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G oing P laces

ISSUE #4 – FREE

Taking a fresh look at General Practice An initiative of GPRA

More real life GPs who are Going Places A look at the new Going Places Network and our team of GP Ambassadors

More true confessions of a 21st century intern

An initiative of

GENERAL PRACTICE REGISTRARS AUSTRALIA

The Future of General Practice

PGPPP – a great way to experience General Practice What’s your diagnosis?

Financial Health Check, Dr Fairytale and lots more

An initiative of

GENERAL PRACTICE REGISTRARS AUSTRALIA

The future of General Practice


G oing P laces

In this edition:

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Taking a fresh look at General Practice An initiative of GPRA Greetings fellow future GPs

It is with great pleasure that General Practice Registrars Australia (GPRA) brings to you another fantastic edition of Going Places – the magazine designed to place the spotlight on General Practice.

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The Going Places Network is all about junior doctors talking to other junior doctors about General Practice – sharing information, highlighting the benefits and busting some common misconceptions. Our GP Ambassadors play the role of ”GP Champion” in their hospital to develop and promote the network. In order to help you find out who your local GP Ambassador is, there’s the opportunity to get to know 16 of the GP Ambassadors located at hospitals around the country. We really hope we’re an approachable bunch who are more than happy to help junior doctors like you with any General Practice related questions. The featured GP in this issue is Dr Ginni Mansberg who combines a career as a GP, writer and broadcaster – as well as being a devoted mother of three. Other inspirational GPs featured in this edition include Dr Allison Turnock, Medical Observer/GPET Registrar of the year, Dr Janelle Hall who keeps herself amazingly busy and Dr Helen Tatsis who explains what life is like as a GP locum. Dr Melanie Winter, our GP Ambassador for Eastern Health in Victoria, was granted an exclusive interview with Professor Michael Kidd, Executive Dean of the Faculty of Health Sciences at Flinders University. He tells Going Places readers about his involvement with HIV from the start of the 90s and the many roles he has held within the General Practice arena. This edition of Going Places also contains some other great articles, including a look at automated defribrillators, a retrospective on blood transfusion, the financial ins and outs of buying a property and how to be an expert medical witness. Dr Danika Fietz has also conjured up another interesting “What’s the diagnosis?” from her case files in order to keep you guessing. As usual, there’s a further instalment of Confessions of a 21st century intern by our undercover intern reporter and another case from Dr Fairytale. Finally, Going Places talks with two doctors who have just completed a PGPPP and they share all their experiences – what they’ve learned from their practical, hands-on experience in General Practice for 10 weeks. There is also a page of handy tips from other junior doctors and GP Registrars about how to get the most out of your Supervisor. You’ll undoubtedly be seeing activities for the Going Places Network in your hospital, organised by one of our friendly and passionate GP Ambassadors. Don’t be shy – get involved in the Going Places Network and explore the wonderful world of General Practice, which we all love so much! Yours in General Practice

Dr Lana Prout Hospital Registrar – Southern GP Training Latrobe Regional Hospital, Gippsland, Victoria GPRA Board Member (Prevocational)

Going Places! If you have a t We welcome your feedback on us an email and tell us wha few spare moments, please drop you’d like to read about and t wha ine, you think of our magaz goingpla ces@gpra.org.au even if you can contribute! 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.

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38 21

04 Dr Lana Prout Talks about the Going Places Network 13 Dr Ginni Mansberg GP in the media 18 Professor Michael Kidd An interview by Dr Melanie Winter 22 Dr Laura Carter GP in the High Country 28 Dr Scott Lewis The outback GP 30 Dr Janelle Hall The GP that keeps herself super-busy! 32 Dr Helen Tatsis Life as a locum 36 Dr Ann Ward The GP with a love of adventure 38 Dr Allison Turnock Medical Observer/GPET Registrar of the Year 42 Dr Lina Nido Cruising into General Practice

We would like to acknowledge the help and support provided by Australian General Practice Training 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 3000. Phone: 1300 131 198. www.gpra.org.au


Dr LANA PROUT

Talks about the Goi Lana is passionate about General Practice – that’s why she is one of the Directors of GPRA and a GP Ambassador for the Going Places Network. She graduated from Monash University in 2009, after completing her MBBS and Bachelor of Medical Science degrees, and is currently an intern based in Gippsland, Victoria. Lana will start her GP training in 2011. We spent some time with Lana to ask her about her involvement with GPRA and, in particular, the development of the Going Places Network.

Could you tell us a little about yourself – how and why you’re so passionate about General Practice?

What is the vision for the Going Places Network and how do you envisage it working and developing further?

I’ve known I always wanted to become a doctor since I was little. Growing up in the country meant that whenever someone said “doctor”, I automatically thought of someone like my family GP. It was my aim to become a doctor just like him – someone who would provide care “from cradle to grave” ... knowing and caring for multiple generations of the same family. This idea was then reinforced even more after I spent time in Orbost, in country Victoria, where I was lucky enough to be able to be supervised by an extremely experienced GP Obstetrician/ Anaesthetist. If I can become half the GP he is, then I’ll be happy. Finally, I undertook a Prevocational General Practice Placement (PGPPP) rotation as part of my internship and this really sealed the deal in regards to me wanting to be a GP!

It is hoped that eventually every junior doctor in Australia will have access to a GP Ambassador in their hospital and they will have the opportunity to participate in Going Places Network, social and networking events. It’s both a fun way to network and to develop professional knowledge about General Practice. In the meantime, we are working hard to make the GP Australia website (www.gpaustralia.org.au) a one-stop shop for obtaining online information about General Practice.

You’ve been involved with GPRA for quite a while – what role do you currently play and what does this involve? I first became involved with GPRA as a student through being the General Practice Student Network (GPSN) Student Ambassador for Monash University. Then, after graduating, I applied and was successful in being appointed the Pre-Vocational Director on the GPRA Board, which has been a fantastic learning experience. GPRA is all about promoting General Practice and advocating for General Practice Registrars – these are both things that I feel very strongly about. As well as serving as a Director on the GPRA Board, I’m also a GP Ambassador for the Going Places Network in Gippsland, a member of the Going Places Network steering committee and the editor of Going Places magazine.

Could you tell us about the Going Places Network and what’s so important about this initiative? Ultimately, it’s all about raising the profile and esteem of General Practice, as a specialty – highlighting the benefits and advantages, while busting some common misconceptions. One of the problems is that General Practice training all takes place outside the hospital system, so we feel it’s important to bring General Practice into the hospital – and the Going Places Network is the ideal vehicle.

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G oing P laces NETWORK

Taking a fresh look at General Practice An initiative of GPRA

Could you explain the importance of the GP Ambassadors and the part they play in helping the Going Places Network to work successfully? I see the GP Ambassadors as ‘tour guides’ of the General Practice landscape – just like when you’re on a tour. You can ask your Ambassador anything related to General Practice. If they don’t know the answer themselves, they will know how to find it. This means junior doctors will be able to interact with someone just like them to get the answers they want – it’s much better than having to send an email or make a call to someone they don’t know when they want information!

How can you join the Going Places Network? You can do this through your local GP Ambassador or you can join online by visting www.gpaustralia.com.au/goingplaces


ing Places Network

Photography: Carlie Devine

What do you think are the key benefits of the Going Places Network and how would these help a junior doctor trying to decide on General Practice? The key benefit of the Going Places Network is the fact that it’s run by junior doctors for junior doctors – it’s all about peer to peer networking to promote General Practice … junior doctors talking to other junior doctors in an informal manner about General Practice. The GP Ambassadors are junior doctors – so they know and understand the issues faced by junior doctors and will be able to tailor any information to suit particular circumstances. Through the Going Places Network, junior doctors will also be able to connect with GPs and doctors training to be GPs. Even if they don’t ultimately opt for General Practice, this knowledge will undoubtedly help them during their career, regardless of what specialty they ultimately choose.

What type of activities and resources can junior doctors enjoy by joining the Going Places Network?

educational sessions – with some food and coffee thrown in for good measure. A real benefit is that members will have access to other junior doctors with a passion for General Practice who will be able to guide them through the GP landscape. Other resources are the GP Australia website (www.gpaustralia.org.au) and the Going Places magazine.

What advice, help and guidance would you give to a junior doctor trying to decide on their future and especially whether General Practice is right for them? General Practice is whatever you want it to be. I would advise anyone considering it as a career to talk to their local GP Ambassador, as well as undertaking a PGPPP. For more information, see pages 24 and 25. This is definitely the best way to get a real taste of General Practice without any long term commitment … although I believe that anyone who does try General Practice will be hard-pressed not to want to commit. You certainly shouldn’t knock it until you try it!

Activities will take on a variety of formats, but the focus is on learning more about General Practice. There are networking and social events, as well as skills and

Going Places – ISSUE #4

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G oing P laces NETWORK

Taking a fresh look at General Practice An initiative of GPRA

Join the

BECOME A MEMBER – IT’S FREE!

Going Places Network Explore the world of General Practice while you complete your hospital training! Member benefits: GP focused networking and educational events Great opportunities to learn more about General Practice Access to a local GP Ambassador at your hospital – or a nearby hospital – to help answer your GP related questions Membership of a friendly and supportive local community of junior doctors Regular e-newsletter updates with information on your local events and the latest on all things GP The Going Places magazine – a great quarterly magazine showcasing the variety and challenges of General Practice The chance to have loads of fun!

Who can join? All prevocational doctors What does it cost? Nothing!!! It’s absolutely free … so join today! How can I join? Visit www.gpaustralia.org.au/goingplaces

An initiative of

GENERAL PRACTICE REGISTRARS AUSTRALIA

The future of General Practice


Getting to know your GP Am We’re busy recruiting Ambassadors for the Going Places Network … so here’s an opportunity to meet a few! What’s the role of our GP Ambassadors and how can they help me? GP Ambassadors are a key initiative of the Going Places Network – they are junior doctors with a passion and enthusiasm for General Practice. You can ask your GP Ambassador anything related to General Practice. If there are any questions they can’t answer, they’ll find the answers for you! They are responsible for developing the Going Places Network in your hospital and you’ll find they are very approachable. They are really looking forward to meeting you at the Going Places Network events they’ll be organising. For full profiles and updates on new GP Ambassadors, visit www.gpaustralia.org.au/goingplaces Kaylee Nash-Rawnsley, 24

Brendan Fitzgerald, 33

HOSPITAL

Gold Coast Hospital, QLD

HOSPITAL

Northern Hospital, VIC

EMAIL

goldcoastgp@gpra.org.au

EMAIL

northerngp@gpra.org.au

BACKGROUND: Mostly grew up on the East Coast

BACKGROUND: Born and bred in Melbourne.

HOBBIES & PASTIMES: Latin dancing, fishing, walking.

time, live music.

of Tasmania, in a small town called Scamander.

How and why did you decide on General Practice? After a few years of med school I had spent a fair bit of time in GP with my scholarship (RAMUS) and really enjoyed it. I felt that the variety of patients you see and the ability to actually continue to follow up your patients made it a great specialty to choose. Why did you decide to become a GP Ambassador? I feel GP gets a bad rap, and people don’t realise how interesting and rewarding it can be. What do you think you can contribute to the Going Places Network? I think I can encourage just a few more people to think more about how great a career in GP would be. What advice would you give to anyone thinking about General Practice as a career move? If you want a flexible career, that’s never boring, ever-changing and rewarding, this is the career for you. How do you think you can help people with questions about General Practice? I can help with advice about which rotations to choose in the hospital to prepare yourself for GP, about what GP can offer you, how to apply for GP, what different training options are available (RACGP, ACRRM, advanced training) and just about anything else! Why would you recommend people should join the Going Places Network and be involved in the activities? What do you think the benefits are? It’s a good opportunity to find out a bit more if you’re not sure, and a fantastic way to understand the first steps to GP training if you’re already set on GP.

HOBBIES & PASTIMES: My two sons keep me busy most of the What were the influences that persuaded you to study medicine? An interest in biology and the sciences from an early age. How and why did you decide on General Practice? During HMO2 year, a decision supported by a HMO3 PGPPP term. What makes General Practice so special for you as a specialisation? Having a comprehensive approach to your patients’ and their families’ health. What do you particularly like about General Practice? The general nature of the work, flexibility of working hours and Practice. Why did you decide to become a GP Ambassador? To help increase the profile of General Practice in the hospital. What do you think you can contribute to the Going Places Network? Experience with General Practice as a prevocational doctor, PGPPP and GP specialty application process What advice would you give to anyone thinking about General Practice as a career move? Investigate General Practice, go to careers nights, try to do a PGPPP term, speak to GP Ambassadors. Why would you recommend people should join the Going Places Network and be involved in the activities? What do you think the benefits are? Exposure to the varied Registrars within General Practice, contact with GP Registrars and explanation/assistance with the GP application process.

Melanie Winter, 25 HOSPITAL

Eastern Health (Box Hill, Maroondah, Angliss), VIC

Royal Brisbane and Women’s Hospital, QLD

EMAIL

boxhillgp@gpra.org.au

royalbrisbanegp@gpra.org.au

Australia.

Estera Bratko, 28 HOSPITAL EMAIL

BACKGROUND: I’m Polish born and bred – I grew up in Poland but completed almost all of my education here in Australia which has been my home for most of my life now.

HOBBIES & PASTIMES: I love adventure and all it has to offer. When I am not in the hospital you can find me tracking the latest unbeaten track, kayaking in a storm to Morton Island or hanging off a mountain in Nepal. I am also a very amateur artist and love to draw and paint. I love to dance to Latin music and occasionally hit out a tone on my piano. How and why did you decide on General Practice? I decided to do General Practice after my experiences in working in a Rural General Practice as a doctor. What makes General Practice so special for you as a specialisation? I love the variety and especially the continuity of care. In my experience of General Practice, I started to get to know my patients very well and witnessed the improvements within them. I found this to be very rewarding. Why did you decide to become a GP Ambassador? I decided to become a GP Ambassador to meet people in a similar situation to myself and to share the experience. What advice would you give to anyone thinking about General Practice as a career move? Try it, you will be surprised. Why would you recommend people should join the Going Places Network and be involved in the activities? What do you think the benefits are? What the Going Places Network can offer you is invaluable experience of General Practice as well as wisdom from professionals who have already attained what you are striving for.

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BACKGROUND: I’m from Naracoorte in South HOBBIES & PASTIMES: Drinking coffee with friends, casual cycling with my husband, baking, reading, watching TV shows/movies and singing. What were the influences that persuaded you to study medicine? My amazing rural GP inspired me – he was proficient at a multitude of clinical skills from counselling to procedural work and he had such compassion in his dealings with people – I decided that I wanted to do what he did. How and why did you decide on General Practice? The variety of presentations you see in General Practice, the opportunities to have special interests and/or do procedural work, the continuity of care and relationships you develop with your patients, the flexibility of the work and the option to work and/or train part-time if you so desire.... I could keep going … Why did you decide to become a GP Ambassador? I am (obviously) passionate about General Practice as a specialty in its own right and I want other JMOs to be given the true facts about GP so that they can make an educated career choice later on. There are a lot of myths about General Practice that I would like to nip in the bud! What advice would you give to anyone thinking about General Practice as a career move? If General Practice is what they really want, I would encourage them to be positive about this and not allow others to talk them out of it, Why would you recommend people should join the Going Places Network and be involved in the activities? What do you think the benefits are? There’s really nothing to lose in joining and there is lots of fun to be had along the way with the various events. It’s a non-threatening environment in which you can learn about General Practice, how to apply, etc. without having to make any commitments. Why not join up today?!


bassador! Michael (Mike) Cross-Pitcher, 39 HOSPITAL

Nambour General Hospital, QLD

EMAIL

nambourgp@gpra.org.au

BACKGROUND: Born, raised and schooled a city boy in South Perth ... about as metropolitan as you can get in Western Australia. Studied two degrees at the University of Western Australia: Engineering (Mechanical) and Medicine. I spent a lot of time between degrees in rural Australia and overseas though. HOBBIES & PASTIMES: I love being outdoors as much as possible: camping, hiking, fishing. I learnt to paraglide in Canada. I still have the first car I ever owned – a 1962 EJ Holden, which is waiting for a longoverdue restoration. When/how did you first know or decide you wanted to study medicine? Within a year of commencing my career as an engineer! What do you particularly like about General Practice? Two words ... options and lifestyle. It gives me the freedom to direct my career in almost any direction I would like without requiring me to forsake my friends, family, hobbies and interests. I respect, but have no desire to become one of, the frequently grumpy and overtired Registrars I so often meet. Why did you decide to become a GP Ambassador? I believe that there are a couple of specialities that students and many doctors see as “second-best” or “copping out”, with General Practice being one of those. I believe that the more exposure people have to doctors who are proud of their decision to become GPs, the more respect the speciality will receive. What advice would you give to anyone thinking about General Practice as a career move? Explore the career possibilities associated with General Practice (the Going Places magazine is a great start!). Undertake a post-graduate General Practice placement as an option (it is experience that will serve you well whichever speciality you end up choosing ... you’ll all have to deal with GPs sometime). Talk to your GP Ambassador. Why would you recommend people should join the Going Places Network and be involved in the activities? What do you think the benefits are? It is easy when you’re in the hospital system to feel that the hospital system is all there is. It is essential to get the full picture, and the Going Places Network helps put it all together.

Casey Kalsi, 30

Danielle Arabena HOSPITAL

Redcliffe Hospital, QLD

EMAIL

redcliffegp@gpra.org.au

BACKGROUND: I grew up in Brisbane – in a

bayside town called Wynnum. I have a couple of degrees prior to medicine, including one in Communications with a double major in Film and Television and Public relations.

HOBBIES & PASTIMES: I live on five acres with too many animals and my family – I’m currently making a herb/vegetable patch. Also I like doing yoga although I am sporadic with my Practice and have recently started Zumba. What were the influences that persuaded you to study medicine? I wanted to give back to the Indigenous community. Also I wanted to see if I could do it – I wanted to encourage other Indigenous people not to accept second best and challenge themselves. How and why did you decide on General Practice? I spent some time out at Inala Indigenous Health and liked the work they are doing out there. Also the lifestyle was a big factor – I wanted to enjoy being a doctor by having a good work/life balance. All this combined the holistic care of patients and also the continuity of care. What makes General Practice so special for you as a specialisation? I am really interested in women’s and children’s health. As a mother myself, I understand the importance of having a great GP who is approachable and someone you trust. Why did you decide to become a GP Ambassador? I wanted to see myself on a poster every time I got into an elevator like my predecessor Dr Michael Bailey! Also it is a great opportunity to provide information to anyone who is interested in GP. Why would you recommend people should join the Going Places Network and be involved in the activities? What do you think the benefits are? Going Places Network helps to you connect with other GP trainees and trainers. It provides a great snapshot of the lifestyle and diversity of General Practice.

Andrew Pennington, 32

HOSPITAL

Mater Adults Hospital, Brisbane, QLD

HOSPITAL

Wodonga Hospital, VIC

EMAIL

wodongagp@gpra.org.au

EMAIL

matergp@gpra.org.au

BACKGROUND: I grew up in Sydney, going to

BACKGROUND: Brisbane. I was a primary school teacher and I am the first one in my family to have a degree, or two.

HOBBIES & PASTIMES: Interested in Music, playing the piano, staying fit, cooking ... and eating.

school at North Sydney Boys’ High. My father is a surgeon, my uncle is a physician and one set of grandparents both GPs.

HOBBIES & PASTIMES: Lots of sports – ultimate frisbee, golf, snow skiing, tennis, photography, hiking/bushwalking; I love social networking to keep in touch with people; I enjoy encouraging people to get the most out of life and be the best they can be.

What were the influences that persuaded you to study medicine? I persuaded myself to study medicine and made my final decision after I was hit by a car while riding my push bike. I spent a long time in hospital and even longer learning to walk again, and again, and again after different surgery. Being a patient is really difficult, I wanted to be a doctor that could make the journey of being a patient more pleasant.

How and why did you decide on General Practice? I feel GP allows you to be a “real” doctor – ie: you know many things about all aspects of medicine. The variety of Practice, ability to connect in an ongoing manner with patients, work-life balance factors, ability to do procedural work, and much more.

How and why did you decide on General Practice? I chose General Practice because I am interested in preventative health and being the first point of contact. I enjoy building relationships with patients and am interested in providing continuity of care. I also know I can influence the communities I belong to – Aboriginal and Greek. I find I am in a position where I can be a great role model for my people.

Why did you decide to become a GP Ambassador? I am passionate about promotion of GP. I want people to choose to do GP. I believe that rural GP is a fantastic career and being able to do some procedural work as a GP – like Obstetrics, Anaesthetics without the need for a lengthy training program – is an option that I believe more JMO’s would consider if it was promoted to them.

What makes General Practice so special for you as a specialisation? General Practice is so diverse with disciplines to the age range of the patients, I will never get bored in General Practice.

What do you think you can contribute to the Going Places Network? I hope to be a positive role model, providing high standard care to patients, that JMO’s/Med Students can see as the standard of a good GP – and be attracted into the profession. Hopefully I can be available to talk and encourage them when they have questions.

Why did you decide to become a GP Ambassador? Because I am passionate about what a fantastic career GP is going to be for me and would like to help others that might think the same. What advice would you give to anyone thinking about General Practice as a career move? I think it is like with anything in life, if it is something you want to do and it is for the right reason...... do it. It’s a good idea to talk to GPs and get a good idea of where GP can take you or, even better, where you can take it!

What advice would you give to anyone thinking about General Practice as a career move? You need to have good communication skills, be interested in holistic medicine, able to deal with uncertainty and time pressures, and be prepared to look deeper into patients’ presentations, sometimes to find the real reason for attendance.

Why would you recommend people should join the Going Places Network and be involved in the activities? What do you think the benefits are? Being in touch with people with the same interests – staying motivated and in the loop.

Why would you recommend people should join the Going Places Network and be involved in the activities? What do you think the benefits are? Hopefully by associating with people of similar mindset, they can have positive associations with GP.

Going Places – ISSUE #4

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Getting to know your GP Am Lana Prout, 25 HOSPITAL EMAIL

Latrobe Regional Hospital, Traralgon, Gippsland, VIC gippslandgp@gpra.org.au

BACKGROUND: I’m originally from West

Gippsland and went to Drouin Secondary College.

HOBBIES & PASTIMES: Listening to music, all things Japanese (I spent a year there on exchange after finishing high school), volunteering for St John Ambulance and Rotary – dancing as well. What were the influences that persuaded you to study medicine? The fact I loved science and communication at school, my family GP and my 4th year GP supervisor. What makes General Practice so special for you as a specialisation? The variety it offers whilst still giving you the opportunity to pursue special interests. Why did you decide to become a GP Ambassador? I am passionate about General Practice, so becoming a GP Ambassador was the perfect way to be able to share this passion with others. What do you think you can contribute to the Going Places Network? I think I bring a wealth of knowledge about General Practice given my experience with other roles within GPRA, including being a GPSN Student Ambassador whilst at medical school and a member of the GPRA board. What advice would you give to anyone thinking about General Practice as a career move? Ask questions, try a PGPPP placement, and do it! You won’t regret it. Why would you recommend people should join the Going Places Network and be involved in the activities? What do you think the benefits are? The Going Places Network is a great way to be informed about the great things General Practice has to offer all doctors. Having a peer-network also allows for more personalised information as it is coming from other junior doctors. The Going Places Network is a fun way to meet other doctors interested in General Practice.

Elina Gourlas, 27 HOSPITAL

Hornsby Hospital, NSW

EMAIL

hornsbygp@gpra.org.au

Katya Groeneveld, 24 HOSPITAL

Gold Coast Hospital, QLD

EMAIL

goldcoastgp@gpra.org.au

BACKGROUND: I spent much of my upbringing in England, where I completed secondary school before returning home to Australia to embark upon my medical degree.

HOBBIES & PASTIMES: My greatest passions include scuba diving and photography. I endeavour to keep fit and active and make regular trips to the gym after work. How and why did you decide on General Practice? General Practice enables you to incorporate a vast range of practical and theoretical skills and knowledge – there is ongoing learning and endless challenges, but the rewards are long-lasting! What makes General Practice so special for you as a specialisation? I believe in General Practice you have the unique privilege of continuity of patient care and through a holistic approach you can achieve the most optimal outcomes for your patients. What do you particularly like about General Practice? There is great autonomy in patient care and you are often the first point-ofcontact. I like the challenge of being the ‘gatekeeper’! Why did you decide to become a GP Ambassador? In medical school I became involved with the GPSN, and represented my university as the Ambassador. When I commenced internship earlier this year, I became aware of the opportunity to carry this role into the hospital setting and was quite happy to put my hand up for this role! I am determined to increase awareness of the ‘wonderful world of General Practice’ and dispute many of the myths and misconceptions about the profession that circulate in the hospital community. What advice would you give to anyone thinking about General Practice as a career move? Gain some exposure to General Practice (e.g. the PGPPP), talk to colleagues who are on GP training and seek out experienced General Practitioners to investigate their sense of fulfilment in the profession. Why would you recommend people should join the Going Places Network and be involved in the activities? What do you think the benefits are? The benefits are in establishing rapport with fellow like-minded colleagues and sharing interests and advice as you progress through your training. It is a wonderful opportunity to recruit other interested colleagues, showing them how to share in this wonderful profession with you!

BACKGROUND: I was born in Sydney and come from a Greek background. I grew up in Ryde, NSW and went to North Sydney Girls’ High School. 

HOBBIES & PASTIMES: Cooking, listening to music, learning guitar, watching trashy TV and reading.  How and why did you decide on General Practice?  My previous career was in Emergency nursing. I would see a great deal of very good and very poor General Practice referrals to the Emergency Department and began thinking about what General Practice entailed as a specialty. I probably decided on General Practice firmly as a career in my first or second year of university, although had been thinking about it for a couple of years before I entered medical school. I was most attracted to the variety of medical presentations I would see and the opportunity to look after patients in such an intimate and long term context.  What makes General Practice so special for you as a specialisation?  I honestly believe that in no other specialty do doctors create such a close and trusting long term relationship with their patients. GP also gives you the freedom to explore a wide array of personal interests in medicine – it’s unlike any other specialty.  Why did you decide to become a GP Ambassador?  I was involved with GPSN at University and see the cause to promote General Practice as a specialty as an important one. There is little exposure to General Practice in University and even less in the JMO scene within the hospital system. I’d like people to at least be fully aware of what General Practice entails before they dismiss it as a career option. In years to come, I’d hope that General Practice will be considered one of the most prestigious, rewarded and competitive specialties.  What advice would you give to anyone thinking about General Practice as a career move?  Be informed and don’t dismiss it as an option until you have thoroughly looked into what’s on offer. General Practice is not for everyone, although it is so flexible that you honestly can create your own very unique career path and satisfy varied interests in medicine. I would encourage people to look at the AGPT and GPRA websites and talk to their JMO unit about whether or not a Prevocational General Practice Placements Program (PGPPP) rotation is available at their hospital.   Why would you recommend people should join the Going Places Network and be involved in the activities? What do you think the benefits are?  I think anyone interested in General Practice should definitely join Going Places and be involved in activities. This is an exciting new network and will give people the opportunity to meet other JMO’s who have an interest in GP as well as provide a forum to answer all those unanswered questions. I hope I can help to organise some great events for the NSW network 6 JMO’s!

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Rebekah Short, 26 HOSPITAL

Royal Hobart Hospital, TAS

EMAIL

royalhobartgp@gpra.org.au

BACKGROUND: I am from Kettering, Tasmania. I went to school at Woodbridge District High School for primary then on to Fahan school for years 7-12.

HOBBIES & PASTIMES: Taking my beautiful 3 legged border collie to the beach, dinner parties with friends, tennis, playing with kids! How and why did you decide on General Practice? Throughout medical school I was fortunate enough to have a rural GP mentor. He gave me exposure to the breadth of what General Practice could offer. I strive on challenges and pressure, what better way to do that than being a rural GP working at the front line? Whether it’s a trauma, a sore throat, obstetrics or management of chronic disease; you have the opportunity to practise every part of medicine. Why did you decide to become a GP Ambassador? I would like to be able to show junior doctors what General Practice is all about. I would like to open their eyes to the gamut of what General Practice has to offer. What do you think that you can contribute to Going Places Network? I have passion, enthusiasm and commitment. As I embark on my journey into “GP Land” I would like to help inspire other junior doctors to consider GP as an exciting and challenging career path with endless opportunities. A GP is a specialist of all specialties. I am keen to advocate this and help educate doctors and non-medical people on the real truth. What advice would you give to anyone thinking about General Practice as a career move? Congratulations! By all means it will be challenging, occasionally stressful and slightly annoying. But what will stand out far and away is the fun, flexibility and support. The team approach works nicely in conjunction with your individual style of medicine. You will be respected and feel part of a community. This is a career path that could take you anywhere and into anything. Why would you recommend people should join the Going Places Network and be involved in the activities? The shortage of doctors is well known and rarely escapes the weekly news. Instead of people sitting back and saying “one day I must look into that”, the information will be provided to them on their doorstep of the hospital, through publications and social events. Networking is crucial to developing both professionally and personally. To be able to do this with people of similar interests is perfect!


bassador! Jane George, 31 Lang Lang YII, 25

HOSPITAL

Bankstown-Lidcombe Hospital, NSW bankstowngp@gpra.org.au

HOSPITAL

Goulburn Valley Health, Shepparton, VIC

EMAIL

EMAIL

sheppartongp@gpra.org.au

States. I grew up and completed my first uni degree in the USA before moving to Australia.

BACKGROUND: I am originally from a small town in East Malaysia, named Sibu. At the age of 17, I went to a college in Kuala Lumpur for two years and then under took my medicine degree in Monash University, Australia.

HOBBIES & PASTIMES: I love cooking and creating new recipes. I enjoy the art of integrating the spices for dishes and the joy of sharing food with my loved ones. At times, I exchange my recipes with my friends and enhance our relationship by cooking together. How and why did you decide on General Practice? After I started my internship in the medical department this year, I realised the importance of ongoing patient care. Doctors in the hospital look after the acutely sick patients and the General Practitioner would have to take care of them in a full approach. He or she would have to build a long-term relationship with the patients and follow up with them in a holistic manner. I was further convinced to specialise in General Practice when I worked in the rehabilitation ward. I dealt with many GPs with the patients’ care and understand that their roles are indispensable and challenging. What makes General Practice so special for you as a specialisation? A key reason why General Practice is so special is the influence of my partner, who is going to be a GP Registrar next year in Shepparton. He always tells me that General Practice is the backbone of medicine in a community. He inspired me to work together with him and serve the people in Shepparton for the next few years. At the same time, a GP lifestyle is very promising and flexible. Why did you decide to become a GP Ambassador? It was my honour to become a GP Ambassador. I understand the difficulty and struggles in choosing a specialisation, especially in a rural region. However, it will be fantastic if someone who is involved in a GP line to give more information and ideas for guidance. Why would you recommend people should join the Going Places Network and be involved in the activities? What do you think the benefits are? For anyone who is thinking about General Practice as a career move, it is a good idea to start of with joining the Going Places Network and be involved. You will get to know the whole structure of GP and exchange ideas with GPs and those who are interested in GP, too.

Claire Langford, 25 HOSPITAL

Alfred Health, VIC

EMAIL

alfredgp@gpra.org.au

BACKGROUND: I was born and bred in Sandringham, studied Med at Adelaide Uni, and now I’m back and LOVING Melbourne.

HOBBIES & PASTIMES: At present, being an ortho intern, my interest outside of work is sleeping. Otherwise, catching up with friends, being outside exploring new places, travelling, good food, walking, theatre, and still probably sleeping. If I can get back to playing Netball, that would be great. How and why did you decide on General Practice? Because I love working with kids, pregnant mums, older people, and everyone in between. I love the continuity of care, really getting to know your patients and not having to start from scratch at every consult – having that familiarity. I love the management side of things, and being able to treat problems with lifestyle advice and counselling, as opposed to invasive measures, and being able to educate people about their health. Why did you decide to become a GP Ambassador? Because I really want to promote General Practice as a career, and because the Alfred definitely attracts more Physician/Surgeon/Critical Care directed people and someone needs to hold up the GP flag! What do you think you can contribute to the Going Places Network? Maybe I’ll be able to convince some of my Alfred colleagues to see the light! I also love rural General Practice and can answer any questions about how great it is to work outside the suburban sprawl of Melbourne – somewhere surrounded by green hills, rugged beaches, snow covered mountains. How do you think you can help people with questions about General Practice? I spent my 5th year in a rural community doing predominantly General Practice, another 6 weeks in 6th year, and a PGPPP term this year – I have a good idea of what it’s all about! Why would you recommend people should join the Going Places Network and be involved in the activities? What do you think the benefits are? Being connected to other people interested in General Practice – I am certainly keen to meet some more like-minded people!

BACKGROUND: I am originally from the United

HOBBIES & PASTIMES: I enjoy cooking, baking, going to the beach, catching up with friends, travel and reading a good novel. What were the influences that persuaded you to study medicine? With a background in biology I had an interest in building on that foundation of knowledge and medicine provided that opportunity. How and why did you decide on General Practice? I decided on General Practice because I really enjoy speaking to people and I think I will have a greater influence and impact on a person’s health if I provide the cornerstone of their healthcare (General Practice). What makes General Practice so special for you as a specialisation? The endless opportunities and unique experiences that General Practice can offer make it my preferred specialisation. I also like the fact that General Practice provides variety, flexibility and the opportunity to provide patients with continuity of care. Why did you decide to become a GP Ambassador? I have been involved in GPSN (General Practice Students Network) and wanted to continue promoting General Practice amongst my peers as I enter into the hospital. What advice would you give to anyone thinking about General Practice as a career move? I would encourage anyone interested in General Practice to explore the area a bit more. Go to events, talk to people and get involved, pursue a PGPPP placement if you can. Why would you recommend people should join the Going Places Network and be involved in the activities? What do you think the benefits are? I would encourage everyone to get involved in the Going Places Network. The Network offers the chance to learn more about General Practice as a specialty, meet fellow colleagues, find out about the various General Practice career pathways and additionally provides opportunities to hear interesting speakers and attend invaluable sessions.

Rose Kearsley, 25 HOSPITAL

Northern Hospital, VIC

EMAIL

northerngp@gpra.org.au

BACKGROUND: I’m from Ireland and went to medical school at University College Cork. How and why did you decide on General Practice? Because I believe in the ability to make a difference, being a long-term advocate for your patients and I think GP is a job which allows you to give 100% to your patients. What do you particularly like about General Practice? I like the ability to have a broad knowledge base and also the relative nonacute nature of the specialty.

STOP PRESS!

ore GP Ambassadors!

ne m We’ve just recruited ni

, so please check our rk is expanding rapidly e The Going Places Netwo – for the most up-to-dat s ace gpl alia.org.au/goin website – www.gpaustr . listing of Ambassadors Ming Lin Redland Hospital, QLD Adareeka Jayasinge Ipswich Hospital, QLD Sarah Handley Mackay Base Hospital, QLD

Riley Savage Townsville Hospital, QLD Sumit Chadha l, NSW Royal North Shore Hospita Nicole Hall Bankstown Hospital, NSW

Anna Ryan Austin Hospital, VIC

Joshua Crase VIC Ballarat Health Services, Shelley Davies Fremantle Hospital, WA

ador, becoming a GP Ambass If you are interested in more information. see the next page for Going Places – ISSUE #4

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G oing P laces NETWORK

Taking a fresh look at General Practice An initiative of GPRA

Are you passionate about General Practice? Yes? – We want to hear from you! We need you to become a GP Ambassador at your hospital! Help us spread the word and raise the profile of General Practice amongst your peers … while you make useful contacts, have fun and are rewarded for your efforts! What is a GP Ambassador?

What’s in it for me?

GP Ambassadors are an initiative of the Going Places Network. The fundamental role of a GP Ambassador is to be the ‘GP Champion’ in their hospital to develop and promote the Going Places Network.

• You’ll be inspired!

What would I be asked to do as a GP Ambassador?

• You’ll have a warm inner glow because you know you’re helping your peers decide their future • Get valuable knowledge that will be useful to you in your career • You’ll have the opportunity to network

• Establish and promote the Going Places Network to peers within your hospital

• You’ll have fun!

• Be involved in developing Going Places networking and educational events in your hospital to help other junior doctors get a better understanding of General Practice

Who can be a GP Ambassador?

• Engage your peers in discussion about General Practice as a professionally and personally rewarding career choice • Give honest and useful advice to your colleagues about General Practice You’ll be given full support by GPRA and partner organisations to undertake this role.

• You’ll receive a small incentive for your efforts.

Any prevocational doctor who is passionate and knowledgable about General Practice – ideally, you need to be confident and outgoing.

If this sounds like you, contact us right now! email

goingplaces@gpra.org.au or call us on 1300 131 198 ... and don’t forget to tell us what hospital you are based at.

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COVER STORY

Dr Ginni Mansberg

GP in the media Dr Ginni Mansberg has combined her background as a GP with a range of activities including writing, broadcasting, being a political advisor and accredited Methadone prescriber. But above all else she has a passion for General Practice.

Going Places – ISSUE #4

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As a GP, it is privilege to be hear the stories

14


COVER STORY

an absolutely unabated a part of people’s lives and that they share with you

These days, I do three full days of clinical work in a suburban Practice in Sydney and I’m also the medical columnist for several magazines – Women’s Health and Practical Parenting – as well as making regular appearances as the guest doctor on Sunrise, on Channel Seven. I really enjoy the combination of medical journalism and clinical work and I absolutely love doing General Practice. I’ve been lucky to find a really interesting career that I love and that also fits in well with my family life. I grew up in Sydney and when I was 18, I had a bit of a Florence Nightingale complex. I wanted to do something with my life where I could help people … and medicine seemed absolutely perfect. So, I studied medicine at Newcastle University, and really enjoyed it. By necessity, so much of your medical training is in the hospital system. When I was there it really struck me – there was this inherent derision of GPs. I found this really arrogant superiority from the other specialties, so I’ll admit that, initially, General Practice wasn’t even on my radar. I did my internship at the Prince of Wales Hospital in Sydney. One rotation I did with a clinical microbiologist and a physician, Dr Barrie Gatus, was really fascinating. Working with him was like being on a medical crime scene. I absolutely loved it and decided that was exactly what I wanted to do … until I found out I was pregnant. Just after my son, Sam, was born, I did an ophthalmology term in a job-share with another resident. But within a couple of months I was pregnant again – and David was born a year after Sam. With two young kids, I couldn’t manage the hospital shifts and needed to earn money. So I picked up a couple of shifts in a medical centre and discovered I loved everything about it – the diagnosis, which was what I had enjoyed so much when I was a hospital resident – and the relationships you form with the patients.

I stayed working part-time at the medical centre for about three years until my daughter Jade was born. I had always been interested in writing, so while Jade was a baby, I enrolled in a postgraduate journalism degree at the University of Technology in Sydney. The first story I wrote for the course was a medical one. I sent it to a medical magazine and the editor phoned me, offering me ongoing work writing news for them. The fact that I could work from home was great, and meant that I didn’t need to go back to work in a medical centre. After about 18 months working with news, where I had to turn stories around in a day, which was quite tough, I started writing feature articles – longer stories with a longer deadline, which I found I really loved. Then a friend who ran a methadone clinic in Kings Cross couldn’t get a locum, so he asked me to fill in for two weeks while he took a family holiday. I agreed, and so I returned to medicine … to prescribe methadone. By the end of the first day, I was just flying high! No one could have possibly prepared me for how incredibly exciting and unbelievably rewarding that job was. It was very much walking on the dark side, dealing with people who were living incredibly difficult and chaotic lives – completely out of my comfort zone! But it was very satisfying, as most of my patients were people who simply weren’t used to being treated with dignity and respect and they really responded so well. I completed the training required and started doing a couple of shifts each week while I also continued writing for medical magazines. Around that time, I wrote a book with a friend, who is also a doctor. It was called ‘Why am I so tired?’ – all about women and

fatigue. It quickly became a bestseller and attracted lots of media coverage. That led to me being offered some writing with Practical Parenting magazine and Women’s Health magazine, which was part of the same publishing house, owned by Channel Seven. And through that, I started doing some guest appearances on Sunrise. In 2008, I landed the position of fulltime media adviser to Joe Hockey, based at Parliament house in Canberra, so I had to cut back my work to just Saturdays at the methadone clinic. But I still continued writing for Practical Parenting and Women’s Health magazine after hours – exhausting! After a year, I left to work part-time in a suburban family Practice. Two years on and I’m still there and still really enjoying it. General Practice means a lot to me and I love it more and more with every year that passes. As a GP, it is an absolutely unabated privilege to be a part of people’s lives and hear the stories that they share with you. I genuinely feel that I get to make a difference in people’s lives, and I love it.

Photography: Mel Koutchavlis

Going Places – ISSUE #4

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What’s your WITH Dr Danika Fietz

It was 1pm Monday and one of the Practice team brought in a fax that had been sent by the nursing staff at a local nursing home we know fairly well. They were requesting a medical review of Dorothy, a 79 year old female, as the antacid they had been giving her since Friday evening was not helping to address her complaints of indigestion all throughout the weekend.

I ask her more about her condition and she tells me that she has not been feeling well for the last week or so, perhaps even longer, she thinks … she has been troubled with discomfort from indigestion, has ongoing fatigue and suffers regular headaches.

Her past medical history includes Hypertension, Ischaemic Heart Disease, Osteoporosis, Bipolar Disorder, Gastro-Oesophageal Reflux Disorder, Inguinal Hernia Repair, Hysterectomy and Chronic Obstructive Airways Disease.

During my examination, I note a very noticeable tremor in all her limbs, but there don’t appear to be any localising neurological signs. I ask her about the tremor and whether this is normal for her (as there is nothing in her list of diagnoses that I can attribute this to). She tells me that it isn’t normal, but it doesn’t unduly bother her.

Her current medications are Ramipril, Pantoprazole, Metoprolol, Simvastatin, Alendronate, Aspirin, Lithium, Temazepam, Paracetamol as well as Tiotropium and Ventolin inhalers. Her regular GP was away on leave, so I had elected to take on his list of patients at this nursing home in his absence – I organised to visit the nursing home on the way home from work that day … It’s just after 6pm and I’m in the car. On the way there, some of the potential diagnoses are running through my mind … peptic ulcer … acute coronary syndrome … cholecystitis … abdominal angina … aortic dissection … perhaps even polypharmacy causing indigestion! There could easily be plenty of less serious issues as well ... I arrive at the nursing home and meet the nurse in charge who tells me that Dorothy does not want to get out of bed for meals and she has been sleeping regularly during the day over the past week. She lost her balance and had a fall during the week (that unfortunately nobody saw), but it only resulted in a minor skin tear to her leg. She denied hitting her head or losing consciousness. I meet Dorothy, who is an elderly, frail lady who comes across as being rather vague – and I begin my examination. Despite the vagueness, she appears to be oriented to person and place.

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The outcome of my examination is: • no jaundice or pallor • pulse 70 regular, BP125/75 • abdomen soft, non-tender, no pulsatile mass, Murphy’s: negative • chest clear, normal heart sounds • healing leg wound with no sign of infection I begin to consider differential diagnoses – I make a few mental notes about possibilities, cross a few off and then add a few more. I end up with five “suspects” that would go some way towards explaining her symptoms: > > > > >

Acute coronary syndrome Depression Urinary tract infection Subdural Haemorrhage Lithium toxicity

At this stage, do you have any ideas what Dorothy’s problem could be?


My intuition was that the problem could well be polypharmacy-related, which is increasingly common in elderly patients taking multiple types of medication. However, because of Dorothy’s symptoms, I suspected the Lithium. So I decided that the first step should to test her blood for abnormal levels of Lithium, which can be toxic in larger doses and cause some of the types of problems she is suffering. I noted that Dorothy had her blood levels monitored, but somehow, testing her Lithium levels had been overlooked for the last year or so. Dorothy had always been very clear about her intentions in her Advanced Health Care Directive. The nursing home staff and her family were all well acquainted with these and had agreed with her wishes. So, while she insisted on not having any hospital management, she was open to having blood taken for checking Lithium levels.

The results It’s now 10am Wednesday morning and an email arrives from the pathology lab with the results of her blood test for Lithium. I immediately feel a surge of satisfaction that my suspicions of Lithium being the culprit were well vindicated. Dorothy’s Lithium level was 2.8mmol/L … the therapeutic range should be between 0.4mmol/L to 1.0mmol/L – which meant her Lithium level was roughly three to seven times what it should be. When patients are on Lithium they need their Serum Lithium levels monitored closely, as there is a narrow therapeutic index. In the elderly with renal impairment this becomes even more important. It is not necessarily a ‘larger dose’ of Lithium that caused Dorothy’s problems – it was that her kidney function had declined with age and her hydration status (fluid intake and output) had changed.

Further management Dorothy’s dosage of Lithium was stopped until her levels decreased to the therapeutically acceptable range – this could be expected to take up to two weeks, but this can vary from patient to patient. In Dorothy’s case, many of her symptoms began to subside within a week, and within two weeks her symptoms of headaches, indigestion, fatigue and tremor improved markedly. We organised quarterly visits by the pathology lab to monitor her Lithium levels – previously, blood tests were only conducted on an “as needed” basis. Additionally, as a further safeguard, a psychiatry review was arranged to reassess the indication for Lithium treatment and to consider other available options.

About Lithium ad Lithium toxicity Lithium is the lightest metal known to mankind and has important usage in the medical field for the treatment of psychiatric problems, such as bipolar disorder. In small and controlled amounts, it works on the nervous system, assisting in the regulation of emotions and other behavioural patterns. Even though it is an effective medicine for mental illness, it has a very narrow therapeutic window and excessive doses of Lithium can lead to toxicity. In cases of excessive Lithium consumption, patients can often suffer from nausea, diarrhoea, blurred vision, polyuria, light headedness, fine resting tremor, muscular weakness and drowsiness. Those with the risk of heart problems may complain of complications related to the heart. The risk of Lithium toxicity is greater in those with hypertension, diabetes, congestive heart failure, chronic renal failure, schizophrenia or Addison’s disease. In really severe cases of Lithium toxicity, there can be kidney failure, memory problems and disorders of muscle coordination and voluntary movement.

The nurses at the nursing home were given ‘in-service’ regarding Lithium, so they could more easily recognise the symptoms and signs of Lithium toxicity in the future. Going Places – ISSUE #4

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An interview with

Professor Michael Kidd Going Places GP Ambassador for Box Hill Hospital, Dr Melanie Winter, interviews Professor Michael Kidd, Executive Dean of the Faculty of Health Sciences at Flinders University Thank you for talking to me about your career as a GP. Can I start off by asking you what’s involved in your current role. My primary job is Executive Dean of the Faculty of Health Sciences at Flinders University, where I’m responsible for our School of Medicine. That includes all the allied health departments, our School of Nursing and Midwifery, the new NT Medical Program, as well as all of our research centres and offshore programs. I also do clinical work as a GP – one session a week at an Adelaide clinic specifically caring for people with HIV. I also take on occasional week-long locum positions. In addition to all of this, I’m the Chair of Nicola Roxon’s Ministerial Advisory Committee on Blood Borne Viruses and STIs – formerly the Australian National AIDS Council. I have also recently been elected as the next President of the World Organisation of Family Doctors, representing about 300,000 primary care doctors in over 120 countries – this is a role running from 2013 to 2016.

What brought you to General Practice as your specialty of choice, and what path has taken you to your current role? I didn’t make a decision about a specialty until I had graduated from Melbourne University Medical School. After my intern year, I did a year at the Royal Children’s Hospital in Melbourne where I undertook a General Practice placement, which I really enjoyed. I joined the General Practice training program, doing six months of obstetrics and six months of Rural General Practice, then a Registrar position in psychiatry followed by more General Practice, mainly in rural locations. Following that, I took up an academic General Practice Registrar position at Monash University, which was half-time clinical General Practice and half-time learning about teaching and research at the university. At the same time, I was also doing a degree in public health at Flinders University. Monash then offered me a continuing position as an academic and I was looking around to decide what sort of General Practice I wanted to work in, long term. It was the early nineties and, at that stage, the HIV epidemic was hitting people very hard. There were few effective treatments and being a gay man, I had friends who were HIV positive – and friends who died. I recognised that there was a real need for doctors working in that area. So, for the next few years, I was a GP with the Victorian Aids Council, which ran the Gay Men’s Health Clinic in Collingwood and St Kilda. It was a very challenging time – a very sad time … but a remarkable time as well. In 1995 I was appointed the Chair of General Practice at Sydney University, so I moved up to Sydney, where I also started working in General Practice in Darlinghurst. I stayed there for about a decade, continuing with my special interest in HIV, until moving here to Flinders at the beginning of 2009.

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What are the things you like most about being a GP? I’ve been a GP for a long time – actually over 25 years – and it’s work that I enjoy greatly. Working with people is the reason I became a doctor in the first place. Clinical work also helps me to understand many of the challenges now facing Australian General Practice, through health reforms and other changes. This also provides valuable information for my own research activity, which is in primary care General Practice areas. Last year I was very lucky – and privileged – to spend a week as a GP locum at the Congress Aboriginal Medical Service up in Alice Springs.


Photography: Yvonne Milbank

How do you respond to people who perceive General Practice as being the ‘poor cousin’ of all the specialties? General Practice is a specialty in its own right and has been recognised as such for a long time. Some specialties are remunerated at a higher rate than General Practice, but what should be balanced against that is all the benefits and advantages of being able to work in General Practice. As a GP, you can be your own boss – you can determine your own hours – and there’s a great deal of flexibility, which means you have the opportunity to engage in areas of your own special interest.

What about comments that suggest being a GP is ‘the easy option’? There’s certainly nothing easy about General Practice training and there’s nothing easy about the Fellowship examinations. General Practice is a very serious career decision. The aspect of General Practice which now excites me the most is that the world has rediscovered the importance of primary care. We’ve seen this at a global level, through initiatives in the WHO. We’ve seen it in each country of the world that has recognised we can’t afford to continue to invest as we have historically in highend tertiary hospital medicine. We need to reinforce what we’re doing through primary care – strengthening the role that GPs play, working with their communities and keeping people well. Our role as GPs is actually becoming more important as health systems are reforming right around the world.

Could you share with us something you have encountered as a GP that has had a great impact on your life? The most profound clinical experiences I’ve had are really related to my working with people with HIV. At the time when HIV was an inevitably terminal disease, supporting my patients, who were becoming gravely ill and who were dying, was an incredible privilege. After triple therapy became available in 1996, I supported people who suddenly discovered that they did have a future and who started to rebuild their lives. This has impacted on my teaching. It has impacted on much of the research I’ve done. It has impacted on much of the community work I’ve done. It has also impacted on my own philosophy and my commitment to ensuring that health care is a fundamental human right.

Going Places – ISSUE #4

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General Practice Training in Indigenous Health Victoria It is important

Is it for YOU?

It is challenging It is inspiring

What are you doing about Indigenous Health? Indigenous health is a national priority, with Aboriginal and Torres Strait Islander Australians still dying years earlier than other Australians and suffering from a wide range of preventable diseases and treatable illnesses. As a GP working in Indigenous health, you are likely to make a bigger difference to health outcomes than in any other area of medicine in Australia today! • Practice a holistic approach to primary health care in a cultural context by training at an Aboriginal Community Controlled Health Service (ACCHS). • Get an appetite for Indigenous health by negotiating part-time or sessional arrangements whilst doing your GP training. • Experience complex medicine including chronic disease, preventive health care, health promotion and public health management. • Train under inspirational GP Supervisors, who are ACRRM and/or RACGP Fellows with years of experience and in depth knowledge of the clinical status and cultural aspects of the community. • Enjoy complete flexibility with 9-5 daily hours, leave for release sessions, conferences, study and personal life.

Are you interested in Indigenous Health? Contact the GP Education and Training Officer at VACCHO.

5-7 Smith St, Fitzroy VIC 3065 P: (03) 9419 3350 E: enquiries@vaccho.com.au W: www.vaccho.com.au

Victorian Aboriginal Community Controlled Health Organisation


True confesysiniotenrsn of a 21st centur

Part 4

Written by Dr. Ernest Tecrin

*

Dear Journal, , the I’m finally over Vegemite on toast… an intern starts to grow old. Slowly, but surely mirrors the point during the year at which being think I it is that cing one Repla but ce. ent, xisten statem al non-e ophic into Certainly not a profound philos dog wetting itself with fear begins to fade time interns see wetting itself with excitement and scared puppy first dog the is puppy d point excite this en that betwe say ate might fluctu to Some tendency back-up of course). urge to step into bigger shoes (with appropriate with the patient that you’re about to insert a sense of growing self-confidence and the probably not something you’d want to share it’s – elf yours to vation obser that keep if you fine That’s r. docto l actua an as elves thems exactly confidence-inspiring… ed ground on any form of invasive device into. That isn’t in life, can step up to a challenge. The hallow doctor, now affirmed in their existential place junior a that aren’t where ency One t. Emerg nmen to enviro come new a ents’ Such an attitude begs for used term but I often wonder what ‘accid ellation of stars that seem ency. Accident and Emergency is another widely const Emerg this ng called enjoyi place rather little a I’m is s seen. occur be to this which happy to wait a while get it amount of insulin intended but I’m more than ss meeting with my company’s directors to emergencies? ‘Yes, I did take five times the but I thought I’d wait until after my big busine where some object n foreig a have do I to have popped up out of nowhere’ or ‘yes, ed’. morning when aforementioned object was insert taken out rather than come in at 2am in the patient. They I didn’t think so… have to think for yourself. Before you is a new for what seems to be the first time ever, you se becau t may be ship patien the intern , in ns worse rotatio even Or y. other Emergency is set apart from panied by a worried family member or twent the diagnosis and lete medical histor y and are possibly accom make comp a facts, have the t not may collec to or r may l, docto the unwel to up likely are most ‘Mum’. Regardless, it is and Gordon, who all address the patient as Holmes, except without the cocaine or the accompanied by five senior lawyers from Slater particular unit. It’s a bit like being Sherlock a under ward the to them g sendin or home them g sendin either before t patien the treat … well, not the patient’s, at least. of violin – neither would help the situation at hand ous. Your first patient could have a raging bout g, the amount learned in one day can be enorm testin class. be rs can Senio for range ira the Capoe whilst her and ing during amaz hip The variety in Emergency is old lady, who’s fallen over and broken a of bronchiolitis and the one after that a little belly button in a the case in first ‘lint of their case with a bub seen little a never next I’ve the lous’. pneumonia, one would deem as ‘ridicu ’. very few Emergency presentations are what not willing to divulge location with triage nurse Despite popular opinion and urban legend, analgesia and now presents with new pain, word the ad misre guard has the who Unlike . man tment ssed Emergency Depar distressed 24 year old male’ or a case of ‘distre s to the Triage Nurse – the Gatekeeper of the a so-called emergency presentations is thank al reason. Hungover individuals hoping to get medic valid a t withou The reason for the distinct absence of these door the gh throu you get will rs nail slippe st ly neare spark the red to and al tears referr of nt ency to the Wizard of Oz’s laboratory, no amou rned about a broken nail are given an emerg door… the drink Gatorade and sent home, people conce gh to throu told get are my’ cases ne Anato genui Grey’s the on it only ‘saw drip because they a pat on the shoulder. As you can see, on his nose is given a pair of tweezers and salon and that guy with a funny looking hair thing you say- ‘How are you most of the time. need to fight the urge to say STAT after every r. Everything moves at a mile a minute. You docto junior a the ED nurses to hand me a for of one ment ask excite and the out to it try adds The pace of ED r was your bowel motion? STAT!’. I decide to colou ‘What , STAT!’ ? please ball hands it to me. ‘STAT’ she cotton and t today sir? STAT!’, ‘Could you hand me that and then pulls my pen torch from my pocke t. She pauses, takes one long look up and down patien y drows a of pupils the check to pen torch STAT a newbie? to test replies, rolling her eyes. Is it that obvious I’m to be taking a urine sample to the pan room l and calmness when it’s needed. I happen contro of and sense ‘OK’ ing an er amaz an is stamm to there ge , ; you can lend a hand if you like’. I mana Despite what may seem to be utter chaos got a Category 1 coming in, come and watch ‘we’ve says and me grabs trars Regis ency when one of the Emerg any point during this time! d her – no attempts at slow-r unning seen at it’s the worst, because it generally scurry into the main resuscitation cubicle behin – you get seen straight away. For anyone else, view ory to have from a politician’s point of to do. Suddenly, the group of people need they what one every Category 1 is the most desirable triage categ telling Registrar is already at the head of the bed, my and in s come t patien story that the patient’s pretty the The from flash. us too obvio means you’re not doing y from the ambulance officer s. It’s g in lines, applying oxygen and taking a histor ED resuscitation cubicles, I would in rs mirro no are there glad I’m … standing there become a cohesive unit, puttin mine faces of the people in the room. Except for the on le ectab undet is alarm or fear of unwell but any trace now… probably triage myself as Category 1 right ge to muster up enough muscle control to keep whilst they work on the other problems. I mana t patien the into fluid IV ze t is stabilised and being squee to me My Registrar takes my hand and gets lly minutes) passes and, to my relief, the patien squeezing out. What seems like an hour (actua from t. My Registrar, without fluid own patien my next ing their stopp to as off well as moves in squeezing the fluid group hugs, or showboating – everyone just fives, high no are There ICU. to ted admit moved to another cubicle before being on and continues until it’s time to go home. ‘Back to work’. So just like that, the shift moves g individuals, trying to a bead of sweat on her, winks at me and says court. There is just a group of hard-workin ent, after years of watching ER, no basketball pointm t arrives. I leave disap my patien to 1 ory much and Categ s a cheer when no e, team the There’s no fanfar go from stammering idiot to able member of I , weeks few a After shift. hour ten a help as many people as they can during of pride in a hard day’s work. without any smart remar ks, just a quiet sense I finally feel like a doctor… Till next time, Ernie. *

The name and identity of the writer have been changed to avoid recognition and provide complete anonymity!

Going Places – ISSUE #4

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Dr Laura Carter

GP in the High Count

What’s your current role – and how did you get there? I’m currently working at Mansfield Medical Clinic, which is about three hours north-east of Melbourne in the Victorian High Country – I was a Registrar here previously and my vocational registration came through this year. I work three and a half days in the clinic, plus on-call, and I also work as a junior medical educator with the Bogong Regional Training Network. The local district hospital is next door, so commitments there are part of the job. We have six doctors, two Registrars plus a number of nurses and allied health professionals in the clinic. We have visiting surgeons coming in and we do anaesthetics and obstetrics … so there is heaps of variety. I probably only have two days a week for regular routine patient appointments and the rest is taken up with other clinical work. In the winter season, as there’s a big influx of people for the snow, we run the Mount Buller Medical Centre.

What influenced your decision to do medicine and then to become a GP? The decision to enter General Practice evolved with life experience. I grew up in Sydney and didn’t really know what I wanted to do when I left school. I had always been interested in nutrition and dietetics, so I did a science degree with that in mind. Then I did an honours year involving a lot of lab work and was three years towards a PhD in muscle research, when I realised I wanted to have more interaction with people and move away from focusing on the little picture that you often see in science. That’s when I applied to do medicine. I moved to Queensland and did the postgraduate medical degree and then worked there for another five years. I was on a rural scholarship and moved around a lot, spending two years in Bundaberg, which was really good.

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I joined the Pediatric program when I was in Brisbane. I really enjoyed it, but it got to a point where I had to make the commitment to put my life on hold to get through the exams and the work. I wasn’t completely sure if that was what I wanted to do. As much as I enjoyed it, it is very restrictive in terms of how and where you work. I travelled overseas for a while and realised that I wanted more of a lifestyle choice. I decided that Rural General Practice was going to be the best thing I could do to have an interesting career and a good work life balance. So, in 2006, I moved down here, to the Victorian High Country and enrolled in General Practice training. Being able to live and work near the snow was really appealing and I enjoy the work so much. The thing that I really appreciate about General Practice is the amazing amount of freedom it gives you. There’s the flexibility to choose so many different aspects of your career, and to focus on the areas of Practice that interest you … and, of course, there’s your life outside medicine.


try “It’s far more varied than I had previously imagined.”

What skills have you needed to learn or develop to become a better GP?

Have your impressions of General Practice changed since you entered the profession?

The special skills term in Alpine Medicine during my training and the year in an advanced rural skills post in anaesthetics at the Goulburn Valley Base hospital in Shepparton helped me. Anaesthetics was invaluable in giving me confidence in dealing with head trauma, which you sometimes get at Buller, as well as dealing with people who have heart attacks and other emergencies.

It’s far more varied than I had previously imagined. Finishing training has made a big difference, because I have more control over what I want to do. In training, you need structure to get everything done, so there are far more restrictions in what you can do – and what you can’t do. I did my training full-time to get through it as quickly as possible. One year during my training, I was working full-time, and also doing my Alpine Skills training, which meant working up on the mountains on my days off and weekends, plus studying for exams. It was a lot to fit in – and a bit stressful, to say the very least – but it makes it easier living in a small town without all the pressures of commuting and so on.

What are your plans for the future? My partner, Andy, and I really enjoy living here, and I love the work, so I’d like to stay for a good while. It’s terrific to be needed by the community – in Mansfield there is already a 4-5 week waiting list for a routine appointment. We’ve joined the local bike club, which has lots of social rides and fundraisers for the hospital and we do a bit of hiking and camping, too. There’s such a lot of stuff happening here, even outside the snow season – festivals and events and much more. The work life balance is wonderful, so I really don’t have any immediate plans go anywhere!

Photography: Boss Photography

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PGPPP is a great hands-on way to experience General Practice that shows you what it’s like to be a GP. We talk to two doctors – Dr Oliver Huang and Dr Kiran Ramegowda – who have just completed PGPPP placements. They share their experiences and tell us what they have learned from the 10 weeks they’ve spent in General Practice.

PGPPP – A great way to experience Dr Oliver Huang Where did you do your PGPPP? My PGPPP placement was at Belridge Medical Centre near Joondalup, in the suburbs of Perth. There are about eight doctors working in the Practice, some of them part-time – and there’s one parttime Registrar. The Practice also has three Practice nurses and a psychologist. It was really good to have the psychologist actually located in the medical centre. There are subsidised packages available for mental health issues for patients with a referral and it makes it much easier for them to access these.

How did the program help you professionally? General Practice was always a career option that I had in my mind, but as a resident in a hospital it’s very hard to work out whether that is really what you want to do. This is because – apart from student placements, where you are very much an observer – you don’t really get the chance to experience General Practice any other way. In the PGPPP placement, you work just like a basic term Registrar. It’s quite hands-on and you really do get first-hand experience of what it is actually like working as a GP. For example, I got to do a few care plans and that really gave me some insight into managing chronic disease patients, such as hypertension, where you get to follow up on treatment response and progress.

Dr Kiran Ramegowda Where did you do your PGPPP? My PGPPP placement was at the Stirk Medical Group in Kalamunda, which is an outer metropolitan Practice about 20 kilometres east of Perth. The Practice had nine doctors, two GP Registrars (one in basic and one in an advanced term) plus myself on the PGPPP.

How did the program help you professionally? The program gave me the experience of seeing patients as people, and the patients seeing me as a doctor, rather than just a lowly RMO! Also, I gained experience in the areas of managing chronic diseases, in preventative strategies and with the identification of emergencies. I also gained valuable exposure to continuity of care, particularly with one case involving post-operative wound care, which I was able to follow up. It was really great and it felt like such an honour that patients had so much trust in me.

How was the teaching delivered? Every week, on Tuesdays, we all met at lunchtime and a specialist would come from the nearby hospital for discussions about various aspects of primary care, such as women’s health, cardiology,

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I was able to see some really acute cases. One of the things with the PGPPP is that you are the new kid on the block and only there for a short time – I did a ten week placement. So, many patients prefer to see their own GP because they want continuity of care. However, it doesn’t take long before you actually get some patients coming back specifically to see you and that is really rewarding. That continuity of care is something you just don’t see in the hospital system – because most of the time you will only see a patient once.

How was the teaching delivered? My GP supervisor allocated three hours each week for teaching, which involved on-site consultation, sitting in the room with him for consults and then spending time afterwards discussing the cases. There were some lunchtime seminars with people from allied health and so on coming in with information about particular health topics. These were evidence-based and quite useful. I was always able to discuss my cases with the supervisor and could call at any time for a second opinion. In fact, all of the doctors in the Practice were really enthusiastic about helping me, as a new resident starting a GP term. They always made themselves available for questions even though they were all busy consulting, themselves.

What were the program highlights? I had one patient who came in with an unrelated issue and, as a GP, you do use a holistic approach and check for a range of things. After taking her case history it was apparent that her other symptoms were signs of hypertension, which I was able to treat.

immunisation programs and so on. We also held brainstorming sessions during the week at lunchtime about case management. It was a great experience to have a training program that you could get involved with so much. There was also the continuous opportunity to receive information from the other doctors in the Practice.

What were the program highlights? General Practice presents so much variety and there were many memorable moments during my time there. On my very first day in the Practice there was a young man who came in with swelling in the lymph nodes, so arrangements were made for further tests. Subsequent investigations showed that it was actually cancer in the lymph nodes. Managing chronic diseases was also a highlight and quite intellectually challenging because there are a number of things that you must consider at the same time. For example, in a surgical unit in a hospital, you are thinking of only one aspect of health care – and then you hand a patient over to their GP for their care. I learned so much about what the GP does within the community. Initially, when I started the PGPPP program, I was all geared up to let GPs know what needs to be done when patients are being referred to hospitals. But the experience from the program actually gave me a real insight into why things happen in certain ways.


General Practice I followed up with her and got to see her quite regularly. It was nice to know that she actually missed me after I left the Practice and I had to refer her to my supervisor for her ongoing care. Another patient came in and I diagnosed preorbital cellulitis, and gave some initial treatment, but needed to refer to the emergency department at the local hospital for treatment.

How did the lifestyle compare with hospital? The lifestyle was just great – the hours and the predictability made it so much less stressful. This is actually a big reason why I have chosen a career in General Practice. At the moment, I am also studying a Masters in Public Health part-time. I’ve had to miss a few lectures while working in the hospital system, doing after-hours work and covering for people, but General Practice happens in a set time and you can always negotiate your hours to take time off for study and so on. I try to go to the gym every day. However, working in the hospital system makes it really hard and often I’m just too tired.

What advice would you give other junior doctors about the PGPPP? If you are undecided about your career path I would highly recommend doing this PGPPP term. When you discharge a patient from the hospital, you don’t hear any more about what happens, but the PGPP shows you the other side of the story and what really happens in the GP follow-up. Dr Oliver Huang starts his basic GP Registrar term in 2011. Photography: Michele Clarke

How did the lifestyle compare with hospital?

Want a taste of General Practice while training in hospital? The Prevocational General Practice Placements Program (PGPPP) provides professional, well-supervised and educational General Practice placements as part of your training. The aims of the program are to build your confidence, exposure and interest in working in urban, regional, rural and remote areas through supervised General Practice placements of varying duration – approximately 10–12 weeks. You’ll continue to be paid while you’re on your PGPPP rotation. You’ll gain an increased understanding of the integration between primary and secondary health care – this practical experience will allow you to make an informed decision about considering a career in General Practice.

What will you gain on the PGPPP? You’ll have a unique insight into General Practice through this opportunity to work in General Practice. Your placements will be well supported, providing you with these great benefits:

3 A real life experience in General Practice over and above that of undergraduate training

3 Exposure to a variety of health services from migrant to aged care health services

3 Ongoing and personal mentoring by respected and dedicated GPs in the field

3 Direct patient contact in a range of primary care settings such as General Practice, Aboriginal medical services, drug and alcohol services and community-based facilities

3 Enhanced understanding of the Australian health care system

It was totally workable and I really loved it. My wife loved it too! There was no after hours on call or night shift – and the hours were so good. I worked just nine to five, the same hours as my wife, so I felt like I had a life again. I was able to ride a bike from home to work, which I had never done before in my life! It was a really lovely way to get to work and there was very little traffic around.

3 Great networking opportunities 3 Increased confidence and independence to take into future

What advice would you give other junior doctors about the PGPPP?

To be eligible to participate in the PGPPP, you must work at an Australian hospital. For complete eligibility requirements, please contact the junior doctor manager at your hospital.

I would totally recommend this experience. For me, it really confirmed my initial inclination to do General Practice and totally convinced me – without any doubt in my mind – that this is what I want to do. I actually found it quite difficult to return to the hospital, because what you do there really feels like just work. Conversely, I found in General Practice that the work was something that really enriched my life. Dr Kiran Ramegowda is now doing his basic GP Registrar term in Mandurah.

training and work environments

Eligibility for the PGPPP

The PGPPP is managed by General Practice Education and Training (GPET) on behalf of the Australian Government. It is facilitated through providers and delivered by accredited practices and medical services throughout Australia.

Photography: Lachlan Moore Photography: Kerina Puttman

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Tech Talk • Review

Taking A look at AEDs When it’s working at its best, the human heart is an amazing machine. As Doctors, you’d know only too well how the hydraulics and electrical pulses should work. But when things go wrong, the current from the electrical pulses can incite incredible chaos. If a heart is stricken by ventricular fibrillation – a common type of cardiac arrest – then its once-orderly conduction devolves into a scattering of impulses. These impulses travel through the heart as little wavelets, causing unsynchronised tightening and releasing of the muscle fibres in the ventricles. Without synchronisation, blood flow ceases; starved of oxygen, other organs rapidly begin to fail. Within 10 minutes, the victim will almost certainly die. About a quarter of all deaths in the developed world can be attributed to cardiac arrest – an astounding figure … but one that now has a chance to drop, in no small part because of the automated external defibrillator. AEDs are designed to shock a heart that’s in ventricular fibrillation back into a healthy rhythm. AEDs can now be found in hundreds of thousands of public places, including office buildings, transportation hubs, and gyms; they’ve also been installed in police cars, in schools, and even on the International Space Station. The AED’s widespread introduction represents one of the greatest engineering success stories of the last few decades. In just 20 years, improvements in defibrillator design – in the efficacy of the waveform that delivers the electric shock, the way that the unit’s energy is stored and delivered, plus the AED’s overall ease of use – have made it possible for virtually any member of the public to operate it in an emergency situation. From the moment the AED’s brightly coloured box is opened, audio instructions prompt with simple commands. First, they tell the user to place two adhesive electrode pads on the sufferer’s chest, following the diagrams on the pad wrappers. The defibrillator’s built-in electrocardiograph automatically detects and analyses the state of the patient’s heartbeat, and its software judges whether to

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administer a shock. If indeed the heart is in ventricular fibrillation, the AED announces in a firm voice ”Push the button” and the delivery of a tailored burst of electric current may be all that’s needed to restore a normal rhythm to a heart. Meanwhile, what’s happening inside the AED is a technical marvel. The device performs two main functions. First, it needs to recognise the lethal haywire rhythm of ventricular fibrillation. Second, it needs to deliver a 100-kilowatt shock to the heart. This jolt allows the heart to restart its normal rhythm, sort of like a Ctrl-Alt-Del for the organ. If the shock is delivered in the first minute of ventricular fibrillation, in more than 90% of cases the heart will regain a normal sequence of electric signals, and the steady contractions will return. The brains of the machine are quite astonishing – the defibrillator has to figure out, on its own, when to deliver a shock. The heartbeat is most vulnerable during the T wave. A shock administered to a nonfibrillating heart during the T wave could potentially induce fibrillation. To provide a check on such situations, AED designs incorporate an analysis system that checks for a pulse. Once the AED is turned on and the electrode patches are attached, the device’s first task is to recognise the EKG signal to see if ventricular fibrillation has occurred. The system starts by delivering a low-voltage, signal through the two electrodes – this also measures the impedance to verify a good contact on the body. The two-electrode signal is then fed into a very high ­commonmode-rejection amplifier, which differentiates between the two signals by rejecting the voltages common to both. (Additional complicated circuitry protects this microvolt-sensitive amplifier from the 2000V shock – 20 million times the EKG voltage – delivered to those same electrodes used for the sensing).


Automated External Defribrillators A sophisticated peak detector then analyses the signal in search of a heartbeat. In ventricular fibrillation, a noisy, messy signal will appear on the cardiogram, instead of distinct peaks. The peak detector interprets this noisy signal as a series of rapid, randomly spaced heartbeats. The AED makes its initial diagnostic decision by measuring the heart rate. If this rate is more than 150 beats per minute (2.75 Hz), the defibrillation-detection algorithm presumes that ventricular fibrillation has occurred, and the device will announce that the rescuer should administer a shock. However, dozens of subtle issues can undermine this process. For example, if the patient has atrial fibrillation generating high heart rates, potentially causing the AED to call for an inappropriate shock. To deal with these confounding rhythms and other interferences, the defibrillation-detection algorithm performs a simple spectral analysis. This is just one example of such an algorithm – there are many different approaches.

fibrillation. To handle the possibility of atrial fibrillation, the algorithm calculates the average derivative of the EKG voltage. If the average exceeds a critical threshold, that tends to rule out atrial fibrillation. The EKG of a heart in atrial fibrillation has a higher proportion of flat regions of zero voltage, and therefore a zero derivative. Those tests, and many more, are performed during a threesecond window, leading to a tentative diagnosis. The process is then repeated to produce three diagnoses. Only if two or all three analyses indicate ventricular fibrillation will the shock then be authorised. Thanks to the advances in the AED, the weak link in the chain is now actually CPR … but Researchers at Minneapolis-based company Galvani are now exploring an automated electrical form of CPR. Using the same defibrillation patches, this technique relies on complex, lower-voltage waveforms (100V to 200V) that are delivered once or twice per second and cause strong chest constrictions. The constrictions appear to move blood as effectively as would chest compressions performed by a trained human rescuer. If this research pans out, in the future – as soon as the AED is in place – it will do everything: performing electrical CPR for a minute or two, followed by a calculated defibrillation shock if it’s needed.

If too much of the signal occurs at a higher frequency (30 to 100 Hz), then noise contamination, perhaps from an AC power line or some skeletal muscle contractions, is suspected and the algorithm will move away from diagnosing ventricular

Our sincere thanks to IEEE for permission to base our TechTalk article on “Idiot-proofing the Defibrillator”, by Mark W. Kroll, Karl Kroll, and Bryon Gilman, IEEE Spectrum, November 2008. The full article can be found at: http://spectrum.ieee.org/biomedical/devices/idiotproofing-the-defibrillator

About IEEE

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Going Places – ISSUE #4

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k c a b t u o GP The

LEWIS T T O C Dr S

What’s your current role?

How did you get to the role that you’re in now?

I’m the sole GP at Wudinna, a small town of 600 people in central South Australia that’s pretty much equidistant from Port Lincoln, Whyalla and Ceduna. There are about 1400 people in the area. We’ve got a brand new medical centre I work from and there’s an adjoining hospital. Like most small country hospitals, it’s a combination of a fully-staffed hospital and nursing home, with ten nursing home beds and ten acute beds. I’m married with a two-year-old son and my wife is a nurse who works at the hospital, so we see each other during the day! There’s no air service, so to get to Adelaide we have to drive two hours to a town that has an airport. I’ve got my pilot’s licence and I have a small plane here. I’m going to be doing some regular anaesthetics at Whyalla, 240 km away – so it’s only a forty minute flight, rather than a 2½ hour drive. Having a plane makes it easier! The nearest GP is around 100 km away from Wudinna, so I’m pretty much permanently on call. I consult five days a week but I do some medical work nearly every day. I have some very good nursing staff at the hospital who tend to filter out a lot of the calls, so on the occasions I am called, it’s for something they do really need me for. It can be difficult being permanently on call but my family understand and I am usually nearby, which works pretty well.

I’d lived in Adelaide since I was nine and before that I lived in country South Australia. I wanted a career that was science-based but involved interaction with people and I thought I’d like to live in the country. I did a six-year undergraduate degree at Adelaide Uni and, because I wanted to work rurally, General Practice was the ideal option. Early in my degree, I won a John Flynn scholarship, which provided funding to visit a country town for a couple of weeks, over consecutive years. I first came to Wudinna as a John Flynn scholar – the doctor here then was an excellent mentor. In years five and six of the degree, I took the opportunity to do as much rural time as I could. I went into placements in a number of areas throughout the State and in Broken Hill; I did some of my GP training in Clare, but the bulk of it was spent working in Quorn, a little town near Port Augusta. I worked half-time there and half-time working for the Royal Flying Doctor Service near Port Augusta, before coming to Wudinna.

What’s a typical day like for you? I try to keep to fairly gentlemanly hours. Usually, I’m at the hospital from around 8am to 9:30am, doing rounds and dealing with any issues there. I consult throughout the day until about 5:30pm. Sometimes I’ll go back to the hospital if there’s anything I need to deal with there. Of course, any standard day can be thrown into disarray if there’s an emergency during the day – like last week when somebody had cut their finger off! In those situations, if I do get involved in a significant emergency at the hospital, the population here is really understanding and they’re more than happy to wait, come back or re-book at a later time. They are not about to complain about having to wait because I’m treating somebody who needs my urgent attention.

Photography: Gabrielle Photography

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What do you find fulfilling in your role as a GP?

What are your plans for the future?

There are three main things. I like the area, I like the lifestyle and I like the variability in my day-to-day work. It is very changeable and with very little warning almost anything can come out of the blue. It’s everything from coughs and colds and immunisations, to amputations and everything else in between. One of the important benefits is that the local community is so good and so supportive – it is really nice to have that appreciation shown for everything that you do.

As I’ve just had a brand new medical centre built for me, I’m certainly going to be staying in Wudinna for a while – but I’m not going to be here forever. These days, very few graduates stay in the same place for thirty years like their predecessors did. I do have an ambition to spend some time in Canada at some stage, but I know I will always be a rural based GP, because it’s what I enjoy.

style and e f i l e h t I like bility in a i r a v e I like th rk -day wo o t y a d my

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Dr JANELLE HALL

The GP that keeps herself super-busy!

Photography: Patrick Hamilton

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What’s your current role? I don’t actually have one role … I’m doing a variety of roles at the moment. On Mondays and Wednesdays, I’m doing GP locum work. On Tuesdays I run a project at an HIV clinic where I’m using my skills as a Cosmetic Physician to treat HIV positive individuals with a stigmatising lipoatrophy caused by some of the early antiviral therapies used to treat HIV. At this HIV clinic we use injections that stimulate collagen formation which, over a series of treatments, can return faces back to their previous look. This is normally hundreds of dollars for each treatment but it’s now available on the PBS for this group of patients. On Thursdays and Fridays, I work for Marie Stopes International, which is a women’s health organisation. I help with contraception, STI education, diagnosis and treatment and providing medical terminations of pregnancy. I am one of just seventeen RU486 authorised prescribers in Australia. On top of all this, I do some after-hours General Practice work on weekends. I also do some work with Homeless Connect each year … and I’m involved in a charity called Destiny Rescue.

What influenced your decision to become a GP? I grew up in the country, on a cane farm in a small town outside Mackay. My mum was the town GP when I was growing up … and she still is. When I was a kid, she brought after-hours patients to our house and I was her assistant. But when I graduated from high school, medicine had become a postgraduate course. So I did an undergraduate degree in pharmacy and became a registered pharmacist, working in the outback as an outreach pharmacist for a year, before enrolling in postgraduate medicine at the University of Queensland. I did my internship in Toowoomba and spent a year at the rural school in Rockhampton, then went to Brisbane for my fourth year and wanted to go bush again. My plan, when I finished medical school, was to become a child psychiatrist, but when I tried working in psych as an RMO I realised it just wasn’t for me. Then I did a rotation in palliative care – and loved it. I’d already had some exposure to palliative care as a pharmacist and decided that’s what I wanted to do. The best way to train to become a palliative care physician is to do General Practice first, so that was the reason that I initially enrolled in General Practice. I found that I really enjoyed the training and, in the final part of my GP training, did my special skills term in palliative medicine at St Vincent’s, Brisbane.

After I left St Vincent’s, I went to a women’s health conference and met someone from Marie Stopes International, who also offered me some work. And that’s really the story of how I’ve come to do a little bit of cosmetic medicine, a little bit of General Practice and a little bit of women’s health, plus also some after-hours General Practice on the weekends, which I also enjoy.

Have your impressions of General Practice changed since you entered the profession? It’s funny because I really thought I didn’t want to do General Practice. Having grown up with it, I thought I knew what was involved. And because I’m a young female GP, when I’m in a regular clinic, I do cop more than my fair share of “tears and smears”. But, on the other hand, when I look at the things that I’m interested in medically, General Practice has actually been the best way for me to do that. I’m really enjoying the variety of work I do and the fact that I can choose the different areas that appeal to me. I’ve also got the opportunity to move into a different area of interest at any time.

What other things have you been able to do through General Practice? I’ve recently returned from a trip to Thailand and Cambodia with a wonderful charity group named Destiny Rescue, who rescue children sold or stolen into slavery. They help them with counselling and education, including life skills like cooking, sewing etc., and then help them into foster families in the community. Although I went as a regular helper, my medical skills came in handy and by day three, I was the trip doctor. I had the chance to meet my sponsor child, and see that she is doing really well. I’m now involved in speaking for the group in Australia to help raise funds for their wonderful work. I also really enjoy working in areas where there is a need for medical professionals, such as Homeless Connect, which is run in Brisbane twice a year, where we help out local people who would otherwise find it very difficult to access medical care.

How did you get to the role that you are currently doing? After my FRACGP, I took up a Registrar position at St Vincent’s for my advanced training in palliative medicine. But it got too much for me. I wasn’t sleeping and I just couldn’t cope. So I went back to locum General Practice and decided to find a special interest that wasn’t so emotionally draining and might also be a bit more positive! A friend suggested cosmetic medicine, so I rang the Cosmetic Physicians Society of Australia and I organised to sit in a few half days each week with one of their members. I learned a lot about it and I also learned that I really did enjoy it. The Society helped me with all of the training and then they actually offered me a part-time job.

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Life as a DR HELEN TATSIS

I graduated with a medical degree in 2000 and finished my GP training in 2004. About three years ago, I registered with a locum agency in Melbourne – Australian Locum Medical Service – and found that the lifestyle really suited me. My husband and I have two daughters, aged five and two – and that’s my main reason for doing locum work. It’s extremely flexible with a young family. I’m at home during weekdays, so I can take my daughter to school and I don’t miss out on raising my kids. I also really enjoy the locum work itself. I don’t need to have my own little office where I see patients. I like being out and about – I really like the fact that my environment changes all the time and I never know what I’m going to have thrown at me. My working day starts and ends from home. All of my jobs are allocated electronically, so I log in with my laptop and get the jobs, then I just go wherever I’m needed, all within a particular geographic area. We’ve got an unusual arrangement – my husband works with me as my driver. My husband is trained in IT but we made the decision to work together. That means we also spend more time together at home and our kids both see us at the same time. I suppose it’s pretty unconventional but it really suits us and it works well. Most locum doctors have a driver, partly for safety reasons, so there is always someone with you when you make calls, but also because it’s just far more practical to do it that way. Much better than just having a GPS! When you drive from patient to patient, you generally call the patients as the jobs come in, to assess each case. You do a basic triage, in a way – you find out what the problem is – whether they need to go to a hospital or whether it’s actually an appropriate consultation and not something really minor that can actually wait. Mostly, you can do all that between patients, while you are travelling from one patient to the next. Having a driver means you can call patients and really focus, and even get on with typing up notes. This just makes you far more efficient. I work Saturday until Tuesday and my average work week is between 38 and 40 hours. The shifts on Saturday and Sunday are both 12 hours, but that time goes by really quickly. After that, I’m at home during the day when my kids are awake. Monday shifts start at 7pm and finish at 3am the next day, then on Tuesdays it’s 7pm to around 1am. The car is kitted out with all the medicines and equipment I need and the laptop also has a GPS, so the agency can always see where I am and will allocate jobs as they come in to me, if I am the closest doctor working that night. In a typical twelve-hour shift I might see between 20 and 24 patients. I usually average about two patients an hour, although if the jobs are very scattered and we have to do more travelling, it takes a bit longer and so I get through fewer patients. The agency allocates work that comes up within the same geographical area, throughout the shift. So I stay in that area, but as Melbourne is such a spread-out city, we average between 200 and 400 kilometres each day! Most of the calls are to private homes, but there are some nights when you might see a lot of nursing home patients.

LOCUM

There is occasionally some patient continuity – you might return to a nursing home – or there are some patients who you might see a number of times because of their medical conditions. But it’s not like mainstream General Practice. Generally in locum work, you do lack that continuity, and you often don’t get to know what happened to your patients. It’s a bit like working in emergency I suppose, where you do the initial assessment and then you don’t know what happened. I find locum work incredibly interesting. There is always a huge variety in what you are exposed to. Also, because you are going to see people in their home, you see your patients in a different light than you would if they came to your clinic. I find that people will often be more cooperative and more relaxed when they are in their own home. It’s also very rewarding. Often, you will go there and you’re able to reassure people … then you can see such relief in their face, “Thank God I didn’t have to go to hospital in the middle of the night!” Longer-term, I might reduce the hours I do in locum work and perhaps move into part-time work in a General Practice clinic. With locuming you need to trust your instincts, because you don’t have a lot of information about the patients. Admittedly, it’s not easy work – it can be a challenge, but it really suits me right now and I love it.

Photography: Lachlan Moore

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Information about working as a locum

When you are a fully qualified GP, would you be interested in the possibility of working as a locum? What’s involved and how does the system work?

Qualifications

Medical Bag and Equipment

All doctors are independently assessed and registered by the relevant State Medical Practitioners Board. Many hold Fellowship of the Royal Australian College of General Practitioners (RACGP), or are currently studying towards achieving this goal.

The policy on medical bags and equipment will vary from company to company. In the case of ALMS, they provide a comprehensively equipped medical bag at no cost – however, you are required to stock the bag at a cost of around $300.00, with ongoing costs about $50 a week.

Doctors working through the Approved Medical Deputising Service Program (AMDSP) are further assessed by the Department of Health and Ageing prior to placement on the program. They are required to meet stringent continuing medical education requirements. Nic Richardson, CEO of ALMS comments “The Government health reform agenda currently emphasises greater accessibility for all patients to after hours care, whilst lessening the burden on General Practice. This endeavour, coupled with movement towards a shared health record and a national on-line GP triage service, provides exciting opportunities for doctors seeking to work with the Australian Locum Medical Service.”

The Work Working as a locum essentially involves nights and weekends, as this is the period of key demand for deputising services. Flexible roster arrangements are normally available and you’d need to commit to these four weeks in advance – a shift is between 8 and 12 hours. Patients are most often referred by their GP for after hours care – GPs’ instructions regarding the general management of their patients are normally made available to you. In many cases, you will be given a brief medical history for the patients, including known allergies and current medication. Details of your diagnosis and treatment are forwarded by the locum service to the patients’ regular GP the next working day.

Free monthly allowances of PBS doctor’s bag emergency drugs are obtained via Medicare Australia Emergency drug [Doctor’s Bag] supplies, which are ordered through any Chemist via a monthly order form available from Medicare.

What can you earn? Earnings are fee-based. The Medicare rebate for patient services will vary with the time spent, time of day and the complexity of the service provided – they will average about $125.00 per consultation. In most cases, a doctor working 48 to 60 hours per week as a locum would attend 80 to 120 patients during this time and earn between $8000 and $10000.

What do you pay? Doctors working for a locum service pay the company a variable commission based upon the amount of fees they have billed. Often, the commission rates are commensurate with your commitment to a specific number of rostered hours – that means the more you work, the less you pay … and the greater your earnings!


Metropolitan GP positions for Doctors with:

General Registration & Australian Citizenship or Permanent Residency Ideally suited to doctors working in the hospital system thinking about a career in general practice After-hours in-clinic approved medical deputising services in Melbourne [VIC] & Brisbane [QLD] • Excellent remuneration • Work towards your GP Fellowship in our after-hours in-clinic services (AMDS) • Mentoring & opportunities for professional development are available • All clinics offer nursing and administrative support, are fully computerised and have excellent facilities and equipment

For further information, visit www.alliedmgp.com.au Apply to GP Relations Manager info@alliedmgp.com.au or phone 03 9525 3700

llied Medical Group Holdings Limited


e h t t e g o t w o h n S o P TI

r o is v r e p u s r u o y f o t u o rsonal advice know to give us their pe We asked six doctors we a supervisor. get the very most from about the best ways to ful in helping you mendations will be use Hopefully these recom r supervisor. to get the best from you to say! Here’s what they have

Dr Allison Turnoc k – TIPS

of the sessio n (first You shoul d book teaching in at the begin ning . That mean s if one noon) thing in morn ing, or first thing in the after won’t disappear. or both of you are runn ing late, your teaching drain them of their F ind out what your supervisor ’s intere st is–then ice, too. F ind out Pract the in GPs other to es appli know ledge! This know ledge, too. their intere sts and see if they will share their to! r eage be will You’ll find man y with, as it will give Mak e sure you have topics pencilled in to start some struct ure.

most

Lee – TIPS Dr Rachel

dit’ a bit of an ‘au nsider doing , You should co ple am – for ex now and then gether type approach nt records to tie pa om nd ra w fe a ng etimes ki m chec inking, etc. So at you were th don’t u yo to explain wh at th n’t know “what you do s. this picks up tip od go e u can get som know” and yo a supervisor on ur yo th wi in GPs) Sitting of the other e on th wi (even For consultation e. tim to e ating from tim o seems can be illumin e Practice wh e a GP in th er th is , w they ho example d fin d in an on time? Sit n ru ys wa al to ient! so time effic manage to be rving other se ob t ou ab eg: a Why not think e or nearby – in the Practic ful to lp he professionals . It can be po diatrist, etc out ab s psycho logist, tip t ea up gr do and pick see what they . rk with them how to best wo

Dr Melanie Winte r – TIPS

PS nnington – TI Dr Andrew Pe Consider scheduli ng excisions, Implano some minor procedures – skin n insertions etc. your teaching tim – to be during e. That means yo u can be supervise taught at the sa me time – addition d an d ally, it doesn’t tak out of the superv e time isor’s patient loa d to help you. Choose some inter esting cases you have seen to pres your supervisor for discussion, fe ent to edback & learning . Write a diary or compile a list of learning points th want to discuss, at you as they come up (otherwise you’ll forget!). Do something so cial with your su pervisor an d oth colleagues from er work time to time, aw ay from work – way to bond! a great

– TIPS roeneveld Dr Katya G

not be interested in er you may or may ALWAYS gain Regardless of wheth or surgery, you can e icin ed m of ea ar spital rotation. a particular any placement or ho m fro ge u led ow kn d skills an the more rewards yo ore effort you put in, m t e en “th itm is m o m ott co m y ing M through show is ns ea m s thi e at vid Wh pro ues will get out of it”. e, your senior colleag on y da m fro sm sia and enthu nities for learning.  you with great opportu have areas of interest, but I do advise to It is very admirable chance to gain e plans obstruct the ur fut ur yo let you not to  t you may be less tha ry icine or surge ed m ng of s ea ar to re exposu othing ventured, nothi y much a case of “n interested in … it’s ver aware of any ‘gaps gained!” make your supervisor to is tip l efu us r the  Ano ir field of expertise. particularly within the expand your in your knowledge’ – t you are looking to tha see to ed as ple be They will e time to instruct happy to set aside som is a great be ld ou sh d an ge knowled teaching the way, this time for you accordingly. By supervisor. ur yo th wi rt a rappo ckground – opportunity to develop the pervisor about ir ba su ur yo k as e, iat pr If appro me to specialise training, why they ca ir the did y the ere wh outside of at interests they have in their field and wh ild other great way to bu the workplace … an rt! po that all-important rap

1. Introduce yourself with confidence and a firm handshake at the beginning of the rotation. 2. Ask questions as they arise during rounds – and don’t be afraid of the answer “why don’t you go and look that up and tell me about it tomorrow” – you tend to remember things better that way. 3. At the start of the rotation, ask your supervisor if it would be acceptable to meet half-way through the rotation to evaluate your progress – then ensure that this occurs. 4. Ask for tutorials on important topics as they arise during rounds. 5. Take the opportunity to take histories and/or examine patients in front of your supervisor to gain experience whilst you’re under observation. 6. Suggest going for coffee at the end of the round – use this informal opportunity to ask questions and discuss interesting cases.

Dr Belinda Guest – TIPS

I suggest that you work out wh at the key topics are – that’s to say, the areas or skills you would most like to learn – and let your supervi sor and other doctors in the Practice kno w this. For example, if you’re keen to do some specific procedures, you can sit in with other doctors who are doin g them or they can let you know when they have areas that interest you : interesting skin lesions or rashes … … Supervisors are there to help out wit h any patient you are concerned about. “Corridor consults” are wh en you speak to your supervisor informally during a consultation, rather than in your dedicated teaching time, so often there isn’t much time.   When you are asking them abou t a patient, try to be really specific about what you want to know, if you are able to. This means you are mor e likely to get the best advice back. Initially, you might just go to them with an undifferentiated problem because you’re not sure where to go next – however, as you feel mor e confident, you can define things a lot more accurately. An exam ple might be: “I have a patient with chest pain that I think might be card iac and I am wondering what the best scre ening test would be” rather than the more vague: “I have a patient with ches t pain (with long description abou t type of pain and CV risk factors)”. Just be aware that sometimes the supervisor can go off on a different tangent to what you need – tell ing you about acute pain manag ement, etc. Going Places – ISSUE #4

35


Dr ANN WARD

The GP with a love of adventure

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Ann Ward lives and works in the spectacular East Kimberley ranges in Western Australia, as the District Medical Officer at Kununurra Hospital. She’s also an expedition doctor, taking time out each year to accompany groups to wilderness destinations all over the world. Earlier this year, Ann was engaged for a private trip to Antarctica on a super yacht; it was her 25th trip to the continent … and unlikely to be her last! “I manage a trip to Antarctica nearly every year now,” Ann says. She has also supported treks in Nepal (where she has led many treks through the remote Himalaya), Papua New Guinea and Peru – and many more of the world’s wild places. Kununurra hospital has 36 beds for a population of around 7,000, plus much of the outlying East Kimberley as well as a continuous stream of tourists, outside the Wet. There, Ann covers emergency, procedural obstetrics, general surgery and Rural General Practice. She also flies into remote communities, with Warmun (also called Turkey Creek) holding a special place in Ann’s heart. “I’ve been flying into the Warmun Aboriginal community for 18 years now. I’m starting to deliver the babies of women who I delivered as babies! It’s such a special experience, knowing the connections, knowing the families and understanding people’s stories.” After so many years, many of the people are like family, she says. “Going out bush with Aboriginal people and learning a bit about Aboriginal ways of doing things and their attitudes has been a huge privilege.” Ann studied medicine at the University of Western Australia, graduating in 1983. “I expressed a vague interest in becoming a doctor while at high school. When both my school guidance counselor and my first boyfriend, David, said they didn’t think I’d get the marks – I took it as a challenge and decided to do it.” Ann has never regretted that impulsive decision. Her internship at Sir Charles Gairdner Hospital in Perth was followed by several years there as a Resident before doing obstetric training at Osborne Park Hospital and paediatrics at Princess Margaret Hospital – both in Perth. Having a rounded medical education that would be useful in remote areas was her primary goal. After several trips to the Himalaya, she then took a year off to work as a trek leader in Nepal. Although she wasn’t actually employed as a doctor, her medical training was very useful, Ann says. “Medicine is useful wherever you are and it’s particularly useful in third world countries with limited resources. It was very, very interesting to see how people in resource-poor areas work.” During her time in Nepal, Ann met and later married mountaineer Tim Macartney-Snape. Returning to Australia, she went to the outback town of Meekatharra, in Western Australia, to work for the Royal Flying Doctor Service for three years. There, she and another doctor covered an area of 390,000 square kilometers by plane and serviced the local hospital. “I wasn’t terribly experienced when I first arrived. It was seriously difficult and I spent a lot of time flying by the seat of my pants. However, it gave me a lot of practical skills and forced me into making do with existing resources – using my clinical acumen in a remote setting, with little access to blood tests or even radiology.” Diagnostic skills are critical in remote medicine, she adds. “That’s one of the exciting challenges of Rural General Practice

– you’re really forced to use all your skills.” During that time, she and Tim organised an expedition to Mount Everest called the ‘Sea to Summit’ Expedition. “Tim managed to climb Mt Everest from sea level, without supplemental oxygen, and I went along as expedition doctor.” Ann and Tim separated in 1992 and she moved to Kununurra – she has been there ever since, taking around three months off each year to work in remote areas of the world. In 1993, Ann worked for three months as a volunteer doctor for the Himalayan Rescue Service in the Annapurna Ranges, leading several more Himalaya treks over the next two years. Two years later she made her first trip to Antarctica, accepting a summer contract with Adventure Network International, as Base Camp doctor at Patriot Hills in inland Antarctica, supporting expeditioners, scientists and tourists. “I had the most extraordinary experiences, flying in a DC3 over Mt Vinson, Antarctica’s highest mountain … across Antarctica to Queen Maud Land … camping with Emperor Penguins and taking people to the South Pole, where only a handful of tourists have been.” Ann sailed to Antarctica in 1996, working for Aurora Expeditions with Greg and Margaret Mortimer. “By then I was hooked by the allure of the Antarctic and have been returning regularly ever since to work as ship’s doctor – mainly to Antarctica.” She took a year off from her work in Kununurra, spending another summer with Adventure Network International at Patriot Hills, then spending three months in Peru where she completed a Diploma of Tropical Medicine. She also worked for Yorkshire Television on an expedition in the far north Kimberley region to find the rare rough-scale python. Now reunited with her first boyfriend, David Sampson, a Professor at the University of Western Australia, Ann travels regularly to Perth, and maintains regular trips to wild places, with Antarctica at the top of that list. It all goes to show how far General Practice can take you!

Photography: Martin Hadley

Going Places – ISSUE #4

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What’s your current role – and how did you get there? I’m currently spending two days a week in clinical Practice as a GP Registrar at the Sorell Medical Centre in Hobart, plus another two days each week as a Registrar Liaison Officer and a medical educator for General Practice Training Tasmania. I also spend another day each week as a study day. I’ve got my exams coming up and I’m also doing a Diploma of Child health through Westmead Hospital. The Practice I’m working with is quite a large one. There are eight doctors, plus me and one other Registrar. There are often PGPPP and medical student placements in the Practice, as well. There’s really good nursing support and strong links with local allied health professionals – the Practice was recently named RACGP Tasmania General Practice of the Year. I’m in my fourth year out of medical school. I applied for General Practice training in 2008 and I’m now doing my extended skills post part-time in Registrar medical education and I’ll be sitting my final exams at the end of next year.

Have your impressions of General Practice changed since you entered the profession? During our training, we did get quite a bit of exposure to General Practice. My first experience was a two-week placement at a clinic in St Marys, on the east coast of Tasmania. I was lucky to receive a scholarship to do an Expedition Medicine course through my training provider and that really gave me some great exposure to the variety General Practice could offer. I really love the diversity of the work with General Practice. You’re exposed to all the different facets of medicine and you don’t really know what will occur when you walk through the door. I find General Practice is really varied work and clinical work changes from day to day and week to week. Then, on top of that, you can concentrate on other specialties within the scope of General Practice work, which is one of the reasons I also do Medical Education. I also like teaching, and learning from the people you teach.

There is a much greater flexibility to do things you enjoy outside of medicine once you are out of the hospitals. I play social basketball, go for the occasional bike ride and my fiancé Luke and I really enjoy spending time at the beach with our dogs. Luke recently did the Freycinet Challenge, which is the two-day event with kayaking, biking and running and I went along as support crew. These are all things that can be a bit tricky – often just impossible – with hospital shiftwork.

Medical Observer/GPET Dr Allison Turnock

I grew up in Tasmania and attended medical school at the University of Tasmania, mostly in Hobart, but I did spend one year in the Rural Clinical School in Burnie. I also did placements in Tennant Creek and in Yuendumu, in northern Thailand. While I was in medical school, I couldn’t decide what I wanted to do, but General Practice was always something that appealed to me, because you get to know the patient and build relationships over time. I’m also interested in research and during medical school, I did some research that included a Cochrane review of Action Plans for Chronic Obstructive Pulmonary Disease (COPD). I did my basic term here at the Sorell Medical Centre and before that I did my hospital term at the Derwent Valley Medical Centre, plus a placement at the Aboriginal Medical Centre in Hobart.

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Registrar of t One of the things I hadn’t anticipated is how rewarding it can be when you get an opportunity to make a real difference to a patient’s life. I once convinced a man to go to the emergency department when he presented with atypical chest pain. He required surgery within a couple of days, and his wife was so pleased the problem had been correctly diagnosed, as they had just found out they were pregnant with their first child.

What are the main changes you’ve found since leaving the hospital system? I have to admit that I am glad to see the back of shift work and some of the hierarchical relationships in the hospitals. However, I do miss working with fellow trainees and I miss the camaraderie, which is not quite the same in General Practice, as you are in separate rooms most of the day. Overall, I am very pleased to be working independently of the hospital system.

What skills have you needed to learn or develop to become a better GP? The reason I’m currently doing a Diploma of Child Health through Westmead Hospital is partly because I still can’t decide where my interests lie. That’s why I continue to branch out doing different things – it’s what keeps me interested. Initially, I was approached to do the Registrar Liaison role and that really sparked my interest in teaching. So I asked if there was a position, which would allow me to do this and the regional training program actually created one. It’s a very supportive program and there’s lots of scope to do different things within it. I was recently awarded GPET Registrar of the Year, which was an unexpected honour.


the Year “I really love the diversity of the work with General Practice. You’re exposed to all the different facets of medicine and you don’t really know what will occur when you walk through the door. ”

Photography: Fluid Photography

Going Places – ISSUE #4

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Financial Health Check Brought to you by McMasters’

The financial ins and outs of buying a property. This is the second feature in our series – covering a few basics to help you with your finances and keep them healthy. This time we’re taking an initial look at the financial ins and outs of buying a property. The median home price in most capital cities is around $500,000 and – largely driven by surging population growth, a growing economy and rising incomes – the Reserve Bank expects this to rise to almost $1m by 2020. So, if you are intending to purchase a property, it makes sense to “jump on the wagon” and buy sooner rather than later. So, how can you do this? Let’s fast forward and assume you are being paid as a GP. Our advice to young GPs has always been to “buy as much home” as the bank (or other financial institutions) will lend you … as soon as possible.

Negative gearing One way of reducing the cost of a home is to have a tenant and let the taxman help you to pay off your home loan. This is known as negative gearing. Negative gearing is jargon for borrowing to buy an investment, where the expected assessable income is less than the expected deductible interest, with a resultant net deduction against the income earned from your salary (or other assessable income, as the case may be). Our apologies for this sounding mind-bogglingly complicated, but hopefully the example below will bring it to life and you’ll understand the principle. Dr Lucy, a young GP, found a $400,000 apartment in early 2009. It was not located where she really wanted to live, but it was a nice apartment – clean, secure, and well located with excellent capital gain prospects. It was very rentable and a great investment. Dr Lucy contacted us and we arranged for Lucy to borrow the purchase price – $400,000 at 6% interest – from a medical specialist lending group. That meant her monthly repayment on the loan was $2,000 a month. Lucy received the first homeowners’ grant and lived in the apartment for 6 months. She shared with a friend who paid her $235 a week. The Australian Taxation Office considers “board” in these circumstances to be an offset of non-deductible private costs, and not assessable income. This means Dr Lucy did not pay tax on this amount. It was the equivalent of earning about $20,000 a year in extra salary. Dr Lucy then decided to take a position in a regional hospital and rented her home to a tenant for $270 a week – that’s $14,000 a year. Obviously, it wasn’t enough to cover Lucy’s $24,000 home loan, but that’s where all our help, advice, experience and expertise falls into place!

Dr Lucy claimed the shortfall of $10,000 as a deduction in her tax return. As Lucy was earning about $100,000 a year, including overtime, this put her in the 38.5% marginal tax bracket and the rental loss generated a tax refund of $3,850 each year. She also claimed $5,000 building allowance and $5,000 depreciation each year (including her share of the elevator and other common plant and equipment in the apartment block). These two deductions generated a further tax refund of $3,850 each year. The result was that her total tax refund was $7,700, which substantially covered the $10,000 gap between the rent she received and the interest on her loan. She could easily cover the $2,300 shortfall! Dr Lucy has been paying off her home loan for almost two years and her apartment was indeed a great investment – now valued at $500,000. So she is off to a good start and is really pleased that she bought her apartment when she did. She will probably never live in her apartment again and will keep it as a long-term core investment. However, the big advantage is that she can easily borrow against it when she decides to buy her real home a few years down the track … and is well on her way to financial independence. She was lucky because her parents were prepared to guarantee the loan for her and she did not have to wait a couple of years while she saved for the deposit. Using a medical specialist lender made sense: they understand GPs’ income profiles and are aware that GPs are excellent risks for banks – they almost never default on loans. Dr Lucy still did it all herself (with a little help from us) and has the satisfaction of knowing this. We actually have another GP who owns a five bedroom house and receives $200 a week from each of four housemates. That’s $800 a week cash – the equivalent of over $67,500 a year in additional salary. Sharing with four others is a bit extreme for a 35 year old … but he is paying his home loan off at an incredibly fast rate!

And finally, a word on banks and bankers We are often asked “which bank is best” and our answer is usually that it’s not so much which bank, but the banker within that bank that makes the difference. Some bankers are marvellous, understand doctors and have loads of experience dealing with doctors, while others are exactly the opposite! You can be friendly with your bank manager, but you need to bear in mind that your bank manager is not your friend. You sit on opposite sides of the table and your interests can be opposite to each other – his aim is to maximise profit for the bank and yours is to pay as little as possible. In the next article, we’ll continue with our look at buying a property.

About McMasters’ McMasters’ is a multi-disciplinary Practice with offices Australia-wide, specialising in doctors, dentists and other professionals. A complimentary initial meeting is offered to all medical Registrars. For more details, call 03 9583 6533 or email berivan@mcmasters.com.au or visit www.mcmasters.com.au 40


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is bad news? • by our own clinical knowledge and insight. supply a supplementary statement to the engaging party • What by our own clinical knowledge and insight. • Moving backwards in cyclic loops and repeating previous 4. bad news giveConfirm evidence.or break the • Persistent depression – this is the most common form of • Moving backwards in cyclic loops and repeating previous expert to • an may be or required to confer with other expert witnesses news’ carer's can be determined the:may differ from our – e.g. anger denial. A‘Bad patient’s perspective of badby news emotions – e.g. reverting to anger or denial. A patient’s orexpert carer's opinion perspective newsemotions may differ fromreverting our sticking. If you areorapproached to provide an onofa bad forensic and must exercise his or her independent professional judgement. • Avoid medical jargon. own. Theiryou perspective may affected own. Theirby: perspective maytobeconsider affected by: • Cycling is a form of avoidance – going backwards is a strategy may find thebefollowing points helpful before • matter patient’s or carer’s perception, or • Cycling is a form of avoidance – going backwards is a strategy required to be available on stand-by during the hearing and called to

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• by our own clinical knowledge and insight. The patient’s behavioural responses will likely resemble one of the Themedical patient’s behavioural responses will likely A good report is well structured andresemble set outone of the • Mexpert oving backwards in cyclic loops and repeating previous Attributes of an expert medical witness • Show empathy. 3 : three types of sequentially: behaviour associated withofgrief and loss three types behaviour associated with grief and loss3: • the impact of the news on their lifestyle • the impact of the news on their lifestyle emotions – e.g. reverting to anger or denial. AMinimum patient’sattributes or carer'sofperspective of bad news may differ from our an expert medical witness that a party will • the impact of the news on their career.• Numbness – mechanical functioning/social • • Encourage the patient to ask questions. the impact of the news on their career. • Numbness – mechanical functioning/social insulation insulation • acknowledgement of the Code of Conduct own. perspective may be affected by: lookTheir for include: • Cycling is a form of avoidance – going backwards is a strategy • Disorganisation – intensely painful feelings of loss Whereas perception of bad news by:– intensely painful • likely Disorganisation feelings of loss Whereas our perception badprofessional news willour likely be affected by:in • qualifications and inevitable experience of thefor expert • individual fears relevant academicofand qualifications thewill area in be affected to delay the need acceptance. • • Allow the patient to express emotions. • limited clinical understanding • limited clinical understanding

• into Reorganisation –social re-entry into more normal social life. which the opinion is sought • clinical knowledge and insight • Reorganisation morewas normal life. • clinical knowledge and insight • the– re-entry and forms the basis of the material which provided sk the patient what they are thinking and how they are • • Alimited clinical understanding The patient’s behavioural responses will likely resemble one of the • the diagnosis relevant clinical experience in the area at the time the medical • • the diagnosis report

feeling.

the impact of the news on their lifestyle issue in dispute arose • the prognosis • • the prognosis • the treatment • the treatment the medical issue in dispute. specialised knowledge of • • • Anticipate denial and anger. the impact of the news on their career. • empathy for the patient. • empathy for the patient.

Steps in breaking bad news Steps in breaking bad news three types of behaviour associated with grief and loss3: • detailed reasons for each opinion given 1. Prepare for the discussion1. Prepare for the discussion

• Numbness – mechanical functioning/social insulation

• where particular question/s or issue/s fall outside the expert’s • Consider which other practitioners, if any, should be involved in • Consider which other practitioners, if any, should be involved in

the discussion. • Patients may often forget or not understand the bad news, so The court room is of not place the discussion. expertise • Disorganisation – intensely painful feelings of loss Whereas our perception badanews willfor likely befaintaffectedtheby: Patient reactions to bad news hearted strategies should be used • Sopinion. elect a meeting space that provides both auditory and visual Patient reactions to bad newsto help them understand. • Select a meeting space that provides both auditory and visual • the expert’s Reorganisation • • A clinical knowledge and insight privacy. – re-entry into more normal social life. Perhapshave the most vital aspect of delivering privacy. bad news is our • ability medical will ideally thenews ability to communicate Perhaps the mostexpert vital aspect of delivering bad is our ability to anticipate the patient’s reaction. While each patient will Other considerations complex issues to areaction. layoptions audience. Remember – judges or the jury Present treatment • Set a mutually agreed to time; do not inconvenience the • 5.anticipate the diagnosis to the patient’s While each patient will

• Set a mutually agreed to time; do not inconvenience the Steps in patient. breaking bad news react differently, there are common emotional and behavioural unlikelythere to be their and experience in understanding • If you provide an expert report you are entitled to be reactare differently, areclinicians common and emotional behavioural patient. • • the prognosis responses that we might encounter. I deally options should be discussed over more than one medical evidence will vary. They will have difficulty accepting a responses that we might encounter. remunerated. Protect your professional fees and livelihood – • Allow ample time so as not to appear rushed or impatient. 1. Prepare for the discussion • Allow ample time so as not to appear rushed or impatient. consultation to allow forunderstand greater understanding by the patient. proposition if they cannot it. • the treatment The 'grief cycle' agree your fees upfront and ensure you get paid as an expert The 'grief cycle' • Consider if the patient should have friends, family and/or an • Consider which other practitioners, if any, should be involved in the adversarial context the courtroom, a medical • Consider if the patient should have friends, family and/or an Afterofreceiving bad news, the patient’sexpert emotional responsewitness. • • • In empathy for the patient. U se simple language and avoid using medical jargon. interpreter present. Afterisreceiving news, patient’s emotional response likely tobad need thetheskills support their expert ininterpreter willto typically resemble one of theopinion following five phasespresent. of thethe discussion. • Do not breach privacy legislation – ensure you have the will typically resemble one of the following • Collate contact details and information about relevant support 2 five phases of the circumstances. cycle’ and move through the cycle • until the final point of • challenging Ensure this is a two-way conversation where you present the Patient reactions to‘grief bad news Collate contact details and information about relevant support move through the cycle until the final point of ‘grief cycle’2 and groups. appropriate authority to be in possession of a person’s health • Select a meeting space that provides both auditory and visual acceptance: treatment options, andexpert the patient considers, discussesgroups. and acceptance: Cardinal ‘sins’ of aspect an medical witness information. privacy.2. Open the discussion Perhaps the most vital of delivering bad news is our ability 1. Denial: ‘It’s not true. I want more tests, and a second opinion.’ asks questions about each option. 2. Open the discussion Inadequate preparation i.e. not reviewing records, their reports 1.to•Denial: ‘It’s not true. I want more tests, and a second opinion.’ and abide by the relevant rules and requirements for • Understand anticipate the patient’s each patient will earlier?’ • Set a mutually agreed to time; do not inconvenience the • W e should always be sure we are speaking with the correct 2. reaction. Anger: ‘WhyWhile me? Why wasn’t this detected or the brief prior to the hearing. • W e should always be sure we are speaking with the correct • P rovide written material with diagrams to facilitate the 2. Anger: ‘Why me? Why wasn’t this detected earlier?’ writing an expert report in admissible form. patient. react differently, there are and– behavioural 3. common Bargaining: emotional perhaps with you ‘What if I stop smoking now?’ patient. patient. •Bargaining: Ignorance of thewith latest research in the area – this can be most 3. perhaps you – ‘What if I stop smoking now?’ patient’s understanding. • Ithe t is important to introduce ourselves if the patient Or perhaps with God – prayer, pilgrimages… responsibilities imposed under the experts’ • Understand responses that we might encounter. when counsel is bettergrieving briefedrealisation than theofexpert It is important to introduce ourselves if the patient Orembarrassing perhaps with God – prayer, relationship is not already well established – particularly if 4. pilgrimages… Depression: the• inevitable • Allow ample time so as not to appear rushed or impatient. Code of Conduct. relationship is not already well established particularly if we have not met before. under cross-examination! there are family–or friends who 4. grieving realisationconsequences. of the inevitable The 'grief cycle' 6.Depression: Close the discussion there are family or friends who we have not met before. consequences. • C onsider if the patient should have friends, family and/or an 5. Acceptance: emotional relaxation, and objectivity. pliability or rigidity under pressure. • Introduce the purpose of the discussion. • • Undue Encourage the patient to contact you directly with further After receiving bad news, the patient’s emotional response 5. emotional relaxation, and objectivity. interpreter present. • Introduce the purpose of the discussion. Please contact Avant for more information •Acceptance: Observable bias. © Avant Mutual Group Limited Disclaimer will questions. typically resemble one of the following five phases of the © •Avant Mutual Group Limited on• 1800 128 268 or visit www.avant.org.au and lack of assertiveness – remember if you are not Collate contact details and information about relevant support • Indecisiveness Provide appropriate contact details. ‘grief cycle’2 and move through the cycle until the final point of This is general information relating to legal and/or clinical issues within Australia. prepared to support and stand up for your opinion, who else will? Itgroups. is not intended to be legal advice, nor and should not be considered as a acceptance: • Make follow up appointment(s). substitute for obtaining personal and specific legal and/or other professional The ‘Code of Conduct’ 2.advice. Open thewe discussion Whilst endeavour to ensure that professional documents are as current 1.• Denial: ‘It’s not true. I want more tests, and a second opinion.’ Offer other support services such as a support group. Most states and territories in Australia require that for an expert as possible at the time of their preparation, we take no responsibility for matters • We should always be sure we are speaking with the correct 2.report Anger: me?to Why wasn’t thisasdetected or ‘Why testimony be admissible evidence,earlier?’ the expert must arising from changed circumstances or information or material which may have For further information on Avant’s Clinical Risk Management patient. agree to be bound by thewith experts’ Code of ifConduct. The Code become available subsequently. Avant Mutual Group Limited and its subsidiaries 3.resources Bargaining: perhaps you – ‘What I stop smoking now?’ www.avant.org.au email yet will usually Disclaimer: The information in this publication is general information relating to legal and/or clinical of Conductvisit varies between states andor territories will not be liable for any loss or damage, however, caused (including through issues Australia (unless otherwise stated). It is not intended to be legal advice and should not be • Iwithin t is important to introduce ourselves if the patient Or perhaps with God – prayer, pilgrimages… clinical.risk@avant.org.au. considered as a substitute for obtaining personal legal or other professional advice or proper clinical negligence) that may be directly or indirectly suffered by you or anyone else in include the following core elements: decision-making having regard to the already particular circumstances of the situation.–While we endeavour if to relationship is not well provided established particularly 4. Depression: grieving realisation of the inevitable connection with use of information in this forum. ensure that documents are the as current as possible at the time of preparation, we take no responsibility for

• the expert has a paramount duty to the Court and must assist consequences. the Court impartially

5.• the Acceptance: emotional expert is not to be anrelaxation, advocate forand oneobjectivity. or another party

there are family or friends who we have not met before.

matters arising from changed circumstances or information or material which may have become available subsequent. 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 or indirectly suffered by you or anyone else in connection with the use of information provided in this forum

• Introduce the purpose of the discussion.

© Avant Mutual Group Limited © Avant Mutual Group Limited

Going Places – ISSUE #4

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Dr LINA NIDO

Cruising into General Practice Dr Lina Nido was always fascinated by cruise ships and that’s how she found herself a position as a ship’s doctor, cruising around the Caribbean. It gave her a huge amount of experience and taught her how to cope with all types of medical situations.

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The hospital doctors said my case management was excellent Since 2008, I’ve worked two days a week as the GP Liaison – “textbook”. Probably because that’s exactly what it was – I admit Officer at the Royal Victorian Eye and Ear Hospital. My role I had a textbook handy and followed that! involves improving the interface and communications between With two doctors on a cruise ship, you share the on-call the hospital and primary caregivers – particularly GPs – with the commitments and work every second day – plus there are aim of improving quality patient outcomes. Before my daughter was born a year ago, I also did two clinical management commitments, attending Captain’s meetings, and days at a General Practice in West Brunswick, a Melbourne various social events where all the officers are presented formally. Initially it’s good fun, but it can wear a bit thin after a while! suburb (actually the same one where I had completed my GP Cruising in the Caribbean meant that if we had training), but I’ve cut back to just one role for a day off when the ship was in port, I could relax a few years as I’m expecting a second baby soon. “From my first day as on a beach somewhere. The second contract I did involved a brand new ship that was cruising I went into medicine because when I was a GP Registrar I finally the Mediterranean, around Italy and Croatia plus in high school, I was interested in becoming a psychiatrist. But once I started my course felt like, “this is why I Greece and Turkey, so I saw some great places. Some passengers really didn’t want to at Melbourne University I found the rest of became a doctor!” disembark for medical reasons in Europe, so medicine really fascinating and I enjoyed it. we managed cases like pneumonia or even a Then, after my training, I was working at minor stroke on board. Ideally, I wanted them in St Vincent’s Hospital in Melbourne – I was tossing up between dermatology, palliative care and General a hospital, wherever we docked – but because they would be in a hospital where nobody speaks the language, we agreed to keep Practice. I just couldn’t decide which way to go . them on board. Eventually I realised that General Practice was my ideal choice We also provided medical care for about a thousand crew – as it would give me the opportunity to focus on a number of different things. I stayed at St Vincent’s for three years and members on board, who were from all over the world. After the cruise contracts, I returned to the General Practice in although I hadn’t yet enrolled to train with the GP College, I used my third year in the hospital as a year that was geared towards West Brunswick part-time and also took on some teaching work. That’s what’s so great about General Practice – I love being able to General Practice, so that was recognised later as counting combine different kinds of work. The combination of teaching and towards my GP training. GP Liaison have helped to me reflect on what I did clinically and I really loved working in General Practice. I did my rural term have inspired me to do better and enjoy it more. as a six-month placement at Point Lonsdale, on the western My husband also works part-time, so working two days a peninsula of Port Phillip Bay. They provided a house in Queenscliff, week gives me a great work/life balance. However, I do plan to so it was quite lovely. From my first day as a GP Registrar I finally felt like, “this is go back to clinical Practice part-time in the near future as I really why I became a doctor!” I felt I could make a difference to people’s miss it and I don’t want to lose my skills! lives and I loved building a whole picture of my patients and knowing their whole families. Up until that point, I felt that working in hospitals was just a lot of hard work and I didn’t really feel like it was “me” until I got into General Practice. After my term at Point Lonsdale, I took a year off to travel, backpacking around Europe and the US, then came back and completed my GP training. I was always really fascinated by cruise ships, so when I saw an ad in a GP magazine that Carnival Cruise Lines were coming to do some interviews in Australia, looking for ships’ doctors, I applied and was accepted – so I worked on one of their cruise ships. The first contract was for six months. It was cruising-based, with half the time spent in the Caribbean – then we relocated to do cruises from New York to Nova Scotia in Canada. That’s where I met my husband, Brett, who is also Australian; he was working in the onboard Casino. Being a cruise doctor is a big responsibility and fortunately on both my contracts I was on a ship that was big enough to require two doctors. You’re completely on your own when you’re out at sea, but I quickly realised that I was okay. I could handle emergencies and cope with pressures of the work. The nursing staff were all very experienced, with ICU or coronary care or emergency backgrounds, plus the support from the land staff was very good. One case I had was a pregnant woman with pre-eclampsia, which was well outside my area of expertise. I was supported by an obstetrician on the phone and we finally disembarked the patient about 20 hours later (which was the earliest we could get her somewhere).

Photography: Lachlan Moore

Going Places – ISSUE #4

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Blood

Glorious Blood After William Harvey demonstrated his theory of the circulation of blood in 1620, scientists struggled for nearly 300 years to perfect the transfusion of blood to humans. Today, in Australia, the Red Cross collects over 1 million blood donations each year. Professor Pete Moore, author of ‘Blood and Justice’, takes us on a journey back to the origins of blood transfusion.

Fifteen years ago I taught physiology. One of the more memorable practical classes involved a couple of buckets of ox blood. Laced with heparin, it was subjected to a series of ‘experiments’ by often pale-faced undergraduates. But they were great experiments. Blood gave us an opportunity to play with a living organ … a fluid that displayed many different properties – some simple and some complex. While some students were squeamish, few attributed this to a belief that they were handling the very life of the slaughtered animal. Wind back a few centuries and the situation would have been very different … As first established in pre-Christian Greece, life was seen by some to contain blood, by others to be the very stuff of life itself. There was a simple observation that proved the case – let it out and the person’s life left their body. This was so well established that trying to bleed a person became one of the main criteria for determining death. Viz: cut into a vessel and if no blood comes out, there is no life left inside.



The Circulation of Blood

 The seventeenth century saw the first glimpse of a new concept of blood. Arguably it started with William Harvey’s 1620s realisation that blood must circulate around the body. He made a few rough and ready calculations of the blood flow through the heart and realised that this was too great to be sustained by a one-way passage from the heart to the extremities. Looking for inspiration, he turned to Aristotle who had come to similar conclusions from his local river. Aristotle reasoned that the water must be part of some great cyclic activity, otherwise such was the flow that the mountains would soon run out of their supply. Like the presumed water cycle, Harvey reasoned that blood flowed to the extremities in the arteries, and in some way ‘condensed’ into the veins before returning to the heart. He was also convinced that a circular system was in operation as he saw this sort of motion in the stars of the heavens. The God who created had obviously ordained that circles were good. His reasoning may have been flawed, but the conclusion was correct. The 1650s then saw anatomist and astronomer Christopher Wren inject solutions into this circulating stream of fluid. Maybe, he surmised, this would be a good way of distributing medication

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through the body. His one attempt in a human, involved borrowing a friend’s servant and injecting opium into him. The man slumped to the floor. Wren was disappointed, as he felt he had only just started the experiment – he was fairly sure the wretched servant was feigning his faint in order to go home early. Robert Boyle and colleagues then took up the trail, investigating the physical properties of blood and searched for any medical benefits that could come from manipulating it.


Jean-Baptiste Denis

 Into this steady progress of early scientific endeavour stepped a 26 year old Frenchman, Jean-Baptiste Denis. He was keen to make a name for himself and thought that pioneering a cure-all treatment would be a good way to achieve it. Transfusing blood seemed a pretty good possibility. His theory was confused, but incorporated the idea that, if a person was unwell, then their life-blood was damaged. Draining this diseased fluid and replacing it with blood from some healthy donor should restore health. He borrowed some ideas from the English workers, made a few attempts at transfusing blood between animals and then launched into medical applications. On 15th June 1667, Denis connected a sick teenage boy to a lamb. While Denis was thrilled that the boy made a rapid recovery to good health, this was probably due to the fact that the boy’s physicians abandoned him and had not performed the standard treatment of blood letting. All the same, Denis was convinced that the technique was a success and transfused sheep’s blood into a paid volunteer – again with apparent success. However, his next two patients died, and Denis found himself in court accused of murder.
 Not having to go through a 21st century ethical approval system may have meant that he could stride ahead rapidly, but when things went wrong, it left him distinctly exposed. It would be 250 years until science caught up and anyone made a concerted effort to transfuse blood again. We may have moved away from believing in the mystical properties of blood, but in one aspect Denis was right – transfusing it can indeed support sick and injured people and, as such, restore their health.  Pete Moore’s ‘Blood and Justice’ is published by John Wiley. ISBN 0470848421. This article first appeared in JuniorDr.


BOOK Review

The Life Saving Adventures of a Doctor at Sea

Dr Fairytale General Practitioner to the Stars

He may believe that an elephant can fly but I believe that he may be suffering from a number of different conditions.

Dr Ben Macfarlan

Dr Ben Macfarlane

Dumbo’s ears There are many causes of “abnormal ear shapes” – at least 135 causes ranging from 2p21 deletion syndrome to Otospondylomegaepiphyseal dysplasia. In particular, there are numerous rare eponymous syndromes: Galloway syndrome, De Barsy Syndrome (A rare inherited disorder characterised by loose, inelastic skin, involuntary limb movements and other abnormalities) and Say-Barber-Miller syndrome. It would take too long to discount all of these so I’ll take my conclusion from the WikiQuestion “Why is Dumbo’s ears are big?” (sic) – The answer is that he was born that way. Not everyone is perfect. Temporal lobe aneurysm At various points in the documented

life of Dumbo, he begins to hear others singing rather than speaking to him. Although that could be a purely escapist fantasy to avoid confronting his own mundane dilemmas, it would be remiss to not think about the possibility of these being auditory hallucinations (defined as sensory stimuli in the absence of external sensory stimuli). These events are rare, but documented, resulting in all voices being heard as song – or, maybe for Dumbo, it’s as simple as hearing crows “singing” songs about you. A CT should be requested as a matter of course although it would be a challenge to accommodate him into a scanner.


Bon Voyage! Embark on a journey cruising 35,000 nautical miles, through over a dozen countries and thirty towns, cities and islands. On his maiden voyage as a cruise ship doctor, Dr Ben MacFarlane soon realises that the “floating hotel” he expected is more of a “floating madhouse”. Throughout his travels on the high seas, Dr Ben must manage traumatic amputations, anaphylaxis, delirium tremens, liver cirrhosis, ectopic pregnancy, third-degree sunburn, explosive diarrhoea and multiple emergency evacuations, to name a few. He learns all too quickly that a cruise ship doctor must wear many ‘hats’, including A&E specialist, surgeon, counsellor, health & safety officer, dietician, physiotherapist, entertainer and friend. The myth that cruises are for “newly weds and nearly deads” is dispelled in reading this book. You can’t help but warm to the many weird and wonderful characters, all from diverse cultural and social backgrounds. This unforgettable voyage teaches that through compassion and camaraderie, challenges can be overcome. I recommend this book to any doctor with plenty of stamina for both travel and hard work. Perhaps after reading Cruise Ship S.O.S., you, too, will want to embrace the action-packed life of a cruise ship doctor…bon voyage! Reviewed by Dr Katya Groeneveld, GP Ambassador at Gold Coast Hospital, QLD.

Fragile X Syndrome The picture I get of Dumbo’s life is one of psychogenic muteness, repetitive behaviour (the same jump into the bucket of pie filling every night), social anxiety, peer teasing and difficulty with physical feats – most recently, the elephant pyramid disaster – resulting from poor muscle tone. This, coupled with his appearance, suggests the possibility of Fragile X syndrome – a genetic disorder caused by mutation of the FMR1 gene on the X chromosome predominantly in males. It would also explain why Dumbo’s mother was so secretive about his birth, using a stork delivery service rather than a hospital to avoid questions, which may have been raised regarding her family history. Vertigo A belief that you can fly is more often than not, incorrect. Even given his enlarged ears, it is near impossible that Dumbo can lift his own body weight off the ground. Add to this the physiological impracticality of “flapping” one’s ears and the result is that we must assume that Dumbo cannot actually fly. We are therefore left with an assumption that Dumbo experiences what could be misinterpreted as “flight” … the sensation of swaying while the body is actually stationary with respect to the surroundings. Inner ear problems are often the cause of vertigo, as the act to affect the balance mechanisms of the vestibular system. Given Dumbo’s aforementioned distended auricular protuberance.



Schizophrenia All of these symptoms could be brought together in a single diagnosis: schizophrenia. Dumbo reports auditory hallucinations, visual hallucinations and delusional beliefs about flying and his famed destiny. There is a suggested family history of odd behaviour: when Dumbo’s mother assaulted those teasing Dumbo, she is judged to be “mad” by the other circus performers (and locked away). There is a strong genetic component to schizophrenia making the diagnosis more likely. A trial of antipsychotics may be in order – I would suggest Seroquelephant. By Dr Gil Myers. This article first appeared in JuniorDr.

Going Places – ISSUE #4

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Who is GPRA and what do we do? If you don’t know who GPRA is, and what we do, we hope you might be curious …. so, we invite you to find out more by reading this short article!

When you were a student you may have come across GPSN – the General Practice Student Network, run through GPRA within medical universities, promoting General Practice as a career choice. Perhaps you were aware of the GPSN Schwartz First Wave Scholarship Program that provides an opportunity to experience General Practice as a student? And now you’re a doctor in a hospital, you’ll hopefully be aware of GPRA through this Going Places magazine you are reading and our range of publications – possibly even through the increasing visibility of our fast-developing Going Places Network, featuring GP Ambassadors who are helping to raise the profile of General Practice through educational, social and networking events.

Now let’s move on to who we are. GPRA is an organisation run for Registrars by Registrars, as the peak body that provides professional representation to all stakeholders involved in General Practice education and policy issues. This group includes the Federal Government, Australian General Practice Training and the RTPs – the General Practice training providers. There are additional groups involved, including AMA, RACGP, RDAA and ACRRM, who you may have come across. We’re also the industrial body for GP Registrars – that means we negotiate the ‘National Minimum Terms & Conditions for Basic and Advanced GP Terms’ with the National GP Supervisors Association (NGPSA), which govern the minimum conditions of employment for Registrars.

And now let’s explain what we do. At GPRA we present and promote General Practice as the preferred choice of medical specialty. In particular, we want to demystify the myths and correct the perceptions – or misconceptions – about General Practice by providing information and tools that present General Practice as an attractive, fulfilling career choice. We are the voice for the next generation of GPs. By providing essential feedback on Registrar issues to all the relevant stakeholders, we play an important role in maintaining educational relevance and standards – and providing a cohesive vision for the future of General Practice. Through our commitment to ensure excellence in General Practice education and training, we support the Australian General Practice Training Program by providing educational and professional tools and resources, including a website, publications, a number of events and various other facilities that help to optimise the Registrars’ training experience.

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One of our major initiatives for 2011 is to develop and enhance the Going Places Network in hospitals throughout Australia. This new prevocational doctors’ network is dedicated to helping your career to go places in General Practice, while you complete your hospital training. If you noticed that General Practice seems to fall off the radar as soon as you started you hospital training, the Going Places Network will bring the GP experience to you. Please take a look at page 4.

We welcome your involvement! We hope this has gone some way to explain who we are and what we do – and you’ll now be more aware of GPRA! We’re here to support GPs of the future from the very start of their career path, as students, through the hospital experience and right through to working as qualified GPs. If you are considering General Practice, at GPRA we’re with you every step of the way!

Why not join GPRA now? Take a look at the appropriate website below and then join by completing the online membership form. We look forward to hearing from you! Medical Students www.gpsn.org.au Prevocational Doctors www.gpaustralia.org.au GP Registrars www.gpra.org.au


Where to from here? So, you’ve read through Going Places and now you are curious about General Practice as a career. Or maybe you’ve already decided that being a ‘General Specialist’ is your vocation! What’s next? Here are four ways to start Going Places in your career as a GP:

OPTIONS: 1 Join the Going Places Network Become part of the Going Places Network at your hospital. It’s a fun way to network with others who have an interest in General Practice, whilst developing your professional knowledge and credentials! See below for more information. Looking for the Going Places Network at your hospital? Visit: www.gpaustralia.com.au/goingplaces to find out more and join on line.

Email: goingplaces@gpra.org.au with ‘Going Places Network’ in the subject line. Tell us what hospital you are based at – then we’ll hook you up with your local network!

2 Talk to your GP Ambassador Our GP Ambassadors are junior doctors who have a real passion and enthusiasm for General Practice. They’ll be able to answer all your questions about General Practice. If there are any questions they can’t answer, they’ll find the answers for you!

Visit www.gpaustralia.com.au/goingplaces to find out who’s the GP Ambassador in your hospital or area – also look out for posters on notice boards in your hospital.

3 Request an Information Pack Request an information pack and we’ll send you a copy of GP Compass, the comprehensive guide to becoming a GP. We’ll also include a copy of the AGPT (Australian General Practice Training) Handbook, which provides full details of the AGPT program and all the training providers.

Email: goingplaces@gpra.org.au with ‘Information Pack’ in the subject line – don’t forget to include your contact details, including your mailing address, in the email.

4 Visit www.gpaustralia.org.au To find out how General Practice training works, visit the website! It will guide you through who is involved in providing you with the information and contact details to help you plan your path into General Practice.

Going Places – ISSUE #4

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Why is Avant the smart choice for doctors in training? • • • • • •

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*An annual base rate of $100 plus government charges and ROCS Levy of $21.28 annually for NSW/QLD, $27.05 for VIC/ACT/WA/NT, $24.74 for TAS and $37.50 for SA. Rates current as at 1 May 2010 and are subject to change. **Conditions apply for our Getting Started in Private Practice package. Important Notice: Professional indemnity insurance products available from Avant Mutual Group Limited ABN 58 123 154 898 (Avant) are issued by Avant Insurance Limited, ABN 82 003 707 471, AFSL 238 765 (Avant Insurance). Life risk insurance products available from Avant Mutual Group Limited ABN 58 123 154 898 are issued by Hannover Life Re of Australasia Ltd ABN 37 062 395 484 and are distributed by Avant Insurance Limited, ABN 82 003 707 471, AFSL 238 765. The information provided here is general advice only. You should consider the appropriateness of the advice having regard to your objectives, financial situation and needs before deciding to purchase or continuing to hold a policy with us. Please read and consider the PDS at avant.org.au or by contacting us on 1800 128 268.


Going Places Magazine - Issue 4