Going Places #3 by Moksha Web

ISSUE #3 – FREE Taking a fresh look at General Practice

More real life GPs who are Going Places TechTalk – digital stethoscopes & medical apps for iPhones

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EMERGENCIES AT 30,000ft What’s your diagnosis? Financial Health Check, Dr Fairytale and lots more

Dr Lachlan McIver

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Your GP career starts here

Dr Aileen Traves GP REGISTRAR

Find out about the exciting opportunities a career in general practice can offer you! The Australian General Practice Training (AGPT) program offers you a pathway to gain vocational recognition under Medicare Australia. The AGPT program is delivered by regional training providers (RTPs) who will work with you to help you become the best GP you can be. To find out why GP training is the envy of other specialities and about the fantastic training options your local RTP has to offer visit the AGPT website.

Image courtesy of Tropical Medical Training

www.agpt.com.au

Taking a fresh look at General Practice

IN THIS EDITION:

Greetings fellow future GPs Welcome again to another jam-packed edition of Going Places, proudly brought to you by General Practice Registrars Australia. This is now the third edition of this exciting magazine designed to give Junior Doctors an insight into the amazing diversity that is General Practice. Whether it is Dr Lachlan McIver who provides essential services to the islands of the Torres Strait by helicopter, Dr Ameeta Patel of the Royal Flying Doctors’ Rural Women’s GP Service by plane, or Lieutenant Commander Dr Alison Thomas of the Royal Australian Navy by ship, these dedicated GPs are certainly ‘Going Places’ by a variety of means. And even though Dr Andrew Keller may not be travelling himself, through his GP clinic at the Sydney Airport, his work ensures that others can. In addition to these stories, there are the profiles of two well-respected and committed GPs, Dr Carmel O’Toole and Dr Peter Stevens, who are an inspiration to all of us. On a personal note, I was lucky enough to have been under the guidance of Dr Stevens whilst undertaking my recent Prevocational General Practice Placement Program (PGPPP) experience – I would certainly recommend a PGPPP placement to all Junior Doctors. Additionally, this edition of Going Places contains practical information about dealing with Medical Emergencies whilst on an aeroplane, reviews of the best medical apps available for your iPhone and a look at digital stethoscopes, as well as tips on how to make your car tax-deductible. And just when you thought we couldn’t possibly fit anything more into this edition, there is Dr Fairytale – GP to the Stars, a Systematic Review on Umbilical Lint plus the third instalment of Confessions of a 21st century intern … and so much more. I sincerely hope you enjoy reading this magazine and you’ll be able to see how our stories about GPs further demonstrate that General Practice is whatever you want it to be. Be sure to look out for the activities of the Going Places Network in your hospital. Yours in General Practice

Dr Lana Prout Intern – Latrobe Regional Hospital, Victoria GPRA Board Member (Prevocational Representative)

Going Places! If you have a t We welcome your feedback on us an email and tell us wha few spare moments, please drop you’d like to read about and t wha you think of our magazine, 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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Dr Lachlan McIver The island-hopping GP Dr Peter Stevens The Father of Rural General Practice Dr Carmel O’Toole An inspiration to younger GPs Dr Alison Thomas A GP with military precision Dr Andrew Keller The airport GP Dr Sarah Meertens The GP Educator Dr Brendon Fitzgerald PGPPP – A great experience Dr Ameeta Patel The GP with a combination of jobs Dr Jonathan Morling Life as a GP in the Kimberley Dr Sharnti Caulley A passion for Travel Medicine Dr Angela Plunkett The sexual health and wellbeing GP Dr Amanda Torkington A GP who loves variety Dr Jane Wadsley Combining General Practice with Occupational Health

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 3001. Phone: 1300 131 198. www.gpra.org.au

COVER STORY

It was Lachie McIver’s first time out on Boigu Island when he spoke to Going Places, though he’s been doing primary health care clinics on various islands in the Torres Strait from his Thursday Island base for over a year now. >

DR LACHLAN McIVER

The island-hopping GP

Going Places – ISSUE #3

DR LACHLAN McIVER

Every island is a bit different – the way the clinics run and the problems that the patients have … but it’s always interesting and productive. ike quite a few islands, Boigu isn’t large enough for a runway, so Dr McIver’s clinic visits are done by chopper. “It’s a pretty good commute, roaring along at 500 feet over these beautiful little equatorial islands.” Small planes and helicopters are the main mode of transport between the islands – and because Lachie has skills in anaesthetics, he’s occasionally required to do retrievals for critically ill and injured patients. Part of the orientation training before he started on Thursday Island included how to escape from an underwater helicopter, he adds. But it’s not all island-hopping; tomorrow, he’ll be back at Thursday Island Base Hospital to do the anaesthetics for an orthopaedic surgery list. Lachie grew up in far north Queensland, on a small beef cattle property outside the Atherton Tablelands and says that because his mum was a midwife, he was familiar with some aspects of medicine.

He was offered a full academic scholarship at Monash, and went to Melbourne to study medicine. He also received a John Flynn scholarship and went to Halls Creek in the Kimberley region in Western Australia for several years running. At university, Lachie had been involved in the Rural Health Club from an early stage, and had an early taste for indigenous health. After a couple of rural placements in far north Queensland and final year electives with infectious diseases in Darwin, he realised that he really didn’t want to stay in the metropolitan hospital system. “I spent six months in the Kimberley and in Alice Springs doing public health and emergency medicine, trying to decide which of those two I was going to pursue for a career.” His final decision, though, involved a bit of everything. “I realised what I most enjoyed was working in the rural hospital context but considering the population health aspects – that takes in the primary health care, the chronic disease management as well as all the acute care and infectious diseases and tropical stuff that I had always enjoyed.”

COVER STORY For Lachie, training as a rural generalist with the Australian College of Rural and Remote Medicine ticked all the boxes. “I could combine all the things that I was interested in – emergency medicine, public health, indigenous health, chronic disease management and tropical medicine in the one vocation, with the outcome being registration as a GP.” “As a rural generalist, I don’t do much in the way of the office-based or business side of General Practice – there’s a lot more emergency, ward work and either anaesthetics, obstetrics or surgery than most GPs. Nevertheless, a significant part of our training is still chronic disease management and primary health care.” There’s no such thing as a typical “Day in the Life of Dr McIver” on Thursday Island, he says, but these are the events of a recent day that illustrate the diversity he encounters. He was rostered on emergency for the day. It was a busy morning with sick kids, some orthopaedic patients and a hip fracture to sort out, plus a patient with a stomach abscess that had turned septic had to be flown by the Royal Flying Doctor Service (RFDS) to Cairns for emergency surgery. Then a woman came in with a complete heart block – her pulse was 30. “I had to try and increase her heart rate with various mechanical means, then I called the RFDS plane and said, ‘Stop! Don’t go anywhere – we’ve got another patient for you!’. She had to go to Cairns urgently for a pacemaker insertion,” Lachie says. However, the RFDS plane was a nurse-only flight, so he flew down with the two critically ill patients and had them admitted at Cairns Hospital just after 5pm. “I guess that’s not really a typical day, but it’s one where I’ve got to the end and thought, yes, this is why I do this job. I’ve since seen both patients … they’re back here and doing just fine.” In his current position, there’s a lot of overlap between clinical and hospital work, and with the position’s salary funded by the State health system, that’s not difficult to manage. Other rural positions often involve employment by indigenous community-controlled health organisations. The work is hard and the hours are long – more like that of a Hospital Registrar than a GP Registrar – and he admits that most doctors are proceduralists, on-call for emergencies and for other skills – usually anaesthetics or obstetrics. “It’s not everyone’s cup of tea, but for those of us that do it, we think it’s the country’s best kept secret. We live in paradise and work with some very interesting communities that have health problems shared more by developing world communities than by other Australians. We have a wonderful lifestyle where we live in the islands, muck around in boats and go water skiing and fishing and camping on the weekends. It’s great.”

Photography: Kenny Bedford

Going Places – ISSUE #3

Awarded

DR PETER STEVENS

The Father of Rural General Practice

Dr Peter Stevens was awarded an OAM in last year’s Queens Birthday Honours in recognition of his decades of work in rural health education and his dedication to ensuring the survival of critical services like small-town hospitals. He’s not usually one for red carpets and awards – Dr Stevens has been a rural GP for most of his life. For the last twenty years, he has run the Medical Centre in Heyfield, Gippsland, located a couple of hundred kilometres from Melbourne at the foot of the Great Dividing Range. Dr Stevens has been a GP Supervisor in the General Practice Training Program for more than twenty years and in the late 1990s, he set up the first pilot of regionalised GP Training in Gippsland, ultimately resulting in the current national regional GP training system. By 2005 he was heavily involved in setting up GP intern rotations in Victoria – a critical change to fundamental medical training processes, helping to substantially reduce future shortages of rural doctors.

Dr Stevens moved to Heyfield in 1989, when the town’s two current GPs were leaving, because he wanted to go back into a small rural town with its own hospital. He took on General Practice Registrars soon after he started. “I’d been involved in organising training in Dandenong and I also felt there was a workforce imperative, to get younger doctors involved and exposed to rural practice.”

“General Practice, particularly rural General Practice, is medicine’s best kept secret.”

However, his achievements in medical education take a back seat to his real job – caring for the Heyfield community. His three-doctor Practice provides all the medical care for the adjoining Heyfield Hospital, which combines acute hospital beds with an Aged Care Hostel and nursing home beds. Procedural General Practice has long been his preferred career. After graduating from an undergraduate medical degree in Tasmania in 1972, Dr Stevens spent over a decade as a procedural GP in Dandenong. Back in those days, the small hospital ran twice-weekly operating lists where local GPs performed obstetrics, anaesthetics and minor surgery. But as Dandenong grew from a small market town to a busy satellite of Melbourne, the hospital grew to support specialists and the nature of his work changed from rural generalist to a role more common in a metropolitan General Practice.

His two current long-term practice associates both started as Registrars in his Practice, but Dr Stevens’ main motivation was to give young doctors hands-on experience of small rural practice. “Too often, young graduates make decisions about

General Practice that are not based on their own experience, which is a shame. It’s a fairly universal response amongst the young doctors and medical student interns who come here, that their experience was very different to what they expected.” When interns have the opportunity to spend a whole year in a General Practice setting for their primary clinical experience – as opposed to a hospital-based internship – the training is significantly different, he says. “Medical students get the opportunity to follow people and get a real understanding of context and the part it plays in illness behaviour.” He believes that in hospital-based medical Practice, the focus remains on managing disease, which doesn’t reflect primary care. “Too few people have a real understanding of how medicine is practised in small rural communities. Australian medicine has become very compartmentalised into sub-specialities, and in the long term, that fragments the care of people.”

There’s a misapprehension that occupying a sub-specialty niche is a less stressful occupation for doctors than General Practice, he adds. But rural practice doesn’t have to be a high-stress occupation. Full-time equivalent doctors in Heyfield work four days a week and take a share of the on-call roster. The focus on training has reduced the load, rather than increased it, he says. Interns work as GPs, with supervision and support. “We parallel-consult with them, so they get immediate feedback when they see a patient. They learn an enormous amount – but it’s also a very positive thing for supervising GPs, as we have somebody else to share problems with and the interns do a little of our work.” The learning experience is very different from that of a medical student in a large teaching hospital, he adds. “There’s no pecking order. When they’re sitting face to face with a patient, whether they’re a medical

student, an intern, a Registrar, or one of the established GPs, doctors here have the same relationship with the patient, and the same input into the management of the patient.” He believes that his own long-term involvement with GP training has created a vertically-integrated teaching practice with a built-in succession plan – and a real benefit is that it results in a reduced workload for the practising GPs. There’s an enormous service gap in rural Australia, Dr Stevens says – and restricting overseas Australian doctors to rural practice sends the wrong message to junior doctors. “People wonder if there’s something bad about rural practice because people have to be forced out here.” He would prefer if doctors were attracted to rural practice through their own positive experience of it. “General Practice, particularly rural General Practice, is medicine’s best kept secret,” Dr Stevens says. And that’s a secret he’s doing his best to spread as widely as he can.

Photography: Geoff Parrington

Going Places – ISSUE #3

What’s your

It’s a Tuesday afternoon in the Practice and I’ve seen a typical cross-section of patients during the morning. I call for the next patient and I look up to see a tall, slim, attractive girl of indigenous background who is dressed in jeans. I haven’t seen her before, so I greet her and ask her if she’s new to the area. She tells me her name is Sally and she has just moved into an apartment up the road – she works at an office in town. I ask her how I can help her today. She lifts her top to expose a really badly infected bellybutton with cellulitis, which looks like it has been caused by a recent piercing. I look closely at the infection – I see quite a few of these in young girls with piercings – so I know immediately that the problem can be cleared up quickly and easily by not replacing the piercing and an oral antibiotic that covers skin organisms. I cast an eye over the pre-consultation questionnaire she has completed and I see she’s 21 and has a three year history of having an itchy rash that appears repeatedly on various parts of her body – face, body, limbs … just about anywhere and everywhere. I ask her about this and she tells me she “self medicates” with cortisone cream she gets from the chemist – a product like Sigmacort 1% or similar. She explains to me that “it’s just eczema” and she has had it for a long time – she has resigned herself to the fact that it’s a problem that won’t go away. The cortisone cream does clear up the problem, but the symptoms then re-occur soon afterwards and the areas are again extremely itchy. She asks “by the way, could you write me a script for some stronger cortisone cream? … the pharmacy won’t give me anything stronger without a script”. I ask her if I can take a look at some of the most recent outbreaks. I see papular rash in small clusters on her upper arms, upper thigh, cheek, abdomen, along with secondary excoriations from scratching. There are no vesicles, no scale and no systemic features of disease.

I ask her a few questions to try and find a likely cause – I ask if she’d like me to help her with this problem and she’s really happy that I’m taking an interest. Cortisone cream doesn’t work, she doesn’t take any medications, herbal preparations or any unusual vitamin supplements. She hasn’t travelled recently and she doesn’t have any allergies she’s aware of. So, I wonder if it could be genetic or hereditary in some way – she doesn’t know, as she was adopted and has no knowledge of her family history. That seems to hit a bit of an emotional raw nerve, so it concerns me a little. Now I’m really curious. Various causes race through my brain – could it be contact dermatitis, eczematous dermatitis prurigo or even insect bites from fleas or sandflies? Could it be scabies? Given that she’s 21, might it be drug or lifestyle related? Then I wonder if she’s eating properly – fresh fruit and vegetables? I ask her a few more questions and she answers these honestly – I feel satisfied Sally is quite a sensible girl and isn’t leading a harmful lifestyle. Undoubtedly, she is eating a fair amount of “junk food” and consuming a high volume of alcohol at weekends. Because I can’t instantly find a cause for her long history, suboptimal treatment and discomfort (that she had accepted as eczema), I suggest to her that she should allow me to arrange a biopsy, so we can try to solve her problem permanently. She reacts positively and is optimistic that there could possibly be a solution that would put an end to her itchy rashes. I go ahead and perform the two punch biopsies for histopathology and immunofluorescence and to then give her a pathology form for a range of blood tests. She promises she’ll go to the nearest pathology lab in her lunch break the next day.

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

RESULTS OF BIOPSIES It’s a week later and I receive her results. Summary: The appearances suggest a hypersensitivity reaction with a predominantly dermal reaction. Immunofluorescence is negative for IgG, IgA, IgM, C3 and C1q Due to the general nature of the results, I decide to phone the immunologist at the laboratory for further information. He suggests that it was probably a contact dermatitis but could possibly be dermatitis herpetiformis. I wait for her to get her blood tests taken (it seems that apparently she did not go straight away to the pathology lab as she had planned.) Once these results arrive, I find: Coeliac screen = positive

LFT = normal

IgE = 24 (ref range: <101)

UEC = normal

FBE = normal

ESR = normal

FURTHER INVESTIGATION With the positive coeliac result, I seek confirmation of Coeliac Disease. So I arrange a referral for Sally to a Gastroenterologist for Gastroscopy with Duodenal biopsy. Within a few days, I have the results from the Gastroenterologist: Duodenal biopsy = positive for Coeliac Disease Vit B12 = normal

Ferritin = normal

RBC folate = normal

Bone Densitometry = Osteopaenia

I ask reception to recall Sally and ask her to make a follow up appointment, so I can discuss her results.

THE FOLLOW-UP Although there had never been any obvious symptoms of Coeliac Disease, the rash was treated successfully with a gluten-free diet (with the help of a dietitian). Within 3 months, the rash had disappeared completely. Her Osteopaenia (likely as a result of the consequences of Coeliac disease) was discussed and treatment commenced with Calcium and Vitamin D supplements, along with lifestyle advice. Unfortunately, over the next few months, the new diagnosis and the reminder of Sally’s unknown family history due to adoption triggered panic attacks with depression. She resigned from her work and decided to take a trip to Indonesia. This resulted in another attack of Dermatitis Herpetiformis, as she was unable to maintain a Gluten Free diet while she was travelling. Sally came to see me on her return – I’m pleased that the depression and panic is currently responding to treatment and she has resumed a gluten-free diet.

A LITTLE ABOUT DERMATITIS HERPETIFORMIS Itchy papular vesicular eruption symmetrically located on extensor surface of elbows, knees, buttocks, sacrum, face, neck and trunk. 85% of patients with Dermatitis Herpetiformis have intestinal biopsy characteristics but no gastrointestinal symptoms. However, they are still at risk of Small Bowel Lymphoma. 24% of patients with Coeliac Disease have Dermatitis Herpetiformis. Treatment is with Gluten Free diet +/- Dapsone (if required).

GP ISSUES THAT THIS CASE HIGHLIGHTS: ’Just a repeat script‘ is almost always more than that. You also need to check whether the treatment still works, it is the correct treatment, it is being used correctly and whether the correct investigations or follow-up are being performed to monitor the condition. “An uncommon presentation of a common disease occurs more frequently than a common presentation of an uncommon disease.” There were no vesicles to be seen on examination (the patient had never noticed either) as the itch had caused her to scratch so soon after eruption, thus disrupting the vesicles. If the pathology/radiology or other report does not give enough information, pick up the phone and talk to the pathologist/radiologist, etc.

Going Places – ISSUE #3

DR CARMEL O’TOOLE

An inspiration to “Listen to your patients – they are trying to tell you what is wrong with them.”

Photography: Lachlan Moore

he youngest of twelve children, I did very well in school and one of my brothers encouraged me to become a doctor. So I studied medicine at Monash and gravitated to General Practice – I’ve now been a GP for around thirty years. I run my own Practice in Melbourne, with three other doctors, which I initially set up as a “very different kind of medical centre” with herbalists, reflexologists and massage therapists working from the centre. When I first set up the centre, I did courses in herbal and nutritional medicine and things like that, and identified expert practitioners in those areas. But then, realising I’d have to study for many years to be as good as they were, I decided to stay in my central role as a GP who refers people to them. As the General Practice volume increased, I moved to a more traditional Practice model. I still refer widely to complementary therapists, but they are no longer co-located in the same place. I believe conventional medicine has a great diagnostic ability. We can get the diagnosis right – I really support the science and the art of medicine in doing that. Then, depending on the condition, from cancer to chronic fatigue or anything else, you can choose the right therapeutic approach. This might actually be a mixture of conventional and complementary medicine, which has been my later journey in General Practice. That’s the great thing about working in General Practice – you can choose a particular special interest like this, or it could be sports medicine, palliative care … really, whatever you want. I have two simple, important GP philosophies. The first is to listen to your patients – they are trying to tell you what is wrong with them. I realise that’s a very profound statement. It can be hard to do this if you’re stressed and pushed for time and someone is trying to tell you something which might really be telling you they’ve got cancer. But you could miss it if you don’t listen carefully.

She had been off in “specialist land” because she had some rare endocrine problems and fertility problems – she was seeing an Endocrinologist, a Gynaecologist and she was also depressed, so she was seeing a Psychiatrist. I took one look at her and said to myself, “She’s not depressed. There is something wrong with her brain.” I didn’t know what kind of brain problem it was, but she was flat, she was monosyllabic and she clearly wasn’t just depressed. It wasn’t a very sophisticated diagnosis. As we wouldn’t normally arrange a brain scan for someone who is 36 weeks pregnant, I rang her Obstetrician and said, “I’m very concerned. I think there’s something seriously wrong – she has a brain problem”. A week went by and then the Psychiatrist rang me. It transpired that the Obstetrician didn’t see her. Instead, he referred her to the Endocrinologist, who in turn referred her to the Psychiatrist, who simply told me that he wanted to increase her dose of antidepressants. Nothing had happened over the past week. She hadn’t been to hospital and she hadn’t been scanned.

to younger GPs My second philosophy comes from the famous Melbourne ophthalmologist John Colvin, who said, “More mistakes are made by not looking than not knowing”. As GPs we are generalists. We try to cover so many fields and need to be a bit expert at almost everything. Our patients come in with the strangest problems – after 30 years in medicine I still see things and don’t know what they are … like spider bites masquerading as strange rashes. The art of consultation is very important. In General Practice, you’ll find out things if you stop and ask the right questions. In comparison, a one-track specialist will only go down their own track. We’ve got cardiologists, heart specialists, kidney specialists, skin specialists and many other types of specialists. However, if you – as a GP – send your patient to the wrong specialist, they can just go way down their own track before they realise they don’t know what they’re doing. GPs need to be able to argue and be assertive for their patients when dealing with specialists. We really are very powerful because we do the referrals. You can make some spectacular diagnoses just by listening. I’d like to give you a really good example of this. Last year, I saw a patient I have known for ten years, who was at a very advanced stage of pregnancy with her second child.

I had to argue with the Psychiatrist for a scan in the strongest possible terms, in the middle of a normal consulting day in General Practice. I said “I’ve known her for 10 years. She is not depressed. There is definitely something wrong with her brain”. I was absolutely horrified to find out that the first specialist hadn’t arranged a scan. As it turned out, she had a massive frontal brain tumour, which they managed to remove after the baby had been delivered. After being in rehab for six months, she came in to see me. I vividly recall that she sat down and said, “You listened. You knew there was something wrong with me. You saved my life.” It was through just listening and looking, and knowing, and believing in her that this particular story has a happy ending. General Practice is so rewarding. You feel very validated and grounded by your patients. You’re empowered to make a difference, using your intellect and your compassion. It can often be a very difficult thing and when you get it right, it’s very special.

Going Places – ISSUE #3

True confesysiniotenrsn of a 21st centur

PART 3

Written by Dr. Ernest Tecrin

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

Join the Going Places Network! There’s a new junior doctors’ network on the block!

It may already be at your hospital … or it will be coming very soon! The Going Places Network is all about helping your career to go places in General Practice, while you complete your hospital training. Have you noticed that once you start your hospital training, General Practice seems to fall off the radar? Because General Practice training takes place outside the hospital system, you may find you won’t hear much about it – or even come across many GPs. But that’s all changing! The Going Places Network will bring the General Practice experience to your hospital or a hospital near you. By joining the network, you’ll be able to access a range of educational meetings, social and networking events and lots of other resources to help you decide if General Practice is for you! You’ll also be able to connect with GPs and doctors who are training to be GPs, helping you to explore the challenges, rewards and the many aspects of being a GP. It’s a really fun way to network with others who also have an interest in General Practice … and, at the same time, you’ll be developing your professional knowledge. Even if you ultimately decide that General Practice isn’t for you, the experience will be helpful, whatever vocational path you ultimately follow. Hospital-based GP Ambassadors are central to the Going Places Network initiative – they are all prevocational doctors, with a keen interest in General Practice. You can approach your GP Ambassador directly for honest advice and information. Keep a look-out for posters telling you who your GP Ambassador is.

JOIN TODAY!

There are three easy ways to join. Tell us what hospital you are based at and we’ll hook you up with your local network!

• Email us at goingplaces@gpra.org.au • Visit www.gpaustralia.org.au • Call us on 1300 131 198 Going Places – ISSUE #3

DR ALISON THOMAS

A GP with military precision Lieutenant Commander Alison Thomas has been a military doctor since 1994, apart from a brief interlude as a civilian GP a couple of years ago. This year, Alison is working in Canberra for two weeks out of four. For the other two, she works remotely from her Brisbane home, with occasional visits to Gallipoli Barracks in Brisbane. Her main role involves critical policy development, where she says she’s using all her GP clinical skills to advise on future directions, covering all military health. “I can’t think of any other place where, as a relatively junior doctor, I could have such a big role in shaping the way that medicine is practised,” she says. Her six-year old daughter lives in Brisbane and Alison says the work-life balance she has as a GP is wonderful – she spends far more time with her daughter now than she would in most full-time jobs. Alison joined the Navy on a scholarship as a fourth year undergraduate medical student at Monash in 1992. With wide medical interests, her ambition was to work in a General Practice role within the military – and it has been everything she had hoped for. “It’s a wonderful career,” she says. “I’ve had extraordinary experiences in medicine that you can’t really compare against civilian training at all. I’ve done aviation medicine, spent six months in the UK, I’ve dangled out of helicopters and been at ‘action stations’ in the Gulf – it has all been fantastic, and I’ve loved every minute of it.” After an undergraduate entry officer basic military training course, Alison spent two years in civilian hospitals doing the usual intern and resident training, with rotations in emergency and surgery. Following that, she did a five month period of officer training. “I learned about what it is to be in the Navy. It was a fantastic time with lots of learning about naval history and protocol … genuinely character-building stuff.” Then it was time for Defence medical training. “I did basic aviation medicine training with the Air Force, underwater medicine, then a nuclear, biological and chemical warfare course, which was fascinating.”

There is a focus on emergency medicine, which requires similar skill-sets to rural practice, she says. “On a deployment you are pretty much by yourself in a remote locality, with a limited pool of resources at your disposal, so you are forced to be selfsufficient.” Initially, she was posted to HMAS Albatross in New South Wales and had a primary care role. The focus is a little different in Defence though, she says. “Military medicine is a juxtaposition between occupational medicine and General Practice. Everything you do must have an occupational focus, and with every patient you see, you must consider how their condition is going to affect their ability to employ and deploy, and vice versa … how does their work environment affect their condition?”

Through the Navy she went on to complete post-graduate training in aerospace medicine. “It involves things like how a person operates a helicopter, how their health impacts on their ability to fly, the impact of noise and vibration, the limitations of working in the dark, fatigue management, risk management and lots more.” These factors are critical for people working in such a dangerous and exciting occupation, she adds. She’s had a number of overseas deployments in her career, starting with three months as ship’s doctor based on HMAS Darwin and also serving on HMAS Canberra, travelling to Thailand, Korea, Japan and the Philippines.

“I can’t think of any other place where, as a relatively junior doctor, I could have such a big role in shaping the way that medicine is practised.”

“The medical role at sea is quite broad. You’re involved in everything from water quality through to emergency management, as well as routine primary care, of course. There’s a strong public health role, in a closed setting.” Another role travelling to India was even more challenging, medically. “Trying to keep 210 people well and healthy enough to keep working in India is actually really hard – you’re facing biblical diseases, water quality problems and communicable diseases.” In 2002, she was posted to the northern Arabian Gulf, as part of an international naval task force. As well as medical care on her own ship, Alison was overseeing operational health support for the task group, liaising with other countries’ navy personnel and responding to emergencies. She had plenty of interesting medical experiences (like being winched onto an American ship and taken to an Iraqi oil tanker to treat a stroke patient). She says that being in active service was

Photography: Mel Koutchavlis

a very high-pressure, but fascinating, environment that gave her great insights into another aspect of her patients’ work lives. “It was immensely enjoyable, I loved it.” Alison transferred to the Navy Reserve in 2003 to work as a Contract Health Practitioner for Defence, including a six month contract as Regimental Medical Officer for the 2/14 Light Horse Regiment, which she really enjoyed. In 2008, Alison moved to civilian General Practice and then started doing contract medical work for the Navy – again – in 2009. This made her realise how much she missed her military role – so it didn’t take much persuasion to have her back in uniform by the end of 2009! “As a doctor in the Defence Forces, you have the capacity to provide broad-reaching holistic care for your patients, taking into account every aspect of their lifestyle, which you just don’t have in any other civilian practice. It’s a brilliant career.”

Going Places – ISSUE #3

Medical Emergencies

at 30,00

Is there a doctor on board? Settling in for a flight is never the same once you’ve taken the Hippocratic Oath. In the back of your mind is always the fear of hearing the dreaded message asking if there is a doctor on board. But how likely is it that you’ll need to perform an in-flight tracheostomy with only a coat hanger? And what assistance can you expect at 30,000ft?

COMMONEST MEDICAL EMERGENCIES INFLIGHT • Syncope • Gastrointestinal Disorders • Cardiac Conditions • Nausea and vomiting • Allergy • Accidents • Hypoglycaemia

Cramped in a cabin with up to 850 other anxious passengers isn’t the best place to practise medicine. Add in the effects of engine noise, cabin pressure and a limited supply of unfamiliar equipment and it can become your worst nightmare.

likely to face. Most cases are due to exacerbation of pre-existing medical conditions, either from the aircraft effects such as cabin pressure or the stress of flying, or medication problems such as accidentally packing important medication in the hold.

Unfortunately, with an ageing population and greater passenger numbers, your chance of facing a medical emergency whilst jetting off on your summer holiday is on the rise. With between 1 and 10 incidents per 40,000 passengers1 it’s a scenario that many doctors will face at some point in their careers.

Syncope is by far the commonest, making up around 50% of cases. Gastro-intestinal upset and generalised pains are the next most frequent – possibly related to dehydration, alcohol consumption and disrupted sleep. Fortunately, many emergencies will be dealt with by airline staff without the assistance of on board doctors.

In-flight emergencies

Cabin pressure

There have been numerous documented medical incidents in the air but perhaps the most famous occurred in 1995 between Hong Kong and London. A female patient developed chest pain and dyspnoea shortly after take off and was seen by two doctors on board.

Travelling by commercial airliner exerts various effects on the body that can precipitate medical difficulties. The most immediate is the lower ambient pressure, which causes a drop in oxygen saturations to around 90%, even in healthy passengers.

Having diagnosed a tension pneumothorax, they proceeded to insert a chest drain using brandy as disinfectant, a coat hanger as a trocar and bottle of Evian water as an underwater seal. The flight continued and the patient was eventually seen in a hospital in the UK where she made an uncomplicated recovery2.

Airline cabin pressures are usually equivalent to 2000-2400 metres altitude, and passengers with underlying heart or chest disease may require additional oxygen to counter hypoxia. Most people experience the expansion of gas in air filled cavities on takeoff manifesting as pain in the ears or sinuses, but it also has the potential to convert a simple pneumothorax into a tension pneumothorax.

But, before you start revising chest drain insertion, it is useful to know that this is one of the more rare emergencies you are

“In this scenario, the medical volunteer assumes a position of being the eyes and hands, helping in assessing and administering medication,” says Dr Paulo Alves, the Vice-President of MedAire, who run the service.

00 feet Relative humidity is low in the cabin, causing dehydration, worsened by alcohol. The risks of deep vein thrombosis from limited mobility and dehydration are well recognised as the infamous ‘economy class syndrome’.

Airline defibrillators Over recent years, the amount and type of emergency equipment carried on aeroplanes has been reviewed with many airlines now carrying automated external defibrillators (AEDs). One person who has benefited from this is UK MP Paul Keetch. In 2007 Mr Keetch suffered a cardiac arrest whilst on a Virgin Atlantic flight from Heathrow to New York. He was successfully defibrillated and returned to Heathrow for hospital treatment. In a recently published study, one major US airline reported 200 uses of AEDs over a 2 year period, including 13 defibrillations. They found a 40% survival rate for VF or pulseless VT arrests – remarkable when you consider the difficult cabin environment.3

Emergency Landings Many of these medical scenarios can be dealt with in the air, avoiding unnecessary emergency landings. However in around 1-2% of cases, an emergency diversion is necessary. This is potentially a very expensive decision with the overall cost as much as $220,000 to divert a plane.5 If other passengers are left stranded for any reason, then hotel bills and other expenses can increase dramatically. In 1996, a passenger on a Virgin Atlantic flight had a suspected heart attack, and the flight diverted to a small airport in Eastern Canada. However, during the landing one of the aeroplane’s engines was damaged. Nearly 400 passengers (including pop star Gary Barlow) were left stranded for 15 hours at the local curling rink while other aeroplanes were sent to pick them up.6

Support from the ground On any flight there is approximately a 60-85% chance of there being a doctor as a passenger on board7 and most flight attendants are trained to deal with common medical emergencies. Many airlines also have access to MedLink, the largest medical support service run from Pheonix USA, which is staffed by emergency doctors with training in aviation medicine. They deal with nearly 100 cases per day. As well as supplying medical knowledge, they also have access to a database of medical resources and details of runways around the globe, so they can advise on the most suitable diversion, should it be necessary.

Interest is now growing in telemedical devices which will allow vital signs, ECG and other data to be transmitted to staff on the ground. This technology has already been taken up by several airlines.

Good Samaritan Acts Many doctors have concerns that they could potentially be the subject of medico-legal action arising from their decisions during an aeroplane medical emergency. The concensus is that doctors should assist if required. Indemnity against prosecution may be offered by the airline, but this may depend on whether you were asked to help. It is suggested that, before getting involved, you should clearly state your competencies and skills, as well as other factors that may affect your performance, such as alcohol.8 Generally speaking, Practitioner Indemnity Insurance Policies cover members for a ‘Good Samaritan Act’. This is treated as a healthcare act that is performed when coming to the aid of a person in an emergency or accident, where it is necessary to stabilise that person’s medical condition or to prepare that person for transfer, without expectation of payment or other consideration. So, if you ever hear those dreaded words “is there is a doctor on board?” over the airline tannoy, keep in mind that you should do simple interventions, recognise your own limits, and in most cases there should be help of some kind available.

FEDERAL AVIATION AUTHORITY, EMERGENCY MEDICAL EQUIPMENT REGULATIONS4 • Sphygmomanometer 1 • Stethoscope 1 • Airways, oropharyngeal (3 sizes): 1 pediatric, 1 small adult, 1 large adult or equivalent 3 • Self-inflating manual resuscitation device with 3 masks (1 pediatric, 1 small adult, 1 large adult or equivalent) 1: 3 masks • CPR mask (3 sizes), 1 pediatric, 1 small adult, 1 large adult, or equivalent 3 • IV Admin Set: Tubing w/ 2 Y connectors 1 • Alcohol sponges 2 • Adhesive tape, 1-inch standard roll adhesive 1 • Tape scissors 1 pair • Tourniquet 1 • Saline solution, 500 cc 1 • Protective nonpermeable gloves or equivalent 1 pair • Needles (2-18 ga., 2-20 ga., 2-22 ga., or sizes necessary to administer required medications) 6 • Syringes (1-5 cc, 2-10 cc, or sizes necessary to administer required medications) 4 • Analgesic, non-narcotic, tablets, 325 mg 4 • Antihistamine tablets, 25 mg 4 • Antihistamine injectable, 50 mg, (single dose ampule or equivalent) 2 • Atropine, 0.5 mg, 5 cc (single dose ampule or equivalent) 2 • Aspirin tablets, 325 mg 4 • Bronchodilator, inhaled (metered dose inhaler or equivalent) 1 • Dextrose, 50%/50 cc injectable, (single dose ampule or equivalent) 1 • Epinephrine 1:1000, 1 cc, injectable, (single dose ampule or equivalent) 2 • Epinephrine 1:10,000, 2 cc, injectable, (single dose ampule or equivalent) 2 • Lidocaine, 5 cc, 20 mg/ml, injectable (single dose ampule or equivalent) 2 • Nitroglycerine tablets, 0.4 mg 10

References 1. Surgical ad Medical emergencies onboard European aircraft. Sand M, Falk-Georges B, Sand D, Mann B. Critical Care, 2009. 13:1 2. Managing in flight emergencies. Wallace W. BMJ, 1995;311:374-375 3. Use of Automated External Defibrillators by a U.S. Airline. Page R, Joglar JA, Kowal R, Zagrodzky J, et al. NEJM, 2000; 343:1210-1216 4. Federal Aviation Authority Advisory Circular, 2006. www.rgl.faa.gov 5. How much does an airline diversion cost. Martin G. www.gadling.com 6. Unexpected Arctic stop for Brits, Yanks. Van Rassel J. Nunatsiaq News 1996. 7. Health Issues of air travel. DeHart R. Annual Review of Public Health, 2003; 24: 133-151 8. Flying doctors: is protection plain. Williams S. Casebook 2008; 16: 8-11 By Dr Ben Chandler. This article first appeared in JuniorDr. NOTE: Airlines operating into and out of Australia – and within Australia – carry a first aid kit, which contains some, or all, of the items listed above. The Australian Civil Aviation Safety Authority (CASA) regulations specify that the Cabin Manager has the key to this and the items can only be accessed by a qualified medical professional. Any flights that fly into the USA, including Qantas and V Australia, must comply with the FAA regulations covering medical equipment, as covered in this article – and many operators also have access to MedLink.

Going Places – ISSUE #3

My GP clinic at Sydney Airport is open to everyone, but most of the primary care is for airport staff – there are ten thousand staff at the international terminal alone. About half my work now is doing occupational health for one of the airlines at the airport. Passengers arriving and departing, or their family members – as well as people coming in for medicals – accounts for about twenty percent of our work. While the Practice is equivalent to that of a single doctor, I have someone assisting me about 16 hours a week, as we often treat about forty people a day. However, we tend to do a lot more complex consultations – a lot of pre-placement medicals and injury management consultations take two or three hours of work per case. It’s really in-depth medicine. Initially, I wanted to be a Vet but I decided to enrol in medicine. I specifically chose General Practice because I wanted to gain a wide range of broad, hands-on experience … and I also wanted to travel.

DR ANDREW KELLER

The airport GP A big advantage of General Practice is the ability to choose your own hours – something that other professions often don’t offer.

I’ve been able to tick those two boxes. During most of the early part of my career, I’ve been able to travel and to find work that fitted in around my travelling, which has been great. After graduating and doing my first year of GP training, I spent a year doing GP training in England – obstetrics, paediatrics and some casualty work. I also travelled extensively on the way there and back. Returning to Australia, I did a few locum roles, then I took a position in a three-GP clinic in Mackay for three years, which was really interesting. It was a cane farming area and I had lots of interaction with the people – plenty of regular patients, in contrast to many of the driftthrough patients you tend to get in a city Practice. I also did diving medicals. From there I moved to Indonesia, taking a temporary job in Jakarta, looking after expats in a very large clinic with about twenty local doctors and around five expat doctors supervising.

Photography: Mel Koutchavlis

We would go on-site, making visits to mines or factories, taking care of expats and their families, repatriating those that were seriously sick or injured. The job ended dramatically with the coup where Suharto was kicked out. We would normally medivac one or two expats a week but I think we did a hundred in one day – organising jets to get people out when they couldn’t get commercial flights. I moved to a similar post treating expats in Beijing and my wife worked at the Embassy. China has a very different culture and we worked very long hours, but I still found time to undertake some volunteer work with a hyperbaric company treating sick divers. They flew us to places like Thailand or Mexico or Belize and I would treat the divers who were suffering from the bends – in exchange, we got the plane trip and some free dives. As a result, I decided to undertake some postgraduate study and became an advanced hyperbaric medicine doctor. Afer a year in Beijing, we left and spent a few months in Thailand. When we finally arrived in Sydney, I started doing some locum work in hospitals and General Practices before starting up the Practice here at Sydney Airport ten years ago. Only around twenty percent of our appointments are made prior and the rest are drop-ins, which can be really diverse – ranging from someone coming in for a pill script, to migraines, coughs and colds, perhaps an acute head injury from someone banging their head on an aircraft wing, lots of back strains, plus people coming off planes with anything from Bali Belly to Dengue Fever or malaria.

We do flight clearances for people who are deemed possibly unwell to fly, as the airlines require a duty of care that passengers have the fitness to fly. Every now and then we’ll have a peak of a particular thing. Deep vein thrombosis prevention was a big issue a few years back; it’s not as high profile any more, but it’s still an issue. This Practice has a heavy skew towards occupational health, so we generally have fit, healthy people, who are motivated to be at work and want us to help them to get well quickly. I believe there are some aspects of General Practice, which still cause difficulties. For example, it can be difficult meeting expectations – a common negotiation involves a difference of opinion between what treatment should involve and what the patient wants. While GPs offer a very highly skilled and highly required service, they’re often undervalued compared to other professions. Medicare bulk billing has been partly responsible for perpetuating this – creating the impression that health care is cheap or free. However, a big advantage of General Practice is the ability to choose your own hours – something that other professions often don’t offer. Our days at the Practice, here, are usually 8am to 5pm, Monday to Friday, and what’s terrific is there’s no oncall, no weekends, no after hours. It has become the norm for doctors now to not want to work 24/7 – and, in any case, the increase in complexity of medicine means you’re not capable of working such long hours. That’s why more and more GPs are in a reduced-hours arrangement, which is not just desirable, but also sensible. I love medicine, I love my job as a GP, I love the science, the people and the interaction between all of that … and I’ve really appreciated the freedom and travel that it’s given me.

Going Places – ISSUE #3

TECH TALK • REVIEW

DIGITAL STETHOSCOPES – HEARING IS BELIEVING You have patients to examine and you need to perform auscultation …. so just think how much easier, and more effective, this could be with a digital stethoscope. But first everything you need to know about the humble stethoscope … … Technology has come a long way since Rene Laennec, a French physician, developed the first monaural stethoscope in 1819, Rappaport and Sprague created the two-sided stethoscope in the early part in the 20th century and Dr Littmann, a Harvard Medical professor, created a new stethoscope featuring radically improved acoustical performance in the 1960s. You obviously know the basics. A stethoscope has a bell – when held lightly against the chest, this picks up sounds of low frequency. The other side is a diaphragm, which picks up sounds of high frequency. A minimum of four areas should be auscultated using the diaphragm first and then the bell. You use your skill, experience and expertise to selectively listen to one sound at a time – so when listening to sounds in systole, sounds in diastole are initially ignored and vice versa.

Let’s now take a look at what a digital stethoscope can do for you – to enhance the auscultation process The huge advances in digital stethoscope technology have allowed the electronic stethoscope diaphragm to respond to sound waves in precisely the same way as a conventional acoustic stethoscope. The changes in an electric field replace the changes in air pressure as sensed by an acoustic stethoscope. The latest digital stethoscopes – like the 3M Littmann model 3200 – feature a state-of-the-art sound sensor to give you a life-like listening experience equivalent to the very best, top-end cardiology stethoscopes. Then there’s proprietary Ambient Noise Reduction (ANR) technology that reduces, on average, 85% of unwanted background noise, which can interfere with your concentration. Some models incorporate technology that also reduces all the handling noises. You’re probably only too well aware how distracting all these noises can be with a normal stethoscope in your busy clinical surroundings! There’s amplification (some models offer up to 24x) so it’s easier to detect difficult-to-hear, or soft, heart sounds, like S3 gallops, aortic regurgitation murmurs, as well as abnormal lung sounds. That’s hugely helpful for faint heart, lung or body sounds – it’s also essential for auscultating large or obese patients or when a patient’s clothing restricts your listening. All of this all adds up to a superior listening experience – compared to acoustic scopes.

Tech savvy and want to get the most from your digital stethoscope? You can actually capture sounds you hear for later playback and even transmit these sounds to your PC in real time via Bluetooth. That means you can play them back, even at slow speed, allowing you to listen even more closely. Some products can interface with new apps for the iPhone and iPad.

The latest models come bundled with free heart and lung visualisation software, which has been designed to show you visually what you are hearing. The software also allows you to display and print sounds as a phonocardiogram. All of this helps you to save, analyse, compare, review and even email what you’ve heard – and improve your skills.

So how easy are they to use? The answer is very. Most models stay in stand-by/sleep mode, ready for you use at your next auscultation and they’ll let you know battery life/when the battery is low and needs replacing or recharging. You select bell and diaphragm frequencies and volume – with most models the noise reduction technology is activated automatically each time the stethoscope is turned on. The digital technology offers you the potential to customise settings and on some models there’s an LCD interface that provides you with visual information, including a heart rate indicator that displays after five seconds and refreshes every two seconds.

Are they worth the investment? If you appreciate the fact that a digital stethoscope is a state-of-the-art precision instrument that will provide years of top level performance … … and then you imagine what it can do for you on a dayto-day basis … … it’s a really worthwhile investment. At a few hundred dollars, it’s not a huge investment and the cost is taxdeductible. There are some excellent offers and even a free trial, so you can decide – and hear – for yourself. To listen to examples of normal and abnormal heart and lung sounds visit http:// solutions.3m.com.au/wps/portal/3M/en_AU/ Littmann/stethoscope/education/heart-lung-sounds/

TECH TALK • REVIEW

Load your iPhone with medical apps! Your iPhone can be a great tool for all your day-to-day activities when it’s loaded with lots of medical apps. So, here are some of the most popular and highly rated apps we’ve selected as “must haves” for your iPhone or – if you’re lucky enough to have one – an iPad! Obviously, most are American, so you need to be aware of that fact in relation to the content. Many of the apps are free, with others at varying prices – you can find full details on http://itunes.apple.com/au/genre/mobile-software-applications/id6020?mt=8

The battle for the No. 1 contender based on popularity is between Medscape and Epocrates – so let’s take a look at these two first!

Medscape Version 2.1 (April 2010) claims to be the fastest, largest and most comprehensive medical app available. It includes a 24 hour test-drive option that allows you to explore! Users rave about the drug reference and interaction checker. There are over 3,200 diseases, conditions, and procedures in this app, together with over 2,500 images and over 150 videos.

Epocrates Version 3.6 (June 2010) is the premier mobile drug reference app and users appear to have confidence in the content it provides. It features clinical information on thousands of prescription medicines and OTC drug products, pill pictures, a drug interaction checker (up to 30 drugs at one time), formulation data and a dose calculator. Pill ID allows you to identify mystery pills. It’s free, but you can upgrade to a subscription which provides additional features including a medical dictionary and images of diseases.

Skyscape Medical Resources Version 1.6.26 (July 2010) is a really useful collection of medical information, featuring drug dosing information on thousands of branded and generic drugs along wth over 400 integrated drug dosing calculators. The evidence-based clinical resource provides succinct information on hundreds of disease and symptom topics in outline format. MedAlert allows you to stay upto-date with drug updates, journal summaries, clinical trial results and other clinically relevant information.

3D Brain Version 1.1 (April 2010) allows you to use your touch screen to rotate and zoom around 29 interactive structures. You can discover how each brain region functions, what happens when it is injured, and how it is involved in mental illness. Each detailed structure comes with information on functions, disorders, brain damage, case studies, and links to research.

Eponyms Version 1.3 (July 2010) contains a short description of more than 1700 common and obscure medical eponyms – ie: Rovsing’s sign, Virchow’s node and more! This is a perfect tool to quickly look up the meaning of any eponym – no matter how obscure!

Diagnosaurus Version 1.4 (November 2009) is a quick reference tool that helps you to perform a differential diagnosis with speed and confidence. You can quickly search over 1,000 diagnoses by organ system, symptoms or disease – it allows you to consider alternative diagnoses and then refer to those entries. You can also save your favourites! Diagnose the Disease Game Version 2 (February 2010) is a new and improved design with more than 100 disease images! It’s interactive educational and fun. Race against time to diagnose the disease as images are revealed. You are scored on speed and accuracy.

Lieberman’s iRadiology Version 1 (December 2009) has 500 unique radiology images demonstrating classic radiology findings of a multitude of abnormalities. Zoom or scroll around images to identify the relevant findings. Labels (which can be toggled on or off) highlight the diagnostic findings and there’s a short discussion about the findings.

Medcalc Version 1.3 (September 2009) is a medical calculator that gives you easy access to a wide array of medical formulas, scores and classifications. ECG Guide Version 4.2 (June 2010) is the most comprehensive and authoritative ECG app in the App Store. There are over 200 examples of common and uncommon ECGs. All the aspects of normal and abnormal EKGs are covered in an organised and simple interface. There’s a rapid reference section, interpreter and 100 multiple choice questions to test your knowledge. Auscultation Version 1.3 (April 2010) plays different sounds of human heart beat murmurs or lung wheezes, so you can review and test your knowledge and skill at identifying these conditions. The common auscultatory sounds are somewhat stylized, but do provide a good indication of the sounds named.

Going Places – ISSUE #3

DR SARAH MEERTENS

The GP Educator

work part-time in a job I really love, as Strategic Operations Manager for the Adelaide to Outback GP Training Program. I’m also completing a Masters in Health Administration part-time. I’m actually married to a GP who has his own Practice and we have four boys aged between two and nine. I’ve done most of my training parttime and have worked part-time, using a mixture of nannies and childcare. My husband, Sam, is so supportive – I’ve never had to sacrifice either my career or my family. I am so fortunate that I can fit both together and it has all worked really well. He has structured his work so he can pick the children up from school two days a week and coach footy and cricket teams. I think we are testimony to how flexible this career and profession can be in terms of the work-life balance.

I love medical education because it’s so enjoyable working with medical students and prevocational doctors – helping them to understand what General Practice is all about and appreciating the amazing opportunities that lie within General Practice. Let’s be honest – General Practice is not an easy option. It is intellectually challenging. But, in return, it offers you an incredibly rewarding career, allowing you to experience a huge amount of variety in the type of work you do. I grew up in metropolitan Adelaide and by the time I was sixteen, I realised that I wanted to be a doctor. I loved science and wanted to do something that involved working with people – something with meaning. So, when I finished high school I went on to the University of Adelaide to study medicine. In my fourth year of medicine, I won a vacation research fellowship for work on antenatal outcomes in isolated rural communities. As part of that, I spent a fortnight in Port Lincoln to continue the research and stayed with a fantastic GP. He involved me not only in his working life, but in his family life, as well. This also gave me the opportunity to listen intently to his thoughts on being a GP.

I think we are testimony to how flexible this career and profession can be in terms of the work-life balance.

The time I spent with that GP allowed me to see General Practice from a career and clinical perspective but also – importantly – from a lifestyle perspective. I had met my husband while we were both studying medicine and we were living together. Then Sam was selected to play football for Carlton when we were both in our final year of medicine. So we moved and completed our studies in Melbourne, then later moved to Ballarat. Sam worked at the Ballarat Base Hospital and I completed my internship there. I experienced a variety of rotations including general medicine, general surgery, emergency and aged care. Working at the Ballarat hospital, we got to know all the local GPs. Every time someone was discharged, we’d speak directly to that person’s GP – particularly in aged care. We would also be invited to some of the CPD events. Through all of this contact, I got a feel for General Practice, but at that stage I still hadn’t made up my mind. I was considering a few other things like aged care, medical administration and public health medicine. In reality, my ultimate decision was more a slow coming together of the different options. The thing that sold me on General Photography: Yvonne Milbank

Practice – in a clinical sense – is that General Practitioners specialise in looking after people, not just illnesses. By the time I enrolled to become a GP, I was doing my first RMO year, so I was able to count that year as my core hospital year in the GP training program. I became pregnant the following year, while I was completing an extended skills post in Aged Care, still at the Ballarat Base Hospital. After our first baby was born, we moved to Adelaide and I went back part-time, starting my first General Practice placement at a three-doctor medical Practice in the suburbs of Adelaide, which I really, really enjoyed. Then we all moved to Clare in rural South Australia. We spent two and a half years there and I worked two days a week in the same Practice as Sam, who actually finished his training there. We had another baby while we were living in Clare, leaving to return to Adelaide just before our third son was born. Sam bought into a Practice here in Adelaide and I took about a year off on maternity leave. Afterwards, I went back to work between two and three days a week in the same suburban Practice I had worked in before. Then I moved to another Practice in

the Adelaide Hills area to finish my training. I started doing some exam support with my Registrar Training Provider and that led to me taking on a role as a medical educator with the PGPPP program. And this, in turn, then led to me moving into an ongoing medical educator role. I started to increase my days in medical education and moved to an education coordinator role for the hospital team and became Strategic Operations Manager. I really hope to see this strategic work influence the role of the General Practitioner as the leader in Primary Health Care.

Non-clinical work is my focus now, but I’d like to continue to do a little bit of clinical practice. That’s partly because I really do enjoy it and also because it would enhance my non-clinical work, which is where my passion lies.

Going Places – ISSUE #3

DR BRENDAN FITZGERALD

PGPPP – A great experienc Where did you do your PGPPP? I did my PGPPP placement in my RMO3 year at Sunbury Family Medical Centre, a semi-rural area just outside Melbourne. It’s a big private clinic with about five GPs, nurses, a few junior trainees and a physio. As a Practice, it was very well supported.

How did the program help you professionally? On a PGPPP rotation, you essentially work as a junior trainee, so it was a perfect introduction. It gave me the experience of General Practice and it really helped me to make up my mind that I was definitely making the right decision. It was a really character-building experience – I feel the responsibility for making important, independent decisions helped me mature as a young doctor. In a tertiary hospital setting I hadn’t had the opportunity to do primary care, first presentation medicine – including potentially serious cancers or haematological problems, for example. So now I’ve actually tailored my hospital training to answering some of the questions this PGPPP experience raised for me.

How was the teaching delivered? Each week there was an hour of one-on-one teaching with a senior GP in the Practice, which was very interactive and a real privilege. There was also ongoing education with lunchtime seminars and talks. Corridor consultations were actively encouraged – these are where you could ask another GP for advice on a patient at any time. I felt very well supported throughout my placement and I learnt so much.

What were the program highlights? In General Practice there is a lot of responsibility to determine the appropriate diagnosis and then decide upon the appropriate management. I had one patient – a baby with strange bruising – which was a really sensitive case. I organised tests and follow-up. It turned out to be a bleeding disorder, like haemophilia. I felt confident that I was really contributing and had approached it in an appropriate way. Not only had I achieved a great deal and had a good outcome, but it was a diagnosis that the family could manage. So that was a real highlight for me. Another highlight was the weekly consult I did at an aged care hostel. The senior GP was confident to leave me independently and autonomously to look after the patients regarding their ongoing care. It was like having a little hospital of my own twenty patients and I really enjoyed the experience. Even the daily interactions with regular patients were highlights – getting to know them and seeing them come back again after successful treatment. That was very satisfying.

How did the lifestyle compare with hospital? Even though it is busy in its own way, in a GP Practice you have so much more autonomy. In a hospital, there are always people asking you to do something. On top of all that, it’s so noisy and busy, you’re practically running from one place to next. At the Practice, I worked a full-time workload in four longer days, with one day off each week. I also worked one weekend morning every few weeks. There was no nightshift and no on call – that was great. It meant I could spend time with my son at home and do things around the house. You just wouldn’t get that in any other junior medical job.

What advice would you give other junior doctors about the PGPPP? I would encourage any junior doctor to do a PGPPP rotation, whether or not they want to do General Practice. I think it’s important for all doctors to understand what a General Practitioner does, how they do it and to know what the limitations of their resources are. Many specialists are interacting with GPs and their patients every day, so I think it’s important for them to know how it all works. Dr Brendan Fitzgerald is doing his RMO3 year at Austin Hospital as part of his RACGP (VMA) training.

“I think it’s important for all doctors to understand what a General Practitioner does.”

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:

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

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

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

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

Enhanced understanding of the Australian health care system

Great networking opportunities Increased confidence and independence to take into future training and work environments

Eligibility for 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.

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

Going Places – ISSUE #3

DR AMEETA PATEL

The GP with a combination of jobs early seven years ago, Dr Ameeta Patel moved from beach to bush. A genuine “tree change” – from being a regular GP in a suburban Central Coast practice to working in a women’s health clinic in Alice Springs. Three years later, she swapped the health clinic role for a combination of different jobs. She’s now a half-time GP in a mainstream Alice Springs practice, where she specialises in women’s health. “I love this Practice – we have a lovely patient base plus lots of travellers coming through.” And she fills the other half of her time with a diverse range of activities. Ameeta has previously worked as a medical educator and continues to take a GP Supervisor role with Practice Registrars. She’s recently completed a stint as a parttime GP with Headspace in Alice Springs, helping with youth medical services, and has also held a part-time role with the Royal Flying Doctors (Rural Women’s GP Service) for nearly four years. “The program is commonwealth funded to give rural people a choice of gender of their GP. Female doctors visit various locations on a regular basis providing a General Practice service, with a length of stay between one to three days.” A lot of women’s health is involved, she says, and the service caters for towns of over 1,000 people where there is no female GP within 50 kilometres. Ameeta flew into Tennant Creek on a regular basis, until recently – as the town has now recruited a permanent female GP. “The management style, efficiency and standards of practice in the Royal Flying Doctors (Rural Women’s GP Service) are just so positive, and it’s a really worthwhile service, so I hope to continue in another town.”

Ameeta was born in Uganda and her family came to Australia as refugees, fleeing the regime of Idi Amin, when she was nine. “I have quite clear memories of schooling in Uganda and living in Africa, which probably part-explains my interest in doing medicine in Africa and then in central Australia,” she says. Her parents expected her to go to university and have a professional career, she says – and she chose medicine because it would give her a lot of flexibility to travel and work anywhere in the world. After doing undergraduate medicine at the University of Sydney, she spent several years in large Sydney teaching hospitals before taking a year off to travel. She then went to Kenya where she spent six months working in a clinic in a Nairobi slum, run by the Red Crescent. “It was incredible – a really interesting experience – to go from the Australian health system to working in a clinic with very basic equipment, no access to blood tests or any sort of pathology, treating very poor people who were working but surviving on a dollar a day.” In 1989, many patients presented with symptoms that Ameeta often clinically diagnosed as HIV. But with no access to HIV testing, and no treatment, the work was often very depressing. “We had few resources available, so people had to get on with their lives. We had to patch them up and treat them as best as we could.” Returning to Australia, Ameeta worked in the hospital system before deciding her interest lay in primary care. She joined the GP training program and moved to a beachside community north of Sydney where she became an associate in a threedoctor Practice.

If you are interested in finding out more information regarding careers with the Royal Flying Doctor Service, email careers@flyingdoctor.net or visit the website at www.flyingdoctor.org.au

Photography: Jodi N, Elements Studio

“The Practice was very mainstream, and it suited me very well when my children were young. However, I had always wanted to work overseas in a developing country to give my two children the experience of different lifestyles.” A few years later, Ameeta and her husband divorced and she started working for a couple of sessions each week at Wyong Aboriginal Medical Service, with a view to moving to the Northern Territory. “I decided I’d like to take my interest in Aboriginal health care further, so I spoke with a rural workforce agency that placed doctors. I had this romantic idea that I could go and live in a remote Aboriginal community, but as a single mum, it wasn’t a realistic option.” She took up a position at the Central Australian Aboriginal Congress in Alice Springs to work as a clinical coordinator of their women’s health service. “While it was full-time work, there was no after hours or weekends, so it was manageable for a single parent. My kids were 8 and 9 at the time and loved it. We have had the best time and we are all still really happy here.” Ameeta had planned to spend a year, or perhaps two years, in Alice Springs and then return to the coast – but nearly seven years later, she says she’s still there and not looking to leave any time soon. “As a student, I had so many misconceptions about General Practice – I wish I’d known back then that you can actually do so much clinically and there’s such a range of things to choose from in General Practice.”

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Going Places â&#x20AC;&#x201C; ISSUE #3

DR JONATHAN MORLING

Life as a GP in the Kimberley Derby

Broome

Photography: Matt Atkinson

What’s your current role – and how did you get there? For half my working time, I’m the District Medical Officer at Derby Regional Hospital in Western Australia and for the rest, I’m a GP at the Derby Aboriginal Health Service. Derby is a town of about 4,000, which also services a widely-spaced collection of remote communities, as well as an Immigration Detention Centre. About half the population is indigenous and there are also a lot of miners. At the hospital, I’m one of three obstetric GPs. I do antenatal care, deliveries (including caesareans) and General Practice through hospitalbased clinics and community visits – including clinics at the Immigration Detention Centre. I’m on the roster for the emergency department and I’m also involved in teaching medical students based in Derby, as well as throughout the Kimberley region. There’s also no oncall component with my role at the Aboriginal Health Service. It’s very varied! I’ve been here for about three months now and I’m really enjoying it, as the lifestyle is great – work is a minute from home, so I can easily pop home for lunch! We have a two year old daughter and we’re expecting our second baby in October. We often go bushwalking and camping on weekends in different parts of the Kimberley, which we love.

What influenced your decision to do medicine and then to become a GP? My father works as a scientist in the haematology lab at Perth hospital. After leaving high school, I went to the University of WA, taking a year off during medical school to teach English in rural Indonesia. I was interested in the wide range of specialty placements, which I really enjoyed – from emergency and paediatrics to psychiatry and General Practice. I realised that I’d get to do all those things in General Practice. I did a rural GP elective in the tiny wheatbelt town of Narembeen, right in the centre of WA. That cemented my decision a bit, because it gave me the chance to see how effectively the doctor had integrated his family and his work. He was really involved in the community, he would just drop in at home to have lunch with his family each day and they would come over to the surgery through the day for various things – it was a really good example of having that truly satisfying work/life balance. Then I did another rural GP placement in Carnarvon, in mid-West WA. By then I was in the last year of my training – it was really varied and very hands-on. It was the first time I had seen patients by myself, which was really empowering.

Where I am now, I’ve really got the best of both worlds. I’m still working half-time in a hospital, so I still get to experience the teamwork atmosphere that I really enjoy. But I also get the full independence of General Practice, which is so challenging and rewarding. To be honest, I hadn’t realised how much I would be able to direct my focus into a particular area. General Practice is flexible enough that you can still pursue special interests. For me, that’s obstetrics, but I have friends who ‘specialise’ in paediatrics, dermatology and sports medicine for example, within the framework of General Practice.

What skills have you needed to learn or develop to become a better GP? When I’d finished my training and was working in the hospitals for a while, I spent six months working as a doctor in rural Kenya, while my wife Caroline was teaching there. We did some other community development work, like treeplanting and rainwater harvesting and some education programs in the village. I had to help with a few deliveries and because of that experience, I came back and did additional obstetrics training. We’d both like to go back and work in the developing world again – having rural General Practice experience gives you the best range of skills for that kind of work. I think the key skills you need as a GP are communication, relationship building and the ability to think outside of the immediate problem. In reality, that equates to context, prevention and the impact treatments will have on the other parts of the patient’s life. I’ve had to learn to develop patience and realise that I can’t solve all the problems at once. I’ve also had to learn about helping patients to take ownership of their own health.

What are your plans for the future? I’d like to stay working as a rural GP in Western Australia, with a side trip of perhaps five years back to Africa, or somewhere else in the developing world, where I feel I could make a contribution.

How do you feel about General Practice now – and how does it compare to your early impressions of what being a GP would involve? I was always keen to do rural General Practice because I felt there would be much wider scope. Unfortunately, I had to pull out of the rural training program when my wife Caroline was unwell and we needed to stay in Perth for treatment. However, I trained under a fantastic GP Supervisor who taught me a lot of GP skills and completed my training in metropolitan General Practice.

Going Places – ISSUE #3

DR SHARNTI CAULLEY

A passion for Travel Medicine What’s your current role – and how did you get there? I work four and a half days a week at a four-doctor medical centre in a little town on the outskirts of Toowoomba in Queensland. I’ve been here nearly all year and I’m just finishing my FRACGP. The work/life balance is great here and because this clinic is part of a big group of doctors who share the after-hours on-call, there’s not much of it! I’m also doing half a day in a travel medicine clinic and completing a graduate certificate in travel medicine, through James Cook University. A lot of GPs have a special interest – it means you can do anything you want, which makes life far more interesting. For me, it’s travel medicine. I’m about to go to Tasmania to do my first course in expeditionary medicine. It’s snow and mountain medicine, so I have to dig a snow hole and sleep in it overnight, which will be a new experience! I’ve always been really passionate about travel and went to the travel medicine conference in Germany this year, which was awesome. In my travel medicine clinic, I talk to people about how to stay healthy overseas, covering things like food and water safety, vector borne diseases and, of course, vaccinations … and so on. There’s now so much adventure travel that many travel companies want a doctor on the expedition – particularly with older people travelling – so you’ll be given a free trip in exchange for your medical services on the trip. I grew up in Toowoomba, then when I left school, I was interested in genetics so I did an undergraduate degree in biochemistry at the University of Queensland. Although I enjoyed science, I didn’t want to be stuck in a lab all day, so I decided to do medicine because I’d also be working with people. I really enjoyed it.

What influenced your decision to become a GP? I must admit that, initially, I had no thought of doing General Practice. I had planned on doing anaesthetics and did quite a lot of work in hospitals. I was working in Dublin in 2008, doing emergency work involving lots of nights and weekends. I worked a 14-hour shift on St Patrick’s Day while everybody I knew was out having a great time.

The next day, an Irish friend told me, “This is my last day of emergency, I’m going to do General Practice and that means I’m going to actually have a life now.” In Ireland, General Practice is the most sought-after speciality and everybody wants to do it, so it’s hard to get into. I realised I wasn’t happy in anaesthetics because there wasn’t enough patient contact – the reality is that the patients are asleep most of the time so you don’t get to know them! It took the experience in Ireland, and seeing another viewpoint, for me to realise that General Practice was actually a fantastic speciality and maybe I should consider it. For me, what confirmed my choice is that my training was so good, I felt like they really mentored me a lot more than I’d had in any of my training in the past. They took a real interest and tried to help everybody find their own special interest. Now I can’t imagine anything that I’d rather do.

In the hospital system, you’ll meet somebody once and you’ll never see them again, whereas in General Practice you get to meet patients over and over again, and see how your treatments have either been successful … or failed! You can make a diagnosis and treat it accordingly, to see what happens as a result. I think you miss that a lot in the hospital system.

What are the main changes you’ve found since leaving the hospital system?

Every day you’ve got a patient in front of you, so you can’t go off and look up books. It took me a few months to get used to that fact.

I find General Practice is great. It suits me a lot better than any other role would. The things I like about General Practice, I realise now, are the aspects I wouldn’t have had in anaesthetics – like getting to know your patients, being able to follow up on what they’re doing and how they’re going, and getting to treat them from start to finish.

What skills have you needed to learn or develop to become a better GP? I have discovered that General Practice really is its own specialty, which it wasn’t previously in Australia, some years ago. You need to learn all about the different diseases that you see in General Practice. The approach is very different to hospital medicine. I thought I was ready for General Practice because I did so much work in emergency in the past, but it’s different.

What are your plans for the future? I’d like to work predominantly in General Practice and then have my own travel medicine clinic … and, of course, a few times a year I’d like to go on expeditions!

“I have discovered that General Practice really is its own specialty, which it wasn’t previously in Australia.”

Photography: Ian Day

Going Places – ISSUE #3

Financial Health Check Brought to you by McMasters’

You may be great in medicine … but maybe you need a bit of help with finances, which may not be your strong point? So, the objective of this regular column in Going Places is to cover a few basics to help you with your finances and keep them healthy. We’ll be taking a look at a range of topics, which we hope you’ll find relevant and interesting – we want to enlighten you about how to maximise the benefits of your hard-earned finances! In this first Health Check we look at purchasing and running a car.

Next, claiming running expenses. If you claim a high business percentage, your after-tax cost of the car will fall significantly. This example may help you. Dr Angela bought herself a sleek new Mazda 3 with all the options – her pride and joy – and it cost her just about $30,000, taking advantage of finance provided through the dealer.

Cars can cost a lot of money, so it’s probably not surprising that in virtually every client meeting, the “car questions” come up. What to buy? How much to spend? Who should own it? How much can be claimed for tax? Our view is that you should not spend too much on a car. Your money is better spent building up assets and creating a wealth base for later in life. Hold yourself back and consider something safe and reliable – probably costing between $20,000 and $30,000. We also suggest you buy second-hand – one or two years old – as you don’t suffer such a huge loss in its value as you drive out of the showroom! However, you may really like the smell of a new car and just can’t help yourself … OK, let’s look ahead and assume you are now being paid as a GP! As soon as you’ve purchased your car, get yourself a log book and record all your business travel for the next 12 weeks. You can buy a log-book at a newsagency or download one free from www.mcmasters.com.au The key point is that for most GPs, home to work travel is business travel, provided “bulky medical equipment” is on board, or at least in the boot. This is accepted by the ATO.

So, what is bulky medical equipment? Let’s start by mentioning the decision in AAT Case 9235 1994 27 ATR 127, where a doctor’s home to work travel was accepted as deductible business travel on account of the need to carry bulky medical equipment. Bulky medical equipment need not be heavy … just bulky! Certainly, patient files, your doctor’s bag, laptop and emergency equipment book comprise bulky equipment for these purposes and will get most GPs over the line. If there should ever be any doubt, we suggest you invest in over sized fishing boxes to carry “emergency medical equipment” about. Then you are not only safe on the tax side of things … … you are also equipped for an emergency! From the ATO’s perspective, bulky equipment is a question of fact and differs from case to case. But bear in mind the early court cases involved a rugby player’s sports bag and a musician’s saxophone. That’s why these cases apply to doctors, too.

She followed our advice and kept a log-book for a continuous 12 week period, whereby she carefully recorded each business trip she made using her car. She recorded her home to work travel as business travel on account of the requirement to carry bulky medical equipment in her car at all times. At the end of the 12 week log-book period, she compared the total business kilometers to the overall total kilometers she had driven during the log-book period. The professional use percentage for her car turned out to be 90%, which meant that she could claim 90% of the running costs of the car, including the depreciation on the car. Dr Angela’s tax benefits from owning the car is nearly $4,800 cash a year, calculated as follows: Calculation of tax benefits of the car (1st full financial year) Depreciation (25% of $30,000) $ 7,500 Interest on loan $ 2,000 Petrol $ 2,000 $ 2,000 Other costs (insurance, registration, service, etc) Total costs $13,500 Business percentage: 90% x $13,500 = Tax benefit @ 39.5% tax rate

$12,150 $ 4,799

Needless to say, everybody’s circumstances will be different, so this just serves as an example, and benefits will vary. Using professional financial assistance is a good investment and can achieve substantial financial advantages!

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 34

The sexual health and wellbeing GP DR ANGELA PLUNKETT I’m currently a GP Registrar doing an extended skills post in a Practice in inner north Brisbane. It’s an interesting Practice as we have a particular focus on lesbian/gay/trans clients, same sex parents and also people with drug and alcohol addiction, as well as mental health issues. The Practice owner worked for many years in the prison system, so all of this developed around his own particular interests. I have to admit it can be very challenging, but it’s incredibly rewarding – it’s just so fascinating to meet people who, in my dayto-day life, I might possibly not have come across! I’m working part-time, doing a few days at the Practice each week in clinical practice, combined with a day teaching medical students. My grandfather was a country GP in a remote area of New South Wales, so – as a young child, when we went there on holidays – I would pore over all his medical books enthusiastically. I can still remember what the surgery smelt like. I had a strong sense of what a GP’s life was in that very small country town setting, even back then. However, as I didn’t achieve top marks at school, I put aside any thoughts of studying medicine. Instead, I did an Arts degree with Psychology honours, then worked as a Psychologist for about ten years – first at the Children’s Hospital in Camperdown, Sydney, then at King George V Memorial Hospital (which closed in 2002 and is now part of the Royal Prince Alfred Hospital). During that time, I became interested in Public Health, so I did a post-grad in Public Health and then worked at Sydney Uni teaching that same course. At that stage, the Faculty was planning their graduate medical course, so I applied … and I was accepted. I had to go back and do physics and chemistry with a group of 20-something year old men. I was definitely the odd one out, as I was 32 by the time I started medicine and my oldest child was nearly three. I always knew I’d probably end up in one of a few areas – Paediatrics, General Practice or public health. Seeing what was required of people to train in any of the speciality areas in the hospitals made me realise it would come at a very high cost for myself and my family. I only have a small family, but I wanted to actually see my kids growing up. My kids did comment when I came off shift work in the hospitals and into General Practice. I know they found I was a much easier mum to have around! I did my hospital term at Royal Brisbane and Women’s Hospital with another woman – we were the first two interns Australia-wide to actually share an internship posting over two years. We both had two children and had studied together in the fourth year. We were very fortunate that the hospital responded incredibly well, and we job-shared for four years. I did several GP terms, starting with a rural term, then an outer metropolitan term in a satellite suburb, which had some interesting aspects to it. I was really fortunate to work with four very experienced GPs and saw the best possible side of General Practice you could possibly hope to see. After that, I came back into the city to do this extended skills placement, as I wanted to build on the work I’d done in my pre-

Photography: Warren Fleming

medical days. But I didn’t just want to continue to develop my skills – I wanted to train people in the importance of clinical skills, drawing partly on my own experience as a Psychologist, too. Clinical skills – taking a thorough history and actually examining people as they come through – are the building blocks of medicine. I have some amazing patients who come in to the Practice – many are homeless or people who are transitioning out of homelessness. One patient came in with his entire outfit made out of tea towels, with little safety pins holding the whole thing together. He was the most delightful character and I just couldn’t believe how he’d managed to survive in a big city for so many years. He was now linked into this service for homeless people and at the end of the consultation he offered to read my palm. We see quite a number of people going through the process of sexual transitioning. The transgender spectrum produces a wide range of patients – from young people to those who’ve been married, have had kids and have then realised that this really is a part of who they are. I’m really having my ideas challenged about what being male and female is all about – how identity is formed and how it can change over the course of a lifetime. As you can probably imagine, there’s always a very interesting waiting room at our Practice! Even 18 months ago, I’d feel quite shocked at some of the things I came across, but now it’s much more difficult to surprise me. This experience certainly makes me feel competent to discuss issues around sexual health. I think General Practice is often where people feel they can go for help, and it’s really incumbent upon us to become comfortable enough that we can have the discussion and provide the kind of assistance that people would like to have. You realise that, in one way or another, there’s a unique story for every single person on the planet. There are a lot of masks that people wear in everyday life that obscure their own “reality” from other people. It’s very heartening to see that reality and realise, yes, we’re all walking along a path of some kind in our lives. One of the beauties of General Practice as a job is that you are privileged to see the reality of people’s lives.

Going Places – ISSUE #3

s e v o l o h w P AG

NGTON I K R O T NDA DR AMA

Photography: Andrew Rankin

What’s your current role? Next year I complete my GP Registrar term. I’m actually combining a variety of part-time jobs – for the last two and a half years, I’ve done clinical work in a GP Practice in Charters Towers, south-west of Townsville. I do two and a half days a week there, plus my on-call load, which is one night a fortnight and one weekend in five, plus a Saturday morning in the Practice every five weeks. Then, for two days a week, I’m doing an academic post at James Cook University as part of my GP training, which involves some research and also teaching undergraduate medical students. My research looks at the mental health impact of fly-in, fly-out miners in Charters Towers. I’ve presented at a conference and I’m hoping to write this up and get it published. I had a great community response to my study – lots of my patients still ask me how it’s going. I’m also the Registrar on the board of my regional GP training provider and occasionally I’ll do some hospital work in Charters Towers, where we admit patients privately – but it’s not a big part of my job. All of this is a great mix because the work is quite complementary. The GP work can be quite intense when you’re seeing patients each day, so teaching gives me time to look at the bigger picture and also keeps up my skills because the students are up-to-date with the cutting edge aspects of medicine.

How did you get to the role that you’re in now? I was a rural kid and did my high school years in a small town near Townsville. I wasn’t sure what I wanted to do, so I did a broad science degree. Through that, I found I was interested in human physiology and always seemed to gravitate to subjects where the lecturers were clinicians. I took three years out, working in retail and then did postgraduate medicine. I did my internship in Nambour, a small regional hospital. It helped me appreciate the role of a GP as you do interact more closely than in the big hospitals. Then I spent two years as an RMO at Royal Darwin Hospital. I had lots of variety with emergency, obstetrics, paediatrics, palliative care, oncology and haematology. I also did a three month pre-vocational GP placement in a Practice in the town of Jabiru, in Kakadu. It was an interesting mix of everyday General Practice with the mine workers combined with lots of Aboriginal health, including some outreach clinics to the surrounding Aboriginal communities. My first Practice was in an Aboriginal medical service in Mt Isa, which was very interesting and great experience.

My GP mentors have been excellent, providing really good clinical support for me and they are very approachable whenever I’ve asked for help. I’ve never felt my supervisors may have thought I was stupid or that I couldn’t ask questions. I’ve been able to be very open about my deficiencies in dealing with them, so that’s been a really positive thing. It’s actually very collegial.

What would you tell someone considering a career in General Practice? As a junior doctor, you get to do surgery and medicine and obstetrics, but you only get to see how General Practice operates if you choose to give it a go. I would suggest to every junior doctor that they should do a PGPPP placement to explore General Practice as a possibility for them. It is the one specialty where this kind of placement provides an excellent and rewarding experience. If you do pursue another specialty, at least you know what General Practice involves, and that can help you in relating to GPs down the track, too. I would really encourage junior doctors to consider it.

What are your plans for the future? Ideally I would work rurally, but my partner had trouble getting work in a small place like Charters Towers. So, part of the reason I started the academic work in Townsville was to balance us both being able to get work and be fulfilled. My plans partly depend on all those other things that happen in life. The good thing about General Practice is that when kids come along, and you have a family to consider, General Practice is just so flexible. I could work in an urban setting or a rural setting – you don’t have that flexibility with the specialties. I do want to continue to balance my academic and clinical work. So, wherever I am – hopefully in a mid-sized place – I can enjoy the mix of community General Practice work and some teaching.

y t e i var What has the GP training been like for you? I’ve chosen the Rural Pathway for GP training, but I’m not a rural generalist, which tends to be a more proceduralist GP role. I’m far more interested in the community GP role. I like the consultations and treating relatively well people. I like preventative medicine, I like having elderly patients, I like having little patients … I really like all that variety together in one place.

Going Places – ISSUE #3

l a c i l i b m U

ff u fl

t lin

n o t t u b y l l be

Umbilical lint is colloquially known as “belly button fluff” (Am: navel lint). It describes the collection of a soft mass in the umbilicus, formed of textile fibres intermingled with exfoliated skin cells and occasionally the hair of the sufferer. Experience suggests that the disorder is common, but probably under-reported as many of those affected may find the disorder emotionally difficult to discuss1. The medical literature on this disorder is surprisingly sparse, and there are few high-quality studies in this field. Nevertheless, some significant advances in aetiology and treatment have been made in recent years. METHOD A literature search was undertaken of the Pubmed database using the search terms “umbilicus lint” and “navel lint”. Two relevant articles were found. An internet search was also undertaken using the Google search engine and the same terms. Over 50,000 hits returned, and the first 100 were analysed for relevance.

HISTORY The early history of umbilical lint is uncertain, because the disease does not leave any trace in the fossil record. It is likely that the disorder was first encountered when Neolithic man began using woven fibres for clothing 10,000 years ago. The oldest preserved example of umbilical lint was discovered earlier this year in a sealed 17th Century bottle found in London2, mixed with urine, and designed to prevent a witch’s curse. It is not known whether this was effective, but nitrogenous human waste has not been demonstrated to possess occult powers in other contexts.

EPIDEMIOLOGY AND AETIOLOGY Most of what is known of the epidemiology and aetiology of umbilical lint is due to the pioneering invitational survey in 2001 of

Kruszelnicki3. Although this included nearly 5000 participants, the sample is likely to be subject to response bias, and the study has not been subject to peer-review. The survey suggested the disorder affects 66% of people, with a 3:1 male to female ratio, but no racial predilection3. The single biggest risk factor for disease is the presence of body hair, and this may explain the gender difference in prevalence. Additional possible risk factors for the disease are listed in table 1, although these are largely anecdotal. Albert4 and Biesecker5 hypothesized that the origin of umbilical lint is from hair that traps clothing fibres and then directs these fibres towards the umbilicus (80% of those affected describe the presence of a trail of hair from the pubic area to the umbilicus3). However, this theory remains unproven, and importantly, extra-umbilical early-stage disease has not been documented. A disorder similar to umbilical lint can occur in the natal cleft and is known colloquially as “bum fluff”: this disorder likely has a common aetiopathology and affects a similar population.

CLINICAL REVIEW Umbilical lint is a chronic disorder, and may recur daily. In a longitudinal study6, Steinhauser found the most common mass of umbilical lint to be in the range 1.2-1.29g. However there is a skewed normal distribution, with values recorded as high as 9.17g. One individual has collected pathological specimens every day for 20 years7. It is not known whether this individual has coexistent psychiatric disease.

Preventative strategies have also been employed. There are reports that umbilical piercing or shaving of peri-umbilical body hair can prevent disease3. However, piercing carries attendant risks of soft-tissue infection13 and shaving must be repeated for sustained prevention of disease6.

The hertitability of disease has not been determined, but genetic determinants of hair morphology and structure are likely to play a significant role. Known molecular mediators of hair follicle growth include FGF, TGF pathways, Sonic hedgehog signaling, IGF, EGF, HGF, and PDGF as well as components of the cytokine and hormone signaling pathways8. These represent excellent candidate association genes for future research.

and socially stigmatising condition. There have been no studies on the psychological effects of the disease, nor have there been quality of life assessments in the afflicted population.

PATHOLOGY AND MICROBIOLOGY Electron microscopy has confirmed that umbilical lint is composed largely of textile fibres3. Lint may come in a variety of colours, but is frequently reported as of a dull blue/grey hue, no matter what the colour of clothing (Table 1). The reason for this is unknown. Culture of umbilical lint9 has shown the frequent presence of skin commensals, in particular coagulase negative staphylococci (75% of cases) and corynebacterium (75% of cases). Pseudomonas, acinetobacter, klebsiella and enterococcus species may also be found.

TREATMENT Self-treatment is frequently employed in the management of umbilical lint and the disorder rarely comes to medical attention. Digital evacuation of disease is the most common treatment regime, but the diameter of the fingertip10 can exceed the narrowest diameter of the umbilicus in some individuals, leading to incomplete treatment and residual disease. Consequently a variety of purpose made mechanical aids have been devised. This includes simple evacuation devices11, adhesive strips3, and a device utilizing the solidification of wax in the umbilicus to assist in cleansing12. Unfortunately these have not been subjected to randomized controlled trials, and their clinical effectiveness is anecdotal.

COMPLICATIONS Umbilical lint can be an embarrassing

FUTURE RESEARCH Although umbilical lint is clearly a prevalent disease, it has been the subject of very little research in the medical literature. The reasons for this are unclear, but the probable inefficacy of pharmaceutical treatments may be responsible for a lack of large-scale commercial investment. The onus is clearly on noncommercial researchers and funding bodies to further investigate this common but neglected disorder.

TABLE 1: RISK FACTORS FOR DEVELOPMENT OF UMBILICAL LINT MAJOR

MINOR

Body hair

Inverted umbilicus

Age

Washing clothing in a top-loader machine rather than a front-loader

Male sex*

New clothing

*may not be an independent risk factor cf. body hair

REFERENCES 1. Anon. personal communication, 2009; 2. de Bruxelles S. Witch bottle is uncorked to discover spellbinding content. The Times June 4, 2009; 3. Kruszelnicki K. Q and A with Dr K. Sydney: Harper Collins, 2001; 4. Albert T. BMA News Review. London: British Medical Association, August 1984; 5. Biesecker M. Technician. North Carolina: North Carolina State University, April 1995; 6. Steinhauser G. The nature of navel fluff. Med Hypotheses 2009;72(6):623-5; 7. www.feargod.net/fluff.html; 8. Stenn KS, Paus R. Controls of hair follicle cycling. Physiol Rev 2001;81(1):449-94; 9. Kikuchi M, Yano K. Lint in the belly button. J Plast Reconstr Aesthet Surg 2009;62(2):282-3; 10. Murai M, Lau HK, Pereira BP, Pho RW. A cadaver study on volume and surface area of the fingertip. J Hand Surg Am 1997;22(5):935-41; 11. http://trailerparkbarbie.wordpress.com/2007/12/11/homemade-gifts-for-your-tasteless-girlfriends; 12. Okajima T, Fujinami, S. Body recessed portion cleaning agent (US patent #2007/0041923). 2007; 13. Khanna R, Kumar SS, Raju BS, Kumar AV. Body piercing in the accident and emergency department. J Accid Emerg Med 1999;16(6):418-21. FOOTNOTE Although the colour of umbilical lint is grey blue, there is no known reason for this. In actual fact, the vast majority of clothing dyes are a variation of the blue tinted azo dyes such as disperse blue (featured on the British Contact Dermatology Society standard series for patch testing). Azo dyes consist of two aromatic rings connected by two nitrogen atoms which are themselves connected by a double bond. The resulting pi components of all the dissociated electrons merge to cross the nitrogen link giving a striking absorption pattern and a strong colour. A mix of the blue dye is found in all but the most opposing of colours. Aside from bright yellow and pure white, the resulting colour of clothing (including red, purple, black, green and brown) is often a mix of blue dyes. With the fashion for dark underwear amongst men, this would account for this problem with the hair tracking from the pubis to the navel providing the track through which fibres may travel. Coupled with this, the mix of corneocytes (surface skin cells) and clothing fibres will provide a natural chromatography as the fibres travel and collect at the navel, making all but the bluest hue dissipate to less noticable levels. Dr Avad Mughal. Specialist Registrar in Dermatology.

By Mahmood F Bhutta. This article first appeared in JuniorDr.

Going Places â&#x20AC;&#x201C; ISSUE #3

DR JANE WADSLEY

What’s your current role? I work at a GP clinic, which has a contract with the Fire Brigade in Melbourne. I’m also the Medical Officer for the Fire Brigade. That means I share the Fire Brigade medical on-call roster with another doctor and, if there’s a really large fire, we are called out as an on-site resource for them. In reality, we are only called once every few months, so it’s not an onerous role. The Fire Brigade has a really good database covering the effects of different chemicals, so we’re aware of those issues when there’s a big fire, but far more often we’ll be keeping an eye on heat stress in firefighters, especially in the warmer months. There’s normally an ambulance at fires as well, to actually treat people – so we’re there in more of an advisory role, checking things are running smoothly, then reporting back on procedures, afterwards. Most of my time is spent either consulting with firefighters to discuss different issues that they might have with work-related illnesses or injuries, or attending meetings with the Fire Brigade to discuss policies and rehab. I also take part in an ongoing health monitoring scheme for the firefighters. This is a confidential and voluntary service for all firefighters where they can have up to an hour with a doctor to discuss health concerns and have a preventative health

Combining General Pr Occupational Health check. A lot of them can be potentially exposed to high risks and they need to be really fit, so it’s important to catch cardiovascular risk factors and manage them, as well.

How did you get to your current role? I’m a GP but I have done a lot of occupational medicine over the years in different settings, as well as running the staff clinic at Peter McCallum Cancer Hospital and the Alfred Hospital, in Melbourne. I’ve even done some time in Pentridge, working in the prison hospital … now that was an eye opener! Most of the roles I’ve been in have involved being a doctor in various organisations and then helping with occupational health issues as well, so I’m more of a generalist rather than just doing occupational medicine. What I find fascinating is to see how people work and how their work influences their health. I studied medicine straight from school and decided to go down the General Practice pathway. As part of the rotation

in General Practice, I went to the Latrobe Valley and worked for a power generation organisation that has people working on all the big power stations. I was there for a year and that led to me becoming interested in occupational health, with the result that most of the jobs I’ve had involve doing General Practice within an organisation. Since my time in the Latrobe Valley I’ve seen more industrial sites than you can possibly imagine. I’ve been up the top of power stacks and at dockyards. We used to go on the warships and look down to see where the welders were working at the bottom. Sometimes it has been a real challenge ... I still remember how scared I was climbing out of the lift at the top of the Loy Yang Power Station years ago, onto an open mesh platform with absolutely nothing underneath me. I’ve been all over Commonwealth Serum Laboratories, looking at how vaccines were made. I’ve been in different sections of various hospitals – radiology, theatres or wherever someone had a problem and needed advice. Photography: Lachlan Moore

What influenced your decision to become a GP? I always wanted to help people and during my medical training, General Practice was the obvious choice for me. I’ve always liked variety and I think General Practice gives you a really good way of working in different areas and doing different things. I’ve actually never been a GP who’s worked in an office full time. I’ve always had a job where I would go out to do other things – for me that’s what has made it so much more interesting. Being a registered GP with additional training in occupational medicine is a really good combination of skills. Having General Practice in occupational medicine, you are so much more effective with a broad based skill base. It gives you a more holistic approach. As a doctor in that environment, you can be a real agent for change and see the results. Occupational medicine is very empowering – for example, you might see someone with a health problem related to their work. You can call their manager and go into the workplace to see how they work – then recommend changes to what they are doing.

ractice with

Dr Fairytale General Practitioner to the Stars

Dr Fairytale pays a home visit to his celebrity client in Wonderland for a diagnosis. Here’s his medical report. Multiple Drug Use

Despite her protestations, it is clear that Alice has a drug problem. Given any opportunity, she ingests potions, wafers and mushrooms without concern for her personal safety. She reports bizarre variation in her height, changes in her perspective, loses track of time and space - even her own identity. She also refers on a number of occasions to a hookah-smoking caterpillar, which suggests that her social network is that of drug users. More worryingly, Alice displays a total lack of insight into her problem and has created a fantasy to justify her drug-induced hallucinations.

EBV Infectious Mononucleosis

Infectious Mononucleosis is a diffuse disorder which, especially in adolescents and young adults, is characterised by fever, sore throat and fatigue. It can cause encephalopathies, which may include visual imbalance symptoms. Alice reports all sorts of odd things: talking white rabbits, morbidly obese twins and a mad hatter obsessed by teaparties. It would seem more likely that Alice’s symptoms are the result of this infectious symptomatology rather than simply ‘magical’. We know that IM is also known as the ‘kissing disease’ suggesting that Alice has probably not been as innocent as she claims.

Migraine with benign paroxysmal vertigo of childhood

Alice may well be suffering from severe recurring vascular headaches. A migraine is a neurological syndrome characterised by altered bodily perceptions, severe headaches, and nausea. These could explain how a young girl would start to talk about falling down a rabbit hole into a weird world full of odd things making her ill. In addition, several studies have found some migraines are triggered by changes in weather. The worst conditions for this being a high temperature mixed with humidity and we know that Alice was worst effected during a mid-summer picnic.

Alice in Wonderland Syndrome

I should probably mention Alice in Wonderland Syndrome (AIWS) – a neurological condition. The symptoms are the result of cells in the brain firing inappropriately, giving rise to unusual perceptions and experiences. Patients report visual distortions where things seem to be closer or further away, disturbances of time and delusions of their own bodies - for example, their head growing larger. The next time you see that person they are often so much better – and the managers are also really happy, because in many situations they just didn’t know what to do. I always like “closing the loop” rather than seeing people in isolation. I often see patients over a very long period and help them get on with their lives, even when they have a serious work injury or chronic pain. That can be very rewarding and fulfilling.

What are your plans for the future? I’ve still got a lot to achieve in the job I’m doing, so I’m not thinking of moving until I’ve achieved my aims of making the health system for the firefighters so much better. There are lots of challenges in this role that I really enjoy – that’s why it’s such a rewarding job.

In fact, AIWS or Todd’s Syndrome to give its dull name, is clearly a medicalisation of Alice’s attention-seeking behaviour. By claiming to have experienced such changes, Alice is making sure she is the focus of interest to everyone around her. I would strongly recommend avoiding giving her reported symptomatology any credence by allowing this term to be used.

By Dr Gil Myers. This article first appeared in JuniorDr.

Going Places – ISSUE #3

Are you a junior doctor with a passion for General Practice?

Help spread the word. Become a GP Ambassador.

This is a great opportunity for you to help raise the profile of General Practice career options amongst your peers, whilst you make useful contacts, have fun and are rewarded for your efforts! What will I be asked to do as a GP Ambassador?

What’s in it for me?

• You’ll help to establish and promote the Going Places Network to peers within your hospital.

• You’ll gain valuable knowledge that will be useful to you in your career.

• You’ll be involved in promoting educational, social and networking events.

• You’ll have a warm inner glow because you know you’re helping your peers decide their future.

• As a GP Ambassador, you’ll need to be visible and approachable – someone who is seen as being knowledgeable about General Practice … so you can give honest, helpful and useful advice to your peers and answer all their questions. You’ll be a source of valuable information about General Practice!

• You’ll receive a small payment for your time ($3000 per annum).

Don’t worry – GPRA and partner organisations will provide you with full training and support to help you do all this.

“It is fun for me to talk about something I am passionate about. I think the idea of having GP Ambassadors is great, not only for junior doctors considering doing General Practice but also for the profession itself!” Dr Lee, GP Ambassador

Be inspired!

This is a great opportunity to make new and valuable contacts – and to have lots of fun, at the same time!

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

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

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 things you can do to start Going Places in your career as a GP:

1. Join the Going Places Network Become part of the Going Places Network at your hospital. It’s a fun way to network with others who have an interest in General Practice, whilst developing your professional knowledge and credentials! See below for more information. Looking for the Going Places Network at your hospital? 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. 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.

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

4. Find a Mentor GPRA offers a great mentors program – GPs who are willing and eager to give you advice and one-on-one career coaching about General Practice. Simply register with mentors@gpra.org.au and you’ll be put in touch with a current GP Registrar.

Going Places – ISSUE #3

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