In the past year, I have been subject to two notifications via AHPRA. This seems to be a trend across Australia, with numbers of complaints/notifications rising. A recent Age article demonstrated this and some of the predictive factors. For a junior doctor like myself having only practiced for three full years, it was like getting hit with a truck full of bricks. Of course I won’t to go into details, but suffice to say nothing permanent gone onto my record. However in both cases (one being from a parent in a tertiary ED and the other from another doctor), I have learnt a great deal. Yes the medical board is there to protect the public, but both times I had the feeling of having to prove my innocence, not the other way around. I’m sure that it is more the way my mind appreciated the situation rather than the intended effect of the process, but it certainly feels for want of a better word…shithouse.  The length of time taken for each issue was also appalling. It took at least 4-5 months from initial notification to final outcome. This is something that the big GP stakeholders have recognised in this article via Medical Observer. It is something that I would not wish upon anyone, but if you find yourself there…here are my tips:

Take good notes

In both cases, I was lucky to have written good contemporaneous notes that I was able to look back on. They not only helped me remember the particular case, but also to demonstrate that I am a competent clinician to the board. I could not imagine being hauled up and not have sufficient details to help explain my actions. Take good notes, its a must.

Contact your MDO

In trouble for that mo!

Again on both occasions, my first phone call following the notification was to my medical defence organisation. They helped set up a file, had their team look over the case and help me draft a response. Although some doctors may feel comfortable handling the response themselves, I certainly had immense support from my MDO during what is a difficult time. You will save a lot of hassle if you wish to defend yourself from any action the board may take if your MDO is on board from the get go.

Explain your situation

When it comes to writing your response, make sure that you let the reader know the situation you are working in. That might be an overcrowded or busy ED, rural location without support, walk up clinic and everything in between. Without coming across apologetic, if you at least provide some background, the board can put your situation in context.

Ask for support

Often your character or actions will be disputed by the complaint. Fight back! You know yourself the sort of doctor you are and why you joined the profession. If you have collegues that can appropriately support you in writing, do it. These are the people that know best how you work day to day. Not a single patient, family member or doctor you’ve never met.

Debrief

Talk with someone about the situation. Even though I would consider myself a moderately resilient person, when you get that first phone call or letter, your heart sinks. Here you are practicing in a profession that aims to improve the health of others and the big stick gets pointed at you. For me I felt many emotions both times, often all at once! In order to continue practicing and maintain a love of doctoring, I needed many chats with close friends and collegues. I also needed to keep working. The patients that thank you for your time and help can certainly heal a bruised ego. Unfortunately it only takes those one or two complaints (whether justified or not) to damage a whole day of grateful patients.

Over the four day 12th National Rural Health Conference, I was lucky enough for sit down for a couple of minutes with some interesting delegates who told me a little about their path to the country and why they are so passionate about rural health. Listen to their stories here:

Sian Draffin (@rural_speechie)

Speaking with a Speechie

Talking with Sian, a newly qualified speech pathologist about growing up in the country and now working as a speechie in these areas. We also cover the future of social media connecting with patients in her profession.

Ben Crough (@BenCrough)

Talking with final year pharmacy student Ben Crough. He grew up in rural NSW and is aiming towards working in remote areas. Another Robbo (@bitethedust) for outback Australia perhaps?!

Dave Townsend (@futuregp)

Time out downstairs

Talking with medical student and the current GPSN chair about his time studying in rural areas. Dave is in 4th year at the University of New England in Armidale. He grew up Tasmania and has lived in country Victoria.

Andrew (Robbo) Roberts (@bitethedust)

Blending in

Talking with Australia’s most remote and itinerant pharmacist. Some say he travels around because no one can stand him for longer than a few days, but we know it’s because he loves his job working in rural areas. We cover issues facing pharmacy in these settings.

Alison Fairleigh (@alisonfairleigh)

Discussing mental health in the bush

Talking with rural mental health advocate and ‘power-tweeter’ Alison Fairleigh about living in the country and what motivated her to do something about her passion of mental health in the bush.

Katherine King & Rachael Purcell

Talking with Katherine and Rachael who are both medical students in Victoria about their presentation at NHRC 2013. They looked at the supports and challenges for medical students on rural placements.

Donna Burns

Dance floor destructors!

Talking with Donna Burns about working and living in the country and what took her there. Donna currently works for Hunter Medicare Local in both rural and larger regional towns, but has some ideas if she was the NSW Health Minister!

The Leaders’ Forum discussing GP Workforce 2025 was one of the highlights of the conference. Chaired wonderfully by Dr Emily Farrell, it comprised a veritable who’s-who of GP leadership. Prof Murry from ACRRM (covered in the early stages by Dr Davies), Dr Hambleton from the AMA, GPRA Chair Dr Vergara, GPSN Chair Mr Townsend, Dr Baker from NGPSA, Dr Marles from RACGP, Dr Kammerman from RDAA, Sharon Flynn chair of the RTP CEOs and Prof Kidd (no introduction required!).

Leaders Forum FTW

Rural workforce issues were a hot topic for the forum generating plenty of debate and also activity on the Twitter feed and some novel ideas for improving recruitment were offered:

https://twitter.com/ChrisTimms0/status/313811435329302529

Filling in for Prof Murray, ACCRM trainee Marion Davies provided some great advice for aspiring rural doctors during their training:

https://twitter.com/georgacooke/status/313827327945621505

Up and coming GP leaders like Dave Townsend summarised that training needs to have improved information about where it is possible, communication between providers and collaboration towards a common goal. Dave also demonstrated his Gen Y talent by not only taking part as a forum leader, but also concurrently tweeting the points made by the person sitting in the next chair:

https://twitter.com/futuregp/status/313817233220575232

Not so technically savvy, but more than capable of contributing important points was Dr Hambleton. Even though a GP himself and quite likely able to multitask, his AMA media person was helping to keep the Twitter-stream flowing:

https://twitter.com/ama_media/status/313826557519097858

Not only was the topic of learning raised, but also that of teaching and growing our pool of supervisors. Trish from NGPSA admitted that supervisors were getting older and also dealing with a more challening mix of trainees:

https://twitter.com/ashenicholas/status/313804400311283712

Twitter-iffic

One suggestion that Dr Ashe Nicholas provided was to increase the membership and role of the General Practice Registrar Medical Educator Network (GPRMEN). This group of registrars would serve to promote the idea of teaching to form and hopefully increase the future number of medical educators and supervisors. Given that the number of AGPT applications are increasing, a much larger cohort will be needed and won’t simply fall from the sky:

https://twitter.com/ruralflyingdoc/status/313625534301097984

For some, the seed of teaching had been planted long before even commencing GP training as described by Dr. Mel Clothier, a gorgeous GP registrar from Clare. Dr Clothier had positive experiences in teaching medical students in her higher levels of med school and tweeted from SA:

https://twitter.com/drmelclothier/status/313815866825396224

Even the wonderful students tweeted suggestions as to how best promote general practice during medical school. It really summed up the beauty of such a conference. Where else could the future of the field so easily fire off ideas to be considered by the top leaders who have the ability to effect change:

https://twitter.com/mspixie911/status/313805545368862720

The students were a crucial part of the day, not only tweeting, but also providing help for the older generation not across social media or infographics. The infographic (below) constructed by Rebecca Wood, council member of GPSN, summarised the main points made by each forum leader on the topic of workforce issues:

On-the-fly infographic courtesy of @rfrwood

Unfortunately not all the questions were covered, but one that will continue to generate discussion  included the future of primary health care research:

https://twitter.com/doctordeepster/status/313820384787054592

Briefly summarising the latest in GPRA news and updates, Mr Amit Vohra was also proud to launch the new look GPRA website. He told everyone of the brilliant work of GPSN and its incredible cost-effectiveness as a GP promotion tool. Amit also pointed to the Going Places network as the fastest growing of them covering 65% of Australian teaching hospitals while filling the “black hole” that some GP registrars find themselves in while working there. Some of his final remarks centred around the jump of 25% to 35% of all AGPT applicants having been involved in one of the programs. What an amazing pipeline that I’m sure will only increase in calibre and flow (no urology jokes).

The 6th GPRA Breathing New Life conference also offered an insight into GP life as part of the Australian Defence Force (ADF). To begin, Dr Kerry Summerscales described her journey swapping rifle for tuning fork. Although her time in the Australia Army was spent wielding syringes rather than guns, working in the medical corps as a pathology technician. Her stories of deployment and training then flowed into her time at Flinders Uni working with the fledgling GPSN. It prompted some to wonder in jest about the model of employment offered by the armed forces:

https://twitter.com/tmwdoc/status/313853317946163200

The rank and file then heard from Brigadier Rudzki AM, who described the different work that was available to GPs in the military. He told of his operational postings overseas and showed many pictures of the exciting jobs that he held. Having said “I’m not here to sign anyone up” the Brigadier told some amazing storied that had some wondering whether working rurally was challenging enough:

https://twitter.com/DrJRama/status/313853059543474178

Throughout the day, the food was exemplary as always at Parliament House. They were certainly not scraps from the Cabient table that day:

https://twitter.com/tmwdoc/status/313798303580045312

Given the deliciousness of the food described, hands being used to eat therefore restricted tweeting during the meal breaks and as such was observed from afar:

https://twitter.com/nomadicgp/status/313828867355840512

The Great Debate provided a light-hearted look at some of the serious topics facing general practice. The first motion was “Mandatory return of service for all doctors is the only way to guarantee a rural workforce.”

The affirmative took a military approach led by Captain Summerscales, Brigadier Maxell and Corporal Considine who contended that we are at war against maldistribution and that we must form a Coalition of the (Medicare) Billing.

https://twitter.com/Tiffany_King/status/313885360537096192

https://twitter.com/AmitVohra_CEO/status/313883029917532161

The negative team wanted to be more peaceful about the situation and offer more incentives or “carrots”to attract more doctors to the country:

https://twitter.com/EdVergara27/status/313883922914238464

https://twitter.com/tappdr/status/313884359142809601

https://twitter.com/AmitVohra_CEO/status/313885701462712320

By a vote of louder claps to lesser claps, the affirmative team took the honours:

https://twitter.com/GPRALtd/status/313886528667533312

The next motion was that “Generalists will rule the world in 2025″ with some great debate highlighted in the resultant twitter stream:

https://twitter.com/AmitVohra_CEO/status/313888257198936065

https://twitter.com/EdVergara27/status/313889141958000640

Dr David Chessor once again demonstrated his flair for simultaneous debate and tweeting much to the chagrin of the opposition team:

https://twitter.com/dchessor/status/313889813981978624

and on occasion, from the audience:

https://twitter.com/ruralflyingdoc/status/313890163925348352

At the conclusion of the day, everyone present offered a large round of applause and the ‘Twepreciation’ came flooding in:

https://twitter.com/RCremen/status/313930582520385536

https://twitter.com/Alexandra_deVos/status/314250049074917376

https://twitter.com/rfrwood/status/314286996644327424

https://twitter.com/nickycoleb/status/313896786970411008

Although all the days online action may have seen some reaching for the Voltaren gel:

https://twitter.com/michaelbonning/status/313792169188143104

For the students it was an inspiring day to hear about the benefits of a career that they may consider. For GP registrars it was sobering to understand the challenges facing them into the future. For current GPs it must have been heartening to see a motivated group of young students/doctors ready to answer the call for Australia’s health workforce into 2025. For the associated GPRA staff and organisers it was once again another truly magic day and I for one thank them one thousand times over. Until next year, ruralflyingdoc at Parliament House, signing off.

==============================================================

https://twitter.com/AmitVohra_CEO/status/314301509808570368

DISCLAIMER: If any of Part 1 or 2 of this BNL summary ends up in Mr Amit Vohra’s GPRA report, then I am not pressing charges. He will however be buying me drinks for the entirety of GPET 2013….

The BNL conference is the annual showpiece event for General Practice Registrars Australia (GPRA). They are the peak representation body for GP registrars in this country. In the past, GPRA has successfully advocated for National Minimum Terms and Conditions, timely GPRIPs funding, teaching guidelines and many other registrar issues. As a Registrar Liaison Officer with my GP training provider, I am lucky enough to sit on the advisory council of GPRA. We meet bianually before BNL and GPET conference in September to discuss such issues and workshop solutions.

But BNL itself is a day long conference held in the Great Hall of Parliament House that aims to bring GP training, recruitment and support into the spotlight. 2013 was no exception. From the outset, use of Twitter was encourage to pose questions, comment on speeches and connect using the hashtag #bnl2013. As the day progressed, we even started to see comment and opinion from our collegues in New Zealand. It is with this real-time connection, that the role of Twitter in health care is immediately obvious:

@keeweedoc agreed its really good to see a conference that includes students interested in GP -fantastic! Listen @RNZCGP1 #bnl2013—
Vincristine (@vincristine) March 18, 2013

Highlighting the importance of the venue for the day were keynote speeches by the Health Minister, The Hon Tanya Plibersek MP and The Hon Peter Dutton MP which were both warmly received. Even though the Minister needed to hurry off to an ALP caucus meeting and the Shadow Minister was a touch late in arriving before a feisty Question Time in the house of Reps and didn’t get to answer one last question from Dr. Jonathon Ramachenderan:

@peter_dutton_MP Didn't get to ask but, does the coalition have any plans for rural Australia in particular workforce shortage? #BNL2013—
Jonathan_Rama (@DrJRama) March 19, 2013

Health Minister talking up GP

The Minister reiterated the importance of general practice stating that “GPs are at the heart of our universal medical system.” She also affirmed the position and continuation of the e-Health record and Medicare Locals. I was heartening for all present to note that the Governments thinking in relation to the future challenges of health care revolve around improving GP access. The Shadow Minister retorted in his address that he thought that the Government could do a lot better in primary health care and echoed the Minister saying that “GP care would be central” to any future health system. My question from the floor The Shadow Minister was “given there is a lot of uncertainty about the future of government initiatives such as the e-Health record and Medicare Locals in this election year, what advice can you give to the future of GP assembled in front of you.” The response didn’t cover e-Health, but he hinted strongly that Medicare Locals were not the most efficient or efficacious way forward. Once again, Twitter provided the means to pose a few rhetorical follow-ups:

#bnl2013 @PeterDutton_MP if primary health care is delivered well, both in rural & urban areas, this will have a follow on for aged care—
Cass Wys (@casswys) March 19, 2013

@PeterDutton_MP wonder abt the future of #PCEHR and MedLocals. Will they go, or will the coalition cont given the $$ already spent #BNL2013—
Gerry Considine (@ruralflyingdoc) March 19, 2013

The Hon Jim McGinty discussed the work of Health Workforce Australia 2025 and the issues surrounding retention and planning with our current state of workforce maldistribution. The recent controversial paper entitled “Too Many GPs” was also given attention. And promptly panned:

@HWAGovAu "Bob Birrell is wrong" Jim McGinty can't be any clearer #bnl2013 @croakeyblog crikey.com.au/2013/03/01/the…” @croakeyblog—
Amit Vohra, CEO GPRA (@AmitVohra_CEO) March 18, 2013

With The Hon McGinty describing the report as “full of inaccuracies ,” he was quick to remind all present that given the current state of GP distribution, more are needed at the coal face. However, a number of references to nurses evidently ruffled a few Twitter feathers:

#bnl2013 Breathing new life into…nursing?!—
  (@notjustagp) March 18, 2013

Following this brief look at the future, we were allowed a moment to reflect on the amazing work done by the General Practice Student Network (GPSN) which celebrates its fifth anniversary in 2013. We heard of humble beginnings and a huge base of support that now includes over 9,500 student members. This we were told, had been largely driven by the tireless work of council chairs, their councils and the representatives on the medical school grounds holding numerous events.

@rd_mitchell and Joe Rotella – the founders and drivers of #gpsn are recognised #bnl2013—
Michael Bonning (@michaelbonning) March 18, 2013

It was heartening to see that indeed future GPs are out there and will be ready to meet our nations challenges in health demonstrated by Jim McGinty. The Twittersphere also erupted in e-birthday wishes for GPSN:

#BNL2013 Happy 5th anniversary GPSN!—
AGPT Program (@AGPT_GPTraining) March 18, 2013

#bnl2013 Happy fifth birthday GPSN! Love your work!—
NGPSA (@GPSupervisors) March 18, 2013

#bnl2013 GPSN turns 5 years old! Now 21 med school clubs events entirely dreamed up, hosted, driven and held by students exploring GP opps.—
Renata S (@RenataStarter) March 18, 2013

Indigenous health was a highly anticipated topic of the day and was supported by the GPRA Closing the Gap campaign launch. We heard from The Hon Warren Snowdon who stated that “GPs have an important central role in improving Indigenous health.” MP and Dr Andrew Laming MP noted in his speech that the “100,000 Indigenous people living in remote communities will be the real test of the Close the Gap efforts.” It was refreshing to hear bipartisan support and understanding for once.

#bnl2013 long term bipartisan support is refreshing and so important—
Sharon Flynn (@CCCGPT) March 18, 2013

#bnl2013
Passionate plea 4 REAL commitment to Aboriginal & Torres Strait Islander health in AUS by Hon Warren Snowdon and Andrew Laming: Gr8—
Mukesh Haikerwal (@DrMukeshH) March 18, 2013

Also On each table were a number of wristbands that will serve to draw attention to and remind wearers to effect their own small change in this area. To discuss some of the change possible, the Indigenous health panel debated, discussed and took questions from the floor and twitter:

Is there much research into factors that influence non-completion through med school? What needs changing? @timsenior #BNL2013 #closethegap—
Gerry Considine (@ruralflyingdoc) March 19, 2013

Make a difference

The response to this were themes relating to difference in cultural and educational experiences felt by Indigenous students and registrars. Also that the Indigenous population are a heterogeneous mob all over the country and as such may require personalised consideration. Some suggestions from Indigenous doctors in the audience included needing to recognise cultural differences and reducing threats like ‘you might be kicked out.’ Dr Aleeta Fejo was a standout member on the panel who commented that at the GP registrar level “they are already brilliant people, as they have overcome so much just to get there.” She is a testament to this herself having recently passed her RACGP written exams and winning the inaugural indigenous General Practice Registrars Network award:

Congratulations Aleeta Fejo… what a fabulous recognition of your hard work initiating the IGPRN @AIDAAustralia #BNL2013 @manwiththemo—
Tammy Kimpton (@TammyKimpton) March 19, 2013

Aleeta also shared some gems about encouraging young Aboriginal children to join the GP workforce. She showed that it was as easy as asking “Are you going to be a doctor like me? ‘Coz I need your help!” Planting the seed early with children and especially their parents was the message. Getting across to the family that this prospect is actually possible. The facilitator Dr Mark Wenitong tempered that he would always check a kids ears for pus before putting the stethoscope in their ears!

There were some great opinions on how to encourage non-Indigenous registrars to consider working in an Aboriginal Medical Service. Dr David Chessor pointed out that he has got much more out of AMS work than he put in. David Townsend, current chair of GPSN commented on the need to spread this sort of message:

Positive language is important, let's change the story for rural and indigenous health. It's exciting, rewarding work @dchessor #bnl2013—
Dave Townsend (@futuregp) March 19, 2013

He went on to say that AMS cases are much more interesting and complicated. Perhaps then this side of registrar training needs to be better advertised? With Rural Health Workforce Agency doing so much good with their #gorural campaign, maybe it’s time for #goAMS? Drs Tim Senior and Michael Bonning are already doing some amazing and innovated work with the #supertwision project and should be followed with interest:

#BNL2013 participants might be interested in #supertwision posts too for low down on actually doing #indigenoushealth amsdr.blogspot.com.au—
Tim Senior (@timsenior) March 19, 2013

RACGP president Dr Liz Marles weighed into the benefits of AMS work given her long experience in the area with comments like “learning from patients every single day”,”…rewarding place to be” and “patients are non-demanding, generous and trusting” leading to many registrars thinking that these traits in patients have been lacking in their own non-AMS practices.

To come in part 2: The Great Debate, general practice and the defence force, GP Leader’s forum, the GPRA update from CEO Mr Amit Vohra and plenty more tweets!

Online resources:

Haemochromatosis Australia: GP Resources

Australian Family Physician article

GP supervisor on ground and air

Supervisor: “Just drive to Port Pirie and I’ll pick you up from there”

Gerry: “But I could just drive the whole way”

S: “No, no. I’ll fly there and pick you up”

G: “Oh, do you have a plane?”

S: “I’ve got two”

G: “Wow, flying is something I’ve always thought about doing sometime”

S: “Well we need to talk…”

And so I started my first GP placement and my flying training after generous encouragement from Dr. Scott. Following this first year of starting both country GP and flying training, I started to notice some similarities between the two. But GP training is not the first within the medical field to be compared to the aviation industry.

Biggles ready for takeoff (or cuddles)

Anaesthetics has famously been linked to aviation in the past. And it’s not limited to both sharing the first letter of the alphabet. The obvious comparison involves the separate components of a typical flight and anaesthesia. Take off or induction, cruise on autopilot or maintenance and finally landing, or recovery. The other obversed similarity is that both professions can operate on the basis of 99% boredom, 1% sheer terror (or as one doctor so eloquently put, that moment of “S**T S**T S**T!“). The concept of anaesthetics learning from aviation was first described to me by a consultant as a 4th year student at Flinders Medical Centre. He discussed the case of Elaine Bromiley, who tragically died after unfortunately falling into the can’t intubate/can’t ventilate scenario. Her husband, an airline pilot, questioned the lack of standard operating procedures and checklists that were commonplace in his field. Dr. Leeuwenburg in KI commented in late 2011 on this association and brought to my attention an amazing analogy involving the dashing British flying ace Biggles found here (well worth a read).

But having completed some time in both GP and aviation fields recently, I would argue that general practice training has some similarities to flying training…

Ground/book theory:

In flying training, there is a substantial amount of theory that needs to be learnt prior to gaining a recreational or private pilot licence. These are often in the form of books and sometimes a discussion with the flight instructor. Many medical courses require a few years of theory and required knowledge before being ‘let loose’ on the patient population. In the past it boiled down to knowing the nuts and bolts of the field in question before taking to the air or wards. Nowadays the curriculum for both flying and medical training integrates both practical and theory from the outset.

Easier to read than Harrisons any day…

Simulator training:

As a young lad I was a sucker for Microsoft Flight Simulator and took great (nerdy) joy in pretending to fly planes around the world. From top airline pilots to those learning to fly small aircraft, simulator training remains an inexpensive and safe way to practice emergencies. The same is true in general practice using mannikins, standardised patients and Observed Simulated Clinical Examinations (OSCE). These enable practice, honing of skills and assessment of doctors in a way that is safer for real patients.

I don’t feel well doctor

Difficult techniques:

In flying, it is important to practice difficult landings regularly. These can involve crosswind technique which need complex control inputs that allow the plane to land safely. Importantly, different crosswind conditions are tackled as no two landings or winds are the same. This is similar to GP where each patient is an individual, each one requiring different techniques. Especially ‘cross patients’.

Logbooks:

Pilots are very familiar with maintaining a proper logbook and it’s something that I started last year when I took to the skies. Logbooks are a great way to demonstrate your experience in a clear and consistent format. I have also found it good to look back and relive the journey, much as this blog has helped. We are also required to keep a procedure log for the different skills that we might be exposed to and learn during our GP training. This is an online platform and has been beneficial (and will continue to be good) in highlighting any deficiencies that need to be addressed.

Written and practical exams:

Flight computer and heart listening thingo

It goes without saying that both aviation and medicine require thorough assessment of candidates who are entering a high stress workplace that has very little margin for error. Therefore both fields undergo a number of both practical and written exams to ensure that these fledgeling pilots/clinicians are of a reasonable standard. Fortunately, aviation exams are infinitely more fun, but on windy days can be just as nausea provoking as medical exams.

First solo/consultation:

Then the time comes after hours of learning theory and practicing procedures, landings, consultations, takeoffs, examinations and stalling (applicable to both fields!) for the pupil to go it alone. [Side track: Go It Alone being a fantastic track by Beck with a guest bass guitar by Mr Jack White]. It’s time for the first solo flight or consultation! Both will always be memorable, a mixture of sheer terror and adventure. However in both areas, the supervisor or flight instructor is only a room or radio call away respectively. Fortunately in GP if things are going pear shaped, your supervisor can come in person to help. In the air, you’re on your own and may end up literally pear shaped.

Technology:

Throughout training in both fields there is a massive base of shared knowledge available. Increasingly, many of these resources are online and even use novel platforms like smart phones and tablets. YouTube videos can also explain difficult concepts ranging from crosswind technique to vertical mattress suturing. The advent of free open access information has started to take off in emergency and critical care medicine and I wonder if something similar might begin in flight training.

Worried when you’re taller than the plane…

Ongoing review:

In private aviation, there is a requirement for a biennial flight review (BFR). This involves a check flight with an instructor to make sure that no bad habits have formed. Similarly, all GP registrars (trainees) within most training providers, a medical educator visit (MEV) takes place. This is an opportunity twice a semester for another doctor to sit in on consultations to see how the registrar is progressing and if there are any problem behaviours developing or major gaps in knowledge.

Acronyms:

CHF, CHT, PPL, PVD, RA-Aus, RSI, EFIS, ETT, GPS, GPRA, APO, APU…enough said. Both fields are often afflicted with what I like to call acronym overload or AO for short.

So as you can see, there are plenty of similarities. This probably highlights the fact that both fields need to produce highly trained practitioners that often work in stressful environments. Their assessments need to involved observed work so that their performance can be best judged. In many ways medicine has learn a lot from the aviation field. But I have certainly applied much of my medical knowledge or communication skills to aviation. Happy to hear your thoughts!

Welcome to Wudinna

Since leaving the Eyre Peninsula, I’ve started part-time registrar work in the Adelaide Hills, with the other half split between a research project and teaching undergraduate medical students at the University of Adelaide. It has been a great mix of academic work, medical clinics and some on-call rosters. During the year I hope to dedicate some blog-space to my research and some gems that I glean from teaching med students clinical skills and case based learning. In the past, there has been so much to learn from fresh student eyes. The move has meant that my commute has stretched from the not-car-worthy 1.2 km to 34 kms in peak hour traffic. The landscape in the Hills is vastly different too, with plenty of rolling hills, green trees and rows of vineyards criss-crossing the valleys.

Welcome to Hahndorf

Even already, there has been a notable difference in the casemix and behaviours between a remote country town and outer (or peri-urban) medical practice:

• Patients know when their time is up: In the country, many patients are up for a long chat. This is fine for a simple repeat script, but not so much as the clock ticks closer to 20 mins in a 15 min appointment. I have found that patients in the peri-urban setting realise that there are plenty of other people to be seen and usually are out the door by 10 mins without subtle prompting! It could also be that they are busy themselves and are rushing off for a meeting in town.
• Calling back about ANY results: In the peri-urban setting, there have been many more phone calls or emails to the practice about pathology results. Even 1-2 days after collection! Perhaps these patients are more interested in their health (or more health literate)? It seemed that in the country, patients were happy to be called only if something was worth discussing. I’m sure the previous AOGP academic registrar Annabelle would have something to add here. Her research in 2012 looked at some of the predictors of this phenomenon, with rural patients not knowing as much about their health.
• More children with viral illness: I have seen more children with parents saying “I think they’re ok, but just wanted them checked” in the past month than I did in the whole year in the country. Not sure about this one? Perhaps more doctors available for this sort of check up closer to the city? Or just tough country parents “I’m only taking you to the doctor if you arm is hanging off…”
• Medical certificates: Many more patients in the peri-urban areas coming in just for medical certificates. Again, either tough country patients “Can’t come in to work today, Ive coughed up a kidney” or rural companies/businesses not being as strict with the medical reason for not coming in.
• Less happy about waiting: Even after spending time with emergency presentations, *some* patients seem less happy to wait compared to the country. I’m guessing that rural patients are used to having the only one or two doctors busy at the local hospital with other sick patients. Perhaps even because they have been that sick person themselves?

I’m sure there will be plenty to add as the year marches on. In the meantime, hope to hear any other thoughts on the reasons for some of these simple observations.

Doctor/pilot x 2

I remember a colleague in medical school commenting on my intended choice of general practice saying “oh, I couldn’t do that…how boring.” Perhaps a small part of me agreed with them. Sure, I had sat as a student in a room with an urban GP and even completed a 6-week GP term in the country with some tedious moments. But now at the end of 12 months and my first registrar placement in rural general practice, I can look back and see how wrong my classmate was. I can’t even remember the number of times that my supervisor, Dr. Scott Lewis (above), and I would see a particularly interesting case and remark (tongue in buccinator) “geee, how boring is country general practice!”

During the year we have retrieved and transferred patients via RFDS for a variety of conditions including:

• Haematemesis with a Hb of 55
• Three appendices in the last 2 months
• Suspected septic knee joint in an 18 month old
• 2 cases of severe bronchiolitis in the space of 2 weeks (Thanks RSV)
• Numerous renal colic, some with pyelonephritis
• Suspected spinal epidural abscess

But it’s not all about the high end critical care stuff, no matter how much the PHARM/ED/ICU/anaesthetic gurus will trumpet. The nuts and bolts of GP are there too:

• Immunisations and baby check ups
• Cancer screening
• Preventative care for heart disease and diabetes
• Family planning
• Skin lesion removals
• Antenatal care
• One of my favourites, ear syringing
• Palliative care planning, to name a few

For this reason general practice (and country in particular) has been termed “womb to tomb” or “cradle to grave” care. However, I do prefer the alternative: “crack to croak.”

Perhaps the real scope of rural general practice was demonstrated a few weeks ago. Wudinna recorded the highest temperature in the country that day, reaching 48.2C. To add further difficulty, my supervisor (the only other doctor in town) was away. Luckily I had the help of a great Flinders 4^th year student. Here’s a brief summary of what happened:

Start of a *hot* day

Woken up at 3am – Chest pain brought in by ambulance – MSK, likely thoracic spine in origin

Morning Clinic

• Fasting bloods x2
• 12 month immunisation
• Funny rash on shoulders – pityriasis versicolour
• Follow up after USS for ?DVT

Up to hospital for foreign object in eye – used slit lamp to examine

• Follow up after ureteric stenting
• 18 month immunization

Up to hospital again for facial laceration – 7 stitches and epiglue

• Change in bowel habit with PR bleeding
• Diverticulitis

Lunch

*** Cut short by a car rollover with three occupants 30 km out of town. All self extricated. Blood alcohol levels on each and C-spine XR on driver to clear neck and removal collar. ***

An ex-Ford Fairlane

Afternoon Clinic

• Hoarse voice in 7 month old

Up to hospital. 3-year-old not tolerating orals, vomiting – admitted for observation

• Diabetes check-up
• Blocked ear – eustachian tube dysfunction
• INR check
• 6 week post-natal check
• Chronic leg ulcer

Would be hard pressed to call that day boring! Was it stressful? Yep. But fortunately the vast majority of our days were not this busy, but the variety was always there.

More than one SAAS crew at hospital = bad

General practice allows the doctor to be a true jack-of-all-trades and master of some. Some have said that specialities are learning more and more about less and less, until one day they know everything about nothing. The converse might also be said about GP work. But as long as I know what to look for and ask my specialist colleagues for help at the right time, I’m happy. Not only with the management of patients, but also my choice in medical specialty. General practice is never boring, you just need to look for inspiration in right places.

@ruralflyingdoc

Applying for GP training: http://www.gpet.com.au/ApplyforAGPT/NewApplicants/

However, not all is as it seems. When that pathognomonic cough doesn’t behave like croup (from Casey at BroomeDocs): http://broomedocs.com/2011/07/clinical-case-19-if-it-barks-like-a-seal-is-it-a-seal/