48-second GP consultations

Less is less

A recent BMJ study highlighted the remarkable degree of international variation in how much time GPs spend with their patients.

In Pakistan, a patient with a laceration would barely have time to explain how it occurred, let alone have it sewn up.

Whereas in Scandinavia, by the time the consultation ends, the wound has already healed by secondary intention.

Of the 67 countries studied, Australia ranks pretty much where you would want it – our 15 minute slots put us in the top quarter. Generous enough for a country that can afford it, without being inefficient.

Half of the world’s population—predictably, the poorer half—spend less than five minutes with their primary care doctor.

A couple of minutes is all you get in Nepal or China, regardless of how long it took you to travel to the surgery in the first place. I suspect there’s not much chit chat about the family.

KahnemanReading about consultations long and short made me think of the book ‘Thinking fast and slow’. Its author, Daniel Kahneman, won a Nobel Prize in Economics, so presumably he can think pretty fast when he has to. Continue reading

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‘Junior’ doctors: what’s in a label?

junor doctor

Image: ITV News

When is a junior doctor not a junior doctor?

The answer is not ‘When they grow up’, but ‘When they work in the UK’, according to England’s chief medical officer.

The ‘junior’ descriptor was flagged last week by an Oxford professor as being ‘unjust, progressively inaccurate and detrimental to self-esteem.’ Chief medical officer Dame Sally Davies agreed with him that hospitals should consider updating their nomenclature for doctors who have only recently graduated.

However, the online response from the not-senior-doctors themselves has been less supportive.

Some noted that delineations in levels of medical responsibility already do exist, for very good reason, so obscuring them with a more cryptic title helps nobody. Tell it like it is!

The ‘junior’ debate is merely the latest in the endless series of quandaries about naming groups of people. If there is one, universal rule about labelling for any population that is a minority or vulnerable, it is this: after a decade or so, the name gets on the nose.

I recall being amazed as a medical student when I discovered ‘spastic’ referred to muscle tone. Hard to believe it had once been an acceptable description for a disparate group of people whose care needs were defined by reduced mobility.

In my schoolyard, of course, the term was pure insult, and had been replaced by the far kinder ‘disabled’. Kinder for a decade or so, until that descended into the same sociological mire, to be superseded by ‘person with a disability’. Continue reading

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GP Sceptics podcast 12: Doctors’ resilience

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By Kat Ritchie

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What keeps a doctor resilient, when dealing with a high-pressure job helping patients who are distressed and traumatised?

How can doctors balance empathy with self-care? Does easing a patient’s burden imply carrying it for them?

Dr Genevieve Yates teaches the art of resilience to doctors around the nation, and here we distil one podcast-worth of her wisdom.

Listen to it after a long day at work, or when you’re feeling vulnerable.

Even better, listen in bed, where Justin’s soporific opinions will guide you towards a replenishing sleep. Look after yourself, folks.

In Liz’s Special Source, Liz takes a look at the funding and influences behind ‘Therapeutic Guidelines’ — hint: it comes out clean.

Liz reveals her pin-up nerdy-researcher boy (Justin’s is Ben Goldacre), and we invite Dr Google into the GP surgery.

All this and more, in our final podcast for this ‘RACGP Year’ (October to October).

NEXT UP will be our live podcast at the annual RACGP conference in Melbourne. (Yes, that IS Justin’s photo on that link page. My, doesn’t he look worth listening to!) 

We invite all of GP17 to join us in an hour of fun as we go live for the first time on the Saturday morning, at GP Sceptics live podcast – Interpreting media headlines.

Our Guest:

Dr Genevieve Yates is a multi-talented GP who does a little bit of everything. She is the RACGP Queensland Censor, teacher for MDA National, facilitator for the Black Dog Institute, was previously Assoc Director of Training for NCGPT, and has won Australia’s Medical Educator of the Year. She is an accomplished author, plays violin in the Australian Doctors’ Orchestra, acts on TV and on stage, and co-wrote GP the Musical. Quite frankly, she makes us sick.

References:

Balme E, Gerada C, Page L. Doctors need to be supported, not trained in resilience BMJ Careers, Sept 2015

Kearns H, Gardiner M. The Ultimate Time Management Guide for GPs (and in fact anyone in general practice) Published by Thinkwell

Beyond Blue National Mental Health Survey of Doctors and Medical Students 2013

Heneghan C, Goldacre B, Mahtani K. Why clinical trial outcomes fail to translate into benefits for patients 

Interesting reading: 

Doctors’ Mental Health Program A Beyond Blue program for health services

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GP Sceptics podcast 11: Medically Unexplained Symptoms

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Unexplained, by Kat Ritchie

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Medically unexplained symptoms (MUS) are physical symptoms not sufficiently explained by an underlying medical condition after adequate examination and investigation, over a period of time (usually defined in months, rather than weeks).

GPs face patients in this situation regularly, and not surprisingly, find it difficult to deal with. Our training focuses on reaching elusive diagnoses through the scientific method of testing and discarding hypotheses until – eureka! – we land upon the right one.

But what happens when, like the stockade, that eureka fails us?

And if you think that’s frustrating for the diagnostician, try being the patient!

In this podcast, we interview a GP from the Netherlands who is at the forefront of this field. Dr Tim Olde Hartman was the lead author of the MUS guidelines (pdf) developed for the Dutch College of General Practitioners.

The guide’s popularity soon made it clear that this is a universal problem around the world, nowhere more apparent than in general practice. When a series of specialist appointments have failed to diagnose a medical cause for a persistent symptom, the advice is inevitably “go back and see your GP”.

This podcast is for those GPs. Continue reading

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How to measure med student empathy

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An Irish study has indicated that female medical students rank notably higher on empathy scales than males.

Wait—that’s not the news. Almost every survey ever has shown females are more empathetic, to the point where I’m starting to think it is almost certainly true. Not that I care.

The more surprising finding from the study published in this week’s BMJ Open is that the Irish Health Professions Admissions Test (HPAT, the close cousin of Australia’s UMAT) seems incapable of predicting empathy.

This, despite the introduction of a section on the test called “interpersonal understanding”, designed to ensure that students selected by universities have the emotional capability for their demanding career.

The findings from the survey of 263 medical students in Cork weren’t watertight; the gold standard against which the HPAT entrance scores were measured was yet another survey, albeit a strongly validated measure of doctors’ empathy.

But it seems your score in interpersonal understanding on an entrance test has no correlation with your subsequent degree of empathy at any stage throughout the medical course. Continue reading

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The Fed endures, and so must we

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Competitive sport shouldn’t stop when you turn 30.

In case you missed the Wimbledon news, some old Swiss guy beat all the young pretenders. And he was two years younger than women’s finalist Venus Williams.

In fact, the combined age of the four male semi-finalists was the oldest in the tennis open era. A weekend for the ancients.

Federer’s graceful style used to give hope to teenage tennis prodigies. Now, he gives hope to old codgers like me.

Not that we might ever hope to be great, but instead, it says something about holding on. While both knees still work, there’s hope.

Admittedly, the Swiss master’s 35 years does not even take him back far enough to have ever known Dunlop Volley tennis shoes and wooden racquets. But in outlasting nearly all his peers, he drives home the message that competitive sport doesn’t stop at thirty.

We family physicians are familiar with the typical reduction of physical activity as people age. Primary schoolers run around like chooks, teenagers usually play sport regularly and often keep it up for a couple of years after school, but then—bang!

Too many lose the habit in their twenties, and the ensuing decades start to bring all the problems associated with a sedentary lifestyle. Continue reading

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Tamiflu: an expensive lesson in panic stockpiling

Swine flu

Oseltamivir (Tamiflu, Roche) has been downgraded by the World Health Organization (WHO) in the biennial review of its list of essential medicines.

A WHO expert committee removed Tamiflu from its list of “core” medicines, relegating it to the “complementary” list, a category used for drugs with consistently higher costs or less attractive cost-effectiveness.

This represents the latest blow to a drug whose sales hit $4 billion in 2009, riding on the back of worldwide stockpiling during the swine flu pandemic.

The spectacular rise and slow fall of Tamiflu is a cautionary tale worth remembering, if only to protect us from ourselves, the next time the public stampedes to pour money into the coffers of private industry.

Don’t forget; among the newspaper headlines screaming at politicians to stockpile Tamiflu in 2009, there was no shortage of doctors’ voices criticising any delay in access to the drug. Plenty of public health advocates—nearly all those with any influence—got it wrong, and we front-line clinicians were swept along.

The Tamiflu provided free to my Aboriginal health clinic provided the only opportunity in my entire career to stride out into my waiting room, spectacularly arrayed in gown, gloves and mask, to administer a drug to people who were mildly unwell with a fever. For two months I felt like I was on the set of the film, Contagion.

As it turns out, for my patients who did indeed have swine flu, the drug I so dramatically administered would have shortened their symptoms by just half a day, and not done a thing to prevent either complications or hospitalisation.

We only know of the extent of our mistake thanks to the dogged persistence of a few Cochrane reviewers, and the support of The BMJ. These folk noticed an anomaly that had eluded governments all around the globe, whose advisers were allowed to divert hundreds of millions of dollars from other public programs. Continue reading

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GP Sceptics podcast 10: GPs at the Deep End

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Mice-level research, by Kat Ritchie

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We invite Dr Tim Senior to reflect on being a GP for disadvantaged groups. He discusses General Practitioners at the Deep End, an initiative involving 100 general practices serving the most socio-economically deprived populations in Scotland.

Tim works at Tharawal, an Aboriginal and Torres Strait Islander health service in Western Sydney, and is also a prolific writer and thought-leader in Australian general practice. Although Tim has never advertised the fact, @TimSenior plus @realDonaldTrump together have almost as many twitter followers as @KimKardashian.

Justin calls out a couple of Australian researchers who overplayed a ‘breakthrough’ anti-ageing pill that has only been tested in mice.  In doing so, Justin happily overplays his own role in the subsequent Media Watch TV episode where he was (very briefly) shown raising an eyebrow about the miracle pill.

And we introduce the new segment ‘Liz’s special source’.

This segment is a chance for Liz to showcase a reliable, independent source of medical information. First up is the Trip Database, which Liz actually uses mid-consultation.

Tim is wise, Liz is sharp, and Justin can only admire them both from the shallow end.

References: 

General Practitioners at the Deep End, University of Glasgow website

Tim Senior on twitter

Media love a miracle, Media Watch episode 3 April 2017, ABC television.

Trip database, which describes itself as “a smart, fast tool for you to find high-quality clinical research evidence”. And we agree.

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Pain clinics: how did such a fresh idea turn sour?

EnDONE by Ben Frost

EnDONE by Ben Frost

A report from the NT coroner this week about an opioid-related death raises a question I started asking after my very first referral to a pain clinic: what is the point of referral if the patient comes back on the same — or an even higher — dose of opioids?

The coroner’s case involved a Darwin mother with chronic pain and an opioid addiction. Every doctor involved found the interaction difficult, and the patient’s use of the system repeatedly thwarted attempts at reduction.

Each time there was a plan to reduce her dose, a new acute pain event or crisis occurred.

Other medications started creeping in — a sleeping tablet, and pregabalin (Lyrica), which seems to have somehow marketed itself as the high-dose alternative for desperate situations.

One of the frustrated GPs referred the patient to a pain specialist.

If I was designing my ideal pain clinic, it would consist of a specialist doctor (a physician or GP), a psychologist, an exercise physiologist and perhaps a social worker. I could refer patients who had a fixed belief that high-dose medication was helping their chronic pain, even though I observed the exact opposite.

The psychologist would help reframe the meaning of chronic pain. The physiologist would get them moving again, shifting the focus back to function. The specialist would oversee the safe but very strict reduction of their inappropriate analgesia. Contracts would be signed, prescriptions monitored, and we might actually get somewhere.

This coroner’s case typifies why I have almost given up on pain clinics for patients with opioid problems. Continue reading

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Not just a GP – I’m your specialist in uncertainty

uncertaintyAs a GP I’m your ‘specialist in life’. Yet life, as we know, is a tumultuous, unpredictable creature.

What I actually specialise in is managing chaos.

It’s no exaggeration to boast that, after 25 years of constant practice, I have mastered the art of uncertainty.

Mastery is not an end point, of course — the day an expert stops learning is the day expertise wanes. But I, along with thousands of my GP colleagues, am about as good as it gets.

Collectively, we experienced GPs constitute the A-team of sorting out the whims and vagaries of all of life’s assaults upon health.

Give me a thousand people with a fever (or just hang around my office for a year) and I’ll sift through them more accurately, safely, swiftly and cost effectively than any other health profession in Australia.

It’s what I do.

I’ll do it cheaper than a paediatrician, safer than a nurse practitioner, with fewer tests than an emergency physician, and with better outcomes than a whole host of alternative therapists.

Ditto for a thousand folk with tiredness, pain, worry, dizziness or nausea. Or indeed, a thousand well people who want to stay well.

All these grand claims are based upon one underlying precondition: uncertainty. Continue reading

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