July 20, 2016 § Leave a comment
This is a submission I just wrote to the productivity commission inquiry into human services. Been years since I posted here, so here goes, hope I press the right buttons……
I will make two points: the first is general; the second is specific to my work as a GP.
1. Health services cost money. Either patients pay or tax-payers pay. Poor people are the sickest, and sick people are poorest. Making patients pay is therefore unfair. In addition, patients lack the knowledge and power for the health care market to ever be truly competitive. The research is out there. Look at the USA.
2. I’m a GP who mainly works with the poorest people in the community. For over twenty years, I have worked in a Brisbane clinic for homeless young people. I also visit hostels across Brisbane and Ipswich housing people with chronic mental illness, alcoholism and intellectual impairment (often all three). And I work in a clinic in Brisbane’s lowest socio-economic suburb, Inala.
Patients see me because it’s free. Many of my patients have poorly-controlled paranoid schizophrenia and are even suspicious about signing Medicare forms. There is zero chance I can charge copayments, which is perhaps good because carrying a money bag would put my life in even greater risk.
Perhaps the productivity commission likes numbers? Here are figures: in the 2015-16 financial year, I put two days per week into visiting hostels (all Queensland level 3 supported accommodation). My gross income from this was $85,000 but my practice costs are high and rising. I now have an office so I can excise skin cancers and expedite women’s health checks. Including insurance and registrations, my costs are $50,000 pa. Feel free to do the sums.
I provide a cost-effective service for the community. I see truly sick people. I prevent large numbers of hospital presentations. I defuse the occasional (metaphorical) bomb, preventing assaults of members of the public.
Please don’t recommend changes, for instance a shift toward private funding, that will make it even more difficult to provide services to the most needy!
November 29, 2013 § Leave a comment
The Last Word on Wars
Australian Doctor 29 November, 2013 Dr Andrew Gunn
The highlight of a conference is never the presentations. It’s the networking — with taxi drivers.
An Afghan immigrant drove me to the airport a couple of weeks ago. He complained about the stupidity of toll roads and the governments that create them.
All roads no longer lead to Rome, but all taxi conversations still lead to politics. Cab fares cover discourse as well as distance. George Burns once said it was a pity that the only people who know how to run a country are busy driving taxis and cutting hair.
My driver enthused about a 2004 book called Imperial Hubris: Why the West is Losing the War on Terror. Thomas Hobbes was the 17th-century English philosopher who said that, without society, life is nasty, short and brutish (with society, it’s natty shorts and brewed tea). Hobbes believed that the greatest destroyer of peace is hubris.
I bought Imperial Hubris for myself this Remembrance Day. The book’s gist is that Western bombs, not Western culture, create Islamic extremists.
The cartoonist David Pope once expressed this by showing ground crew shouting to the pilot of a bomb-heavy American fighter plane: “And while you’re there, try to find out why they hate us so much!”
The game of thrones is now turning into the game of drones. Almost 10% of US Air Force pilots now fly drones.
My cabbie became distressed talking about drones. He said they are “men using PlayStations to kill people”.
We spoke about his family. He explained that Afghan families “are not a husband and wife, two children and a dog … tribal families can be thousands of people”. And if you kill one family member then it is custom that the others vow to kill you.
He frowned and said: “We all thought it was funny when Australia talked about ‘staying the course’ in Afghanistan … because when the Americans leave, you will be slaughtered … it’s crazy.”
He concluded, “Australians are nice people but their politicians are very bad.” I couldn’t disagree. For instance, an Afghan patient told me today: “You go to Afghanistan, you come back, you just want peace. You don’t want money or job, you just want peace.” Fly-in-fly-out politicians scoring a quick photo op with the troops never return with the same view.
My next taxi driver was Turkish. I talked with him about the Australian celebration of Gallipoli, hubristic pagan sacrifice of youth, and that kind of stuff.
He said: “Gallipoli is very serious for my people.” He lost one grandfather in World War I; the other was wounded.
I told him that one of my grandfathers was maimed at Gallipoli — he’d left Australia as a champion boxer and returned with a mangled arm and missing pieces of skull. His injuries deeply affected me as a child and might explain why I’m so aggro about being anti-violence.
My Turkish driver was relaxed about Australians visiting Gallipoli and harboured no ill will toward Anzacs. Instead, he heaped venom on Winston Churchill.
I actually have a soft spot for Churchill. I can’t detest a man who said democracy is the worst system of government apart from all the others. I also sometimes quote Churchill to patients: “If you’re going through hell, keep going.”
I hadn’t associated Churchill with Gallipoli, but the cabbie was right — Churchill was First Lord of the Admiralty during the invasion. He was then demoted for slaying too few of the cabbie’s relatives and too many of mine.
November 1, 2013 § 1 Comment
The Last Word: on fitness to drive
1 November, 2013 Dr Andrew Gunn
Frank Zappa was right – the world might not end in fire or ice. It could instead end in paperwork – like, say, The Apocalypse of Medical Assessments for Fitness to Drive.
I have zero inherent interest in decreeing whether elderly people should still be driving. Before a walking stick transforms into a walking frame, I generally give patients a choice: they can have, and probably fail, an expensive driving assessment with an occupational therapist; or they can let me clip their wings.
The angst starts when I cross out their motorbike and truck licences. Patients anxiously protest that these licences are still essential “for emergencies”.
I sadly explain that riding a motorbike at the age of 80 is more likely to create an emergency than resolve one. I also reassure them that the police will let them drive a truck if, say, a semi-trailer packed with singing nuns and orphans is being threatened by a hostile alien spacecraft. It’s a pity there’s no tick box on the form that covers that circumstance.
The tension then escalates at the hint of restricting their driving to within their local area and during the day.
I once reluctantly certified a patient as medically fit to drive after first checking with his psychiatrist and optometrist. Pleased as Punch (and more pleased than Judy), he drove straight to Queensland Transport’s offices. Staff watched him park through a window. This involved hitting a wall — twice — and ultimately parking slewed across two spaces.
The driving authorities twigged that things could get tricky and phoned me. My patient returned that afternoon with his version of events, insisting his car was undamaged. I showed him photographs emailed by transport officers that suggested otherwise. He angrily claimed they’d been doctored.
In an impressive but ultimately futile demonstration of functionality, he had his car repaired overnight and took it back to “those liars” at Queensland Transport. Regardless, I took his driving licence off him — so he took his medical file off me. I never saw him again although I did recently hear that he is now safely parked in the beyond.
Another elderly patient failed an occupational therapy driving assessment — but not too badly. He then attended a private driving school and obtained a letter attesting to his competency. I even talked to the driving instructor to check it was legit.
Initiative deserves reward, so I gave him temporary — but now revoked — medical clearance. He got another year or so of restricted driving without, as far as I know, hitting any singing nuns, orphans or Queensland Transport walls.
He’s still angry at the GP who sent him for the driving assessment and won’t see her again. Perhaps he won’t see me now either. Another GP phoned me this afternoon saying my (ex?) patient was asking for medical clearance to drive.
This is a stupid system, and one that destroys therapeutic relationships. I’d prefer everyone to sit practical driving tests every five years from age 70 (and yes, I’d also do revalidation to keep practising medicine).
Not that this would eliminate all problems. Another patient is an interesting guy but not the fullest stubby in the slab. It didn’t surprise me that he said he had two accidents while sitting his driving test. It did surprise me that he was passed.
I don’t know for sure if his story is true. I do know, however, that I dread Judgement Day — that’s the day he approaches me with fitness-to-drive paperwork.
October 4, 2013 § Leave a comment
The Last Word: on breeding
4 October, 2013 Dr Andrew Gunn
A friend learnt as an adult that her parentage was complex. At her father’s funeral, she anxiously expected to meet her other father, the biological one, for the first time.
It wasn’t to be. He had a car accident driving there and died. The death of two fathers within a few days didn’t kill her, so I guess Nietzsche would say it made her stronger.
I read today that scientists can now create babies with three parents. The technique aims to avoid inherited mitochondrial disease; but unlike old-style IVF, or the wandering of my friend’s mum, all three parents contribute a little DNA.
Getting diverse DNA sounds okay. Even Oedipus knew inbreeding wasn’t good — although in 1991, a Louisiana Democrat called Carl Gunter argued against allowing abortion for incest because “inbreeding is how we get championship horses”. Of course, Gunter also said: “There ain’t no way to make people equal, one’s born a man and one’s born a woman.”
But just quietly — let’s keep this in the family — the truth is we’re all inbred. Early descendants of Adam and Eve had few eligible partners — and that’s irrespective of whether we’re considering Y-chromosomal Adam and Mitochondrial Eve in Africa over 100,000 years ago, or the Judeo-Christian-Muslim couple later created from dust and non-pork spare ribs. Climate change from the Toba super-eruption about 70,000 years ago might also have trimmed the human population down to a few thousand breeding pairs.
Without inbreeding we should have two parents, four grandparents, eight great-grandparents, sixteen great-great grandparents and so on. The maths indicates that about 700 years ago, the required number of ancestors exceeds the total human population.
This effect is called pedigree collapse. We are all kin. Many geneticists think all humans are 50th cousins or closer, and we’re all descendants of rapists, murderers and royalty. Although of course royal families are never ill-bred, just inbred. The Hapsburgs are the pin-ups of royal inbreeding. Archduke Franz Ferdinand was the Hapsburg whose assassination prompted World War I.
He visited Australia in 1893 and was described as a man on a mission to see as many strange and exotic creatures as possible. And then kill them. His pedigree included great-grandparents who were double first cousins, sharing the same four grandparents.
The Archduke’s shooting in June 1914 followed a botched bombing earlier that morning. The failed bomber, Nedeljko Cabrinovic, then swallowed cyanide and threw himself in a river to drown. The cyanide didn’t work and the river was only ankle deep. He eventually died in prison from tuberculosis.
It’s not known if Cabrinovic’s great grandparents were also double first cousins.
I recently learnt about my mother’s mother’s mother’s mother. She entered Australia in 1849 on a boat crammed with dodgy ethnics practising a religion associated with terrorism. Bridget McQueeney was in a shipment of young female orphans from Irish workhouses. Australia was suffering a chick drought; and Ireland was suffering a potato famine with too many eligible spouses and too few edible spuds. Win-win. No politicians competed to turn back the boats. Bridget dutifully bred 86 grandchildren.
My father’s side have also been in Australia for yonks. In fact, Ned Kelly’s sister married a Gunn. Come to think of it, Bridget’s mum was a Kelly … Uh-oh.
September 13, 2013 § Leave a comment
The Last Word: on words
13 September, 2013 Dr Andrew Gunn
Two thousand five hundred years ago — before being killed by a falling turtle — Aeschylus said that words are the physicians of the diseased mind. I reckon words are just weird.
If I concentrate hard enough on any written word it soon appears misspelt and then dissolves into unrecognisable symbols. Jamais vu — when familiar things seem unknown — is more or less the opposite of deja vu. It’s speculated that chronic jamais vu could underlie Capgras syndrome, where schizophrenic patients think a familiar person has been replaced by an imposter.
It’s kind of like knowing someone both before and after they enter politics.
One study found that writing the word ‘door’ 30 times in 60 seconds is enough to make most people doubt that the word ‘door’ is real. But don’t try it at home unless you like climbing through windows.
The ambiguity of English words has its pros and cons. I know a GP who upset a young American student with a foot injury. He innocently asked her to slip off her thong.
Puns do add interest to consultations. Chair-breakingly-obese patients always report they’re trying to lose weight. This permits the response. “Yes, I know you’re trying …”, while a thought bubble continues, “… very trying.”
English does, however, lack certain useful words. For instance, the Japanese word arigata-meiwaku is said to mean an act done for you which you futilely try to stop, and which as expected causes trouble, but nonetheless you feel obliged to express gratitude for it.
If only English had more words like this. For instance, when a patient reports that the dog ate their Oxycontin, we need a word that means you think someone’s lying, and they know you think that, but they hope you can’t be buggered making a scene about it.
Or maybe we already have that word: electioneering.
Tony Abbott will, I expect, be Prime Minister when this article is published. I’m no fan but he’s entitled to occasionally mangle words. Ignorance is not always bliss but if someone was “the suppository of all wisdom”, I’d stick to being stupid.
Names are another problem area.
I have a friend who thinks that, before naming a child, couples should have to clear it with a fat, fierce matron seated behind a desk. If a particularly dipstick name is suggested, couples are slapped, yelled at, and sent to the back of the queue to try again. Melena and Candida might narrowly pass but kids would be protected from monikers such as Mafia No Fear, Anal or -er (I’m told it’s pronounced ‘dasher’ not ‘hyphener’).
Names can be cruel. I once overheard an elderly man complaining that he’d been a polling official at hundreds of elections but nobody called him Bob the vote tucker; and he’d trucked thousands of boats all over the country but nobody called him Bob the boat trucker. He then fell silent and stared glumly into his beer before intoning, “… but a fleeting moment of passion … just ONE goat …”
The internet created a new type of name trouble. An early, well-known instance was the island’s and the land’s fight for possession of penisland.com. In fact, this article was prompted by my disappointment on following a slightly intriguing link to womenstalk.com.
Other examples include powergenitalia.com (Powergen, an Italian electric company), expertsexchange.com (not what you’d think), lesbocages.com (Les Bocages, a tree surgeon), the missing apostrophe in hollandshitfestival.nl and the physicians for the diseased mind (or not) at therapistfinder.com.
August 18, 2013 § Leave a comment
The Last Word: on conspiracy theories 16 August, 2013 Dr Andrew Gunn
My patient quietly said: “Well, you already know of course, being a doctor.” She looked at me quizzically while rocking gently, the legacy of decades of anti-psychotics.
The weathered face and long dark hair made her look like a Native American tribal elder. I felt as if her real name was surely something like ‘Wise Owl’.
I confessed ignorance. Wise Owl smiled toothlessly and leaned convivially toward me.
“Tomatoes would have been better but they’re too expensive, so instead I used the juice of grated carrots ¬ It’s fixed my angina.”
I hesitated before speaking the truth: “The hospital didn’t think you had angina.” In fact, last week’s hospital letter gave a diagnosis of mental illness: unspecified — but I don’t tell everybody everything. Paternalism has its place.
Wise Owl’s feathers were ruffled, but her voice then softened.
“You know, there’s a conspiracy,” she said conspiratorially, “and you do know, being a doctor.”
Wise Owl isn’t my only patient who believes in conspiracies. Lots do. Some even think the US National Security Agency runs a massive, secret, global electronic surveillance program called PRISM. Pretty wacky, huh?
Until recently, PRISM stood for Psychedelic Research in Science & Medicine, an Australian group researching the use of ecstasy to improve PTSD.
Please note that this is in no way related to Project MKUltra, which was a CIA group researching the use of LSD to improve hippies.
In March, US voters were surveyed on 20 conspiracy beliefs. The results confirm that it’s comforting to think that someone somewhere knows what they’re doing.
The survey demonstrated high confidence in fluoridated water but rather less in vaccines. The slimmest majority, 51%, think global warming is no hoax.
Just 46% rejected the proposition that “a secretive power elite with a globalist agenda is conspiring to eventually rule the world through an authoritarian world government, or New World Order”.
Thirteen per cent think Barack Obama is the Antichrist, and another 13% aren’t sure he isn’t. Four per cent think the world is controlled by reptilian shapeshifters who take on human forms.
Three questions put me into the conspiracy camp.
First, like 44% of respondents, I believe GW Bush knowingly lied a decade ago about the existence of weapons of mass destruction in Iraq. As did Curveball (see the mother and seed of all conspiracy theorists: Google).
As did, I think, our then-Foreign Minister while parroting the phrase “Saddam Hussein and his weapons of mass destruction”. You might act the fool, but you can’t fool all of the people all of the time. Some will twig you’re actually a liar.
Second, I agree with the 29% who think aliens exist. The universe is apparently teeming with untold gazillions of exoplanets, so this is surely a no-brainer.
In fact, when the Large Hadron Collider failed on activation in 2008, I briefly wondered if pan-galactic aliens had used spooky action at a distance to stop it destroying the universe.
And then that mysterious time-traveller guy got arrested at the collider, saying: “The discovery of the Higgs boson led to limitless power, the elimination of poverty and Kit Kats for everyone. It is a communist chocolate hellhole and I’m here to stop it from ever happening.”
Third, I’m one of the lonely 15% who think the pharmaceutical industry “invents” diseases to make money. One day I might reveal the truth about this. But first I have to clear it with the shapeshifting reptiles.
July 19, 2013 § Leave a comment
The Last Word: on voodoo medicine 19 July 2013
Could computers do the work of GPs? Australian Doctor recently raised this question (14 May 2013), and, last week, a medical student asked me a question that I’d like to hear a computer answer: “What do GPs do?”
My reply was: “Voodoo.”
This wasn’t an attempt to belittle either general practice or voodoo. It’s just that most of the stuff we do isn’t particularly scientific. Well, most of the stuff I do isn’t. A Cancer Council CEO once accused me of being so unscientific that I would have been against electricity — or, as a friend calls it, “electrickery”.
For instance, on completion of a home visit this week, I gave a sick 91-year-old woman a quick peck on the cheek.
I recklessly did this despite my profound ignorance of randomised controlled trials on this intervention in this patient cohort.
AHPRA probably won’t hear about it. My patient doesn’t speak English and, more importantly, she was delighted. Her carer quietly commented that no medication could be so helpful. A stint in palliative care taught me the therapeutic power of a handshake and smile, regardless of a patient’s condition and smell. In fact, the worse the patient’s condition and smell, the better it works.
Here’s more evidence that I practise voodoo: computers are awesome at doing K10s, depression scores, pain scales and all that stuff. But I viscerally detest the lot.
This might be genetic. My octogenarian mother recently had a tense argument with a nurse.
The nurse wanted to record a pain rating number but my mum insisted a pain scale was relative, not absolute, so she might as well just tell the nurse if the pain stayed the same, got better or got worse. The nurse lost because my mum’s blood pressure skyrocketed.
A Prevocation General Practice Placements Program resident asked me last week what questionnaire I use to diagnose depression. I silently reflected on the science behind putting antidepressants in the tap water.
Then I said that I’m an analogue, not digital, doctor. I diagnose depression when patients are saddening, mania when they’re fun, schizophrenia when they’re interesting, borderline personality disorder when they’re irritating and psychosomatic illness when they’re angrily denying that their symptoms could have any psychological component.
If greater diagnostic or therapeutic effect is required, I dance around rattling my skull stick or stethoscope — whichever first comes to hand.
The 1791 Haitian Revolution apparently began with a voodoo ceremony.
White folks in the southern US were frightened their slaves might get similarly uppity ideas. Uppity blacks also had grounds to be frightened. A participant in the 1811 Louisiana slave revolt “had his hands chopped off, then shot in one thigh and then the other until they were broken, then shot in the body, and before he had expired was put into a bundle of straw and roasted”. Voodoo has never been the scariest thing in Louisiana.
Voodoo dolls are usually used to bless people, not to hex them, yet the connotations of voodoo are invariably bad. For instance, the term ‘voodoo economics’ is self-evidently derisive.
As it happens, voodoo economics — that’s the supply-side, trickle-down variety — is the opposite of voodoo. Like most religions, voodoo teaches that greed is bad and generosity is good although, for some reason, the walking dead and eating flesh are less creepy when labelled as the Resurrection and the Eucharist.
So, could computers do the work of GPs? I don’t think they’ll replace us anytime soon but I am making a small straw computer. I could do with a pincushion.