I started week two in Collingwood with Barbara again. One of the more interesting patients we saw was a refugee from Syria who had been in Australia for the past 5 years and had his permanency. Amazingly, he had been able to learn to speak English in just 7 months and so well that I could hardly tell he wasn't a native speaker (heck, he did even did a much better Australian accent than I can do!). Strangely enough, he said that he had learned to speak English from the drug dealers that hang out outside the Collingwood clinic..so I guess they're good for something!

He also had a pretty severe congenital disorder of his vision, altho again he compensated for it so well that I didn't even notice for the first few minutes of the interview. Got me thinking about how much more important the tone of your voice was in conveying information for a patient like this (showing sympathy with your face wouldn't come through).

Sympathy was especially called because I later learned that his brother and father had been killed in Syria before he fled (leaving his mother behind in Syria). When anniversaries of their deaths came up, he would become very depressed. And interestingly, he said that the worst depression seemed to be triggered during these periods when he got good news (we didn't really go anywhere with this idea tho). Most recently he had developed a severe head ache on the left side of his face (an 11/10 on the pain scale he said). He also was feeling somewhat numb in the left side of his face. Barbara thought this was most consistent with a migraine, but wanted to send him on to another GP that specialized in refugees (Tim Lightfoot).

Barbara also told an interesting story about a GP out in a small Australian town who was keen on doing microsurgery that she wasn't particularly trained to do. She was especially keen (at least in her own opinion) at identifying tubal problems in women as well as ectopic pregnancies and using her suspect microsurgery skills to fix these things. Apparently, compared to most other GPs in the area, this GP identified many more ectopic pregnancies in her patients than other GPs. A cautionary tale of sorts.

Also saw a patient with osteomas in her ears, a relatively common thing (or at least benign) that can happen when the ears are exposed to cold water for a period. In each ear you could see two bony protruberances that partially hid the tympanic membrane. I guess they don't cause any problem except for obstructing view of the tympanic membrane.

In the afternoon I teamed up with Dr. Jacka again at Fitzroy. Learned a little bit about psoriasis by way of one patient. Apparently it's what happens when the skin cells (for unknown reasons) start to divide up to 20x faster than normal. Scaley skin overlying red areas results. Tar based products are apparently used frequently here to treat it.

Dr. Jacka also identified one patient of ours as having "Narcissistic Personality Disorder". We looked up the DSM-IV criteria for it to confirm the diagnosis. Really, based on what I saw today it wouldn't have had any inkling about this. But I guess one clue was that, altho he had a heroin problem, he considered himself to be unique among heroin users - everyone else in his eyes was a dirty junky. He, on the other hand, was a good person who had simply been entrapped by heroin. In the same way, he saw nothing wrong with his having a girl friend, exploiting her for things like her car, and having affairs on the side. He also apparently never tuned into other people's thoughts or feelings (lack of insight into others I suppose you could say), talking about nothing but himself ad noseum and not realizing that other people might be busy or have interest of talking of something else.

Mixed into the afternoon was a homeless man who had come in to be seen by one of the nurses (Lisa). Lisa came in to get some advice from Dr. Jacka, and we both ended up going with Lisa to examine the patient. He was even at that moment quite intoxicated (according to him he'd only had 2 beers on Saturday), and he had apparently slipped in such a way that he did the splits and his pelvis came crashing against something hard. Dr. Jacka's examination of the man made him think that it was a tear of some ligaments in the pelvic region, but a couple things made him wonder if it might be something more serious like a tear of the urethra. For one, he was an older gentleman, and I guess the urethral tear is more common the older you get. Second, the patient kept saying that his urine was the color of a piece of paper in the examination room, and that piece of paper was quite unambiguously red. Thirdly, the patient was just in a lot of pain.

The reported redness of the urine convinced Dr. Jacka that the patient needed to go to St. Vincent's hospital, something which the patient resisted quite strongly (he said the doctors there treated homeless people poorly). Dr. Jacka also suggested something called the Cottage, a step-down unit affilliated with St. Vincent's where homeless people could spend a week regaining their strength (but the patient didn't like this idea either because he said that you weren't allowed to leave for the 7 days you were there...why he would want to leave was arguable since his current home was a sleeping bag in a set of grandstands not far from the clinic).

In any case, Dr. Jacka went back to his office and made call, the result of which was that if we got the patient to the hospital soon he would be able to get a urethrogram the same day. The trick now came to convincing the patient to go the hospital, which eventually he agreed to do. Lisa, the patient, and I hopped in a clinic car and brought the patient over to the Emergency room of St. Vincent's where we passed him off to a triage nurse.

As a final note, the urethrogram results actually came back later that day saying that it was normal and that the patient had been released. As Dr. Jacka said, it was all a rather neat and tidy finish from the hopsital's perspective, whereas more effort would have been taken at the clinic to make sure that there would be some follow-up for this patient and more effort expended on getting him into some sort of shelter.

Also saw my first baby today, the 3 month baby of two former and current heroin users. She had a nasty wheeze, and cigarette smoke was identified (which both parents contributed to) as a likely culprit. The parents were concerned that DHS might take the baby away from them. Apparently, DHS is not so concerned about their drug use as whether they are taking good care of the baby and providing a good argument-free environment for it to grow up. I agreed with Dr. Jacka's assessment that the baby was being well taken of, but the parents weren't taking care of themselve (not getting enough sleep for example). That was possibly setting them up for problems, because the least additional stress could prove to be the straw that broke the camel's back. "No spare capacity" was the way Dr. Jacka put it.

More discussions of insurance with Dr. Jacka...picture slowly becoming clearer. Keep point absorbed today is that no matter whether you have the national or the private insurance, you can find yourself responsible for covering a portion of the health bills because doctors often charge more than what either type of insurance is willing to pay. You have to 'know who to ask' to find doctors (in whatever specialty) that will do the favor of 'bulk billing', i.e. not requiring more than what the government is willing to pay for a given service.

Also interesting discussions about how private insurance is doing its best to lure the under-30 crowd to purchase private insurance with incentive like massively reduced premiums (like 40%). All sounds very familiar to the story of how private insurance got started in the States.

Really interesting coincidence to wind up the day. I'm going to be at an outreach BBQ for Aboriginal people, and I asked about whether they had medicine men and a cultural interpretation of disease...these kind of ideas being fresh in my mind from reading our book. Then mentioned the book itself and the H'mong and their beliefs, and Dr. Jacka noted that there is a considerable H'mong population in Melbourne. Moreover, Dr. Jacka jumped up and we walked out into the waiting room where on the wall was a tapestry made by a H'mong woman detailing there escape from Laos and Thailand: on it was depicted military men with guns and bullets, busses used by immigration officials, and many other symbols of the journey. Quite amazing. Dr. Jacka is looking into getting me a meeting with some of the H'mong in the community, which would be interesting to say the least...let me know if you have any questions you might have for a H'mong clansman!

Some other clinical notes:

-I've seen a lot of the doctors here drawing pictures for their patients. Everything from vertebral columns to how to pile pillows for best neck support. Pretty effective approach.

-Also seen doctors take a note back from a specialist and read/translate it for a patient line by line.

-Dr. Jacka is always on google looking up notes on diseases and printing out information he finds for patients. He's a particular fan of http://www.dermnetnz.org/ for dermatology pictures and info. (Might come in handy next semester! Speaking of which, seems micro is already queued up in courseinfo :(

-One of the doctors here considers "pediatrics" and "general internal medicine" to be specialists by Australian standards. Not at all the case in the States.

Ozzie-isms and other notes:

"Knock me over with a feather"

Breaky or Brekky = Breakfast
Kellogg's "Saltana Bran" = "Raisin Bran"
grouse = super
whinger = complainer
bludger = free-loader

Australia has its own version of 60 minutes and Dateline...
...As well as its own completely inane version of Big Brother...which is hugely popular. It's on every night, sometimes several times in various forms: Big Brother, Big Brother Uncut, Big Brother Up At Night, and on and on...

Many to most restaurants have a BYO policy on alcohol...they don't have a license to sell liquor, so you're encouraged to bring your own into the restaurant to drink with their meal.

Souvlaki = Greek version of a Kebab

Melbourne has the largest Greek population outside of Greece

Vegimite is pretty popular here. As the story goes, beer makers had extra yeast and they turned it into the product "vegimite". Most American tongues find it rather disgusting tho!