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IMMERSe Survival Guide in HORSHAM The student doctor’s bag for getting around town Chris Ip, Jack Crozier, Laura Smith, David Breed

2012


Contents Introduction ................................................................................................................................. 4 Lister House Clinic ........................................................................................................................ 5 Parallel Consulting .................................................................................................................... 5 The Doctors and their patients .................................................................................................. 6 The Nurses ............................................................................................................................... 7 Midwives.................................................................................................................................. 7 Practice Nurse Sessions ............................................................................................................. 7 Other .......................................................................................................................................8 Specialists ................................................................................................................................ 9 Wimmera Medical Centre ............................................................................................................. 9 Parallel Consulting .................................................................................................................... 9 GP supervisors ........................................................................................................................ 10 Specialists .............................................................................................................................. 10 Arapiles Building specialists ..................................................................................................... 10 Wimmera base hospital ............................................................................................................... 11 General structure:.................................................................................................................... 11 Ward rounds .......................................................................................................................... 12 Intern lunchtime teaching meetings ......................................................................................... 13 Clinical meetings ..................................................................................................................... 13 Radiology meetings ................................................................................................................. 13 Melbourne students ............................................................................................................... 13 Interns/Registrars ................................................................................................................... 14 The Emergency Department .................................................................................................... 14 Dinners and Workshops .............................................................................................................. 15 Recreational Activities ................................................................................................................ 17 Festivals ..................................................................................................................................... 18 Sport ......................................................................................................................................... 21 Food .......................................................................................................................................... 22 CafĂŠ ....................................................................................................................................... 22 Asian ...................................................................................................................................... 22 Pub ........................................................................................................................................ 22 Fast food ................................................................................................................................ 22 Fine dining.............................................................................................................................. 23


Nightlife – the circuit .................................................................................................................. 23 How to think about Rotations...................................................................................................... 24 Women’s health ..................................................................................................................... 24 Surgery .................................................................................................................................. 25 Medicine ................................................................................................................................ 27 Children’s health.....................................................................................................................28 Mental Health ........................................................................................................................ 29 Musculoskeletal ...................................................................................................................... 29 ELPD ......................................................................................................................................30 DPCI .......................................................................................................................................30 Study Resources ......................................................................................................................... 31 Useful websites .......................................................................................................................... 32 Useful contacts........................................................................................................................... 32 2011 OSCE Stations..................................................................................................................... 33 2010 OSCE Stations..................................................................................................................... 36


Introduction Horsham is such a splendid town. It’s a place that is not too small and not too big. In many ways it’s just right. When I first learnt about my posting there on the IMMERSe program, I jumped right at it and thought that I would have a wonderful experience. In reality, there were few supports set up in the town and it took quite a while to get accustomed to it. Firstly it was the first time there were four of us. The hospital staff were not accustomed to having students all year-round. In addition, the Melbourne Uni students weren’t always the most interactive bunch of students and when they came usually had some clinical experience behind them from other rotations at the Royal Melbourne. It was the first year that Lister House had any students and therefore it was hard for such a large and historic clinic (perhaps the first multi-doctor clinic in Australia) to adapt to such changes. In many ways through trials and tribulations we have managed to make Horsham our home. We have learnt a lot in that journey and have built up a lot of support and friendships work and otherwise. This guide is written as to fill the void (after the honeymoon period) that we felt when we arrived. Hopefully it will share with you some of the experiences and lessons from 2011 and help you take ownership of your posting in Horsham. It really is a lovely place when you visit the surroundings and really get to meet the people who make up the community. I congratulate you on taking on the challenge that is rural health in Horsham, and I wish you well in your studies this year. I know you’ll do fine! If you need help in any way, we are only a facebook message/email/phone call away!

Chris Ip

Former IMMERSe Horsham Student (2011)


Lister House Clinic Parallel Consulting Parallel consulting was not done effectively in 2011. At the beginning of the year neither the students nor the GPs had any understanding of the process. This has largely been overturned with the increased presence of Deakin students over the year, however there is still a long way to go. Most notably is the paucity of occasions where the doctors make the time to watch what you are doing and provide constructive feedback and ask you questions/make suggestions about what you could have done better, things which must not be missed, what the next step in the management might be and other such questions. The staff at Lister House are very welcoming but tend to stay within the comforts of their own offices – do take time to visit them and discuss any issues or needs with them at any time. Amanda Wilson was for us a self-appointed student co-ordinator whom we used as the first port of call. She is awesome with timetabling and communicating with doctors, after all she is married to one. The Good – you will experience styles of practice from all the different doctors at the clinic, because they tend to keep to their own rooms they may even be unaware of how someone else practices. You can learn from habits by taking the ones you like and discarding those you don’t like. Yu Yu the GP registrar is a great friend and is often to be found in the library during her lunch break and will call you up to talk about cases and so forth if you tell (ask/request) her to. Good to invite her over for a barbeque (since she probably needs the peer support and friendship as much as you do given the communication problems at Lister house). In contrast to the doctors, all the practice nurses and the reception staff are really friendly and will bend over backward to help you out. NB: When being with the duty doctor during parallel consulting and seeing a patient whom your supervisor may be unfamiliar with, you may have the upper hand since you have followed them with their regular doctor at the clinic. The Bad – there will be a fair amount of moving around rooms at Lister House, although you can get accustomed to the student room. Your parallel consulting will most likely be in a different room nearly every time (let the girls at reception know which room you are in in case you need to be found or ask them which room is free in case things have changed on the day). Because they tend to keep to their own rooms (a numer of the doctors have the reception staff bring them tea/food etc into their rooms) it is often very difficult to engage the doctors socially which partially negates one of the key benefits of IMMERSe. We used to make appointments for ourselves on the doctor’s schedules to remind them that we were parallel consulting with them (Amanda usually sorts this out on the rosters). Still, it is important to talk to the doctors or phone them the day or morning before. They are only human and will forget at times. The appointments were also designed for them to allow time to give feedback and sign assessment sheets. The lack of supervision and familiarity of our coursework and its requirements sometimes made doing things like mini-CEx under supervision difficult. This is especially more of a headache since there is a lack of consistency with the supervisors (you may be with Dr. Leembrugen one day and Dr. Foord the next) as it becomes hard for all of them to keep track of your progress (especially when they don’t talk enough with each other!). So, make your progress known with each of the other doctors! Know their case mixes (listed below) and strengths (you will figure this out) and use


these to your advantage! At times we resorted to Doctor’s signing assessments with only the handover feedback at the end of our consult (which is not ideal, as there may be parts of your consultation which your supervisor has missed which they could critique and provide feedback on). The Truth – Not knowing what’s happening can be frustrating at times on both ends. Make sure that everyone is on the same page in terms of parallel consulting, logbooks, and assessments with some good communication (this may mean repeating things). At the risk of sounding repetitive, communication, communication communication. It may seem that this is not reciprocated but persevere. We have talked to the doctors about the problems with communication and social inclusion so hopefully things will improve this year. Otherwise it’s not such a bad place to be.

The Doctors and their patients Dr. David Wilson Case mix: Mostly a mix of children’s health, women’s health, and the regular GP chronic disease management. As with Dr Wimbury, you are likely to see a number of patients with substance abuse issues and may see some patients in police custody. Dr Wilson also deals with child abuse victims and DHS clients. Dr. Chris Wimbury Case mix: As with Dr Wilson, you are likely to see a number of patients with substance abuse issues and may see some patients in police custody. In addition to the chronic disease management, there is quite a wide mix of patients. Dr. Chris Foord Case mix: Chronic disease management with his (very) long term patients is a given with any session. Dermatology and musculoskeletal issues also appear regularly. Along with Dr Sood, most likely to get patients ringing on the day for an appointment so often an interesting mix of acute/subacute issues. Dr. David Leembrugen Case mix: As with Dr Foord, chronic disease management with very long term patients is a given. Aged care issues and patients with disabilities are also common. The only doctor in the region able to complete immigration medicals. Dr. Francois Pretorius (leaving to Penola) Case mix: You may not encounter Dr. Pretorius as he has announced that he will be leaving Horsham, but his case mix is mostly children’s health, women’s health, and the regular GP chronic disease management. Most likely to encounter 25-45 age group during these sessions. Dr. Ashraf Zachary Case mix: Chronic disease, in particular diabetes, makes up a lage component of patients. Expect to see GP care plans and coulples coming in together as well as the common dermatology and musculoskeletal issues. Dr. Divya Sood Case mix: Expect to see girls/women of all ages with gynecological and often pre-school/school aged


children. Of all the doctors, you are most likely to meet the acute/subacute patients who ring up on the day for appointments during these sessions. Dr. Yu Yu Khiang (GP Registrar) Case mix: Similar to Dr Sood. There will be another two GP registrars coming in 2012!

The Nurses Deb Krueger & Julie Mayer: they do a lot of chronic disease management care-plans and health assessments. Their office is in the same building as the student room! Yvette O’Kane: does chronic disease management care-plans and health assessments, and runs women’s health clinics Therese Florence: runs women’s health clinics and often found in Theatre Pat James: often found in Theatre Amanda Wilson ** (Student Co-ordinator): Women’s health Jo Merschini: diabetic nurse educator Leanne: you may find at reception doing admin or sometimes doing some nursing jobs too!

Midwives Cher McIntyre Jenny Bull: also a lactation consultant

Practice Nurse Sessions Theatre – wound dressing/excisions, bandaging, slings, injections, Implanon insertions, etc. Theatre is great for all these clinical skills. Pat will usually find you people to see if you are bored or have you do something. I always used to be good and do the dishes up there just for kicks.Procedural skills such as suturing and wound dressings can be achieved here. Flu clinic- starts around March is a great time to practice your jabbing technique. Expect to be really good at injections. You will do heaps and build up confidence and speed. Don’t forget to get the flu shot yourself! Also good time to learn about side effects of injections as this will come in handy for counselling or convincing patients to get the shot. Women’s health clinic – organise with Amanda Wilson to do this. This is fantastic for pap smears (especially for guys as your gender may limit your opportunity without a friendly female introduction). Patients never shy away from you with her around (they are often friends with her plus Amanda can talk people into just about anything). After a couple of attempts you will be confident to continue and improve on your technique. Good for mini-CEx assessment for women’s health. Amanda also does routine breast checks – which is great for Surgery assessment/log book. Therese and Yvette also do women’s clinics. Midwifery Antenatal/Postnatal clinic – Jenny Bull and Cher McIntyre run antenatal care and baby checks for mothers which is fantastic to check out and familiarise yourself with the ladies before catching babies at the hospital.


Diabetes Nurse Educators – Jo has some handy resources for getting your Type 2 Diabetes in check. She also works at the renal dialysis unit at the hospital and is a friendly face in the business. For Type 1 Diabetes experience arrange a time with the Leanne at the hospital or Fergis’ paediatric endocrinology team who visit every 3 months at the hospital. Medicals and ECGs – you will encounter many ECGs at the clinic with the practice nurses. Usually these are for work purposes. Care Plans – talk to Yvette or Deb about how to write the perfect Care Plan – this comes in handy for when patients come to have their careplan explained and signed by the GP. Also learn how to do a mental health script, as you may be asked to these during parallel consulting. Use your mental health scrips for your Psychiatry portfolio Finger-pricking – this is a skill you can pick up with either the Diabetes Nurse Educator or the practice nurse doing INR readings. Spirometry – during the year WestVic division held a workshop on spirometry, which our practice nurses did not attend. I’m not sure if they will hold the same events in 2012. We pretty much had our technique perfected by the end of the weekend workshop. Probably the best way to get a handle of this is if you check in with Andrew Bradbeer’s Respiratory clinics which he comes a few times during the year from Hamilton. This is good practice for general medicine – learning about COPD and Asthma – and also for OSCEs in terms of counselling and interpretation of results. Practice nurses also do a simplified version of spirometry for things like workplace medicals.

Other 

Home Visits – Dr. Wilson has a few interesting patients whom he does home visits regularly, tag along with him for the experience. Alternatively you may volunteer to do one yourself to check up on some patients. Some of these may be worthwhile for case presentations, as they are often quite complex cases. Practice nurses (Deb and Julie) also regularly go out on home visits as does the visiting psychiatric nurse, Sister Lee.

Allied Health visits – when you thought you were done with all the allied health visits in first and second year, there are some that you might find useful this year. A lot of this has to do with understanding how healthcare services work in Horsham, particularly how to get hold of certain services for your patients (making referrals) and for knowing who they are talking about if they say “Stuart” for example. These are a list of highly recommended for one/half day visits: Audiology – hearing aids are fitted by WIDEX who work a couple doors down from the student room at Lister House. The practice nurses also do a version of audiometry for workplace medicals. Optometry – Ross Both and associates are located across the road on Bailie St, they are quite keen to have students. Use this opportunity to work on your fundoscopy skills (otherwise you are stuck watching people measure optics) and if you are curious find out how the lenses are cut and fitted into frames.


Podiatry – good to spend a half day there to cover all your musculoskeletal foot questions (e.g. plantar fascitis, hallux valgus, pes cavus, pes planus, ankle instability, patella-femoral instability, Morton’s neuroma, nail problems, etc). Physiotherapy – good to work out their scope of practice if you haven’t already, ask about exercises and techniques you can prescribe your patients who have low back pain, shoulder injury, etc. Pharmacy – this is a worthwhile visit if you are dealing with scripts and calling the pharmacy regarding takeaways and methadone patients. Good to clarify what they expect on a script. Dr Wilson can organise a visit to a community pharmacy, if you want to visit the hospital pharmacy ask Prof Wolffe. Pathology – this visit gives you an appreciation for the speed in which it takes to process pathological specimens and good to clarify what they expect on a path slip. Psychology - Visit WestVic division of GP next door to Lister House to talk to psychologist and organise yourself if IMMERSe doesn’t do it for you.  Scripts – if you are bored and want to do something that will store drug names into your subconscious brain volunteer to help print out GP scripts for their webster pack patients. You will encounter many trade names for the same drugs and this will help with medication history with some patients. Learn the generic names, indications, and contraindications using the eMIMS software on Zedmed.

Specialists We have been led to believe by IMMERSe that there will be quite a number specialties timetabled in for you but FYI, these are the ones who consult from Lister House Clinic (you will also be timetabled sessions with the specialists at Wimmera Medical Centre): Psychiatry – Dr. Robert Proctor is a private psychiatrist who practices at Lister House every Monday. He works of sister Laurie Lee who attends most house visits and private one to one or family sessions with mostly subacute and chronic patients. Laurie has also an interesting research career in schizophrenia and family groups that you can ask her about. Paediatrics – Dr. Louise de Plussey and Dr. Maurice Easton are two paediatricians who visit regularly from Ballarat base hospital. Check with their schedule to arrange a time to sit in with them. They also have a couple of paediatrics lectures recorded on DSO/D2L. If you have questions about those lectures, you can ask them in person when you see them at the clinic. Cardiologists – Dr. Reddy and Dr. Chris Hengle are two cardiologists from Ballarat who visit regularly. They also travel to Aarat and Stawell. My experience with them has been rather fortuitous with sessions arranged on the fly, but they are very happy to have students. You will examine patients, read ECGs, and do a little bit of counselling. Surgery – Mr. Ian Campbell is the last general surgeon yet to move to Wimmera Medical Centre. Mr. Campbell is a fantastic teacher and clinician (he is also an examiner for the College of Surgeons, so be nice to him if you want to do surgery). Let him know in advance, as he can be quite busy at times. Respiratory- Dr Bradbeer or his off-sider visit periodically along with a respiratory technician, Vanessa. Have your own spirometry done if you can, for the complete experience.

Wimmera Medical Centre Parallel Consulting


There is a lot to gain from sitting in the driver’s seat, even when it seems like you don’t know what you are doing (most of the time). It’s amazing how little or how much you do can change someone’s health and life. The situation at Wimmera Medical Centre (WMC) with parallel consulting is much easier than Lister House Clinic where there is little confusion between GP supervisors.

GP supervisors Dr. Yvonne Cymbalist- sees a lot of women and children, and it is good to be in touch with her if you are not her GP student in WMC in order to see some women’s health. She does not have a great deal of patients with chronic medical conditions, or many male patients, so it is important to see these at the hospital with the medical team or in emergency. Yvonne does not do any procedural/surgical general practice, so it is important to sit in with the surgeons at WMC in order to see removal of skin lesions. She does do a lot of pap tests, so you will definitely get experience in this area when supervised by her. Dr. Gerard O’Brien- sees a lot of musculoskeletal/sports medicine and chronic disease patients. Well known for musculoskeletal issues. Dr. Doug Jinks- sees a lot of general medicine and has his regular chronic disease patients. Also has a background in anaesthetics and obstetrics, which he no longer practices.

Specialists We have been led to believe by IMMERSe that there will be quite a number specialties timetabled in for you but FYI, these are the ones who consult from Wimmera Medical Centre(you will also be timetabled sessions with the specialists at Lister House Clinic)

General Physicians – Dr. Martin Ebenezer and Dr. John Niall (locum) regularly consult from offices at WMC. Don’t be fooled by the octiginerian rambles of John Niall, he is a well of knowledge and teacher of many of the clinicians, including our very own professor Brendan Crotty. Dr. Niall is also a renal physician and does a lot of internal medicine. Whilst, Dr. Ebenezer has an interest in respiratory medicine (I believe, although when asked he seems to like everything). Dr. John Richmond – renal physician from Ballarat and topic leader of the medical rotation at Ballarat base hospital. Surgeons – Dr. Heinz Kohler and Mr. Shiran Wijeratne consult from here. You can organise tutorials, parallel consults or sit-ins with them. Be sure also to check out he procedures room and attend fracture clinic for logbook items. Dr Michaela Hock- is the obstetrician gynaecologist, and is very happy to have you sit in with her during consulting hours. She is usually in theatre Tuesday mornings, Wednesday afternoons, and Thursday mornings for general gynaecological surgeries, and does emergency cases also. There will also be a new O&G in 2012, Yacob.

Arapiles Building specialists Professor Samuel Menahem – a paediatric cardiologists who visits every 3 months (he consults out of the Arapiles building). Great experience listening to murmurs and seeing congenital cardiac conditions first hand. Worth at least three or four sessions. Make sure you obtain a copy of his notes


from the HOW-TO-TREAT compendium from the AUSTRALIAN DOCTOR magazine on innocent murmurs and Congenital murmurs. These have been rather useful. Either email me or contact Menahem’s rooms directly for a copy or search Australian Doctor archives. Dr. Tate – a dermatologist who visits every 3 months (he and his team consults from the Arapiles building) Dr. George Kanaourakis – oncologist Mr. Richard McMullin – urologists from Ballarat who consults regularly here. Mr. John Patrikios – orthopod who consults weekly in conjunction with theatre time when he is in Horsham. Mr. Niall McConchie – ENT and Maxillofacial surgeon consults once every few weeks in Horsham. Changes in 2012: There are a number of specialist staffing changes in the pipeline for 2012 which may result in further opportunities later in the year. Of particular note is the speculated addition of another full time physician, another full time obstetrician/gynaecologist and another ED registrar. For full details consult Professor Alan Wolfe.

Wimmera base hospital General structure: It is important that we make some general comments on the structure of the hospital which will help you make sense of how you and others fit into the everyday operations of the hospital. This is not a GP run hospital, think of it rather as a miniature version of one of the larger clinical schools. i.e. there are specialists on staff under whom patients are admitted and have junior doctors (registrars and interns) reporting to them who look after the patients on a day to day basis. In 2011, there were 8 registrars (4 medical, 1 Ob/Gy, 2 surgical, 1 Emergency) from the Austin and 12 interns (2 medical, 2 surgical, 2 anaesthetic, 2 emergency, 2 nights, 1 Ob/Gy, 1 GP) from the Royal Melbourne Hospital. These are part of their external rural rotations. Much of the time the interns will be doing the jobs which you may hear your classmates do in the other IMMERSe sites which don’t have interns (indeed at times there is a struggle to find enough work for the interns at times). Thought to be fair, the breadth of experience is greater here even though you may not get as much hands on experience as in other towns. The 4 medical registrars and 12 interns change every ten weeks (the registrars changing 3 weeks before the interns), meaning you will need to train a new set of doctors to call you and be aware of what you can do every 3-6 weeks. This can get extremely frustrating during the year. However the 2 surgical registrars are there for 6 month rotations and the ED and Ob/Gy registrars have been there for years (for other reasons).


While the GP's have admitting rights to the hospital, if the patients have anything other than issues with aging or "acopia", they will be admitted under the medical or surgical departments. The communication between the GPs and the hospital doctors is often quite poor making things difficult for you. The Good - Thankfully, the nurses are well skilled and will do a wide variety of procedures which you will need for your log book. The large number of nursing staff, quite a number of whom rotate though the different wards and areas of the hospital, can make it difficult to establish a working relationship with many of them. The Bad - Aside from not being run by GPs, in Horsham as compared to other towns, the hospital is staffed by doctors 24/7. This means that being "on call" with the GPs is of little use as people will take themselves to the ED bypassing the GPs completely or the GPs will send them to the ED and go back home to bed (the exception is with Dr. Cymbalist who prefers to see all of her patients personally even if they are in ED!!). The less obvious consequence of this is that you will not hear about the interesting cases unless you happen to be at the hospital when they come in. Despite all efforts of 4 people over 12 months, it was extremely rare for us to be called about interesting patients or things to do. The final difference which must be mentioned it the inordinate number of medical students, at times there will be upwards of 20 medical students at any one time. This is far from ideal and may negatively impact your learning. The Truth - Unfortunately IMMERSe is reluctant to reveal that fact and even more reluctant to listen to the problems created by this, but rather prefer you to be more closely attached to the clinic. Their standpoint is that it is a fact of medical student life, and that we have the advantage of sharing formal teaching organised for Melbourne Students. (Hopefully this may change?)

Ward rounds Medical ward rounds start at around 8AM in either Oxley or ICU depending on which one of the two medical teams you follow. If you decided to go it may be worthwhile to go for a few weeks to become integrated into that medical team (almost like a mini-rotation). Ward rounds can be useful if you know the patients yourself; otherwise they can drag on and get boring rather quickly. Dr. Ebenezer will ask you questions if you are on his rounds. Surgical ward rounds start at 7AM in the morning. These are not very useful unless you are following a patient (e.g. for ELPD patient journey assignments). The rounds don’t last for very long as the surgical team need to be ready to start in theatre at 8am. OBS/GYN ward rounds are dependent on who the patient sees. Dr. Wilson usually does a round each morning around 8.30 (but this can be variable depending on his schedule). Dr. Hock (Wednesdays and Thursdays) does rounds at 7.30 – as they will be required for theatre usually on those days. There is no real need to go to all of these. She also does colposcopys on Friday afternoon. GP ward rounds can be rather laid back and often more social than medical. It may be useful to help out and admit patients for GPs or keep a tab on patients while they are busy in the clinics. There is no need to go to these ward rounds.


Intern lunchtime teaching meetings These are run every Tuesday lunchtime and features free hospital grade food (sandwiches and a cold plate). Meat is a rarity at these, so either bring your own or be prepared to miss out on your lunchtime protein hit. The talks can vary and can be on anything of interest for the presenters. If you want you can get involved and present a topic yourself. Treat it as a PBL with experts to help you breakdown learning objectives/discussion points. Excellent opportunity for evidence based research (good for some of the assignments, such as EBM psyc or paeds talk).

Clinical meetings Dr. David Leembrugen runs talks for clinicians on Thursday lunchtimes. There is a schedule with the talks in H.I.S or in your clinic on a noticeboard somewhere. There is free food at these as well. Speakers usually feature visiting specialists and are worthwhile going to. Occasionally registrars and interns may present interesting cases as these as well, often in preparation for the professorsorial meeting (which I will come to later).

There are also weekly OB/Gy meetings with food on Wednesdays, these started late last year and I have not been to one. There is also a Rehab meeting weekly which may be worth going to, again this started late last year and none of us have been to one.

Professorsorial meeting These occur twice a year and feature a panel of professors who visit and are put to the floor to pick their brains. You may want to be involved in presenting a case to do just that. Usually the meeting goes for a whole day and features presentations from interns, registrars, and GPs. Talk to Dr. Leembrugen if you wish to be involved. These events are quite popular amongst health professionals in the Wimmera region including those from Stawell and Aarat (and all the other towns within 2 hours of Horsham, includes Hamilton).

Radiology meetings These may or may not happen depending on the case load, and the interests of the medical teams/intern appointed by Dr. Ebenezer to organise these are supposed to be more regular for next year, fortnightly I believe. Reza, the radiologist, is usually quite good at explaining things. If you want a private tutorial with him you can organise one directly (he is even willing to come in on a weekend – it was useful covering chest x-rays, abdominal x-rays, and some common pathologies with him, but make sure it is when the Melbourne students are not around as he prefers groups of no larger than 8.

Melbourne students There are a few rotations of medical students from the University of Melbourne who spend a period of 6 weeks in Horsham for their Gastro rotation. Most would have done at least one clinical rotation, usually haematology. The students can vary in knowledge and skill base. From our experience, by the time they arrive you would have a better practical skill base than they do, however they are better with their knowledge. The students run a very structured PBL course and have tutorials with Ian Campbell and the surgical/medical registrars which Deakin students are welcome to join. The registrars will hold tutorials for Melbourne students based on their timetables which can be flexible


from a day-to-day basis. Best thing is to make friends with a Melbourne student and ask them what is on for them, if you wish to attend these sessions. DO join Mr Campbell’s tutorials with the Melbourne students. They are very well worthwhile, and he is a great teacher (be prepared for 8am starts). Dr Leembruggen facilitates their PBL sessions which you are also welcome to attend, though why you would want to I don't know! It is important that you endeavour to get as much of you surgical experience during the times they are not there as you can. Your opportunities in theatre may be severely limited during the half of the year when there are Melbourne students present (usually restricted to after hours or emergency lists, but it really depends on the enthusiasm of the students).

Interns/Registrars Days when interns are away on orientation, the Monday before their first shift (Monday afternoon) is when you can seize the opportunity to become the intern for a day. Write notes, divide jobs with the registrars, and get the on the job experience. This can be on the wards in Oxley/Yandilla, in Emergency or in Theatre (anaesthetics or even surgery). You will get four opportunities to do this: DO NOT MISS THEM!! When the Interns are around, make the most of them (conversely, also make the most of the opportunities when they are sick or away!!). Most are friendly and understanding, after all they were in your position not that very long ago. Some especially in the first couple of groups are quite resourceful and good with exams (since they completed their finals not that long ago). We used them to help us run tutorials to brush up on clinical skills (bedside tutorials), which some were quite happy to do. Registrars are the go-to people for knowledge. Speak to them if you have questions about certain conditions within their field of interests. These are the people you should talk to when ploughing through your common conditions, try by organising tutorials with them regularly. They will be studying at the same time as you in preparation for their exams so it is often a good chance for them to revise as well. The consultants at the hospital did not play much of a formal teaching role apart from intern teaching on Tuesdays and including us with Melbourne students. There is great deal of bedside teaching which the medical consultants do, particularly Dr Ebenezer, during ward rounds. TIP: For surgical related informal teaching Heinz and Shiran thrive on questions, Roger the anaesthetists will teach you anything you ask. I believe that there will be more formal teaching this year, based on our feedback and our enthusiasm and thirst to learn from their experience and knowledge as well as the consultants complaining about the teaching (or lack thereof) which we received.

The Emergency Department The emergency department is the place where a number of us felt at home this year. Learning from Jonathan Leslie (the ED registrar) is very useful. He will often get you to look at an ECG, or a chest xray, and is a very useful resource for examining x-rays of the musculoskeletal system. Jonathan will


also teach you how to do a ring block, and suturing. One of the most important things with Emergency is to be there frequently. You will not be called by the doctors or nurses if there is something exciting that comes in, because they are often too busy for this. Therefore you will see the most if you are there frequently- even if the department is quiet, an intern can run you through something you do not understand, or talk you through a clinical skill, or you can practice plastering with one of the nurses. It is important to always be polite to all of the nurses, even if they are not always very understanding. The ANUM can give you patients to see yourself, but will not always do so, particularly if the department is busy, or when they don’t know you very well. Jess is a particularly helpful ANUM, ask her for any information and she will always try to help. There was an Emergency department netball team at the end of this year, and we all played. If there is one at the beginning of 2012, try to become involved, because it is a lot of fun, and helps you get to know your workmates outside of the place!

TIP: Sometimes it can get quite empty and quiet. As a general rule of thumb, if nothing happens in the 20-30 min that you are there, you should probably do something else and come back later. Sometimes the department can get really busy and you may also be forgotten. Be proactive and help out in any shape, way, or form and be those spare set of hands. The interns and nurses will greatly appreciate it.

Dinners and Workshops West Vic GP division holds regular training sessions on various medical topics for GP continual professional development (cpd) points. Although these are targeted at GPs, med students are always welcome. These are held in Horsham/Stawell/Aarat and cover a variety of topics in GP/medical practice. There are usually quality clinical speakers and a nice dinner is provided. To find out, make sure you sign up to West Vic GP division’s mailing list or ask your GP supervisor (who usually receives flyers for these events) or email Annette Metcalfe (a.metcalfe@westvicdiv.asn.au). Visit: http://www.westvicdiv.asn.au/Site/EducationCalendar.aspx (not updated frequently) Drug reps visit regularly at the clinics. This can be a good source of information for your pharmacological knowledge, if taken with a large grain of salt and a critical mindset, and to familiarise yourself with drug names, indications, contraindications, interactions, PBS listings, etc.

Some of these are new drugs about to be released on the market and make topical discussion points amongst medical colleagues. Make sure you ask the reps questions, and make them work for your free lunch/dinner. Debbie Norton from NPS (national prescribing service) is a clinical pharmacist who runs workshops either at the clinics or she can make arrangements to see students only. She is the guru on common


prescribing practices of common drugs such as analgesia (chronic pain), benzos, antidepressants, and antipsychotics. Really useful pharmacy knowledge helping you get your head around some of the medications.


Recreational Activities Mt. Arapiles (only a 20 min drive away) is Natimuk’s claim to fame and is known to be a mountain climber’s paradise. There are numerous treks that can be taken to reach the summit of the mountain, or you can conveniently drive to the top. Speak to Graeme Excel (HMO manager) for information about maps of walks. If you like are into smaller rocks, Mitre rock is situated only across the road from Mt. Arapiles and offers climbs for beginners. Grampians are not far from Horsham and offers stunning landscapes and hikes which are worth seeing. Mt. Zero – This is an easy hike to the top, but offers a nice view from the top and can get a little windy. If visiting also visit the olive farms, as Mt. Zero Olive Oil is second to none. Mt. Stapleton – rated moderately difficult to difficult according to Parks Victoria. This is quite a rewarding hike to the top, can get slippery in the rain so watch out. Hollow Mountain – is also close by and offers a reasonable walk if stunning views too.

Roses Gap and Mt. Difficult - The walk around Roses Gap can be as short or as long as you like. You can start your journey around Beehive falls and walk all the way up to Brigg’s bluff and from their make your way to Mt. Difficult (might take you one very full day, you have to set up camp). You can also get to Mt. Difficult from the Mt. Difficult campsite. Look up Parks Victoria or google for maps and details. Mt. Difficult, fittingly, is rated difficult according to them and allegedly the hardest one to climb in the area. (The view from Brigg’s Bluff is breath-takingly beautiful and very much well worth the 3 hour trek from Bee Hive Falls) NB: @ Bee Hive Falls, there is Aboriginal rock art off a small track - keep a lookout for a small sign as you head out of Horsham on the Western (blink and you’ll miss it)


Wartook Valley and Halls Gap – There are plenty of things to do around here, including visiting Lakes and waterfalls (Silverband and MacKenzie are probably the most well known), tea houses,

eating and drinking. It’s a real tourist destination and things can be expensive.

Little Desert (Dimboola) – This is not a desert that you would expect, but earned its name from the desert-like soils. Only go here, if you are into native botany or getting lost in the middle of nowhere. Great for a quiet camp out, B.B.Q and star gazing. The Giant Koala- you will inevitably drive past the giant koala on the Wimmera highway on your way from Stawell. It is a great place for a photo and an ice cream. Apparently the Indian restaurant next door is not bad either.

Festivals Field Days (March) – is perhaps the largest agricultural machinery expo in the southern hemisphere. Go to get countrified! Great for the DPCI wiki on Farmer’s health, as there are usually a couple of related stalls set up. Also sit in a tractor/header or check out your dream caravan/boat/tractor/header.


Natimuk Show (March) and Horsham Show (September) – good to check out local produce, pet animals and go on rides. Horsham Cup (October)– might win some money here with a small gamble. Spring garden festival (October) – if you like gardens and mechanical organ pipes is held at the botanical gardens. Kannamaroo festival (November) – the Wimmera equivalent to Moomba and involves the closing of Firebrace St to make way for rides and stalls. Kannamaroo apparently means “no worries” in the Wimmera tongue.


Asthma Camp

Dr.

Wilson and several members of the community who are part of the Wimmera chapter of the Asthma Foundation run an annual camp for children with asthma. This is a great chance to go over asthma devices and counselling advice with children. It is also a lot of fun looking after the little ones and hopefully helping them and their parents improve their asthma management. I believe it is on the calendar this year for everyone and is a very rewarding experience.


Sport Laker’s football club – This has to be perhaps the best way to get to know local townsfolk as nearly everybody is mad about country footy. There a couple of leagues out there though, also requires quite a bit of commitment with regularly training and weekend games. If you are in the district league, some of these games will require travelling. Laker’s football club is located at Taylor’s lake about 15-20 min drive from Horsham CBD. Squash – Dr. Chris Wimbury is a keen squash player, talk to him if you want to join or if you need practice and want to have a hit. Racquets are available to borrow at the club or bring your own. There are a couple of tournaments run during the year for players of all levels (A/B/C/D). The club is very welcoming and can get quite sociable despite the competitive nature of the players. Great fun and good to get to integrate with the community. Fees were $80 for the pennant competition which included a bonus tournament later in the year. Games start at 7pm on either Wednesdays or Thursdays. Contact details: Horsham Squash Centre, 76 McPherson St, Horsham. Ph: 03 5382 2943 Badminton – Social badminton runs in the summer on a Monday night at the multipurpose centre at Horsham College. It costs $10 per night for a round-robin tournament socially. Welcomes players of all levels, you can pick up a racquet there to play with or bring your own. There is also a more serious winter competition which is played in teams, usually requires a bit of a commitment. Some of the senior players might even offer coaching if you need. If you don’t feel like you can commit you can always write your name down as a fill-in. Golf - Horsham offers a very nice 18-hole golf course, which once burnt down but has now been rebuilt. There is also a driving range. Costs are around $20 for 18-holes. NB: Dr. Leembrugen is a very keen golfer, if you want someone to go with but be warned he is rather good at the sport. Mixed netball – During the last off-season, the emergency department at Wimmera Base Hospital formed a mixed netball team which students were invited and welcome to play. Fun to see staff play and occasionally win. Dr. Leslie (Jonathon) is plays and often brings his son along. Some of the nurses Jane, Bernie, Jackie are organisers. Fees were $10 per person per game, held at Lanes and Games. Money left over go towards a kitty for drinks after a win!! Cricket – Stick around after exams and you may be involved with the annual VMO vs. HMO cricket game. This is perhaps the best way to get into cricket during the summer as you are welcome to play for the GPs and Surgeons against the interns and registrars. Indoor soccer – I know there’s a league around at Lanes and Games but did not join. Instead we had a kick around with a couple of the interns who were soccer fanatics. Horsham Aquatic Centre – is a YMCA facility that offers a gym and pool. They run fitness classes as well. Full membership is around $21 per fortnight per person (you can use your association with the hospital or claim that you are a family with your housemate to earn a discount).


Food Café Cheeky Fox – Arguably the best coffee in town. Dr. Proctor gets his coffee from there. Good food, reasonable price (a tad expensive). *#Chris’ favourite place+ Café Jas – I really enjoy Café Jas, especially the crayons and the butcher’s paper as table cloths. The food isn’t that bad either. This was where we used to meet up with Ruth. Coffee isn’t that fantastic but tolerable by my standards. Figtree café – According to our pioneer Deakin student Bree, this has the best coffee in town. Worth a try, but thought it was rather expensive. Chickpea café – great sandwiches. Didn’t get to try their coffee. Café Baghdad – quite the hipster paradise with decent coffee and a real organic feel about the place. Same goes for Café Oasis (which I have only driven past, but never visited)

Asian Thai Basil – the only Thai restaurant in town with excellent service and BYO, where premix king is just next door (how convenient). Some decent pad thai and reasonably generous portions. Palace (and the Jade Lantern)– the local’s like this place for Chinese. It is a little expensive. Personally, I’m not a huge fan and wouldn’t recommend it too much. If it’s Chinese I’m after I’d much prefer to settle for cheap eats at noodle kingdom (as they have chopsticks there) on Firebrace St. *#David thinks “the asian place ain’t bad”+ Toy’s – was not an enjoyable experience when we went with a group of interns, as they ran out of rice that night. The mini-golf isn’t too bad though, some very challenging holes there.

Pub Bull and Mouth – this is the standard eatery for almost all hospital functions, but doesn’t have a huge variety of foods. The Exchange – Not a bad dining experience, but sometimes can be a hit and miss. Dooen Pub – for an interesting pub experience, I’ve heard. The White Hart – the poorer cousin to the Bull. Collect Safeway/Coles dockets for 2 for 1 offers.

Fast food Capones – our regular pizza/pasta joint. They do some filling pizza/capone/pasta for a reasonable price. Much better than any Domino’s/Eagle boys garb. Doin’ Pizza on Dooen road – nice pizza joint if you are living on that side of town (Perry Drive residents)


The Chicken Shop – awesome chips and nice roast chook on the go. Conways – for a large variety of pies with nearly every pie imaginable, but some Cold Pie stories [ask David]. For the best pies, the Oven door bakery has a fine selection.

Fine dining The Capital (comfort inn on Firebrace) – awesome 2 course meals at $35 (choose from anything on the menu), nice dining experience. Even better when a drug company forks the bill, may be worth suggesting when they come to visit. The keen foodie can save up for a trip to the Royal Mail out in Dunkeld (approx 1.5 h drive) for an awesome degustation experience like no other. Alternatively you can offer to drive your equally keen registrars and have them to “pay for petrol” (you will miss out on the wine tasting).

Nightlife – the circuit 1. Bull and Mouth – Pool Table/ Juke Box 2. The Royal Hotel (TIP: get in before 10.30, as there is usually a line that starts forming at around then on a big night) – Pool Table, Dance Floor, Juke Box 3. Wilson’s night club (“dirty Wilo’s”) – Dance the night away at the only nightclub between Adelaide and Ballarat. Aarat features a disco with 8 regulars aged 30+.

Work Functions The Emergency Department holds an annual fundraiser ball at the town hall for some hospital flavoured fun! Christmas Party for Lister House Clinic if you stick around. Last year it was at an amazing goat farm with Kris Kringle, Gliterazzi awards, and excellent buffet food. Nice to see some of the girls out on the dance floor (especially Dr. Sood!!)


How to think about Rotations As you know in IMMERSe there are no formal rotations and all the six major themes are integrated which is more applicable for daily clinical practice in the GP/ED setting. There is an obvious advantage in this, as one would expect to see more often common presentations of conditions (and sometimes very rare ones too). There is also added flexibility in when or where one should study a certain aspect of a rotation. However, when it comes to assessments unfortunately these are broken down into the traditional rotations, and therefore it may be useful to study them separately but at the same time. I found that the best way of doing this was to choose two different rotations a day and try to focus around these. There will be some book study required as it is impossible to experience the whole gamet of clinical presentations from the common conditions list in Horsham alone. Here is a snap shot of how to get the most of IMMERSe to meet assessment criteria/logbook items/ and experience for these six rotations.

Women’s health Attend the antenatal classes (talk to the team midwives). Scout out the women you will follow. And catch some babies. Get on top of this early! (Something which all four of us learnt a little late in 2011) 1. Lister House runs a Women’s health clinic every week with one of the practice nurses: Yvette, Therese, and Amanda. Speak to one of them to tee up a time that suits. This is a good opportunity to practice pap smears, vaginal exams and breast exams. Not to mention other important holistic health issues for women (e.g. hypertension, dyslipidemia, obesity, musculoskeletal issues). 2. David Wilson in conjunction with the Jenny Bull/Cher McIntyre run antenatal clinics weekly that you can attend. You will get accustomed to doing an antenatal consult quite quickly. Dr. Wilson is pretty keen to use his portable ultrasound machine (these count as 1st and 2nd antenatal U/S) and would let you practice using that or the Doppler during these consults. Francois Pretorius (will be leaving to Penola) also runs these which you may see during your parallel consulting with him. If you are at Wimmera Health, Michela Hock also runs these sessions with her patients. This is a good way to practice antenatal stuff as well postnatal checks for OSCEs (this was one of the stations last year). Antenatal clinics are also a good way to meet women who you may be involved in their labour in the hospital (earns you street cred with the midwives), especially if you follow them for long enough (I followed one lady from 6 weeks until birth, having said that make sure you calculate roughly when they will deliver so that you don’t miss out on the date – as you may be away on face to face or whatever). 3. Antenatal ultrasounds are easier when you have a clientele of pregnant ladies that you are following – just ask for their permission and you can pretty much go with them. Otherwise, you can ask Pam in radiology to book yourself in randomly. 4. Antenatal classes are run weekly by a midwife from Yandilla (the women’s ward). When we were there they ran on Monday nights at 7.30pm. There are 6 sessions per group of mothers and


fathers to be. Light refreshments are provided. These are great as you can have a bit of fun, enjoy a tour of the birthing facilities and learn a little about birthing practices and postnatal care. Also great to meet women to observe for labour. 5. Deliveries are probably the most rewarding aspect of women’s health. C-sections are easy. Get involved in scrub in to assist. Vaginal births are a bit more difficult especially when there are midwifery students about. There is a list of bookings available on Yandilla which you can use to track the women you are following. In addition you can leave post-it notes on their medical records to call you when they come in, in the cupboard of preadmission medical records (ask the ward clerk to find out where this is). If Gwen (the OBGYN registrar from PNG) is around and if you ask her nicely she will get you involved. Joy and Fiona are also happy midwives who are full of experience and knowledge and have been quite helpful too. You will need to follow a few during the year. Pace yourself as this can be quite tiring with waits of up to 20 hours. Groom the ladies and respect and be nice to the midwives. Also take care of the support person, especially for C-sections as they can sometimes be forgotten (usually the fathers). There are roughly about 400 births per year in Yandilla, so that should be plenty for everyone. Start early, be on the lookout and get involved! 6. Gynaecological procedures are done in theatre usually on Tuesdays and Thursdays with Michela Hock. Make friends with Gwen and Yacob (who was not there when we were, but is returning as an OBGYN) who are keen to have you in on the action.

Surgery There are plenty of opportunities to suture and help out. Make yourself useful and get out there! 1. Melbourne students do their Gastro rotation here. Make the most of it, especially if they are a nice bunch of people and rather sociable – sometimes they might not be. You should receive a copy of their timetable in your pigeon hole at the hospital. Join in on their activities, especially tutorials with Mr. Campbell and the registrars (this may save you time organising your own). 2. Mr. Kitchen’s tutorials – Mr. Kitchen is a retired surgeon who still lives in the area and gives regular tutorials to the surgical registrars. Attend these for an insightful lesson on surgery. Very useful and he is a great guy. He is a little old-fashioned though. Be prepared to use your noggin! Find out when these are on from the surgical registrars. 3. If you are going to follow a patient, speak with the friendly nurses at Day Procedures (DPU) as they will get you orientated and ready to go. Meet your patients before they go in so that you can take a history or examine the patient. Having done this you are have increased your chances of scrubbing in or being involved as you have taken some ownership for your patient. Stay with that patient at least until recovery (this may mean that you miss the next case, but there should be plenty in a day’s work). 4. Patient Journey Assignment – It’s a good idea to get these done in the first half of the year when the Melbourne students aren’t around to save you some stress when it comes to exam time. The surgery assignment consists of two parts. One is a case journey and the other is a case report. Tell the staff that you are following a patient and they will be most helpful and fill you in with all the details you need. The same goes for the ELPD assignment. In addition to this, Wimmera Base has a pathway system – grab a copy of the pathway notes to see how things


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operate. This is a really good resource for ELPD. These pathways are reviewed by a working group, you can attend one of these if you are so inclined. Attend Preadmission Clinic (PAC) –Arrange a time with the surgical intern or check in with the girls at the PAC. Useful for your patient journey assignments, pre-op history, scouting patients before they return for surgery, and health assessments/examinations, etc. Theatre – this is a good place to take pre-operative histories, assist in surgeries, help out in recovery, learn to gown and glove with David or Glenda and/or help out with anaesthetics. The best time to do anaesthetics, getting airways, bag and masking, are on the first day of a new term of interns on the Monday morning. Although you are not technically required to learn this material for exams this year, it is examined and it wouldn’t hurt getting a feel or a head start. Preop bays are also good for getting IV cannulation practice, just ask one of the two anaesthetics interns. Make really good friends with Roger or Grajne and you may with luck get a chance to do a spinal (it didn’t happen last year despite our enthusiasm, but a few med registrars and interns got a go). TIP: As part of general theatre etiquette always ask for permission and helping out to clean and restock items and transferring patients are always appreciated. Assisting in theatre - one should read up on theatre assistance etiquette and maybe gain at least some familiarity with the names of the instruments (this is not necessary, but worthwhile). Assisting can be fun and exciting or painfully boring, it depends what floats your boat. You will definitely get a better view of the operating field and gain a better appreciation of the procedure. Don’t get bogged down in details in your studies, but ask plenty of questions (this also depends on the surgeon and time of day and type of case). You will see plenty of open procedures such as open appendicectomy. Laparotomy and bowel resections also occur. If you are assisting, ask for permission first, and get accustomed to holding instruments for a period of time. The surgeons if they have seen you suture, may involve you in the process which is always a plus. On call – did not really happen for us last year. Instead we logged our emergency cases by hanging around emergency, seeing cases and following them through (afterhours or on weekends). It’s worthwhile telling one of the surgeons Heinz and Shiran, giving them your number and asking them to call you from their office if they need an extra set of hands. Thursday nights are the way to go and can get busy, trying to fit cases after the ortho list and also making the most out of JP the orthopod’s expertise. Scopes and Laparoscopy- there are plenty of colonoscopy/gastroscopy lists around. These get rather boring and you do not need to go to them regularly (mostly normal, sometimes a polyp here or there). Understand the indications/contraindications/complications and be able to explain things to a patient. Have some appreciation for what a scope can do in terms of treatment and investigations. For a bit of variety ask about anatomical locations and how to know where you are. Laparoscopic procedures are common in theatre for general surgery (usually lap chole and lap appendix) and gynae procedures. You will see many of these if you stick around. Urology – Mr. Richard McMullin is an Urologist who visits regularly from Ballarat. He also has a few recorded lectures on DSO. Great guy for prostate stuff. Sometimes he is without a registrar and this is great for all your DREs, cystoscopy and TURPs. He will even let you assist in some cases if you are keen. Sit in with him to observe how he does a prostate consult (this may be an OSCE station).


11. Pre-op/Follow up clinic – speak to Shiran or Heinz about sitting in with them and doing a little parallel consulting. They may invite you to do smaller skin procedures with them at their practice. This is a good opportunity to practice your suturing skills and wound dressings. 12. Breast Screen – Only optional. Ask Shiran or Heinz about breast patients. They perform some Hook Wire Biopsy. Otherwise speak to the radiology department (this may change due to changes in management) or ask Colleen to book you in! 13. Multidisciplinary Team Meeting – Ian Campbell and the surgical team, George Kannourakis & Carmel, St. John of God pathologists get together regularly via teleconference to discuss a list of cancer patients and their MDT management. Worthwhile to find out when these are on and to attend at least one. You may know the patients yourself that they are discussing. Also a logbook item. 14. Stoma Care Nurse – you can hang around the stoma care nurse to ask questions about Stomas. She usually has some type of pack which she gives out (apparently, we never received one). If you can’t get hold of her, usually someone in ICU like Anne is pretty good with fittings and changing bags that can help you.

Medicine 1. Oxley & ICU- is the place to be for gen med. Ward rounds are worthwhile to get embedded into the team. Learn to write notes on these rounds and learn from the tiers of clinical management from consultant to registrar to intern. Word of advice: Don’t be the unfortunate ward bitch, that’s the intern’s job – holding folders and running errands can sometimes get in the way of your learning. Cover shifts with the intern are also a great experience. It gives the intern some kind of reassurance as they can talk to you about their decisions and it’s also a good chance to be in the driver’s seat and take on some responsibility. Cases vary depending on season, most commonly you will encounter a lot of cardio, respiratory, renal, and oncology. Some may be common others may be rare, it’s hard to predict what you will get. 2. For venepuncture/IV cannula practice – ask nurse Deidre who is a clinical skills educator who teaches the nursing students. She will take you on a round to do a handful of path venepuncture, makes sure you there before the path nurse though (who does it routinely). 3. Visiting specialist consultants – Dr. Richmond is a renal physician who visits regularly from Ballarat Base to run the dialysis unit; he is also one of the topic leaders at Ballarat Base. He is very keen to have students. Spend some time with the dialysis nurses if you haven’t done so before to see how it is run. Dr. Hengle and Dr. Reddy are two cardiologists who visit Horsham and see patients at Lister House. Dr. Hengle in particular is very keen on having students around. Dr. Steinfort and Dr. Bradbeer are some respiratory physicians who visit Horsham on a regular basis too. Dr. George Kannourakis is an esteemed oncologist from Ballarat. Spend some time with him, if you can (he is hard to get hold of, as he has a very busy schedule. You may need some help with neuro, but the speaker from Mt. Gambier’s Face to Face Prof John Willobrough is usually quite good and comprehensive about this (only problem is that you may have to wait until later in the year). Check to see whether these sessions have already been scheduled, if not ask Colleen!


4. Endocrine - best to spend some time with the Diabetic Nurse Educators. Thyroid cases may come up during parallel consulting or with the surgeons. Other endocrine conditions are less common to find. 5. Parallel consulting – you will encounter some more common conditions here which are more subacute/chronic, but is also unpredictable. Best way to cover your bases is probably to read a clinical cases textbook, I found these much more helpful than a Harrison’s or a Davidson’s. It is for one more clinical and engaging to read and more likely representative of what you will classically encounter. The same goes for all rotations. 6. Emergency Department - This is perhaps the best way to encounter acute gen med cases first hand. Take a cardiac history, do a respiratory examination, manage a patient and admit them. To make the most out of ED, pick a patient and stay with them for their entire journey – take their history, examine them, write out investigations, and assist with management. Make sure you use the registrar/intern as support. Jonathon is always willing to help and will show you some cool stuff if you are around. It is also fantastic if you are able to present their case to the consultant the next morning on the ward round. The more mistakes you make now, the less you will make when you are an intern so present as many as you can.

Children’s health 1. Paediatrician visits – These visits with Maurice and Louisse show you what a paediatrician generally does. These are worthwhile visits to learn how to do growth assessments and deal with behaviour/psychiatric issues. 2. Professor Menahem – Sam comes up regularly every few months with his wife and registrar. He is great for heart murmurs and echocardiograms. Just remember to read up on murmurs and practice a few times before you go. He will ask you. He will get you to examine patients after him and report the findings. He will correct you too. Don’t be afraid though, because he is just a really big granddaddy teddy bear. 3. RCH outreach for paediatric endocrinology – Fergis and his team visit every 3 months for paediatric patients in the region. This is good to get your head around type 1 diabetes, congenital endocrine disorders, etc. Make sure you find out the dates in advance. Leanne the Diabetes Educator is also good for this, as she starts patients out on pumps. She runs a workshop about insulin for interns, which is worthwhile attending. 4. Parallel consulting – Dr. Wilson and Dr. Cymbalist see a lot of children. Usually there is a lot of ENT stuff to explore with them during your consult. Dr. Wilson also runs asthma camp for children with asthma in the region. 5. Emergency Department and Yandilla – during the winter there are a lot of kids visiting the departments. Sometimes an occasional night in emergency may be worthwhile to check some of these cases and to gain the best teaching (not as busy, but be warned they can be awfully quiet sometimes too). The nursery may be place where you may encounter neonatal issues, e.g. neonatal jaundice and sometimes emergencies involving NETS. 6. Paediatrics assignment – is a matter of finding a topic that interests you and reporting on it. Read a few journals and present. Not much of a hassle at all.


Mental Health 1. Dr. Proctor – is a private psychiatrist who visits Lister House once a week on Mondays. He is some interesting views on psychiatry and how it should be handled in the community. He is also a keen aviator, and if you like to see his plane and help him pour in some fuel at the Horsham aerodrome, it’s just a matter of asking! 2. Parallel consulting – Mental Health scripts is something which the GPs don’t really have much time for and which you can make a huge difference. To do one properly, you should sit down for at least one hour with the patient. These are the referrals for counselling or psychologists. These are a great way to practice your MSE and suicide/harm assessments as these are requirements for the scripts. At Lister House there is an official form that you must fill out that goes through the WestVic Division that is available on ZedMed. You can talk to WestVic to find out what happens on the other side. Otherwise, don’t forget to get the patients to sign the front page before they leave (even if you haven’t finished typing out the form)! If you do enough of these, there should be sufficient material to build up your mental health portfolios from this (and best of all your notes are recorded already)! Bonus, you can also follow these patients up easily! 3. Drugs and Alcohol – Dr. Wilson and Dr. Wimbury see a lot of patients affected by drugs and alcohol. In addition there are several local community services which are committed to helping people affected by these problems such Grampians Psychiatric Services. You will need to be at hospital to do the Alcohol withdrawal scale – namely emergency or Oxley. Ask the interns when the opportunity arises. Same goes for MMSE (they are more than happy to have you do these for patients with suspected delirium/dementia)! Emergency Department – acute cases may be difficult to find. However, the ED is a good place to see some "frequent flyers" with mental health issues, all the staff will be more than happy for you to talk to them if only because it means they won't have to until later. Regardless of how badly you might do, they are still going to come back again and this can be used for the mental health folio "see a patient on 3 occasions". 4. Ballarat Psychiatric Services – The head of Ballarat Psychiatric Services at the Horsham campus have been less than helpful. Alan Wolff has previously negotiated with them and they have been less than welcoming for an unknown reason. As a result, you will not be able to access their facilities. Colleen last year organised some visits for us to the Adult acute unit at Ballarat Base Hospital. Although these were mainly for ECT, if you ask nicely you can tag along with the consultants and watch how they do assessments (so as not to waste a 2 hour drive to see a list that lasts for an hour at most).

Musculoskeletal 1. Orthopaedics with JP – occur in theatre on Thursday afternoons. Mr. John Patrikios (JP) who runs these clinics. He doesn’t do trauma cases, and the majority are hip and knee replacements. These are always interesting to watch and be part of. He is quite a philosopher at times and eccentric with his car and pen collection. Very smooth indeed. If you are doing the MSK patient journey, ask the girls at DPU or theatre reception about the lists and see if you can follow that patient from DPU to the operating theatre to recovery and the wards. Then attend their followup a couple of weeks down the track. 2. Fracture clinic – these are held regularly and are rather brief and quick at Wimmera Health Clinic. Sometimes the lists are long and at other times they are short. You will look at X-rays, but may


not get a comprehensive explanation due to the pace of things. This may be the only opportunity you get to practice plastering, the GPs almost never do it. 3. Emergency Department – this is the best place to examine x-rays and relate these to clinical signs/findings. You will encounter a lot of common musculoskeletal conditions especially during sporting seasons (footy season), if you stay on weekends. 4. Ask Reza/Dr. Wilson for a radiology tute if you are still lacking in some x-rays which you haven’t seen. Reza explains things better. 5. Parallel consulting – you will encounter a lot of arthritis and occasionally soft tissue injuries. Great to practice your joint exams.

ELPD 1. Forensics - Dr. Wilson and Dr. Wimbury are the forensic doctors in the community and are involved with police cases. Dr. Wilson deals with child abuse cases and it is worthwhile speaking to him about mandatory reporting. Dr. Wimbury is the prescriber for the police station and anyone they hold in custody. Go with him to the police station for an interesting experience. 2. Theatre time – this is a must for the assignment. Clinical pathways are very useful for this. 3. WestVic division hold a clinical safety meeting annually (equivalent to morbidity and mortality) – this is with local GPs to discuss de-identified cases from local practices/hospitals to improve clinical outcomes. 4. Death certification you can come across at the hospital with the interns/registrars. The hospital does have a morgue, but usually you will not be required to go there unless the registrar needs to cite a body.

DPCI 1. Kim Galpin is the AHLO - Aboriginal peoples’ hospital liaison officer, make an appointment with him in his office and talk about Aboriginal peoples’ affairs and their role in the hospital. He also runs cultural safety workshops during intern orientation during the year. 2. Goolum Goolum Co-Op – is the local co-op, I’m not too sure how to get involved with their services, but Bree Dare was involved with women’s business over there and had a good experience. 3. GP referrals – there will be a lot of these. Be on your feet and follow the ones you admit to the hospital and track their progress (useful for continuity of care). 4. Field Days – a lot of fun to go to and experience and you may come across something to write about for your farmer’s health wiki. 5. Wiki’s – get on top of these before exams. A lot of us didn’t know until it was too late last year and therefore had a lot to juggle during the exam period and get feedback (although not always helpful). The punishment is a workshop held after exams and the rewriting of unsatisfactory wiki (at least it was for us).


Study Resources There is an underground Dropbox set up for students to share some online resources. These have been helpful in terms of PDF material and some past papers from other uni’s. Send us an email and we can add you to the list for you to access. Women’s health Surgery Medicine Children’s health Mental Health

Musculoskeletal Practice MCQs

Clinical Cases in Obstetrics, Gynaecology and Women’s Health, de Costa Surgery – Case Files Pocket Guide to Internship: Common Clinical cases, Singh Paediatrics – Case Files, Psychiatry - Case Files *There is an interactive CD from the Crisis Support Services called “Men At Risk – Suicide Risk assessment in rural and remote places” which you can borrow from the library (great for OSCEs) Apley’s (prescribed text) AMCQ book, MCQ Revision sessions (Geelong Clinical School), PreTest Series

Tech Savvy Mobile phone Apps for iPhone/Android ACCRM offer their clinical guidelines for download from their website. RCH also offer download of their clinical guidelines. You must download iSilo to open these files, which can cost money (approx $12, but there are ways to get around the costs if you are using an Android device). Online Resources Join the RACGP and ACCRM to gain online access to modules designed for GP registrars and GPs (Gplearning and RRMEO). Some of these are like the workshops you may attend through the WestVic division. In particularly RRMEO has a good module for radiology practice. There is also a weekly dermatology challenge. Membership is free for students for both organisations (you may have to ask IMMERSe staff to help you organise this for ACCRM). http://www.racgp.org.au/ https://www.acrrm.org.au/membership Australian Doctor – How To Treat guides are available free from their website (may require login). These provide a very comprehensive expert opinion on some common conditions and often some handy hints. And because they are Australian they usually fit in with guidelines. Every year they release a year book which your GP supervisor may have purchased and which you can borrow, otherwise there should be a collection in the library (although I must say I haven’t really looked, might be worth asking Shirley). http://www.australiandoctor.com.au/education/howtotreat.asp


Useful websites http://mednoteshare.blogspot.com/search/label/Medicine http://almostadoctor.co.uk/

Useful contacts NPS Pharmacist Debbie Norton d.norton@westvicdiv.asn.au WestVic division Annette Metcalfe a.metcalfe@westvicdiv.asn.au Past students Chris Ip

Mob: 0401 686 955 Email: ccki@deakin.edu.au

David Breed Email: dpb@deakin.edu.au Jack Crozier Email: jcroz@deakin.edu.au Laura Smith Email: lsmit@deakin.edu.au

Bree Dare Emily Harrison


2011 OSCE Stations 3rd year 1.

A nursing student is concerned that she may have Pertussis during her placement in a nursery. Explain the condition and how you would manage this asymptotic patient. 2. Hand exam - perform a focused exam on the hands of a patient with RA. Interpret a bilateral hand x-ray and comment on findings. 3. 6 week check - perform a routine 6 week postnatal check. 4. Inguino-scrotal exam - Take a focused history and examine the patient who complains of pain in the groin. There was an accompanying GP referral letter with this station and some initial investigations ordered with no significant results. 5. S/E of antidepressants* - written station where you had to write a patient handout on antidepressants, explaining what they were, how they worked, how they were used, what contraindications there were, sideeffects, and emergency planning. 6. Antenatal tests for Downâ&#x20AC;&#x2122;s Syndrome and Neural Tube defects* - written station where you had to explain the different types of antenatal tests available for DS and NTD including what the test is, when it's performed, what to expect on results, what to do about it if result is positive. 7. PTSD/Depression - policewoman who has been avoiding work and made to see you by her work. She had recently been exposed to some trauma on the job and has decreased mood and affect. Make a relevant differential diagnosis list. Explain what you think is the most likely diagnosis. Talk about management. 8. Back Pain* - written station where you are asked to write a letter for a patient explaining the different treatments for back pain - including non-pharmacological and pharmacological explaining indications, contraindications, side effects. 9. Diarrhoea with hematoschiza and pus in stools - Examine a woman who presents with these symptoms. Explain the rationale behind your examination. Give DDx. What is the most likely diagnosis. What investigations are required? What management? 10. Prostate LUSCs - take a history from a 63 year old man with lower urinary symptoms who is concerned about Prostate Cancer. After the interview a PSA result is provided which reads 6.2 (RR <4.0). You are asked to interpret the result. Give differentials. Explain further investigations and management. 11. Pediatric respiratory - 6 week old child presents unwell with difficulty breathing and wheeze. Take a history from the mother and examine her 6 week old doll - talk aloud as the examiner will explain the findings. Make sure to look at the SpO2 probe - as represented by a foam cup with a print out reading on top. The thermometer is also broken - so ask!! 12. Haemoptysis* - written station where you had to explain the investigations for a patient presenting with haemoptysis. Give differentials. Then explain why you would do blood tests, sputum culture, CT scan, and bronchoscopy.

4th Year (by Steve Kunz) Same drill as last time - 8 minutes in each section, 1 minute to read, 1 minute to move, and a whistle went off at 6 minutes to warn you to summarise and present a management plan. Paliative care: A patient presents for routine follow-up and is well, despite her advanced breast cancer, liver, and bone metastases. She is concerned that a late friend of hers suffered from constipation in the weeks preceeding her death. Discuss with her - the mechanisms behind constipation, the possible causes she's likely to face, how you could manage it should it occur - (and then interpret these two abdominal xrays). GP: Breaking bad news/giving results - 3 days ago, this 20 year old university student presented with itchy vulva and peri-genital tender lesions. You suspected herpes, informed her of this, and gave her valaciclovir, however at the time she didn't want to discuss the possibility, saying "We'll talk about it if it's confirmed". PCR tests have yielded HSV2. Tell the patient this, address her concerns, and discuss the future implications of the diagnosis.


Paeds (written): A bright and bubbly young boy presents with a petechial rash on his face (see photo), and mutliple ecchymoses on his legs. What is your differential. What signs would you look for examination of the body (in general inspection, the head, neck, chest, arms, chest, abdomen, legs, back). If it had alternatively presented with a fever and 5 day history of unwellness, what investigations would you order? (I think, I can't remember that for certain) Here is his FBE result - interpret the platelet level of 35. What is the level of platelets below which spontaenous bleeding occurs? What pathological findings on bone marrow aspirate would suggest that this was a self-limiting condition?

Women's/GP (written): A patient presents after having given birth 2 weeks ago with a tender breast. Here are photos of it. Describe the pathology. What would you look for on examination of the breast, and the peripheries? What is your differential? What is your advice to her? What is the likely causative organism? Write a prescription for an appropriate antibiotic. If you didn't know the dosage, what resource could you check? What if she had this breast instead - describe the pathology and diagnosis. She has these questions for you - answer them "Shouldn't I just switch over to the bottle immediately?" "What should I do with the milk that I express?" And then 3 other questions that I can't remember.

Psych (and a secondary domain, take your pick): 47 year old presents with a fractured humeral head. They've been worked up by the orthopaedic registrar, but it's been revealed that they drink 18 standard drinks a day (the patient, not the registrar). Take a focused history of their alcohol intake, determine their risk for alcohol withdrawal, and outline your short and long term management of this patient.

Gen med/anos/ED (written): Lumbar puncture. What its indications, contraindications, complications and therapeutic applications. What advice would you give to a patient following an LP? Which equipment would you use? What kind of anaesthetic? Name these landmarks. Why do you take 3 samples?

Aged care/Gen med (written): Dorothy presents to the GP with her daugher Betty, complaining of memory troubles. Why is it good that Betty is there? What questions would you ask on history? How would you distinguish dementia from delirium? What is your differential? Which of these medications impair cognition? Why is it important to discuss urinary continence? Would your DDx be different if she had a conjugate gaze problem? Here is are 3 CTs - describe the pathology, and diagnose the condition (and for one of them, if she presented with symptoms of difficulty walking, continence problems and dementia, what would your alternative be?) GP: Take a focused asthma history for 4 minutes, outline your management plan and demonstrate asthma devices for the other 4 minutes. ICU: Breaking bad news - a woman's husband had been admitted for emergency appendicectomy. During the anaesthetic induction, he vomited and aspirated. They elected to continue with the procedure. The appendix was removed and found to be inflammed, however for his ventilation and management of aspiration pneumonia, he has been admitted to ICU. There he is sedated and being treated with IV metronidazole and a beta-lactam. He is stable, and is expected to recover fully.


You are the first doctor she's spoken to since he was admitted: Tell her what's happened. ED: A mannikin has fallen off a bike, and been brought in by a friend with their head unsupported. Take a focused history, assessing for its risk of C-spine injury, perform an examination, determine if it requires a hard-collar and/or x-ray, and then interpret these films. Ortho: A guy stepped in a pot-hole while walking his dog last night. This afternoon he comes into the emergency department complaining of ankle pain. Perform an examination of his ankle, interpret these x-rays, discuss the management. Advanced life support: You are an intern at the Colac hospital. Mr. Dodds is a 64 year old man with a past history of ischaemic heart disease, hypertension and diabetes. He is taking aspirin, atenolol and verapamil. He has been admitted for central crushing chest pain radiating into his left arm. The nurse calls you to say that he has collapsed, and she's called the resus team, but they're attending another arrest. Go and save his life.


2010 OSCE Stations 3rd YEAR OSCE STATIONS (by Steve Kunz) I know that you're far from thinking about what next years exams will be, but here is a document of what ours were today. Each rotation had 2 stations, they were a combination of written and oral, and there were 8 minutes in each station, 1 miniute to read, 1 minute to move between stations. 1.) Surgery: Consent a patient who has been diagnosed with bowel cancer for an anterior resection, explain the procedure, risks and how those risks will be addressed. 2.) Medicine (written): Interpret a chest xray of a patient who has been a heavy smoker, has recently been short of breath and has coughed up occaisional bloody sputum. 3.) Psych (written): What are the side effects of lithium, interpret this thyroid function and renal function tests, and explain why they are performed. 4.) Ortho (written): Describe this pelvic x-ray after a patient has had a fall, what are your differentials, how would their leg be positioned and what are the (5) risk factors for osteoporosis. 5.) Medicine: Perform a cardiovascular exam on the patient who has had a murmur incidentally discovered, and interpret your findings. 6.) Ortho: Take a history of hip pain, present your differential and non-operative management of osteoarthritis. 7.) Women's (written): Write down the process for a Pap smear and further gynaecological management of abnormal findings. 8.) Paeds: Take the history from a parent of a child who has recently had a cough, and has incidentally been noted to be pale. Then, present your differential, and interpret these blood tests. 9.) Surgery: Perform a vascular exam on a patient who has been complaining of left calf pain. 10.) Women's: Advise a woman about contraceptive options, as she is going away with her boyfriend on the weekend. 11.) Paeds: Education and management about febrile convulsion, in the context of a worried mother in the emergency department. 12.) Psych: Take a focused history and perform a suicide risk assessment on a patient who has previously taken 20 temazepam tablets and half a bottle of vodka.


IMMERSe Horsham Survival Guide 2012  

This is a guide prepared by former students of the Wimmera region for prospective students doing placements in the area.

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