Confusing red and green things in our bloodstream
Last month’s column was ‘Dealing with uncertainty’, and I haven’t got any better at it, so figured I’d stick to the theme. Might even make it a series.
This month’s uncertainty involved a haematologist—I’ve never actually met one, but that wasn’t the uncertainty. I do believe in them, based on the phone evidence.
Anyhow, I listened to him discussing cytochrome p450, then he mentioned HLA-B27, and right about there is where he lost me.
The thing is, I have trouble visualising things named with numbers. Especially little things. If you’re going to float about invisibly in the bloodstream, at least have a sensible name, like RBC.
RBC – Red (yep) Blood (gotcha) Cell (bingo)! Continue reading
Gandalf ponders a management plan dilemma
My GP registrar’s body language suggested the tute was going poorly, although I blamed the topic: ‘Dealing with uncertainty’.
In retrospect, I could have stuck to medical examples, instead of opening with Gandalf’s dilemma about when best to attack Sauron.
My plot synopsis inexorably led us even further from doctor-patient interactions and into the dark tunnels of Moria. At which point I noted the aforementioned body language sending mixed messages—she was nodding, yet also pacing furtively backwards towards the door.
She stopped, embarrassed. ‘When can we discuss actual doctors having to deal with uncertainty?’
‘I’m not sure,’ I replied. Then, warming to the theme, added, ‘Deal with it!’
The US Choosing Wisely
What interventions do you think GPs should do less of? Do you think we sometimes prescribe inappropriately or order too many tests? I’m not talking about individual anecdotes, but widespread trends accepted as ‘normal’ in some parts of Australian general practice.
I am chairing the RACGP working group for the NPS MedicineWise Choosing Wisely initiative, tasked with developing a list of five tests or treatments which GPs should be doing less of, or not doing at all.
Published for the first time ever, below are 28 suggestions and our shortlist of ten. We will hone these down to the five best ones and formally launch them on 29 April 2015. Continue reading
Photo taken by the author just before eating fish and chips.
I love being a doctor. I love the variety, the capacity to touch lives. But most of all, I love the holidays.
The very best bit of my job is not doing it, and instead doing the crossword on the beach.
I won’t name my favourite holiday town for fear of spoiling it: quite frankly, I don’t need you there. Instead, I’ll code it anagrammatically.
Your presence would be superfluous, because sQueencliff already overflows with relaxed doctors: many so relaxed they’ve retired or died. I know these things because for six years I was these retired doctors’ doctor, and I also lived opposite the cemetery. Probably should have split that sentence into its two unrelated halves, actually.
It’s more fun being a relaxed doctor than looking after one. Whenever I holiday in a small town I always envy the local GPs, but of course in my imagination I’m sandy footed and solving cryptic crosswords between appointments.
“Do your urine sample at the surf club just past that jetty, Mr Jones, while I complete 6-down: ‘sQueencliff, idyllic village’. No rush.”
Bowel charts are a thing of the devil. I hate even mentioning them. In fact, I won’t; let’s talk about blood glucose diaries instead.
A bunch of folk just like me, but sweeter, fill in a smattering of glucose columns whenever they can, missing a few days while getting on with their lives. They never bingo all eight sugar boxes on the one day, because they are normal, fallible human beings. They diarise to please their diabetic educator, who secretly knows that the patient eventually learns to write fiction and will merely go through the motions. Which brings us straight back to bowel charts.
Examining the motions is acceptable only in very isolated social groups: mainly microbiologists or dung beetles. Even then, it’s only ever someone else’s sh**. Describing your own waste products in any more than vague terms is, as I say, diabolical.
I have a middle-aged patient—let’s call her Julie: the name and gender have been changed to protect his identity. Actually, his real name is Julian. Julian is a hypochondriac with a comprehensive approach to health—all known diseases are divided into those he has had already and those still to come. Although he is essentially a good person, Julian owns a bowel chart. Unsatisfied with the date and time column, he devotes two thirds of his page to description. And, unlike my diabetics, this white space is never left unsullied. Continue reading
Gandhi looking for salt
Recently I have found myself becoming more pugilistic and less pusillanimous.
Or, to use fewer ‘pu’ words, more disputative and less tentative. Simpler still – and with apologies to women and rats – more man and less mouse.
Not for me the Gandhian civil disobediences and passive salt marches of yesteryear.
No, never again will I walk the long route to buy condiments. Gandhi’s passivity ruined a good pair of sandals, when he could have bought the salt locally and yes, even forcefully.
My refusal to be pushed to the back of the queue in the supermarket spice section is just one minor example of my newfound capacity to stand up for myself. It also fits nicely with my new preferred descriptor, ‘seasoned warrior’.
It all began with a few letters to the editor in the online medical media. I padded up nonchalantly for replies, but soon found myself facing Mitchell Johnson on a dry Perth wicket. Continue reading
Most conference presentations wash over my spongiform brain and swish straight down the drain. But one presentation at last month’s Australasian Medical Writers Association conference (forgive the plug) stuck in my mind, almost as if something had sealed up my brain drain (perhaps another plug?)
It was UNSW psychologist Jason Mazanov discussing performance enhancement in sport. He began with a fascinating thought experiment: ‘Imagine there was a drug that improved your performance as a doctor by 20 percent. Would you take it?’
Well yes, obviously, especially if it involved a double-shot macchiato delivery system. Late on a Friday, 20 percent would be conservative.
But then Mazanov asked whether, if it resulted in the same improvement permanently, we would choose to have a brain operation. His point was we don’t baulk at enhancement per se, but draw a line when it comes to the method. And everyone’s line is different.
NAP launch, 11 Oct, Adelaide
Pic by Stuart Anderson
In the month since first appearing on the 7.30 Report, the No Advertising Please campaign has gained substantial media interest, reaching the shores of the US and UK. (Updates 6 Nov in red)
Below are links to all the TV, radio, print and video news I could find. I have included a couple of ‘double ups’ in major newspapers, but have otherwise ignored syndication and blog mentions. Some of the pharmaceutical media articles require log-in.
The NAP website. Web designer and webmaster David Townsend. Content: Justin Coleman and 24 other NAPsters.
ABC 7.30 Report, Tracy Bowden.
Radio National with Fran Kelly (minutes 26 – 32) Justin Coleman
4BC radio w Michael & Clare, Justin Coleman
Radio Adelaide 101.5 fm w Angus Randall, Jon Jureidini
Justin Coleman was also interviewed on Sydney 702 ABC, Darwin 105.7 ABC, Sydney 2GB, Sydney 2UE
Jon Jureidini was interviewed on Adelaide 891 ABC
MJA Insight, Ray Moynihan. No to marketing.
BMJ, Amy Coopes. Australian campaign aims to stop visits from drug representatives. BMJ 2014;349:g6183
Croakey.com, Justin Coleman. New campaign urges doctors to stop seeing drug reps.
Guardian, Melissa Davey. Australian doctors to ban drug company reps from visiting surgeries.
Sydney Morning Herald, Harriet Alexander. Rebel doctor group calls for ban on drug reps.
Tonight the ABC’s 7.30 report will feature an idea I dreamt up six months ago, called ‘No Advertising Please’.
Twenty five enthusiastic doctors and health advocates from around Australia have put together a campaign we are proud of.
As readers of this blog will know, I believe that patients’ interests are best served if doctors distance their clinical decisions from the influences of marketing and advertising. Medications are a vital tool for doctors, and pharmaceutical companies have every right to try to maximise their profits – clearly this will involve advertising.
However, doctors have a duty of care to their patients to ensure that their prescribing choice is based on the best available evidence, and on their knowledge of the particular patient circumstances. This choice should not be influenced by which pharmaceutical sales rep happens to have visited the doctor’s surgery in the past month.
The ‘No Advertising Please’ campaign asks doctors to consider the evidence – which we lay out in detail – that seeing drug reps does directly influence prescribing decisions, and that those decisions tend, on average, to be less appropriate as a result of marketing.
The delightful Aussie colloquialism ‘sickie’ can describe both the person who is sick, and the time taken off work to allow said sickness to flourish to its full potential.
Unfathomably, many employers still require a certificate even for one or two days out of the cell.
Diagnosing such brief, self-limiting illnesses relies entirely on the history anyway, so in effect the poor patient has waited 45 minutes tell you “I was unable to attend work from TUESDAY to WEDNESDAY due to a medical condition.”
This completes the only known consultation where the one sentence covers all four components—presenting complaint, history, diagnosis and management. I usually cut-and-paste x4, and hope Medicare doesn’t audit my notes.