The Last Word: on screening clinics

June 21, 2013 § Leave a comment

http://www.australiandoctor.com.au/opinions/the-last-word/the-last-word-on-screening-clinics

“So, for $292, I can be up-to-date on how my body is functioning.” 

My patient – let’s call him Fortunato, a trusting character in a 19th-century horror story – had received an amazing offer: a personally addressed letter recommending a complete check-up at a screening clinic. It sounded too good to miss so he called the phone number. 

Fortunato said the first four tests would cost $199 but it was less than $100 more for another five. He figured this was a bargain. Perhaps even an Incredible, Once-In-A-Lifetime Bargain! 

Trapped like a roo in a spotlight — or an Italian nobleman in a catacomb — Fortunato supplied his credit card details over the phone. Research does actually suggest it will be easier to sell overpriced, unnecessary products to destitute pensioners than to rich doctors.  

The tests weren’t yet done when Fortunato told me his story, so I suggested he try to get his money back. I spoke my mind about the screening clinic but did not commit libel. Bad-mouthing is instead classified as slander. Slander is as serious as libel but hard to prove unless, say, the offender stupidly writes about it. 

Fortunato could recall little about what he’d just purchased but returned this week with the advertising letter. The outfit was called ‘Screen For Life’ — coincidentally, Edgar Allan Poe’s fictional Fortunato did indeed scream for life. From his initial description, I’d thought he’d booked a complete body CT. Instead, he was getting an incomplete body ultrasound.  

I felt partially responsible for Fortunato’s predicament because I’d been keeping his natural paranoia at bay with antipsychotics. Trust is the key to all relationships. Fortunato has paranoid schizophrenia — but trusted the company. I don’t — but didn’t. 

Apparently being trusting increases oxytocin levels and makes life worth living — although trusting nobody at least keeps your surprises pleasant. To paraphrase my favourite writer, Anon: “Trust God. The rest, virus scan.” 

One wonders, before taking payment, do Screen For Life telephone operators counsel patients on the complexities of false positives, false negatives, incidentalomas, over-diagnosis and iatrogenic harm? Perhaps information on population screening tests is provided from last month’s NPS Medicinewise News? And patients would presumably be asked what tests they’ve already had?  

As it happens, Fortunato sees GPs for more than just fortnightly antipsychotic injections and financial advice. He also has type 2 diabetes that necessitates regular monitoring of his cardiovascular risk factors. Fortunato had already had many of the tests booked at the screening clinic. And these had been bulk-billed at no cost to him. 

Fortunato ultimately cancelled his screening tests and, to the company’s credit, received a full refund. This news created the same pang of anxiety I feel when I so effectively explain the problems of PSA testing that patients don’t get it done. Would Screen For Life have discovered something important? Is Fortunato now the opposite, Sfortunato? 

I explained to Fortunato, as I do with many patients, that to negotiate life is to negotiate probabilities. Poor decisions can end well and sensible decisions can end badly but it’s best to keep the odds on your side.  

I therefore told Fortunato that he was right to cancel the tests. He is not wealthy and has better uses for his money, like food and rent. 

Another Italian, Niccolò Machiavelli, once said: “Wisdom consists in being able to distinguish among dangers and make a choice of the least harmful.” He could have made a great doctor.

The Last Word: on choosing your career

May 23, 2013 § Leave a comment

http://www.australiandoctor.com.au/opinions/the-last-word/the-last-word-on-choosing-your-specialty-1

 

“Only rugby players?” My elderly mum fell last week but was less interested in her fractured wrist than the orthopaedic practice’s photographic décor.

 

I briefly explained how a burbling pool of primordial soup and an electrostatic generator had conjoined to beget Neanderthals, Cro-Magnons and Orthopods; albeit some say not in that order. Grrl power can’t fight the fact that your archetypal orthopod spent his formative years on a footie field breaking bones and tearing ligaments. Occasionally his own. Hence the career in corporal carpentry.

 

It’s natural to be interested in your own problems. That’s why diabetic doctors become endocrinologists, asthmatics become respiratory physicians, madcats become psychiatrists and dodgy docs do expert legal opinions. I’d best not mention drug and alcohol physicians.

 

It’s therefore predictable that form-filling fetishists become GPs. And don’t try to deny it for that would be repression—or is denying it denial?

 

Denial, the least lucrative defence mechanism, has a bad reputation. Beyondblue has just launched an awareness-raising campaign aimed at people who are anxious but don’t know it. Why do mental health professionals keep knocking denial? Isn’t reality just a crutch for people who can’t handle being drug and alcohol physicians?

 

I recently had brunch with a sick friend. She finished chemo last year and says she’s taken my counsel—which I totally deny giving—that, far from being bad, denial is a fantastic defence mechanism. She then vented about a psychologist who shatters patients by encouraging them to think about their past traumas.

 

Time heals all wounds—if you don’t pick at them. Okay, nearly all wounds. There’s a reason patients fear psychotherapy. As must I.

 

Last year, I had a curious patient encounter that ultimately involved nine paramedics, a dozen police, two TV crews and a small riot. Youth service staff commented that for twenty years I have been the only employee who never receives debriefing. My spine chilled and I quickly fled. I must have debriefing phobia.

 

This afternoon I spent $15 purchasing a pre-loved 125-year-old Dictionary of Medicine. It goes from phlyzacium to phosphatic diasthesis without an entry for phobia. The book’s contributors included Braxton Hicks and Florence Nightingale but not Sigmund Freud.

 

Two decades would pass before Freud published about little Hans’s horse widdler phobia. Hans was of course also phobic of widdler-less horses, but Freud never let the facts get in the way of a good stiffy.

 

A friend once worked with a phobic dentist. Equine widdlers weren’t her issue. The dentist would not, however, enter a treatment room until a certain organ was covered with gauze. Moral: don’t do dentistry if you’re phobic of tongues.

 

I can relate to a tongue phobia. I don’t have arachibutyrophobia, the fear of peanut butter sticking to my palate, but Google Translate suggests I do have adhesitlinguafrigidametallumphobia. I’m petrified my tongue will stick to a metal ice cube tray. I can’t enter rooms with uncovered ice trays yet I’m too scared to get therapy. True. Ish.

 

I was about 18-years-old when a yahooing uni student fell from a car. He died. A friend of mine was also in the car. He seemed to cope. I don’t know if he got counselling.

 

In a physiology prac, the friend asked me to listen to his heart. He thought it sounded odd. We’d never used a stethoscope before. It turned out we were listening to the machinery murmur of his undiagnosed patent ductus arteriosus. He’s now a cardiologist.

The Last Word: on intimate exams

April 27, 2013 § Leave a comment

http://www.australiandoctor.com.au/opinions/the-last-word/the-last-word-on-intimate-exams

A GP in the UK has been arrested for recording intimate examinations with a spy cam. I hide a contrary secret from patients: I hate examining genitals.  

Once upon a time, I had an obs and gynae job. I didn’t deliver vast numbers of babies but did once race a hospital trolley through a car park with my fingers inside a vagina. Prolapsed cords make odd things happen.  

Most of my time in O&G was, however, spent gazing intensely at a small area between women’s legs. I spent a thousand nightmarish hours suturing vaginal tears and episiotomies.  

When I close my eyes to sleep after a day on the highway, I see the road. And when I close my eyes to sleep after a 57-hour O&G shift, I see girlie bits. And definitely not in a good way. Vaginal examinations now probably trigger PTSD.  

My reaction to naked females is also knotty because I was informally questioned as an intern about a breast examination I did in A&E. A combo of inexperience and diligence meant that, without explanation, I’d checked the breasts of a female patient with back pain. I no longer bother with such stuff. If you’ve already got back pain from the bony secondaries of a breast cancer, then ignorance can be bliss.  

Of course, there are worse things to touch than nipples.  

I once popped behind the curtains in my consulting room to do a Pap smear. I have nothing against beautiful young women, but this one had inexplicably failed to heed my instructions to remove her lower clothing, lie down and cover herself with a sheet. Instead she stood smiling and facing me. Totally starkers. 

Despite this hiccup, a Pap was completed without incident. Back then, doing a digital vaginal examination with Paps was routine. When my gloved fingers made contact, she started to emit disturbingly non-clinical moans. I scampered away like a startled rabbit. Hopefully she had a laugh about it with friends. I didn’t.  

That happened quite early in my career so I wondered if it would be a portent of things to come. It wasn’t. In fact, if anything, female patients who appear to harbour fantasies that would, if acted upon, be a menace to my registration, don’t want me examining their genitals. Which is 110% fine by me. Win win. 

Despite all this, I rarely use chaperones. What’s the point when both doctor and chaperone are sometimes accused of sexual assault?  

I figure patients either aren’t psycho or are psycho. If they aren’t psycho and you’ve done nothing wrong, then misunderstandings should be rectifiable. And if they are psycho, then a chaperone isn’t sufficient — you really need video evidence. Ooh, wait … Maybe not.  

Nowadays, patients often hope their own photos will preclude an examination. My first experience of this was when a well-covered Muslim woman passed me her phone, which showed an odd red lesion protruding from her vagina. It turned out to be an endometrial carcinoma. 

Sometimes you must look to learn. 

I once knelt to examine a patient’s penis while he leant against the examination couch. I failed to sense the lurking danger. No checkup-hastening capacious penile thingy occurred but moments later I was on the floor with a semi-naked man on top. I’d inserted a urethral swab and he fainted. 

I related the event in the staff tearoom. In a disturbingly graphic dramatisation, a receptionist provided solace that it could have been worse. As he fell naked against me, I might in horror have opened my mouth.

It’s a living.

The Last Word: on strange encounters

April 14, 2013 § Leave a comment

http://www.australiandoctor.com.au/opinions/the-last-word/the-last-word-on-strange-encounters

Sucking at relationships has an advantage. You get to know more people.

Late last Friday night my mobile unexpectedly rang. The display just said: “private number”. I knew my sons were home but I answered anyway. A frightened young voice started blurting out something about strange men in her house. I hoped it was a wrong number.

It wasn’t.

The caller turned out to be one of my very favourite people on the planet. Now 13-years-old, she had—with her mother and older sister—lived with me for several of her formative years.

Training trumped temperament. I flicked into emergency doctor mode to get the important information.

She was at home and unhurt. Her mum and sister were at a late movie. A couple of men had broken into the house but ran off when disturbed. Her mum’s mobile was off so she’d called me. She didn’t want to bother the police.

I told her to bother the police and that I’d be there in five minutes.

I arrived within the allotted time and didn’t find any intruders. The police appeared a few minutes later.

Assorted bits and pieces had been stolen but the biggest nuisance was the missing spare car key. The police said the thieves were likely to return to collect the rest of the car.

I generally avoid such issues by not owning cars that anyone would want to steal.

A couple of lifetimes ago, my then-partner and I returned at night to her car. A man was sitting in the driver’s seat. The car lacked certain refinements, for instance, a working inside handle on the driver’s door. After we appeared, the thief got panicky because he was trapped inside. He couldn’t open the door to escape.

Then-Partner took pity and let him out. He responded by giving her a peck on the cheek and saying, “Thanks Sis, next time I’ll steal a V8”. He’d destroyed the ignition switch but obligingly showed us how to hot-wire the car so we could drive home.

We drove off but—not surprisingly in view of the tangled spaghetti wiring dangling beneath the dash—the headlights died. This happened just as a police car passed. They stopped but weren’t interested in our story and quickly left. We were just instructed not to drive without headlights.

Funnily enough, years later I got the opposite advice from an NRMA roadside mechanic. My alternator died one night, so he charged the battery and suggested I drive home at high speed with no headlights.

My cars also break down during the day. On one occasion, I returned late at night to try to get it going again. There was a surprise inside. A corpse lay stiffly across the front floor, its pale face frozen in a ghastly grimace.

One’s thoughts during moments of high stress can be telling. Mine was, “Dang! I’m working in the morning and now I’ll be up all night waiting for the forensics team.”

I was therefore relieved when the corpse moved. It climbed out of the car whilst explaining that he’d been frozen wide-eyed with terror because he thought I was a cop. The Corpse was apologetic, said “God, I’m a bastard” and insisted on shaking my hand. He didn’t seem to have time to help get the car going but he did want to be friends.

Sucking at car maintenance has an advantage. You get to know more people.

My Last Word on Wisdom From Experience

March 1, 2013 § Leave a comment

Australian Doctor 1 March 2013

http://www.australiandoctor.com.au/opinions/the-last-word/the-last-word-on-wisdom-from-experience

‘It could kill you,” I said. My patient struggled to speak. His eyes bulged as he rasped: “I couldn’t care less.” After catching a couple of quick breaths, he continued: “They’re all dickheads. The lot of ’em.”

He was referring to the hospital doctors who’d stopped his quinine. He wanted it for leg cramps.

In Through the Looking-Glass, Lewis Carroll invented the word “chortle”. It’s a combination of a chuckle and a snort.

My patient started chortling. And I started prescribing. We can at least allow people to control their lives even if we’re not supposed to allow them to control their deaths.

If asked, I’d have also explained what quantities and combinations of drugs might be hazardous. But that subject never arose.

My patient was short and barrel-chested, with a white beard.

A cartoonist would draw him as Grumpy, the dwarf from Snow White.

Confucius said wisdom could be gained in three ways: reflection (the noblest), imitation (the easiest) and experience (the bitterest).

Grumpy the dwarf gained wisdom from experience. In the re-imagined fairytale TV series Once Upon a Time, he told Snow White: “I don’t want my pain erased. As wretched as it is, I need my pain. It makes me who I am. It makes me Grumpy.”

Grumpy the non-dwarf also gained wisdom from experience.

He wound up an elderly pensioner in Brisbane’s poorest suburb, clinging to life for years, slowly dying from lung cancer and emphysema.

Maybe he was hanging around to see if things got better. I wish they had. The day after I watched a zombie movie, Grumpy shuffled grey-faced into my consulting room. I suddenly realised it takes phenomenal willpower to be the walking dead.

I last saw him a couple of weeks ago. He’d recently started treatment for brain secondaries.

People often act like their life’s dramas are some sort of real-life drama. Grumpy didn’t. It was impressive.

Last week, in a rare triumph of modern medicine, I received timely news from a hospital. Grumpy had died.

Two receptionists were teary. I’d have also shed a tear if my lacrimal sacs weren’t shy.

All my patients die. Eventually.

I miss most funerals but rescheduled patients for Grumpy’s. I arrived to an empty car park. It seemed nobody was even interested in checking he was really dead.

The folks at the cemetery office said they were running no funerals that day.

They were, however, aware of a separate Muslim group gathered down the hill organising their own service.

Grumpy started chortling in my ear: “Less use than a body snatcher late for a cremation.”

I rang the clinic receptionist. Yes, Grumpy’s widow had given her the same funeral details that I’d been told. And no, Grumpy wasn’t a Muslim.

“Are you sure?” I ventured hopefully. “He’s got a beard… ”

The receptionist made an odd noise. It wasn’t quite a groan or a snort. Maybe it was a grort?

As I drove off, my phone rang. It was the receptionist. She’d called Grumpy’s widow but she was out. Somewhere. Probably a funeral.

I was also told that an elderly patient had just fallen heavily at home. His wife had said his blood pressure was low and she’d wondered if I’d do a home visit.

I agreed to drop in before returning to the surgery but felt anxious driving there.

Should I have called an ambulance? And if things didn’t go well, how would I find his funeral?

Climate stability believers

December 6, 2012 § Leave a comment

 “Faced with the choice between changing one’s mind and proving that there is no need to do so, almost everyone gets busy on the proof.”  — JK Galbraith

Galbraith is also credited with modernising the old expression “when the soup hits the fan”.

Let’s hope the fan is turned off as the heat hits the permafrost, because the environment determines human health. The scary thing about global warming isn’t tropical diseases or storms — it’s our need to grow food for 7 billion people. If the climate is screwed, so are crops.

Everyone needs a hobby. Mine is reading climate change deniers’ internet commentary.

Trends are noticeable. In days of yore, they would literally deny the climate was changing.

Research has killed this meme countless times, yet it still staggers zombie-like in the wilderness, eating people’s brains.

Now it is often admitted that the climate is changing but not that humans might cause this; or admitted that there is human-caused climate change but, reassuringly, this won’t be “catastrophic”.

Until 2010, CAGW stood for Citizens Against Government Waste, not Catastrophic Anthropogenic Global Warming.

The technique is reminiscent of Sir Humphrey Appleby’s four-stage strategy in Yes, Prime Minister.

First, say nothing will happen. Second, say something might happen but we should do nothing. Third, say maybe we should act but that’s impossible. Fourth, say maybe we could have acted but anyway it’s now too late.

Deniers do, of course, deny they’re deniers. Better to be a sceptic than a denier of the bleedin’ obvious. Anyway, deniers typically have a specific belief system: they are Climate Stability Believers.

Of necessity, climate stability believers believe that 97% of climate scientists are corrupt liars; the world’s national science academies are run by fools; and that a two-decade conspiracy explains why only 24 of 13,950 peer-reviewed climate change papers argue against human-induced global warming.

Climate stability believers also believe they are fighting a power-grab by the gubmint, lefty-greenies, the UN, the Illuminati, Jewish bankers or elephants with trunks that look like uncircumcised penises. And no, I’m not making it up. Not all of it.

A recent study found rejection of climate science was associated with belief the moon landing was faked and so on. Outraged climate stability believers now accuse the Australian researchers of conspiring to paint them as conspirational.

The strongest association found with rejection of climate science was, however, belief in extreme free market economics. It seems creating a social wasteland isn’t sufficient.

Other research has found “hierarchical individualist” personalities tend to reject climate science whereas “egalitarian communitarians” accept it. Ideological battles are cute but you’re only entitled to your own opinions, not your own facts. Or physics.

The psychological studies explain why for six absurd years a climate stability believer chaired our nation’s Future Fund. Tony (“It’s complete crap”) Abbott has admitted his error but David Murray might never do so. It’s said old theories don’t die but their adherents do.

Of course, if it actually is climate scientists — not mining and oil tycoons — who are partying tonight with the cash, stripper factory and beer volcano then there’s only one rational conclusion.

I did the wrong uni degree.

(Australian Doctor 7 December, 2012 http://www.australiandoctor.com.au/opinions/guest-view/climate-stability-believers )

huh, more stuff?

August 19, 2012 § Leave a comment

Okay, somewhat surprisingly I’ve finally found the time and inclination to trawl Australian Doctor for assorted articles hidden behind their you.must.be.a.doctor.wall.

It’s probably bad form to post 13 blogs on the same day, but I figure if nobody reads them then nobody cares.

So here they come …

17 August 2012 The Psychopathocene Age
13 Jul 2012 Sick and spotty (which the sub editor should have called “Sick and Spotted”, for reasons which might be apparent)
26 Apr 2012 Diagnosing Dr Google
3 Feb 2012 Perverse incentives
6 Jan 2012 Life’s random route
28 Oct 2011 Lifting the veil of ignorance
7 Oct 2011 Evidence in practice
24 Jun 2011 Dying to go
4 Feb 2011 Un-Australians of the Year
18 Jan 2011 A view from the waters
3 Dec 2010 Our risky business
8 Oct 2010 A matter of choice
17 Jun 2010 Dead write

… cool, I just discovered the date posted can be edited — let’s now pretend I uploaded them when they were originally published.

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