Australia’s best doctor comes in from the bush

What I imagine I’d look like if I swung my stethoscope like C.Dundee

Dear big-city-GP-job-agency Sir

After years living in the remote NT, for my Christmas present I would like to unwrap a new GP job in a place with more than one general store. I believe you call them supermarkets, but even two or three ordinary markets would be fine. Somewhere big.

Your job ad optimistically requests a long application letter, yet my CV requires only a single line:

I am the best doctor in Australia. No question!

However, I guess you might actually have a question. Let me pre-empt it, by starting with my medical degree.

I didn’t get the highest mark in my entire year just to be an ordinary doctor, okay?

(More truthfully, that should actually read:

I didn’t get the highest mark in my entire year. Just to be an ordinary doctor was okay.

But who am I to limit your imagination with punctuation?)

As Australia’s number one intern, obviously every specialty courted me. The cardiac surgeons offered guaranteed college membership if I aced 18 months at the Royal Melbourne. The orthopods offered full college Presidency if I aced 18 holes at the other Royal Melbourne.

I remained undecided as I blitzed my way through the hospital system—self-nominated Intern Of The Year two years running!

But then my ED consultant made a seemingly trivial observation. “General practice is the easiest specialty to do badly, and the hardest one to do well.”

I retorted that where I come from, we spit on ‘hardest’ and eat it up for breakfast.

Even as he mumbled something about my family being unhygienic, I had made my decision. ‘Twas the GP life for me.

Although I had already mastered hearts and bones (and sand bunkers), upon becoming a GP Registrar it took quite a few weeks to excel at all the other bodily systems. Patients have so damn many of them, and if you’re not careful they’ll mention two within minutes!

Needless to say, within a month I had already outstripped my rival Registrar colleagues. I diagnosed lupus three times in my second week, back-to-back carcinoid syndromes and a progeria.

Look it up. I didn’t have to.

Soon I was offered all the best GP rotations in Australia. A Nigerian email even guaranteed me a coveted position at Yale and Harvard (which turned out to be the name of a bulk billing clinic in Ipswich).

But not for me the bright lights of the city and its plurality of supermarkets.

Encouraged by my Melbourne GP Supervisor at the time, I took up the challenge of a career a very long way from Melbourne.

“The most suitable job in Australia for the best GP like yourself,” she said, studying the map and pointing rather randomly towards the middle, “is here.”

Mistakenly, her finger landed in the unpopulated Central Australian desert, but just two fingernails away lay the township of Tennant Creek, famous for its light aircraft and GP jobs. Within a week I had landed both.

At the behest of my fellow GPs, over the years I steadily moved my jobs further and further north, until I ran out of map and found work in Darwin. My diagnostic capacity hit that town like a cyclone (too soon?) as I brought a raft of fresh new diagnoses to a place that for too long had rested on its laurels of rheumatic heart disease and melioidosis.

I discovered rare cases of Lyme disease, a progeria (again!) and the NT’s first ever diagnosis of frostbite, in a woman whose arm had come off after she fell into a crocodile-infested river in Kakadu. Definitively frostbite, or at least a similar diagnosis within the bite family.

Within only a few months of working with me, my peers suggested that someone of my calibre should not be bounded by map edges. They gazed wistfully at the ocean and almost guaranteed that if I swam far enough north I would strike land.

On the Tiwi islands somewhere off Australia, this career ladder finally reached the very top rung.

Being the best of the best is not for everyone. Technically, in fact, it’s only for one person at a time and that person is called the GOAT. I recall the medical fraternity calling me exactly that as I swam offshore.

But now this apex doctor has returned to the mainland. Buckle up, Brisbane GPs, if you can handle the competition.

So would somebody please give me a job?

This article was first published in Medical Observer, Dec 2021

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Tiwi GP – I can run, but can’t hide

Justin – Wurrumiyanga 5km finish (17’05”)

As the local doctor on a small island, for three years I have struggled to ensure my personal lifestyle choices don’t stray too far from my professional lifestyle advice.

Around here, my conduct doesn’t have to pass any pub test with AHPRA or even Twitter—it has to pass the pub test at the pub.

When I say a small island, the Tiwis are second only to Tasmania in size, but the population is tiny. With just one person per 300 hectares, you can drive for a couple of hours without seeing a lone soul. Most of the lone souls are at the pub, getting less lonely by the hour.

That’s where the small-town problem starts. After a long day in the tropics spent telling a full list of patients not to drink too much, it’s nice to wind down with a cool glass of relaxant.

Hypocrite much? You bet your hypocritical oath I am.

Pubs in the remote NT are a throwback to the good old days when there was more smoke in the air than oxygen. Two thirds of my patients smoke daily, and the other third seems to make a special exception down at their local.

The only upside is that no one further than five feet away can see what their doctor is drinking.

I usually avoid the caliginous atmosphere and instead sip wine at home. Not that this escapes scrutiny – you can’t purchase wine on the island, so have to pick it up during a Tuesday two-hour window when the barge sails into port. Half the town is there to remark on your choice of beverage.

My mate at the barge offered to pack mine in a pharmaceutical box labelled, “Medicinal. To be administered only by a doctor.” One nocte. Maybe two, if pain persists.

What I lack in teetotalism I try to make up for with exercise and sporting activity. If the good folk of Wurrumiyanga witness their physician being physical, it will assure them my lifestyle advice is sincere.

Heartfelt exercise, and not in the anginal sense.

I may not be the fastest runner on the Tiwis, but I am certainly the oldest. Teenage footballers stop mid-speckie to marvel in the grey-haired fella jogging by.

“Mantani” they call out to me. “Old man” here is the exact opposite of an insult. I believe it’s a nod to my accrued wisdom, although it well could be a mark of amazement that I passed the age of 50 without COPD or claudication.

All else being equal, I prefer to exercise out of sight of onlookers. My mouth gasping for air acts as a 4wd snorkel, making all my fun-run photos look like Munch’s “The Scream”.

Regardless, I run right down the middle of the main street, in full view of the town centre. I figure this selfless act of public exertion might inspire a few townsfolk to heed their doctor’s advice.

Plus, that’s the road with the fewest camp-dogs. Once bitten, twice shy, and if there’s a third time I’ll take up indoor yoga.

The term ‘camp dog’ turns out to be a legal pearl, whereby the dog only has an owner up until the moment it bites someone.

A moment so oft repeated that our clinic’s wound-dressing Medicare revenue could almost pay for a dedicated statue of dripping teeth: The Canine’s Canines.

As soon as it behaves badly, the offending camp dog suddenly becomes stateless. Its immediate past owners claim the mutt has recently been living in the next street, gathering ticks and antisocial chewing habits so common downtown.

Despite the dog numbers, our store rarely ever sells a bag of dog food.

Your camp dog style is more scrounging for leftovers; ribs of a Sunday roast, tail of a camp-fired wallaby, calf of the slowest jogger.  

So I’m learning to run faster.

Although I’m not a morning person, running early avoids the heat.

Prior to moving to my island home, I had never before witnessed a sunrise outside an all-night poker game, but it seems humans are capable of both waking and exercising at such an hour.

The pain, the tears, the endorphin surge as I hit the wall—all inevitable consequences of trying to leave my bedroom in the dark without waking my wife.

But once I find my way outside, watching the first sunbeams pierce the Arafura Sea is worth the effort. Splendid!

The concept of moving fast without a footy in your hand is a novelty up here in Rioli country. I didn’t invent jogging—it already existed in rudimentary form before my arrival—but by George, I’ve helped popularise it.

Follow my advice and do as I do. Just don’t take a peek inside those pharmaceutical barge deliveries.

First published in Medical Observer, June 2021. Photo by Jane Astalosh, 19/6/21

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Coleman’s guide to poisoning and the dark arts

After listening to my most recent podcast on toxicology an anaesthetist friend reflected that his job essentially involves poisoning people with potent toxins.

He could have made a fine living as a Royal Poisoner in the Middle Ages, except for his soft spot for administering antidotes towards the end of the operation.

Scheming royals traditionally considered that sort of thing a character flaw.

The ancients liked their poisons irreversible. Anyone who accidentally woke up in the recovery room was given a pillow, but not in the modern sense. Let’s call it airway management.

When Therapeutic Guidelines: Toxicology approached me to do a podcast I jumped at the chance.

I had always been fascinated by those Russian spies who could drink enough vodka to kill a bear yet die soon after sipping a cup of tea.

So, imagine my disappointment once I discovered the book was all about managing accidental poisonings rather than being a Soviet instruction manual.

Useful as a GP reference, but as a bedtime read? Very putdownable.

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Bad Habits

Serenity

The wellness industry sells good habits to those who can afford them but don’t need them. Superfoods for super dudes.

Turmeric, quinoa and curecumin; so easy to sell, even if hard to spell. Actually, it might be curcumin. Or cumcurin?

Not cucumber, which isn’t considered a superfood, despite those sandwiches having kept our Queen alive for longer than any other celebrity.

And I bet you Ma’am doesn’t take rhodiola root powder in her Earl Grey.

Regardless of spelling, modern society gives the worried-well ample opportunity to get even weller, for a price.

Happily for marketers, the wellness scale has no upper reference limit, which means no one can ever reach peak health, at least while there’s a coin in their purse.

COVID-19, touted by conspiracy theorists as an infectious disease (that’s the unwellness talking) is instead a gift to wellness promoters. Because if you don’t have it you are, by definition, well.

That’s almost everybody — a market of very well people who won’t stay that way without help.

They will be kept well by the purveyors of hydroxychloroquine, organic house sprays and celebrity chef BioChargers ($25k and there’s not even a Thermomix setting.)

Living a natural lifestyle never cost so much. Continue reading

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Avoiding doctors like the plague

Tojetti_bee_sting

“The bee sting” Virgilio Tojetti 1898

Unlike many colleagues, I have no tales of being inspired to study medicine by my childhood family doctor, mainly due the fact that I didn’t have one.

Logic tells me those vaccine syringes didn’t plunge themselves, but I honestly have no memory of ever visiting a doctor. My parents opted for the set-and-forget method for the health care of their many children, recklessly ignoring the danger posed to GP income streams.

I’ve met a couple of colleagues who share my doctorless upbringing, but they both had a father who was a GP. Being treated by a parent is frowned upon, but at least they own a script pad.

My mum must have cottoned on that the medical board had no jurisdiction over part-time librarians, because whatever couldn’t be put right with aspirin and poultice would be managed by me lying down in a corner and reading—quietly—until it healed.

Dad was no better. He was a barrister, back in the days when that was a more appreciated skill than being a barista.

He almost took me to a doctor in the summer of ‘78, after I was stung by a bee in our front yard. Instead, mum talked him into a trial of placebo—a trip to the Kew pool.

As I walked barefoot across the hot grass to the pool edge, a second bee flew at me (technically, made a beeline) and stung my other leg! Dad suspected I was crying wolf until I pointed out the golden assassin writhing in its death throes. No, I was merely crying.

My swelling leg finally tipped dad into definitive action—at the pool shop he bought me a Paddle Pop instead of the usual Icypole.

Nope, no doctor for grazes, gastro or gluten tests. I suspect if I’d lost a fingertip they would have sent me out looking for it. “And bring us back the superglue with your good hand.”

Skip forward four decades, and I have become the very thing I had been trying to avoid all my childhood: a GP (no, not a third bee, obviously).

In one of life’s remarkable coincidences, it seems that my children also turned out to be the type whose parents rarely sent them to doctors.

To be fair on their mother, this neglect was paternal in origin. She often raised her eyebrow at my recalcitrance and even, when occasion demanded, raised her ire—this involved two eyebrows, plus sharp movements of the tongue.

I occasionally gave in. I did take one of the kids to the doctor when he lacerated his face under my watch (“The swing was an unpredictable torsional pendulum, yer honour.”)

The only available doctor was my junior registrar, so I oversaw the suturing, but his name was most definitely on the invoice, so it still counts.

Probably the most pressure brought to bear was when our youngest son hadn’t started walking by 21 months. My hand-drawn normal distribution curve had become less reassuring over the months—though I’m still chuffed my wife never spotted my distortion of the horizontal axis.

She started collecting opinions from friends who were teachers and physios and other sensible people, dropping these into dinner table conversation. Get him to a paediatrician. It seemed the whole, slightly underqualified world was against me. If Facebook was a thing, she would have recruited the trolls.

My explanation that my lad was merely a skilled negotiator—convincing his older brothers to ‘fetch’—started to look thin as his second birthday approached.

Then one day he just upped and walked. Attaboy! A month later he ran. Maybe he just didn’t require anything out of reach before then.

I hope my kids don’t have the same neglectful attitude to their own children, not least because we GPs need all the customers we can get these days. It’s fine to avoid doctors like the plague, until there is one.

The new telehealth items are the way to go: the perfect solution for the reluctant parent. On your precious day of carer’s leave, why let the Weet Bix go soggy while seeking a medical opinion?

Pour the milk, Skype the GP and hold your baby up to the camera.

Are they pixelations or a rash? Ah whatever—she’ll be right.

 

This article was first published in Medical Observer, June 2020

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Podcast 14: Alcohol-related harm in general practice

REACH_alcohol

(43 mins)

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GP team Liz Sturgiss and Justin Coleman bring the GP Sceptics podcast back to life, and this time it’s all about alcohol…but not in a good way.

Liz leads a Monash University project called REACH — for you, that’s “Reducing alcohol-related harm in General Practice”. As usual, I’m just the guy who asks the dumb questions on your behalf, as you while away your time during coronavirus lockdown.

This podcast is all about encouraging behaviour change.

The experts in the podcast are Liz herself (you’ll recognise her distinctive voice and smart questions) and two of our favourite GP-experts (see below) who have built their careers on maximising the chances of someone reducing their alcohol intake as a result of an ordinary consultation with their GP.

Nothing fancy, but if every GP got 10 per cent better at it, the effect on Australia’s physical and mental health would be formidable.

Dr Paul Grinzi is a GP in North Melbourne who educates about alcohol and other drugs for the RACGP. We ask him about his tricks of the trade when it comes to taking an accurate history of alcohol consumption, and he describes how to subtly prompt patients to come up with their own ideas of what might motivate them to change.

I loved his concept of GPs being ‘actively curious’ in what makes the patient tick. Listen in to find out how to become a ‘travel agent of change’.

Dr Hester Wilson is a Sydney GP, a lead clinician in the GLAD (GP Liaison in Alcohol and other Drug) Project, and Chair of the RACGP Addiction Medicine Network. She discusses the new Australian Guidelines on reducing health risks from drinking alcohol (2020).

Although you may have never thought of yourself as a cheerleader, Hester describes how GPs should cheer people on towards healthier behaviours.

Finally, Liz takes me to task with a ‘What would Justin do?’ dilemma, which quite frankly was my easiest yet. I blitzed it!

Happy listening to your 43 minutes of GP education. Soundcloud and Apple links will be added soon.

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Managing diabetes is not all about expensive medication

After 2 1/2 years, Dr Justin Coleman finishes as Editor of the Diabetes Management Journal. He will continue to remain involved with the DMJ, as a member of its Editorial Advisory Board. This is his final editorial.

Around 100 articles have hit this editor’s desk over the past 2½ years, journeying us through a hundred different aspects of managing diabetes.

The desk itself has gone on a journey too, when last year I transported it from Brisbane in the southern half of Australia (yes, check the map) to almost as far north as you can go. The Tiwi Islands just cling on to the nation, counterbalancing Australia’s only larger island—Tasmania—on the opposite edge.

In terms of diabetes issues, the people walking into my general practice have considerably more in common with East Timor to the north than with most Australians to the south. Here, type 2 diabetes (T2D) is so common that it is a general expectation.

My small community of 1600 includes 22 people on haemodialysis, with almost as many again waiting in the big city to ‘return to Island’ when a haemodialysis bed becomes free. Where I live, ‘new bed available’ has become a sad euphemism to mark the ultimate end-point of our diabetes and renal management.

So when an article lands on my desk discussing cutting-edge technology around the artificial pancreas, or a drug research breakthrough, I have to remind myself that most Australians live in surroundings where these advances will improve lives. This progress heralds an exciting future for those who are already effectively accessing what we have now, and many readers of the DMJ will soon be delivering it. Exciting stuff!

Yet in my time at the helm, I have also made sure to commission plenty of articles that go back to the basics, to ensure we do them well. After all, it is at the ‘blunt edge’ of medicine—far from the news headlines—that most health gains are made.

Primary health care, rather than the specialist diabetes clinic, is the health home of most Australians who have T2D. A few dip in and out of tertiary clinics and private hospitals offering advanced complex care, but it is the daily work of general practitioners, diabetes educators, dietitians and exercise physiologists—often generously supported by endocrinologists—that meets the bulk of the care needs for Australians with diabetes.

If asked to list the things that really matter, I’d note that diet, physical activity, weight loss and simple, cheap pharmaceuticals (hypoglycaemics and cardiovascular preventatives) carry the load. Management of these basic factors does not require much advanced technical knowledge, but absolutely requires skills around ‘what is likely to work’ for the individual with diabetes sitting in front of us.

Take something as simple, cheap and basic as physical activity. By any measure we know it is beneficial for people with diabetes; let’s not limit the claim—it is beneficial for life as a human!

For a sedentary person, the end-goal of ‘more activity’ is backed by more research than a health professional could possibly need, and has greater health benefit than any front-page medical advance this century.

Yes, the goal is obvious, but not so the solution.

After all, that same goal would equally apply to a Brisbane business executive attending a corporate health check and to a Tiwi man I opportunistically pluck from my waiting room. The real skill—the subtle art—is in finding the ‘solution’: an approach to management tailored to that individual.

The  exec may benefit from their GP having read DMJ articles about High Intensity Interval Training, tai chi (see p23) and barriers to exercise, while my clinic staff might take more note of DMJ features on poverty and diabetes, free community exercise programs and exercise with diabetes complications.

A sedentary lifestyle, a poor diet, and an obesity issue are all wicked problems that demand that the health professional has access to a kit full of evidence-based, low-tech tools. Selecting the right tool requires communication, trust and an ongoing relationship nurtured over time.

Sometimes the intervention will involve something new, exciting and shiny—wearable technology or a novel drug class—but don’t confuse the ‘thing’ with the ‘process’.

Diabetes management is no sprint race.

The Feb 2020 edition of the DMJ is available here.

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My perfect medical statistics day

I don’t know how others celebrated International Statistics Day, but I decided to dedicate an entire morning clinic to the cause.

If I’m honest, I usually drift into the old habit of seeing each patient as an individual, but for once I made a concerted effort to treat everyone as a statistic.

I didn’t want any atypical patients ruining my outcomes, so I worded up my receptionist Joan about who to book in.

“Please exclude anyone who has heart failure, doesn’t speak English or is on two or more medications.” She raised a dubious eyebrow. “Oh, and I want them allocated randomly.”

Joan’s eyebrow went decidedly bell-curve. “Randomly how?”, she protested. I gave her a coin to toss and a friendly wink. She means well.

The first patient on my list was “Baby 4136 (gender blinded)”. Joan had received my memo about de-identification.

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GP Sceptics podcast 13: Nurses’ conflicts-of-interest

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Few ever talk about it, but it’s not just doctors who are courted by the medical industry. Nurses are also frequently targeted when it comes to promoting pharmaceuticals and medical devices.

Barely anyone except Quinn Grundy talks about it, in fact, so Liz Sturgiss and Justin Coleman point the microphone at this registered nurse who did her PhD on that very topic.

The extent of what Quinn reveals will surprise you…it most certainly surprised all the nurse managers who were sure she would find nothing when she started digging.

From surgical devices to wound dressings and pharmaceutical purchasing committees, it turns out nurses have far more influence on where money gets spent than most people assume, not least the nurses themselves.

The only ones not surprised are the companies who have been pouring substantial resources into reps educating nurses, thereby ensuring their brand features prominently when it comes to spending taxpayers or patients’ money. Unlike marketing to doctors, there are no legal restrictions to marketing to most nurses, and few health services have even considered the issue.

I know nurses at my general practice continue to see ‘educational’ reps who promote expensive wound dressings, glucometers and other devices, a full 10 years after our GPs stopped seeing reps altogether.

The discussions around the ethics of this seem to be a decade behind, within a nursing profession which is otherwise such a champion at the forefront of promoting best practice.

Dr Quinn Grundy is a postdoctoral research assistant at the Charles Perkins Centre at the University of Sydney, soon to assume a faculty position at the University of Toronto.

She has just launched her wonderfully titled book Infiltrating Healthcare: How Marketers Work Underground to Influence Nurses   [The code DNB290818 gives a 15% discount]

Quinn mentions the dataset Pharmaceutical industry payments to healthcare professionals which is my go-to database for discovering the degree of links between doctors quoted in media articles and the pharmaceutical industry. That dataset was almost going to sit on my website here, actually, after a friend of mine collated all the reports mandated under the Medicines Australia transparency arrangements. However, I figured the University of Sydney had better lawyers and thicker skin, so I facilitated its publication there.

Also in the podcast, Liz delves into the Therapeutic Guidelines series and finds they come up clean as a whistle when it comes to independent expertise. Such a fantastic evidence-based resource for prescribers! Justin interviewed Susan Phillips, the CEO of eTG, at the recent GP18 conference.

In the final segment we look at the latest controversy from wonderful troublemaker John Ioannidis who has dreamed up a world where professional associations don’t get to author their own guidelines.

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A textbook case walked into the room

Pityriasis

Textbook rash with a ponytail, by Ben Sanders

Four days ago, a textbook case of pityriasis rosea walked into my room. Well, technically it was the girl who walk in…the rash was just a hanger-on. But to me, the rash was everything.

The more I looked, the more textbook it became. It was as if a Murtagh’s patient education handout had grown legs and a ponytail.

The lesions weren’t just red—they were salmon-pink. Salmon-pink, I tell you.

If an Atlantic salmon had leapt into her T-shirt and flopped around in a “Christmas tree” pattern for a few minutes before being sustainably released back into the ocean, those lesions could not have looked more classic.

“And I don’t suppose that oval patch on her back appeared 7-14 days ago did it, Dad? Goodness, see how the scales attach to the outer border of this herald patch like a collaret? Your daughter has become a thing of rare beauty Mr Smith! A textbook case.”

Note to self: it is more exciting to diagnose a textbook case than to father one. Beauty, as it turns out, is only skin deep.

Addendum: the modern man neither knows nor cares what a collaret is, which is somewhat of a shame. The dapper legacy of the early dermatologists has been supplanted by the drab business tie.

Back to textbook cases, however. Have you noticed how few there are about, these days?

Not just rashes, but all the classics seem to present rather half-heartedly. Continue reading

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