We live in an instant world and we seek convenience. How can technology give you more of what you want while Your GP gives you more of what you need?
We never want to lose the doctor patient relationship in General Practice. It’s the most valuable part (and the most rewarding part) of our vocation and service as GPs. If we can have technology in the background rather than in the way, I think we can strengthen this. Facebook is one example.
Here’s another. Step one: buy a gaming keyboard. Step two: Program some macros. Step three: Spend more time with Our Valued Patients and less with our technology and medical software!
Here’s me cutting my login time to zero. It’s one small step for Dr Nick….
What do you think?. Is this part of the future? Too soon? Not what you want? Let me know. In the meantime, we’re all still here for you at Partridge Street General Practice, face to face, IRL 😎
Not so long ago it was quite hard to contact Your GP. You had to phone the practice to make an appointment (some waiting), come to the practice (more waiting), and then sit in the waiting room (more waiting). We live in an instant world and we seek convenience. How can technology give you more of what you want while Your GP gives you more of what you need?
More and more of our valued patients are choosing to book online but You can still call Partridge Street General Practice and we’re always happy to talk to you. You can also email us or contact us here for non-urgent inquiries, remembering that email is not a secure form of communication.
Imagine if you could ask some simple questions of Your GP, without waiting on the phone or sitting in the waiting room. Simple questions that have been asked of me in the past:
When should I come in to see you next?
I lost my script, what do I do?
I was discharged from hospital, what next?
We never want to lose the doctor patient relationship in General Practice. It’s the most valuable part (and the most rewarding part) of our vocation and service as GPs. If we can add to it, by improving communication before a face to face consult, I think we can strengthen this. We have a trial project with free access to a secure app where you can speak with me (not Facebook!). It’s not for urgent consultations and it’s not for ‘prime time’ or clinical use at the moment. It’s free to sign up and you can test it out. Contact me for details!
What do you think – tell me here (or on the app!) about what you think. Is this part of the future? Too soon? Not what you want? Let me know. In the meantime, we’re all still here for you at Partridge Street General Practice, face to face, IRL 😎
It’s a great time to be a GP in Australia at the moment. We live in an affluent First World country with good social services and welfare and a strong public health safety net. It’s peaceful, spacious, and even the winter cold feels good after the warm summer! Have a look!!
We’re meeting this challenge by recruiting great GPs who want to do great work in our great practice. We offer:
😀 Healthy work-life balance
😀 Practice in one of the most beautiful parts of South Australia
😀 SA owned and operated Clinic with a Great Team
😀 Plenty of Patients
😀 A strong Teaching Focus
Our practice is fully computerised and as paperless as we can make it, AGPAL accredited, with a strong teaching ethos supported by a great nursing team who assist with Chronic Disease Management and Treatment room duties. Our team delivers an efficient and friendly medical service to our patients and our GPs.
Partridge Street General Practice is a mixed billing practice with bulk billed and private accounts for services. This allows 15 minute appointments as a base. We’re proud to offer the time for:
😀 Women’s Health, Mirenas, and Implanons
😀 Mental Health Care and Counseling
😀 Skin Cancer Medicine and Surgery
😀 Travel Medicine and Immunisations
😀 Iron Infusions
Our patients will be as important to you as they are to us, they are the foundation and the focus of Partridge Street General Practice!
Be part of the future here at Partridge Street General Practice. Enjoy the autonomy of private practice while retaining the collegiality and teaching ethos that is so important to all of us. R U OK…or could you be Better?
Email Ms Tracey Mills, our awesome Practice Manager on firstname.lastname@example.org or pop in to have a coffee and a chat!
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.
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 . 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 .
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.
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)
Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet. 2009 Aug;374(9690):609-19
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.
The humble Pap Smear is over ninety years old so just to jog your memory, the Papanicolaou test (abbreviated as Pap test, known earlier as Pap smear, cervical smear, or smear test) is a method of cervical screening used to detect potentially pre-cancerous and cancerous processes in the cervix (opening of the uterus or womb).
The 1st of May 2017 brings about a change in Australia’s approach to screening for cervical cancer. Here’s what you need to know about an exciting revolution in health for people with cervixes!!
Pap smears involve sampling cells from a specific part of the female anatomy: your cervix. This is the gateway between the vagina and the uterus, and its function is to hold a baby inside your uterus for 9 months: then stretch to let it out!
In order to sample cervical cells, the medical practitioner uses a speculum to view your cervix; but many people consider this examination physically invasive and unpleasant. A pathologist then examines these cells under a microscope for signs of pre-cancerous and cancerous change – what we refer to as cervical cancer. Identifying these changes means you can treat early, preventing more serious disease.
Australia introduced the National Cervical Screening Program in 1991. Since then most cervix-bearing people are prompted by their GP to undergo a pap smear every two years after becoming sexually active. Since its introduction, this program has halved the incidence of cervical cancer in the general population.
The thing is: science is rapidly progressing. Our knowledge of cervical cancer has grown substantially, which has prompted a review of how we screen for abnormal changes. We now know:
You need to have contracted a high-risk Human Papilloma Virus (HPV) to get Cervical Cancer.
HPV is a viral sexually transmitted infection, like the flu, but downstairs.
Infection with HPV is really common! Most people are infected during their lifetime but clear it (like the flu!), with 12% of cervix-owners infected at any given time.
Most cervixes infected with high-risk HPV will not develop cervical cancer. The chance of a HPV infection developing into cancer is low.
There are 40 recognised types of HPV, but only 15 are currently considered high-risk.
Luckily, most HPV infections will cause no symptoms and often are cleared by your immune system.
Cervical Cancer develops very slowly and over a number of years.
If you have recently left school, you would recall receiving the HPV vaccination, also known as Gardasil or Cervarix. The National HPV Vaccination Program was introduced in 2007 giving three doses of a vaccination that can protect against two high-risk HPV strains, namely 16 and 18. 71.2% of women in Australia have been vaccinated by the age of 15. Of course, this only works if you haven’t already been exposed to HPV.
Given all this new knowledge, pap smears actually aren’t the most accurate way to measure abnormalities in your cervix! A single test will accurately detect abnormalities in only 40-60% of samples, as it depends on which cells are picked up. This can be improved on with repeated testing (for example, every two years!), but HPV DNA testing is more accurate.
HPV DNA testing involves taking a swab of your cervix, and using genetic assays to look for known DNA that is HPV. It specifically tests for high-risk HPV infections, looking for evidence of the virus from their DNA. This test is better at detecting HPV infection which is the cause of cervical cancer. Using this we can have high confidence that you will not have a HPV infection causing cervical cancer.
Thus, the National Cervical Screening Program is changing to high-risk HPV DNA testing as an alternative to pap smears from the 1st of May 2017. This change benefits us because:
High-risk HPV DNA testing is more accurate.
Less of the people screened will have to undergo further diagnostic or treatment procedures. These are often invasive and potentially damaging to the cervix.
You won’t need to be screened as often! Only every five years, and only from 25 years old, until 70 to 74 years old. Of course, if your test is positive you will be required to undergo further investigation, and potentially more regular testing.
There is the potential for people to self-collect the specimen, allow those who are uncomfortable with formal collection by a doctor to still participate in the screening program.
That all sounds good, hey? However you may have some other concerns. I’ve tried to address them in the questions below…
If the pap smear is gone, does that mean the procedure is much nicer and less intimate?
No, unfortunately the procedure is almost identical from your perspective, and you will likely notice no difference. All that has changed is its frequency: every five years instead of two. This is one way of reducing how often you have to have a test! The only change to the procedure is exactly how the doctor or nurse collects a sample and its examination by the pathologists.
Wait, if I’m not getting screened before 25 could I have cervical cancer that no one knows about?
As I mentioned, cervical cancer is incredibly rare before the age of 25 and takes a long time to develop. Most women with cervical cancer experience symptoms.
The main symptom is vaginal bleeding in between periods, and/or during or after sex.
Other symptoms include unusual vaginal discharge, discomfort or pain during sex and lower back pain.
If you or someone you know is experiencing these symptoms you should make an appointment with your GP for investigation. Just because we don’t screen everyone below the age of 25, does not mean we will not test you if you have symptoms.
Why do I know women under the age of 25 who have had cancerous or pre-cancerous cells requiring further treatment?
By screening from the age of 25 a number of women will no longer undergo procedures that are unneeded because some abnormal pap smear results may return to normal over time. In fact, 90% of people with HPV clear the infection in two years, and the abnormalities return to normal! Also, evidence shows that screening below the age of 25 don’t reduce the cancer outcomes, as it is so slow to develop.
If they do have persistent infection linked with abnormal changes, they will be detected when screened at the age of 25, which is soon enough – as cervical cancer is incredibly slow in developing. Screening less often will also reduce stress, time, cost and discomfort and risk of complications from treatment of harmless abnormalities.
In addition, given the success of the HPV Vaccination Program, it is anticipated that infection with two major high-risk groups of HPV will decrease, therefore reducing the number of women who would have had abnormal cells in a pap smear.
There a few cases where screening might be considered earlier, in the case of immunocompromised patients or instances of genital contact childhood sexual abuse, which need to be managed on an individual basis.
How do I know if I was vaccinated for HPV?
All teenagers are currently vaccinated from the age of 13. Males began to be vaccinated in 2013, so if you’re past year seven you will not have been vaccinated. For females, if you finished or left school in 2006 you will not have received a HPV vaccination, but beyond that, unless you or your parents declined you’ll have received it. There was a catch up program run, but it ceased a few years ago. If you have not been vaccinated you can pay to have this done as an adult at your local GP.
You can also contact the National HPV Vaccination Program Register if you are unsure. But remember, being vaccinated only prevents against the most common high-risk strains, not all HPV, so cervical screening is still really important!
I’m in a relationship where there are no male sexual organs involved! Does that mean I won’t get HPV?
No! You are at the same risk of HPV in a relationship where sexual contact involves two people with cervixes, as one with a male sexual organ and one with a female. Don’t neglect getting screened!
Isn’t the government just trying to save money reducing how often we are screened?
There are definitely financial benefits for our government in reducing the frequency of screening tests. However, that’s not the main reason for this change. Cervical screening for HPV DNA will be put in place because evidence shows that your cancer will be detected at five-year intervals, and reduce the cost to you in time, money and discomfort of undergoing the examination.
Do you have some published scientific data to back up what you’ve said?
Of course I do! If you’re interested in the government’s process that researched and recommended these changes, head to this website. The documents on this page cite numerous resources made in reviewing our screening program, as well as published research from across the globe. This was developed by the Medical Services Advisory Committee, which is an independent non-statutory committee under the Department of Health. You can learn more about it here.
If you would like further access to specific evidence, please feel free to get in touch!
It’s the Sunday after the RACGP AKT and KFP exams for some and before a busy Monday for others. You may be a little flat and the world may seem a bit chaotic at the moment so I thought I’d take a minute to remind us all of how good we have it in Australian General Practice. What are some of the little things your patients have done for you? These are three that come to mind for me: