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).

 

 

When patients think I’m too young

What often annoys me, is when patients think I’m too young, and therefore they perceive that I’m not experienced enough. It doesn’t help that I’ve only just started work as a GP, and every now and then I have to phone up my supervisor for advice. In fact, I probably still am quite inexperienced, but which starting GP registrar isn’t inexperienced? It comes with time, and right now, I’m doing the dam best that I can to improve my knowledge and experience, something which patients can’t appreciate in that 10-20 minute consult that I conduct. Never mind the weekends that I end up spending trying to study up on the cases that I didn’t know much about during the week.

I remember in the first few days of work at my practice, one of the patients said “oh, it seems that doctors are getting younger and younger”. In reality, I feel flattered that I look young for my age (I’m around 28 years old this year), but at the same time, I feel like that me being so young means that the patient won’t have as much confidence in my diagnoses, in my management plans.

Just yesterday, I had a 20 year old patient talk about “closing the gap” program, to which I advised that I wasn’t entirely familiar with it.

“Are you sure you’re a doctor?”. Fed up at this so called “joke” (what an utterly tasteless joke by the way), I shot back matter of fact “Yes, of course I’m a doctor”. From what I make of it, I don’t believe that she would have made such a “joke” if I perhaps looked much older. The fact that I was feeling a little stressed out at the time didn’t help, as the patient mentioned irregular vaginal bleeding. In my mind, I was trying to work out what the best approach was. Thoughts about ruling out pregnancy, ruling out STIs and ordering blood tests swirled through my head. But this patient’s a lesbian. Do I still do a pregnancy test? She seemed the patient that was easily offended, and very crass with her comments. I opted to do some blood tests, and stealthily added a “serum bhcg” to the form.

Being the youngest in the practice (every other doctor has greying hair), it would appear that if patients had a choice, they’d obviously go for the greying hair doctors. I mean, who would trust a young doctor who just started out over someone who’s had 20+ years experience as a doctor right? What they forget though, is that being young and still learning, I’m probably more up to date with the most recent guidelines, more technologically savy as well, and well um, less cynical as well.

But I don’t think all that matters in the 10-20 minute consult. It’s just first impressions. At the end of a consult, if I am able to convey a sense of confidence, an attitude and an approach that seems beyond my years, I hope that the patient won’t just think that I’m too young and inexperienced just based on how I look. That behind the young face is someone who has worked hard, studied hard, and knows what they’re doing to do a great job of treating the patient.

 

 

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.

The Last Day of Hospital

Today was officially the last day of hospital. I was doing the dreaded postnatal checks (which I have done usually on Saturday, and those were busy as ever), so imagine my surprise when I went in today to find only 9 postnatal discharges (I have usually had to do 14- 18, with many ward call jobs as well in between).

By 12 noon, I had managed to see all my patients. Best day ever I must say. It has never happened before, and I am so glad that it happened on my last day of hospital.

Even the PAOU (pregnancy assessment and observation unit) was “quiet”, so they didn’t really need the help I offered them. So, I ended up spending 5 hours doing something productive like reading up stuff on medicare (prior to my orientation tomorrow), and some stuff on hypertension.

Also, today was a really nice day. Last few days have been muggy days with 33 degree temperatures. Today was a nice 27 degrees. Very pleasant.

Looking back at my 3 years in hospital, I can say that I’ve come a fair way. But being in training as of tomorrow, I have even more to go. Hospital time was stressful at times, but I can certainly say that I have learned a lot from it, and I am grateful to my patients, to my colleagues and the to the registrars and consultants who gave me great support and educational opportunities.

Before I left the hospital, I posted some internal mail to “Human Resources” with my ID badge, parking card and a letter written on a progress note.

“Dear Human Resources,

Please find enclosed my ID badge and car parking card.

I have had a wonderful time working here at the hospital.

Kind regards

The Placebo Effect

 

I dropped it off at the internal mails box, to never see my name badge ever again.

Leaving the hospital, I crossed the street, before deciding that I needed to take a photo of the hospital entrance, and so went back. Just like my last regional hospital, I don’t know when I’ll be passing the entrance again.

I race off to catch my bus, thinking that this is the last bus ride back home from the hospital. A nice finish to the day, and a nice finish to the last day in hospital. I need to pack my stuff up for tomorrow for… The start of orientation as a general practice registrar

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.

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.