Country GP taught me to fix my jumper

IMG_1785

Poor old jumper

I have a favourite black jumper. In fact, its helping me write this post at this moment. Everyone has an item of clothing just like it. Unfortunately, the price paid is increased wear and tear. My black jumper started to develop a large hole under the armpit area at the start of last year. The nurses in Wudinna would give me grief when I started wearing it in the winter (sometimes for the cold, other times to disguise a non-ironed shirt…)

Tools of the trade

Tools of the trade

Eventually, enough nurses, family members and people on the street convinced me to get it repaired. Some said take it to a shop and other offered to stitch it up themselves. After politely declining on a few occasions, I found the opportunity to repair my old friend on a recent trip to Melbourne. Mum provided the obligatory box of needles, thread and scissors. But I had never fixed up any sort of material damage before, the only relevant word I knew was ‘darning’ from Elenor Rigby by The Beatles.

But the truth was I had done something like this, in fact I would do it once or twice a week. Often patients would present to the clinic with large cuts and lacerations and need stitching. Surely I could use these skills here? During a medical student and intern placement in country South Australia, I learnt a number of tips and tricks for suturing. In Jamestown, a pulley type horizontal mattress and running subcuticular stitches were taught to me by the great GPs there. To finish off each run of suture, I managed to remember how to do a hand tie. Amazing what can come back to you after three years!

Concentration at the kitchen table

Concentration at the kitchen table

So away the stitches went attempting to close the large axillary dehisence in my jumper. One aspect that was different was having to thread the cotton through the needle tip. That took steady hands and a large amount of accomodation (see cross-eyed picture above). Luckily I avoided any needle stick injuries as the material edges started to oppose. It probably took me 3 times longer than stitching up skin, but I eventually finished. And I can report that there has been no further wound separation since!

Has anyone else used medical/surgical techinques for everyday tasks? Im sure there’s more out there…(looking at you Leeuwenburg)

I had to cut my own threads!

I had to cut my own threads!

 

Taxing matters: cuts to doctors deductions

A few weeks ago, the Government introduced plans to cap education related tax deductions at $2000. The AMA has already weighed heavily into the issue, but its message was somewhat blunted by the revelation that the Queensland branch of the Association planned to hold its conference in Santiago, Chile. Unfortunately, the reporting and our Federal Treasurer to date have focused on “first-class and five star” junket type conferences. What has seriously been forgotten is the damage that this reform could mean to training doctors, those in rural setting and above all, our patients.

RichDoc1

White coat hyperinflation

As a GP registrar, I can already think of many ways that the new tax deduction cuts would mean for my own training. This year I am planning to sit RACGP written and practical exams. This alone will cost $6000. Already three times over the limit for the education allowance! Of course events like these are once off payments, but there is an ongoing need to keep up continuing professional development (CPD) points for medical registration and our patients’ safety. This is especially true in the bush.

When practicing in the rural setting, GPs and GP registrars also need to have a range of skills to meet the needs of their patients. The cost to a rural doctor only increases as you travel further from the major cities. This is due not only to GPs needing a wider skillset and therefore CPD, but also the vastly increased travel commitments to attend such training events .

RichDoc2

I thought I heard a murmur…

For example, last year here is a snapshot of the courses that I attended in order to practice in a small town:

  • Rural Emergency Skills – up to $300
  • Advance Paediatric Life Support – $2500
  • Diploma of Child Health – $2500
  • X-ray licence – $150 per year

This doesn’t even include travel to upskilling and other CPD events. I fear that some doctors may find that having the most up to date knowledge and skills is not justified by the cost that they may be forced to shoulder. It doesn’t mean that they will be bad or dangerous doctors, just not as ‘top notch’ as we could have. To me it makes sense to invest in primary health care (including skilled GPs) in order to prevent further burden on the tertiary health system and already over crowded hospitals. If the Federal Government can foresee how to return a budget to surplus in 5 years, why can’t it do the same with healthcare.

As with any cut to health care or the opportunity for doctors to continue education, it is patients that ultimately suffer. The Australian public live in a country and an era in which they expect (and for their tax dollar, deserve) the highest quality health care. Any disincentive for doctors to maintain skills, especially those in country areas will directly impact health outcomes. It may not happen overnight, but it will happen. This is the real story behind the proposed cuts and the saddest one too.

But it’s not all doom and gloom. The rise of Free Open Access Medical Education (#FOAMed) has the potential to augment and possibly reduce the amount of travel required of doctors to keep up with the latest clinical trends. Myself and others who use this online service don’t see online education replacing all conferences, but as a valuable resource to call on away from the face to face meetings. Of course hands on skills training will always remain, possibly with increased use of video and podcasting. It is an exciting future and if this current furor at least highlights the usefulness of of FOAMed, then it has done *some* good.

And you don’t need a five-star hotel or first class boarding pass to learn online….

Interview with Jim Muir from Telederm

A face not just for radio!

A face not just for radio!

Speaking with Dr Jim Muir about ACRRM‘s Telederm program. Jim is a dermatologist based in Queensland who says he has ‘a face for radio.’ He has been running Telederm for the past 10 years which provides online dermatology diagnostic and management help. I’m chatting with Jim about the service, its benefits, how it started and what the future of it might be. Unfortunately, the funding for Telederm is threatened. To learn more about the crisis and how you can help, please have a read of this post.

To add your name to the petition to #savetelederm, visit the page here.

#SaveTelederm

Arm - close up

Arm – close up

About a week or two ago I had an interesting dermatology case that I saw in the clinic. It took me a second visit to get my head around what could be going on. By then, I had tried some treatment and taken a fairly good history. But it made me think. What had I not thought about? Was there more important history? What did the rash look like to other doctors? In this grand age of #FOAMed, I wrote this post and asked the online doctor community for some help. The response and discussion was amazing. But this concept and process is nothing new. It has been the bread and butter of Telederm. The post also sparked a discussion and recent realisation for myself and some other rural GPs that the future of Telederm was at risk.

But what is this Telederm?

Dr. Jim Muir - Telederm

Dr. Jim Muir – Telederm

Telederm is an online dermatology resource faciliated by ACRRM and run by Dr. Jim Muir, a dermatologist based in Queensland. Listen to an interview with him here. The Telederm service has been operating for the past 9 years. Jim has been prolific in his posts online and education of GPs around the country. In fact, I was able to dig up an article about Jim and Telederm from 2005. Interestingly was quoted then as saying:

“the uptake of Telederm is not as high as it should be, because it is seen as time-consuming for GPs to have to take photos and upload them.”

Fast forward to 2013 and the use of Telederm has grown exponentially. Perhaps the advent of smart(er) phones and better cameras has helped with increasing uptake? I also like to think that GPs, registrars and students have realised what an amazing resource it is and have spread the word. Along with case discussion threads (that I have lurked and watched without posting on for the past 4 years!) there are quizzes, a service for a proper dermatology opinion often within 24-48 hours and instructional excision videos.

Why is it so important?

Unfortunately, there is still a wide gap in the medical services that are available to rural and remote patients. Access to specialists is still woeful in many parts of the country. Telederm not only reduces the tryanny of distance for these patients and their GPs to specialist advice, but also saves big bucks through reduced Medicare expenditure.

Some other benefits of Telederm include:

  • Free advice on diagnosis and management of tricky skin conditions
  • Saving of patient’s time and expense
  • Increased speed of diagnosis and treatment for patients
  • Up-skilling of GPs in rural and remote areas
  • Ability to provide local medical services that would not otherwise be possible

So what is all the fuss about?

Unfortunately the funding required to keep this service online is currently at risk. ACRRM, the rural GP college that keeps Telederm running has made a submission to the Department of Health and Ageing to continue funding this valuable resource. A response was due in March and has not been forthcoming. Therefore, we need your help to advocate and make some noise….

#SaveTelederm facts

How do I make a difference?

Already there has been a lot of noise coming from Twitter using the hashtag #SaveTelederm and blogs penned by rural doctors (Minh Le Cong, Tim Leeuwenburg and Jonathan Ramachenderan) that use this service and are passionate about its continuation. If you have a blog, please write something. If you teach students, tell them about it. If you are a patient in rural areas, talk to your local member. And everyone, get online and sign this petition: https://www.change.org/en-AU/petitions/keep-telederm-funded-savetelederm

Every signature sends an email to the Health Minister and the Department of Health and Ageing so that they can realise what a tragedy it would be to lose Telederm. Thanks for your time and support.

 

A tale of on-call radiology

Better than the iPhone x-ray app

Proof I can take x-rays, my own finger

Hi all, a little story (somewhat of a rant) that I’d love for you to read and comment on.

This year I have been helping with an after hours GP clinic about 30 mins drive from Adelaide. It runs out of a small ‘country’ hospital between 6:30 to 10:30pm. Attached is a private radiology department that has x-ray, CT and ultrasound capabilities. The after hours service is mainly for small emergencies that are easily treated by a GP that can’t wait until the morning. Even still, there are some who come for repeat prescriptions…but I digress.

I was at the clinic when a 9 year old boy presented one night. The poor lad had fallen off his little motorbike coming down a hill at about 20 kmh or so. On initial examination he had a few grazes and a 3 cm cut to his left forehead (was wearing a helmet!). Secondary survey revealed a very sore left elbow and sore right metacarpals that he didn’t want to move at all. Before suturing him up we called for the on-call radiographer to come in and shoot some x-rays at these sore spots. Just as the last stitch went in, he was whisked away to get irradiated. Luckily, there were no nasty breaks. We thanked the radiographer and got the boy cleaned up.

An hour later I had two more patients that I thought needed x-rays. One was an 11 year old girl who had fallen in large pothole. It sounded like she had suffered an inversion injury, was unable to weight bear and was tender over her 5th metatarsal head. BOOM! Ottawa Ankle Rules, she needs an x-ray. Just as it happened, the next patient came in 5 mins later. This time it was a 7 year old girl who had falled on her outstretched hand the day prior, non tender over her scaphoid bone, but was maximally tender over the distal radius. I thought “this could wait til tomorrow with a backslab, but if the radiographer is coming in for the first one…” The lovely casulty nurse dutifully called up and returned after I seen a few more patients and reported:

“I don’t think the radiographer is very happy with you, they want to know how qualified you are and if the x-rays really need doing. They are about 30 minutes drive away.”

There was so much in that short discussion that made my neck hairs stand up. It was something that had irked me before at a large tertiary hospital. That is someone being on call, getting paid to be on call, but then giving some resistance to coming in. To their credit, the radiographer came in and took the x-rays for me. There were no fractures in either of the young girls who in turn didn’t need a plaster on overnight. Some tubigrip bandage, RICE and home it was to follow up with their usual GP in a few days. That did make me feel a little silly for the call to be honest.

Before leaving, the radiographer and I had a chat about what was company policy was with regards to what they should be called about in the future. Apparently the motorbike injury was OK, the girls apparently not. I might have stepped over the mark by going on to say that I was not only qualified as a doctor, but also to take x-rays (even of my own finger after dislocation). Of course I wouldn’t be allowed to use the company x-ray machine in the hospital I was working, but certainly any of them 15-20 minutes towards the country. In fact up until about five years ago, the GP after hours service could use a portable x-ray machine that lived in A&E. But it was removed following pressure from her company. Now not wanting to point the finger at  company policy, the radiographer who helped me out this night, any of the patients and hopefully myself, what is the best move here?

I would be interested to hear your comments!

Was I being too cautious in asking for the last two x-rays?

Should I have just broke out the Plaster of Paris and sent them for a GP/hospital review the next day?

Should you actually have to put up a fight to get someone who is on-call to come in for a patient?

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