A textbook case walked into the room


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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Vitamins: mostly harmless, mostly profitable

VitaminsVitamin D is mostly harmless. Sure, it can cause toxicity (mainly hypercalcaemia), but usually at megadose levels of around 60 capsules per day.

Vitamin C is also mostly harmless. My parents, advised by the medical zeitgeist when I was a child, gave us one citrus-flavoured tablet every day during winter.

And extracted fish oils are mostly harmless, except of course to the extractees: the fish.

Another thing these three supplements have in common is that they are all wildly successful products of health marketing. Marketing that uses ordinary doctors to amplify the message…doctors like you and me.

Arthur Dent (upon reading the description of planet Earth in The Hitchhiker’s Guide to the Galaxy): “Is that all it’s got to say? Harmless! One word?”

Ford Prefect: “I managed to transmit a new entry off to the editor. He had to trim it a bit, but it’s still an improvement.”

Arthur: “And what does it say now?”

Ford: “Mostly harmless.”

Douglas Adams

As highlighted recently the US has seen almost a tenfold increase of vitamin D sales in the last decade compared to the previous. Yet a recent meta-analysis  of 33 randomised trials showed that vitamin D or calcium supplementation has no effect on the incidence of fractures.

After years of venerating the “D”, it seems the vitamin is more often a marker associated with an illness rather than its cure. Continue reading

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Post-truth therapy: alternative medicine with alternative facts



Sweeping out the dirt


Being a medical sceptic is a hard gig, these days. Our negativity cops bad press; we lack the faith of traditional healers, the chutzpah of health bloggers and perhaps even the imagination of Donald Trump.

Lift the carpet to scrutinise the evidence for surgical procedures or pharmaceuticals, and detractors will point out that at least western medicine eventually responds to scrutiny – so how about first sweeping out the badlands of alternative medical practices?

But, take a broom to the dust at the foundation of so many complementary medical claims, and devotees will tell you to first get your own house in order.

We critics get used to sweeping criticism.

So, when the RACGP approached me last month to write their official submission to the Senate Report on the TGA reforms, I keenly obliged.

Over the last couple of years I had written the RACGP Choosing Wisely recommendations, aimed at reducing unnecessary procedures and treatments. Or, if some staunch traditionalists are to be believed, conspiratorially aimed at undermining the very basis of our rights as doctors to order whatever we want.

Having disturbed the peace at home, the TGA submission was a chance to kick up some dust over at Alternative House.

“More than a thousand claims…the majority are unscientific”

The issue is the bill before the senate that will allow manufacturers of complementary and alternative medicines to make therapeutic claims for their products without pre-approval. Marketers will be allowed to choose a claim from a selective list. Continue reading

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Drug seeker basted me like a turkey

Turkey, by Ben Sanders

Illustration: Ben Sanders

This month I got done over by a drug seeker. Tattoo Man basted me like a Christmas turkey, peppered me with garnished praise and slow baked his way through my seasoned outer crust. Bugger.

Usually, when it comes to slamming the script pad shut, I’m all Fort Knox.

Reception deliberately sends all hopeful newcomers down dead-end street to my brick wall. Five minutes later they exit, loudly proclaiming to the waiting room that, in effect, my clinical decisions are being influenced by the rather unlikely combination of both my genitalia and distal GI tract.

Funnily enough, those occasions are relatively easy. My patients in the waiting room know me well enough to guess what might have happened. And everyone knows their role: the receptionists blame me, as instructed, and I blame our Practice Policy—the only thing I’ve ever written which remains unsigned.

“Sorry madam, I’d love to help now that your grandmother mistook your oxycodone for pot plant fertiliser, but Policy says no. Those bureaucrats in Canberra are blighters, aren’t they!” Continue reading

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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


By Kat Ritchie


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.


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

Kat Ritchie_unexplained_symptoms_small

Unexplained, by Kat Ritchie

soundcloud     itunes-logo

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


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


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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