This morning on the way into work I remembered something Dr. Jacka talked about yesterday. Apparently, when heroin users have maxxed out on their heroin dose (the amount they can afford per day is no longer enough to give them the sensation they're after), they have been known to inject heroin with things like 'unisom' or 'temazapam'. These somehow heighten the effect of a given dose of heroin, yet also are extremely caustic to the veins they are injected into. In fact, over time the number of veins available for injection dwindle away (one fellow we saw was a case in point: all his veins were used up except his femoral, so that's what he went for now). Since there were plenty of alternatives to temazapam for normal use, the Australian government was successfully lobbied to remove this drug from pharmacies.

This morning I followed a nurse named Trish who does a lot of outreach work at local homeless shelters and the like. We started off visiting the room of a 70 year old former journalist. He was in another place for the week getting a gastroscopy (the "Cottage" which is run by sisters and is connected with St. Vincent's hospital). But while he was gone, somehow it had been arranged to have his 'home' room completely cleaned up. This was quite a good thing because his room was rather foul and smelly, and after the professional cleaning it was much better. In the process he also got a new bed as well a microwave, the idea being that he would be better able to local after his own diet with a microwave and better avoid getting sick.

We next headed over to a park where some people from the Fitzroy clinic (as well as others) were putting on a BBQ for some of the people in the neighborhood, many of whom were of Aboriginal descent. I found myself a bit disoriented and at a loss for words, not quite being sure how to strike up a conversation, so I mainly tried to hang out on the periphery and listen in on what was being said. Altho there were no didgeridoos or boomerangs on display, the omnipresent footy was out and about.

Here we picked up a man named Rob / Dooda who needed a ride an accompaniment to the private section of St. Vincent's for an x-ray of his mouth. It was pretty clear he was a little nervous (or more than a little drunk), but it went off smoothly enough.

We next headed over to a homeless shelter where I met a man named Stuart who was a Kangaroos fan (AFL team). We also met up with Ken who seemed to have a very serious problem because there seemed to be significant blood in his urine. He also had terribly deformed hands, altho this was not a concern at the moment. In any case, he was resistant to giving a uring sample or going to the hospital, and he instead walked off to get a beer. Trish wasn't happy about that, but they did at least agree for him to see Dr. Paul tomorrow.

We then headed over to the "Cottage" and met up with the man who's room had gotten the cleaning. He was apparently feeling better but still was due to get a gastroscopy in the next few days. We also met a guy named Chris who was 10 days sober and in need of a little transport around town for some errands, which Trish provided. In the meantime, he did his "American" accent impression and Trish claimed that Australians had no accent. Funny how no one, including Americans of course, think they do. Interestingly, Trish finds the British accent much more offensive than the American accent.

My morning was more or less done now, and I switched over to working with Paul at Fitzroy. We got to speaking about a part of Australian history known as the "stolen generation". Apparently from about 1900 to the 1960s, the Australian government came up with an interesting scheme to assimilate the indigenous Aboriginal people into Australian society. What they did was steal children away from Aboriginal parents and culturally 're-program' them as white Australians. Quite a story. Now, in a sense of retribution, it seems that Australia bends over backwards never to take kids away from Aboriginal parents, altho this too has supposedly gone too far. Parents who have used and abused multiple chances to do right by their kids often are left to keep their kids even when they are clearly being destructive to the kids.

Also heard of the 'doctor shopping' phenomenon. For higher class folks, the government subsidizes drugs (especially the newest and most expensive) so that they cost Australians $26. For lower class folks, the government subsidy gets the price down to $4.50 or so. So what some enterprising people do, is see as many as 3 doctors a day collecting prescriptions for drugs (for a mere $4.50 a pop) that have significant street value. Apparently the government does alert GPs about this, but it takes time. Today for instance, the government had warned the clinic that a particular patient had seen 6 different GPs in the last 2 months and collected benzos from each. A note in the chart from Dr. Jacka from the patient's last visit was quite stern, saying that an ultimatum had been given that the patient had to identify these 6 GPs and why he was seeing them or we would stop prescribing for him. Paul saw the patient today and reiterated the message, altho the patient denied both having seen 6 GPs and getting benzos. Guess it will be an ongoing battle.

Interesting side story is that the government gets significant bargaining power over drug companies by keeping a list of drugs it will subsidize (and that GPs are therefore likely to prescribe). The government gets significant say in dictating to drug companies how much it will pay for a given drug. There are worries however that a new free trade agreement between the US and Australia will undercut this tho, as drug companies might call this government bargaining power a restriction on free trade.

Interestingly this also explains why the government hasn't put drugs like viagra on the official drug list. From the government's perspective, this doesn't address a significant health concern and therefore subsidizing would not be in the government's interest (or the public health interest). All subsidizing it would do would be to create a huge deficit for the government (it'd be stuck holding the bill for a drug of dubious public health value).

Heard that Eric Bana, the guy who played the Hulk, is an Australian. He was also in Black Hawk Down, and he also played the role of "Chopper" who is apparently a legendary figure in the Melbourne underground. Did all kinds of illegal stuff, did some time in jail, and now goes about writing books and giving speeches (for which he's highly paid) to people around Victoria! This story came up in the context of a patient who was so notorious for getting into fights that the Melbourne police basically invented a special code so that they would know it was this particular person that they were about to run into! Apparently he was a body guard in the seedy underworld of Melbourne, altho when we saw him today he was looking much mellower than such a job title would lead you to expect. Apparently Epilim was helping with his potential bipolar disorder.

Discussed how many people coming of drugs and alcohol have the desire to become a drug/alcohol counselor and whether this was such a good idea. Paul really leans heavily to no, and I guess I agree, altho I'm sure having been there gives you some perspective that a doctor might not have. Paul would agree, but thinks it takes years upon years to get that kind of insight and that most people never get there.

In other chats with Paul, I cleared up the educational path to becoming a GP:

6 years medical school
1-2 years internship
3 years GP training

So in the end you are looking at about 10-11 years, which is actually more than an FP would do in the states. On the other hand, here is how it breaks down for a neurosurgeon:

6 years medical school
1 year internships
3-4 years general surgery
Up to 4-5 years of neurosurgery

So now you're talking about 14-15 years, which I believe is similar in the States.

Also talked about how one gets into medical school...apparently in the 12th grade, the last grade of high school, you take a test that's standardized in your state (eg Victoria) that covers the courses you took in your 12th year. Based on your score on this test (out of 410 points), you are able to go to medical school. When he did it, it was all based on your score (above 365 for example and you went to med school if you chose). Now, the top top scores still get in automatically, but they do interview people more in the middle of the pack.

Apparently out of 140 students in his med school class at Monash, all but maybe 10 went to private school growing up. Paul went to a public school himself, but one which had an entrance exam (so his classmates were of above average intellect). He doubts whether he would have made it into medical school had he gone to a strict public school since he thinks the 'bar' there is set much lower than at a 'magnet' public school or private school. On the other hand, his wife made into a competitive field from public school and thinks it can be done. It will be interesting to see what their kids do...as Paul says, do really want to sacrifice your kids' futures for your own philosophy about schooling. No easy question to answer.

Some Aussie-isms:

-"Good on ya"

-"Dob" = Squeal or tattle

-John Saffran is apparently a funny Australian of the ilk of Ali G, Raphael Mezrahi, and maybe Michael Moore. Should check some of his stuff out...

The tram police came knocking this morning on my way into work...apparently they are cracking down on bludgers (there's a big ad campaign on tv for example). And luckily I did have my tram card punched appropriately...otherwise it would have been a $150 fine!