GP Sceptics podcast 11: Medically Unexplained Symptoms

Posted on August 10, 2017 by
Kat Ritchie_unexplained_symptoms_small

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

Posted on August 4, 2017 by

empathy2

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

Posted on July 19, 2017 by
Federer

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

Posted on June 21, 2017 by

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

Posted on May 20, 2017 by
pod10_mice Kat Ritchie small

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?

Posted on May 11, 2017 by
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

Posted on April 21, 2017 by

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

Posted on April 18, 2017 by
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

Posted on March 14, 2017 by

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

Posted on March 7, 2017 by

$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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