The Centre of it all: What is a man to do?

The Diagnosis of Dr. Morse by Rod Moss 2008. Please click on the image to go to his gallery.

I met a woman with two young children and a sore arm this week. Her husband broke it in a violent outburst and she took the plaster off because it was too itchy. It was healing well. Her husband was in jail. Later, at Ingkintja, the men’s clinic, I saw a man in his mid 30s who had taken on work and rented a flat since coming out of prison for violence and alcohol. He was bright and sophisticated. He didn’t want to go back but he had quit his job because his boss was unreasonable (long story with good insight). Centrelink could help him after 8 weeks. He was distressed, anxious and hyperventilating. What to do?

I see myself as a feminist, largely due to living with Merridy and letting her advice and thoughts through my defences from time to time. I am serious about it. Despite this, as a young man I slapped her once. On the face, hard. It was nauseating. I did it to my mother once too, as an adolescent. I never saw anyone else be violent to women; it was in me. I am ashamed to admit it, but when I do, occasionally others speak up. Once a dear and gentle friend told me how he lifted his young bride by the neck up against the wall. Just once. They both laughed as they told me the story. Merridy slapped me too, once. She’s quite strong. She immediately apologised; probably quicker than I did when I hit her.

Family violence has been gradually gaining attention over the past 40 years. My father could beat my mother with impunity; he didn’t, but he could have. Even watching in the emergency department as a young medical student in the 1970s doctors would not get involved with family stuff. Nor would the police. We would feel pity and patch it up. The first laws regarding family violence in Australia were national in 1975. At that time abused children were said by paediatricians to have Silverman’s Syndrome which was “discovered” in 1962 based on multiple healing fractures on Xray! We now call it child abuse. Reporting of child abuse became mandatory in the 1980s. In the NT family violence has been a mandatory report by any suspecting adult since 2009.

Now I am living in Alice Springs and there is apparently more violence about although I have not witnessed any. Rod Moss, the painter, has written a wonderful account of his relationships with local Aboriginal people called “The Hard Light of Day“. It is largely uncensored and observational, without much judgement. It is hard to read at times and tells stories of the shortened life of men who often spend time in jail, and their suffering women. This has a lot to do with family violence and a lot to do with alcohol.

Peter Sutton in his controversial work “The Politics of Suffering” has a more scientific angle and has investigated historical violence in the Wik people at  Aurukun. He makes estimates of murder rates of women before contact, during the mission days and following that. Interestingly quite high rates dropped to virtually zero during the mission influence and have been higher still since. There is general concern about the level of death from violence in the NT. It appears to be warranted from anecdotal evidence and also from national statistics. Some years, such as 2010, all murders were of and by Indigenous people. One surprise, it affected both genders equally; the victims and perpetrators half male and half female. This is surprising to me. I looked on “GooGoo” and discovered there is a national effort to increase knowledge about male victims of family violence. Is this correct?

Australia as a nation has a very low homicide rate at 1.3 per 100,000, inherited from the UK which has been at this level since the 16th Century. The NT murder rate, as high as it is, is still far less than Brazil or many other countries and even when applied to the Indigenous population alone (15/100,000) is far below many cities in the USA such as St Louis, Baltimore or New Orleans which run at over 40/100,000. Alcohol is universally involved here. What are we doing about it? There appears to be one approach from the outside; we are incarcerating Indigenous men. Anecdotally, their assaulted partners visit them in jail and defy Restraining Orders to be with them once out.

There is more to this. My close Aboriginal friend, Ada, surprised me when we were working together in medical education in the 1990s. She had been the victim of domestic violence interstate and had separated from her partner. She attended a seminar on “Domestic Violence” with GP Registrars and came away quite perplexed. “I don’t call that violence”, she said to me. She had obviously been affected by the issues raised. We discussed the fact that it has only recently been seen as violence in the broader Australian society, and that I probably didn’t either until I was educated about it.

What happens when we apply our own legislation, based on an understanding arising from recently changed culture which aims to reduce already low levels of violence, to a population that has limited education in these matters and a relatively high pre-existing rate of violence? The answer would appear to be incarceration. Of men. To an unholy extent. To the shame of our country.

Is there an alternative approach? I was very impressed with Judge Roger Dive running the drug court in the recent “Ice Wars” program on the ABC.  He has been working since 2004 keeping drug users out of prison and has developed an almost parental relationship with those in trouble. Could senior Aboriginal people work with someone like that to get an alternative approach to the use of alcohol and violence? The reason to do this is to try and get some community authority into the mix and communication and education as well. Just like those using drugs in Sydney, locals are using alcohol and drugs with similar consequences; and if it goes on long enough then it escalates. Does incarceration help? It does not appear to.

Apparently, I learned very recently on Friday night at Monty’s, this has been tried before in 2011. The SMART Court (Substance Misuse, Assessment and Referral for Treatment) was established in 2011 but then removed by the CLP in 2013, labelled “do-gooder”. Megan, a nurse working now for Congress but who was one of the SMART Court clinicians, was mortified when it closed; couldn’t believe it. I told her that people must forget very quickly as no one had mentioned it to me!

If a judge and Aboriginal elders were to reconstitute a suitable alcohol, drugs and violence court in the model developed by Judge Dive and the SMART Court , it would have to be a long-term bipartisan or Federal commitment. The decision makers would have to learn how to influence young people setting off on a path of violence. Other agencies would need to understand their role. The range of sanctions might be broader and more culturally sensitive and possibly include:

  • Having intermediate educational and supportive environments which could take people who were doing well
  • Having secure social environments where fathers, mothers and children could mix safely and with zero tolerance of alcohol or drugs – this might include after school centres or other facilities with security precautions
  • Enabling community feedback to people with a history of alcohol or drug induced violence on a path to recovery in a safe way.

I have discussed this with some leading men at Congress. Steve, a visiting GP with a lot of experience in the NT, advised me to steer clear. He might be right, but I can only see opportunity. A lawyer from a women’s legal service came to see me and I raised this. Not sure what she thought. JL, the lead of the Ingkintja Clinic at Congress is talking to me about it, very aware that it can look like I don’t care about the women and children. That is what makes it so hard.

The Centre of it all: beyond the pale

20170118_064216As a rural kid you learn that not everything comes past your door. I went away to school in the city and I could feel the difference. I didn’t like all of it but I liked the opportunities that seemed to present themselves. My parents had to move to a small house to keep it all going so I felt obliged to do my best. I road with Merridy to London and thrived; we spent 12 years there and had 4 children. It takes some bottle to head back to smaller places. The smaller the place, the more bottle.

Mutijulu is the furthest out of our (Congress’s) five remote clinics. I have learned all their names and some alternatives. (The Santa Teresa local names are still beyond me, but I have got Utju and Ntaria now). To get there Teena, Samarra (the team), Ann (from policy) and I take the 30 minute tourist flight west from Alice. I let some Germans have my window seat. The rain nourished African and Asian buffel grass works its tortured agar shapes as we come in to land, crowding out the bluer resident spinifex in many areas. Then there is the rock. Wow….. We get a car and drive through the park gate with a nod from Teena and the ranger. Everyone knows Teena.

Mutijulu is just to the east of Uluru where non-Aboriginal visitors gathered in the old days. Like Yulara for tourists today, Mutijulu is a centre for Aboriginal people from all around. No Sails or restaurants here for visitors though, just mats or cars as bedrooms. The population is running at about 3 times normal due to ceremony. We arrive at the clinic which is a Heath Robinson affair; disconnected, different parts in different styles, lean-tos and dongas tied together with electricity cables, all donning a modern shattered solar panel which has a pram on it! All this wrapped up in high fencing including a car park and a cage for the ambulance bay which leak with neat round human-sized holes at regular intervals. It looks like something from the war in the Iraq.

We meet the staff. A nod and a wry smile from Maria, the new clinic manager. She takes an angle on life which is not familiar. She has worked as a remote nurse for many years, diluting her angled Italian features with flavours from far flung places. A pair of sidelocks hang on each side of her friendly face like Hasidic payots. She is new here and an unknown to Sinead, a tall Irish nurse and midwife who has been working in remote and deprived parts of the world forever. They have two colleagues who are relieving for a while. Dr Julie is here too. She is an experienced remote doctor who survived taking care of the victims of the boat disaster on Christmas Island in 2010. She lives in Yalara with her husband who is the Park Ranger. Robby and his sister are working here; two locals who really know what is going on. Robby is busy with ceremony and his sister chats about how things are going. So many people wandering around town, awake all night, playing cards and having fun. Some break ins and damage by some of the young people. The shop too.

Robby has started training as an Aboriginal Health Practitioner and will be in Alice in a few weeks. I help with some stuff I promise not to talk about. It changes my view of myself as Australian, like my brain grew a little, pressing on my skull.

The toilet is blocked so patients have to use the one entered through the doctor’s room. You can hear and smell the consequences – sometimes there is a rush into the room and an accident. Dr Julie is not sure how long she can take it. The blocked toilet is part of the Heath Robinson construction with drains added to drains. It’s not going away. Bob the (local) builder charges $400 to clear it but it blocks again. It makes everything I take for granted seem so fragile and temporary.

We drive to dinner in Yulara and pass the Mutijulu swimming pool which is exploding with golden spray and gleaming children as we squint against the massive setting desert sun. The rock provides mood lighting above its recent rain nourished green beard.

The staff, like the locals from Mutijulu, are not allowed to drink at Yulara as Mutijulu is a prescribed community under the rules of the Intervention. This is not law but regulation to prevent upsetting tourists with intoxicated locals. Take-away alcohol is illegal. Sitting in the excellent restaurant we have many young Aboriginal people serving fine food and we hear about Sinead’s life. From Ireland to Africa to Canada and all over then to Australia and Mutijulu. She has been a fierce advocate for home birth, particularly in Canada where she did her midwifery training and her remote practice. We share a lot of heroes including Yehudi Gordon and Janet Balaskus who took care of Merridy and I when our children were born. The day I spent with Michel Odent is interesting to her. We share birthing stories – her’s are far more exotic than my London and Darwin homebirth stories. Respect.

I work as the Malpa that night, supporting Sinead on a call out. Two staff have to go to every call-out now due to a recent murder of a nurse in the PTY lands to the south west. Sinead works her web of magic with the family, slowly carefully, showing mother, aunty and grandmother care and attention. The febrile child settles and heads home in arms, cooler for the outing.

I vow to do what I can to get everyone I know to contribute to getting a beautiful clinic at Mutijulu, a place that reflects the values of our Board and managers. It is, after all, our most visible remote community and should reflect in part the offerings we make to our overseas visitors, many of whom have made less effort to get here than their Aboriginal shadows behind the grand ol’ rock. Now that’s a job.

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The Centre of it all: the road ahead

West of UtjuTime to put some cards on the table so people can feel my aspirations, knock the edges off and gather shape. I came with some ideas about what I might achieve, and I presented them to the clinic staff. I feel a little at risk sharing my ideas early on but I want to take people with me if the innovations might be helpful.

My themes are simple but derived from my reading and experience both within and outside medicine. First, I want us (Congress) to be the best in the world at some things, and if we are already, for that to get known. We need to do things well to have an impact in health. I have chosen dealing with people with multiple health problems or co-morbidities as a genuine opportunity for Congress to  stand out. A search on the internet (“GooGoo”) finds a number of papers and an Australian literature review confirming that no one really knows how to deal with patients like this, that is, many of our mob. If we just treat each separate condition according to the guidelines our patients will have no life other than health care. We amplify the patients’ burden of disease as they either soak up all sorts of outpatient visits and investigations or just turn away and get on with their already multi-dimensional and complex lives. How to compromise on patient effort and give some real benefit? How to feel it all from the other perspective?

Second, I want to change the idea of team to a dynamic concept; the team that suits the person we are with at that moment. It will vary a great deal depending on the personality, experience, the conditions, the person’s family and other supports. We need also need to vary our role; offer different knowledge and skills to different people at different times. It is maximising the relevance of the resources we have to hand at each encounter. I learned it at Palmerston Super Clinic from Chris Harnden and Sue Chambers. It requires preparation and focus. Patients then vote with their feet.

Third, I want to see if we can consult more effectively with multiple people at the same time and with the same sort of conditions (known as shared medical appointments). Will people like that? Will it impinge on their privacy? I think it will allow them to discuss what is going on and why. How did she get a better reading than me? What does it mean if your kidneys are not working as well as they might? What can we do that makes a difference? It is definitely a foreign concept in Australian medical practice but many of us have seen it work in special circumstances.

Finally, health care for chronic disease means very little to many people in the community; there is no experience of benefit from all of our interventions, except perhaps in late stages. It has to be accepted on trust and requires considerable health literacy. Congress carries a lot of trust; it belongs to and works for our patients and community. We can gain further trust in two key ways: an ongoing satisfying relationship with individual patients and effective management of acute illness. Both are palpable and offer clear value.

I think I did OK. It was a big audience for a GP and a lot more Aboriginal people than I usually speak to in such a setting. Some Aboriginal health practitioners, general practitioners, nurses, interpreters, receptionists, Aboriginal liaison officers, podiatrists, dieticians and drivers. A number of people drop past my room after this. I made a few friends. I hear some concerns and some ideas from a variety of people. Glen, the interpreter tells me about his after hours efforts to get a new opportunity out of town for kids who are niggling the police or courts. I promise to go out with Tony the bus driver. I confess I haven’t done that yet but I know my reputation will depend on it. But first I’ve got to meet the people working and living in our remote townships.

2017 Scooter at Uluru

The Centre of it all: meeting

I started work. Well, I have been in a wash of information and glimpses of what is to come. Fortunately Samarra started on the same day and will be a key part of the team I am ostensibly leading. And Teena, another key team member, was there too. Both have been in Alice for a very long time and seemed to know everyone. Teena has done most jobs in Congress and is the local Wikipedia; she takes (great) care of the remote teams. We are to oversee the 3 town clinics and 5 bush clinics . Mutijulu is the furthest out at Uluru (“the rock”). We also have doctors at Alukra (women), Ingkintja (men), Headspace and in a variety of teams for the frail aged, disabled and people with kidney disease.

My introduction to the workplace and town is spread over five days, organised by Victoria. She is youthful, helpful and sharp; if in doubt, “Look it up on GooGoo!” Despite training from 12 grandchildren I have yet another vocabulary to learn here. A sort of international creole. Everyone is friendly, smiling, laughing. Its still raining so we can talk about the grass which is growing tall like spear grass in the very wet north. Not just snakes that I have to prepare for but moths, mosquitoes, locusts and, to the horror of many, mice.

I am clearly working for a mature and Aboriginal organisation. My boss Tracey is Aboriginal, as is her boss, the CEO. I am introduced to people passing by, or some just come into the room. My impression is that there is joy in the place, lots of energy. Commitment is obvious with concern for the Mutijulu community which has been flooded and now has an influx of people involved in ceremony that outnumbers the local inhabitants. Maria, the new clinic manager is having to swim against a lot of currents to keep things operational. She is the long distance type.

I have a phone and a car and a desk and a computer. I have brought my tools of the trade and have rescued them from boxes of guitar and microphone leads. I put them into empty draws in my desk. Stake my claim on reality. I have to learn to use Communicare, the health record system. I used it in the late 90s at Bagot in Darwin for a while but it has developed a great deal. No one seems to know exactly how to use it for everything, and some of the remote clinics had their own installation before joining Congress and the alignment is taking time. I know I can help with this.

This organisation is definitely a 21st century operation in a place of wonder and ancient ways. Aboriginal culture, mixed with Central Australian religious influences and business best practice; as a result a young Aboriginal man named Jonah fixes all my IT concerns. I get an email asking for feedback. What can I say?

“Blown away”?

There are some other cultural influences. Eric from South Africa runs the business department and is a very active and influential character. He knows how much Medicare each clinic claimed last week. I sense he has changed many things. Chipo from Zimbabwe manages risk. She is a force, managing accreditation, incident reporting and work health and safety. And Bipin, who runs CQI (continuous quality improvement) gets the data people need. In the clinics there are doctors from Australia, New Zealand, Belgium, Sri Lanka, China, Britain, Myanmar and Zaire. Many working here for more than 10 years and one over 20. I am the oldest though.

I am meeting an old place that has always been threaded with colour. I’ve got to choose my depth of field and focus. Best find a few people to help me with that.

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The Centre of it all: anticipation

I am a 61 year old general practitioner (GP) and I am on the move. With my family’s consent, I have accepted a job that will take me a way from most of the things I love and, I anticipate, challenge me more than any so far. I am heading to Alice Springs and the centre of Australia. I am a saltwater person so leaving the sea is painful, but I have my music with me.

I will be working in a number of clinics spread along the McDonald Ranges. The region goes as Central Australia, almost a state or territory of its own. Like most Australians I live 1500 or so kms away; in my case to the north, directly north, in Darwin where I have spent the last 25 years as a GP and educator. Darwin is the capital of the Northern Territory which includes Alice Springs but only part of Central Australia – of which Alice Springs is the unofficial capital. I have visited Alice Springs many times for a few days at a time, teaching or passing through when driving up and down the track to Adelaide and beyond. I have even seen the famous Todd River flow three times. That used to mean that you were never leaving Alice. It flowed again just before I got here so everywhere is green. That means first flowers and then snakes. I better be ready.

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The Todd River in Alice

I took this picture in the Todd last night and wondered at the inhabitants. A group of Aboriginal people chatting with children playing, a group of Asian men playing volleyball and thousands of tadpoles trying to mature in the rapidly shrinking puddles. I have asked a few people where the Todd River goes. People just shrug their shoulders. Surely it joins the Finke after flowing through the famous Gap – the gateway to Alice from the south through the beautiful McDonald Ranges. More shrugs. I guess there are other names for this Gap that I will hear and ponder. How many?

So I know something about the Northern Territory and I know something about medicine. That is a good start for my new job. I will be working in a health service set up by local Aboriginal people to provide a service to their community. It is called Central Australian Aboriginal Congress and it was the second such clinic established in the country immediately after Redfern in the early seventies. On the front page of the website is a quote which has me in mind.

Our Clients

Our clients are the most important visitors on our premises.
They are not dependant on us.
We are dependent on them.
They are not an interruption on work.
They are the purpose of it.
They are not an outsider to our business.
They are part of it.
We are not doing them a favour by serving them.
They are doing us a favour by giving us the opportunity to do it.

This motivational statement is attributed to Ghandi but this is contentious as you can read on the Quote Investigator website. Historical attribution is always difficult and usually shifts to the person with media access. The struggle for attribution is a constant part of Northern Territory life. For instance, I know of two people involved with the establishment of Congress; Dr Trevor Cutter and Dr Fred Hollows, both European Australians. People have done some work to set that straight but I have a lot to learn about the struggle for health and dignity in this part of my world. I start work in the morning. I hope I sleep OK.

Bum Steer: to be human is to be limited?

origami_rose from Mumtastic

I have always been amazed by the different approaches people take to what appear to be very similar issues. Is this the expression of boundless human initiative? Or could this just be positive spin, a conspired plot by our leaders, teachers and gurus to help us feel empowered? I am inclined to think so and now wonder if we actually choose from a very finite set of responses, basking in a delusional sense of freedom. So, to be fair to everyone, should we perhaps bemoan the limited opportunities we have and share our pain? Let me tell you how I happened on this analysis of life.

In a slightly intoxicated state, at a large family gathering, in the warmth of a southern European late evening sunset, with dear friends from various generations (relaxed I guess), I chanced upon the realisation that people used toilet paper in different ways to achieve ‘anal cleansing’, a topic that appears to remain controversial. And to my continuing amazement, not many used it the way I do. If you are from a culture that uses this tool (we have to have a range of tools ready these days) then you might be as surprised as I was at the time.

At the beginning of this convivial discussion it appeared that humans had developed a wide range of techniques to achieve this same sparkling outcome. However, as the general enthusiasm for the discussion grew and more spoke of the intricacies of their own technique (including input from a few recent users returning to the group) we discovered that in this large group there were only three methods employed. These were as follows:

  1. Folders – usually along the perforations when available and using 2-4 sheets;
  2. Wrappers – wrapping the toilet paper around the flat hand; and
  3. Scrunchers – just randomly building a ‘bouquet’  of paper to do the job (crumple is an alternative label but does not quite capture the engineering).

I was delighted to have led this small scientific inquiry and to have managed to set up an all encompassing classification system on the spot. Further, it illustrated the magic of three. I have yet to find any alternatives in the literature despite considerable epidemiological data being available. What does all this mean?

By now you have probably realised that I am a folder. I seek some order in things and am a committed utilitarian. I firmly believe that folding is the most efficient and environmentally friendly technique and so it appeals to my moral character – or at least I can work on that. I have good friends who are wrappers and I even know a few scrunchers. We all get on regardless, on the whole. I am also prepared to proceed in life blindly respecting others privacy and can say quite honestly that I do not know what most of my friends and acquaintances do. I like to think it would not greatly alter my opinion of them. To be honest, I do sometimes wonder about the prime minister and leader of the opposition but am not overly troubled by these musings.

Which brings me to the metaphysical relevance. I suspect that much of the time we act or think in a way that feels like the embodiment of freedom. Consider the case in point. No one told me what to do with toilet paper and my solution worked fine. I did not realise there were alternatives, and when I found out, I did not realise that there might be a limited number. This was terribly enlightening. Are we all behaving similarly, within a very limited range,  in most aspects of our lives? Are humans patterned  in a profound manner, developing their uniqueness from the range of exposures rather than the range of responses? I suspect so. It hurts a little to think of it and I have contemplated briefly what this means for humanity in general. How can this enlightenment help? I can only rummage through my own experience and musings at the café yesterday morning.

Like all humans I don’t feel good at times. But I choose, on the whole, to blame the ache in my stomach or chest when I lie awake at night or other fleeting symptoms not associated with acute illness on what is going on in my life. This usually involves the ones I love or work with or recent past or upcoming events. I realise from my general practice that this is not what everyone does. Others look in directions such as deficiencies of vital substances, the food they eat, their genetic makeup, the exposures to toxic substances or the drugs and medicines they use or have been given.

I must declare, as a rural boy of the 1950s, that I have my own potential causes of symptoms which are recalled apparently without effort but which I choose to ignore. I will confess that I grew up in an asbestos house with a father who smoked until I was 10. I also sprayed the carcinogen DDT into the air I was breathing on a grand scale across the countryside, earning pocket money from farmers who were friends of my parents and perhaps had an inkling that there was some risk. (By the way, no one has apologised to me for the possible harm done). I have, to the suffering of my friends, been emotionally buoyed by and a proselytiser for the research into the extension of the lifespan of earthworms suggesting ongoing exposure to low level toxicity is a powerful enabler. Caffeine has since officially joined the likes of low level radiation, starvation and dehydration.

The advantage of looking at what is going on in your life rather than other sources of ‘illness’ is that there is likely to be an answer there. If there isn’t, I have usually found it fairly simple as a GP to find out what is wrong. However, when not accepting symptoms as generally harmless expressions of a person’s existence, it poses a massive diagnostic dilemma which is potentially never ending. The bedevilling of food as toxic agent is a current example, causing distress and pain from birth to old age.

By not blaming food for my symptoms, I and my relatively large and extended family all have the joy of eating everything presented to us without concern, just as my 92 year old father does between playing golf and avoiding doctors. I think, perhaps naively, that I still get the same symptoms as others – it hurts after I exercise, my head aches regularly, my stomach regurgitates and grumbles, my bowels complain randomly, my haemorrhoids are troublesome at times. I don’t look for biological answers unless I am really affected, which is fortunately extremely rarely.

In my work as a GP I see hoards of patients searching for answers to their subtle symptoms and dysphorias before they are ‘really affected’. It seems so complex but how many places do people actually look? Could we classify them usefully and gain understanding? I want to be clear that in my wildest dreams I am not suggesting that their individual responses would correlate with how they use toilet paper, but I do wonder if we are as diverse in our responses as we might think. This all came to a head yesterday when out for breakfast. The extensive and diverse menu was carefully classified as ‘gfo’, ‘gf’, ‘vo’, ‘v’, ‘df’ and ‘dfo’, carefully understated in lower-case. I guess that catered for most concerned customers – and if we take out the ‘o for option’ that leaves ‘gluten free’, ‘vegan’ and ‘dairy free’ – the magic number of 3. To be human is to be limited.

 

Registration status on view

I have been advocating in the Northern Territory for changes in the way doctors present themselves to patients. I want to see transparency of a doctor’s registration status so that patients are aware of who is working under supervision and the name of that doctor’s supervisor. That way patients can escalate any issues to a supervisor if they are not satisfied with the care they are being offered.

Currently in Australia patients have to go to the AHPRA website and look up their doctor. Also, the doctor’s supervisor is not named on that site. How are patients to know who they are dealing with?

I propose the use of 3 colours – red, orange and green – to represent registration status based on supervision requirements. These would have the following meaning:

transparency-in-registration

Doctors accepted into a formal training program would be recognised by a mixture of yellow and green.

Badges might look like this in hospitals:

transparency-in-registration-hospital

And like this in primary care:

transparency-in-registration-primary-care

In general practice the colours could be on the name tag on the door rather than on a badge. The point is that patients could understand where we all fit into the world of medicine, whether in hospital or primary care.

Let’s make it clear for patients. The current universal response by doctors to this challenge is that patients have “no idea about the registration status of doctors”. Well, who is to blame for that? I am certain that they want to know.

 

 

Time Share

Time traveller
Time is the basis of human experience, it is the foundation of narrative, the vehicle of observation and the thread of trust. Its linear and physical path draws our attention away from the cyclical daily routine we inevitably follow at times. Understanding the importance of the future is health itself. Building and discovering a past that nourishes us is what provides our peace, contentment and a framework for generosity. As a healing profession, we must work with time, give our time and help people regain or maintain their desire for health and well-being.
Many people we see as general practitioners need our time more than our tests or our treatments. Just spending time with someone on a few occasions can have a significant impact on their lives. This is not well understood but does depend on our care and reputation. We do know that science has not been able to determine which components of many effective ‘talking therapies’ (such as cognitive behavioural therapy) actually make a difference over and above the engagement of a significant person with shared goals for a period of time. Spending time in conversation with someone in difficulty is inherently worthwhile. It must involve listening, should involve challenging the key determinants of the person’s situation and may involve sharing some insights gained elsewhere. Doing so builds two narratives; the narrative of the person’s life and their difficulties as well as the narrative of the time shared with us. Insights inevitably arise and as a consequence a changed view of the past and future. These narratives, now shared, allow trust to grow with a mutual understanding, and can be drawn on in the future when further difficulties intervene.

This approach also has a role in acute care. If we think of ‘monitoring’ a person’s condition as limited to taking measurements and making observations, it reduces our impact to the singular (and sometimes very important) biological dimension. However, we can also use time when someone is acutely ill in much the same way as when the person is distressed, building trust and a shared narrative. That way we can work with the ill person not only to make sure they are safe, but also to learn how we should work together effectively in the future. Such an approach allows a mother to take her sick child home for a short period (perhaps 4 hours or overnight) and return to discuss any changes, what social support they have been able to muster and how they are both coping. What we learn together can be used to ensure a good outcome and also to determine appropriate care when similar situations arise in the future. This provides a much greater gain than a prolonged trip to the emergency department to be tested and scanned unless, of course, there are signs of major illness.  The shared narrative is valuable to all concerned regardless of the next decision.

And what of protracted physical symptoms such as back pain or headaches. Although tests seem most likely to provide benefit, it is rare that they do. We know, for instance, that most changes seen on CT or MRI scans of backs do not correlate with symptoms. But doctors tend to make these spurious correlations, leading to ongoing concern and even an unwarranted deterioration in perceived health. Using time, as part of a naturalistic approach, is far more helpful, leading to observation, trust and a shared narrative. If the person will not take time to get stronger and more active or take time out to relax and nourish themselves or other simple measures to address the problem, then this can be challenged, but only from a position of trust. Arthroscopies may damage knees (especially in the elderly) while time often heals them. It takes a practitioner’s time to gain the trust of a person that allows them to give their bodies time to recover.

No one is time poor, for we all have the same day-to-day allocation. Horizons shrink with age and illness but time marches constantly. Even when our patients die, the once shared narrative remains as illustration or, in its public form, to share with relatives and friends and provide a new basis for trust. Time has one demand. We must be realistic. As Camus said, “Live life resolutely without hope for there is no consolation.” This is not a call to hopelessness but a call to being realistic and it is a very helpful stake in the ground for people who have a grave diagnosis and much uncertainty.

A growing personal narrative, more valuable if shared, is at the heart of our humanity. When thin or missing it is a mortal wound. People create this story with parents and kin, often regigging and changing the colour of bits and pieces. It becomes who we are, the gaps , the inconsistencies.  It is far harder to fill gaps retrospectively when they emerge later in life. The stolen generation and secretly adopted children testify to this. The value of memory with anchoring narratives is probably paramount to a happy life, no matter the distress that may have been part of the experiences that generated it. Working with our patients to put together the narrative of their lives, despite their focus on the woes of the present, is a wonderful experience and can make a difference for generations.

Why bother?

Hong Kong Hang OutIt is easy to get the feeling that we could all do a good job in general practice if it wasn’t for the crazies, the difficult ones, the slower types and the worried well. It is a bit like John Cleese in Fawlty Towers – who made the same mistake.

Today I saw a woman that I met a decade ago. She looked dreadful, much as she had done then. At that time she had been banned from our local emergency department. Now she is unable to get care from the psychiatrists. A decade ago she was complaining of pain and was relentless in trying to get medication and something done. In fact she had an abscess in her neck, no doubt due in some part to her lifestyle. She was sent away to a tertiary center and put through the mill. Spinal surgery, intensive care, rehabilitation.

She recovered in terms of her abscess but remains as out of control now as she was when all this started. Today, 10 years later, she is again begging me not to see her as a drug seeker, a doctor shopper, a write off. It was difficult not to do so all that time ago despite her neurological signs, just as it is now.

I have never prescribed her painkillers or benzodiazepines despite massive protestation: the sort that makes you bleed. It is heart felt, theatrical and even a little endearing before it becomes somewhat intimidating, quickly tedious for those measuring their own responses in terms of best practice or guidelines. There is absolutely no vaguely visible road to success. It is so compelling only because she genuinely suffers so much; wailing, pleading as tissues amass in or near the bin.

She sees her future only in terms of medications provided by doctors; me and my colleagues only in terms of degrees of rejection. She is “The Hulk” of medication users – she even looks a little green. There is no end of medical and social labels that apply, made all the more compelling due to her lack of insight. She is stark naked in her intoxicated disguises.

How to help? Her life is always on a thread. Efforts to help from a myriad of agencies lead nowhere noticeable. The pain is felt by all.

I shook her hand today and we parted peacefully enough. She might take me up on my offer to help her be a little healthier without feeding her hunger for intoxication. Some I have known like her have died younger, some have stumbled into middle age where they sparkle like drunk adolescents in a bowls club. I really wonder at her will to live and be fed. I feel for her family.

Do I have room for hope?

Je suis feminist

Southern Beach Gender is a big topic in medicine at the moment. Since Elizabeth Blackwell (US) graduated in 1849 and Elizabeth Garret Anderson (UK) gained recognition as a Medical Practitioner in 1865, women have been making headway in taking their rightful place in our ‘honourable’ profession. Constance Stone, Australia’s first woman in medicine, graduated in the US in 1888 as the University of Melbourne did not admit women. With hindsight, it appears immensely unfair that women could not study medicine and at what cost to humanity? It has been tough on those leading from the front in what is indisputable social progress. This progress does carry with it implications for our profession and for interactions with our patients and peers.

As our profession becomes more gender-balanced, the status of medicine becomes more dependent on the general status of women in society. Some will know of what happened to the standard and resourcing of the medical profession in eastern block countries when a majority of female practitioners were trained and employed without the status of women changing in those societies. Thus, if we are to be a gender-balanced profession and maintain the status of the profession then we all have an interest in the status of women. Self interest for all!

The majority of patients presenting to general practitioners are female and having access to a greater number of female doctors is positive for those who seek this. Research shows this correlates with the more ‘patient-centered’ approach of female doctors; but as men and women have the same medical training I suspect this is a social skill of women rather than a professional attribute. At the start of my career approximately 40% of women preferred female doctors for PAP tests, 15% preferred men and the rest had no preference. I could find very little data in Pubmed on current preferences but in a recent paper on gender preferences of men with erectile dysfunction it was approximately the inverse. Clearly this varies with cultural influences; importantly the lack of access to a doctor of the preferred gender may lead to reduced uptake of a required service, particularly in non-acute care. This may extend to colonoscopy.

I am aware that modern society is more sexualised and this almost certainly has an impact on gender preference in the consultation. At a Taylor Mac performance I recently attended he described his gender as ‘none’ and his sexual preference as ‘audience member’! Should we ask patients not only their preferred provider gender but also their preferred sexual preference? Would this change things for patients? A heterosexual male patient, whom I have counselled through a distressing period in his life, told me that he would prefer to see another doctor for his check up as he liked me! Presumably this was due to the possibility of an intimate examination. Very young girls with asthma are quite often reluctant to show me their chest when I am examining them. Sexualisation of life further promotes gender alignment in the consultation out of a feeling of safety.

An unintended result of increasing gender alignment is the deskilling of general practitioners in gender-specific medicine. I would propose that this is already a significant problem, added to by an increasing number of doctors working in primary care who are uncomfortable with cross-gender medicine for cultural reasons. Some avoid this aspect of practice altogether. In large cities this is not such an issue but in rural practice it can be catastrophic. The wonderful female doctor visiting program is a patch for this but is not a long term solution as it is very expensive and does not address men’s needs. All doctors need to understand gender and be in touch with those aspects of gendered behaviour that make others feel either comfortable or uncomfortable. General practitioners must take care of humanity, leaving gender preference to their patients.

What are the consequences within the profession itself of becoming gender-balanced? Clearly there are more opportunities for cross-gender interactions with peers; some of these will become sexual. One visible result is the larger number of dual-doctor families rather than the common doctor-nurse couplings of previous generations.  Let’s not get too hung up on people making sexual approaches within the profession even if these are a little foolish or fumbled. When the approach is sexual harassment then there are well established legal pathways. But any association of such liaison with job progression is completely unacceptable – whether through negative threats (“you won’t progress if you don’t”) or positive inducements (“I could do a lot for your career”). Calling this out for what it is should bring the spotlight on the unwanted attention rather than the individual in receipt. Managers must address this, and if the person providing the unwanted attention is the manager, then there must be a third party involved.

Our professional colleges could be a means for this to be dealt with when there is no other mechanism or the system is failing.

We must also consider the possible inappropriate calling of harassment. I am a non-gendered shoulder-touching and kissing sort of person and not everyone finds that acceptable (male and female); but it is my culture and I have got better at recognising when it is not accepted by others. I have never made any sexual advance to anyone at work in my career but I have had one doctor feel uncomfortable with my approach to physical contact. How far can we be expected to change for individuals? It is a general question worth asking. Recognising others’ cultures is important but being genuine and relaxed is also a positive attribute. How far does a widely acceptable non-sexist culture have to take into account another’s culture in these matters? The answer is probably “to reasonable lengths”.

So let’s all be reasonable in most matters but intolerant of any indications that women are being treated in a way that is unfair. This is all about fairness and humanity.