Sore Throats at Partridge Street General Practice

Spring is here but it has been a big flu season at Partridge Street General Practice!

 

 

 

What should you do when you have a cough, cold, or sore throat?

 

Flu-Shot-logo
This may have helped before getting ill…

 

 

Here’s some information:

 

 

Do I have the flu?

 

 

 

Should I be on antibiotics?

 

 

 

My ear is sore?

 

 

 

Should I be immunised?

 

 

 

How do I stay healthier?

 

 

Any other ways to stay healthier?

 

 

Got anything else?

 

 

 

And, of course, What should I do instead?

 

 

There’s a new paper, at the link, saying this:

 

 

 

steroids in sore throat at Partridge Street General Practice

 

 

 

Need more information? Leave a comment or see us in person.

 

 

 

We’re Here to Help!

 

 

 

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You can see any of our Great GPs right here:

 

 

Dr Gareth Boucher

 

 

Dr Penny Massy-Westropp

 

 

Dr Monika Moy

 

 

Dr Katherine Astill

 

 

Dr Nick Mouktaroudis

 

 

Dr Nick Tellis

 

 

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Check Your Skin with Dr Nick Mouktaroudis at Partridge Street General Practice

Dr Nick Mouktaroudis is a GP and co-owner at Partridge Street General Practice. He’s  passionate about health education, has a special interest in Skin, and a lot of expertise to share when it comes to helping people cope with and improve Skin Conditions. Let’s hand over to Dr Nick!

 

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What is a Skin Check?

 

 

A Skin Check is a Comprehensive Skin History and Examination which is done at Partridge Street General Practice.

 

Your GP will ask you questions to assess the extent of Your risk/exposure to UV radiation and Your risk of solar related cancers.

 

They will examine you head to toe, examining the skin surface, focusing on any areas of concern (including the eyes, mouth, and anywhere else you may have noticed any spots, lumps, or bumps).

 

 

 

Are there any tools used for the Skin Check?

 

 

A proper examination needs proper equipment and we use handheld LED illumination with magnification as well as polarised light and clinical photography.

 

skin check dr nick mouktaroudis light

A dermatoscope is used to examine specific skin lesions. This is a particular type of handheld magnifying device designed to allow the experienced examiner to further assess skin lesions and determine whether they are suspicious or not.

 

 

 

Who should have a Skin Check?

 

We encourage all Australians over the age of 40 to have a Skin Check annually. Australians have one of the highest rates of skin cancers in the world.

 

Australians who have above average risks should be having Skin Checks before the age of 40 and sometimes more than annually.

 

You should have a Skin Check at any age if You are concerned about Your skin or particular skin lesions/areas.

 

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We ask You to identify any lesions of concern prior to the Skin Check wherever possible.

 

These may include new lesions that You have noticed or longstanding lesions that may be changing in some way or that You are concerned about. If You are worried – Ask!

 

Skin cancer check risk dr Nick Mouktaroudis

Risk factors for skin cancer

 

 

 

People at higher risk of skin cancer are those who:

 

have previously had a skin cancer and/or have a family history of skin cancer

have a large number of moles on their skin

have a skin type that is sensitive to ultraviolet (UV) radiation and burns easily

have a history of severe/blistering sunburns

spend lots of time outdoors, unprotected, during their lifetime

actively tan or use solariums or sunlamps

work outdoors

 

 

 

 

Does My GP take photos of My Skin?

 

 

 

During a skin check at Partridge Street General Practice Your GP will ask Your Specific Consent to take photos if they are concerned or want to make note of a particular skin lesion.

Photographs are useful as an adjunct to description of the lesion and act as a reference to position and comparison if required.

The photos will be uploaded onto Your Private Medical Record at Partridge Street General Practice.

 

 

 

What if My GP finds something?

 

 

 

This will depend on what Your GP has found.

 

If they are concerned about a particular skin lesion they may suggest a biopsy to clarify the diagnosis.

 

A biopsy is a surgical procedure during which they take an appropriate sample of tissue from the lesion of concern and send it to a pathologist for review.

 

Generally pigmented lesions (coloured spots), will be biopsied in their entirety whereas non pigmented skin lesions may be sampled partially if the lesion is too large to sample in its entirety.

 

The results of the pathology report will guide further treatment.

 

Your GP may elect to treat without a biopsy if they are confident of the diagnosis.

 

This may include freezing/cauterising a lesion, cutting it out (excising), or offering topical treatments such as creams.

 

Biopsies are scheduled in the Partridge Street General Practice theatre and our Practice Nurse will assist Your GP.

 

 

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What do I wear for a Skin Check?

 

 

 

Comfortable clothing.

 

Your GP will ask to examine you down to your underwear.

 

A sheet or towel will be provided for you to preserve your comfort and dignity.

 

A chaperone (Our Practice Nurse) is always offered.

 

Please avoid makeup or nail polish as the Skin Check involves the face and skin under the nails.

 

 

 

 

How long is a Skin Check?

 

 

Allow half an hour for Your GP to perform a thorough history and examination.

 

 

 

 

Do I need to see My GP or should I see a dermatologist?

 

 

GPs are Primary Care Physicians on the front line of Skin Cancer detection.

All GPs can check your skin, though not all GPs have formal training or a specific interest in skin cancer medicine and dermatoscopy.

Dr Nick Mouktaroudis has trained extensively in General Practice, Skin Cancer Medicine and Surgery, and has formal qualifications in Skin Cancer Medicine.

Dermatologists are sub-specialists in all skin conditions including Skin Cancer Medicine and Surgery although some will focus on other skin conditions.

 

 

 

 

Can I do more than a Skin Check?

 

 

 

You can Reduce Your risk by:

Avoid unnecessary exposure to the sun

Wearing sunscreen regularly and on all sun exposed areas.

Wear Hats and Sunglasses when appropriate.

Be aware of Your skin – both You and Your partner can check at Home.

 

 

 

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Book Your Skin Check Right Here.

 

 

 

Need more information? Leave a comment or see us in person. We’re Here to Help!

 

 

 

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You can see any of our Great GPs right here:

 

 

Dr Gareth Boucher

 

 

Dr Penny Massy-Westropp

 

 

Dr Monika Moy

 

 

Dr Katherine Astill

 

 

Dr Nick Mouktaroudis

 

 

Dr Nick Tellis

 

 

Lemons and Lemonade

We live in an age of wonders. Generations past would be amazed by the ease of travel, free information, and the standard of living enjoyed by the majority of the Western world. One of these wonders is Modern Medicine and part of that is medications. We are privileged to live in a time when cancer can be cured, fatal diseases are controlled, and previously life curtailing conditions can be managed.

 

‘Nothing is all good and nothing is all bad’ is something I heard from a trusted friend. Does this apply to medications? General Practitioners are Your Specialist Generalists – we do a LOT more than just prescribe medications! Read on.

 

 

Oseltamivir

 

Lemon: This blockbuster drug was supposed to deliver us all from pandemic flu. The Australian government stockpiled it at a cost of many millions. It will expire before we do. It promised the world but perhaps shortened the duration of symptoms by not much.

Lemonade: Get a yearly influenza vaccine and if you’re unlucky enough to still get the flu – rest, fluids, paracetamol, and see Your GP if you’re not improving as you think you should.

 

 

Donezepil

 

 

Lemon: Life expectancy increases every year and so do our expectations of our older age. This drug promised an end to Alzheimer’s, later downgraded to ‘it may delay the rate of the decline in your mental abilities’. How would we know if it worked? What would have the rate of decline been without this drug?

 

donepezil lemon

Lemonade: Save your money and try some alternatives without side effects. Keep your mind and body as healthy as possible for as long as possible with diet, exercise, rest, and the support of family, friends, and Your GP. Should age related decline set in, there are many supports you can access – check out My Aged Care. Medications can play a role – ask!

 

 

Codeine

 

 

Lemon: This drug has been available over the counter at pharmacies for many years. Evidence shows that products with low dose codeine are no more effective than products without for pain relief and so the regulatory authorities have recommended it be rescheduled to prescription only from February 2018. This will be a big change for the community – some of whom will have been taking large amounts of this drug on a regular basis.

 

 

codeine lemon

 

Lemonade: Partridge Street General Practice is proud to be a low prescribing practice and especially of this drug. Our advice is to see us for advice on alternatives and non drug alternatives in particular.

 

 

 

Need more information? Have you any other lemonade thoughts? Leave a comment or see us in person. We’re Here to Help!

 

 

 

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You can see any of our Great GPs right here:

 

 

Dr Gareth Boucher

 

 

Dr Penny Massy-Westropp

 

 

Dr Monika Moy

 

 

Dr Katherine Astill

 

 

Dr Nick Mouktaroudis

 

 

Dr Nick Tellis

 

 

The New Royal Adelaide, Ramping Up and Down, and Health Pathways

Hi from South Australia! Winter is here but change is coming. Our flagship hospital and one of the most expensive buildings in the Southern Hemisphere, the New Royal Adelaide Hospital (nRAH), is about to come online in September after a 2 year wait.

 

 

Bernie Cummins (see below) previously spoke to the Southern Regional GP Council about Outpatients Services in SA and she generously spoke to us again about how things will proceed over the coming months and years.

 

 

Here is some information she prepared.

 

royal adelaide hospital and nRAH and outpatients and health pathways

 

You can find further information right here.

 

 

 

 

The good GP has a stewardship role in the Australian medical system and part of this is referring to subspecialist and hospital care. This is an important role and we don’t take it lightly. We want to do our best for our patients and help them get the care they deserve. One of the challenges is referring to public hospitals, where our referrals sometimes get ‘bounced’ back to us. In private practice, for the patient to receive a (Federal) Medicare Benefit (like when you see Your GP), the GP referral must be to a named provider (Dr Smith, Dr Jones, for example). When referring to a public hospital, there has historically been no Medicare rebate for the patient – public hospitals are funded by the State Governments and Medicare is funded by the Federal Government, and care is free at the point of service. This is changed recently, and public hospitals are now using Medicare funds to run their services. Therefore they now seek named referrals. But to who? It’s very hard to find out exactly which doctor will be seeing you, and so it’s hard to do a named referral, which may delay you being seen.

 

So, as a public service, we’re Here to Help! Bernie Cummins (Director of Nursing Statewide Outpatient Reform) has provided the following documents to help GPs and patients navigate this system and avoid the ‘named referral bounce’.

 

 

 

 

directive+medicare+billing+outpatients

 

 

medicare+directive+and+outpatient+private+practice

 

 

Good luck, and may the odds be ever in your favour!

 

 

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You can see any of our Great GPs right here:

 

Dr Gareth Boucher

 

Dr Penny Massy-Westropp

 

Dr Monika Moy

 

Dr Katherine Astill

 

Dr Nick Mouktaroudis

 

Dr Nick Tellis

 

 

Mr Perfect and #socks4docs

Mental health and depression are serious issues. GPs see, treat, and support people with these issues everyday but who looks after the GPs? We can see that doctors are only human and suffer the same stresses as everyone else. Sadly, sometimes, it is too much.

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I wrote previously about how to detect depression in patients. ‘Listen to the patient’, ‘How do they feel?’, ‘How do they make you feel?’. Experienced GPs can spot depression a mile off…in other people. How many turn that acumen on themselves? How many have their own GP to care for them?

 

 

I also wrote ‘American studies show patients are scared of psychiatric referral. Australian GPs are also scared of psychiatric referral’ and ‘Untreated depression is associated with decreased quality of life and increased mortality. Depression can be successfully treated and treatment is effective. The earlier the better!’. This is as true for GPs and doctors as it is for every other person.

 

 
So GPs, doctors, and others – Exercise, diet, psychotherapy, GP counselling, reducing drug and alcohol use, getting more and better sleep are all options. These take time and effort so give yourself permission to spend these on You. Your friends, family, and colleagues are here for you. They will #bekind.

 

 

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Depression is not just a chemical imbalance. No pill can defeat the entirety of the patient’s life and circumstances pushing them in the wrong direction. Consider the your environment and be aware of the particular pressures of medical work and life. GPs have a fantastic and privileged therapeutic relationship with their patients, and they can use this to capitalise on the essential window of time before delivering medical advice. This “privileged moment for change” prepares people to be receptive to a message before they experience it. Robert Cialdini has coined the term ‘pre-suasion’ to describe this. The therapeutic relationship allows pre-suasion, and therapeutic change can then be addressed, with consideration of motivation, opportunity, and ability.
 

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Dr Eric Levi has literally stepped forward online with the #crazysocks4docs / #socks4docs hashtags. It’s a lighthearted way of getting us to acknowledge a serious topic. I’m in!

 

#socks4docs (holiday edition)

 

 

 

 

 

 

The equally dapper Terry Cornick has been kind enough to contribute his story to my blog – and I hope it gives some of you hope, a good read, and another option for you and your patients.

 

 

Terry is a Healthcare Consultant, Mental Health Advocate and Freelance Writer.

His professional background includes Consulting in Healthcare and he loves creating, research, technology, and communications. Daily he deals and develops relationships with Doctors so knows a little about them too and the unique stresses they are placed under.


Initially as a hobby, Terry created a grassroots men’s mental health support network named “Mr. Perfect” that is growing by the minute. Although it does not pay a cent, it pays handsomely in purpose. You can check it out at
www.mrperfect.org.au


Known sarcastically by his wife as “Dr Terry” he lives on the North Shore of Sydney with his young family and is currently contemplating his next move professionally, navigating the ever challenging and life-threatening dilemma for men of “providing” yet being “Mr. Perfect” personally too.

 

Trying to summarise and reduce my story to a blog is a challenge to say the least. Although a relatively spritely 33 years old, the increasing grey hairs and wrinkles around my eyes and my “old soul” remind me daily this life is a battle. And the battle is ultimately with yourself (hands up I have paraphrased this from a song I once heard, I just cannot remember which).

 

 

I love to compartmentalise and segment so my mind can attempt to process things, ideas, events, thoughts, feelings. Broadly speaking I did this with my life; pre-25 years old, 25 to 30 years old and 30 years old and beyond.

 

 

The first stage can sometimes appear as a blur. But perhaps an easier way of me dealing with it. It was a painful period for the majority of it. A challenging upbringing, tragic events, abuse and trauma pushed me so far into a shell that I never thought I would emerge from it.

 

 

During the okay times, this was okay with me. My introverted character and lack of self-esteem meant hiding was easier and far less painful. Until the occasional explosions. But life then returned to the blur.

 

 

A couple of moments in my early Twenties truly made me question my sanity. So at 21 years old I googled “Depression”. I matched 6 out of 8 symptoms. So clearly I was fine. I closed the laptop and the cycle of darkness continued as did the periodical suicidal meltdowns (behind closed doors of course).

Then the “Great Escape” took me to the other side of the world travelling. Less than two years later I was back in Australia for good, despite this being the deepest, darkest scene of my life. After a night out on the Gold Coast I stood on a balcony peering and leaning over contemplating that this was a good time to jump and end the pain. I felt so weak and thankfully, eventually, stepped back.

 

 

Somehow, after a few more substantial blips and obstacles, my life starting to become what others saw as “success”. More money that I knew what to do with, travel, a waterside apartment and a beautiful partner. One of my best mates teased me at work and called me “Mr. Perfect” regularly, not knowing 1% of my history or what was going on in my complex mind.

Look familiar?

 
Behind the acting and those curtains and backstage was a chaotic scene. Anxiety, PTSD and Depression drove me to the edge. But approaching my 30th year on this earth I made some changes. As I was about to get married, my absent dad passed away in the UK. I was sick of my job and when we started to talk about having a family, I could imagine putting my child through a similar existence.

So I visited my in-law’s family GP. He looked me in the eye and asked “How long have you felt like this?” I paused. “For as long as I can remember.” His usually relaxed face turned serious. “I know a great Psychiatrist I would like you to see”. It took every ounce of energy to do so but once that train was in motion I was getting professional help (lucky enough to have the resources to do this privately) and within six months I felt positive.

I started writing a book and then a blog (I did not show my wife) and Mr. Perfect was born. A chat in the pub with mates, a cursory read of a report about men’s “connectedness” and healthcare professionals I know telling me there was little grassroots support for their male patients, and the Mr. Perfect movement gained momentum.

 

 

There have been many blips, I am not “Perfect” after all. From stopping my medication without advice, from stopping my Doctor appointments to then leading back to professional help when the cloudy spells turned into storms and into hurricanes. These weather systems are here for life, and that’s okay, but with the right strategies I can turn this into something impactful for others.

 

 

But there is hope. Friends, family and colleagues have all benefited and most importantly my son will arguably be the most loved and supported kid when it comes to talking about his mental health.

Thanks Terry! You can see the themes above of time and a relationship as potent therapy for the management of major depressive disorder in general practice. The initial clinical gestalt and the ongoing therapeutic relationship can be powerful tools for change. Depression is subjective and has been part of the human condition throughout history. This gives us all we need to move forward.

 

 It therefore seems fitting to end with the words of a doctor from another time:

“The three grand essentials of happiness are: Something to do, someone to love, and something to hope for.”

Alexander Chalmers (29 March 1759 – 29 December 1834)

If you are worried about depression, anxiety, or have any other mental health concerns, reach out:

ACIS 131465 (South Australia – Acute Crisis Intervention Service)

Partridge Street Doctors

Your GP at Partridge Street General Practice

Dr Gareth Boucher

Dr Ali Waddell

Dr Emmy Bauer

Dr Nick Mouktaroudis

Dr Nick Tellis

Beyond Blue & Beyond Blue New Access (free mental health coaching)

Mr Perfect

Doctor’s Health SA

GPs Down Under

GPDU

Business For Doctors Conference

Good Medicine is Good Business.

I’ve summed it all up in five words. The End. I’ve been an owner of medical practices for over 10 years and a doctor for nearly double that. Good Medicine is the bedrock of all Good Medical Businesses  but it’s not all that goes into a Good Medical Business. How do you practice Good Medicine when you can’t pay your bills? How can you keep your mind on your valued patients if business worries are weighing on you? Your Business starts with You and so looking after yourself is a great start. A healthy mind in a healthy body and a business focus in a medical career are great systems for allowing doctors to practice the great medicine their valued patients deserve.

nick tellis running melbourne

I’m heading off to the Business for Doctors conference in Melbourne. I’ve packed my running gear and I’ll be working on my business focus, a healthy mind, a healthy body, and a great practice.

melbourne by night
Melbourne – who can resist?

Here’s some of the conference details.

Friday Program

Friday June 2 2017


2 Keynotes, 23 workshops including 2 interactive business learning workshops for BAS and Web design.

Keynote Speakers
Dr April Armstrong – Founder and Director, Business for Doctors
Michael Traill – Using Business Disciplines for Social Purpose. Lessons from the trenches of social enterprise.
Headshots Professional Photographs (Full delegates only or $50 onsite) from 10am

Workshop Presenters include:
Dr Jon Brown – Web Design
Dr April Armstrong – MBS – Pack & Stack – strategic model for maximising income in general practice
Dr Juvi Arulanandararajah – Stress management – “Burnout”
Dr Sachin Patel – Seven secrets of a Successful private practice
Dr Cate Howell – Navigating Relationships
Jamie Holroyd – Stratosphere – How to grow your practice & One page business plan
Alan Smith – Accountant – BAS workshop
Matthew Holden – Accountant – Business Structures for Doctor & Understand Tax Strategies
Arabin-Foye Private Wealth – Ryder Widdowson – What I wished doctors knew about money and wealth (double session)
Health & Co – Selling your practice to a corporate & Tax consideration when selling your business
Medlife- Roy Bostleman – – Understanding Personal Insurances: Tips for Optimising your Policies & Personal Insurance for Practice Owners: Tips and Trap
Tego – Melanie Tan – Demystifying medical indemnity and ways to mitigate your risk
BOQ – Melinda Goddard & Lloyd Levin – Financing a practice – New start-ups and Buy ins

Cocktail Networking: Included with Full, discount and day delegate tickets. Tickets Available on request for partners, practice managers and medical colleagues and BFD Facebook members – $50

Saturday Program

Saturday June 3 2017

2 keynote speakers, 23 workshops and including 2 interactive workshops.
Headshots professional Photographs (full delegates only or $50 onsite) from 8.30am

Keynote speakers
Noel Whittaker – Building wealth in Challenging Times
Dr Cate Howell

Workshop Presenters Include
Dr Jon Brown – Web design 2 – marketing and google analytics
Dr Sachin Patel – The 5 pillars of preventative life care
Dr Cate Howell – Work-life integration & Emotional Intelligence
Stratosphere – Jamie Holroyd – Budgets Forecasts- Profit & loss/Balance Sheet/Cash flow
Dr George Forgan-Smith – Marketing and Branding – interactive workshop
Dr Juvi Arulanandararajah – How to keep your self (and yourself) sane, productive and happy
Nexus Legal – Alan Prasad – Business Structures – understanding tax and strategies to minimise & Case Study on Legal Risks
Employsure – Brad Walkes & Elizabeth Burns- The importance of contracts and policies for business owners
Araban-Foyle Private Wealth Pty Ltd – Ryder Widdowson – Superannuation and Self managed super funds (double session)
Brentnells SA – transitioning from Employee Doctors to Independent Practitioner & High Performing Medical Practices

Gala Dinner – Tickets $150 – additional tickets now available for practice manager, partners and medical colleagues. BFD Facebook members $175

Sunday June 4 2017

Key Note Speaker
Tim Read – Marketing – The Boomerang Effect
Dr April Armstrong – closing address and special announcements

Workshop Presenters:

Dr Cate Howell – Health and Wellbeing Script
Stratosphere – Jamie Holroyd- Shareholders and Partners Agreements & Debt and balance sheet gearing
Dr April Armstrong – MBS workshop (double session) Implementing Billing Strategies – double your billings in 60 days
Property Investment – Quantity Surveying

Workshop Recordings: All Keynote speakers, practice set up and MBS workshops will be recorded as well as a number of other workshops over the 2 1/2 days. Full delegates can request recordings at no charge once available from armchair medical

You can read more here.

I’m really looking forward to this and taking back some valuable information. Feel free to say hi when you see me running around at the conference and like this post and there’s a coffee in it! Partridge Street General Practice is also looking for Great GPs – could it be you?

Remember – GPs and other doctors are always learning. Learn more, be better, practice better medicine AND have more time for you, your family, your patients, and your health! What more could you ask?

Named Outpatient Referrals in South Australia

The good GP has a stewardship role in the Australian medical system and part of this is referring to subspecialist and hospital care. This is an important role and we don’t take it lightly. We want to do our best for our patients and help them get the care they deserve. One of the challenges is referring to public hospitals, where our referrals sometimes get ‘bounced’ back to us. In private practice, for the patient to receive a (Federal) Medicare Benefit (like when you see Your GP), the GP referral must be to a named provider (Dr Smith, Dr Jones, for example). When referring to a public hospital, there has historically been no Medicare rebate for the patient – public hospitals are funded by the State Governments and Medicare is funded by the Federal Government, and care is free at the point of service. This is changed recently, and public hospitals are now using Medicare funds to run their services. Therefore they now seek named referrals. But to who? It’s very hard to find out exactly which doctor will be seeing you, and so it’s hard to do a named referral, which may delay you being seen.
So, as a public service, we’re Here to Help! Bernie Cummins (Director of Nursing Statewide Outpatient Reform) has provided the following documents to help GPs and patients navigate this system and avoid the ‘named referral bounce’.

 


 

directive+medicare+billing+outpatients

 

medicare+directive+and+outpatient+private+practice

Good luck, and may the odds be ever in your favour!

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You can see any of our Great GPs right here:

Dr Nick Tellis

Dr Nick Mouktaroudis

Dr Ali Waddell

Dr Gareth Boucher

Dr Emmy Bauer

(Or BE one of our Great GPs right here!)

Care to Plan, Plan to Care

Whichever way you look at it, there is a great little health precinct on Partridge Street! Let us work together to Help You. Care Plans, Team Care Arrangements, Health Assessments, and Mental Health Care Plans may allow You to receive Medicare Rebates for Great Care from Our Team.

 

 

Read more here:

 

PSGP GP Management Plan Information Sheet

 

PSGP Health Assessment Information Sheet

 

 

 

Your GPs, providing great General Practice Care:

 

 

Partridge Street General Practice sign

 

Dr Gareth Boucher

 

 

Dr Penny Massy-Westropp

Dr Monika Moy

Dr Katherine Astill

Dr Nick Mouktaroudis

Dr Nick Tellis

 

Great Physiotherapists at Aspire Physiotherapy and Pilates – Sally, Alex, Bret, and Monique

 

A Great Dietician and Diabetic Nurse Educator – Helen at Family Nutrition and Diabetes Services

 

A Great Podiatrist – Ryan at Sense Podiatry

 

A Great Psychologist – Dr Amber Keast

 

Add Great Nurses at Partridge Street General Practice and all the other Allied Health Services and We have a Great Team to Help You!

 

 

bev gregg new practice nurse at partridge street general practice
Bev Gregg – Our New Practice Nurse at Partridge Street General Practice

Feeling down about Depression?

(Cross posted from the ThinkGP blog)

 

Many years ago, coming to general practice from an emergency medicine background, I sat down with a group of trainee GPs. We started to talk about what we would see in general practice. I’d been working as a locum in general practice for a year and I thought I knew everything. ‘Coughs and colds are the bulk of the work’, I confidently declared. Those older and wiser than me set me straight, and told me that general practice is all about depression and anxiety and that it’ll be a rare consult where these won’t play a role. They were wise words then and now, so let’s talk about major depression in general practice.
 

The books would describe major depression as a subjective diagnosis which depends on reported symptoms rather than objective signs. There are cardinal symptoms of depression, rather than signs. Five or more of the symptoms below, present most of the time nearly every day for at least two consecutive weeks. Depressed mood or loss of interest or pleasure must be present. The symptoms cause substantial distress or impair function, and they are not better explained by substance abuse or a general medical problem. They are over and above what the GP thinks would be normal given the patient’s situation.
 

depression

 
The GP who relies on books alone will be well read… and alone. Listen to the patient! It’s a mood disorder. How do they feel? How do they make you feel? Clinical gestalt is the theory that healthcare practitioners actively organise clinical perceptions into coherent construct wholes, or simply put, how experienced GPs can spot depression a mile off. Listen to your gut. Countertransference can be a powerful tool to show you where you need to go. We’ll come back to the Art of General Practice later. Experienced GPs can’t be everywhere, and so we need some other ways to screen for depression.
 

Enter the rating scales for depression. They read like the alphabet – PHQ-9, BDI, HDRS. They can be used for screening and measurement of progress. Perhaps only 50 percent of patients with major depression are identified without screening [1]. Patients may not volunteer depressive symptoms without direct questioning for many reasons including fear of stigma, a belief that depression is not a matter for primary care, or a belief that depression isn’t a “real” illness but rather a personal flaw, as well as concerns about confidentiality and antidepressant medication [2].
 

In Australian general practice, we use the K10 and the DASS21 or 42. These are validated, easy to administer, reproducible, and recognised as part of the Mental Health Care Planning process. This enables patients with diagnosed depression to obtain a Medicare rebate for psychological therapy with a psychologist. American studies show patients are scared of psychiatric referral. Australian GPs are also scared of psychiatric referral, as it can be hard work to access private psychiatry. MBS item number 291 comes to the rescue and many psychiatrists will use this. They also know that depression masquerades as a variety of somatic symptoms. Untreated depression is associated with decreased quality of life and increased mortality. Depression can be successfully treated and treatment is effective. The earlier the better!
 

I recommend non-pharmacological treatment regularly. Exercise, diet, psychotherapy, GP counselling, reducing drug and alcohol use, getting more and better sleep are all options. These take time and effort, both from the patient and the GP. Remember, your time and presence are important to your patients. Ten minutes of education on diet and exercise can be worth months of medication and the effect can be long-lasting. Red flags include significant physical signs (weight loss is the big one in my opinion) or symptoms such as suicidality or psychosis on mental state examination.
 

Depression is not just a chemical imbalance. No pill can defeat the entirety of the patient’s life and circumstances pushing them in the wrong direction. The good GP will consider the patient in their environment and have an awareness of the social determinants of depression. Personality disorders, illicit drug use, and past abuse can lead to poor life choices and situations. Think about these before printing out a script.
 

When selecting an antidepressant, ask the patient what they’ve been on before. Ask about expectations and experiences and how they define success or failure. I tend to use medications that I’m familiar with and can then counsel patients accordingly. I find SSRIs to be an appropriate first line treatment. The side effects that concern my patients are anticholinergic (dry mouth), sexual (decreased libido and prolonged time to orgasm/ejaculation – so common that medications are now marketed for this purpose alone), and changes in sleep (too wakeful and agitated or too sleepy and hungover). I combat these with the advice to drink plenty of water and to time your medication according to how it makes you feel.
 

Traditionally, antidepressants are taken in the morning, but for those with a significant anxiety component, evening dosing is best. Trial and error will determine the optimal time for a good night’s sleep with no morning hangover. Sexual issues often require a change in medication. The newer medications promise fewer sexual issues, but often an older alternative can achieve the same goals at much lower cost.
 

depression2

 
The literature tells us the most resistant symptoms to treatment are insomnia, followed by sad mood, and decreased concentration. Depression is more likely to reoccur if these symptoms are persistent. I find that fatigue, anhedonia, guilt, worthlessness, and poor concentration are the hardest symptoms to treat successfully. It can be a long road for the patient (and the GP) back to wellness, and it can be hard to stick with treatment over time.
 

GPs have used many strategies to improve treatment adherence and all of us will remember pre-contemplators from our studies. We all get frustrated when patients don’t take our advice but providing information and warning of future consequences doesn’t always work. However, a solution is in clear sight. GPs have a fantastic and privileged therapeutic relationship with their patients, and can use this to capitalise on the essential window of time before you deliver your medical advice. This “privileged moment for change” prepares people to be receptive to a message before they experience it. Robert Cialdini has coined the term ‘pre-suasion’ to describe this. The therapeutic relationship allows pre-suasion, and therapeutic change can then be addressed, with consideration of the patient’s motivation, opportunity, and ability.
 

You can see the themes above of time and a relationship as potent therapy for the management of major depressive disorder in general practice. The initial clinical gestalt and the ongoing therapeutic relationship can be powerful tools for change. Depression is subjective and has been part of the human condition throughout history. This gives us all we need to move forward. Focus on the whole person sitting in front of you. Give them your time and expertise, be thorough, be kind, and be present. It therefore seems fitting to end with the words of a doctor from another time:

 

“The three grand essentials of happiness are: Something to do, someone to love, and something to hope for.”


Alexander Chalmers (29 March 1759 – 29 December 1834)




If you are worried about depression, anxiety, or have any other mental health concerns, reach out:

ACIS 131465 (South Australia – Acute Crisis Intervention Service)

Your GP at Partridge Street General Practice

Dr Gareth Boucher
Dr Ali Waddell
Dr Emmy Bauer
Dr Nick Mouktaroudis
Dr Nick Tellis

Beyond Blue & Beyond Blue New Access (free mental health coaching)

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Reach Out

References

  1. Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet. 2009 Aug;374(9690):609-19
  2. Bell RA, Franks P, Duberstein PR, Epstein RM, Feldman MD, Fernandez y Garcia E, Kravitz RL. Suffering in silence: reasons for not disclosing depression in primary care. Ann Fam Med. 2011 Sep;9(5):439-46.

Thanks to Klarem for the beautiful picture above, Marcia Vernon for the Beyond Blue link, and the guys at ThinkGP for their editing and help.