June 28, 2005

the irony of this morning was that ambulances, police, and the fire department were called in to the clinic i worked at yesterday (fitzroy), but i was 'luckily' and 'safely' 30 minutes away in prison seeing patients with dr. jacka!

from what i heard later, 15 minutes after the fitzroy clinic opened today a 60 year old man (who's quite a regular and has been having trouble finding a place to live) staggered into the clinic bleeding profusely. it took a while to figure out what had happened, but it turned out he had made a large cut across his throat, cutting his jugular vein. he had been walking around the neighborhood in this state for a few minutes before finally coming to the clinic, where the doctors did everything they could to stabilize him. he had no pulses at the point, altho his heart kept beating, and the ambulance somehow arrived in time to get him to the hospital where they are able to bring him back to life.

as you can imagine, this was pretty traumatizing for everyone involved...the docs, the receptionists, the other patients in the waiting room. in fact, the clinic actually shut down temporarily from 4-5 this afternoon and the entire staff got together to 'debrief' and talk about how people were and could better cope with their feelings about the whole event in the next few days. i don't know that the staff found it very helpful (it seemed a bit forced at times as the leader kind of used a cue card to direct the meeting) but it seemed a good idea in general and i was impressed how quickly it got organized.

on a less dramatic note, i was over at the parkville youth residential center with dr. jacka this morning. this is for minors (girls and boys) that have done something bad enough enough times to get themselves sent to a detention center for potentially quite a few months. since they're almost all drug users, dr. jacka is a particularly good doc to meet with the people here to see how they're doing both physically and mentally while in the center...and to help make sure they'll be mentally ready to get going in the right direction when they go out. we definitely talked about drugs with the three girls we met with, but we also talked about contraception (he offered but was denied to put an implantable contraceptive in one girl's arm, a second girl already had it going). we also saw a girl with thyrotoxicity (hi T3/T4, lo TSH) who was suspected of having graves' disease, but more tests were needed to make a firm diagnosis.

an interesting thing i hadn't seen before was this programmable baby that could do all the basic things that real babies could do (cry, pee, poop). seems many of the girls in the detention center think it'd be great to be pregnant. so they give these girls this baby for a few days (programmed to be a usual needy baby) as a test run, in the hopes that the girls will be able to make a more informed decision about getting pregnant when they leave parkville.

i shadowed dr. paul maccartney in the afternoon. he is unbelieveably young looking, so we got to talking about how medical school works in australia. turns out that (at least traditionally) medicine is considered here like any other undergraduate major. so right out of high school, he started in on his md degree (making even our 7-year program at bu seem like a pretty slow track thru med school). the training is 3 years pre-clinical and then 3 years clinical followed by 2 more years to become a full-fledged general practitioner. 'residency' he says used to require 'crazy' hours but now they are capped at something like 40 - four-ty! i think i may come back here for residency. also, university/medical school has traditionally been free (aka government subsidized), which also sounds pretty good (altho this has been changing slightly in recent years).

regarding patients, we saw a young guy with saturday night palsy...it really does exist! sadly, i've long since forgotten my brachial plexus and median, radial, and ulnar nerves so i wasn't much use. good motivation to review a little anatomy tho.

other ozzie-isms:

hang out = crave
ta = normal good bye
how you going = normal ozzie greeting
cheers = seems like you can say this anytime you like, works for hi, thanks, bye, and much more...
mate = good for both men and women

oh, and it seems that australia does use a different model for treating heroin users than the us does (altho i have to say, in many ways my knowledge of doctoring in the us is so limited i often find it hard to know if the ozzie way of doing things is the same or different than the us way, so maybe i'm wrong about this). but in any case, the ozzie approach is that most any general practitioner is the point man for orchestrating treatment of heroin users. the gp and the patient work together to find a dosage of methadone (or sometimes bupenephrine) that works. this methadone is then daily dispensed to the patient at most any pharmacy around the country. so there is really no concept of a 'specialty methadone clinic'. from what little i know of this in the states, it sounds like this is a rather different way of handling things.

and last last note, based on numbers from a few years back, it seems that the gp:specialist ratio is something like 2:1 (also, for every gp there is 1 lawyer and a little more than 1 policeman). i forget exactly what that ratio is in the us (guess i've forgotten my eph too), but i think it's skewed the opposite way. also, there's 145 gps per 100,000 citizens or 1 gp per 700 folks, which i guess is a decent ratio. the problem they have in australia is apparently that 91% of the gps are found in urban areas and only 85% of the population is urban...so there's some concern about unequal distribution of gps.

enough for now.

...

I think the main difference between the US and Australian systems is just that you don't spend/waste/invest (depending on how you look at it! :) four years in an undergraduate degree. So for example, you would have gone to U Delaware and started on your MD degree straight out of high school at 18/19 years old...you wouldn't have gotten an 'extra' BA/BS degree in biology first. On the flip side, for someone like me who took a little time coming around to medicine, that might not be a good thing!

The medical school part is actually quicker in the US than in Australia...we do 4 years (2 pre-clinical years and 2 clinical years), but they do 6 years (3 pre-clinical years and 3 clinical years) before becoming MDs. After that, residency training seems to be more or less the same (they might do a year less than we do, I'll have to double check). And I'm pretty sure that specialties do more residency years than say GPs do, just like in the States...another good question to hunt down the answer to...

And for insurance, it seemed more complicated on the first day than it turned out to be. Basically every Australian citizen has "Medicare" which covers all their health visits. GPs are the 'gatekeepers', meaning you have to see your GP before getting referred out to a specialist. And basically, the insurance aspect of this is just that the patient signs the "Medicare form" at the end of the appointment (the medicare form says how long the visit was for), the clinic sends this form off to the medicare office in Canberra, and the clinic gets reimbursed $30 for the average GP visit the next day. It all runs very smoothly and I'm pretty envious ;)

There are catches tho...the big one is that GPs have been getting paid the same $30 for their basic visits for the past 10+ years, so their reimbursement hasn't kept pass with the times. Consequently, some private GPs now require that patients pay $20 in addition to the $30 that Medicare pays the GP. And so suddenly some Australians are having to pay for something they've never had to pay for before. And suddenly there is starting to be a market for private insurers that will pay the extra $20. So in many ways the Australian insurance system is moving towards a more American style system. Kinda bizarre, but I guess the conservative government here (ironically called the Liberal party, as opposed to the Labor party) is wanting insurance to move in this direction (cuz they want smaller government, less taxes etc etc. Taxes here, by the way, are like 45%!)

And then for methadone treatments, it works out that patients on methadone need to pay $30 per week for their 7 methadone doses. Not too bad, considering that 1g of heroin out here goes for $380 (and I just met a couple who were quite proud of 'cutting back' to 1/3 gram a day!) All in all, that's a huge savings!

All in all, Australia seems pretty progressive in how they treat heroin use. For ex, the clinic I'm at has a needle exchange program where users come in to exchange used needles for new ones (in the hopes that hep c, hiv, etc will be contained). This apparently happens in the US in some places but on the very down low...heck, people in the US get up in arms at providing condoms in public locations because they say it encourages sexual promiscuity. I can only imagine what they would say about providing needles to heroin users!