Category Archives: Specialists

Rural GP Anaesthetists – a ‘special needs’ mob?

As a rural doc I’m very lucky to have a job that is varied. I tell students and junior doctors that rural medicine offers all the stimulation and challenges of all the ‘best bits’ of medicine.

Currently I practice primary healthcare, emergency medicine and anaesthetics (I gave up obstetrics last year).

So this weekend just gone was a highlight – a chance to attend an annual GP-anaesthetics conference at one of the mainland tertiary hospitals. I’ve had this date ruled off in my diary for 12 months now…so you can imagine my disappointment when the ferry to/from Kangaroo Island sustained damage in the recent storms and the replacement therapy had to be hurriedly re-surveyed, launched and pressed into service. Needless to say all Rex flights were booked out days ahead and despite lots of people needing to get to/from KI, Rex declined to put on extra flights.

Noone can control the weather, but the lack of a contingency plan was disappointing. Not that Rex have a strong history of customer service…

Anyway, I missed the first day of the two day conference. But although I made it to the second, I was somewhat underwhelmed by what I did attend, cementing further my belief that there needs to be content tailored to the rural GPA delivered by people who ‘get’ rural medicine.

To backtrack, I went to my first rural GP-anaesthetist in NSW last year. It was really good, a day and a half of lectures, plus a half day in the sim lab doing emergency scenarios. But what struck me there was the disparity in equipment and resources available between city and rural anaesthetists…as well as between rural GPAs in different parts of the State. Lectures by some of the FANZCAs were all very interesting…but often they did not realise the conditions in which rural GPAs work (isolated, minimal equipment, no backup, cash-starved). At the same time I was getting increasingly inspired by blogs such as Resus.me, BroomeDocs.com, Prehospitalmed.com and LifeInTheFastLane – all of which seemed highly relevant to my practice.

So I resolved to look at some quality improvement in my own practice on my return to SA, mindful of the fact that it made sense to have commonalities in equipment and protocols available to rural anaesthetic providers. Setting up a GoogleDocs survey was relatively easy, and I was gratified to get a 2/3 response rate from rural GP-anaesthetists around Australia on my topic of difficult airway equipment availability. I’ll be talking about this at the Fremantle Rural Medicine Australia conference and my paper should be out in the Oct-Dec volume of Rural & Remote Health. Stay tuned…

So, a year down the track I had really high hopes of further upskilling in SA. Whilst most of the content was good, there was an alarming propensity of some lectures to cover topics like cell salvage, lab-markers in major transfusion and the like – all very interesting, but not translatable to the rural practice environment where such resources aren’t available. Questions on topics such as delayed sequence intubation and whole blood live donor panels were unfamiliar ground for the FANZCA experts, although very pertinent to many of the rural doctors.

Small group sessions made up for it, with hands on experience and chances for case discussion.

But a common theme amongst the people I spoke to was that city anaesthetists task with lecturing had very little idea of the resource limitations in country areas. The vast majority of us don’t have remifentanil..or desflurane..or BIS…or access to FFP/cryo/platelets…or labs..or $15K videolaryngoscopes. The FANZCAs who visit rural hospitals, whether for elective lists or retrieval, did at least have an idea of our circumstances Yand ‘special needs’

So, what does the rural GPA really need?

- lectures from experienced anaesthetists? Hell yes.
- small group sessions and case discussions? Even better.
- topics targetted to the audience and suggestions for improvement. Absolutely!

…and to top it off, perhaps consideration be given to sharing the knowledge base by holding two sessions per year (allows more docs to attend…as if one doc is at the conference, the other needs to be oncall)

…and even better, consider delivering content in rural areas by taking some of the ideas on the road.

The other thing that concerns me is the lack of communication between rural docs. Locally the RDASA has a ‘rural anaesthetists’ email group, but it has been inactive for a few years. It seems that many of us have the same issues with respect to equipment procurement, training and upskilling – yet operate in silos. Moreover there is little ‘top-down’ direction – certainly I have no sense of direction from the ‘Country Health SA Anaesthetic Consultant’ and it would be nice to see some more dynamism.

Maybe next year will be better…I’m going to keep pushing the barrel for local delivery of leading edge concepts in EM/anaesthesia that are rurally relevant for myself and other doctors.

Email me if you have any thoughts on this.

How I Met My Specialty

I’m a big fan of rural practice. To me it offers all of the ‘best bits’ of medicine and has been a rewarding career. But it is not everyone’s cup of tea…many junior doctors make their career decisions based on what they don;t like…and many will not be exposed to the over 70 different career options within medicine. Sadly many will be put off rural medicine through lack of exposure and the misapprehension that the work is unrewarding.

I have just been sent this piece by a colleague, spoofing the manner in which choice of specialty in medicine is made. I seem to recall a similar collection of comments posted on ‘Doctors Net UK’ – regardless, it is deserving of a wider audience.

I particularly like the concept of specialists ‘stuck in a loveless marriage of convenience’. I’m lucky to be a rural doctor, flirting with many different interests…

How I Met My Specialty

I was an impressionable yet cock-sure intern when I started a relationship with a girl called Surgery. She was really sexy and I’d had my eye on her most of my time through medical school. I finally wooed her after a lot of hard work and for a little while things went well. My friends thought she was hot and my family thought she would be good for me long term. But behind closed doors, she was either aloof or extremely demanding and I seemed to be spending all my time trying to please her. In the end she was just too high-maintenance for me and we went our separate ways. I think we both knew from the beginning it wasn’t going to work out. On the quiet, behind closed doors, she was far too much into sadomasochistic control and humiliation. She liked to inflict pain on all her new boys, for a very long time and whether they want it or not, and I’ve never been one to put up with that kind of abuse. Plus she was obsessed with how people are put together rather than going any deeper. Never the girl for me, although I spent a lot of time thinking I wanted her, until I got to know her.

I soon started a relationship with a lovely girl called Anaesthetics. I have to admit I had been kind of seeing her behind Surgery’s back. She was a wonderful girl. We spent ages just sitting there watching the world go by, talking about nothing. We had some really exciting times too. Well at the beginning. But those times became fewer and farther apart as I got to know her better. I was comfortable with her and she was very supportive but there was a side of me that was never going to be happy. Added to which I kept on flirting with Surgery over the green curtain. In the end, as much as I cared for her very much, I just couldn’t see myself with her for life. Besides that, a friend told me that she went to sleep with multiple partners…


Of course, it wasn’t all bad – there was a weird little ménage-a-trois going between Anaesthetics, ITU and General Medicine for a while. They both got along really well – they were quite alike in some ways but really bewitchingly different in others. ITU is like the supermodel version of medicine – a tired, broken shell of what she used to be. General Medicine, or Genny as we call her, has been too kind to too many for too long and spends all of her time overwhelmed, so there’s no love and attention anymore, she’s just dragged from one disaster to another, never really loved and used by so many people. It would be great if she could harden up and say no to some people now and again, but her upbringing won’t allow it and her old fuddy-duddy parents accuse her of laziness, and manipulatively demean her with “in my day” stories when she points out modern problems. She’s got some great new mates really trying to help her out and make some opportunities for her, but I can’t be there whilst she gets sorted out – it may never work, and I’ll give up too much watching her sobbing through every night to spend my life with her.

Anaesthetics was such a calm, sorted out person but sometimes when I just wanted a bit of crazy in my life she was not really up for it.  Fortunately ITU was there and was always ready for a riot – usually at 3am on a Saturday night! She could be pretty aloof sometimes, and picked and chose her moments – Genny Medicine really got upset with the way she sometimes just sauntered off and refused to get involved.

Our happy little ménage-a-trois was suiting everyone really well – Anaesthetics had her devotees who would see no-one else, and ITU had a couple (but not many) regulars – she didn’t like the full commitment, too much pressure.

Unfortunately some of the more judgemental of the new-wave evangelists couldn’t understand our love, and hated us for it. They said we were only dabbling in a relationship and kept trying to split us up. They said I should make a decision now and forever between the two. It was all very confusing.

So I left the girls at it and flirted with EM (she’s changed her name – she was A+E when I met her of course) and I seemed to have found the right girl. It was tricky at the start because my friends and family thought she was a bit of a nightmare and rather unconventional. My mum certainly took time to approve of her. My uncle, an orthopaedic surgeon, thought she was a bit of an easy tart. But they came around because they realised that I loved her. We were made for each other. Sure she often threw complete hissy fits and I was up all night essentially getting abused, but she calmed down eventually. She tolerated my short attention span and my own tantrums. She was always challenging me (she’s rather experimental at times!) and coming up with something new for us to do together. I look back on those times with some fondness – it was dysfunctional, chaotic, passionate, stimulating and somehow it worked.


As a mate said, EM’s always good when you are on the rebound because: 
  1. EM is easy in, easy out. If you don’t want a major commitment you can have an on/ off relationship with EM and it’s OK.
  2. There’s a lot of variety. You want to try something new, pretty much anything and EM will let you get away with it.
  3. You want to have a bit of a dalliance elsewhere for a few months, or bring an old flame like anaesthetics or surgery into what you do at nights with EM and that’s all good…

EM liked a bit of the rough stuff, and didn’t half knock me about but it was all in the heat of passion so it was ok. She certainly knew what got me going. However, I noticed that my juniors seemed to prefer a more stable nurturing relationship – with a girl like, say, Anaesthetics – where they may start off quite unsure of themselves but they can be taken in hand and gently shown all the tricks and the way to do things without fear of embarrassment or feeling neglected and unsupported.

So, although I was very happy with my tempestuous relationship with my wildcat missus EM, I was quite jealous of the number of suitors the somewhat homelier girls seem to attract. I began to think that perhaps EM needed to clean up her act a bit (actually, a lot) otherwise she faced the very real danger of ending up as a bitter lonely old spinster


So what to do? By this time I was several years out of medical school – I’d had dalliances with surgery, with anaesthetics (and a bit of ITU on the side) and a rough n tumble with EM. I needed something different…

I think it was at a party when I met Psychiatry. I’d heard about her before I met her, and to be honest she sounded a bit scary. But as soon as I met her I found her a fascinating character. There was never a dull moment in our relationship, always something wild and crazy going on, and although she’s often misunderstood by others I thought she was just the most amazing girl ever. Until I realised she was a bunny boiler.

I reckon it was then that I sought solace in someone younger. I had a romance with a teenager called Paediatrics. She was a wonderful member of the family; very rewarding, fun, an excuse to have good toys and everything can be made right with a sticker. My parents loved her, although my ex-partners were very jealous of the attention that I gave her. Like EM she tended to have tantrums at night and woke me up at very inconvenient times, even if she was staying with someone else. There was also the massive problem of her birth mother, Midwife. She is an evil witch and tries her best to undermine me at every turn. One minute Midwife is being nice and asking for my help, the next she is a screaming banshee! 

Paediatrics tended to behave like the child in the nursery rhyme; when she was good, she was very very good but when she was bad she was horrid! She inflicted great joy but also great sadness. Her best friend and ally, Parents, were also trying at times. In the end I realised that she was just too young for me… I needed something more mature.


I met someone called aged care. She was profoundly unattractive, obese, smelled terribly and was into all sorts of kinky shit. She knocked me out, kept me in the basement and beat me daily, frequently anally violating me violently and forcing me to eat broken glass and drink my own piss. Gradually I came round to see that this sort of shit life was all I deserved anyway. For a solid six months it seemed normal to dress in a gimp suit daily and if was lucky, she’d occasionally let me out on a leash. I was still getting sodomised everyday though…

Then one night I met a lass called Neurology. She was sexy, and everyone was very impressed that I’d managed to woo her. It was a very cerebral relationship – she loved setting me puzzles and watching me solve them and at first we had lots of fun together. But gradually, I realised that once we’d solved the puzzle together there was nothing afterwards – she didn’t know how to treat anyone well in the long term. As the puzzles kept on coming, I gradually saw that even my clever-seeming girlfriend didn’t really know all the answers.

I started dating GP. She had some of the nice qualities of EM, but was a little less erratic. Plus I found that things were almost tantric, sometimes going on for months rather than the hours that EM had. I eventually married GP but I always remembered EM, though…

Recently EM and I got back together after a chance encounter in Australia. Turned out GP was a bit curious too – and so I have found myself with EM several times a week, and sometimes with GP at the same time! GP is really happy about this as she knows that when I am with her I am actually better than I used to be. EM likes it too, as sometimes GP pops up in the hospital and I’m better there too. 


As if that wasn’t enough, Anaesthetics comes to play a few times a month and we have the most fantastic times together – I’m not as young as I used to be, and there’s a chance that doing all three will kill me…but I’ll keep it up for as long as I can manage.

Who’d have thought that I’d have ended up a polygamist!

Still, I look at some of my specialist colleagues from medical school – trapped in a loveless marriage of convenience.

Reductio ad absurdum

Recent discussions with fellow rural doctors in South Australia have left me somewhat depressed.


I reckon that being a rural doctor is one of, if not the best job in medicine. You really get to enjoy all the ‘best bits’ of medicine, with a diverse workload that is continually challenging. Its also a great lifestyle (I don’t miss living in the city nor being stuck in traffic when commuting to/from the tertiary hospital). And the remuneration for a rural procedural GP is relatively good.

Dr Tim – proudly South Australian



But last night I heard from colleagues that specialists now outnumber generalists (GPs) in this State…and that they find medical students are increasingly pursuing careers in lucrative 9-5 specialties rather than general practice. 


Personally, I find that some specialists are more like partialists – how many times have we seen patients discharged form the ‘chest pain assessment unit’ with a scrawled discharge summary “serial troponins negative, normal exercise-stress test. Diagnosis = non-cardiac.” What the? That’s not a diagnosis…it just means that the patient hasn’t had an angina attack or infarct. They may still have a pulmonary embolus, or a pneumonia, or gallstones, even shingles – all of which can cause chest pain. Thankfully there are still a few “general physicians” around who get the big picture (mostly geriatricians) but they, like the rural doctor, are increasingly marginalised as partialists take over.


Now there is a danger here – increasing specialisation can lead to loss of the overview that is so important when treating a patient (and despite modern advances, medicine remains art as well as science). Patients seeking a ‘partialist’ may end up being passed from the cardiologist (not cardiac) to the gastroenterologist (not reflux) to the respiratory physician (not lung). The costs of fragmenting care in this way can be huge, particularly when there’s noone taking control.


Trigger-happy GPs (you know the ones – the guys who are writing the specialist referral even as the patient enters the room to sit down) are partly to blame, as is a culture that expects a specialist to be the be-all and end-all in the medical journey.


There remains value in a good family doctor, who can see the overall picture, take a decent history and initiate management, perhaps refer for an opinion when necessary, then continue ongoing care. I’m proud to be a generalist, not a partialist. In these days where everyone wants a holistic approach, the family GP is best-placed to deliver such care.

Jack of all trades, 
master of none
But oft times better,
than master of one



Money is also an issue – medical students face increasing debts (some are coming out with debts approaching $100K) and need to pay off their training. There is a perception that general practice is poorly remunerated. The ceiling may be less than some specialties, but the non-monetary benefits of a flexible portfolio career are worth money in the bank. Rural proceduralists can command high incomes, but the cost for this can be no time off and a life cut short by long hours. As the rural workforce dwindles, this problem compounds and the attrition rate accelerates.


Why then are we struggling to recruit and retain rural doctors? It may well be lack of exposure, or a teaching hospital that denigrates generalism vs partialism. I was one of these naysayers when I was a junior doctor, but was soon converted once I was first exposed to rural medicine. And there’s the rub – we need to get student doctors exposed to rural medicine early in their careers, and sell them on the lifestyle benefits and income potential that is the drawcard for many in Gen Y


The current contract between RDASA and Country Health SA is up for negotiation (contract expires Dec 2011) and of course one way to hang on to the current declining rural workforce is to improve remuneration for the most arduous part of the work ie: on call duties as outlined by RDASA. Whether the bureaucrats will see merit in this or not is moot – experiences on KI last year, when CHSA willingly spent $2000 a day on locums rather than negotiate with local doctors, leaves me to suspect that bureaucrats may well save a few bob by failing to meet RDASA demands, and instead end up paying 10x more through use of locums. But it probably comes from another budget, so that’s OK?!?


On Kangaroo Island we have recently become involved in the PRCC programme, whereby third year students spend a year located in a rural environment to pick up their skills, rather than rotate through traditional ‘firms’ in the teaching hospital. It’s an innovative idea and I hope it works (for my own succession planning and the ongoing needs of my community).


South Australia may also soon head down the pathway of encouraging a career in rural medicine through dedicated rural procedural training pathway – a sort of cadetship if you like, similar to that used in Queensland, whereby medical graduates are fast-tracked through rotations relevant to a rural career, not least obstetrics and anaesthetics (traditionally hard to come by)….with the whole deal sweetened by a guaranteed income from State coffers to work as a rural proceduralist.


We need these sort of innovations. Because one thing is for sure – if we continue down the pathway of referring everything more complicated than a hangnail to a specialist, health costs will skyrocket and the needs of the public will not be well met.