ISSUE #2 – FREE
Places More real life GPs who are Going Places More true confessions of a 21st century intern – where GPs go to get their information online
A guide to medical
emergencies + How to break bad news
Taking a fresh new look at General Practice
Dr Heidi Spillane Médecins Sans Frontières
Taking a fresh new look at General Practice
Greetings fellow future GPs Welcome to the second edition of Going Places! After all the positive feedback received about the first edition, GPRA is delighted to bring you the second great issue of the magazine designed to give an insight into the fantastic opportunities available within General Practice – for people just like you. I am also delighted to join you as Editor.
In this edition:
As an intern myself, I understand the time pressures of being a hospital-based doctor. That is why I especially favour the format of this magazine – an easy read – even if you only have a few minutes to spare before your pager goes off, yet again!
This issue contains profiles and stories of some GPs and GP registrars that are certainly ‘going places’, including Dr Heidi Spillane who works for MSF in China, Dr James Doube, a expedition medical officer in Antarctica and Dr Stratos Roussos who has also worked for MSF in Africa.
In addition, the amusing sagas of internship continue in the ‘True confessions’, there’s a review of the new iPad and there are articles full of tips regarding breaking bad news and dealing with emergencies outside of work. You will also find an article on the new GP website that will assist anyone wanting to know more about how to get into General Practice – after reading this magazine you will be sure to want to check it out. General Practice is a dynamic, flexible, exciting and fulfilling career, as demonstrated by all the interesting articles featured in this edition. Every journey through General Practice is unique, so if you would like any information regarding how to start your own unique General Practice journey, all you need to do is call or email us. We’ll be very pleased to send you an information pack that will tell you everything you need to know. I sincerely hope you enjoy reading this edition of Going Places. Be sure to look out for future editions as they make their way into your hospital common room. Yours in General Practice
Dr Lana Prout Intern – Latrobe Regional Hospital, Victoria GPRA Board Member (Pre-Vocational Representative)
Going Places! If you have a t We welcome your feedback on us an email and tell us wha few spare moments, please drop t wha you’d like to read about and you think of our magazine, goin firstname.lastname@example.org even if you can contribute!
14 05 08 11 13 14 18 20 22 26 28 32
Dr Heidi Spillane The globe-trotting GP working with MSF Dr Stratos Roussos Making waves Dr Liz Wearne Combining Aboriginal health and teaching Dr Keith Ananda Happy being a “jack-of-all-trades” GP! Dr Sarah McEwan A passion for indigenous health Dr James Doube Out in the cold Dr Georga Cooke Enjoying the diversity of General Practice Dr Michael Wong In the heart of the bushfire area Dr Genevieve Yates Country GP with the sound of music Dr Danielle Butler At the Top End Dr George Forgan-Smith The GP who loves working with kids
We would like to acknowledge the help and support provided by General Practice Education & Training Ltd. and Avant, which has made Going Places possible. Our sincere thanks to all the GPs who have generously given their time to be interviewed and photographed. Going Places is published by GPRA Level 4, 517 Flinders Lane, MELBOURNE VIC 3001. Phone: 1300 131 198 www.gpra.org.au Designed, managed and produced by wam Pty Ltd. Interviews with GPs by Fran Molloy © GPRA 2010. No material contained within this publication may be reproduced in full or in part without the express permission of the publisher. Our thanks to Kate Froggatt for her input into the article “8 really good reasons why you should become a GP”, which appeared in the first issue of Going Places.
Fast forward Need fast finance for a new or used car? Medfin delivers the finance you need to drive the car
that you want, within 24 hours of your call1. With Medfin, it is possible for you to borrow up to 100% of the cost of your vehicle. And the good news is there are no annual fees and no application forms to fill out.
Want more information? Talk to your Medfin Relationship Manager on 1300 361 122 or visit medfin.com.au .
On any business day, when Medfin has all information required and subject to credit assessment. Approved customers only. Terms and conditions apply. Other fees and charges may apply. Medfin Finance Australia Pty Limited ABN 89 070 811 148. A wholly owned subsidiary of National Australia Bank Limited, and part of the NAB Health specialist business. *Supplied by NAB Health.(GPRA01/10)
Practice • Equipment • Motor vehicle • Residential investment property • Cash flow • Life and income insurance * • Home *
Dr Heidi Spillane The globe-trotting GP working with MSF
Médecins Sans Frontières ” Having that General Practice training, combined with all the MSF experience, gives you such a broad range of skills. It genuinely covers all aspects of medicine, so you have a great foundation for approaching any new medical problem you come across – I’m so glad I did it. I’d recommend it to anyone considering General Practice as a career.”
Going Places – ISSUE #2
COVER STORY was born in Ireland, did my medical degree in Sheffield, England and worked for a year there as an intern. Then I came to Australia on a holiday, fell in love and stayed … and I have spent most of my working life here since. I was interested in science at school and I’ve always been quite idealistic – I really like the idea of being able to help people. Medicine combined the mental challenge that I enjoy with doing something that I felt was very worthwhile. I took a job in emergency at Hornsby Ku-ring-gai Hospital in Sydney for a year and then moved to Royal Prince Alfred for about two years. After that I took some time off and travelled around South America for a while. I came back to a job in St George Hospital and then kind of “stumbled” into sexual health – which I really loved. I worked at the Sydney Sexual Health Centre for a couple of years and became a Sexual Health Registrar. But I realised to go further, I really needed to do physician’s or GP training. I didn’t want to go back in the hospital system and so I found my way into General Practice. Very strange – as it wasn’t something I’d considered before. I started my training up in the north coast, and I loved it. It was the first time I felt so at home, and totally comfortable in medicine. I felt that I was really well supported through the entire training program – a feeling of being nurtured and valued – and I enjoyed the work as a GP Registrar. In the middle of the GP training, I ended up going off to MSF. Ever since I was very young, I had always wanted to work with MSF – that was something that really inspired my desire to work in medicine. All through my medical training, I would read about their projects and hope to be involved one day. I have to admit it took me a long time to volunteer because I didn’t think I was ready or I had enough skills to offer. Then I turned 30 … the big 3 – 0. I realised I hadn’t yet done something in my life that was really important to me, so shortly after my 30th birthday I signed up and was despatched on my first MSF mission to Kenya. I knew I had done the right thing from the moment I arrived in Kenya to the moment I left. I loved being in a different culture and meeting such inspiring people. The medicine is very challenging and interesting – the experience there fulfilled a lot of the criteria of what I thought my “ideal job” would entail. In many ways, the six months of my basic training gave me so many skills I needed in Kenya. I thought two years in sexual health would give me experience in managing STIs, but I found the six month basic term gave me so much more to work with when I was out there. Partly it was the responsibility – in General Practice, you are much more autonomous. I had also been part of the roster for the Byron Bay emergency department. Actually I was the Byron Bay emergency department for 24 hours once a fortnight. That gave me a lot of confidence!
Ninety percent of the people who came in to be tested for TB, we also diagnosed with HIV. TB clinics have been around for decades in Africa, so we were trying to integrate HIV management within the TB clinic. We added a counsellor to our staff, did HIV testing on the spot, started people on TB drugs and after a CD4 count, we’d start them on anti-retroviral treatment for their HIV as well. I co-authored an article about this new model, which has just been accepted for publication. After my first mission I wanted to continue working with MSF, but felt that I needed to have more grounding and so I decided to return to Australia to finish my General Practice training. Not surprisingly, perhaps, it took me a while to adjust back to life in Australia! My first position involved lots of on-call work, being phoned at 2 am for minor complaints and people having quite high expectations of your time … it was such a change from the MSF experience! It also made me appreciate how much we have available here in Australia. I then moved to another practice and took on a research role – an Academic Registrar post – which looked at how GPs teach medical students in the General Practice context. I knew this would be useful for the future, because a lot of MSF work is about training others and capacity building. And so where do I find myself now? You guessed it – away from Australia … again! I’m now on an MSF project in Nanning, China – that’s the capital of the Guangxi province, China’s “Green City” in the South West of the country. It’s an MSF progam where we are treating both sex workers and injecting drug users. I’m supervising three national doctors, as well as providing some training for nursing and medical staff. We also have an outreach team who visit vulnerable populations. The project finishes in October, so I will probably return to Australia and save up a little before my next mission to …. well, I have no idea where MSF may send me! That’s what’s so exciting! Having that General Practice training, combined with all the MSF experience, gives you such a broad range of skills. It genuinely covers all aspects of medicine, so you have a great foundation for approaching any new medical problem you come across – I’m so glad I did it. I’d recommend it to anyone considering General Practice as a career.
I have no idea where MSF may send me! That’s what’s so exciting! I was part of a big MSF project in Homa Bay in Kenya, coordinating the TB and HIV activities in an outpatient setting. I felt a little strange being brought in to supervise people who had been doing HIV work for years. But it’s not necessarily the medical knowledge that you bring there, it’s more about your way of understanding how systems can work and – perhaps more importantly – how teams can work in an allied health setting. Photography: Jonathan Browning
Going Places – ISSUE #2
Dr Stratos Roussos
waves Photography: Elements Studio
What’s your current role – and how did you get there?
What influenced your decision to do medicine and then to become a GP?
I started work this year as a GP for the Central Australian Aboriginal Congress health clinic in Alice Springs, after two previous elective placements here. I really enjoy the medicine and people here – and Central Australia is a fantastic place to live! I grew up a long way from Alice … in Hobart, where I did my medical degree at the University of Tasmania and my internship at Royal Hobart Hospital. I spent a few years in the hospital system on various rotations, before enrolling for rural and remote GP training. In 2008, as part of my training, I spent eight months in Southern Sudan with MSF. Then I spent a year as a GP Registrar at Anne Street Medical Services, in George Town, which is in Tasmania’s rural north. I also did daily ward rounds at the small local hospital and fortnightly rounds at the nearby nursing home, before I came to my current role.
Growing up, I decided I wanted to become a chef, a doctor or a musician. I realised I could still cook and play music as a doctor, so it seemed a logical choice! I liked the idea of not being behind a desk all day and also that you were doing something to improve people’s lives. I played several instruments in various bands and, after my intern year, took a year off, toured Australia and recorded an album with my band, Waiter. It was great to chill out and take a breather from medicine for a while.
What experiences did you find valuable during your General Practice training?
The MSF assignment in Southern Sudan involved working in various programs, including maternal and child health and the emergency coordination of the cholera epidemic. I was in a little town called Aweil, ravaged after decades of civil war. I worked with some really amazing people. It was a very steep learning curve and the medicine was pretty mindblowing. A whole range of things that you would never, ever see here, like severe malnutrition, huge outbreaks of cholera What are your plans for the future? and tetanus. But with very little, we were able to do a lot. I’m enjoying the work here, and would like to stay It was a new way of practising medicine for me – without for a while. I do like to travel and I may go to Peru to the luxury of x-rays and other investigations – and, of do a tropical travel medicine diploma, which can be course, with language barriers, your examination techniques accredited as part of my training. There’s just so much and clinical skills are far more critical. A child might have scope in this job, you really are spoiled for choice! malaria, malnutrition and pneumonia, so we would throw everything we had and use more aggressive treatment. I feel there are definitely some similarities between Initially, I planned to the Sudanese and the indigenous population here. become a surgeon and ty After Sudan, when I cial spe of did a number arrived in George Town, e surgical jobs. But thre Tasmania, I was fortunate years after my internship, to work with some great I changed my mind. It GPs. In the small hospital, was all because of a life I learned a lot, like taking you like. x-rays with our own x-ray changing moment! An epiphany, if ing his said to me “You know, my son’s play machine. The area has an One Saturday morning, a surgeon realise me e mad It tre. thea in , was interesting demographic – he e ther first game of soccer today” – and other had ys alwa I’ve an industrial town that has life. re enti your s over that being a really good surgeon take me. for very high rates of obesity n’t was just it ise real these made me interests outside of medicine and and diabetes, along with k. bac ed look r neve have I l General Practice and wealthy people living next I made the decision to go into rura to three generations on welfare.
One Saturday morning, a surgeon said to me “You know, my son’s ay” playing his first game of soccer tod – and there he was, in theatre.
What are the most fulfilling things you’ve experienced in General Practice? What I have really enjoyed are the relationships I form with patients and colleagues. The beauty of General Practice is, if you’re feeling stifled in one area, you can move to something else. Flexibility is the key – you can make what you want out of it. Being able to travel around, as well, is fantastic. And you really impact people’s lives. In Sudan, I worked in a satellite clinic we set up 200km outside Aweil, treating malnutrition and malaria. The roads were cut off through the wet season. There were no other health services – we were it. A woman rocked up one evening, she’d had about six or seven miscarriages previously and was in labour. The baby arrived … he couldn’t have been more than seven months. We had some oxygen, but no ventilators or sophisticated equipment. But this baby kept on chugging along. The mother was so stoked, she ended up calling the baby Stratos! It was a highlight of my time in Sudan – a really special moment that made me realise what a rewarding career I have chosen.
Going Places – ISSUE #2
Tech Talk • Review
Looking for a new work tool … or toy?
Try Locum Work The iPad has arrived. Well, that’s not quite true – it’s actually not quite here yet … but it’s coming – and it’s something to look forward to. Although it was revealed back at the end of January, it’s not likely to hit these shores until perhaps late March. And then it’s likely to be just the base Wi-Fi model, without access to iBooks (providing access to downloadable e-books). So, let’s take a look at what Steve Jobs describes as “an entirely new category of devices that will connect users with their apps and content in a much more intimate, intuitive and fun way than ever before”.
So, what can it do? iPad allows you to browse the web, receive and send emails, store and listen to music, store and look at photos, watch videos, play games, read e-books and run more than 140,000 applications available through the App Store. The intelligent soft keypad makes jotting down notes easy … and you can buy a wireless keyboard if you really need one! If you’re mac-based, you’ll need to be on Mac OS X v10.5.8 or later and have a USB 2.0 port. If you’re using a PC, you’ll need to be running Windows 7, Windows Vista or Windows XP Home or Professional with Service Pack 3 or later – with a USB 2.0 port.
Is it more than just an oversized iPhone? Indeed it is – based on the same operating system as the iPhone – but it’s really the next generation, powered by Apple’s A4 system-ona-chip processor, which delivers awesome graphics and processor performance. iPad syncs with iTunes just like the iPhone and iPod touch, using the standard Apple 30-pin to USB cable. That means you can sync all of your contacts, photos, music, movies, TV shows, applications, etc., from your Mac or PC.
Are there any drawbacks? iPad isn’t perfect and has a few little niggles … Firstly, it’s not yet clear what the costs might be for data download packages by the telcos on any plans they might offer, when the 3G model is finally introduced. Secondly, the large screen images may be crisp and clear, but they aren’t high definition. Sure – the 1024 x 768 resolution is what you’ll find on cheaper plasma TVs, but it’s not 1920 x 1080, which is full HD and it’s not 16:9 widescreen! Thirdly, a collection of little gripes – features not found on iPad version 1.0 that may well be corrected on future generations of the iPad. These include a lack of having more than one program open at one time, difficulty in transferring your own files onto the iPad, the need to buy a USB connector, no SD card slot, no built-in camera and no GPS on the base Wi-Fi model.
So there you are …. when it arrives, go and take a look, have a play and then make up your own mind. Perhaps you’re an “early adopter” and you just must have one!
your n e d a Bro ons Horiz
Dr Liz Wearne
Combining Aboriginal health and teaching What’s your current role – and how did you get there? I work as a GP across four sites in the Lakes Entrance area, in both mainstream and Aboriginal health centres. I also teach undergraduate medical students at the East Gippsland Regional Clinical School based at Bairnsdale Regional Hospital. I did my first two placements at Latrobe Regional Hospital, then I spent a few years in the Monash Medical Centre network doing oncology, lots of emergency and ICU, paediatrics and obstetrics. By that stage I had decided I really wanted to do rural General Practice to gain a really broad range of experience. I interviewed with the senior doctor at the clinic I’m at now, in Lakes Entrance. He’s been my supervisor for the past four years. I’ve had amazing training experiences and a lot of freedom to do certain projects I’ve wanted to do. Last year, all of my clinical work was in Aboriginal health, which I really enjoyed. The year before that, I worked two days a week for the East Gippsland Regional Clinical School, doing face-to-face teaching and a lot of curriculum development – one of the best experiences I’ve had.
What influenced your decision to do medicine and then to become a GP? Initially, I wanted to be a pharmacist but a good family friend was a GP and I was inspired by him. I’m really glad I made the decision! At Monash, I was a John Flynn scholar, sponsored to do a twoweek placement every year for four years at Groote Eylandt in the Northern Territory. I learned more on those trips than I did in the rest of my degree, and the GP who mentored me up there was probably my most important influence. She was an amazing woman. I loved what she taught me and I loved the way she structured her work around her life. I realised being a GP was a great job that was very portable and could take you to some amazing places.
Have your impressions of General Practice changed since you entered the profession? Coming straight from the hospital system to practice in a rural area, I expected lengthy waiting periods for patients to see specialists or to see allied health professionals. But I soon learned that your relationships with people in the network mean that things actually get done a lot quicker. Specialists in Melbourne often bend over backwards to help out a rural GP. You tend to build relationships and networks because you’re isolated – so that means that patient care
Photography: Trilby Steinberger
is really comprehensive and responsive. Over time I’ve also realised that General Practice is not a static thing, but is a career that can really develop and change.
What are the main changes you’ve found since leaving the hospital system? I was glad to see the back of shift work. I hated going for weeks on end doing nights and not seeing my friends or having any exercise or eating properly. I do miss working with a lot of people who are my own age, so that’s partly been hard – leaving to come to a town where I’m working with people who are generally a lot older than me. When I was a hospital doctor, every single rotation I went into, I’d really get into. I loved emergency medicine, I felt very efficient. But the thing that I love about General Practice is you can specialise in little things, but still remain a generalist. For example, you can manage someone’s mental health as well as their respiratory disease. Photography is my other life outside of practice and I’m lucky enough to live in a place where I can do that really regularly. Any chance I can, I get out with my camera. I was part of a group exhibition in a Melbourne gallery last year, which was exciting and very successful. I’ve got this amazing environment around me to photograph and the work has allowed me to have the time and space to do that.
What do you wish someone had told you before you made the decision to do General Practice? General Practice is not the easy way out, nor should it be what you do if you can’t be bothered going through other specialist training programs. I think that really disrespects the intricacies and the challenges of the job. There’s no doubting it is a really hard job. It is time-consuming, it’s emotionally draining sometimes, it requires a lot of focus, a lot of organisation, a lot of study and a lot of work. But it is really worthwhile.
What are your plans for the future? I’ve done an Irish exchange and that gives me the opportunity to go back and do some locum work periodically. I’d also love to be doing some locum work in Northern Australia, relieving some of the doctors in remote communities who don’t get a lot of respite. We’ve got a good bunch of doctors in Gippsland who do that every year. What else? I’d like to be teaching.
Going Places – ISSUE #2
s n o i s s e f n o c e Tru tern of a 21st century in
Written by Dr. Ernest Tecrin
Dear Journal, A few weeks ago, I finally completed my surgical rotation. I’m surprised to find that even after a few months, my skills and confidence have both increased twenty-fold. Putting in an intravenous cannula no longer needs to be done using general anaesthetic and a portable ultrasound machine, writing up fluids for the next 24 hours doesn’t require a consultation with ICU and I’ve finally mastered the art of writing, walking and talking at the same time! Sitting down with the Head of the Unit turns out to be a rather pleasant experience. Not only does he tell me that he’s had good feedback from everyone, he also states that if I was willing, I should definitely consider surgical training. He smiles, then adds that he would be happy to assist me in the future, should I need his help. At this point, waves are crashing in my ears and my heart pounds as I stammer a thankyou at this offer. Me? A surgeon? I’ve never really thought about it. Wait, I’m not sure, I’ve got no idea yet – it’s only my first rotation! I look upon the plate offered to me and take a small nibble and ask for the rest to be packed into a doggy bag to consider for consumption at a later date. Our coffee ends with a warm smile and brisk handshake before I head back to the Surgical Ward to farewell my beloved nurses, who I have really grown to love during my time on the wards. My next stop is Aged Care. In summary, the transition is like learning how to ride a motorbike and then riding into quicksand just as you’re getting the hang of things. All of a sudden, everything I knew was gone. My registrar, my team of nurses and even my favourite sandwich (don’t laugh, it was a good sandwich). I find myself sitting at a desk waiting for things to happen – as opposed to waiting for a chance to sit down or even go to the toilet! The pace is so unfamiliar … but soon I find myself enjoying the slower speed of aged care. No cover, no evenings and best of all, time for a lunch break! This is all new and unfamiliar territory. But above all, the patients are the best part of the job. Rather than needing to race through every patient so I can get my registrar to theatre, I find myself spending the morning with my registrar seeing everyone, finding out how they are travelling and then once we’re done, getting jobs done. The ward round goes at such a speed that I get a chance to find out that one patient once travelled to Antarctica, another was in the Australian Ballet Company and their neighbour had walked the Kokoda Trail – for real! As a younger person, nothing is more humbling than hearing what these people have gone through and achieved for the following generations. I’ve certainly got nothing to complain about next time I have to go to the shops to get milk – I know it’s going to be there when I arrive. However, aged care does have its downsides. Firstly, everyone seems to like you so much they want to feed you. Soon I find myself struggling to sit down because my shirt and pants are much tighter than I remember. My lunch break is joined by a morning tea and afternoon tea break with a little extra to take home after work. Five kilograms later and I become much more adept at diverting attention away from offerings of food and more towards ‘so how is that hip going?’. Another difficult area is the occasional offering of match-making with granddaughters, such as ‘I’ve got a lovely grand-daughter about your age, who’s single?’ to which I respond ‘Oh, really ... ummm ... she sounds nice ... ummm how old is she?’ ‘She’s about 40’ What the …? I’m 24! I look older? That’s just the dusted sugar in my hair from Mrs Jones’ biscuits this morning! Occasionally I encounter a confused patient who demands to see the nice doctor that saw them yesterday. Unfortunately, they’re not too impressed when I inform them that it was me – but today, I’m wearing the blue shirt. They scoff at the idea and shoo me away only to greet me the following day with a big smile and a story about some rude doctor in a blue shirt. Still beats a few of the senior doctors I’ve worked with in the past, who still needed to know who I was after two months, let alone two days ... Regardless, the rotation goes on without much disruption and I feel a lot more relaxed than in my previous rotation. I must admit I didn’t think I’d learn much in aged care but I’ve come to appreciate my older patients and the lessons they’ve learnt. Age is a funny thing – everyone wants it until they get too much of it, but even then, some people want to get as much as they can. Others have their fill and long to be rid of it. And there are even those who would like to have had more, but outside factors prevent that from happening. You see people who are visited daily by flocks of children, grand-children and even great-grandchildren, while their neighbour looks on wistfully wishing for a familiar face to walk into the room. You soon learn to go from witness to participant as you walk across, sit on the bed and ask them about their lives. It’s amazing how valuable ten minutes can be in one person’s day when it seems so irrelevant in your own. Internship is funny in that way. You think you know what you’re meant to learn and you find yourself learning something completely different. I’ve only been through two rotations and already I’m starting to understand the meaning of being a doctor. Just a little ... more to come. Till next time.
The name and identity of the writer have been changed to avoid recognition and provide complete anonymity!
Dr Keith Ananda
Happy being a “jack-of-all-trades” GP! What’s your current role – and how did you get there? I’m actually right where I started in General Practice, working in the Ocean Keys Family Practice, located in an outer metropolitan beachside suburb of Perth. This was my first training position, before I had my country posting to Broome for six months. I’ve been back here for the last year completing my training. I work three and a half days in this practice and I also work one day a week in the emergency department at Armadale Health Service, a peripheral hospital with a good mix of tertiary and VMO staff. My family moved to Perth from Singapore when I was eleven. After doing my medical degree at the University of Western Australia, I did my internship and residency at Sir Charles Gairdner Hospital. I was doing surgery as a specialty for almost four years, taking surgical exams, registrar posts and ENT training, but I left to enrol in General Practice training.
What influenced your decision to do medicine and then to become a GP? My uncle is a geriatrician, which had some influence on me. I was also drawn to the healing side of medicine. After I took time off from my surgical training, I made the decision that surgery wasn’t for me. I thought I would be far happier with the worklife balance that General Practice offers rather than the oftendemanding schedule of surgery.
What do you enjoy about your work now – and what do you find challenging? I do enjoy building a rapport through the ongoing care of my patients and I find it very satisfying to receive a level of appreciation for my efforts. You do feel that you are adding a personal touch – it’s not a cold interaction with people. I start around 8.30 and finish at 5.30, with an hour lunch break. We have a weekly practice education meeting and we all eat together, which provides a good forum for discussion of interesting cases or just simply social downtime. There is a great curry house about ten minutes away, so sometimes we take a Friday lunch break there. There’s a genuine team environment in my current practice and each doctor is comfortable discussing concerns freely with colleagues. Our complementary interests really facilitate the overall care of our patients. I feel much more at ease being a GP mainly because the worklife balance is fantastic – it’s very flexible and it allows plenty of time to enjoy life outside work. At weekends I often go to Margaret River wineries, I have a very active interest in sport, I get to the cricket. All in all, it’s a much better life than the alternatives. To be honest, I can’t think of any minuses. I get to treat and manage a wide variety of conditions, ranging from simple things that are readily sorted to more complex ones, where further tests and specialist involvement is required. Sometimes I come across conditions, which require close liaison with the emergency department. One of the key aspects that’s so rewarding is that I also get to follow-up on my patients’ progress.
Photography: Michele Clarke, Karma Creations
What main differences do you find between General Practice and the hospital system? I’m still spending one day a week in a hospital emergency department and I do enjoy the camaraderie of the smaller hospital setting. There is far less of a hierarchy, unlike the larger tertiary hospitals. Doing that one day in emergency keeps up my minor procedural and acute emergency management skills, so I’m in touch and upto-speed with all the various processes. I believe that being in General Practice does not mean that you should sever your ties to hospitals. Of course, most medicine is done outside the hospital but I do think that it’s important for people who are going to be in that front line, in General Practice, to really spend some time in the hospital setting. This not only allows them to develop their skills, but also gives them an understanding of what the hospital process involves. All of this also helps you expedite what can be done in the community … and the more that can be done in community and General Practice, the more we will ease the burden on the overloaded hospitals. What skills have you needed to learn or develop to become a better GP? I like to think of a good GP as a jack-of-all-trades, but most of us will carve out niche areas where we are most comfortable. In my case, that tends to be minor procedural, paediatrics and emergency medicine. I have been developing my skills in chronic disease management and the preventive/lifestyle medicine that I believe is emerging as a stronger focus in General Practice. The skills I would personally like to work on a bit more are in the area of the management side of General Practice. I would like to be involved in the educational aspects, too – so I could be more involved in steering the direction of General Practice.
A Day in the Life of a Metro GP Registrar
See Dr Keith Ananda’s video on the WAGPET website. Visit: www.wagpet.com.au/ training-opportunities/ gp-registrar-training/ supervisingprevocational-doctors
Going Places – ISSUE #2
DR Sarah McEwan
A passion for indigenous health 14
Sarah McEwan is a very inspiring young doctor, but she credits much of her own success to the inspiration she received from others, like her father – a generous community worker with police, rescue and ambulance services – as well as her childhood doctors, a husband-and-wife GP team who helped deliver her. Sarah is a Wiradjuri indigenous woman who grew up in Mudgee in rural NSW and went to the University of Newcastle to study medicine after graduating from Mudgee High School. She is just completing her Advanced Rural General Practice Graduate Diploma and has also already accumulated many extra qualifications including sexual health, obstetrics and gynaecology, and child health. Last year she was named the 2009 National Rural Faculty’s General Practice Registrar of the Year. “I decided to undertake all of these extra skills to enhance my ability to be able to cope in an isolated remote medical environment,” Sarah says. She currently works at Tweed Heads Hospital, where she has completed an advanced diploma in obstetrics, routinely doing caesareans and other procedures. She also performs a part-time role with North Coast GP training, redesigning the curriculum to improve teaching GP registrars about Aboriginal health – and she is also the indigenous support officer for North Coast GP Training. But that’s not all … she also undertakes a 24-hour shift each fortnight in a Brisbane private hospital ICU. Sarah is no stranger to strong community service. “My dad was a volunteer who helped out a lot in times of need. As a child, I remember stormy nights with dad’s CB radio going berserk in the background – it really rubbed off on me. In high school, I had a really fantastic teacher in PE and health, so it was very much a series of things over time that led me to medicine.” Early in her medical degree at the University of Newcastle, she made the decision to go into General Practice.
“I loved rural and remote health and in General Practice, I could be everything I imagined a doctor to be. I really didn’t consider anything else.” Her fourth and fifth years were spent in Tamworth – a perfect placement, she reminisces. “I was closer to the rural life I knew and loved – and closer to family, an important factor in my success gaining a medical degree.” Her elective placements were always in rural or remote locations, laying the foundation for future rural practice. A six-week third year placement at Danila Dilba Aboriginal Medical Service in Darwin, followed by a four week placement in Port Hedland in WA in her fourth year, fuelled her ongoing interest in Aboriginal Health and remote medicine. A locum stint at Port Hedland Hospital for eight weeks last year reinforced her own commitment. Much of this was attributable
”I loved rural and remote health and in General Practice, I could be everything I imagined a doctor to be. I really didn’t consider anything else.” to a GP she worked with – Dr Pascal Burton, whose long-term work in remote/ Aboriginal health was so inspiring. “The variety of presentations and severity of pathology I saw in these early exposures to remote medicine was fascinating,” Sarah says. “Having to work only with the tools and knowledge that you have at hand was challenging, but exciting.” Sarah’s internship and part of her residency were spent at RPA Hospital in Sydney, then as part of her General Practice training, she spent six months in Emergency at Tweed Heads hospital, followed by another six month term there in obstetrics and gynaecology, where she
undertook a diploma in obstetrics. Sarah then spent nearly two years at Queen Street Medical Centre in Murwillumbah, completing a diploma in child health – in her spare time – before moving to her current role in Tweed Heads hospital. “Being back in the hospital system is quite a shock to the system. People can’t quite comprehend that a GP Registrar is doing things that other people in specialties do! It’s actually quite a difficult balance finding your place, as you’re not a Resident – but you’re not a Junior Registrar, either.” The hardest part is a loss of independence, Sarah says. “In General Practice you’re making decisions all the time but in the hospital system you’re working with a team of people and you lose that ability to be independent.” Sarah admits that, conversely, the transition from hospital to General Practice can also be daunting. “It’s nerve-wracking at first, finding the confidence to be independent and make all those decisions on multiple levels.” In a few months, Sarah will take up a position as a District Medical Officer at Port Hedland Hospital in Western Australia – a position that combines emergency and obstetrics work in a remote region with Aboriginal populations. Her father is working in the area now, and she has other family there, so the new job is ideal. Sarah’s husband will even be able to continue his law studies … remotely! Sarah’s enthusiasm for her work is infectious. “I will never forget my first delivery as a GP obstetrician – it cemented all the reasons why I chose the profession,” Sarah says. “The mother had a stillbirth the year before and then chose me as her GP obstetrician. We met each Friday afternoon and I would reassure her by monitoring the foetal heart. It was more like counselling throughout the pregnancy and, ultimately, it was an unforgettable experience to be involved in her delivery of a healthy baby.”
Photography: JK Photography
Going Places – ISSUE #2
Searching through vast amounts of information on the net can be time-consuming. But the internet can be used as a great source of knowledge for General Practice.
The Medicare Australia site provides information for healthcare
19 million citations for biomedical articles from MEDLINE and life science journals, PubMed also has full-text articles and links to other resources. www.pubmed.gov
The Cochrane Library can be accessed through the Australasian Cochrane Centre website. This is provided by the notfor-profit organisation, which provides up-to-date information on the effects of health care. As a note of interest, the international site (www.cochrane.org) has top links for GPs and podcasts on reviews for your commute to work. www.cochrane.org.au
Patient Friendly Information
PubMed (US National Library of Medicine) comprises more than
GP Learning Online (A RACGP initiative) www.gplearning.com.au PrimEd (continuing professional development) www.primed.com.au
evidence-based healthcare information in the UK. The awardwinning electronic version at ebandolier.com reportedly receives almost 90,000 visitors every week. www.medicine.ox.ac.uk/bandolier
Australia. The register contains the latest records of current and recently completed research projects with details of published research. www.radar.org.au
The Medical Journal of Australia (Journal of AMA) is Australia’s leading peer-reviewed journal of medical practice and clinical research. www.mja.com.au
Australian Family Physician Online (Journal of Australian Doctor) is the official peer-reviewed journal of The Royal Australian College of General Practitioners. www.racgp.org.au/afp The WONCA (World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians) website has a Journal Watch section. This scans the internet for journal articles and medical literature from around the world. It includes synopses and directs you to relevant websites. www.globalfamilydoctor.com The Medical Observer website has excellent links to GP resources and patient handouts. It also has a useful Clinical Review tab to keep you updated on medical news. To access content, you have to be a registered Medical Practitioner or healthcare professional to log in. www.medicalobserver.com.au
The Australian Doctor website has resources for clinicians, linking to respected journals from Australia and around the world. www.australiandoctor.com.au
The Better Health Channel offers GPs consumer based information, checked regularly, with useful handouts for patients. www.betterhealth.vic.gov.au
My Dr (MIMS Australia) website contains a range of consumerfriendly tools; quizzes, calculators, a medical dictionary and information on medications. www.mydr.com.au Health Insite is an Australian Government Initiative, which aims to provide patients with the latest information on health/wellbeing and has links to health services across the states and territories. www.healthinsite.gov.au
GP Notebook is an encyclopaedia of medicine, updated on a continual basis and contains over 26,000 pages of information. www.gpnotebook.co.uk
Bandolier is a key source for high quality information on
RADAR – Register of Australian Drug and Alcohol Research is a project of the Alcohol and other Drugs Council
GPs looking to update their skills can easily access these professional development platforms.
Here are some reputable sites as recommended by our panel of GPs we consulted.
get the Where GPs go to
GP Psych Support (RACGP initiative) offers GPs patient management advice from psychiatrists within 24 hours. www.psychsupport.com.au/default_home.asp The National Prescribing Service is an independent, not-forprofit organisation providing accurate, balanced evidence-based information about medicines. Their website contains sections for consumers, health professionals and other members and stakeholders. www.nps.org.au The Department of Health and Ageing Therapeutics Goods Administration website provides information on the Australian Register of Therapeutic Goods. The TGA monitors and assesses therapeutic goods in Australia, ensuring they are of an acceptable standard and any therapeutic advances are readily available to the Australian public. www.tga.gov.au The Australian Government provides information on the
Pharmaceuticals Benefits Scheme through this website, including the Schedule of Pharmaceutical Benefits, listing medicines under PBS. www.health.gov.au/pbs
The Australian Prescriber is an independent publication offering information on drugs and therapeutic goods. It is run by the National Prescribing Service. Full-text articles are available free of charge. www.australianprescriber.com
MIMS Australia supplies Australian health professionals with products and publications that assist GPs to make decisions in the clinic. www.mims.com.au The Australian Drug Foundation works to educate the community on the problems associated with drugs and alcohol. They conduct research, hold seminars and undertake community development work. www.adf.org.au Going Places – ISSUE #2
Dr James Doube
Out in the cold ” If something goes seriously wrong, I’m anything from anaesthetist to surgeon – and everything in between.“
Going Places – ISSUE #2
I’m currently three months into my second rotation at Macquarie Island, on the Australian Antarctic Division base. This is an advanced training post for the Australian College of Rural and Remote Medicine. I have the accolade of being the most remote GP in Australia – the nearest doctor is 1,500km away!
Macquarie Island is the very last bit of green before you get to the ice. It’s an amazing place, a bit like living inside a David Attenborough documentary! Antarctic wildlife mostly don’t breed on ice (perhaps a little too cold and uncomfortable!) so seals and penguins, albatrosses and so on, breed in more hospitable places like this. The island is extremely rugged – it’s basically a mountain range sticking out of the ocean, so you go everywhere on foot or quad bike or these amphibious vehicles called Larks, which look like an oversized Tonka truck. They are genuinely a “go anywhere” vehicle – you can even drive them through heavy surf to a ship. There’s usually less than fifty people here, and all are fairly fit and healthy, so there’s no chronic disease management at all. I do quite a lot of physiotherapy and dentistry, a bit of pathology and even wound dressings and other nursing roles. If something goes seriously wrong, I’m anything from anaesthetist to surgeon – and everything in between. At the moment, I’ve got a couple of people I follow-up with more regularly. One has been bitten by a seal and has a big wound in his arm, so I’m dressing that and letting it heal up. Another has a chronic musculoskeletal problem, so I’m doing daily physiotherapy. Another of my responsibilities is public health – like our drinking water supply. With millions of penguins, seals and birds, our dam is full of poo and bugs. So, part of my job is to do the water testing and then treat the water appropriately to make it safe to drink. And, asif all this isn’t quite enough, I’m also involved in search and rescue training and disaster preparation. I have a normal consulting room, plus an X-ray machine and an extensive lab with microscopes, various centrifuges and analytical machines. In another room, there’s a dental facility and a darkroom for developing x-rays, plus I have a small ward, some storerooms and even my own operating theatre.
Another part of my responsibilities is to collect data for medical research. With very low environmental vitamin D levels from sunlight, and everyone eating the same food, we’re doing detailed sunlight studies. We’ve had the occasional emergency – animal bites, search and rescue. Hypothermia and frostbite are quite uncommon here, as everyone is very aware and cautious, plus the clothing now is so high-tech. It’s a fantastic job, great fun. Some of the time I’m a biologist, helping with other research projects. For example, at the moment, I’m helping catch seals. It’s a teamwork thing and it’s not that easy. There’s a knack to it – if anyone wimps out, the seal’s going to turn around and bite you. And that can be very painful! So, how did I end up in the Antarctic? I grew up in Strathalbyn, a rural community outside Adelaide, then did a science degree and worked as a biology field officer at Flinders University for about four years. Both my parents were country vets and I helped them quite a lot. In my late teens, I was heavily involved in the local volunteer fire and ambulance service, on the rescue side. I was helping out some doctors who treated marine venoms, by catching various marine animals for them, and this really spurred my interest in medicine. So, I sat the exam to get into medical school. I remember turning up to the interview in board shorts and thongs after diving all morning. I must have really stood out, as all the other interviewees were wearing suits! Anyhow, they let me in, despite the outfit – and I did a four year postgraduate medicine degree. All the way through, I was undecided between surgery and General Practice. Through the rural community-based program, I spent my third year in the Riverland area, and fourth year in the Territory, which reinforced my commitment to rural work. Then, after spending time with a GP surgeon, I realised I’d found the job that was perfect for me!
I did my internship at Flinders, then went up to Whyalla into a rural surgical post, followed by a locum year in Jamestown, doing quite a bit of surgical stuff and I was accredited to do colonoscopies and endoscopies. After that, I applied to the Polar Medicine Unit of the Antarctic Division. This is the ultimate General Practice. There is no hope of medical retrieval in the Antarctic, so you’ve got to be fully prepared to deal with just about anything. They developed that into a training program, as I was a GP Registrar, and I was appointed Expeditionary Medical Officer – initially for 20 months. There really are very few jobs with this level of paid training. I had two weeks of training at the Royal Dental Hospital in Melbourne … then anaesthetics training … followed by pathology training, so I could do my own pathology, like cross matching blood for blood transfusions, all from scratch. I also had training in water testing and treatment for the public health role – all the training was amazing and I learned so much! The important thing to remember is you’re not undergoing all that training to learn all these skills because you’ve got an exam – it’s because you need to know all of this and it’s possible somebody’s life may depend on it. We don’t get many visitors around here – it’s a bit out of the way – but it’s a really fantastic job. I love it.
Photography: Tessa Bickford
Dr Georga Cooke
Enjoying the diversity of General Practice What’s your current role – and how did you get there? I’m doing several roles at the moment – a few sessions each week as a GP Registrar in a Brisbane Medical Centre, as well as working as the Registrar Liaison Officer for CSQTC, my training consortium, and I’m also at Bond University as an academic registrar. My first Registrar term was in a practice in inner Brisbane. My grandparents used to go there, so I had a sentimental attachment, which also reflected my own feelings that in General Practice you’re looking after families and often several generations. My own connection with that practice mirrored my hopes for my future clinical practice. I did my rural term in Toowoomba, a big town with three hospitals, away from my usual support network, so I learned to appreciate problems from a different aspect. My patients’ stories touch me in a way in General Practice that they didn’t in the hospital – you’ve got much more of a personal connection with what’s happening for them in their lives.
What influenced your decision to do medicine and then to become a GP? My decision to be a doctor started young and came out of left field. But as my mother is a teacher and I’m married to a teacher, my interest in education is probably less surprising. In high school, I wanted to be an obstetrician – but I changed direction in the second week of medical school, at a lecture from the Professor of General Practice. I thought that I could see myself doing that if I tried really hard. I also had a pretty good role model in my own GP. I did a science degree at the University of Queensland, then did postgraduate medicine, doing all my hospital time – three years – at the Royal Brisbane, choosing terms that were pretty broad, to give me a variety of experience, plus I also did a bit of emergency every year. I particularly enjoyed the experience with geriatrics – it’s slower paced, but there’s a lot more family involvement and ethical considerations. I spent my geriatric term trying to get people back into their homes where they wanted to be, so they’d have the support of their families. I’ve maintained an interest in obstetrics, I still like seeing pregnant women and babies, and I’ve also continued my interest in geriatrics, the other end of life.
Have your impressions of General Practice changed since you entered the profession? My early impressions were that General Practice can be what you make of it. I saw a lot of GPs that weren’t particularly happy in their choice – but I also a lot of GPs who were really dynamic, keeping several balls in the air. With General Practice you can be involved in so many different areas of the practice, as well as teaching or professional advocacy. I went to a lot of the physician’s education in the hospital, and
their outlook on things interested me. In my surgical terms, I quite enjoyed the procedural element. These opened my eyes to the opportunities, so I believe I can think like a physician in the community and I can do procedures as a GP. I see something surprising and interesting every day – often something I haven’t seen before. In three years of hospital practice there were lots of conditions that I still understood only on a textbook level – most days a problem would present itself, which is interesting or rare or just unusual. I’ve seen a temporal arteritis, I’ve seen a case with Kawasaki’s Disease. But doing General Practice doesn’t mean you miss out on the exciting things or the emergencies or the intellectually interesting problems.
What are the main changes you’ve found since leaving the hospital system? In a practice, it’s much easier working with a computer so everything is in the same place – I can’t imagine going back to handwriting all my scripts. I also found night shift disrupting, it made me pretty cranky. I also get a lot more respect. I’ve had some lovely letters from specialists, “Thank you for sending me this fascinating case.” I don’t remember that happening in the hospital. It’s much more of a collegiate approach.
What skills have you needed to learn or develop to become a better GP? I had a pretty good understanding of how to manage most things that I was going to see and I needed to learn to rule out potentially serious things quickly. In a hospital, you can order a test that comes back within a few hours, but you don’t have that luxury in General Practice. My history-taking and my examination has become more sophisticated and I have to think what my likely diagnosis would be, much faster. You need to work quickly, as you only have 15-20 minutes with the patient to get through all of that, plus decide what you are going to do. Refining my diagnostic process is the number one thing I’ve had to get better at.
What are your plans for the future? I’d like to continue to combine medical education and clinical work because I really enjoy the variety of working a few different roles. Each one seems to give energy to the others. Photography: Ian Day
Right Product, Right Place, Right Time Right Product
Our range of MIMS products gives you the choice of how to access medicines information that best suits your work practice
PC, PDA or print format ensures MIMS is always within easy reach
Monthly updates give you the surety that you are accessing current information at all times
MIMS is Australiaâ€™s most trusted medicines information, with 46 years of experience, giving you peace of mind as you work.
DR Michael Wong
Dr Michael Wong’s clinic was a media circus when he spoke to Going Places. There were news crews from all over Australia descending on the town of Kinglake to mark the one-year anniversary of the devastating Black Saturday bushfires in 2009 that destroyed over a thousand homes in the area. Michael is one of ten doctors who work several days a week at the Kinglake Ranges Health Centre in rural Victoria – a temporary clinic initially set up in a tent in a paddock, but now housed in a relocatable building. Whilst much of the clinic work is regular General Practice, he says that ongoing trauma following the fires adds another dimension to his work. “In this role, I focus on looking after each patient, whatever happens with all the politics and the other organisations around us. It’s a job that is at times difficult and stressful – but at other times very rewarding.” He also spends a day each week at a clinic in nearby Buxton, servicing the population around the Marysville area, after that town was also decimated by the fires. “It’s quite an unusual situation to be involved in actively helping with bushfire relief and rebuilding … but opportunities to do something unusual do come up quite a lot in General Practice. There are so many things you can do and I feel it’s a privilege to be part of that.” Michael has certainly managed to combine a balance of unusual and interesting work activities for a GP – he also works in a Melbourne city clinic for homeless adolescents, and as a Custodial Medical Officer for the Victorian Police. He’s responsible for looking after prisoners in police custody as well as some non-clinical sessional work, helping to administer the service at the Victoria Police Centre. Despite his packed schedule, he still manages to take an extra day off each fortnight, as well as most weekends. Michael’s father was a family GP in suburban Melbourne – and Michael knew from a young age that he wanted to follow his father and work in medicine. Part-way through his medical degree at Melbourne University, Michael had made the decision to go into General Practice – but he wanted to do it differently to his father, which is why he specifically chose rural General Practice training.
In the heart of the bushfire area “ It’s quite an unusual situation to be involved in actively helping with bushfire relief and rebuilding … but opportunities to do something unusual do come up quite a lot in General Practice. There are so many things you can do and I feel it’s a privilege to be part of that.”
Photography: Lachlan Moore
“ People are more interesting to me than any particular medical speciality – that’s what attracted me to General Practice in the first place. I didn’t just want to specialise in one area of medicine, because I enjoy a lot of the different areas of medical practice – particularly pediatrics and procedures.”
Following his internship at Box Hill Hospital, he enrolled in the three-year rural General Practice training program, based at the Latrobe Valley Hospital in Traralgon. “Local GPs in the Lakes Entrance and Lansdale area are very active both in the emergency department and with hospital in-patients, so there was always lots to do – and, besides, it’s a great place to live!” When he had finished his GP training, Michael took on a part-time role in research and teaching at Melbourne University for a year – an advanced academic training post. “Although I’m not planning to move into research or academic work, it was very good experience and helped me to understand the research process. I worked on a project in adolescent health, which is an area that still interests me.” Around the same time, he started a position he still holds, five years later. This involves undertaking five hours a week of clinical work with the Young People’s Health Service, which provides primary health care to homeless or at-risk youth aged from 12 to 22. “This is a role I really enjoy, because it involves managing patients with complex medical and social problems, including mental and sexual health, substance use, poor living conditions and high-risk lifestyles,” he says. Despite his dislike of psychiatry when he was a medical student, Michael says that he now finds the mental health side of General Practice very rewarding. “Sometimes there are parts about a job that you like and parts that you don’t like, so it was a bonus for me that mental health – something I was apprehensive about as a student – became one of the more rewarding parts of what I do.” Michael’s packed resumé also includes experience in a rehabilitation hospital and training GP Registrars. “I know this sounds ironic, but even though I’m now doing many varied jobs, the more diverse things that I become involved with, the more I actually look forward to just ‘normal’ General Practice.” He explains that in General Practice, you see patients on their terms, rather than within the somewhat alien and clinical environment of a hospital. “You see people how they normally act and, in turn, you are accepted as yourself. Your interaction with your patients is far less formulaic – that allows you to be able to develop quite close and personal relationships.”
Going Places – ISSUE #2
'How to'... series 'How to'... series
'How to'... series How to break bad news
How to break bad news
How to break bad news
Australia’s Leading MDO
It is important for all medical practitioners to learn how to Getting stuck in one phase break bad news; as it is an integral and frequent part of our job. • Persistent denial – e.g. demand for more and more tests Research suggests that breaking bad news is often done poorly1, or opinions. This can be common because it seems more so improved knowledge canpractitioners help reduce any stresshow or to It is important forand all insight medical to learn in one phase culturally Getting acceptable stuck than anger. anxiety associated with as breaking news. and frequent part of our job. break bad news; it is anbad integral • Persistent denial – e.g. demand for more and more t • Persistent anger – e.g. suing for delayed diagnosis. 1 , Research suggests that breaking bad news is often done poorly
What is bad news?
or opinions. This can be common because it seems so improved knowledge and insight can help reduce any stress or • Persistent depression – this is the most common form of culturally acceptable than anger. sticking. anxiety associated with breaking bad news. • patient’s or carer’s perception, or • Persistent anger – e.g. suing for delayed diagnosis. Constant cycling through stages ‘Bad news’ can be determined by the:
It is important for all medical practitioners to learn how to Ge What is bad news? break bad news; as it is an integral• and frequent part of our job. • by our own clinical knowledge and insight. • Persistent depression – this is the most common for Moving backwards in cyclic loops and repeating previous ‘Bad news’ can be determined by the: • sticking. reverting anger or denial. A patient’s or carer's perspective of bad news may differ from our bademotions Research suggests that breaking news– e.g. is oftentodone poorly1, • patient’s or carer’s perception, or own. Their perspective may be affected by: • Cycling is a form of avoidance – going backwards is a strategy Constant cycling through stages so improved knowledge and insight can help reduce any stress or to delay the inevitable need for acceptance. • by our own clinical knowledge and insight. • individual fears • Moving backwards in cyclic loops and repeating pre • limited clinical understanding The patient’s behavioural will likely of the anxiety associated with breaking bad news. emotionsresponses – e.g. reverting to resemble anger or one denial. A patient’s or carer's perspective of bad news may differ from our : three types of behaviour associated with grief and loss • the impact of the news on their lifestyle own. Their perspective may be affected by: • • Cycling is a form of avoidance – going backwards is • the impact of the news on their career. • Numbness – mechanical functioning/social insulation 3
What is bad news?
• individual fears
to delay the inevitable need for acceptance.
• Disorganisation – intensely painful feelings of loss
• The patient’s behavioural responses will likely resembl • Reorganisation – re-entry into more normal social life. ‘Bad news’ can be determined by the: three types of behaviour associated with grief and loss • the impact of the news on their lifestyle
Whereas our perception of bad news will likely be affected by:
• limited clinical understanding
• clinical knowledge and insight • the diagnosis
• the impact of the news on their career.
Steps in breaking bad news • Numbness – mechanical functioning/social insulati
• patient’s or carer’s perception, or
• the prognosis
1. Prepare for discussion • the Disorganisation – intensely painful feelings of loss Whereas our perception of bad news will likely be affected by: • the treatment • C onsider which other practitioners, if any, should be involved in • empathy for the patient. • Reorganisation – re-entry into more normal social • clinical knowledge and insight the discussion.
• by our own clinical knowledge and insight.
• the diagnosis Patient reactions to bad news
• the the prognosis Perhaps most vital aspect of delivering bad news is our ability to anticipate the patient’s reaction. While each patient will • the treatment react differently, there are common emotional and behavioural • empathy for the patient. responses that we might encounter.
Steps in breaking bad news • Select a meeting space that provides both auditory and visual privacy.
A patient’s or carer's perspective of bad news may differ from our 1. Prepare for the discussion • Set a mutually agreed to time; do not inconvenience the • Consider which other practitioners, if any, should be i own. Their perspective may be affected patient. by: •
Patient reactions to bad news The 'grief • cycle' individual fears
• Allow ample time so as not to appear rushed or impatient.
• Select a meeting space that provides both auditory a
• Consider if the patient should have friends, family and/or an privacy. Perhaps the aspect of delivering bad news is our ability After receiving bad most news, vital the patient’s emotional response interpreter present. will typically resemble of the following phases of the to anticipate theone patient’s reaction.five While each patient will • Set a mutually agreed to time; do not inconvenience • Collate contact details and information about relevant support ‘grief cycle’ and move through thecommon cycle untilemotional the final point react2differently, there are andofbehavioural patient. groups. acceptance:
• limited clinical understanding
• the impact of the news on their lifestyle
responses that we might encounter.
1. Denial: ‘It’s not true. I want more tests, and a second opinion.’
The 'grief cycle'
2. Open the• Allow ample time so as not to appear rushed or impa discussion
• the impact of the news on their career.
Whereas our perception of bad news will likely be affected by:
• clinical knowledge and insight
• We should always be sure we are speaking with the correct • Consider if the patient should have friends, family an After receiving bad news, the patient’s emotional response patient. interpreter present. 3. Bargaining: perhaps with you – ‘What if I stop smoking now?’ will typically resemble one of the following five phases of the • It is important to introduce ourselves if the patient Or perhaps with God – prayer, pilgrimages… • Collate contact details and information about releva 2 and realisation move through cycle until the final point relationship of ‘grief cycle’ is not already well established – particularly if 4. Depression: grieving of thethe inevitable groups. there are family or friends who we have not met before. acceptance: consequences. 2. Open the discussion 5. Acceptance: relaxation, objectivity. • Introduce the purpose of the discussion. 1. Denial:emotional ‘It’s not true. I wantand more tests, and a second opinion.’ 2. Anger: ‘Why me? Why wasn’t this detected earlier?’
© Avant Mutual ‘Why Groupme? Limited 2. Anger: Why wasn’t this detected earlier?’
• the diagnosis 3. Bargaining: perhaps with you – ‘What if I stop smoking now?’
Or perhaps with God – prayer, pilgrimages… 4. Depression: grieving realisation of the inevitable
• the prognosis
• We should always be sure we are speaking with the c patient.
• It is important to introduce ourselves if the patient relationship is not already well established – particul
'How to'... to'... series series 'How Howto tobreak breakbad badnews news How
'How 'How to'... to'... series series 'How to'... series 'How to'... series How How totobreak to break bad bad – checklist How break badnews news –checklist checklist How to break bad–news news – checklist 'How to'... series
Australia’s Leading MDO
3. Explore the patient’s understanding References 1 E Kübler-Ross, On Death and Dying, Macmillan, NY, 1969. It is important for all medical practitioners to learn how to Getting stuck in one phase • Before we break the bad news, it is important to know what the 2 ibid. break bad news; as it is an integral and frequent part of our job. ThisThis This listlist islist intended is intended is intended as as a guide a guide as to a to guide assist assist you to you through assist through you thetheprocess. through process. the process. patient understands at this stage. This will allow us to reinforce • r. R Temes, Living With An Empty Chair - a guide through grief’ New Horizon Press; Persistent denial – e.g. demand for more and more tests 3 D list is intended as a guide to assist you through the process. Research suggests that breaking bad news is often done poorly1, This Enlarged ed 1992. accurate information, correct inaccurate knowledge and or opinions. This can be common because it seems more so improved knowledge and insight can help reduce any stress or Activity Activity Yes activity Additional Activity Additional activity needed needed activi understand what the patient is expecting to hear. culturally acceptable than anger. YesYes Additional anxiety associated with breaking bad news. Activity Yes Additional This list is intended as a guide to assist you through the process. Recognise the definition ofcan bad Recognise Recognise thatthat thethat the definition definition of bad of bad news news can news can • Persistent anger – e.g. suing for delayed diagnosis. determined by both theorpatient’s be determined bebedetermined by by both both thethe patient’s patient’s or carer’s carer’s or carer’s 4. Confirm or break the bad news
How to break bad news – checklist
What is bad news?
• Avoid medical jargon. ‘Bad news’ can be determined by the: • Allow silences – they don’t have to be filled. • patient’s or carer’s perception, or • Show empathy. • by our own clinical knowledge and insight. • Encourage the patient to ask questions. A patient’s or carer's perspective of bad news may differ from our • Allow the patient to express emotions. own. Their perspective may be affected by: • A • sk the patient what they are thinking and how they are individual fears feeling. • limited clinical understanding • Anticipate denial and anger. • the impact of the news on their lifestyle the impact of the news on their career. • • Patients may often forget or not understand the bad news, so strategies should be used to help them understand. Whereas our perception of bad news will likely be affected by: 5.• Present treatment options clinical knowledge and insight the diagnosis • • Ideally options should be discussed over more than one to allow for greater understanding by the patient. • consultation the prognosis
Recognise that the definition of bad news can
perception, our own knowledge andor insight. perception, perception, andand ourand our own own knowledge knowledge andand insight. insight. be determined by both the patient’s carer’s
• Activity Persistent depression – this is the most common form of Yes Additional activi sticking. prepared for each of the likely emotional and Be prepared BeBeprepared forfor each each of the ofthe the likely likely emotional emotional andnews can Recognise that definition ofand bad perception, and our own knowledge and insight.
behavioural reactions the patient may cycle through behavioural behavioural reactions reactions thethe patient patient may may cycle cycle through through be determined by both patient’s or carer’s Be prepared forcycling each ofthe thethrough likely emotional and Constant and how to handle these. andand how how to handle to handle these. these.our perception, and own knowledge and stages insight.
behavioural reactions the patient may cycle through and how tothe handle these. • Be M oving backwards in cyclic loops and repeating previous prepared for theeach discussion: Be prepared BeBe prepared for for the discussion: discussion: prepared for of the likely emotional and
emotions – e.g. the reverting to anger or denial. behavioural reactions patient may cycle through • Who should be present? • Who should be present? • Who should be present? Beand prepared the these. discussion: how tofor handle • Cycling is a form of avoidance – going backwards is a strategy • When should the discussion occur? • When should the discussion occur? • When should the discussion occur? • Who should be present? Beto prepared theinevitable discussion: need for acceptance. delayfor the • Where should the discussion occur? • Where should the discussion occur? • Where should the discussion occur? • When should the discussion occur?
• Who should be present? • Are we equipped with relevant information? • Are we equipped with relevant information? • Are we equipped with relevant information? The patient’s behavioural responses will likely resemble one of the • Where should the discussion occur? • When should the discussion occur? three types of behaviour associated with grief and loss3: clear onbest how best tothe open the discussion: Be clear BeBe clear on on howhow best to open to open the discussion: discussion: • Are we equipped with relevant information? • Where should the discussion occur?
• • Are we equipped with relevant information? Numbness – mechanical functioning/social insulation Remember to introduce ourselves and the purpose of • Remember to introduce ourselves and the purpose of • • Remember to introduce ourselves and the purpose of the discussion theBe the discussion discussion clear on how best to open the discussion: • Disorganisation – intensely painful feelings of loss
clear on how best to open the discussion: • Be Remember to introduce ourselves and the purpose of ready to explore the understanding patient’s understanding of the Be ready BeBeready to explore to explore thethe patient’s patient’s understanding of of thethe discussion Remember to introduce ourselves and the purpose of • • theReorganisation –expecting re-entry into to more circumstances and what they aretoexpecting hear.normal social life. circumstances circumstances andand what what they they areare expecting to hear. hear. the discussion
Be ready explore the patient’s understanding of the Steps in breaking bad prepared to confirm orthe break thenews bad news. Be prepared BeBe prepared to confirm toto confirm or break or break the bad bad news. news. Be ready to explore the patient’s the circumstances and what they areunderstanding expecting toofhear. Remember - simple use simple language Remember Remember - use - use simple language language andthe what they are expecting to hear. 1.circumstances Prepare for discussion - empathy show empathy - show - show empathy Be prepared to confirm or break the bad news. prepared to confirm or break the bad news. • Be Consider which other practitioners, if any, should be involved in - emotional allow emotional expressions - allow - allow emotional expressions expressions Remember language Remember- - use usesimple simple language
• • Uthe treatment se simple language and avoid using medical jargon. • empathy for the patient. • Ensure this is a two-way conversation where you present the the discussion. - - present show empathy show empathy prepared to treatment Be prepared BeBeprepared to present to present treatment treatment options options in simple inoptions simple in simple treatment options, and the patient considers, discusses and Patient reactions to bad news • S elect a meeting space that provides both auditory and visual language and schedule another appointment to language language and and schedule schedule another another appointment appointment to to asks questions about each option. allow emotional emotional expressions - - allow expressions continue the discussion (if required). continue continue the the discussion discussion (if required). (if required). privacy. Perhaps the most vital aspect of delivering bad news is our ability • to Provide written material with diagrams to facilitate the prepared present treatment options in in simple Remember - needs this needs beway aconversation. two way conversation. Remember Remember - this - this needs be to be a two ato two way conversation. BeBe prepared tototopresent treatment options simple anticipate the patient’s reaction. While each patient will • Set a mutually agreed to time; do not inconvenience the language andschedule schedule another appointment to to patient’s understanding. language and another appointment react differently, there are common emotional and behavioural Be clear continue the discussion (if discussion: required). patient. clear onto how to close the BeBe clear on on howhow close to close thethe discussion: discussion: continue the discussion (if required). responses that we might encounter. Remember this needs to be a two way conversation. Remember - - this provide our contact details Remember Remember - -provide provide ourour contact contact details details 6. Close the discussion Remember needs to be a two way conversation. • Allow ample time so as not to appear rushed or impatient. • The Encourage the patient to contact you directly with further 'grief cycle' - how schedule follow-up appointment - schedule - schedule follow-up follow-up appointment appointment Be clear on to close the discussion: • clear Consider if the patient should have friends, family and/or an Be how to close the discussion: questions. -support support - offer - on offer support services services Disclaimer Remember -offer provide ourservices contact details After receiving bad news, the patient’s emotional response interpreter present. Remember provide ourrelating contact • will Provide appropriate contact details. This is general- -information todetails legal and/or clinical issues within Australia. schedule follow-up appointment typically resemble one of the following five phases of the • C ollate contact details and information about relevant support It is not intended to be legal advice, nor and should not be considered as a 2 schedule follow-up appointment ‘grief cycle’ and move through the cycle until the final point of - offer support services • Make follow up appointment(s). substitute for obtaining personal and specific legal and/or other professional groups. acceptance: offer supporttoservices advice. Whilst- we endeavour ensure that professional documents are as current • Offer other support services such as a support group. © Avant ©References ©Avant Avant Mutual Mutual Mutual Group Group Limited Group LimitedLimited 3. Explore the patient’s understanding as2. possible atthe the time of their preparation, we take no responsibility for matters Open discussion 1. Denial: ‘It’s not true. I want more tests, and a second opinion.’ 1 E Kübler-Ross, On Death and Dying, Macmillan, NY, 1969. arising from changed circumstances or information or material which may have For further information on Avant’s Clinical Risk Management • Before we break the bad news, it is important to know what the We should always be sure we are speaking with the correct become available subsequently. Avant Mutual Group Limited and its subsidiaries 2 ibid. 2. Anger: ‘Why me? Why wasn’t this detected earlier?’ ©• Avant Mutual Group Limited resources visitunderstands www.avant.org.au orThis email patient at this stage. will allow us to reinforce 3 Dwill not be liable for any loss or damage, however, caused (including through r. R Temes, Living With An Empty Chair - a guide through grief’ New Horizon Press; patient. 3. Bargaining: perhaps with you – ‘What if I stop smoking now?’ email@example.com. accurate information, correct inaccurate knowledge and negligence) that may be directly or indirectly suffered by you or anyone else in ©Enlarged ed 1992. Avant Mutual Group Limited • It is important to introduce ourselves if the patient Or perhaps with – prayer, pilgrimages… connection with the use of information provided in this forum. understand whatGod the patient is expecting to hear. relationship is not already well established – particularly if 4. Depression: grieving realisation of the inevitable Disclaimer. This is generalor information to legal and/or clinical issues within Australia. It is not intended to be legal advice, nor and not beor considered as a who substitute for have obtainingnot personal and before. specific legal and/ 4. Confirm break relating the bad news there areshould family friends we met consequences.
'How to'... series How to break bad news
or other professional advice. Whilst we endeavour to ensure that professional documents are as current as possible at the time of their preparation, we take no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently. Avant Mutual Group Limited and its subsidiaries will not be liable for any loss or damage, however, caused (including through negligence) that may be directly• Avoid medical jargon. or indirectly suffered by you or anyone else in connection with the use of information provided in this forum.
5. Acceptance: emotional relaxation, and objectivity.
• Introduce the purpose of the discussion.
• Allow silences – they don’t have to be filled. Avant MutualGroup GroupLimited Limited ©©Avant Mutual • Show empathy. • Encourage the patient to ask questions.
Going Places – ISSUE #2
Dr Genevieve Yates
“I wanted to choose where I would live and where I would work – aspects that just aren’t possible in specialty training.” Genevieve Yates is a country GP working in a small practice on the Sunshine Coast hinterland in Queensland. A keen equestrian, for a few years she lived alone on an acreage, where she ran horses, repaired her own fences and wielded a chainsaw – but she’s since moved into town so she can spend more time on theatre, music, writing – and teaching music. “I’m a big believer that you can do everything in life that you want - you just can’t do it all at once,” she says. Genevieve studied the violin and piano from an early age and has been a member of the Australian Doctors Orchestra for five years – she’s even starred in an ABC TV series, ‘Outback House,’ where she played the role of a nineteenth-century governess. “I feel that I’ve found the freedom of living a really full, interesting and different life both inside and outside my work,” she says. “Working in General Practice means I can work part-time or
work at different places and different hours to suit myself – it’s just so incredibly flexible.” Originally from the Gold Coast, Genevieve says she was always fascinated by medicine and wanted to be a doctor since she was a young child. Her family relocated to Canada, so Genevieve supported herself through medical school, teaching music to between 20 and 30 students each week – while competing in equestrian events! “It was a really crazy time, it was great to be an intern and cut back a bit.” As a very high-achieving student, she had her pick of specialties. “I was offered several training positions but I definitively chose General Practice. By the time I had finished medical school I was quite definite about my choice.”
P with the sound of music It was a first-year university lecture by a GP about the detective work involved in diagnosing symptoms in General Practice that intrigued her. “That single lecture really started me thinking about General Practice.” By the third year, Genevieve had started giving serious consideration to pediatrics. However, it was a comment from a senior pediatrician in her forties made her re-think. “She told me, ‘I’ve looked after lots and lots of kids but I’ve missed out on having my own kids and my own life’. She had been caught up in this
Genevieve to pursue another of her passions – teaching. “I’ve taught music for so many years – kids from three up to adults – and I’ve now been able to go into medical education, which I really enjoy.” A couple of short country relieving posts as a second-year doctor in the hospital system were initially challenging. But Genevieve was relieved to find the General Practice training pathway was very well supported. “From the very first day I felt that I had someone I could call straight away if I had any problems. I felt it was a very
specialty to such an extent that it was allencompassing lifestyle.” It was the continuity of care that happens in General Practice that attracted Genevieve – but probably her biggest driver was the lifestyle that goes with it. “I wanted to choose where I would live and where I would work – aspects that just aren’t possible in specialty training.” She says that as soon as she had made the decision to do General Practice, she focused her post-graduate hospital work on ENT and pediatrics. ENT because she thought it would be really useful in General Practice and pediatrics because she really liked it and wanted to focus on this when becoming a GP General Practice has allowed
encouraging and supportive environment. It was actually quite different from a lot of other specialty training programs where it was all very adversarial, where people are trying to catch you out or belittle you – it was the absolute opposite.” She believes the most critical skills for a GP are listening skills – and finding the balance between caring, and caring too much. “At first, I took things on board too much and outside office hours. I’d worry, stress and think about cases and get a bit too personally involved. When you see people on a regular basis, you do get to know them. However, you’ve got to make sure you keep your professional boundaries and look after yourself, so you
Photography: Lindy Photography
don’t burn out.” Genevieve received federal funding to make an educational DVD titled ‘What Would the Coroner Think?’ and then travelled around Australia presenting the short film. “It was just wonderful to have a project that allowed me to combine scriptwriting, acting, medicine and education,” she says.
“General Practice doesn’t mean you have to sit in an office all day and consult.”
”In a typical week, I spend three days in the practice, one to two days in direct education of registrars and perhaps I might work a shift in the Noosa Hospital emergency department.” She also visits several nursing homes in the area and is able to check patients who have health cover into the local private hospital in town. “It’s great to be able to do acute medicine in a hospital setting just next door.” With five or six different medical activities in a typical week, Genevieve says that she’s never bored and always enjoys her work. “There are just so many diverse opportunities within General Practice – so much flexibility and so much scope.”
Going Places – ISSUE #2
Dr Danielle Butler
At the top end ’m in the final couple of months of my training at the Centre for Disease Control in a two-month extended skills post. It’s an unusual GP training post, but I have a strong interest in public health in the Top End. I grew up in Ballina, on the far north coast of NSW and then went to Sydney, where I did a medical science degree with honours in neuroanatomy. After that I studied postgraduate medicine at the University of Sydney. In my third year of medicine, I started a Masters of Public Health, through UNSW. Reading Fred Hollows’ books as a teenager had a big influence on me. I was good at sciences, I wanted to work with vulnerable communities and I also wanted to work overseas. So, choosing medicine seemed to follow as a natural way for me to meet my social justice goals. Spending time in remote communities and overseas in Uganda as a student reaffirmed to me that this was the area that I wanted to be in. I did my internship at the Royal Darwin hospital, then as part of my Public Health degree, I spent a year in rural Cambodia working with Save the Children Australia. I helped set up an area health service equivalent and ran an HIV education prevention program. When I returned, I spent another eighteen months in various hospital jobs in Darwin, trying to choose between rural General Practice, paediatrics and infectious diseases. In the end, I chose rotations with these in mind, so I accumulated a real diversity of experience, which built my skills for rural General Practice! I chose rural General Practice because it would allow me to work overseas and in rural remote areas. Also, I love working in the community and didn’t want to work in a hospital for the rest of my career. I really enjoy the holistic nature of General Practice, developing relationships with patients and understanding their health in the greater context of their lives. After a hospital post in adult internal medicine and anaesthetics, I did my basic term out at Gove District Hospital, Nhulunbuy. I spent a couple of days at the mainstream clinic in town and then the rest of the time I was on the air medical retrieval roster, which is similar to the Flying Doctor Service. I flew out to remote communities to spend a couple of days there doing clinics.
It was really enjoyable and interesting work, with an amazing group of people who are predominantly indigenous. They have a unique culture and it’s really fascinating to work with them and learn about that – a real privilege. When you are so remote, you have to deal with as much as you can. If a case is quite complicated, unusual, or different, you manage it there or call people to get advice and decide when to send the patient to a more specialist centre. It’s all very interesting and really keeps up your skills. You get to do all sorts of different medicine, which you just couldn’t do in the city. But there is a down side! You often end up working extremely hard and you don’t get much of a private life! We were very short-staffed at the time, so I was working a minimum of 60 hours a week, in addition to the two days that I was doing at the clinic. The intensity of being on-call was pretty tough – to get some time out you actually had to physically leave town. The specialists there are very supportive of the regional and remote areas and always tend to be extremely accessible. Visiting specialists would come out at different times, too, and they were always available so we could ask their advice or ask them to see particular cases. Having good emergency skills or acute care skills is important in this role. My hospital time in anaesthetics, ICU and doing adult medicine as a medical registrar gave me really useful acute medicine skills that I could call on.
“ I love working in the community and didn’t want to work in a hospital for the rest of my career.”
After Gove, I spent six months at the paediatric hospital in Brisbane as part of my advanced rural skills post. It was really fascinating to see how the experts approach and think about things. However, the hierarchy was a little frustrating, because I had become accustomed to being able to operate a lot more independently. Then I did nine months at the Wurli Wurlijang Aboriginal Medical Service in Katherine, followed by a scholarship in the USA, where I spent two months working with the Robert Graham Centre in Washington. In future, I’d like to be more involved in research and developing primary health care policy, but I hope to integrate that with clinical practice. Next, I’ll probably do some locums in remote communities, depending on what’s available.
My training has been amazing and really different, mainly because I have had such a range of opportunities. I love the diversity of General Practice. You can change it to suit your niche interests and there’s the flexibility that allows you to shape your practice to address those interests and be innovative in what you want to do.
Photography: NG Photographics
Going Places – ISSUE #2
A guide to MEDICAL EMERGENCIES Medical emergencies invariably happen outside the controlled environment of a hospital emergency department. Depending on the location and the circumstances, it is quite conceivable that you, as a GP, could be the first on scene. Calling 000 is the logical first and instinctive reaction … but what do you do in the interim? Do you have any equipment to manage the patient (or patients) while waiting for the paramedics to arrive? Being confronted with a medical emergency outside work can be unnerving! Years of work as a paramedic has confirmed one thing for Greg Gibson: when in doubt, the best place to start is with the basics, irrespective of how complex or traumatic the case. The basics used to be as simple as ABC or Airway, Breathing and Circulation. However, these days, ABC has been adapted to DRABC – or Danger, Response, Airway, Breathing and Circulation, which is now the recommended guideline to dealing with medical emergencies.
What are the types of medical emergencies that you may be confronted with? • Cardiac Arrest • Drug overdose • Acute Coronary Syndrome • Anaphylaxis • Asthma • Acute Pulmonary Oedema • Hypoglycaemia • Cardiac Arrhythmias • CVA • Trauma 30
In any type of medical emergency, this Primary Survey should be your first step.
DRABC for non-clinical settings check for Danger
Clearly this is about self-preservation. Your safety and the safety of others at a scene are paramount. This can be as basic as watching out for passing traffic at the scene of an accident or wearing Personal Protection Equipment (PPE), such as gloves, goggles and mask. Never assume that you – as a rescuer – are free from danger. Your management of the scene and patient (or patients) starts here and often its success is dictated by how you manage the dangers. Never underestimate the importance of recognising and managing dangers.
check for Response
Once you have satisfied yourself that the scene is safe, you can now approach the patient. The patient’s response to a simple “Shake and Shout” will dictate your ongoing management. If you are unable to rouse the patient, then you must be aware of the importance of managing the airway. This is not the time to diagnose reasons why the patient has an altered conscious state. You need to continue your examination.
Every year, patients die for no other reason than a compromised airway due to unconsciousness and their inability to protect their airway. Once you have ascertained that the patient is unconscious, your immediate response is to examine the airway and clear it, if necessary. If suction isn’t available, simply roll the patient onto their side and manually clear the airway with your fingers and gravity. In managing the airway, it is important to utilise simple airway management techniques, such as the triple airway manoeuvre. Once you have established a patient’s airway, your next step is to establish whether the patient is breathing.
check for Breathing
This is as simple as placing your hand on the patient’s chest to “look, listen and feel” for signs of breathing. If the patient is apnoeic, then two breaths should be administered. Mouth to mouth is a contentious point, as more often than not people are reticent to provide it. In this context, the administration of chest compressions at 100/min in the absence of Expired Airway Resuscitation (EAR) is still worthwhile. The ARC guideline for cardiac arrests has adopted the principle that a pulse is not checked in the presence of an unconscious and apnoeic patient – so compressions should commence immediately. At this point, a defibrillator should be attached and DCCS administered without delay. This is worth remembering, considering defibrillators can now be found in a number of public places e.g. shopping centres, sporting grounds and airports. Using defibrillators in a public place is not uncommon. One story which comes to mind involves a physiotherapist who grabbed the defibrillator off the wall at a rural airport and saved the life of a middle-aged woman, who had collapsed after leaving the aeroplane.
check for Circulation
Checking the quality of a pulse is your next step, assuming the patient is breathing. This can dictate your management of the patient.
Vital Signs Survey Just as soon as you have completed the Primary Survey of DRABC, it is then important to establish the patient’s vital signs, including conscious state (GCS), pulse, respiratory rate, and blood pressure. As soon as you have done this, it provides you with a baseline set of observations that enable you to establish and assess your ongoing management.
Secondary Survey This is a systematic examination of the patient, starting at the head and working your way down. If possible, clothes should be removed or at least loosened to make sure you don’t miss things like a flail chest or lacerations, haemorrhage or fractures. Obviously, your management of the patient can be instigated prior to the secondary survey. This can include the establishment of an IV line, oxygen therapy and ventilation, as well as control of external haemorrhage. All of this sounds very straightforward, but we haven’t touched on what tends to confound people in the process and that is the emotional response of the rescuer(s). This can range from witnessing an accident happen and having to handle the shock of the incident. Then having the presence of mind to take control or to manage the scene.
The following list is a good standard to work towards. It’s enough to get you out of trouble, but at the same time, not take up the entire boot in your car. At the very least, having a Bag Valve Mask and Oropharyngeal Airways in your car could make a big difference. I personally carry a bag with the following: • Bag Valve Mask – these are disposable and relatively inexpensive. It is good to get one that has a disposable CO2 detector. • Oropharyngeal Airways • Laryngeal Mask Airway (LMA) – often underestimated, but a great adjunct to airway management – especially if you are not comfortable in performing endotracheal intubation in an uncontrolled environment. • Laryngoscope – fibreoptic laryngoscopes are also relatively inexpensive and you can also get disposable metal blades. A size 3 Macintosh blade is all you need.
Or it could mean being called into a next door neighbour’s backyard to resuscitate a child dragged from a pool.
• ETT – a 7mm and 8mm endotracheal tube would suffice. Don’t forget some tape to secure it after it has been inserted.
It is amazing that bystanders take a step backwards when you announce yourself as a health professional. There is an immediate expectation that you will take control and you know exactly what to do! More often than not, this could be unchartered territory for you and that’s why we go back to basics.
• IV cannula – various sizes including a long 14g to use for decompressing a tension pneumothorax. There are various makes of cannula but my suggestion is to use a safety type that provides added protection to the user. Also make sure you have tape, op-site, tourniquet and a small sharps container.
Having said that, things have a habit of going pear-shaped and you may need to assert yourself to get things done. Don’t be afraid to direct people to do things to help you.
• IV fluid and giving set – a 500ml bag of Normal Saline will suffice in the short-term until an ambulance arrives.
In my role as a Medical Educator for the RACGP Clinical Emergency Management Program, I am often asked by participants what equipment you should carry in your car in case you come across an emergency.
• Syringes – 10ml and 3ml is needed. • BP cuff and stethoscope • Combine dressings – a range of sizes to control haemorrhage and lacerations.
Remember – if in doubt – go back to the basics of DRABC. The RACGP has criteria for GP practices with respect to equipment and the Doctor’s bag www.racgp.org. au/standards/521 The Australian Resuscitation Council publishes resuscitation guidelines for common medical emergencies including patients in cardiac arrest. www.resus.org.au/policy/guidelines/ index.asp
About the Author: Greg Gibson has a career spanning over 30 years as a Paramedic. He is currently a Mobile Intensive Care Ambulance (MICA) Team Manager with Ambulance Victoria. He is also a Senior Medical Educator with the RACGP Clinical Emergency Management Program, a Flight Paramedic with QBE Insurance, as well as a lecturer at Monash University. As a result of his involvement with the CEMP, he has developed an Emergency Response Kit for General Practitioners and medical professionals. Full information on the Response Kit can be found at www. emergencyresponsekit.com.au
You need to be aware of Indemnity Insurance! Generally speaking, Practitioner Indemnity Insurance Policies cover members for a ‘Good Samaritan Act’. This is treated as a healthcare act that is performed by the member when coming to the aid of a person in an emergency or accident, where it is necessary to stabilise that person’s medical condition or to prepare that person for transfer, without expectation of payment or other consideration. This cover is, of course, subject to policy terms and conditions, which may vary depending on your Indemnity insurance.
Going Places – ISSUE #2
Dr George Forgan-Smith
The GP who loves working with kids
“ I was attracted to General Practice because of the lifestyle.”
What’s your current role – and how did you get there?
What influenced your decision to do medicine and then to become a GP?
I work three days each week as a GP Registrar at a General Practice in Ballina on the NSW North Coast. I’m also in my third year as Medical Team Leader with Camp Quality, a children’s cancer charity, where I run the medical centre for the main camp and the senior camp each year. After my medical degree at the University of Queensland, I did my internship at Logan Hospital. I had originally wanted to be an anaesthetist, but I was then drawn to psychiatry. I spent several years in a variety of psychiatry roles, in Port Macquarie Base Hospital, Logan Hospital and The Prince Charles Hospital, but eventually I decided that it wasn’t really what I wanted to do, so I enrolled in GP training. I then started my training in Bangalow, also in the Northern Rivers region, before moving to my current practice.
I grew up in a medical family. My father was a pathologist – that meant if I needed a sick day, I had to give blood! I did a degree in science and medicine was a natural progression from there. I’m a keen opera singer and took a year off from my degree to perform with The Ten Tenors both here and overseas and I really enjoyed that time. After a number of years in the hospital system, where I had a very busy schedule working in various areas, but concentrating on psychiatry, I realised I wanted to leave. I was attracted to General Practice because of the lifestyle. I wanted to move towards the beach and have time outside my work life. General Practice was the natural choice, and it still allowed me to continue an interest in mental health treatment.
What experiences did you find valuable during your General Practice training? As a Registrar Liaison Officer, I’ve been doing peer-to-peer education with registrars, as well as keeping registrars up to date with what’s happening in the big wide world. They are often so focused on getting through exams they can become a little detached! As a GP Registrar, I also get a good sense of knowing my patients. With an increased continuity of care you get a depth of understanding and a feeling for your patients. A specialist will look at just part of the problem. The patient comes back to their GP for the holistic care. You have a much broader perspective. For example, it’s not just a patient with a broken hip – it’s a person with a broken
hip in a house with stairs, who won’t be able to cook – so you need the ability to foresee future problems and to guide people towards dealing with these types of difficulties in advance. Working with CanTeen has been a wonderful experience. It’s about three weeks a year all-up, with training. The majority of the kids are really well, so it has been a great experience … although I’ve had some hair-raising times as well! Initially, I was concerned that I didn’t have the skills to care for children living with cancer, but I now realise that although keeping up to date with current chemotherapy was useful, skills like communicating, compassion and caring are, by far, the most utilised.
Photography: Sue McLeod, Suze Photography
What skills have you needed to learn or develop to become a better GP? You quickly become very good at managing time. In General Practice, you often have a room full of people waiting for you, so you have to become very time-efficient. You also learn to deal with a whole person not an illness, and that entails mastering the skills to engage that whole person. So you’re not treating a urinary tract infection, you’re treating somebody who’s worried about themselves, who has a urinary tract infection. In General Practice you are working with your patient to help them make the best decision and you can’t force anything on them. You need to be able to explain things in a clear and succinct way that enables the patient to make a decision that would be in their best interest – so communication skills are very important. I believe you also have to be very curious. Without that curiosity, you won’t find out the important information. In many ways, each patient is a new and exciting detective novel, where you have to work out what’s going on. One or two mysteries will turn up most days. To me, that’s part of the attraction – and fun – of General Practice.
Going Places – ISSUE #2
A gateway to go places with General Practice Exploring becoming a GP just became easier
With the arrival of www.gpaustralia.org.au there is now a gateway to connect you to all the information you need. This ranges from how you can test drive General Practice, through the training and being a GP Registrar, to what it’s actually like to be a GP. GP Australia can show you the intellectual challenge, the variety of work, patient interaction and great medicine that is all part of General Practice. See what others have to say about their General Practice experiences. • Prevocational doctors who have undertaken a PGPPP placement • GP Registrars training in all kinds of practices – city and country … and sometimes in places you may not expect! • GPs with their own practices, working in private practice, or mixing it with being a VMO, doing research or being a sports team doctor. PGPPP is the Prevocational General Practice Placement Program. It’s a means of getting some General Practice experience during your hospital training. You can discover how it works, and in a placement, how your hospital training is a critical foundation. All your training gives you the skills and ability to attend to the breadth of presentations you will encounter, as well as the background to tackle a range of medical problem solving. One intern from Tasmania said: “My PGPPP experience
has promoted my confidence with assessing and managing most medical and minor surgical problems independently.” This is typical feedback from those who have undertaken a placement!
Please note that the finished design of the actual website may vary from the image shown.
If you are already considering General Practice, be sure to have a look at the required hospital training. You can get a step ahead by having this covered off before you begin your GP Training. With recognition of prior learning, your remaining hospital training time could be spent in areas where you might want to develop special skills. As the largest of the medical specialty training programs, with a working “coal face” throughout the community GP Registrar training, the Australian General Practice Training program (AGPT), is unlike training for other specialties. There are training providers right across Australia and a centralised application process. www.gpaustralia.org.au can guide you through how it works, who is involved and connect you with information and contacts to help you plan your path to General Practice.
Where to from here? You’ve read through Going Places and now you’re interested in finding out more about how to become a GP? So – who do you turn to for more information?
We’re here to help – and make it easy for you. All you need to do is call us or email us and we’ll send you an information pack that will tell you everything you need to know.
We’ll include a copy of GP Compass – the comprehensive guide that covers all aspects of becoming a GP and explains about training plus a copy of the AGPT (Australian General Practice Training) Handbook, which provides full details of the AGPT program and all the Training Providers.
Contact us now! Email: firstname.lastname@example.org Phone: 1300 131 198 Fax: (03) 9629 8896
Would you like to hear about being a GP straight from the horse’s mouth? We have a stable of GPs who are willing and eager to give you advice – and help you with your decision to pursue a career in General Practice. Just call us on 1300 131 198 or email email@example.com and we’ll put you in touch!
Peer Ambassadors for General Practice in Hospitals:
Spreading the word about General Practice In every corner of Australia, teams have been busying themselves with promoting General Practice in our hospitals. Activities and programs are being rolled out across the states. Relationships forged and networks created. All in an attempt to get you to understand how interesting General Practice is – and to make it your specialty choice. This year, new initiatives are being introduced, including educational meetings, social events and peer networks. GP Ambassadors have also been selected in some hospitals to get this moving – mainly GP Registrars or interns – who will act as a source of information for General Practice and fly the flag for General Practice within the hospital system. Being the face of General Practice in hospitals, they also assist in the planning and coordination of events for interns and prevocational doctors. Many RTPs are still in the process of placing GP Ambassadors in hospitals within their training regions. Some RTPs, such as Tropical Medical Training in the north, have already allocated three Ambassadors in Cairns, Mackay and Townsville Hospitals. Without doubt, one way of reaching the pre-voc masses is through fun and interaction, such as Central Southern Queensland where
PGY1-5 doctors were treated to an evening full of fine food, drinks and good company in November last year. Nineteen doctors attended the dinner and they came from all around the area. Guest speakers talked about their personal experiences as GPs and provided some insights regarding their day-to-day work within General Practice. The dinner proved to be very successful – so much so, that 24 additional doctors indicated that they were keen to attend an event in future. In South Australia, the Regional Training Providers are meeting with interns and junior doctors at training hospitals to recruit GP Ambassadors. If you would like to be a GP Ambassador or would like to find out who your local GP Ambassador is, please contact firstname.lastname@example.org. au and we will get things moving for you. In some cases, your local Regional Training Provider is involved in managing this initiative.
Going Places – ISSUE #2
New Doctor in Training Package Protect your career and reputation. Our experience indicates: As a practising doctor you have a 1 in 5* chance (every year) of needing medical indemnity insurance or medico-legal advice. Based on a representative sample of notiﬁcations received by Avant Insurance Limited between 2006 – 2008.
Call now on 1800 128 268 www.avant.org.au
IMPORTANT: Before you decide to purchase or continue to hold an insurance product with us you should read and consider the product disclosure statement (PDS) and the policy wording to determine if this product is appropriate for you. The policy and PDS are available at www.avant.org.au or by contacting us on 1800 128 268. Insurance policies are issued and underwritten by Avant Mutual Group’s licensed subsidiary, Avant Insurance Limited ABN 82 003 707 471, AFSL 238765. Applications for insurance are subject to approval and insurance cover is subject to the terms and conditions of the policy.
Australia’s Leading MDO