Rural Health - GP Self-Care
Jessica Ledwidge
Good evening and welcome to the latest instalment of our Rural Health Webinar series. Tonight's session is on GP Self-care and it is presented by Dr John Buckley. Before we start, we will do an acknowledgement of country. I would like to begin this session by acknowledging the traditional owners of the lands that we are coming together from and the lands on which this event is being broadcast. I would like to pay my respects to elders past, present and emerging and also like to acknowledge any Aboriginal and Torres Strait Islander people who are joining us this evening. Welcome. Just before we begin, there are a couple of housekeeping tips for tonight's webinar. You are all on mute to ensure that the webinar is not disrupted by background noise, but we do encourage you to use the chat function to ask questions or the Q&A panel. We will have time for questions at the end, but we would also like you to use the chat box during the session as well. Please make sure if you are using the chat function that you do, write your message to everyone rather than just to panellists to ensure that other attendees can see your questions and comments. Finally, just letting you know that this webinar is CPD accredited for one hour and to be eligible for that, you must attend the entire session and complete the evaluation that is automatically sent to you at the end of the webinar. I am now going to hand over to our facilitator for this evening, Dr John Buckley. John is a GP in Brisbane and he has worked in GP vocational training space for 27 years. His particular interests include the patient/doctor relationship, support and training of GP supervisors and GP teachers and rural training. Welcome, John.
Dr John Buckley
Thank you so much. I hope everyone can see me and let you hear me and let you know if they cannot. Interesting. We adjusted the slide ratio before we started and I thought it all looked fine, and now I look at the double RACGP down in the bottom corner, but that is life. Things happen. Hey welcome everybody. I will just go back two slides. If we were presenting in a room live together I would be asking someone to tell me about this quote, and I will give you a chocolate prize or something if you got it, but first of all, can anyone in the chat tell us what the quote is from and then anyone want to have a guess as to why I put it there? And I can see stuff from you, Jess. I am not sure I can see it from everyone. It might be the issue. Is anyone answering?
Jessica Ledwidge
No. Not yet. We will just make sure all.
Dr John Buckley
They all are too scared of me because I can only send to hosts and panellists. I am not sure if I can see everything. Can someone just send a test message and see if I can see it? That would help me for the rest of the night.
Jessica Ledwidge
Even in the Q&A box if you cannot see the chat.
Dr John Buckley
Anyway, so I will answer my own first question and we will keep moving. That is from the end of the movie Casablanca by Humphrey. It is a line from Humphrey Bogart, but the reason I have put it here is, so the question really for tonight was about who looks after the doctors, and I will give you the answer now, the answer is we have to manage that ourselves, but hopefully with the support of a team that we construct and build around us to help it happen, and by using our own awareness and our own skills, and the quote is there because some of us are not great at looking after ourselves and not great at seeking help to look after us, but when it happens, it usually stays. I was probably in my mid 30s before I got my own GP and started being a bit more active and, it kind of once you realise it, you stick with it. If you are not already looking after yourself and organised who is looking after you and how it works, maybe it will not be today or tomorrow, but sometime soon please, and then for the rest of your life. Anyway, so that is why it is there. I am going to step through a few different things tonight and feel free to interact, and if I cannot see stuff, I will get Jess to point out. Sometimes I will ask you to put things in the chat box, and it would be great fun if you do. Speaking of great fun, I love putting a cartoon in and this is one of my absolute favourites. For those who do not know The Far side, it is fantastic, but for some of us, looking after ourselves and seeking and getting our own health care is a new trick, and some of us are old dogs. I am PGY 41 this year. I do not look it, I know, how about that? and some of you will be doctors in training, some of you will be very junior, some of you have been around as long or longer than me. If you feel up to it, if you could pop into the chat where you are and how long since you graduated, it would give us a nice picture of who we are talking to because I think, the issues are a little different for each of us at different ages and stages of career.
The next thing that happens when people start talking about looking after health and we do it with our patients, it is always about what you should not do. That is not my goal tonight. I think it is not all the bad news. It is not all the do not smoke, do not be lazy, do not drink too much, do not take drugs, do not abuse people. This is I want you to think a lot about what are the things that we do that are actually good for us, and what are the things in ways we can promote our health and look after ourselves? How can we get help to look after ourselves? So I want us to focus on the positives rather than concern too much with all the things we should not do, because we kind of know all the things we should not do. It does not mean we do not do them, of course, but at least we know, and that is one of the problems of course. We think that knowledge protects us and it does not because we can be really good at knowing things, but not being able to put them into action or making excuses for ourselves or ignoring things for too long. I often tell the story of my fantastic GP who gave me seven diseases in one week. At the end of one week, I thought I was just perfectly healthy man with no diseases or illnesses and nothing needing any treating, and seven days later I had seven diseases, and of course I blamed him entirely and while it was happening was he was helping me to find all the things I had been ignoring. Thanks, Judith. I decided it was finally time being fairly overweight to check up on those slightly raised fasting blood sugar levels that I had been having for a year or two. We decided to do an oral glucose tolerance test in the same week because my son had been diagnosed with coeliac disease, and I had been for a chat with a gastroenterologist and I tried to tried to avoid the endoscopy, but we agreed that we should do it. I had an endoscopy and a colonoscopy because I needed that. I was due for that because a family history of polyps. By the end of the week, I had carb loaded for my glucose tolerance test and come out in an incredibly itchy, small blistery papular rash all over my thighs and buttocks. Anyone want to guess what that is? Think about it while I tell you the other diseases. The gastroenterologist said, well, John, I do not have to wait for the biopsy, but let us wait, but your villi will be completely flat and you have coeliac disease and you need to be gluten free. By the way, will you please treat your reflux for me? And I am pretty sure you have got Helicobacter, and you have got your diverticulitis and your polyps, with all of that. Good guess, Michael. Not the one, it relates to the other diagnoses I just mentioned. I also had poor glucose tolerance and needed to manage that, and we also decided it was time to treat my blood pressure and my lipids. I thought I was totally healthy, but you know what, in my heart, yes, Judith. In my heart I knew that I was not and that is why I allowed him to do these things, but still I blame him for all my diseases, and still he is my GP 15 years later. It is not all bad, like I said on the last slide, yes, dermatitis herpetiformis which I knew not too much about, but it relates to my gluten enteropathy, and in fact, remarkably, I had such limited knowledge of how intensely itchy and irritable and horrible it is and that it took me two years of being completely gluten free before my rash went away. I feel I were perfectly normal within months, but my skin was not. I already had problematic skin with some eczema and psoriasis, but I knew about them and did not count them as diseases. There we are. I transformed myself thanks to the care of my GP, but as I said, I still like to blame him when I show up. Yes, two years. It is tough and it is surprising and the amount of each was incredible, and the blisters were all coalesced and just form areas of raw skin day after day after day. It is quite amazing. It was a disease I had never appreciated or seen much of. We have some learning outcomes because it is a good idea, and they are not bad things for us to think about, and I hope that at least one of these things enhances for you as the evening wears on. I really hope that we get something from this that you can think about your own awareness or what you are doing about your health, or how you can get better care for your health, or how you can look after things better yourself, some combination of all those things.
Here is a little start, and I always credit this to a fantastic GP on the on the Southern Downs, David Downs at Stanthorpe who used this in a presentation. I want you to think for a minute about yourself five years ago wherever you are in life and yourself now. In any of those areas, do you feel a change from what you were five years ago, or can you think of another area that has changed very much in your life in the last five years? Again, feel free to pop something in the chat. You do not have to. This is a personal reflection, but if you think of something else that has been different that I could add to my list, pop that one in the chat so that I can see it and add it next time I use a similar presentation. The point is not really, of course, what has happened, but why has it happened and what is going to happen next? And if we go back to our old friend Einstein, whatever has happened in the last five years, if you do not change something, it is likely that same trend will continue. I will just go back a slide. If you are less active than five years ago, it is very likely that unless you intervene in some way five years from now, you will be even less active. If your happiness or your time with hobbies and recreation is less than five years ago, unless something changes and it does not have to be you, it could be something else that changes, but unless something changes, you will be having even less time with hobbies and recreation than you do now, and so the purpose of this couple of slides is to get us thinking about reversing trends that we are not happy with. If you are financially better off and you are more happy and you are more active, that is wonderful. I would like you to think, how did you do that? How can you make sure that trend keeps going but if you are unhappy with any of those trends or others that you have thought for yourself, then now is the time to think, I would like to change that and I want a few takeaways from tonight and that is the first one. If you can commit to yourself something that has been going in the wrong direction in your life for the last five years that you will after tonight, look at what you can do about it now. It is not always in our control, but look for ways to reverse a trend that you are not happy with, and as a second goal, if there is a trend you are happy with, please try to think about how it happened and how you can keep that going, so that five years from now it is even better. I find that a really useful way to think about myself and where I am at. People always say, where do you want to be in ten years' time, all that sort of stuff, but I think a lot of it is where have you come from and where do you want to be and where do you want to be, that is different, and when we talk with patients, we talk about things that we want them to do and they agree to do, and so often they do not do it and they do not do it because they do not think about planning and they do not think about the realities of making something happen. If we chat with the patient and they decide to join a gym, it is a fantastic thing. They walk out of the room all enthusiastic and a month later they come back and there is a very good chance they have not joined a gym and the barriers they have not thought about, they go home and it all becomes overwhelming, and we do know that change is best tackled in little steps. If in fact instead of go and join a gym, it is go and research the gyms in your area and find out which ones have got the best reputation and the best prices, and we will talk about it next time, and the time after that, we will go and research the shoes or equipment that you need, and maybe the time after that will work out how you are going to find the time, and then by the time you get to it three or four visits down the track, they are much, much more likely to be able to make that change, so change is difficult even when we wanted and even when we know about it. The first step is to recognise what you would like to change, and the next really hard bit is to actually think about how can I do that and what will my barriers be? Will they be money? Will they be family? Will they be time? and we all know how precious time is. I just want you to get started on that tonight and think about one trend that you would like to tilt in the other direction. Write it down because when you write things down, interestingly, it seems that it is a 30% chance greater that you will actually do it, and thanks, Chris. You win. You may not be the oldest online, but you beat me, so congratulations and good on you for being here. Maybe you should be telling us all how to survive.
The next thing is to talk about change, and I often gave a talk like this to people just starting out in their general practice careers, and they had just left the hospital system and entering general practice, and for those like Chris, 40 or 36 years ago, 38 years ago, I do not know, remember what that was like. It is an enormous change in life getting out of the hospital system and coming into general practice, or if you move general practices or if you move towns or if you have a major change in your practice or in other parts of your life. It is a bit funny. We try not to burden patients with too many changes at once, and we are certainly all told please do not tell someone to lose weight, stop drinking, stop smoking, look after their spouse better and do more exercise, off you go and do it all. Of course we do not. We want to see what changes are doable, but when life changes, it is a chance to reflect about what other changes I can do that will be in harmony with that. If you have just cut from five days a week to four, what can you do with that extra time if you have just stepped into a job that with earns you a higher income, what can you do with that extra money? And so often we do not take the opportunity to change when that comes for us, and again, the example I always think of is patients who stop smoking. If they could completely stop smoking, they save a lot of money, but I asked them what they can do with that money and they have not thought about it, and I try to recommend that they get what they would have spent on their smokes and stick it in a bank account and then treat themselves to a holiday or a new TV or a surprise dinner with their partner or something, and then remember I got that because I stopped smoking, but when you get more time or a different time or a different pressure of work or something that creates a release, then it is better to plan something else that you can do to take advantage of that rather than just let it happen because if we do nothing, it will just drift on and we will not have maximised what we can do. If any of you are in a situation of changing, scaling up, scaling down, moving careers, think about what lifestyle or what advantage can I take with this shift, even if in some ways it is harder, what can I do to ameliorate that difficulty? That is about using opportunities when they arise, but I am not expecting things of people. I think that is the difference. Take an opportunity, but no one should say you have to or you should. It is really a case of what can you make of this that will help you to look after yourself better and put you in a better situation. Anyone who has been through a change in the last year or two or has an upcoming career change, really think now about how can I make the best advantage of that, particularly if that is something that is going to give you a little bit more time.
My next challenge to you is if a patient says to you, why should I bother having you as a GP? What would you tell them? Again, I would love some comments in the chat about how to answer that question. How do you justify why patients you know 90% of people see a GP every year in Australia. It is in the health of the nation report elsewhere every year and it does not change much. Why do we think they should do that? Why do not we have a different health system that just lets people drift into whatever care they think they need, whenever they need it? All silence on the chat, but that is okay. Hopefully you have all been thinking about that and lots of people give me answers like, well, it is continuity of care, trust, picking up things early, monitoring things, building relationship, having someone who can talk to when they are really hard times come, having someone who will be straight with me when I need information, having someone who will follow up, having someone who will advocate for me, having someone who will actually care for me, and I think they are all pretty reasonable answers. They are not mine. They are from other people, but the attempt is to lure you into a trap because what we tend to do is defend our position and say, of course you should have a GP. You should see me for this or my colleague for this, this, this and this and it will be really worth your while, and we really look after your health. If that is the case, do not we all deserve the same? Again, I am used to standing in a room with a whole lot of new general practitioners, either in training or just finished training and asking them if they have their own GP, and last week I was with a group of RVT Registrars, Remote Vocational Training scheme who are a little bit older and remarkably more than half the room put their hand up. I do not see that very often. Hey Judith, thanks for the comment. Yes, totally different world that, huh? Normally I am used to being in a room with 20, 30, 40 registrars and seeing about two hands go up about having their own GP. Point number two for me for the night is somehow sometime, maybe not today, maybe not tomorrow, please have your own GP and have a GP that you like and trust and can work with. If you are someone in training and you have to move around or Judith if your situation has changed and maybe you cannot access that GP anymore, find another one. If you are not happy with your current GP, find another one because it is really important. We know the care that we strive to provide to our patients, and this is not a nice thought to think of someone striving to provide that care for us. On that line, there are numerous programs around about doctors, for doctors, there are online modules. There are all sorts of doctors health organisations. The AMA often will put up lists of doctors who are willing to see doctors as patients. There are two sides of it. How can you be a good doctor for doctors? and it does not suit everyone, but if you think it could suit you, please be one and be that fantastic doctor that other doctors need, GPs and non GPs, and also there is an art to seeing a GP and having a relationship where there is mutual respect for knowledge but no great expectations, and it is a little bit challenging to who overrides who and what if the patient has already got a diagnosis and I certainly fall into that mistake as a patient. Being mindful of the relationship and the mutual respect and finding someone that it works. This, of course, is a rural health webinar, and the challenge is even greater for rural doctors. Seeing a colleague in your own town as your GP is really good until it is not. It can be fraught with challenges. You have mutual working responsibilities. You do not want your personal or family secrets spread about town even though you trust your colleague. What about sitting in waiting rooms? There are all sorts of challenges, and we know from research and I have doing a little bit of work for the Rural Doctors Foundation that many GP's go hours to see an independent GP for their care, and that access is problematic in terms of it is a long drive. There are safety risks. They miss a date consulting. I know of a woman who spoke with me recently who drives about three or four hours each way to see her GP when she needs it and she misses her days consulting, and she has already got a four week waiting list for patients. You can see what that does to her and her practice, and yet that is the arrangement she has to find the care that she wants, and it is not that she does not respect the other GP's in her town. She just does not want them to be her GP and I really get that. I will just briefly mention the Rural Doctors Foundation because at the moment they are running a pilot of sending two GP's out to some rural and remote towns in a couple of different ways to be a GP on a visiting basis for local health professionals, and I mentioned that because I am one of those two and I will be going out to Stanthorpe, Goondiwindi and Saint George and my colleague John Dyer, who you might know is going to Quilpie, Cunnamulla and Charleville. In fact, he is there this week. It is a pilot. It is not easily sustainable in itself, but they want to research some more and see, how can we do it, and good on you Judith. It is great to have that GP. As I said, I still see mine. So get one, really connect with one and hang on to them while they can. Of course, eventually they will retire or do something nasty to you, like I left the practice I was in and all my patients were not happy, but, the access challenges for rural doctors are distance and there is also time, and that is one of the advantages of this program is that we can show up in your town and you can see us in almost in a normal appointment time and get on with your day, whatever else you want to do, but confidentiality is an enormous problem. Just being seen at the doctors or being seen having tests. It is all very challenging to look after yourself in a small community and I just appreciate how you all go about it as you do and survive and keep going. It is fantastic, but the one of the things and if we can get at government level to convince about better help to give doctors better access to their own doctor is it is fantastic for communities. If it keeps you healthier and happier and improves retention rates, then that can only be a good thing as well as being good for our wonderful colleagues like yourself. That is the plug. If you do not have a GP, please get one. If you do not like them, get another one until you like them. Then hang on to them, Judith, and if you think you could be a good doctor for doctors, really put your hand up and let that happen. Do some online modules, get some support if you want, but just be yourself and learn on the job and occasionally mess it up and then apologise and have good relationships because that is how it works.
We will raise a couple of other issues that sometimes challenge us. Doctors have been in the past notorious for self prescribing, self-treating, self investigating. We are probably all a bit guilty at times in certain ways, and boundaries are a great challenge. Boundaries for ourselves and our family and friends, and again, I spent long enough not rural at the moment, but I spent long enough in rural towns to know how those family, friends, neighbours, community members in small towns, it is even more challenging sometimes to manage those boundaries, and it is one of the things that can get us in the most trouble and help us not sleep at night. Another thing for tonight, if we really think about our boundaries in managing the people who approach us. Having said that, I do find and I think we all know with relationships it is a challenge Sometimes the medical authorities do not understand rural all that well and access issues all that well. If I am a single person in a remote area, and I am going to committed to stay, am I never going to date anybody ever, because they are all my patients. There has to be ways of rationally dealing with boundaries. I will give you an example of something that happened to me a few years ago about treating families. It was Christmas Eve. This is an absolute 100% true story. About 7 or 7.30 at night and I was away with my wife in a really quite rural remote B&B for Christmas. It was lovely, and I got a message from my adult son, who was 29 or 28 at the time, saying I have this terrible rash that on the back of my head and it is really itchy and it is quite burny and he sent me a photo. How is that for modern technology? Is not that lovely? And so 7.30 Christmas Eve, doctors are all shut, nearly all the chemists are shut, and I had a son who had a quite obvious herpes zoster. That was beautifully located, excellent picture, and perfect symptomatology. There are treatments available that are quite safe to use, and he had a time frame where if we did not do something, of course he had already got the rash, so normally to say we have a 72 hour window, he probably had less than 48 hour window, so yes, I organised an after hours chemist and a script and he was treated. Now if it was not Christmas Eve, probably a different story, but there are always exceptions and challenges, but what you need to be able to do is tell your story, make it a story that you are willing to say in public like I am, and defend your story if challenged. That is a clear boundary. I would not have treated him in other circumstances, and I think boundaries are not "do not cross," boundaries are understanding who you are, what you will do, why you will do it, and be willing to defend that if it is really legit, and if it is not and you are not willing to defend it, you probably should not do it. Here is a simple question and you have your own ideas about maybe what makes a good doctor, but when people talk about good doctors, these are some of the things they talk about being really doctors who are admired and particularly that last one able to sublimate your own immediate needs for longer term needs of others, and I have any of you not had your spouse say to you, why are you going out and doing that? I am sicker than they are, or even I remember coming home one day and saying, I was sicker than every single person I saw today. We are a bit crazy, are not we? So sublimating your own needs and we do that out of duty and responsibility and oath and a whole lot of things we can justify, but is it good? The flip side of some of those things is it makes us vulnerable. If we are self-critical, driven, sublimate our own needs, we are vulnerable to emotional and physical ill health and we need to again, we do not have to change that. We just need to be aware of that vulnerability and what is happening and what we do. Keep that in mind when we try really hard to be a good doctor. We do try so hard that sometimes that is not the best thing for ourselves, and again, in rural areas, if we as the doctor are not being looked after, then we end up in a position to not look after our community. Even if you want to be community minded, self care is a critical part of that. This is some things that we are really good at and some of them are very, very sad. I think we are still up near the top of trusted professionals. It is funny whenever surveys bag doctors and especially GPs, apparently the recipients always say yeah, GPs are terrible money thieving, grubbing mongrels, but my GPs is fantastic. We are trusted and valued. Despite recent changes, we are still well above pharmacists and we are way, way above used car salesmen, but these other problems are very true. I can talk being a second married person myself. Luckily, I do not think I have any problems with substance abuse. Part of it is knowledge. Part of it is access, either money or access to drugs or things that people just take from trolleys or order. I am not blaming anyone for that. I mean, we have problems of stress and access and resources allow us to do things that are harmful. I said it was not all about do not, but there are some don'ts, and sadly with suicide we get stats like this, and I know this is a little bit old, but, there are fairly high profile suicides, especially among doctors in training in the last couple of years, which is just particularly sad. Female GPs commit suicide far less often than males, but they are proportionately way more than women in other professions. The risk is there for women as well and not to be ignored in our colleagues or in ourselves. It is a terrible thing for us to be good at again. We have got knowledge and we have got opportunity and we have got access and we have got resources. Unfortunately for doctor chooses to commit suicide for whatever terrible reason, they are going to be very good at being successful in that task. You will see lots and lots of lists of the stressors that GPs have, and they probably change over time and they have changed at different stages of career for each of you. You can take those ten and put them in any order you like, and they might change next week. If there is a really terrible meteor article, move it up from number ten. You might add some of your own. This slide is just to acknowledge that there are a lot of stressors, some of them are in our control, some are not. Some we can mitigate a little bit. We can reduce our litigation through great doctor patient communication. Another one of my favourite things we can try to say no to help with number two, but some of them there we are always going to have patients who are difficult to manage paperwork. You look back at medical journals in the 1890s and 1900. They were complaining about the paperwork and government interference then. Those things are not going away. I think the unrealistic community expectations have changed, certainly over the course of the careers of even myself and Chris. It is changed immensely in that time. Be mindful of the stressors, know that they are there. The goal then is what do we do about them? One thing about stress and this was my sister-in-law gave me this after a traumatic experience of her own. It is a fantastic way of remembering it. I find it really useful helping patients. The person in the middle who is having the biggest problem is allowed to dump outwards to any of the other circles. The close people, the further out people, the further out people, and each person as you go out can dump their problems outwards, but you cannot dump on the person closer to the action. If the terrible patient who is suffering a whole lot of pain is giving the partner grief, the partner can complain to you, but you cannot say to the partner, oh God, yeah, they drive me nuts too and you will drive me nuts. You are at me all the time and there is nothing I can do about it. We have to find a way to manage those stresses that we absorb, and the key is to move it out to someone, whether that is a colleague or your own counsellor, your own GP, and I have put down the bottom, though an important reminder this ring theory applies nicely to general public. It is very important for us, of course we have confidentiality. I cannot come home and tell my wife about this patient who is giving me a really difficult time when I am feeling terribly worried and sad. We have an extra barrier. We have to work a little bit harder to find where we can take those emotions that we are getting. Think about and I will come to support networks and things that you might have. So think about where can I take those things, and Michael Balint came up with this with the groups and things back after World War II about where GPs could go to talk about the challenges they faced. We do absorb a lot of suffering and it needs an outlet. We cannot hold it all in.
Now this is a very straightforward question, but I just need you to say it to yourselves. The best way is to look after yourself. If you cannot look after yourself and because we say I do it for my family, I will work harder. I will keep going. I will do this, I will do that, I will earn more money, I will make it all secure, I met plenty of old men who said they did everything for their family, but their family has nothing to do with them. Was it all for the family in the end but the other reason this always reminds me somewhere in my mid 30s, I had quite a good insurance policy and the kids were little and you had a mortgage and the kids were going to start school and all these things, and one day I woke up and I realised that at least in a financial sense, the very best thing I could do for my family was accidentally drop dead because they would have half the money and be set up for life, and would not that be good for them? Fortunately, I did not mean suicide, I just meant bad luck, heart disease, not in the family. My parents lived to their 90s, but, is it was interesting. I was fascinated that I thought that even for a little while, but the best thing I could do was hang around and be there and support them as best I could with all the mistakes of course, that I have made with family as we all do, me more than others maybe.
The next little task for yourself. Something to take home, can you answer these questions for yourself honestly? and again, no need to share it online. You are welcome to, but this is meant to be your own reflection. Thinking about me and my seven diseases I knew I had some problems. My GP helped me identify them. Really how healthy are you? What are the things that could be improved and how can you do it? Whose help do you need? Who do you need to see or who do you need to talk to, to make changes? or to check out the things that have been in the back of your mind that you have been ignoring or not making time for, and if you are not obviously unwell at the moment, we all have risk factors. What are your risk factors and are they being addressed? And are you having proper prevention and monitoring of those risk factors? What can you do about your risk factors? The second takeaway for tonight is think of one thing from there that you can do about your own current health assessment that might make a difference. We used to have this, I think it was not COVID, it was swine flu that suddenly changed, when people worried about spreading all the germs at work and suddenly it was okay to stay home instead of pushing on when you were sick. That was a useful change. Thank you Swine flu, but I still think it is a major doctor problem, and I mentioned certainly at the time I remember coming home and saying I was sick of it and everybody I treated today. It is kind of a weird madness, and I think the key word there is we minimise the consequences. We do not look at what is the downside of me working today, could I infect others? Could I be off longer? Could I actually run into a serious health problem that I am missing because it is early presentation? Soldiering on is not about today. It is about where is this taking me and what is it doing? If that is still you, then and I know that we do not have paid sick leave. We do not have other things, but still the principle is important. It is amazing. On those really rare days and only in recent years because I used to be like that, that I have rung up the practice 7.30 in the morning and said, I am really sick and I cannot come today. The receptionist, somebody amazing people and they say, it is okay, John, stay home, and they just ring everyone up and they rebook everyone and I have never got grief from them. It is really quite amazing what people will do if you allow them to help you. They are remarkable people.
This is the next thing and it is linked to that we often do not disclose to ourselves that there is something wrong or that we should be worried, and we have all the excuses in the world. It is human, perfectly human trait. We just seem to be particularly good at it. Again, I think we pretend that our knowledge protects us and that we can decide it is not an important symptom, and really, you want your own GP or someone else to help you decide that, not do it by yourself.
Here is a question for you to ponder again in the chat if you wish, but this is also about recognising distress or problems in colleagues, and for each of you, those colleagues could be someone else in town, another doctor you know, somewhere else, it could be someone in your practice, either junior or senior to you, the two things are how would you decide there might be a problem and what would you do about it? That depends on power differentials and relationship, but would you sit and do nothing? And if you do not know what to do, who would you ask? How would you get the ball in motion? I just want you to think that through because I think if you got the tap on the shoulder from a colleague, first of all, you might be embarrassed, you might want to deny, you might want to fight it, but ultimately it might plant a seed that says what maybe there is something, maybe I am grumpy that I used to be, maybe I am frustrated more than I ever was. Perhaps I should think about it. How can you tap someone on the shoulder and give that message, even knowing you might be brushed away, and if you think about what are the things you would look for in a colleague, can you commit to saying, I can look for that in myself and then admit it and talk to someone, whoever that someone might be? again, I would encourage that to be your own GP, but there might be other trusted colleagues or that might be the time to talk to your partner or someone else about how you are feeling or what is going and the stressors, the money pressure, the need to look after the community, keep the practice running, stop us doing those things. I would ask you to think about trying not to stop them. Here are some things to watch out for as if you do not already know them, but here they are. I do like the fourth one. Clear as crystal to me. What is wrong with everyone else? I think that is a sure warning sign, but for me it is a feeling I get sometimes, and number five is important. If your spouse is brave enough to tell you that they think you are not right and they keep telling you, then you have got to listen because they know you better and they will. They might be wrong, but you have still got to listen, and we again have all the excuses in the world and the ones near the bottom, concentration, emotional ability, grumpy, annoyed with staff in the way you should not be frustrated by patients who used to always be happy with all these things that can just creep in. You need to act on them or it will only get worse like those trends. Self-care is more than health. We need to be legally looking after ourselves. We need to have proper arrangements in our practices. We need to have proper medical defence. We need to have proper arrangements with our property and whatever else we have. Make sure that you have got all that lined up. I am no lawyer, but you should have people who you can go to for your legal problems and questions and you should have proper protection. It also involves financial security. Do you have financial advisers? Have you got proper systems set up? Have you got a good financial system in your practice and your family and your trust or whatever mechanism you use to manage your finances? If you do not, then you need someone, whether it is an accountant or a financial advisory, just like you need your own GP. Particularly early career people, what I was told a long time ago and it is true, doctors are very good at having a lot of money run through their fingers, but not much of it sticks. If you can make it stick a bit better, then you are better than I am. Some thoughts about prevention strategies and I like this I got this slide from someone else I wish I could remember who, but you can have a problem focused strategy where things are somewhat within your control. It is the way the practice is run, and I am the owner of the practice so I can get in there. What is the problem? How can I fix it and focus in on the problems and solutions, but if it is something out of your control like Medicare and government interference, then we have to focus on our own emotions? How is this affecting me? Why am I letting it affect me that way? What can I do to minimise the impact of that on me even though I cannot change the reality? So the focus will be different depending on our locus of control over the particular problem and the lifestyle balance. Self-awareness is hopefully you realise the theme of tonight, but relationships and leisure balanced into life. I do not think work life balance, I do not think work is against life, but it needs to be balanced with other things. In fact, work is a great joy in my life. Most days, not every day. Thinking about your own self-care and doing positive things. Managing your time, and if you do not now, you are the only one who can change that, and this notion of a personal philosophy, who am I? Why am I doing medicine? Why am I doing the work I do? What does it mean to me as a person? and then I think that gives you strength to tolerate things better and also to change things if you need to, because you can offload them. That is not part of my philosophy. It is not my philosophy to work to the bone. It is my philosophy to do a great job when I am with people. Coming up with that notion of who you really are is a really nice thought.
This is a little fun one. I will give you just a minute to have a read. We are nearly at Q&A time, so I will not give you long. I just want to ask you if you are a dog person or a cat person. The cat is hilarious, but I would like to be the dog, and this is a little bit about, I do not know if any of you know the fantastic book fish, which is a fictional story about fixing up a workplace, and the number one thing is choose your attitude, and seriously, if you walk in for the day thinking this is going to be a horrible day, look at that list of patients. It is all ghastly. I do not want to be here. Guess what sort of day you are going to have, and if you walk in and smile and say good morning to everybody and say it is going to be good, and you look at that list and you see the patients you want to see, you are going to have a better day. I can guarantee you that. So it is a choice, and people say to me sometimes, John, why are you all so happy and cheery and lively and things, and the answer is because I choose to be, even if I do not feel like it, and you know what, it is a bit contagious, and even if everyone else is grumpy, they are not grumpy back at me. They are nice to me and that is a good feeling that helps my day go better.
Boundaries. We have talked about. If you are the only doctor in your family, it is a challenge, and I think many of us have faced that, having the pressure of family members or medical staff in the hospital challenging you and then at the same time you say, no, I am only a son, I am only a daughter, but then you want to look at the fluid chart or the drug chart, and then sometimes you write there is an improvement that should be made. It is a dilemma and I cannot solve it for you, but just be aware of the boundary. Think about how you wind down at the end of a day whether it is a book, a hot bath, a nice meal, a chat with a partner, going for a run does not matter. The one thing I would say to you if part of your answer is alcohol then do something about it. Nothing wrong with drinking alcohol in moderation, but it should never drink it as a way of relieving stress. If that is part of your wind down after a big bad day, then really think about is there a better way? I mentioned support networks. Some of you have a support network. It will change. A doctor will leave, a friend will leave, someone else will come. When it changes, think about how it changes, but particularly think right now. Who can I add to my support network that will enrich it? Is it too small? Do I need more people as confidants and friends and colleagues and people in a treating capacity? Really think about who can I add.
A couple of final thoughts. These are all just different quotes from people. I particularly think that the last two are important. I think we underestimate the power of transference and countertransference and recognising that. We impact our patients, but they impact us and we need to recognise that particularly if we go home at night and they are still on our mind about how we are reacting, and you are worthwhile and you do amazing work, so keep that as well. A little tip and this is task number three for the night. Think of something that when you have just had a difficult time you can look at that will make you remind you of your personal philosophy or who you are or what you are really doing. A lot of people have a family photo on their desk. You might have a particular something that reminds you of something I was telling the group last week. Mine is socks. I like wearing interesting socks. Last week I had penguins on the first day and I had some nice charity socks on the next day and at Christmas time I have Christmas socks. It is just a nice way to ground me back to my humanity when I can. The problem is it is not so visible. I have to think about them and lift my trouser leg, but, think of something. If you do not already have something, it is hard in this modern era where we often hot desk in practices and you do not have your own room. Think about something small you can have there just to look at or think about when you have had a difficult time.
We have done this. There are three things really, a trend that you would like to reverse, something about your health you need to acknowledge, and something that you can use in your practice as a way to re-centre yourself. Second last quote, and the last quote love is always the answer. Just ask the Beatles. We will stop there, Jess, and we have got a little bit of time left for Q&A. I spoke a bit long, but it is not too bad. I just appreciate you all being here and just want you to take away something for yourself that will make a small difference because if it makes a difference in you, it will make a difference to your patients and your family and your community, and thanks for all the work you are doing in rural practice as well.
Jessica Ledwidge
Thank you John. I think some very important takeaways in that presentation that we all need to think about. We have not had any questions come through at this stage. There is still some time. Any thoughts you can put them in the chat box or use the Q&A box if you do have any questions. We have still got eight minutes for that. There we go.
Dr John Buckley
Excellent, and again I just want you to reflect. You can tell. I do not have answers, I have thoughts, I have my own responses, and I have my own flaws and failings to think about and acknowledge when I can. We do not need questions and answers, but if there are questions, I will give it a go. Otherwise, reflection and pondering is what I would love to see in here.
Jessica Ledwidge
Absolutely. I did love the cat and the dog perspectives up there.
Dr John Buckley
That is great. The cat is worth a read if you just want to sit silently for a bit. I hope you can see the whole thing. It is great.
Jessica Ledwidge
Judith has put a comment in the chat. Thoughts on the list which stated depression is an occupational hazard of GP.
Dr John Buckley
It is great, Judith, is not it, to think, how often do you say I feel flat flatter. You know that you are not caring as much today as you might the day before, AND you know what, all of that is okay for a day or two days. I think it is what you need to pick up is when it is gone on long enough that other people are telling you or it is gone on for a few days or a week or two weeks. Yeah, we get tired, we get jaded, we get overwhelmed, but it should not last. A colleague I worked with some time ago, what he noticed is that holidays and time away refreshed him for a much shorter time, so he would get back from a break and he would be jaded within a week or two instead of within three months, and I think it is that sustained thing. We all have hard days. We all have things when things inside or outside the practice or at home are not going well, and that is entirely normal, but if it is persistent or if it is enough for others to notice and brave it, people are brave when they tell you, particularly GPs to GPs. It is challenging and being irritable. I try really hard not to be irritable, but everybody knows what I am because I try so hard not to be. Mandatory reporting. What a fantastic question, Chris. Mandatory reporting is so misunderstood, but it absolutely is stopping people doing things. Chris, you come and see me and you are depressed, I do not have to report that. If you are depressed and we decide between us that your patients are at risk, I tell you to not practice for a while. If you keep practising, then I have to report you. If we decide your patients are not currently at risk and you are willing to have treatment and monitor and check in with me regularly, I do not have to report you. It is really misunderstood, and I am sure it is a barrier to care. It is a barrier to care for doctors in the Defence Force as well where the mental health is not allowed to be a problem. I would love to correct that somehow. Chris, as far as I know, there are only two absolutely mandatory reporting and for these you have to factually know it. One, practising under the influence of drugs or alcohol and two, sexual relationship with patients. Everything else depends on what the issue is, how well it can be ameliorated, and whether the person is appropriately cooperating with the relevant and appropriate treatment. That should be a treating doctors great care for a colleague, but it is also the great care to say, you know what, I do not think you should be practising at the moment and being able to say the hard things and trust the relationship will work. I hope that is an adequate answer, Chris, but I agree with you. It is a problem and I do not know how we get around it. It is very stressful.
Jessica Ledwidge
John, we have got a couple more questions that have come through the Q&A. The first one is do you have any tips for surviving and/or changing a poor workplace culture?
Dr John Buckley
Seriously, I would laugh, but seriously, get out. If you cannot easily change the culture, if you are not in a position of any power, get out. If you are in a position of power, start having conversations with people who will agree with you and champion you because if you are feeling it, probably others are as well. If you have a chance to have influence and power, get a few people on board and if they do not support you and they are surprising, then again, get out. Doctors, we are very employable. Maybe not where we want initially, but if you have no power, you just get out. I went to a fantastic talk by a psychiatrist and he talked about personality disorders and in those days psychopaths, and he said, if you ever find that you are working for a psychopath, leave because you cannot fix it. It is tough though, is not it? but yeah, change it, but you cannot change it on your own. You need a movement to make change and you might be the one to start that movement. Thanks, Jess.
Jessica Ledwidge
Thank you John. Next one. What are the pros and cons of locoming from a self care perspective?
Dr John Buckley
We should ask Judith unless the question is from her. It is the good and bad things. I do not know if you remember the movie Blazing Saddles, where that where Billy Crystal's and the guy says, what is your best day, and he talks about the day that he kicked his father out for abusing his mum. He said, what is your worst day, he said, same day, and I think the challenge of locoming and Judith will know much more about regularly is, you walk in and at the end of that time you walk out and you do not carry that other load with you and all that sort of stuff, which is great, but you walk into an environment over which you have very little control. You do not have the systems, you do not have any power, you do not have a say on how it works, and so it is all two-edged sword. I would think that the tip is to what I was saying at the very beginning, maximise the benefits, but, what is good about locoming is reasonable income, time off at the time of your choosing, only going back to places that you like because you are all really popular as locums and experiencing the freedom of walking out at the end of your stay. If you can do those things and realise them and be self-aware, then hopefully that balances some of the things that are hard, like travel or I really cannot go this time. I do not feel well that you have made a commitment and all that sort of stuff. I do not know if Judith wants to comment, but that would be my take on it, maximise the advantages.
Jessica Ledwidge
Two more. Are GPs lad self prescribe?
Dr John Buckley
Yes and no. We are allowed, but not everything. I do not know about every state but certainly recently in Queensland, self-prescribing and prescribing for family of certain drugs has become more limited, which is overall a very good thing. Unfortunately, people will nick things out of drug cupboards and out of doctor's bag supplies and all that sort of stuff. That is not self-prescribing, that is abuse, but we can self-prescribe and again, I would think we could all think of times in the old days, like I say with my white hair and Chris will know, doctors would go and get themselves out of the drug cupboard where you would have antibiotic samples and samples of Imodium and samples of pretty well anything, and use them. I mean, that is self-prescribing, but it is pretty weird. It is a bad idea, maybe for an acute presentation, if you are out rural and you are on your own, you have got an obvious infected sore on your toe and then yes, until you can see someone else, it is probably a good idea, but other than that, the problem is we have access. It is not a good idea. Having said that, my GP does say to me, hey John, if you run out of tablets between visits because we did not get it right, do you want to write your own script or do you want to contact me? so I think that is probably okay if I am having that monitored by someone else and it is not a new medication. So, overall bad idea, mostly you can do it and sometimes you cannot and avoid it if you are at all possibly can would be my tip.
Jessica Ledwidge
All right, one last question before we wrap up. Do you have any tips for working with psychopaths?
Dr John Buckley
I do not. Seriously, I have done a lot of stuff on doctor/patient communication and things over the years and all the ideas that are really helpful and effective. First of all, none of them work all the time, but almost none of them work with people with severely affected by drugs and alcohol or affected by significant personality disorders, borderline personality and psychopaths or whatever the proper term is now. There is no easy way to work with those people because they do not behave in a way that you can develop mutuality. Avoid trouble, do not get sucked in by when they are on their way up, cuddling up to you saying how great you are because they want to use you as their next sounding board. Pick who they are and avoid being sucked in and avoid the traps, and then probably get out or hope they get promoted. Terrible cynical is not it, but then it is just not easy. Everyone who is ever worked for me said that. I should tell you a quick joke if you got time for a joke, Jess. There is this highway and a main road and a dirt track all sitting at the bar after a hard day having a chat, and they are talking about how dusty and rainy it was and the dirt roads, and you think it is bad for you guys, I am all mud. It was a complete mess, and they said, the highways are water trucks and the traffic on me and the main road says, yeah, well, that is all right. You are built for it. I get potholes, it is a mess, and then having this big chat and then this little bit of bitumen comes in with a yellow line painted right down the middle, and the three guys go completely quiet. Will not say a word, and the other the other bloke with his bitumen and his yellow stripe, he orders a drink, has his drink and leaves and then they start chatting again. The barman comes over and said what happened? They said, oh mate, you do not want to do anything around him. He is a real psychopath. And Yuma is a good thing. It helps if the jokes are good. Anyway. Hey, Jess. Thanks for the invitation. Thanks so much the rural faculty for what you do for our rural practitioners and the 30 odd people joining tonight. You are amazing. Great general practitioners doing more than you deserve than you get credit for I mean, and I wish we could all give you the proper credit for just slogging it out every day, and the best thing you can do is look after yourselves a bit better, even if it is just so you can look after everyone else. Thanks, Jess.
Jessica Ledwidge
Thank you so much John, and thank you for a brilliant presentation. We have recorded it, so we will make it available to people that were not able to attend live and put it on demand so that more people can also hear it too. I appreciate your presentation and hope everyone has a great night. Thank you and goodbye.