Oxycodone

Working in a first available GP clinic gives me the wonderful opportunity to see how other doctors in my practice are managing these patients who come in to see the first available doctor. I must admit, sometimes I am scared.

Take the case of Mrs X, a woman in her mid thirties. She came on a Saturday at 7pm. Having had a read of her medical summary at the start of the consult, I note that she has had issues with back pain, having had a recent back injury, likely a simple musculoskeletal back strain. I quickly glance over at the previous treating GP’s notes, and see a few prescriptions of endone. I seriously hope she doesn’t ask me for more endone.

“What brings you in today Mrs X?”

“Well, there’s really only two things today doc. I’ve been having these flu like symptoms for the past 3 days. And the other thing was that I just wanted a pregnancy test. I’ve heard that there have been some recalls with some brands of home pregnancy kits with false negatives.”

After doing the usual history and examination, I give the patient a urine jar to collect a urine sample, and advised to come back into the room afterwards.

With the patient out of the room, I snoop back to the previous GP’s notes and the entries made.

2nd March 2017 – Presents for review of back pain. Wants Endone repeat.  


Scripts written: Endone 5mg, quantity 120. 5mg QID PO

 

15 March 2017 – Review of back pain. Needs more pain relief.


Scripts written: Endone 5 mg, quantity 120. 5mg QID PO

 

Having had a read of these notes, there are many things wrong. First are the extremely brief notes. Having read many of this doctors notes, his notes are at maximum 2 sentences. They hardly document anything at all, and I would believe theses notes will not hold up in a court should he need to give evidence.

Secondly, the fact that a whopping 120 tablets of endone needed to be given. Add to the shock, that 120 tablets should last 30 days, yet this patient has needed to get another script in just about 2 weeks.

Having been at this practice for just 6-7 weeks, I have only prescribed 10 tablets of 5mg endone to one patient who had excruciating hip pains from a work place injury. Even then, I had trialled him on just some panadeine (paracetamol + codeine) prior to stepping up to endone.

This makes me conclude that some GPs probably just end up giving anything the patient asks so that the consult won’t extend over 5 minutes (which in my opinion, is a very shocking way to practice medicine – at the end of the day, I will make my own decisions according to my own independent assessments, not on recommendation of the patient). I have had the temptation to do that at times just because it seems like the easy way out, but I always tell myself, the easy way out may sometimes be the wrong way out and end up later on, being the hard way out (eg when asked to justify decisions, or when in court for such decisions).

 

 

Now that I’m a GP, I get to see all sorts of people

As a GP registrar, I’ve come to see many different things. Some things are straightforward, some are a little more complex. The challenge is being able to manage both fairly well.

For those straightforward cases, they are time savers, and give me that little bit of confidence that I’m doing something right. But those more complicated ones, I end up spending time looking up databases and management guidelines to figure out what to do. And even then, I may still have to speak to my supervisor.

Working today, I got the opportunity to essentially to tell a drug seeker to get lost. Well, not so bluntly, but essentially, I told him “I’m not allowed to prescribe you that”. He ended up saying he’d go to ED (after possibly having a fractured hand because he punched someone yesterday – all in the name of ‘self defence’). Trying to tell this man up straight that I wouldn’t prescribe it was pretty tough I must say. The patient persisted and persisted, but I had to hold my ground and just say no.

My next patient was a woman who came in for review of her test results. Of course, being the curious one and trying to do a thorough job, I had to enquire why the tests were ordered in the first place. It was largely due to hair loss. A quick inquiry into her social background revealed more about her possible hair loss than any blood test could tell. She was having a strained relationship with her daughter, she was essentially cut off from family due to her current partner, and her father was quite ill. My hypothesis is that her hair loss could be from stress. The patient also revealed, that her partner just told her that he was leaving her right before dropping her off at the practice. She broke into tears right in front of me. I offered her some tissues, and tried to advise her about constructive ways of dealing with this difficult event ie don’t drink alcohol, get some exercise, get social etc.

We’re I’m currently working at, I see all sorts of interesting people. Probably because of the low socioeconomic status group that come through. Really, I see a lot of blue collared workers. I could have potentially seen more well off people by working across the road at the mall. But I don’t think I would learn as much, and wouldn’t be made ‘tough’ from the relatively well off people there.

Having come across a variety of people in the last few weeks, I realized that there’s going to be lots of stuff I don’t know. And also lots of people who may not be the most reasonable of people to talk to.

And this is perhaps where I think it’s important for me to stick to my principles. I believe in being respected as a doctor, rather than liked as a doctor. I think I’ll go further if I’m respected, rather than if I’m only liked.

Last Week

Having spent close to 3 years in the hospital system, I have just one more week before I permanently leave.

General practice here I come!

But honestly, these past 3 years have been challenging, rewarding, and I must say I have come a fair way from being a medical student.

In 1 weeks time, I am no longer a resident anymore. I’ll be thrust into the world of general practice, where almost anything is fair game. I’ll be a registrar, and that means being thrown in the deep end.

One more week of obstetrics and gynaecology. I don’t think I’ll miss the postnatal checks, because they were very mundane. But I suppose I will miss scrubbing in for cases. Next week will be the last time probably I scrub in to assist an operation again.

Much work lies ahead… Hopefully I’ll be ready for it!

The Legal Responsibilities

The hospital system is the mash up of many different specialties, all with the common goal of patient centred care; people are sick, so they come to hospital to get better.

With these different specialties, comes different responsibilities, and if you overstep your boundaries and encroach onto a different specialty, there are legal liabilities. Hence, a physiotherapists providing medical advice about orthopaedic problems becomes a legal issue.

I understand why there are such legal liabilities, and in fact, I think these boundaries are necessary to protect patients. But having been in the hospital system, I think it can get pretty ridiculous at times. For instance, at the previous hospital I worked at, an ultrasonographer could mark out the level of pleural effusion, but would not mark the spot for fear of legal liabilities should any issues arise if it was drained. Hence the doctor (usually a resident) would need to come and mark the site that the ultrasonagrapher had indicated. So as a result, any issues with a drain insertion would be blamed on the resident, even though it was the ultrasonographer who technically marked out the site.

In a way, I feel that some of these legal responsibilities leads to a decay in upholding good moral standards. The other day I was asked by the nurse to come and console an anxious patient who had her belonging stolen by an outsider. It was a strange request, because what was I supposed to do as a doctor? I felt that a social worker would have been more appropriate. So I arrived and sat at the patient’s bedside, and started listening.

“Ms X, I’m sorry to hear about what happened to you. How are you feeling?”

“I feel terrible. This everything has gone missing including my phone and all my credit cards. I have at least 12 credit cards in my wallet!”

“Ok. Have you started trying to cancel your credit cards yet?”

“I have Westpac here in Australia, and all the others are in England. But I wouldn’t know how to cancel the cards.”

“Ok, maybe I can try and call the Westpac number and we can try and cancel the card.”

I went back to the doctors desk, and asked one of the nurses if social work was doing anything about cancelling the credit cards. Apparently, social work thought it was not their job to cancel credit cards, and declined to help (it was a Sunday anyway).

Anyway, the dect phone I was holding was too unreliable and kept cutting out, so I ended up asking the patient to come to the doctors desk to use the landline. Partway through, one of the surgical doctors asked me to come into a side office. When I got in, she stated firmly “You need to stop what you are doing. It’s not your role to cancel credit cards, and there are legal boundaries in helping her to do so.”

I had a think about this, and could definitely see where she was coming from. It looks sketchy to say the least when a doctor is helping a patient to cancel her credit cards. Almost like I could somehow financially benefit from the situation. I know I couldn’t do much for the patient aside from listening, so I thought the least I could do was to help her cancel her credit card to prevent someone from stealing her money.

In the end, her daughter arrived, and I quietly left the patient in the care of the daughter.

It frustrates me that because of legal issues, it prevents us from doing something decent. It’s something that I hear about to no end in China, where people are too afraid to help people on the streets who are hurt or ill, due to the fears of legal proceedings against them with false accusations.

But then again, in any system, if things like that are allowed to happen, then people end up changing. If the patient made a complaint against me, or if I was penalized for what I did for that elderly woman, I would be pretty stupid to do it all over again if something similar happens.

In the Deep End

I remember my very first formal interview – it ended in failure. What made it so depressing too was that it was THE interview that my future depended on – medical school.

So having failed at that, I realized that either I was an immature 19 year old that lacked life experience, or that I lacked interview experience. I chose to realize the second option, and vowed that some day, I would be great at interviews.

Since then, I suppose interviews just happened. Interviews for entry into the GP program, some interviews for part time jobs. With each interview, I picked up basic skills, such as knowing what to say, and what not to say. I learned to never offer more information then was required to answer a question. And that advice has served me well.

It just so happens that on the 1st of June, all GP registrars could apply to practices for next year, and of course, this would mean submitting a CV, cover letter, and attending an interview.

So in my holiday in China, I spent a great deal of time updating my CV, looking back at the past 3 years and deciding what to put on my CV. I put effort into making it look neat, and to also demonstrate my well roundedness for GP (to my credit, I have done lots of different rotations including surgery, medicine, ED, psychiatry, Paediatrics, O+G and orthopaedics).

Having submitted my cover letter and CV for 5 different practices, I was offered 3 interviews. It was just a matter of preparation.

I think I may have over prepared for these interviews, since I anticipated questions asked, and thought of thoughtful answers to say. And then I reflected on past cases seen, and what I really wanted out of the practices I applied to. And research. Probably the most important thing was knowing about the practice I applied to.

It was a total pain trying to attend interviews when I’m on ED because of the weird rostering. So I ended up attending an interview even though I finished a night of ED. So, I rocked up probably with only 4 hours sleep.

In the end, I managed to get an offer from all 3 places that I interviewed at, which I was pretty impressed with, since I had failed so miserably in my first ever interview. The interviews were so easy compared to what I expected, and I felt a tad silly for overpreparing. But I don’t think one can ever overprepare for an interview.

Again, I stress the importance of research, because I was asked by one interviewer what I knew about their practice. And that’s when I said “I understand that your practice opens 365 days per year, and holds an excellent philosophical principle of providing affordable and accessible health care which is exactly in line with what I believe health care should be.”

In the end, I chose a practice that would be very busy and most likely stressful. But hey, at least I’d learn a lot from it. The supervisor even told me that he would “throw me in the deep end”, so I even got a warning that it was going to be stressful. But isn’t that how one grows and learns, by being outside of their comfort zone? So why not.

Next year’s going to be interesting….. And probably stressful too.

 

Looking at the World

Since having a medical education, it has made me look at people in ways that I never used to look at them. I’m more observant of people around me.

In medical school, the crucial thing we were taught, was to use our eyes. In our clinical examination classes, we were taught that a general order of examination of the patient was: observation, palpation, percussion, auscultation. Note how observation comes first and foremost before you touch them, and before you use your stethoscope.

And so we’re told that you can glimpse a lot of information about your patient just from watching them. A person who limps into your practice may indicate something like pain from the knee or hip (maybe from osteoarthritis), and an infant who is brought in in the mother’s arms with reduced responsiveness and alertness is probably quite sick.

When you’re observing people all the time, it only becomes natural that you apply it in public. In general, the major thing I glean from seeing people are whether they are well or sick. Then little other subtle things I may observe – things like gait, scars present (may indicate things like past knee replacements), and just other things in general like if they’re pale, have rashes or so.

In turn, I guess being able to apply it in public means that I’m constantly using the skill of observation, and hopefully it will aid in my further career development.

Anaesthetics

I’m still constantly amazed by the new stuff that I’m exposed to as a doctor. Take anaesthetics for example. This week is the fourth week I’ve been on it for, and yet I still really don’t know how to use that damn anaesthetics machine well yet. It’s got a lot of fancy knobs, 3 (yea, three!) monitors that displays lots of numbers and pretty graphs, and lots of buttons that I could press, but I’m afraid to.

My job as a resident anaethetist appears to be the most relaxing job I have done to date. I don’t have to hold a phone, and I don’t get pestered much by nurses (they’re all too fantastic at looking after recovering patients to give me a call 🙂 My job is to put oxygen on the patient. Well actually, it’s more involved than that, but putting on the oxygen seems to be what I do a lot of. As well as putting in cannulas, and taking a brief anaesthetic history of the patient.

I must admit, anaesthetics seems like an extremely cool specialty. For one, it is the only specialty so far that I have seen that gives allocated breaks (yea, another person actually comes to relieve the anaesthetist so that they can actually eat lunch). Next, it is the only specialty that surgeons can’t bully. If an anaesthetist says that a surgical procedure can’t occur, then it can’t occur, and the surgeons have to stand there looking dumbfounded that they’ve just been told that they can’t cut up their guinea pigs er.. I mean patients. In fact, one of the anaesthetists that I was with felt it was too unsafe to perform surgery on a patient, given the arrangement of the theatres – the theatre was too small, the equipment was way too far away from the patient, and the theatre was horrendously understaffed (the anaesthetist was not pleased that all the nurses had left at the same time, meaning the anaesthetist had to be the orderlie staff, the anaesthetist, and the nurse – yea, not fun to be 3 people at once.

I find it funny that I have learned more about operating theatre procedures, and have spent more time in theatres than I have in my 20 weeks of surgical rotations. I have actually felt like I’m learning new skills for once, rather than just using the pen. I have put in numerous laryngeal masks, and have successfully today intubated my first patient without any consultant intervention. It’s a great feeling.

But, I must say however, that I can’t imagine myself doing this long term. It’s as boring as hell. From what I’ve seen (largely elective cases, exclusions including emergency anaesthetics, paediatric and obstetric anaesthetics) the majority of cases go smoothly (95%), while only 5% provide you with some adrenaline pumping action. So it’s either goes very smoothly (boring) or extreme adrenaline action (stressful). I don’t think I’d really want a job that swings in between these two extremes. And perhaps I don’t feel like it’s very rewarding. Just sitting for hours monitoring a patient’s vitals, and occassionally giving some more drugs doesn’t seem to be a particularly rewarding job to me.

Did I learn much from anaesthetics? Yea, I learnt quite a bit, and got to do a lot of procedures. Was the rotation enjoyable? Not a great deal to be honest (I was told that I was supernumerary – yea, like a spare tire), given that I didn’t feel I was doing too much. Despite all this, I still respect the jobs that anaethetists do, although I feel like it isn’t something that would suit me.