Boots on the ground in Goondiwindi. March 24, 2024

So, age 60, PGY37, I am about to do my first week working outside of MM1.

I've started by providing some telehealth support (3 sessions in the past few weeks) and tomorrow I'm "boots on the ground" at Goondiwindi (MM4) and I'm somehow feeling a mix of calm, a little excited and a little bit anxious.

I'm an experienced GP.

I'm sure most of what I'll see is general GP work.

I can ask a colleague for advice.

I know how to follow a Health Pathway and use a QHealth Smart Referral.

This morning I watched the swim leg of Hell of the West (annual triathlon) and it's raining for the first time in the 32 year history of the event. There is a whole world outside of my usual routine!

I am not moving from Brisbane, my plan is one session a week TH and 2 weeks a year F2F. It's time for me to give back to my country and while it's just a little something that I'm doing, I hope the something it is is better than the nothing it's replacing.

We need more hands on deck though....

Having handed over the last of my maternity leadership roles late last year, I have time to do something that's been on my heart for more than 20 years.

Wish me luck, I'll keep you posted.

Day 1, boots on the ground in Goondiwindi (aka Wendy's new adventures in MM4) March 25, 2024

OK, so everyone is new.

The printer set up is different.

The room set up is different.

The QScript function worked just fine.

The event summary in My HR was useless x 2 (he came to ED, if you want to know more, contact us).

I didn't have my HPI-I number with me, the PM had gone home and I needed it to reset the password for the Health Provider Portal, (hey, my computer in Brisbane knows the password, but it wasn't in my phone....) but this is all usual stuff that could happen with any new practice.

I haven't sorted out the BreastScreen Qld/NSW border town issues for a woman, but can step around it via a private referral - she has symptoms anyway, so a full work up is appropriate.

Otherwise, it was Drivers Licence Medicals (all with long records in the practice that I could follow/refer to), repeat scripts, pathology/radiology/specialist referrals, sore tummies, vaginal discharge, anxiety, medication review in a hypertensive patient and, being 2024, immunisation, immunisation, immunisation - Covid, Flu, Prevenar, Shingrix and, because it's Gundy, Jap B encephalitis.

No one accepted the Covid booster and I saw a lot of over 75's today. My regulars trust me on this and 80% or more would be boosted.

Sure, the end of the day tea room conversation between two GPOs was different to the conversations I have in Brisbane, but honestly, today, I was a GP.

I'm not a rural generalist, I'm not a hero, nor do I need to be one to fill this role. I was a general GP.

And I was a valued team member doing an important job that needs to be done.

I'll let you know how I pull up by the end of the week, but day 1, feeling like this is something I can do.

Comment from Dr Konrad Kangru:

Lesson #1: You don’t need to be a hero to be a Rural GP. Just be a good GP.

Comment from Dr Michael Rice:

Of course it is and of course you can. The “super doc” trope is potentially discouraging when there’s a lot of general practice to be done and keeping the punters out of hospitals is more important (but less visible) than getting them out. 

85% or more of Aussies need primary care in a year. Very few need the advanced care of the rural generalist (or metro consultant). Fewer, if we community GPs are performing at our (invisible) best. 

We need recognition for the pre-eminent advanced primary care generalist!

Comment from Dr Lih Ling

If you know your AHPRA User ID, simply add 800361 to the front of the ID to get your HPI-I

And love your adventure! Keep us updated!

My reply: how do you know that!!!

Practice point: none of us know everything, but together we know so much!

Day 2, boots on the ground in Goondiwindi (aka Wendy's new adventures in MM4) March 26, 2024

Oh, today was just FUN!!!

It was such a mix - two teenagers with menorrhagia and dysmenorrhoea, one with a Hb of 94 and Ferritin of 5, fellow with gout who has decided to commence a preventative, complex, chronic medicine in those who are vulnerable as they have to get a new GP (their previous one has left), travel medicine (PNG, Kokoda), follow up of a young farmer who’d worked with chest pain, shortness of breath and whose offsider had noted to be pale. Thank goodness there is a visiting Heart bus! And last of the day was a drivers licence medical in a young woman with a medical condition who I had been able to get advice from a specialist via the Mater's eConsultant and felt empowered with the advice I was giving and the medication changes required. She was overdue for her CST, needed a referral to a dermatologist etc and I had booked a 45 min appt for her as I knew it was complex, so there was no stress in getting all of this done.

Full breadth and depth.

Just wonderful! Nothing out of my depth. :-)

Day 3, boots on the ground in Goondiwindi (aka Wendy's new adventures in MM4) March 27, 2024

Well, this was more complicated and not as much fun as yesterday....

I'm getting into the swing of things, but the printer played up (not unique to MM4) which put me behind and I met an extremely complex woman with a traumatic background. One of those folk there is no answer for, we simply hold space...

A teenager who needs a paediatric neurology review (anyone got any leads? Will travel...)

Removal of an Implanon, Ferinject infusion where the RN did the cannulation (well, that helped speed up my day!) GPMP/TCA reviews (patients orphaned by exiting of their previous GP), cough, BP/medication review etc, postpartum/neonatal reviews Day 9.

All general GP stuff. I'm finding it difficult to place some of the patients as the results come in (vs I know my regulars), but again, that's not an MM4 thing.

We had Kases and Kebabs for lunch = 3 medical students who move between the hospital and the GP practice presented hospital cases and we all discussed = a great way to learn (for this PGY37 in particular!!).

People are disappointed I'm not staying, but grateful I'm here. The staff are cheerful, helpful, skilled and it's a well-oiled machine. The medicine is complicated by distance (young farmer with IHD until proven otherwise and I want to start Atorvastatin ASAP, but he's 40 min from the chemist, so Saturday will have to do).

So, as I've reported previously (and as I suspected) it is general general practice. It's complicated by not knowing the referral pathways intuitively, and I'm aware that I can't take over the care of all of the people I am seeing this week (I won't have capacity).

But I think it's something I can commit to (as a 1/2 day TH a week and 2-3 weeks a year F2F) until retirement.

Stock photo: not actually me!

Day 4, boots on the ground in Goondiwindi (aka Wendy's adventures in MM4) March 28, 2024

This is how general practice should be.

I work in an excellent practice in Brisbane. I have been there for 22 years. I have terrific colleagues, a great team and we do lots of good, good work. Our treatment room is busy, we do minor procedures, infusions, excisions etc and I am proud of our standards.

But this is better.

Why? Hmm, perhaps it's top of scope. Perhaps it's genuine collaboration/a well oiled machine. No doubt it's the culture of the practice which is reflective of the leadership and that is specific to this practice, not to MM4 (although top of scope stuff may well be).

Breadth and depth. Humour and appreciation. Warm welcomes.

Lunch time presentation today (3 GPs, 2 medical students in a conference room, specialist via Zoom) with excellent use of power point and oh my goodness, a really helpful deep dive into childhood constipation with a paediatrician in Toowoomba. The presentation was led by a GP, who did such an excellent case review - it puts my efforts to shame, and I am a good GP who prides herself on her presentation skills!

The bar (for me) has been raised by this experience. I have ideas (and I hope my colleagues in Brisbane will engage) but now that I'm part of this practice, if they don't, I can link in with their excellent peer education.

One more session (Saturday morning) with my boots on the ground, then it's back to TH.

But I'll be back.

Choose wisely, but if you are thinking of doing something like this, engage. Start a conversation. It hasn't been scary, I've been supported. I have asked for advice here (as I do when I'm in Brisbane) and I have looked stuff up (as I do when I'm in Brisbane) and I've referred (as I do when I'm in Brisbane) but mostly, I've dealt with what was in front of me.

Proud to be a GP. Best job in the world.

Matt Masel, Sue Masel, Sarah Gleeson, thank you for your generous hospitality.

Photo: taken this afternoon, the first blue sky all week!! I'm looking forward to seeing the stars tonight.

Day 5, boots on the ground in Goondiwindi (aka Wendy's adventures in MM4) March 30, 2024

So, after having yesterday off (Good Friday) I did a Saturday morning session. This is a book on the day, no BBg session and it was simple stuff - wound infections, repeat scripts (full time worker who can’t afford a day off) and the like. As Dr Matt Masel showed me through the hospital, he reflected that the “simple stuff” we did today will keep some of those folk out of the ED this weekend and indeed, this is such an important part of the work we do.

I had enough time to update a couple of records, follow up on a previous consultation and finish some left over paperwork.

I’ll process this experience further and share my musings with you, but overall it’s been a positive experience. I had some complex and chronic patients booked in with me on purpose (they had asked me if it was ok) and I’ll need to get my head around their situation. The complexity of their conditions is exacerbated by their geography and distance to services, something I’m still learning/factoring in. But I’m a clever woman. I’ll get my head around it.

For now, it was a good week, I provided a service that is sorely needed. While I haven’t fixed the system, not that I thought I would or could, I’ve done something positive.

Comment from Dr John Kramer:

Small steps by many equate to large strides collectively.

Rural reflections March 31, 2024

Boots on the ground in Goondiwindi, aka Wendy's adventure in MM4.

Was it Dr Bruce Chater* who said “if you've seen one rural town, you've seen one rural town”?

Age 60, PGY37, I stepped outside my comfort zone and, for the first time since I worked as an intern for one term in Bundaberg Base Hospital (1988), I worked outside of MM1.

And it was fine.

My skill set was adequate.

The CDM nurse was happy that I "got" CDM.

The bush does need rural generalists, but mostly what they need is general GPs. A well-trained, skilled workforce that can flex to meet a variety of clinical needs. That is you and that is me. The GP workforce.

Every town is different. Every MM1 practice is different. Every MM4 (or MM whatever) practice is different.

My experience won't be yours, but for what it's worth, here is my 2 1/2 cents:

View fullsize

If you are interested in working outside of MM1/MM2 etc, then ask around. There are multiple models - from the one Dr Jo Butterfield is doing as a QHealth/GP Locum 1:2 DIDO from the Sunshine Coast to Tara and the one Dr Maggie Robin used to do 1:4 FIFO GPO roster from Brisbane to Charleville, to the Brisbane GPs who are providing TH support to Goondiwindi Medical Clinic, Drs Yong Suk Jeon and Aye Aung, to the VIP model being researched and part funded (I think) by UQ https://medical-school.uq.edu.au/.../virtual-integrated... to the work I have started to do in the past month.

If you've missed my previous posts, I am providing TH support one session a week and I will provide F2F services for 1 week at a time 2 - 3 weeks a year.

My choice is to choose a practice, and once I'm confident we are a good fit, to stay (there is no shame in trying something and realising it's not right for you - failure is ALWAYS an option - I usually learn more from what doesn't work than I do from the stuff that does). So from here until retirement, I plan to work with GMC.

Why?
Because I was the child of country GPs.
Because I have family who live in regional Qld.
Because I have a son who was working FIFO in rural and remote parts of Qld.
Because there is a need I can fill.
Because it worked just fine.
Because I can.
Because, why not?

I have come up with some ideas/suggestions/a checklist (those of you who know me know I love a good checklist) and a resource document. Please feel free to use/modify/add your own input/reach out.

We have a workforce crisis and the ability to provide telephone/telehealth services from the comfort of your own home is a game changer for the delivery of medical services to some of our fellow Australians. If you link with a practice who have seen the patient in the past 12/12 then Medicare funding follows. You may or may not choose to do F2F work, but it's a great way to see the country and explore other models. Take your kids/partner/parents! Life is too short to be a spectator!!

* Dr Bruce Chater, who is well known in Australian rural medical circles, became known for this quote, however the original quote is much older and from an American rural GP, Dr Roger Rosenblatt. With thanks and acknowledgment to Dr Ian Kamerman for knowing and sharing this.

Going bush, week 5 April 4, 2024

So, it's back to TH/TP consultations.

Personally, I found having been in the practice and the town was very helpful with getting my bearings. It was easier to understand the workflows and to know where things - and people - are.

Quite the variety today, certainly everyday GP stuff (including the need to have an onsite clinician review a skin rash - one I could handle via video (P. Versicolor) the other one, no - a swab needed to be taken and medication started).

I'm still looking things up. Still having to book a follow up appt so I can start to understand the intricacies of the case. None of this is unique to MM4 - it would be the same with any new practice/patient. At least here there are usually some records to help me. Finding QScript helpful for confirming stated medication use. Finding MHR hit and miss. Finding that missing discharge summaries are just as frustrating in MM4 as they are in MM1.

But, I'm able to do this while sitting at home. I'm providing a small lift in capacity from my living room. You don't have to have your boots on the ground to be of use. So far people have been grateful, but I can see the cracks that people have fallen between due to lack of GP care. They exist in the city too, perhaps they are just more visible to me here.

There is no one simple solution.

Me, in front of the magnificent photo of a snow gum, Mount Kosciuszko National Park, photographer Adam Gormley

“Single answers to complex life situations only look good on paper.
If they could have been emulated easily in real life, they would have been.”

Dr Angie Kiren

Dr Sarah Bird's story April 7, 2024

Just home from another 3 weeks in Broken Hill with the Royal Flying Doctor Service. Always a fun team to work with and sooo much medicine to be practiced, well supported with the retrieval team and the local ED too.

Pic of the local emu family outside our house last week!

Dr Elizabeth Christie April 7, 2024

I literally had a year on the road during Covid locumming through outback NSW with my Troopy and dogs. I worked in country hospitals, ACCHOs and General Practices. I am still a rural locum but now I get to go home to Victoria between placements. Amazing experience!

Dr Maria Da Costa June 29, 2024

I survived my 2 week post in Katherine, NT, without major incidents. It was the usual diverse GP work. More diabetes than expected, my share of paperwork, dermatology I had only seen in an Atlas. I had to research investigations and management choices as there were no other options in a reasonable radius. There were the women happy to be pregnant, others hoping not to be. There was grief, alcohol misuse, relationship problems. There were cheeky ones and the brightest 97 year old of them all. My little sample of humanity.

I have enormous respect for the colleagues who do it long term. I had it easy. Competent staff, a pleasant environment, managers who are trying to improve their community. I am relieved I made it but above all I am grateful. I have had opportunities to travel and work in amazing places. Come Monday I will be back to my usual routine. But I will be refreshed. I don't know how long it will last. Perhaps until I get the urge for some more red dust...

#justaGP

(Editor: by way of further explanation: Maria is a GP based in Sydney who enjoys doing locum medical work in remote communities and has done previous volunteer work in Timor Leste.)

I try to do a locum job once a year. When I first started I did a REST course and emergency obstetrics training. I have always just wanted to work in a community that had at least some sort of hospital not too far away for support. I now avoid less mainstream software too, it takes me too long to learn a new system and I find it a source of frustration. I was meant to have come to Katherine a few years ago when they were desperate and the only GP practice in town had closed. But Covid happened. I promised at the time I'd come back when possible. It happened that whilst there is now another Practice in town, the GP I replaced took some leave.

So, I do my more than needed CME but have no major extra training. I have a fair idea of how the system works in NT as I worked in a smaller community here before. I am aware of my areas of comfort and discomfort. And I suppose I have a little gypsy gene that needs to express itself once in a while 😜