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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GP Sceptics podcast 9: The Environment

Justin in lycra, small, Kat Ritchie

Justin’s lycra legs, by Kat Ritchie

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Justin dons his finest lycra and tackles Dr George Crisp, WA chair of Doctors for the Environment Australia.

How do health gains in the doctor’s surgery stack up against environmental and population-based interventions? Could the nanny state be good for our grandchildren, and does Liz actually believe in wind farm health conspiracies?

Liz wonders if her recent public health-screening day with medical students did anyone any good, while Justin suspects that ego is, at least in his case, a dirty word.

We encourage listeners to join Doctors for the Environment Australia 

References:

The Cost-Effectiveness of Environmental Approaches to Disease Prevention Chokshi D, Farle T. N Engl J Med 367;4 July 2012

Upstream or downstream? By medical student Victoria Smith Med J Aust 2015; 203 (10): 412-413

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Let’s celebrate the bolt-cutter surgeon

bolt cutters

When orthopaedic surgeon Chris Phoon sent someone to a local hardware store in Bega, NSW, to buy bolt cutters mid-operation, his admin bosses weren’t impressed.

But I was.

Dr Phoon’s hospital-supplied bolt cutters snapped mid-operation and his attempt to source a pair from Canberra Hospital failed. Time for plan C.

Staring at a stubborn steel pin needing urgent removal means only one thing to a red-blooded Aussie male…Bunnings!

Quite unreasonably, in my view, the surgeon’s heroic attempt at pulling the pin was frowned upon by the hospital administrators, whose lawyers pulled the pin instead. The plan was abandoned mid-operation and the patient may be still, for all we know, languishing somewhere on the hospital’s 247-day-average surgical waiting list.

Now, I’m as guilty of poking fun at my orthopaedic friends as the next bloke—guiltier, because I put it in writing. Like when the orthopod took six days to solve a simple jigsaw puzzle and was proud, because it said “From 4-6 years” on the box.

But these bone grinders aren’t hired to lead group discussions around whether psychological therapy helps healing after a fall out of bed.

If I have a thick metal shaft poking out of my leg and the fella with big hands tells me I’m better off without it, I want to wake up with it cleaved in twain and in the bin. Keep subtlety for the soft tissues. Continue reading

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Greater transparency on specialist fees: a no-brainer

$7 and a Medicare card

The question as to whether medical specialists should make their fees more transparent has long ruffled a few feathers.

The debate is raging afresh this week, sparked by a new study of billing data that reveals wide variations in specialist fees. The study, published in the Medical Journal of Australia, finds fees can vary up to five-fold within a single specialty.

As with any service, of course, some providers are of higher quality. But this is unpredictable. And as the study authors note, the rationale for fee variations is opaque without data on quality of care in private outpatient services.

An accompanying commentary cites unpublished research by the Royal Australasian College of Surgeons which finds “no correlation between the size of the fee charged and the quality of the surgery”.

Commenters have been quick to react, noting that the cost variation may reflect differences in office rental costs, the time spent per appointment, and the experience of the practitioner.

While these may be valid arguments for the existence of cost variation, they do little to counter the contention that costs should be made more transparent for consumers.

As a rule, transparency is the grease that keeps supply-and-demand systems running smoothly, and the confusion of the specialist fee system should be no exception. Continue reading

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Four Corners Big Vitamins exposé: cuts both ways

Vitamins, by Steven Depolo

Photo: Steven Depolo

Last night’s Four Corners exposé of Big Vitamins marketing their supplementary pills via community pharmacists would have had doctors throughout the nation nodding their heads.

We only have to walk past a pharmacy shopfront to see how rife the problem is. Clearly most pharmacist-owners see it as a profitable—some would argue, a critical—part of their business plan.

As for pharmacist-employees, most are presumably resigned to selling these supplements by the kilo, and some would perhaps believe the industry’s own hype that ‘pick me up’ vitamins really do pick people up. Even well people, with clean livers.

The issue is not so much the selling of products in a free market, but the dubious veneer of scientific credibility, beginning with exaggerated or false advertising claims and ending with a highly trained, trusted professional. As a pharmacist said on the show, “If they’re after complementary medicines, then I’m happy to provide them”.

After such media reports featuring sceptical doctors, inevitably some commenters retort by questioning why they pick on pharmacists, when the medical profession itself is so influenced by Big Pharma. Something about sinners casting the first stone.

And, you know what? They have a point. So, let’s lob a few stones in every direction, even if a wall of my own glass house cracks. Continue reading

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Five reasons why I’d still encourage my child to do medicine

Back Camera

If you read the wrong kind of comments in the online medical media – as I do, religiously – you might conclude that retiring doctors are glad to be leaving the sinking ship. These disembarking medicos  proclaim they would discourage their child from ever boarding the leaky vessel. Why commit to years of study, long hours, frustrating paperwork, little respect and crappy pay?

After all, being a doctor is a tough gig these days. Especially if you stretch ‘these days’ to include one million days ago. Hippocrates noted in his opening line of the first ever book about the burden of being a doctor, “Life is short, and art long, opportunity fleeting, experimentations perilous, and judgement difficult”.

Life is less short since Hippocrates’ day, but the rest still rings true. Today’s graduates will face increasing bureaucracy and regulation. Recent reports highlight the threats of bullying from within the profession and of litigation from without—although I’d argue neither is escalating.

Would I encourage my child to do medicine? You bet I would, and here are five reasons why. Continue reading

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GP Sceptics podcast 8: Marketing

kat-ritchie_pod8_marketing

‘Carrots & Sticks’ by Kat Ritchie

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Doctors try to ‘sell’ behaviour change to patients, who are often reluctant to ‘buy’ the message. What tricks can we learn from the modern experts at selling?

Justin and Liz bite the bitter bullet and enter the strange world of marketing.

We grill Dr Ninya Maubach, whose former life involved a PhD in marketing, but who has now seen the light and is studying medicine at ANU. That’s a powerful combo when it comes to teaching doctors how to sell a message.

Our starting point is a paper ‘Carrots, Sticks and Promises’, and it turns out that most of our attempts at behaviour change involve the least effective selling method: “I promise that if you stop this pleasurable thing today (e.g. smoking, lying on your couch), you will reap rewards in the future.”

That message is pretty easy to trump (are we still allowed to use that word?), and plenty of full-time tobacco and food industry marketers know just how to trump it.

Turns out the ‘stages of change’ model  we all learned (precontemplation, contemplation)may not be so useful after all. Continue reading

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Google Health Cards: the first test drive

google-health-cards

Google’s new health cards became active in Australia just a few hours ago, so I figured I’d be first to give them a test run.

Health cards are Google’s attempt to give the lay public sensible and evidence-based results on searches for medical conditions.

The ‘cards’ appear as a stand-alone box to the right of the usual Google search results, and contain a few sentences and a picture.

For example, when I type in ‘cold’, the usual, familiar results appear – first is my local weather (despite today being decidedly warm!) followed by the hits from more than a billion search results.

But in addition, a new box automatically appears, labelled ‘Common cold’. It contains an artist’s impression of nose-blowing (happily, a ‘before’ image with the tissue still clean) and three clickable sections: About; Symptoms; and Treatments.

Each section typically contains a couple of brief statements and some dot points. The health information is general, but accurate, having been developed in conjunction with doctors from the Mayo clinic. No unpleasant surprises suggesting your cold might require antibiotics. Continue reading

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GP sceptics podcast 7: EBM Hijacked!

 

pod7-by-kat-ritchie

by Kat Ritchie

 

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Just when you thought GP Sceptics put the E in evidence-based medicine, we pull the rug from underneath your trusting feet.

Western Australian GP Casey Parker, of Broome Docs fame, joins our twosome to become the ‘third nerd’ – a role which fits him like a cardigan and a new pair of glasses.

Casey delves into EBM’s dark recesses, where p-hackers subvert the concept of ‘significance’, and RCTs answer all the questions no one bothered asking.

Justin discusses a hot-off-the-press systematic review revealing the over-optimism of doctors.

And Liz? Liz invites us all aboard the EBM gravy train.

Bonus nerd points for any listener who comments below correctly describing when affect is a noun and effect is a verb.

This podcast is dedicated to the fond memory of the late Prof Gavin Mooney, editor of Evidence-based medicine in its place.

Thanks to Dr Kat Ritchie for her brilliant artwork.

Continue reading

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Does the weather affect our joints?

midsummer

Therefore the moon, the governess of floods,
Pale in her anger, washes all the air,
That rheumatic diseases do abound.

A Midsummer Night’s Dream

Long before Shakespeare, vagaries in the weather have been blamed for flare-ups of joint pain. The rheumatic curse seems to redouble on a cold, wet day…or is it a hot, dry one?

But a new study from The George Institute casts doubt that we can ever really “blame it on the weather”.

In every place I have ever worked, patients will swear their knee or back pain has eased since they moved to that town, crediting their temporary cure to the local conditions. Curiously, this remains true regardless of where I am working at the time, whether at the bottom or the top of Australia: from the windswept southern coast to the burning central deserts or humid tropics.

Are rainfall, humidity and temperature really affecting my patient’s joints, or is there a less exciting interpretation? Perhaps joint pain is a randomly relapsing condition, and we humans love attributing causation whenever two unrelated events roughly coincide.

Previously, researchers at the George Institute published a study where 345 Australians with confirmed knee osteoarthritis recorded their pain scores. No correlation whatsoever was found between pain flares and the local weather conditions (temperature, precipitation, humidity, barometric pressure).

This negative study, which countered such a long-held belief, not surprisingly copped plenty on social media. Contrarian anecdotes flew in faster than a cold southerly over Bass Strait.

So other researchers decided to see if they could replicate the findings in different circumstances. Continue reading

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