six million-plus requests received a tick back in 2004/05, according to an Australian Doctor report. You could have been forgiven for wondering whether the money saved by knocking back 3% of requests was worth all that red tape. Happily, since then, the number of drugs requiring an authority script has been slashed and Medicare expects requests from doctors to drop by about 20% this ﬁnancial year as a result.

TO DO CPD IN AREAS YOU DON’T LIKE

Step outside your comfort zone WHEN YOU need a few more CPD points, the most attractive option tends to be to pick something in an area you find passionately absorbing – whether it’s obstetrics, mental health or musculoskeletal pain. After all, you know you’ll enjoy it and there’s always more you can learn. But have you ever considered deliberately picking an area of practice you can’t stand? It’s worth considering whether the reason you dislike doing, say, prostate exams so much (apart from the obvious), is that you don’t actually feel all that confident about them. With increasing public pressure for more accountability in continuing medical education, it may be only a matter of time before the content of CPD is mandated, anyway. So, why not get in first and live a bit dangerously? Some GPs even report that learning more about a hated area of practice actually helped them to start enjoying that aspect of their work.

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THE VALUE OF GOOD PEER SUPPORT

HOW TO LAUGH

All in this together

Matt Clare

General practice can feel like a lonely profession. You may go through a whole day without exchanging a word with a colleague, left to grapple on your own with all the clinical and personal challenges thrown at you. Creating your own peer support network is an easy and rewarding way to combat the problem. GPs who have regular peer support, such as a journal club, often say they can’t imagine how others cope without it. Meetings can provide a safe place to, as one GP puts it, “air your insecurities” and receive moral support and advice from colleagues on tricky situations. All that and CPD points as well! And setting up a journal club is not that much harder than starting a recreational book club. Contact the RACGP for advice on CPD requirements, ﬁnd a congenial group of doctors and a pleasant place to meet, and you’re away.

Good days, bad daze

Life can be tough in general practice, but it can also be very funny, so let’s not take ourselves too seriously.

LET’S PLAY a game, shall we? Let’s call the game ‘Ain’t It Awful’. This excellent game was described by Eric Bern, a US psychologist and father of transactional analysis. It is easily recognised and requires no special training. Take four colleagues sitting around a table, perhaps at a drug do, and add a bottle or two of wine and a ﬁne meal. Player one opens with: “I spend half my time these days ﬁlling in forms for the government. We’re swamped with red tape.” Players two, three and four must then top this awfulness with their own stories and Ain’t It Awful is off and running. “Half the patients want to sue you. You make one mistake and the lawyers are on to you like vultures.” Much sage nodding around the table. Woe betide anyone who breaks the rules and suggests they had a great week or that they feel that they are pretty well paid for what they do. It’s true that general practice can be tough, it can be demanding, but it can also be funny, embarrassing, ridiculous and bizarre. And that’s just the doctors. Add patients and the process can be heroic, silly, inspiring and weird. Looked at

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Ask a businesswoman if she has ever had to miss her kid’s netball ﬁnals because of the demands of a deadline. Doctors are not the only people who face tricky days.

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BY DR JON FOGARTY

in the right light, many consults can have all the gravitas of a fart joke. To avoid grumpiness and hubris, we need to take our job seriously but not ourselves. How can we be serious when much of our day is spent looking up nostrils or inspecting bums? How can we be self-important when, deep down in our quiet moments, we know we are genuinely confident about what we say about half the time on a good day and the other half is spent with a quick perusal of the tea leaves and fingers firmly crossed? Sure, our job can be tough and patients can be demanding. Government expectation and red tape can be unrealistic.

Australian Doctor | Top 50 Things GPs Should Know

But let’s not be too precious or special. Ask a high school teacher if they have ever faced an unreasonable student or a demanding parent. Ask a businesswoman if she has ever has to miss her kid’s netball ﬁnals because of the demands of a deadline. Doctors are not the only people who face tricky days. We practise better medicine when we laugh at ourselves and laugh with our patients. Some patients are unreasonable. Some are old and dithery. Some insist on taking herbs and tonics but decline our pills. Welcome to general practice. In fact, welcome to life. The best GPs I know are passionate about things other than medicine. They have a circle of friends that may include the odd doctor or two but no more than that. They like their patients and their patients like them. We are all guilty of the occasional game of Ain’t It Awful but if we take the view, like Hanrahan, that “we’ll all be rooned”, a bit of the spark of life goes out for us. There are better games to play and most involve a bit of sweat, some laughter and a few good friends. DR JON FOGARTY is a GP on the Central Coast of NSW and a columnist with Australian Doctor.

HOW TO HANDLE THE LIST

Paper chase “I HAVEN’T been in for a while, doctor,” the patient says, digging into her handbag. “So I’ve made a little list.” You’re already running 20 minutes late and it looks like there’s a lot of writing on the crumpled piece of paper she’s holding. Odds are you’re looking at a Pap smear, some episodic queasiness, an ill-deﬁned pain in the back and perhaps a quick skin check. And, of course, she’s booked a short appointment. So, do you just sigh and get on with it, mentally apologising to all the other patients waiting outside? This could be one of those occasions when it pays to know how to say no and here’s how to do it: Step 1: Ask the patient to give you the piece of paper – remember, possession is nine tenths of the law. Step 2: Run your eye down the list to see if there is anything urgent, calculating what you can look at today without getting further behind. Step 3: Tell the patient what you plan to deal with now and ask them to make another appointment – specifying length – to talk about the other items.