Carrots and Needle Sticks

I’m in favour of universal vaccination, aside from in cases of genuine medical contraindication. Rates of vaccine refusal are rising, threatening herd immunity in many areas of Australia. Herd immunity offers protection to those who are unable to be vaccinated, and reduces spread of vaccine-preventable diseases.

It makes sense for the government to design incentive schemes to improve immunisation coverage. They have to do something. It’s a good idea to provide a financial incentive for parents to vaccinate. However, I am unconvinced that rendering the child care rebate provisional on having your child vaccinated is the right way forward.

Public health leaders and some health professionals are warning that the scheme could backfire.

I worry that the scheme will further alienate many vaccine refusers and be used by some as ‘evidence’ that the government is part of some huge Big Pharma conspiracy, which may help them gain more followers.

In a highly predictable turn of events, removing the ‘conscientious objector’ clause but keeping religious exemption had hordes of vaccine refusers conspiring online about how they could get suitably religious.

Now the government has removed the religious exemption loophole. An aside- as an agnostic I am heartened by this belated acknowledgement that church and state are and should be separate. I also would argue that religious beliefs are no different in nature to the frequently unscientific health beliefs of many vaccine refusers.

The punitive approach the government seems to be taking doesn’t feel quite right to me, though the majority of GPs seem to be in favour. I agree immunisation is the right choice to make, but if you choose otherwise, you now face losing financial benefits that significantly alleviate the struggle of raising a family.

Could there be a better way forward?

It’s one thing to make the Family Tax Benefit part A contingent on being up to date with vaccinations. Fine. Perhaps rename the payment though. How about ‘Family Vaccination Incentive Payment?’ And make it a bigger payment, by all means. To provide a financial incentive is a completely different notion to withholding an unrelated payment.

Anyone who is paying for childcare and who is a tax paying citizen should be able to claim the childcare rebate, while such a rebate exists.

Vaccination is currently not mandatory in Australia. Choosing not to vaccinate your child is usually the wrong choice, but I defend the right of any person to have the choice just the same.

What would be a better way forward? Aside from offering a ‘carrot’- incentive payment rather than a ‘stick’- punishment, I propose that public science education would yield better results than the No Jab No Pay scheme.

The decision not to vaccinate is often based on poor quality information, myth, hype and pseudoscience.

Empowering parents to access quality information and to assess the validity of that information they are presented with would allow them to decide which information to use and which to discard, as they make this important decision.

Teaching about science, how science works and how to evaluate studies would enhance the general health literacy of the Australian public, helping protect well-meaning parents from hazardous and inaccurate ideologies on this and other topics.

It is pleasing that the government has plans to fund some education/advertising on vaccination. An increase in the incentive payment for GPs and provision of educational resources to GPs is in the pipeline. I have mixed thoughts about this.

I for one would continue to educate my patients without any added financial incentive, and in a way I would prefer not to be seen as benefitting financially from every childhood vaccine I give. I give them because it’s the evidence based, best thing for my patients, not for the six dollars that later floats my way.

Also, I already have good information to give my patients. I would rather they be educated about how to deal with health information they come across elsewhere, and learn why the information I give them is good quality.

Parents want to make the best choice for their children. Many who have decided not to vaccinate are still willing to discuss their concerns and to take new information on board. We need to reach these people, not alienate them. They need time and resources to address their concerns and develop their understanding.

Of course, there are some who are lost forever, who will dismiss all evidence as being cooked up by the evil Pharm empire; who think that doctors are either ignorant or part of the conspiracy. These people will never be convinced by scientific fact. I’m quite happy for them to miss out on an incentive payment. I’m just not sure their whole family should be punished by denying the childcare benefit.

I welcome comments and discussion aside from vitriol (from either ‘pro’ or ‘anti’ camps), which will be promptly removed! I’m especially interested in hearing what other GPs out there think about No Jab No Pay.

Be Patient, Doctor

I’ve been told I’m a really good patient. I think it’s partly my desire to please, to make my health professional’s job easier that reminds me to give a succinct history; makes me compliant to treatment. I also know the value of evidence based care and have the good sense to apply it, with guidance, to my own health issues.

I guess wanting approval doesn’t necessarily mean you will be a good patient. A misguided attempt to lighten the doctor’s load could see you give a history full of holes, or leave some complaints unvoiced. It could lead to over-tolerance of side effects and treatment failure, as you don’t want to ‘fail’ your doctor.

Contrary to popular opinion, I think many doctors make excellent patients. Certainly the doctors I have cared for, and their families, have all been wonderful to treat. An appreciation of the doctor’s role, the capabilities and limitations, and knowing the limits of medical knowledge itself, means you may be more accepting of the care you are given. Your expectations may be more realistic.

When I am treating a doctor, especially a fellow GP, I feel self-conscious; highly aware of my shortcomings. I don’t mind though, as I know they are likely to be similar: self-critical, but very forgiving of others. They know what I can offer, and what I can’t.

My physiotherapist tells me that his doctor-patients are more respectful of his time than the average customer. They ring to cancel if they aren’t going to make it. If they miss an appointment, they insist on paying for it anyway.

I think these doctors are being ‘the change they wish to see’ in their own patients. We would do well to insist our own patients treat us with this much courtesy. Going a little off topic now: what makes a good patient?

I appreciate patients who:

– are on time for their appointments (I try to reciprocate by being on time myself)

– if they have multiple concerns, show me the list at the start of the appointment, so we can prioritise. ‘By the way, I’ve been having chest pains’ is not a good thing to tell me at the ‘end’ of our allotted time. We won’t finish for a long time after that! Try to tell me at the start

– know how long their appointment is and that not everything can be sorted out in the one visit. Book multiple appointments, or a double if you have a lot of issues to sort through.

– ring to cancel rather than just not showing up

– offer to pay for appointments they missed or forgot about

– believe that I care about them, know I’m not a Big Pharma shill, I am their doctor who wants the best for them

– know that I have trained for a long time to practice good, evidence based medicine; that I actually do keep up with the latest science, which believe it or not, trumps google university or watching 60 Minutes on telly

– know that it’s my job to give them the best health advice, but it’s their job to prioritise their health and to implement the advice. I can’t solve all their problems for them, even when I wish I could, and

– are willing to pay me for my time (depending on their financial and health situation).

Many private patients don’t realise that by asking me to bulk-bill them, they are asking me to work for about half my normal rate. After a percentage goes on the practice overheads, tax, etc. bulk-billing an appointment leaves me with about $15 in my pocket. I doubt they would ask any other professional to reduce their hourly rate, just for them, because they just had to pay their naturopath $300 and now they’re a bit short of cash, or say to their hairdresser ‘I know you charge $65 for this usually. But how about today you just accept $37 for the same job? Just don’t pay your mortgage or feed your family this month.’

I had one pensioner patient who insisted she pay the full private fee instead of me bulk billing her and claiming the incentive. ‘My health is worth just as much as anyone else’s. Why should you get paid less, just because I’m old and on a pension?’ She asked.

Why, indeed? Needless to say, she’s been a favourite of mine ever since.

Those Who Can- Teach

Some of the best teachers I’ve had got good results from me by seeming to expect them.

If I gave a subpar performance, they seemed confused. I worked harder if only to avoid that look on their face. I felt like they’d mistaken me for a high achiever, but I was determined they should not now be disillusioned.

The first teacher I remember using this technique- quite by accident I’m sure- was my year 9 history teacher. I had been skulking along through the early years of high school trying not to do too well or seem too smart; not doing my classwork or homework; reading novels under the desk. I made the mistake of participating in the first history lesson of the year, probably to be polite to the new teacher. She jumped on me as a ‘talent’ and so, not wanting to disappoint, I had to actually do history that year.

Later as a medical student, I remember presenting a case in the corridor to my tutorial group and our tutor, let’s call her Dr. Winner. I was about to run off and go to a job interview. I thought I was doing a reasonable presentation, but Dr. Winner kept shaking her head.

‘Come on De Loony, you can do better than this’, she said. Still I floundered. ‘You must be nervous about your interview,’ she offered, and I gladly dropped my eyes to the floor, nodding solemnly.

Under her hopeful gaze I swotted Talley and O’Connor, practiced my examination techniques at home and especially applied myself in neurology- a favourite of mine anyway, but it happened to be Dr. Winner’s speciality.

Another tutor would race up the hospital stairs ahead of us, despite her Cam-booted broken foot. Come to think of it, I think she had broken her foot running on those stairs. She taught us how to get our case presentations to be ‘really slick’. Her enthusiasm was admirable. She had enough energy for our entire group. We were swept along by her backdraft.

Dr. Staghorn taught us ‘the backhand technique’ for examining a prostate, which I still use today. When I must.

Now I’m trying to think of the less memorable teachers, or those who were memorable for their negative effects.

Dr. Claude taught using the always popular Socratic method, which I hated. Still hate, if it’s not done well. Firing questions at impressionable students who don’t yet have the knowledge to answer them is humiliating at best. On the other hand, he let us observe while he inserted a chest drain. That was pretty cool.

And I’ll never forget the tutor who had me perform a testicular exam with no gloves. ‘You don’t need gloves’, said he. I often fly back in time to supply this quick rejoinder to my former, mouselike self: ‘Oh yes I do…’

I’ve learnt a bit about teaching from my years of being a student. I think a good teacher has enthusiasm for their subject, confidence enough to remain patient and kind even in the face of belligerent pupils, and knows enough about their material to be able to explain it well to those who know nothing. As another excellent teacher told me: ‘losing your audience is not a mark of intelligence’. (Who else out there remembers a certain expat American who made neuroscience come alive?)

A good and memorable teacher is one who also brings a little personal colour to their work, whether through the use of stories and anecdotes, well placed jokes or just a little eccentricity.

I would love to hear your stories about memorable teachers, or what you think are the characteristics of a good teacher.

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Some things are easy, but GP ain’t

One of the first things I remember noticing as a new GP registrar was the isolation. After working as part of a team for two or more years in the hospital system, suddenly you are in a room by yourself. Managing your own patients. All by yourself. If you have a nice, approachable supervisor then good advice is a phone call or door-knock away, but you are the one who decides when to call, when to knock.

It’s like you’re on an island sometimes, working as a GP. The patients one by one maroon themselves on your island and you try to help them get back to shore. The other practice doctors are like ships passing in the night. Sometimes you blink SOS signals to each other. But they have their own islands to attend to.

The responsibility skyrockets. After working in a hospital where the ultimate responsibility rested with your consultant, as a first term GP registrar, you see patients who are ‘yours’. If they sink or swim, you are responsible. All the enormous problems they carry in with them are yours for the sorting. You are heavy with this weight and can rarely put it down, if you are anything like Dr. De Loony.

There is so much to know. So much that is barely taught in medical school and that you aren’t expected to know in hospital. The whole of dermatology, for instance. Musculoskeletal medicine, the non-emergency kind. Counselling. Managing depression and anxiety disorders. Nutrition. Advanced paediatric medicine.

You are never finished learning. In any branch of medicine it is the same, but it’s a wider array of subjects to learn about in general practice, that are continually evolving. You not only need to read the studies, but also need to assess the quality of the evidence, to determine how seriously to take the findings.

The RACGP exams are no walk in the park. Dr. De Loony considers she was lucky to pass and credits this achievement entirely to her study group. She was not entirely useless in study group, being voted the most likely to ‘volunteer to fetch beers from the fridge’.

If you are going to sit for the college exams, having a small group of peers (ideally people you like) that you study with is my top tip for success. Resources and knowledge are pooled. You cover more ground and keep each other on track. ‘Have a study group’ and ‘Go to Work’ are the two most passed on exam tips I have heard.

For those non-medicos and medicos-who-don’t-know-any-better who think being a GP is easy and you just have to type referrals, print scripts and sick certificates, trust me. It’s not an easy job. Well, it’s not an easy job to do WELL. And if you’re not doing it well, or suspect you’re not, it’s a scary job to be doing.

A GP, slaving away in the trenches, can encounter any problem in any patient. Newborns, children, adolescents, young adults, the middle aged, the elderly… No patient is ineligible for GP attention. They can walk in with anything and they bring with them their own context, history and emotional baggage. The good doctor engages with them and sifts through the history, performs a laying on of hands, thinks hard while tapping out notes (leading some patients to think we are feeding info to the computer that then spits out ‘an answer’).

There is the world of billing to contend with. It takes practice to charge people for your time, especially when there is a strong altruistic element to your work. Bulk-billing means you take a pay cut, but you may do it too readily as you are kind. Your patients ask you to do it, perhaps not realising your take home pay can be drastically reduced as a result of bulk-billing. You end up not being paid enough to do what you do, to work so hard. Resentment brews.

A GP doesn’t sort out one problem and then send their patient back… to their GP. The patient comes back again and again. You are never finished with them. They are never finished having issues. They are never fixed.

It’s not easy.

As a junior registrar I would find myself fretting over clinical conundrums and finally thinking ‘what this person needs is a really good GP.’ Then I realise ‘Oh. That’s supposed to be me.’

Image courtesy of freedigitalphotos.net.

Great Expectations

I’ve been thinking about the rigorous demands society places on the medical profession, the demands doctors place on themselves, and the resulting fall-out.

A recent article in Good Practice discussed the Good Samaritan laws and the now well-known case of the radiologist who ‘failed’ to stop and render assistance by the roadside (at night on a lonely road, with no torch, no phone and no equipment, in a state of shock). She was found guilty of ‘unprofessional conduct’ though later this judgement was, thankfully, overturned. I say thankfully, as otherwise we’d have to change the meaning of ‘D’ in DRABC.

The Good Samaritan laws are not just there to protect doctors. In some states, the law mandates our response in emergencies. Common law apparently obliges no one to rescue another person who is not known to them- unless you are a doctor. In NSW, for example, a doctor may be guilty of unsatisfactory professional conduct if he or she ‘fails to attend’, in an emergency, or to make provision for another doctor to attend in their stead. To me, this amounts to all doctors always being on call, which is hardly fair. Can’t we at least make a roster?!

Does this mean a doctor should never sleep with earplugs, should never get drunk, should never retire, in case it affects our ability to respond effectively to a medical emergency?

Many would argue that this is the price you pay for becoming a doctor, that with the privileges of the profession come responsibilities. To an extent, I agree. However, shouldn’t individual autonomy and humanity come first? And are the privileges really so great?

I certainly agree that we should assist where we can. Where we can! Most doctors have a strong sense of duty without legal dictation, myself among them. Should our actions be a legal requirement, though? We should have the choice, even if the ‘right’ choice is to assist.

I’m still mulling it over and would welcome your input. There has been interesting debate about the case on the Australian Doctor and Medical Observer websites.

I have been guilty myself of expecting too much of doctors. Growing up in a medical family that regarded the rest of the town practice as extended family, GPs seemed to me like demigods, all powerful, unflappable, a noble breed. Is it any wonder I chose GP training in the end, with this upbringing? And is it any wonder that I found myself lacking when compared with this youthful ideal?

I remember, prior to medical school, expressing disappointment with someone’s actions to a friend, saying ‘I mean, she’s a doctor!’ My wise friend replied ‘I don’t like it when people assume doctors aren’t human. They are, with normal human faults,’ or words to that effect.

When I have accidentally let slip to my patients that I am a real human and not some robot automaton, the reactions have varied. To sum it up in the words of a pre-teen, when I mentioned that I see the same physio as her: ‘um, that’s weird.’

I took the hint and try to keep myself, the person, out of consults. However I do sometimes resent this. It is a bit artificial to give nothing of your personal perspective when you are seeing people for people-problems. I know we are professionals and that part of what we offer is impartiality, but there is a limit. Do our patients really want robots?

Sometimes it is a relief for me to have a patient who is also a doctor. I feel they know how much they can expect of me, understand what I cannot provide and that they come with the knowledge that I am a fellow person. Many doctors actually make fantastic patients, in part for this reason.

So, do the ‘privileges’ of our profession really make up for all the demands? With falling rebates, high patient expectations, pressure from the bureaucrats, and harsh judgements like the initial ruling on the WA radiologist, we all may wonder.

A Burnt Out Case

It is a difficult time in Australian general practice at the moment. The government has been toying with Aussie GPs by arranging to cut Medicare rebates. Instead of investing more in primary, universal health care, they are trying to devalue it and make it unsustainable. I can foresee even greater time pressure and responsibility as we try to care for our patients in fewer visits. I envisage less remuneration, with constant pressure from patients to accept a lower fee for the same good quality care.

It is at times like this this that a GP may be even more vulnerable to burnout.

What are some of the warning signs of burnout?

You may notice:

Irritability- increasing exasperation with patient demands, the critic in your head that talks back to patients becoming louder and more voluble.

Feeling empty, drained- with nothing left to give. Certainly nothing left over at the end of the day for the people that matter most; family and friends.

Compassion fatigue- Our capacity for empathy is not endless, despite what we set out believing during medical school. You may become impatient with the suffering you encounter. ‘You’ve got a sore elbow? Oh poor you. Some people have real problems!’ says the critic in your head. Meanwhile, the poor patient is actually in great discomfort and perceives you as uncaring, and the patient-doctor relationship is damaged.

Feeling like a fraud- this is quite common among sensitive, perfectionistic doctors to begin with. You may feel you are unfit to be practicing as you are ‘bound to miss something’ or somehow do the wrong thing (although in reality you are probably a very thorough and competent practitioner).

Disorganisation- feeling unable to cope with the competing demands, to juggle paperwork, patients, phonecalls, getting to daycare pick up on time, getting more and more frazzled with no relief in sight… Being an organised GP is hard at the best of times!

Signs such as those above may indicate you need a break, more support, or a change in the way you practice.

What are the signs you watch for in yourself, that tell you it’s time for a holiday, (or a career change)?

Wouldn’t we all love to be the reliable, full time country doc, there in his chair for generations to come, always available, always kind, competent and zen? However, not all of us can do that, and that’s ok. For some of us, this is just not a sustainable life.

I don’t think I can always be that doctor. I need to work out, and then be, the kind of doctor I really am.

What to do if you are burnt out:

Take time off- this is essential. How much? Enough.

Physical exercise. Intense, heart pumping exercise is a great treatment for anxiety. It also helps regulate your mood and manage stress.

Clean habits- good food in sensible portions, quality sleep. Reduce alcohol.

Peer support. This is vital. (My study group has reformed, years after our exams, to enjoy the support that was the best part of our study sessions. We hold ‘study group’ once a month but for the purposes of peer review, friendship and case discussion. It is fantastic).

Watch how you practice. When you start back at work, go slow and take your time. Don’t overload yourself in the attempt to catch up. (‘None of us are indispensible’, a mentor said to me recently, and it is good to remember this. There are other doctors there to care for our patients when we can’t be there).

Remember, it is the patient’s responsibility in the end, to prioritise their own health. Your job is to give them the best advice and care you can, but it is entirely up to them whether to take that advice and accept that care. This can be difficult, especially when the medical profession is made to feel legally liable for everything our patients do. Being on the frontline of healthcare as a GP is particularly tough as we are the first and often the last port of call for all aspects of patient health.

As always, I welcome all of your insights and suggestions for avoiding and managing burnout, a common problem in medicine and other caring professions.

Psychological Pain Relief

Most people in the population self-medicate in some way. Headache? Take a couple of paracetamol. Had a bad night’s sleep? Make it a double shot flat white the next morning. Rough week at work? Hello happy hour!
When does it cease to be socially acceptable, this treating of our own minor ailments? Drowning your sorrows to the point of mild tipsiness is almost encouraged, but end up weeping and drunk on the floor and we cringe. Perhaps when the line of normality is passed and we not only relieve our pain, but become altered in some way, it is viewed in a similar way to the use of performance enhancing drugs.
There are good over the counter options for aches and pains, sore throats and dry eyes. There aren’t so many options for psychological pain. I am not referring to the type of ongoing or recurrent pain due to mental illness, but the kind of distress we all experience from time to time in our everyday lives.
The common responses to these intense feelings are maladaptive, such as the stereotype of the girl who has been dumped by her boyfriend sitting in bed scoffing chocolates then getting trashed with her friends, followed by a drunk-dial of the well-known number to berate him for leaving or to beg for another chance. We can all predict that the following day she is likely to feel worse, not better!
Think of a young girl, trying her best to cope with emotions that feel out of control, aims for short term relief, distraction or other catharsis through cutting herself, or the middle aged man unable to cope with day to day life without a bottle or two of wine. These are familiar stories.

What are some better, kind-to-yourself ways to relieve psychological pain? There are plenty of behavioural techniques and cognitive strategies that can help. Here are some suggestions (and I would love to hear yours):

-Exercise. This can be a mindful, refreshing walk with or without company. It can also be a good heart starting workout that releases endorphins. There is plenty of evidence that intense exercise is beneficial for anxiety and depression, with an effect comparable to medication.
-Distraction, ideally with a pleasant sensation (how about a massage?) or spending time with a friend doing something fun.
-Write it down. Design a haiku that exactly sums up your mind state.Write a journal entry. Write a letter (don’t send it yet but let it sit until the intensity has passed, then re-read it).
-‘Self-soothing’. Run yourself a sweet smelling bath, or brew a loose leaf tea. Sit in the garden and stroke a pet. Listen to some relaxing music. Think of what calmed you as a child and try to recreate it. Wrap yourself in a soft blanket. Have some warm milk.
-Mindfulness can help with the sense of being out of control and can also be very soothing. Use your senses to bring yourself back to here and now. Feel the ground under your feet. Feel the breath flow in and out of your chest. Can you feel the warm sun on your skin? Smell the spring blossoms on the breeze?
-Debrief. After a traumatic event, basic event debriefing (that is, talking about what exactly happened, who, where and when) can be helpful. It is less helpful and can be damaging to do a deep psychological debrief in the early stages following the event.
-Talk to a friend who is in need themselves- not about your problem but about theirs. Providing someone else with support gives you a sense of usefulness and competence, improving your self-image.
-Acceptance. Remember it is normal to feel emotions and react to them. Try to identify the emotion you are feeling and how you are responding to it. For example ‘I feel anxious about going to this party and so I am very frustrated with myself because I wish I was more comfortable socially’. Accepting the primary emotion and not punishing yourself for it through guilt or shame can make the first emotion easier to bear.
-Remember that emotions cannot remain at that intense peak for long. Use a safe technique that helps you cope in the moment, knowing that the wave will subside. Ride that wave.
-Finally, congratulate yourself for being a thinking, feeling human being who is sensitive, alive and expressive and thus makes this world more beautiful. It is good to feel things and you can cope. It may feel like almost too much to bear but you, my friend, can bear it. Feel your feelings, only detaching from them for the purposes of distraction. Do the best you can in the state you are in and look after yourself.

Resources: Psychiatric Times (various articles)
The Dialectical Behavior Therapy Primer, B. Brodsky and B. Stanley, Wiley-Blackwell 2013

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