Doctors, Magicians and Unicorns

 

 

The patient looks at me, desperate – “but what do you think it is Preeya?” Honestly, I have no idea – which is not what I say out loud to the patient who is getting increasingly anxious about the abdominal pain she has had for 3 days. “I know it’s nothing nasty – your appetite is normal, you don’t have a fever, your tummy is soft on examination and you’re still able to attend work and the gym despite the pain – so I think we should catch up in 72 hours and see how you’re going. If anything changes you come sooner.” She stares back at me – “OK, but what’s causing the pain?”

 

The truth is that we don’t always have the answer. Despite how the community often perceives us (or how we project ourselves) doctors are not magicians. When I tell my patients “honestly, I don’t know” or “I can’t answer that” I’m often faced with a shocked expression – “but you’re meant to know everything” a patient once said to me. Medicine is grey, very very grey (certainly more than 50 shades) a lot of the time. Perhaps not all of my colleagues will openly share this– but we don’t always have a single diagnosis for your tummy ache/headache/fatigue, we don’t always know what’s going on in the human body. As a GP in particular, we often rationalise your symptoms; we know common things occur commonly, we know there are certain life-threatening diagnoses like meningitis or an ectopic pregnancy that we cannot miss – but we can’t always tell you with 100% certainty what is causing your niggling symptom. Time or what we call “watching and waiting” in GP land (as it is known) fixes these non-specific symptoms you have; we may never know exactly what caused your ache or niggle but it settles on its own simply with time.

 

A decade ago my patients would have referred to me as “Doctor Alexander”, now it’s “Preeya” most of the time (some of my older patients still insistent on the “Doctor” part), and I have to say I much prefer the more casual relationship with my patients. Back in the day, the therapeutic relationship was paternalistic – the doctor would tell the patient what to do, how to treat their headache or back pain and there was no involvement of the patient in the management plan. Now however, I work hard to give my patients options, empower them with knowledge and resources so that they can make their own informed decision about their treatments. Despite the casual (first name basis) relationship many now have with their family doctor, I think there is still a perception that we are Gods, magicians or some other magical creature – personally, I would prefer Unicorn. Despite calling me “Preeya” and plenty of lively banter and laughs in our consult, my patient often still expects me to have all the answers and they’re often disappointed when I don’t.

 

My husband, a nearly qualified plastic surgeon, will often have to explain his patients (and our friends at BBQs) that just because a plastic surgeon does a procedure does not mean there will be no scar after a surgery. If you put your hand in a mincer/juicer/lawn mower (all things he Will has had to operate on in his time) you will most likely have some form of scar. Some patients will comment “but a plastic surgeon did it and I have this scar” – I’m often having to explain that the “scar” they have is a pretty good result given the procedure they’ve had but a scar (in most cases) is the norm; it’s the size and nature of the scar that we have some control over and why we might involve a plastic surgeon in the first place. No scar at all usually isn’t feasible – we are doctors, not magicians after all.

 

When you ask me “what would you do Preeya?” sometimes it’s easy to answer, “well my child has had the full meningococcal B vaccination course so you can see where I stand on that one” but when you ask me if you should leave your husband who repeatedly pushes you against a wall in front of your child or chips away at you verbally telling you how useless you are day in and day out – I can’t tell you what I would do when you ask. It’s not ethical – I risk making you feel further alienated and judged; your sister/mother/brother/colleague/neighbour have already told you (usually a hundred times) to leave him; adding to the chorus just makes you feel further isolated. Generally, a doctor can’t ever answer that question (and we are trained not to); it’s our job to provide counsel, support, options, resources – not give our opinion. So, whilst you look at me like I have no idea when I say “I can’t answer that one for you” it isn’t because I don’t have an opinion, it’s because I shouldn’t.

 

Recently a friend of mine, also a GP, suggested I explained that when we say “I’ll just look up the guidelines” or “I’m going to check the dose of that,” we are not “googling”. I’ve heard from multiple patients and family members that a doctor started “googling” in front of them; they’re completely shocked as if the roof on the doctor’s office had blown off and Dorothy (with Toto) had flown straight over with her ruby red slippers mid-consult. On behalf of my profession, let me be honest – we cannot possibly remember every dose of every drug, every management regime, every set of blood tests that should be ordered when we suspect someone has lupus. We often look at guidelines – not google- reputable medical bodies that exist to help doctors navigate the abyss of ever changing medical information. Sure, there’s probably the odd doctor who really does “google” but I can tell you most of us don’t. When I say “I’m going to see what antibiotic we should use here given you’re allergic to penicillin” or “we need to exclude you don’t have an underlying cause to your high blood pressure – let me check which tests we need to do for someone in your age group” I’m not asking Larry and Sergey (they founded Google – I had to Google to find that out), I’m consulting my medical search engines.

 

And on that note, whilst we are discussing Google, please know that I have done years (and years!) of study to sit in my office with my plaque outside my door. I’ve done 6 years of medical school and sat gruelling exams, survived (barely) an internship filled with night shifts and tumultuous evenings in the emergency department. I’ve spent nearly 2 years of my life doing a different speciality training before I made the decision to become a GP; it took an additional 2 years (and another patch of written and clinical exams) to get fully qualified. So, when you say to me, “but Google suggested I have a brain tumour” please know that my years of study, the heart beating in my chest make me a sounder medical practitioner than your laptop. I may not have all the answers, I will admit to that, but I promise I can go a better job than Google at diagnosing your headache.

 

Despite the perception that I should have all the answers, all the time – I don’t, none of us do, and if we, the medical profession, tell you we do – we are lying. The beautiful thing about general practice (but also the reason why many of us burn out or develop a mental health disorder) is the uncertainty – we cover the entirety of medicine – asthma, diabetes, children, elderly, vaccinations, cancer screening and diagnosis, headaches, back aches, psoriasis and acne; we do it all. No doctor, GP or otherwise, can know the answer all the time. That uncertainty of medicine can be beautiful, but sometimes it can be very anxiety provoking. As the patient walks out your door you desperately rack your brain wondering if you missed something and that same patient pops into your mind as your head hits the pillow; you say a silent prayer, even if you don’t have anyone to pray to, that you haven’t missed anything major. It has taken me years in a relatively short career to realise that not knowing everything all the time is OK. I’m very honest with my patients who most of the time are grateful for it.

 

So, please know we are not magicians. We are doctors who rely on guidelines and, sometimes, the power of time to heal odd niggles that we will never be able to diagnose. We don’t have all the answers all the time. We do grapple with uncertainty every day in our job. And we do leave scars. That’s the truth.

 

 

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The Mental Health of Sport

 

As Australia imploded when news of the ball tampering saga reached our shores I felt all the sadness, outrage and shock along with my fellow cricket enthusiasts. I watched the story unfold and grew increasingly concerned by the aggressive nature in which people were attacking their fallen heroes. I watched on social media as people labelled Steve Smith a “cheating w–ka” and ruthlessly tore into his partner and family. I cringed seeing the comments on Candice Warner’s social media calling her an “attention seeking materialistic cheater’s wife.” Despite all the open discussions in schools, workplaces and the media about bullying, everywhere I looked there were people clearly crossing the line to make deliberately hurtful and negative comments about another individual. As a GP, a health professional who deals with the consequences of bullying nearly every day in my clinic, I watched with sheer horror.

 

For me, one of the interesting aspects about the ball tampering saga was the subsequent discussion that flowed about the culture within the Australian cricket team and their antics on field – suddenly the sledging and, let’s be honest, bullying on field was being openly discussed. The footage of the former Australian captain Michael Clarke telling Jimmy Anderson to “get ready for a broken f—ing arm” was replayed again and again– overt bullying had somehow pervaded the “gentleman’s game” and now we were talking about it. And cricket was not alone – AFL, NRL, other codes were succumbing too.

 

I’ve intentionally delayed the release of this piece until the (saw) dust had settled from the ‘sandpaper saga’, because I wanted to talk about the much bigger issues that arise from such a horrific incident. Yes, the ball tampering is bad, but the bullying and lack of awareness for a fellow human’s mental wellbeing is worse.

 

As a GP I frequently encounter patients who are dealing with bullying in some capacity. It’s not just the school children you might be envisioning; of course, I see the 13-year-old girl who is picked on because she is “too hairy” and the 16-year-old boy whose friends suspect he might be gay so he is berated in the locker room when other boys are changing. But I also see the 42-year-old woman who is at breaking point, now afraid to leave the home and battling significant depression because of persistent subtle and targeted bullying at work. I’ve also treated the secretary who was deliberately excluded from social events, a clear message from her colleagues she wasn’t wanted – she eventually left after unsuccessfully trying to lodge a Work Safe claim for the damage done to her mental health by a workplace drenched in bullying. Bullying comes in all shapes and sizes and to me, a GP, bullying in sport is no different. We have seen bullying from spectators towards competitors (just remember the horrific racial slurs against Adam Goodes) and we’ve seen people bullied on various sporting fields across the country – from the MCG to the local footy field. At what point did we deem that “sledging” was acceptable? At what point did bullying become part of any game?

 

I frequently talk to adolescents alone as a GP; often their parents willingly leave the room when I ask so that someone else can have a crack at finding out what’s going on with their increasingly withdrawn and flat teenager. Adolescents often open up much more to a GP without their parent there. I always ask about school – do they enjoy it, have they got friends, do they play sport? I cannot tell you the number of times they disclose that are being picked on for some reason – be it their skin colour, sexuality, their parents jobs or their choice in clothing. My job is to provide support, involve adults (parents, the school) if physical or mental wellbeing is at risk. My doctor brain works on how we can prevent deterioration of mental health in an individual and keep them safe from ongoing emotional or physical harm, but, my soul is crippled by their pain, at knowing how much they dread going to school, leaving the safety of their parent’s car or the bus.

 

We know children who are bullied are more likely to experience anxiety and depression – so why are adults any different? Why do we assume that because a person has large biceps, countless bruises and a strapped shoulder that he or she is able to withstand persistent bullying on a sporting field? And, how can we expect our children to know what is acceptable and what isn’t if their sporting heroes reflect that bullying, sledging, putting down your opponent verbally is the norm?

 

We know that sportspeople are often reluctant to openly seek help for or discuss mental health issues – the rolled ankle, sore knee, torn hamstring will always take precedent. When Buddy Franklin took time off for mental health issues everyone watched shocked that an in-form player was sitting out the crucial stages of Sydney’s finals campaign. The truth is that mental health is potentially harder to recover from, harder to recognise and deal with than a knee reconstruction. I thought it was wonderful Buddy openly discussed his mental health issues and need to take time off football, but by the same token, the media storm that followed his openness further perpetuated the stigma that many males battling mental illness already struggle with. “A man admitting to mental health issues is a big deal, I can’t tell anyone” a young male patient recently told me as I suggested he was significantly depressed and should share this with someone to increase his support network; the Buddy attention highlighted that.  As a GP I agree that we need to talk about mental health more openly, but when it gets sensationalised it only emphasises the stigma in some ways. And on the note of mental health, as I watched the press conferences of the 3 players embroiled in the ball tampering saga I felt for them – yes, they had done the wrong thing, but was someone monitoring their mental wellbeing with all the negative media attention and overt bullying being directed their way?

 

Some argue that sledging is harmless and part of the game. Personally, I disagree. If someone were to come up to me at a cocktail party and comment on my race, husband, child or that I was “weak as piss” – I would most likely cry, loudly. To say that sledging is acceptable on any field is unacceptable.

 

I ask you to sit in my chair for one day – see the broken people who walk through my door; successful, well dressed, functioning people who will disclose how hurt they are by someone else’s careless words. I ask you to see with your own eyes the pervasive bullying that happens in countless workplaces across our country and the damage it really does to people’s mental health.

 

Bullying is bullying. Let us not blur lines accepting that some sledges are OK, but some go too far. We shouldn’t need to attack another human to win a sporting competition. We shouldn’t need to deliberately hurt a fellow human to help our team succeed. If you’re good enough, you’ll win anyway.

 

To put it simply, my soul would ache if my daughter was ever called names, put down for her sporting abilities or targeted for her choice in partner or sexuality. It would hurt me if it happened to her at school, on a playground, at work or on a footy field. We are all human, we are all vulnerable – bulging biceps, a 6 pack, a gold medal doesn’t change that.

 

Bullying is bullying – and I say no way.

 

 

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The Delicacies of Discussing Fertility

 

Asking any couple when they will have a baby is the equivalent to opening Pandora’s box whilst naked with no protective eye wear on – it’s a total no go zone, and extremely dangerous. There is a possibility the couple have been trying for 2 years and are currently saving their pennies for their first round of IVF. There is also a chance they don’t want children and no one should have to justify their personal choices. Years ago, a friend said to me “you and Will should have kids”– little did he know we were 3 weeks post miscarriage and I was still suffering physically; my tears as we walked into the wedding marquee were the reason you don’t ever broach the subject. What I’ve learnt about fertility and trying to conceive is that anxiety levels heighten very, very quickly. I’ve also witnessed the subtle fertility competition that exists; the “trying to conceive” race amongst friends and colleagues– the “we got pregnant without trying” people versus those who have to try a little bit harder. My word of advice – don’t ask about kids, when someone will have kids, when they will “try,” unless they start the conversation – just don’t.

 

When Will and I decided we were ready to start adding to our family I saw my GP, had my blood work done and got told to “give it a crack”. I remember the day I stopped taking the pill – it was a momentous occasion; suddenly we were saying we were ready to take this thing to the next level (little did we really know what the next level really was by the way!).

 

The minute we stopped contraception we wanted to be pregnant. Not tomorrow, not next cycle – today. For years I had been compliant with the pill, freaking out constantly that I was pregnant if I felt a strange niggle or was a day late. I had spent years avoiding, like the plague, the one thing I now desperately desired. To this day I think it’s interesting that we spend years avoiding something then desperately want it; a switch very suddenly flicks! I spend years helping women with contraception as a GP, finding the right option to prevent pregnancy and then suddenly we throw it in the bin, hoping she conceives instantly. Of course, nothing happened the first cycle for us; my poor mother listened as I questioned my ability to conceive. I found myself uttering words like “I’ve never been able to envision myself pregnant, maybe that’s a sign” and “I always knew something would be wrong with me.” My mother gently pointed out that in her day no one worried – people just cracked on. What mum didn’t realise is that everywhere I went I was forced to question my fertility. After 2 months of “trying” I recall driving to work when an IVF centre played their advertisement on the radio, “have you had trouble conceiving? Has it been 3 months?” I felt like the woman was talking directly to me, were they targeting me? And were we having “trouble”? Like a lot of times in my life, my GP hat blew up on my head and ruminating Preeya shone through. The truth was nothing was wrong with me at all – but all the advertising was excellent fodder for my wound-up mind to feed on! I know I am not alone here – patients often come in seeking reassurance after hearing people’s stories of conceiving easily or these same radio ads. Back in the day I’m sure there wasn’t the pressure to be fertile and conceive quickly – people just persisted. Now though every tabloid cover highlights somebody’s fertility issues or struggles with IVF and the radio constantly tells us trying for 3 months is too long – it’s no wonder lots of women start to get anxious before they even attempt to conceive.

 

When you’re desperate to get pregnant you see pregnant women everywhere. When I went to the supermarket it was a pregnant woman who got my park, when I was busting for the toilet at an event it was a pregnant woman who took longer in the cubicle, when I walked down the main street all I saw was prams and babies taking over my footpath. “Did they know how lucky they were?” I kept asking myself. I distinctly recall a patient who came to see me asking for a termination of pregnancy when we were “trying” (FYI I have never had an issue with treating these women as a GP because I am very much of the view a woman has a right to choose on these matters). Suddenly though I was slightly jealous – she didn’t want a baby (and that was her choice) but I was desperate for one; why was the universe torturing me like this?

 

Women (and men) can get very, very anxious about fertility. It is not unusual for a woman in her 20s or 30s to ask me if she should have special fertility testing done because she is keen to get pregnant soon. For most heterosexual couples it’s crack on and see how you go – 92% of couples will conceive within 12 months and 98% within 2 years. There are some women however, we refer early for fertility assistance (this doesn’t always mean IVF, there are lots of other options). This includes women with a history of polycystic ovarian syndrome and irregular cycles, women who have unusual pelvic anatomy, or who have had previous surgery on their pelvis and women who have had recurrent miscarriages. We also refer women over 35 earlier for input from a fertility specialist because we know that the earlier we intervene the more chance there is of a successful pregnancy. For older women we also consider doing a blood test that looks at the ovarian reserve; the test is called anti- Mullerian hormone (AMH). We don’t do this test for everyone and it does incur an out of pocket cost, but for those women who might be older and are concerned about whether or not they have eggs left this test can help plan.

 

With my GP hat on, and for a very practical moment, if you are planning a pregnancy the first step is seeing your GP for blood work to check things like your immunity to rubella and to talk about potential extra testing prior to conceiving (there are now genetic carrier screening tests available for conditions like cystic fibrosis you can do). If you get the green light to “try” then sex every second day in the week before ovulation increases chances of conceiving (days 7 to 14 for women with a 28-day cycle). The husband who says sex 4 times a day is the only way to get pregnant is lying, trust me! I end up telling my patients to relax and not let sex become a chore. When you decide to start a family, suddenly sex isn’t just sex anymore – it has a purpose and lots of couples start to find that very stressful understandably. If after 6 to 12 months (depending on age and other factors) things haven’t been successful then is the time to speak to a fertility specialist and talk through the options, of which there are many!

 

In our case, after 3 months we did get pregnant but sadly, it ended in a miscarriage. Just as we were emotionally recovering in Greece, lazing on beaches, trying every potential gyros combination known to man and contemplating life, Miss S decided to make her entrance. Despite all the insight I now have, if we ever decide to have a second child I can’t say that I won’t get equally stressed and catastrophise!

 

We all have different journeys when it comes to fertility; there is no “right way” when it comes to starting a family. For same sex couples the journey can be even more complex looking for potential donors or surrogates. At the end of the day, if we choose to have children we just want to share the love we already have with another soul– it doesn’t matter how we get there, or how long it takes, and it certainly isn’t a competition.

 

 

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Dear Motherhood

 

 

Dear Motherhood,

 

I have held back from this conversation for fear of being judged, of being deemed ungrateful or whinging. I suspect a lot my comrades feel similarly to me but are reluctant to tell you how it really is. What I now know about you, nearly 2 years on, is that you are a tricky beast and every woman has a unique relationship with you.

 

I find you difficult a lot of the time. For a type A, controlling, perfectionist personality you can be a struggle. Before becoming a mother, I was used to writing lists of jobs (and crossing them off gave me the greatest satisfaction), working my butt off and reaping the rewards. I was used to “Preeya – great job” or a medal if I excelled at something. I was used to being in control.

 

Then you came along – and you brought the wonderful Miss S with you. The first 8 weeks were fairly horrific I have to say – I was sleep deprived, trying to master breast feeding and dealing with intrusive ruminating flashbacks after an unexpected emergency C section. I was suddenly at home with a new born, an unwanted scar (and its associated pain) and a truckload of emotional baggage. Whilst breast feeding was fairly easy for Miss S and I, like most mothers and babies we did have our rough patches. I wasn’t used to trying my best at something, using all my knowledge and still struggling. I wasn’t used to failure, and those first few months were tough as I wrapped my head around the notion that not only did I not have control anymore, I wasn’t excelling despite trying my best.

 

I often wonder if being a GP and helping women with similar issues (breast feeding, emotional trauma post birth) made me more conscious of my failures –I would try and tell myself to snap out of it, I knew what to do – but my own advice and knowledge weren’t working; in fact, my expectations were making it all harder.  

 

I found that despite preparing home cooked meals for my small family, managing a somewhat tidy home and having done a 30-minute walk with Miss S, I could still feel like a mammoth failure when Miss S rejected the left breast for her afternoon feed. My day could come crashing down because of a single breastfeed that went wrong or because I felt incompetent to settle Miss S at witching hour. I became very aware of the fact that I could write long lists and have ambitions for the day and tick none of the jobs off because Miss S refused to be put down in her rocker. When she was older I would spend time preparing meals in the thermomix only for it to all end in tears (for me!) because she rejected the mush I was offering her.

 

Because of you I have found myself sobbing uncontrollably multiple times over the last 22 months. Sometimes the tears are due to feeling incompetent or under prepared for the breastfeeding challenges/toddler tantrums/stresses of balancing a career and you. Sometimes the tears are because I feel utterly grateful for our beautiful little girl – I can be reduced to tears because she pats another child when they’re upset or seeks me out for a cuddle. Somehow motherhood, you bring me my highest highs and my lowest lows.

 

As a GP I am aware that when it comes to you women can be very hard on themselves. I’ve had women come into my consulting room devastated that they are failing their child because they can’t breast feed despite having tried everything. I’ve seen mothers who have blamed themselves for every single illness their child has struggled with, thinking it is somehow their fault. When it comes to you, mothers are their harshest critiques. When it came to me, I was no different. I would constantly expect more of myself– why wasn’t breast feeding working as I had envisioned? Why couldn’t I get all the jobs done I had planned for the day? I could always do better, according to me.

 

And then I encountered the competitive aspect that you incite in some women – the “competition” of motherhood. I had heard about this phenomenon from my patients but when I saw it first hand, finding myself slowly taking the delicious bait in front of me multiple times, I was horrified. Mother’s would boast that their child could sit at 5 months and “oh can’t Miss S sit yet?” like we were lagging behind in the race. Later I encountered mothers at swimming and music lessons who would tell me that their child could speak in 4-word sentences – “oh are you still on 2 words are you?”  And the competition didn’t stop there -suddenly women were happy to judge each other on how they had birthed their child. The badge of natural birth was often worn proudly, and loudly, and those of us who had been forced down the C-section path were made to feel like inferior mothers. If you couldn’t birth your child naturally, how were you going to do the rest of it was the sentiment. I very aware of the fact that if Miss S and I had been in a third world country we would have died given the events of our labour and so to me, the birth a woman had is irrelevant as long as both parties survived. What I have learned is that when it comes to you, motherhood, women can become competitive about the most trivial issues, and the key is surrounding yourself with mothers you who roll with the punches, admit to the struggles and compare stories for comfort, not competition.

 

It was at 7 months that my mum told me all about you– she concisely wrapped you up for me and my outlook on you changed. “Preeya you’re too hard on yourself, you’re a wonderful mother but no one is going to give you a medal for this job darling.” I actually felt myself take a deep breath- a real breath where the air fills the bottom of your lungs. It was my glorious epiphany– much like when Cher on Clueless realises she loves her step-brother- this was my moment in front of the fountain. I finally had your measure motherhood. I wasn’t going to “win” when it came to you or “succeed” –there was no race or battle, it was a journey and everyone’s was different. I needed to take things less personally – Miss S’ rejection of her lovingly prepared puree or the left breast at the afternoon feed was not her way of telling me she hated me. It wasn’t personal.

 

Some women adore you – some relish being a mother so much they have 5 children and “can’t get enough of babies” as one woman told me. That isn’t me though and for a long time I’ve felt ashamed to admit that, fearing that I am somehow less of a mother. Truth is, I find you challenging because I have very high expectations of myself and I bring that baggage to motherhood. I choose to work part time because I love my job and I enjoy the intellectual stimulation and satisfaction that comes from a hard day at work. But, the 3 days of work can be tricky with childcare drop offs, packing bags, getting us dressed and out the door–but that is a choice I’ve made and so far, it works for us. I am sure my experience of motherhood is significantly shaped by the fact that my husband is a training plastic surgeon who is studying for the biggest exams of his life – I often find myself looking at my friends with husbands who work 9-5, envious of the help they get at bath and bed time as I battle the dinner, bath, bed beast alone for 7th night in a row. And perhaps that’s why I think I am not ready to join you again for a “second” as they say – I’m content sitting on the sidelines for now. Give me a year or two, and a husband who isn’t training anymore, and then we can talk.

 

What I have learnt is that you work differently for different women. To find you a challenge (and admit that) should not be something to be ashamed of. Miss S is my soul – and whilst I knew love before, I didn’t know it to this degree until I met her. When she smiles my soul smiles with her and when she touches my face and says “Mummy pat pat” I know that I am the luckiest woman in the world. So, I am grateful for you, for the journey you provide, for the growth and self-reflection you have forced me to do. Whilst I am still a type A perfectionist I know now not to apply all my standards when it comes to you – I try to go with the flow and let the small stuff go – sometimes it works, sometimes it doesn’t.

 

Whilst I may not tick all the boxes or get a medal I’m at peace with you now– I’ve learned there is no “right way” of doing all this and that realisation gives me a great deal of comfort and confidence. I’ll curse, praise, hate and adore you many more times in the years to come – please don’t take any of it personally motherhood, I certainly don’t anymore.

 

Love Preeya

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PCOS – More Than a Little Acronym

 

I’m going to blow your mind – polycystic ovarian syndrome (PCOS) has little to do with the ovaries.

PCOS is a common, but often misunderstood condition. 12–21% of women of reproductive age will suffer from it and despite the small acronym the diagnosis has many implications.

The syndrome, despite the name, is more about the body’s metabolism and how it deals with insulin as opposed to the ovaries. Whilst most people’s minds jump to overweight women with excessive hair growth when they think of PCOS, take a look at Victoria Beckham – a very slender woman who has struggled with the condition. There may be friends or family members who have the condition that you are not aware of – remember how they said to never judge a book by its cover?

Here are the main things you should know:

  1. The disorder has 3 characteristic features and you only need 2 to be diagnosed. Irregularities of menstrual cycle, high levels of testosterone (with features like excessive hair growth or elevated levels on a blood test) and characteristic features of the ovaries on ultrasound are the 3 criteria. The ovaries are not essential to diagnosis, so everyone harping on about them can be very misleading! You can be diagnosed with the condition and have perfectly normal ovaries on an ultrasound.
  2. The ‘cysts’ everyone refers to are actually follicles in the ovary. A follicle is where the eggs are made and when a woman ovulates there is one lucky follicle (usually!) that gets to release an egg. People often ask me “what will happen to the cysts? Do they get surgically removed or burst?” The image that many of my patients have in their mind of a huge ovary with pimples all over it isn’t necessarily correct – and the follicles don’t need removal.
  3. Insulin resistance is the main issue in PCOS. This means that the body needs more insulin to keep the blood sugar levels normal. It is the high levels of insulin that cause a lot of the problems in PCOS. It is the reason why patients have a much higher risk of both type 2 and gestational diabetes. The higher insulin levels also stimulate more testosterone production which can cause the excessive hair growth and acne that many PCOS patients struggle with. Ongoing monitoring for diabetes in patients every 2-5 years is recommended and for women with PCOS who are pregnant, we screen for gestational diabetes earlier on.
  4. Before we can diagnose you with PCOS we need to do blood tests to exclude other conditions like thyroid disease. If you meet the criteria for diagnosis (for instance you have excessive hair growth on the lip or tummy and long menstrual cycles) you don’t always need an ultrasound. Remember you only need 2 out of the 3 criteria to be diagnosed. Having said that, most of my patients who meet the criteria still want the ultrasound for peace of mind and to know exactly what they are dealing with – and that’s fine too.
  5. Patients with PCOS can have problems with fertility, with irregular ovulation and menstrual cycles some patients need assistance to conceive or take longer. I see lots of patients panic about this – please know that many with PCOS go on to have successful pregnancies with no assistance. For others, some help may be needed and early referral to a fertility specialist can be arranged.
  6. Patients with PCOS are at a higher risk of conditions such as depression and anxiety. Mental health is an aspect to PCOS that often gets ignored. Struggling with weight, excess hair and concerns about fertility can be stressful and talking to someone like your GP can help.
  7. Women with increased time between menstrual cycles have an increased risk of endometrial cancer, as there is too much oestrogen exposure to the lining of the uterus called the endometrium. Some women with PCOS can have months and months between periods as opposed to regular monthly bleeds. Controlling the menstrual cycle with some form of contraception (there are many options!) is key to protecting against endometrial cancer because it provides the uterine lining with some progesterone and not just constant oestrogen.

 

For women who are overweight when diagnosed, losing 5 to 10% of body weight can have wonderful benefits for regulating menstrual cycle, improving fertility and reducing diabetes risk. So, the minute we diagnose someone a lifestyle review is high on the agenda.

Of course, for some weight loss can be very hard to achieve (or not indicated if their weight is already in the healthy range) and that is when other options can be used to manage the condition. Given the main issue is insulin resistance (and high levels of insulin) lifestyle factors like regular exercise and a good diet are key to managing the condition. For some women using type 2 diabetes medications such as Metformin can also help. Given that women with PCOS are at increased risk of type 2 diabetes it is crucial that women get ongoing monitoring of their cholesterol and sugars – it is this aspect to the condition that many women are not aware of!

I am currently managing 11 women with this condition as a GP and each woman has different concerns about her PCOS. For one patient the excessive hair growth affects her confidence significantly. For another the thought of having issues conceiving in the future causes her major anxiety. I work with all my patients very closely to achieve lifestyle shifts that can help – we work towards regular exercise, a good diet and aim for a weight in the healthy range and in some instances, we use medication as well. Every woman with PCOS has a different journey.

When you hear the acronym PCOS from now on think insulin resistance, diabetes risk and mental health issues– not such a small acronym after all is it?

 

 

A version of this was initially published by Dr Preeya Alexander on Women’s Fitness online.

 

 

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My Favourite Healthy Toddler Snacks (that Miss S loves!!)

 

 

  1. Dried mango

This is literally just dried fruit and the sugar content is only the natural sugar in the fruit (if you buy the right brands). Miss S loves it- it’s a clean snack so she can eat it on the go without causing a mess. Perfect for on-the-go snacking.

  1. Cucumber slices

I peel the skin off and give this to Miss S in her snack box. Cucumber is wonderful – high in fibre, low in sugar. Another great clean hand-held snack. And FYI I peel it because Miss S won’t eat it with the peel on – if your toddler will eat it with the skin on go for it!

  1. Cheese sticks

I buy the Beqa stringers and Miss S will munch through these when we are out and about. She doesn’t drink much milk currently so her dairy intake comes from cheese and yoghurt. A cheese snack is an easy way to get dairy into a toddler

  1. Yoghurt pouch

The greatest treat for Miss S – high in calcium and you can buy brands with a low sugar content (aiming for less than 10 grams of sugar per 100 grams). You can also freeze them so they can be a great snack on a hot day! When I freeze them I simply cut open the packet and give Miss S a yoghurt block to play with outside – fun, messy and healthy!

  1. Sultanas and dried peel

I often put this in Miss S’ snack box so she can eat it on the go. I buy the sultanas with fruit peel combined in it. A great source of fibre and again, if you buy the right brand and read the labels you can get products with no added sugar.

  1. Frozen peas and corn

You might think this is strange but try it! Fun for kids, not overly messy and seriously good for them! A fun way to get some extra veg in.

  1. Frozen berries

A hit in our house. Miss S loves frozen blackberries and blueberries. Again – no added sugar (other than what is in the fruit) and high in fibre. Warning – can be messy!!

  1. Fruit and veg chopped up

Simple I know but lots of my patients don’t think about this when their kids want a snack. Chop up celery, carrots and let kids dip it in hommus. Cut up apple, pears, banana are also wonderful snacks. It doesn’t have to be a muesli bar or biscuits all the time!

  1. Banana chips

Lots of banana chips have added honey or maple syrup but there are several brands that have lower sugar contents than others so you need to read the label and pick the right ones. These are a good clean snack on the go for kids and Miss S will now request these; a real hit!

  1. Cherry tomatoes + grapes + blueberries snack box combo

I often do this for Miss S in her snack box. I always chop up grapes and cherry tomatoes in half or quarters (please always cut these before giving them to kids under 3 as they are a choke risk and children have died from consuming these whole). I often put this combination in her snack box and she loves it!

  1. Kale chips

Honestly, I love these and now Miss S does too! When I make spicy ones for the adults I also make some for Miss S. I coat hers in some lemon juice and garlic powder. She loves the crunchy snack (they can get messy because they crumble!) and it’s a great way to get veggies in!

12. Broad Beans

My mum always used these as a snack when I was little and now I do the same with Miss S. I buy frozen broad beans, blanch them in hot water and once they are cool they are an easy vegetable snack! A great way to increase vegetable content in your toddler’s diet (and your own because trust me they are very more-ish).

 

 

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My “Chickpea/Veggie Deliciousness” Recipe

 

This is an easy, healthy go- to meal that can last the family for a couple of days (if you really want it to last add an extra can of chickpeas and tomatoes!).

 

What you will need:

1 x 800 gram tin of diced or crushed tomatoes – whichever you prefer

1 x 400 gram tin of chickpeas – vital to rinse these before you use them (or you can soak your own overnight, I often make this on the fly so need quick and easy can chickpeas)

1 medium sized zucchini chopped into 2cm pieces

1 brown onion chopped

3-4 cup mushrooms chopped into chunky slices

Spices: What I use varies every time but this batch has Cayenne pepper, Moroccan spice and cumin (and it is a delicious batch)

Greek style feta to sprinkle on top

Lemon zest – literally just a little bit, about the size of a 50-cent coin finely chopped

Handful of coriander

4 free range eggs

 

 

  1. Heat olive oil in a fry pan, brown the onion for 4-5 minutes
  2. Next add zucchini and mushrooms – let these soften slightly for 5 minutes
  3. Add the chickpeas, can of tomatoes and lemon zest. Also add the spices you have chosen– I add a fair sprinkle of cumin, a dash (very little because Miss S eats this) of Cayenne pepper and a generous sprinkle of Moroccan spice. No salt is added as Miss S eats this and it’s better for all of us.
  4. Allow this to simmer gently for 30-35 minutes, occasionally stirring. I simmer this for at least half an hour to soften the zucchini and mushrooms.
  5. Once satisfied with the consistently – crack 4-5 eggs on top of the mixture and close the lid of the pan. Allow this to cook for 5-6 minutes. I tend to only do this duration as I like the eggs to remain slightly soft. If you like them cooked through then cook for longer.
  6. Finally, once the stove is off sprinkle with crumbled feta and coriander.
  7. I serve this with couscous or roti wraps (which are awesome to dip in) and can highly recommend Greek style yoghurt on the side!

 

 

The doctor in me loves this dish because it contains loads of vegetables, it is a vegetarian dish (so excellent for cholesterol), contains no additional salt (hence, excellent for blood pressure control) and has an abundance of protein without containing meat. Chickpeas are also a source of iron so if you are vegetarian this is a great meal to increase iron intake. The working mum in me loves this because it is easy to make, contains ingredients I always have at home and it lasts us 2 days usually so I am off the hook for cooking. The mother in me loves this because Miss S will demolish this with cous cous and yoghurt and it’s so good for her. An easy, healthy, delicious family meal!

 

Let me know what you think! And if you create it please share and tag me!

 

 

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The Extra Childhood Vaccines I Get Asked About

 

 

Most patients and parents are aware of the vaccinations available on the Government funded schedule – all Australian children are eligible to receive these for free. Diseases such as hepatitis B, pertussis (whooping cough), diptheria, polio, measles, mumps and rubella are just some of the ones we vaccinate against. BUT, there are now many other additional vaccinations available to reduce your child’s risk of disease even further – and I can tell you more and more patients are starting to use these.

 

Compiled here are the common additional vaccinations that you may want to consider for your child. All of these are available on private script (which means you have to pay out of pocket, unless you fit into the high risk group that the Government will fund the vaccination for – the criteria varies for each vaccination so you need to speak to your GP).

 

  1. Meningococcal B vaccination

 

On the Australian schedule all vaccinated children receive a Meningococcal C vaccine at 12 months (they receive this at the same time as the measles, mumps, rubella vaccine). Meningococcal is a potentially fatal disease and there are many strains; children under 5 years old are most at risk, as well as those aged 15 to 24. Being vaccinated against the C strain does NOT protect you from the other strains of the bacteria and this is where I find most patients get confused. Imagine a bug with 5 different variations – each slightly unique, a different colour or shape. I can vaccinate you against the blue circular variation, but you won’t be protected against the green square or the yellow triangle types. That’s where each vaccination is unique and covers a different strain.

The vaccine against meningococcal B is called Bexsero™ and the number of doses depends on the age you start vaccinating your child. Children under 6 months need 3 doses, however, those over 6 months only require 2. The Bexsero™ vaccine is in short supply in Australia so if you want to vaccinate yourself or your child then you might need to wait for pharmacies to get stock.

 

Personally, we vaccinated Miss S against this before she was 6 months old due to our overseas travel and our professional experiences with meningococcal – we have both seen patients with those diseases and we were not going to take the chance.

 

  1. Flu shot

Children with chronic medical conditions such as asthma and diabetes will get this funded for by the Government. For everyone else however, you have to pay and it generally costs $20-$30. The flu shot and the strains it covers changes every year (as the flu virus is constantly adapting, they have to keep adapting the vaccine). If you choose to vaccinate your child from Influenza you need to get the vaccine yearly. The first year you vaccinate your child they require 2 vaccines (IF under 9 years old) at least 4 weeks apart to mount an adequate immune response. Influenza can be lethal due to its complications such as pneumonia.

 

On a personal note, Miss S was vaccinated against this as a 1 year old – she received 2 doses 4 weeks apart. As a GP I am vaccinating more and more children against this as parents try to protect their children from the highly contagious disease.

 

  1. Meningococcal A, C, Y, W vaccine

This is a vaccination that many Australian parents are now giving their children now that the W strain is making a resurgence in Australia. Currently, the Government is funding vaccination against this strain for high school children; everyone else has to pay for the vaccination. There are 3 vaccines available –Menveo™, Menactra™ and Nimenrix™ (there is a range of doses, and target age groups). Whilst these were traditionally recommended when travelling to high risk areas, many parents are now vaccinating their children because the issue is closer to home.

 

We did vaccinate Miss S against this in 2017 – she received a single dose of Nimenrix™ (she does not need a booster dose as she is not high risk).

 

  1. Tuberculosis

The tuberculosis vaccine is one you might need to consider if travelling to an ‘at-risk’ area (India, Fiji etc) with your child. This vaccine is in short supply but if you’re planning travel to one of these countries then it’s worth speaking to a paediatric travel doctor who can assess your need for the vaccine (your GP can refer you). Miss S received this vaccination prior to our India trip as she was under 12 months old and at risk of complicated disease due to her age. It is worth noting that the vaccination is in short supply world-wide so only high-risk individuals are vaccinated currently – a paediatric travel doctor must be the one to assess you.

 

 

I hope this helps answer your questions and allows you as a family to decide which additional vaccinations you may want to consider. If you found this helpful please share it with other parents – I find this is one of the commonest areas I get asked about.

 

 

 

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Dear Patient – An Open Letter

 

 

Dear Patient,

 

It’s about time we had an honest discussion don’t you think?

 

Firstly, you’re not the first patient to say “you wouldn’t understand Preeya” when you try to justify your non- compliance with therapy, whether it be the tablet, exercise or meditation I prescribed. When you admit that you keep forgetting to take your iron tablets, how hard it is to remember your asthma puffers every day or that you’re finding it really hard to find the time to exercise; I get it. May I be completely honest without losing credibility? I had iron deficiency after breast feeding for 6 months. My iron levels were low and I was told to take a supplement by my GP (yes, I have my own GP)– I took them sporadically (insert sheepish face)– I kept forgetting, my guts hated it and I wondered if the universe had given me the nutritional deficiency solely so I would gain empathy for my patients who had the condition– well, it worked! I also have asthma – I take my inhalers 80% of the time. I counsel all my asthmatic patients that the condition is long term, cannot be cured but can be very well controlled. The preventer puffer, if you need it, is essential to keep the lungs stable – it stops the airways from over reacting to cold air, pollens, exercise – whatever your triggers are. The preventer is vital, even if you feel well, to keep the asthma under control. I give the spiel often. But when it comes to me –I am not as reliable as I would like my patients to be. I often forget my inhaler when I have been well with no symptoms. Life gets in the way. I get busy worrying about Miss S’ nappy rash, work outfits for the week, meal planning – who could give a crap about my asthma?

 

Please don’t forget I am human too. When you sit across from me and say I wouldn’t understand, I grimace, because I struggle with all the same stuff you do – taking my medication every day, fitting in exercise, not reaching out for a wine every night. Being a doctor certainly doesn’t make me the perfect patient.

 

When I talk to you about bumping up exercise to aim for 30 minutes most days, I know how difficult it can be. I face the same battle every day. I notice your face fall when I ask you how the lifestyle changes have been going (my patients and I often work on diet and exercise changes to treat high blood pressure and type 2 diabetes amongst other conditions). I am not here to judge or punish you. I am simply here to guide, motivate and help you take the steering wheel of your own health. I feel sad when you say “Preeya you don’t know how hard it is to fit the exercise in.” Do I become immune to life’s challenges because I sit in the GP chair? These days, I am very honest with my patients; I juggle (and whether I succeed or not is a different matter) my motherhood, work, home life, an attempted social life and marriage; and trust me, I struggle fitting it all in too. I cannot possibly do 30 minutes of exercise every day – so I don’t expect you to either. I do something active 5 out of 7 days most weeks and I don’t even expect my patients to do that; I only expect that you will TRY to take control of your own health will all the information and tools I give you. If you don’t succeed every time that’s OK; I don’t expect miracles. So please don’t be scared to tell me if you haven’t done a walk 3 times a week or reduced your pastry intake; being a human I face all the same challenges as you.

 

Running late makes me very stressed. I know you’re waiting out there wondering why its 2PM, your appointment was booked for 145PM and I’ve just called someone else in before you. When I look at my list on the computer and see 4 people waiting, time ticking away – I get a big knot in my stomach because I know unless someone comes in for a quick cold and sick certificate I will not make up time (and even a cold isn’t ever really a cold FYI, there’s always something else –a sexually transmitted infection, an ingrown toenail – it is never ever “just a cold”). Trust me, I know you’re in the waiting room peeved off, getting angrier as each minute ticks by. And I promise you that if I could always run on time I would, I try my very best but sometimes things get out of control. When a person comes in and answers “yes” when I ask if they have been thinking about harming themselves, that takes longer than a standard 15-minute appointment. Likewise, the new mother who comes in for mastitis but sobs, struggling to take a breath because she is just that exhausted – I can’t throw antibiotics at her and push her out the door. And that’s not the kind of GP I am anyway, which is likely why you are still sitting in my waiting room despite me running behind. So please understand, if I am running late it isn’t because I’m playing Candy Crush on my phone.

 

Whilst on the topic, there are some things that most GPs struggle with and I’m ready to tell you what leads to many of us running late (and I haven’t seen anyone share this with patients before) – “The list”. The dreaded list. When you have booked a single appointment, which is 15 minutes for most GPs, and you have a list of 5 topics you want covered, there is no way humanly possible I can take care of your period problems, acne, pap smear, breast lump and anxiety properly in a standard appointment. So please don’t be offended when I say “can we choose the 2 things that are most important to you and deal with them today?” I need time to do my job properly and do justice to all the issues on your list and if you think you might need more time book a double appointment.

 

On a more awkward topic, let’s talk money. Doctors are shocking when it comes to talking about finances and billing. But, given we agreed to an honest discussion, let’s do this. It has taken me 4 years to know my worth, even then, I often struggle with billing people. Unless we have an agreement (like you’re financially struggling or you have a health care card for instance) I will privately bill you. And please know this, I have a toddler in childcare, I have bills to pay too. The notion that all doctors are rolling in it is far from the truth – I work hard for my pennies I can assure you, so please understand that just as you pay your dentist, physio, beauty therapist, personal trainer – the service we provide as GPs is also fee for service. The money you pay at the front desk doesn’t just go into the GP pocket either – we get a percentage; the rest goes to the clinic to pay admin and room costs and from the pennies we do get we pay significant medical indemnity insurance, college and medical board fees. Having said if you tell me you are unemployed, struggling to make ends meet but you need regular appointments for your Depression – I will always agree to bulk bill you (and I have many patients in that boat).

 

A few key things I want to share with you:

  1. You never need to apologise when you need an examination of your nether regions – whether it be for a rectal examination, rash or cervical cancer screening test. I’m not ever “grossed out” – your words not mine, and you don’t need to profusely apologise as you climb onto the examination bed. Likewise, ladies, when I examine under your armpits in a breast examination (for lymph nodes) you don’t need to worry– I’m not judging you on how sweaty you are; my mind is completely preoccupied on ensuring I cannot detect a breast cancer.
  2. When you ask “door open or shut Preeya?” as you leave the consulting room my heart swells every time. It’s kind and my decision changes constantly depending on the room temperature.
  3. I don’t have all the answers all the time – no doctor can know everything and there are so many things in medicine (tummy aches, bouts of nausea, strange tingly feelings in your left big toe every Tuesday) that we can never explain and they disappear on their own. If I say “it is nothing sinister, I can assure you of that, let’s watch and wait and see each other again in 2 weeks’ time” know that I am not blowing you off – I’m using the power of time (the greatest weapon in general practice) to help us find the diagnosis. And usually, your symptoms are gone in 2 weeks anyway, and if they’re not we will look into it with whatever investigation is needed.
  4. My tissue box is there for a reason. Please don’t worry about apologising, “sorry Preeya, this is embarrassing,” as you break into tears. You’re not the first person, and you won’t be the last. Ravage the tissue box, that’s what its there for. On that note, you don’t need a medical reason to see me either. Loads of patients book an appointment to debrief, have a cry, unload their worries – that’s part of my role as a GP so don’t feel guilty. You don’t need a cold, headache, sore ear– if you’ve had a bad day at work, the marriage is crumbling – I am here.

 

Finally, you should know this. I often think about you when you leave my consulting room when the sun has set and you’ve well and truly forgotten your appointment with me. If I’m worried about your diagnosis, your mental health, your stress levels or anxiety – I think about you. You pop into my head and I think “I just hope he/she is going OK.” You’re more than a number or a ‘patient’ to me – you’re a person. Like many GPs, I don’t just switch off and forget the story you told me that day about your recent relationship troubles, bullying at work or family violence issues at home. I do think about you – a lot.

 

Perhaps now, the next time I’m running late you’ll know just how anxious I really am. Perhaps you’ll modify your list so that the 10 issues are whittled down to a more achievable 2 for a single appointment. Maybe now realise I’m just a regulation human who doesn’t have all the answers and doesn’t live the perfect “healthy” life.

 

See you soon (but for your sake, hopefully not because if you see me it means something is wrong).

 

 

Your GP, Preeya

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Preezy’s Tuna Slice

 

 

I love my tuna slice; it is so easy to make and works as both a hand-held toddler food and an adult meal. Miss S, Will and I all love it and if I make a large batch it ends up feeding us for a few days, which means a cooking break for me! The medical wins of this meal – it is fish based so excellent for cholesterol management and given you pack so many vegetables in it’s an easy way to get the 5 daily serves in (especially if you have it with salad on the side!).

 

What you need:

1 medium sized onion chopped into quarters– I use brown or red; whatever I have

Eggs – the number depends on how much veg you put in –I usually use 6 eggs because of my vegetable content. The egg is the binder so if you use loads of vegetables or you are making a gigantic slice, you may need more. When you are pouring into your baking dish at the end you want a thick biscuit mixture- like consistency so add enough egg to achieve that!

1 x 415 gram tuna can – I like to use tuna in olive oil as it gives the slice some moistness. You can use brine or spring water bases; whatever you fancy.

1 cup of milk – I use low fat

Approximately 100 grams of savoury crackers – Savoy for instance

A good handful or 2 of cheddar cheese – aim for 80 to 100 grams if you’re into measuring

Parsley (I use this as it goes beautifully with tuna and we have loads in the garden) – you can use whatever you have though– basil also works really well!

1 cup of frozen peas thawed – please note you can use whatever you like here – you can just use peas or just use corn – I use both as my family loves them

1 cup of frozen corn thawed (I throw boiling water on the cup of frozen vegetables and leave it for 5 minutes then thoroughly drain the fluid off)

1 zucchini – grated

Whatever other veg you have – I sometimes put in the following depending on what I have

2 stalks of celery chopped

4-5 mushrooms chopped

Spinach from the garden –I often chuck in loads

1 tomato chopped – be careful with more that this as it can add to much fluid to the slice

 

FYI my last batch contained 1 whole zucchini, 1 cup peas, 1 cup corn, 4 mushrooms and a handful of silverbeet– it was seriously delicious and perhaps my best batch yet!

 

I use the thermomix to make this but you don’t need to – I’ve provided both options below.

 

For thermomix kids:

  1. Chuck in the chopped onion and blitz it on speed 7 for 10 seconds
  2. Scrape down the sides, chuck in the biscuits and cheese and blitz again for 10 seconds on speed 7 (it should be a thick paste like consistency)
  3. Throw in the eggs, vegetables, herbs (literally everything else in the list up there) and season with pepper (I do not add salt as Miss S eats this)
  4. Stir on speed 3 for 1 minute or until all the ingredients are combined. Sometimes I put the speed higher just to really mix it all up.
  5. Chuck it in a lined baking tray and bake that baby on 180 degrees for 25 – 30 minutes (it should be golden brown on top)

 

If you don’t have a thermomix (and I have made it sans thermie before and it worked) just chop the onion finely instead. You will need a blender though for the biscuits and cheese for it to really work well. If you blend the onion, biscuits and cheese for the first few steps then mix in the eggs, herbs and vegetables by hand it still works beautifully!

 

I often serve this with salad on the side (Miss S gets chopped up cherry tomatoes, cucumber and lettuce) but if your child won’t eat the salad then you still know you’re getting enough goodness into them anyway through the slice. This makes a fantastic on the go meal for adults and kids.

 

Good luck – and if you try it, post it and tag me please (@thewholesomedoctor)! Love seeing what people do with my weird and wonderful recipe ideas!

 

 

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