Do you know what you don’t know? Want to find out?

Here’s a fantastic new list of things doctors should consider avoiding. The list is the brainchild of GP Rob Park, who borrowed the brains of hundreds of doctors on the GPs Down Under facebook group.
Plenty of food for thought.

FOAM4GP

How can we know what we don’t know?

question-1018843_960_720

I asked an amazingly brilliant GP, who has been one of my long time mentors, why he had had a few patients with a TSH <0.05 for many years. He replied that he titrated to T3/T4 levels as he always does. He was horrified when I showed him that best practice is to titrate to TSH not to T3/T4 and that his patients were possibly at increased health risks. He couldn’t believe it! How could he have been practicing for such a long time and never come across this!! In reality, his patients felt fine, and therefore there was no opportunity for feedback. And this doctor is brilliant! It is SO easy to keep doing what we have always done and not know if it is best practice!


“Makes you think – what might you be doing in not the best way?…

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Calling all hospitals: reduce Pharma marketing

MJA pharma

My 2014 No Advertising Please campaign, while aimed at all doctors, ended up impacting mainly on GPs. The pledge not to see drug reps is more easily fulfilled when one is in autonomous, private medical practice.

However, it is equally important that prescribers working in hospitals choose their medications on the basis of best evidence rather than marketing.

In today’s Medical Journal of Australia (MJA), I co-author a paper with Monash doctors Dr Jessica Dean and Prof Erwin Loh.

We call for a severing of ties between pharmaceutical sponsorship and hospital-based medical education. Continue reading

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I could have been a logician

Dr 'Grand Master' Only 10,000 hours away?

Dr ‘Grand Master’
Only 10,000 hours away?

With medical jobs so commonplace, I sometimes fantasise about alternative career choices.

Three logicians walk into a bar. Says the bartender, “Would all three of you like a cider?” The first logician replies “I don’t know,” the second also says “I don’t know,” so the third one says “Yes.”

I got that joke immediately, which suggests I might have made a good career logician. Except I doubt such a career exists. Ergo, I’d currently be an unemployed wannabe and unable to afford cider.

Incidentally, my answer to the bartender would still have been correct; not my fault his question conflated the desire to drink with the ability to pay. Never lend money to a logician.

The thing about doctors is, in different circumstances most of us could have chosen other careers. Even interesting ones. I might have chosen music if I hadn’t jammed my left hand in Mrs Bell’s patio door-rail while attempting to escape a piano lesson early. In retrospect, it was my sliding door moment. Continue reading

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Cochrane 2015 – writing for a non-expert audience

Cochrane15Apologies to anyone reading this who is not currently listening to me live at my Cochrane Symposium writing workshop (Melbourne, Wed 25 Nov); I’m teaching clever researchers how to write for ordinary folk. I have just dumped a few exercises and links for workshop participants.

If you’ve been falsely lured here via automated social media alerts, and have read this far (second paragraph means you’re a bit curious) please feel free to browse around my other posts. If nothing else, the tedious nature of this one makes the others look brilliant in comparison.

Given the Cochrane theme, I humbly suggest starting with, How Archie Cochrane flipped the medical world on its head

The workshop content starts below: Continue reading

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GP’s pocket guide to the partialists

partialistAs a career generalist, it’s easy to forget that many friends from med school – even some of the smarter ones – chose to limit themselves to just one organ. Medicine is a broad church, and every church needs an organist.

Don’t get me wrong: these partialists serve a purpose. During my full day dealing with whole people, it can be a relief to involve someone who has the time to tidy up the loose ends.

“We’ve sorted your diabetes, depression, cardiovascular system and digestive tract today, Mrs Jones – would you mind if I left your knees to my assistant? He only does two out of the four limbs, but luckily the two he chose include both of your knees.”

Here, for the busy GP, is my pocket guide to the organists:

Ophthalmologists. They chose the smallest bits of all –just 15 grams worth of human. The back-of-eye sub-partialists complain that the cornea guys just aren’t carrying their weight. Continue reading

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Today Tonight: product promotion dressed as health news

Today TonightLast Friday on the Seven Network’s Today Tonight (TT), an episode on arthritis featured respected GP Dr Robert Menz, who gave a very solid interview – warning about the over-use of opioid medications, and promoting exercise and weight loss.

Dr Menz, speaking on behalf of the RACGP, would have known the TT episode’s byline – Are doctors over-prescribing pain killers for arthritis? – quite reasonably concluding the topic was worth comment. I am also a spokesperson for the RACGP (disclaimer: not at this very moment!) and also happily add my GP voice to various health issues.

However, what the good doctor didn’t know was that the whole episode was a thinly disguised advertorial for the products of two multinational companies, IBSA Biochimique and Bioceuticals (Blackmores).

In fact, virtually the entire footage besides Dr Menz’s interview was cut-and-pasted from two previous TT episodes promoting the exact same two arthritis pills.

Dr Menz’s footage was substituted for the sections in the previous episode, where marketer Andrew Mowbray was given air time to offer his opinion as to how good his product was, and TT journalist Annelise Nielsen helpfully noted the company had just received TGA marketing approval. Talk about lucky timing – the very same month in which arthritis was recognised as an issue worthy of the TT audience. Continue reading

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How Melbourne Uni survived 20 years without me

Monument to my dreams as a young man. (My dream was the one in the middle)

Monument to my dreams as a young man.
(My dream was the one in the middle)

As I walked through the grounds of Melbourne University last week—my first time for twenty years—I decided to dedicate this column to medical students.

I felt poignantly nostalgic about my own experiences, and also judged it an opportunity for a cheap laugh at the most vulnerable fish in the pond. Nothing like a good belittling to toughen their scales: necessary armour if these minnows are ever to grow up to swim with the College of Sturgeons.

I had arrived at Uni on a crisp Melbourne morning, an hour before I was due to lecture, and strolled across the glistening South Lawns. The only change was a new statue of a scantily clothed angel, uncannily reminding me of my 18-year-old attempts to study anatomy while lying on those very lawns, amidst clusters of fine arts majors.

I paused at the entrance to the Brownless Medical Library, feeling a sense of pleasure previously only ever experienced at its exit. Inside, I managed to locate the same, thick volume of Muir’s Pathology that had supported me all those years ago. It had always been a little firm on the cheekbone, but had raised my head above the desk just enough to curb snoring. Continue reading

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Fifteen things good doctors should avoid – Choosing Wisely II

Less is moreThis is important reading if you’re a doctor.

And maybe of some interest even if you’re not.

Following this year’s successful launch of the Choosing Wisely Australia campaign by NPS Medicinewise, we have produced a second round of recommendations about unnecessary tests, treatments and procedures.

I chair the RACGP working group, and we have just shortlisted the  fifteen items shown below. Yesterday we sent the list to all RACGP members for a ‘top five’ vote, although many wanted to vote for all 15!

This is part of the important conversation among doctors and patients that sometimes, less is more. Over-testing and over-treating can harm patients both directly, and also by robbing time and resources that would be better spent on things that are actually helpful.

No surprise if some items are a tad controversial – we have deliberately focused on tests and treatments that are commonly used by Australian doctors.

Screening

  1. Don’t routinely perform a pelvic examination when doing a Pap smear or prescribing an oral contraceptive
  2. Don’t advocate screening mammography in women < 50 yo or > 74, unless high-risk
  3. Don’t order colonoscopy as screening test for bowel cancer in the 98% of population where faecal occult blood testing (FOBT) is recommended

Continue reading

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Don’t just sign on the dotted line: assessing fitness to drive

My friend and colleague Genevieve Yates tells her tragic story of losing her partner to an elderly car driver earlier this year. She reminds us that driving is a privilege, not a right, and that doctors who sign ‘fitness to drive’ paperwork have a responsibility which extends beyond the person sitting in front of them.

Genevieve's anthology

The RACGP 15 conference is on in Melbourne next month and as part of the focus on social media, there is a Pecha Kucha competition.  Members of the Facebook group, GPs Down Under, are being encouraged to prepare a Pecha Kucha talk – a 6min40sec talk comprising of 20 slides, each lasting 20 seconds – on a topic about which we feel passionate.

I have put together a talk to try to raise awareness of the importance of the doctor’s role in assessing our patients’ fitness to drive. I also talk about the valuable “virtual” support that can come from online communities.

I hope that by sharing my personal story in this way, it will help encourage other doctors to be more mindful.  This might just result, indirectly at least, in someone’s husband, wife or child being spared. Of course, I have no way of knowing if it will, but…

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The neglected art of stopping medications

Whenever a medication is re-prescribed, some thought should be given to the important art of ‘deprescribing’.

Doctors are taught far more about starting medications than stopping them, and most pharmaceutical research ignores the ‘cessation’ question altogether. Each 6-monthly round of prescriptions inevitably seems to include more than the last.

Some categories of drugs are particularly prone to outstaying their welcome, long after the initial problem has resolved – just think of antidepressants, opioids and vitamin B12 injections.

Our team of five GPs on the Choosing Wisely Australia initiative decided to highlight the example of stomach antacids as a classic example of over-prescription.

These ‘proton pump inhibitors’ (PPIs) are wonderfully effective at reducing acid reflux symptoms, but unfortunately patients tend to stay on them long after the symptoms have resolved. Not only for months, but years – even decades!

Why? Well, heavy marketing helps, and also the aforementioned relative lack of education and discussion among doctors about pressing the ‘delete’ button in their prescribing software.

DEPRESCRIBING: the one topic you can guarantee never makes the agenda during a pharmaceutical-sponsored education evening!

Last week I put my creative juices to work, and produced this 3-minute video about deprescribing PPIs. It took far more hours’ work than I like to admit (I had to learn to draw, for a start!), so please do share it on your own social media if you can.

Even if you’re not a prescriber yourself, a share might go a little way towards highlighting the issue. By the time we all get old and juggle ten medications, we’d better hope plenty of research and educational effort has been put into deprescribing!

 

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