10 Fun Facts About the Flu Vaccine

 

  1. Influenza and the “common cold” are very different – influenza tends to be more serious with significant fatigue, muscle aches and reduced appetite – people often require a week or more off work. Pneumonia is a potential complication of influenza. A “cold” however, tends to be milder with coughing, sneezing and nasal congestion – people can tend still to work through a cold, perhaps taking only a day off if that.
  2. The flu vaccine protects you against certain strains of the influenza virus. It does not protect you from all the potential strains (there are many!) – the vaccine is developed and changed yearly to reflect which strains are likely to affect the community that particular flu season. The effectiveness of the flu vaccine changes yearly but usually sits somewhere between 40-50% – it does reduce your risk of contracting the flu.
  3. If you choose to have the vaccine you need to get the new vaccine annually. The effectiveness of the vaccine wears off after 3-4 months and the strains covered in the vaccine change from year to year.
  4. Once you get the vaccine it takes just over 2 weeks to take effect – it does not work straight away.
  5. Hand hygiene, covering noses and mouths when coughing and sneezing are still KEY to preventing spread of influenza! If you think you have influenza (muscle aches, fevers, fatigue) try and avoid contact with pregnant women, infants, the elderly and anyone who is immunocompromised.
  6. Children from 6 months of age are eligible to get the vaccine; in Victoria the vaccine is funded for children under 5 years of age. For any child under 9 years having the vaccine for the first time 2 doses of the vaccine 4 weeks apart is required to induce the right immune response. From there on the child only needs 1 vaccine annually.
  7. If you or your child have an allergy to egg (including anaphylaxis to egg) it is still safe to get the influenza vaccine. We ask anyone who has just been immunised to remain in the clinic for 15 minutes because if a reaction is going to occur it commonly occurs in this time period. We keep you in the clinic for 15 minutes so that we can easily intervene with adrenaline should it ever be required (I have never seen anaphylaxis post vaccination despite having given hundreds – it is rare).
  8. Anyone 65 and over is eligible to get a different flu vaccine funded by the Government called Fluad – essentially it is a more potent and enhanced vaccine and provides better protection against influenza in this age group.
  9. Your arm might hurt for a day after the vaccine – for this reason it is best to avoid the gym and heavy lifting 24 hours after the vaccine. But the sore arm is much better than influenza trust me!
  10. Finally – the flu vaccine doesn’t give you the flu. The vaccine is inactivated (it isn’t live)- it cannot infect you with the flu virus. If you get sick with a viral illness it’s likely you were going to get sick anyway after contact with another sick person and you can’t blame the vaccine, I’m sorry!

 

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Surgical Training: Could you make the cut?

 

Like lots of you I recently read the article this week that outlined a female surgeon’s harrowing journey in the hospital system in New South Wales. Dr Yukimo Kudota discussed her health issues that arose as a result of work conditions; the continuous on-call shifts, hundreds of hours of overtime and lack of support in the hospital system – despite seeking assistance, she did not receive it.

 

As I read the article my heart broke – I am a GP who honestly, did not enjoy my time in the hospital system. Whilst I have never aspired to be a surgeon I did dabble in physician training for 18 months, I had toyed with becoming a geriatrician or rheumatologist but the hospital system, the hours, the culture, the “don’t speak out because it will most definitely ruin your career” did not sit well with me, and so I left and I have never looked back.

 

What scared me most when I read the article was that Dr Kudota’s story was not unfamiliar. I am married to a training plastic surgeon – he is in the final 6 months of his training program and honestly, if there were more time left I don’t think his mental health (and mine) or our marriage could take it. The truth, that I suspect many in the community don’t fathom, is that unrealistic and untenable work hours are the norm for aspiring surgeons.

 

I’ve seen many terms used in the media this week without much background being given for those who don’t live and breathe medicine. Dr Kadota was an unaccredited registrar – this means she was not in the training program yet – she was working the hours, doing the surgeries aspiring to get a place on the plastic and reconstructive surgery training program. There is no guarantee, none, that despite doing years and years of harrowing hours/surgeries/on calls you will get onto the program. I’ve seen people try for 5 years or more; their families, partners, children waiting with baited breath every year as they sit the interview hoping that this time they “get on” so that they can start the actual 5 years of training in will take for them to be qualified. Once on the program, if you are ever accepted, you are deemed an accredited registrar – you do all the same hours, with more obligations to training (exams, tutorials, course requirements) but your time is ticking – you know there is a light at the end of the tunnel and that one day you will be qualified.

 

This week the medical world has been buzzing with this story – I’ve spoken to my GP colleagues (many of whom considered surgery seriously earlier in their career) and surgeons (my husband being one of them) and the consensus is – this is normal. Every doctor I have spoken with is surprised to see the attention it has received in the media and those in medicine know that there is a lot of work, far more than is possible in the next 5 years, to change the story of training surgeons like Dr Kadota.

 

This story has shone the light on not only surgical training but the plight female surgeons, of which there are very few compared to their male counterparts. Recent research has revealed at only 10% of surgeons in Australia and the UK are female – whilst some could argue that less females consider surgery as a career option given the hours and barriers family life and motherhood as a result – there is also the issue of entrenched gender imbalance and the fact that a female surgeon does, without a doubt, have a harder road in surgery when compared to a male trainee. Whilst we like to think a lot has changed – surgery is still very much a male dominant field and the term “boys club” would not be an inaccurate descriptive term. If a female surgeon speaks about gender imbalance/unsustainable work hours/lack of support then she is easily branded “hysterical” or “emotional” – surgery and medicine are not the only field to do this, but the problem still deeply exists. And not just from colleagues by the way – most patients will assume a female looking after them in a hospital is a nurse, and female doctors and surgeons have to correct them (or just go along with it). A female surgeon I spoke with recently told me her struggles with how she is perceived – she wanted to be taken seriously, be firm and knowledgeable but she did not want to lose her femininity and so she felt she had to roam the wards in high heels and high waisted skirts to preserve her femininity. I’ve seen my husband in at 5AM most mornings either throw on shorts and a tshirt because he knows he will be in scrubs all day or wear a very similar chino and shirt combination because he will be on the wards – the same issues do not plague a male surgical trainee and thankfully my husband will readily admit that.

 

My husband is not a whinger, if I was doing his job (and thankfully I am not) I would be emotionally and physically broken. It is not unusual for my daughter and I to not see him for 4 nights in a row because he is stuck in the hospital. He leaves the house at 5AM returning at midnight – it’s not uncommon for my 2 year old to ask me if Daddy is on holiday or sick when these spells of absence occur. When not on call he is finishing late surgeries, checking in on patients post operatively and seeing patients for the next day. The 100 hours of overtime in a month that Dr Kadota mentioned in her story sadly, is the norm for lots of surgical trainees, I know that’s what our household lives through on a frequent basis. When my husband is on call the phone rings often consistently through the night – amputated fingers/machete wounds/skin infections/ dog bites are run by him at 2AM in the morning. When his alarm goes off at 430AM you can be rest assured that he hasn’t properly slept but he will be operating through the day. This is the norm for a large proportion of both unaccredited and accredited surgeons in Australia – his story is again, not unique.

 

The notion that a surgeon can be sleep deprived and exhausted and be deemed “safe” to perform surgery has baffled me for a long time. When I raise it with my husband the response is “it’s just the way it is.” In surgery, like a lot of training programs in medicine, the unspoken word is to never ever question the system, never appear disgruntled with the gruelling hours/lack of support or supervision because your career will likely take a hit. If you’re deemed someone who rocks the boat or who doesn’t fly under the radar then it’s likely your journey through training will be more difficult, if you ever get onto the surgical training program that is.

 

Despite medicine being an industry where we help our patients with physical and mental wellbeing- honestly, we’re just not that good at it when it comes to ourselves as a profession. Doctors supporting their colleagues, fighting bullying, sexual harassment and gender biases is not done as well as it could be. There are attempts being made, but we are still a long way off from an acceptable standard.

 

My husband and I have spent some time discussing the issues raised in this article, before the article was in fact published. The truth is that these issues are deep seated in the medical and surgical world – and just because the gruelling hours, on calls, unsupervised surgical time is the norm does not mean it is acceptable. Dr Kadota’s story is not a surprise to most of us in the system and that’s the most frightening part. I’ve said to my husband plenty of times that change needs to come from within the system – it needs to come from the majority within the profession who need to dispel the notion that just because they did it tough the next generation should too. Perhaps think about it this way – if your child or mother was being wheeled into surgery to have their appendix removed would you be content knowing that the training surgeon about to do the operation has slept a total of 8 hours in the last 3 nights, is emotionally and physically exhausted and dealing with some baseline anxiety that is perpetuated by sleep deprivation and fear of failure? The answer most often is no, and so something needs to change.

 

 

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The Pregnancy Switch

 

 

For years women are fearful of accidentally falling pregnant. As I ask the 18-year-old with the abdominal pain, “is there a chance you could be pregnant?” trying to exclude an ectopic pregnancy or early pregnancy bleed as the cause, the look of shock and response, “God, I absolutely hope not” is fairly standard. Fast forward 10 years though and the same woman comes in suddenly desperate to fall pregnant having stopped the pill yesterday. For a while I’ve marvelled at the sudden switch that women experience – and I was no different.

 

I was an extremely rigid with my pill in my twenties, I would follow the rules like the type A personality that I am. If I missed a pill, if I even thought I might have missed it you could be rest assured I would be considering emergency contraception. I was fearful, like many women I now treat, of getting pregnant.  Then something happened, Will and I had been married for 4 years, I had started to look at babies and yearn for one and I stopped the pill – I remember the day distinctly. I had gone from a regimented pill taker to a woman desperate to get pregnant. One cycle passed, nothing – and then I panicked. Yes, I’m a GP. And yes, I know the statistics (92% of women will get pregnant with regular unprotected sex within a year, and 98% within 2 years) BUT like many things in life my GP brain blew up and I lost all ability to rationalise.

 

I often think back to that time and marvel at how quickly the switch flicked for me. I went from fearful of pregnancy to desperately yearning it within days. My patients are no different. After years of trying to find the right contraception – my patients suddenly come in ready to get pregnant and often the expectation is – it will happen today. Patience and rational thinking go out the window very quickly- the desire to get pregnant almost induces a temporary insanity of sorts – I say this in the kindest possible way having been there before!

 

I should point out that some women never experience this switch – some decide they don’t want children and that’s fine too. Having children is a choice – some choose to have them and still sadly, cannot whereas some despite having the ability to conceive decide they don’t want to pursue that aspect of life. I’ve spoken to several of my friends who have made the choice not to have kids and they experience loads of judgement from people too, “what you don’t want kids? Why?” or “Gosh, I can’t imagine a life without kids.” Personally, I take my hat off to those women – I think lots of us do things in life to simply tick boxes and fit in – those women who make firm choices, stick by them and stay true to themselves I believe deserve credit.

 

To go down a health tangent for a moment (I can’t help myself), most forms of contraception actually don’t have an impact on future fertility despite what many patients think, and what gets written on forums online. The combined oral contraceptive pill for instance (AKA “the pill) doesn’t affect fertility later – it may take up to 3 months for the underlying menstrual cycle to return to normal after one stops the pill but in many it returns immediately. The Mirena (the intra-uterine device) is one of the best forms of contraception for return to fertility – fertility returns immediately in most cases. With the Implanon, the rod that sits in the inner arm secreting progesterone, it can take several months for the underlying menstrual cycle to return.

 

 

The journey of fertility/ trying to conceive is a tricky one. You lose all control, you lose the ability to plan and for some that can cause stress. For those in same sex relationships it’s even harder – the ability to simply stop the pill and “try” doesn’t exist, the ability to control any portion of the journey is somewhat taken away.

 

For the last 2.5 years I have absolutely shuddered (to my toes) when I think of pregnancy or another baby. For a long time, I thought 1 child would be enough for us; I’ve been terrified of delving into the lucky dip again for lots (and lots) of reasons. And yet literally 6 weeks ago I looked at Will, a sudden certainty had come over me, “I’m ready to have another baby.” Will, who had been gently trying to convince me or a while beamed back at me. The same tendencies started to creep back – I wanted control, I wanted it to happen on my terms, I wanted to know exactly when I would be pregnant. Full disclosure – I am not pregnant, nor are we currently trying – but the switch has somewhat flicked, I would call it a half flick – I’m not averse to the idea, nor am I completely ready but the desire to control every aspect of the conception journey, the switch from aversion to desire has again occurred suddenly – again.

 

 

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The Bachie Dissected

 

I recently caught up with some girlfriends for dinner and naturally the topic of conversation turned to the recent season of the Bachelor – of course we ruminated on the Honey Badger’s moustache and it’s practicality and whether or not the constant use of Australian colloquialisms would drive us mad (reassuringly I realised it wasn’t just me who would end up screaming at him to stop mentioning a bag of cats or dogs in a butcher shop or speaking in any code).

 

We did get fairly stuck, however, on the behind the scenes footage we got shown this season, the invasion of the contestants’ privacy and perhaps, one might say, breach of their trust.

 

I can tell you now I would never ever do reality TV because I am extremely conscious of the fact that material can be edited to make you look unhinged, very easily. It wouldn’t take much to make me look a bit kookier than what I am, especially with a glass (or 3) of champagne in me.

 

This season though we saw some extra footage, didn’t we? We saw the stuff after the cameras had supposedly stopped rolling from the contestant’s point of view anyway. We saw Cass speaking to producers, apologising then breaking down. We saw Tenille run away from a cocktail party, throw her shoes off, unzip her dress and try to get as far away from the Bachie mansion as possible- and honestly, I don’t blame her. And yet the camera kept rolling, the producers followed her, asked her to come back and despite her asking repeatedly to be left alone – they followed her, filmed it and televised the footage. A part of me wondered if they had flared the situation – surely leaving the distraught overwhelmed woman alone would have helped her regain composure quicker?

 

So, my question is do the TV producers have a duty of care to these contestants? If they do, where does it lie? If one girl is being persistently being bullied by the others (as we saw this season, but then again how much of that was edited we will never know)- do they take her aside, provide counselling, suggest ways in which she can manage the situation and her stress or anxiety? Do they suggest reducing alcohol intake because it is known that it clearly worsens anxiety and isn’t helpful in acute stress? Do they offer counselling or any other form of independent support? Or do they run cocktail party after cocktail party throwing more alcohol at an already volatile situation with vulnerable individuals?

 

I’ll be honest- in my 20s I had abundant moments of having a big cry after a wine or running away in a dramatic fashion. But my moments were never filmed and aired on national TV – thank goodness. If they had been however, I can imagine it would significantly affect my self-esteem and perhaps even job prospects in the future. I can also tell you that in my self-declared hysterical moments the hysteria would have most definitely escalated if there had been a camera and producer following me.

 

I am aware that lots of people say “they know what they were getting into” about the contestants who sign up for these reality dating shows and to an extent I agree. But I don’t think Cass quite imagined that she would be painted as the “stage 5 clinger” as she has come to be known. I don’t think she expected that the footage of her getting teary when she says “I’m sorry” would be shown. I don’t think she thought the producers would push her with questions to make her look even more invested in the Honey Badger than what she probably was. I think she might feel as if her trust was breached and I don’t blame her. Even if the contestants go in knowing they are being filmed and good TV needs to be made, should someone be exploited when they are absolutely vulnerable?

 

I think if you put 20 women in a house, ply them with alcohol and ask them to compete for the attention of one Honey Badger man then you should expect to see normal human insecurities and vulnerabilities play out- but the question is does all the footage need to be shown to me, the viewer? Is it fair to the women? And where does the duty of care of the producers lie?

 

 

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Dr Preeya’s First 5: Dermatitis/Eczema

  1. Dermatitis/atopic dermatitis/eczema (all the same condition) is the red itchy rash people develop due to the immune system being heightened. Dermatitis typically occurs in the elbow and knee creases. In children it also commonly involves the face.

 

  1. You are at increased risk of dermatitis if you have a family history of allergic conditions or a personal history. We call it “atopy” in the medical world – the triad of hay fever, asthma and dermatitis are known as atopic conditions. To break it down and give it some context – my husband I both have a history of asthma and hay fever. This makes our daughter extremely high risk for atopic/allergic conditions; she is automatically higher risk for dermatitis and even asthma. So, when you come in with a red itchy rash –taking a good family history is key to diagnosis!

 

  1. Management of dermatitis varies according to the patient and severity of the disease. But these are the simple skin care rules all patients with dermatitis should follow:
    1. DON’T use soap to bathe – this is a big rule lots of people break. Soap is drying to the skin and dry skin is more likely to flare. Soap free washes are crucial and there are many suitable ones available. For kids – bubble bath is a big no no!
    2. DO moisturise skin religiously and regularly – I cannot harp on about this enough. Most of my patients eventually manage their dermatitis with regular moisturising and we end up using fewer steroid creams overall! The KEY to dermatitis management is giving the skin moisturise – I explain to patients that moisturising makes “on edge” dermatitis skin a bit calmer. And on that note – pick the right one. You need high oil, low water moisturisers – Sorbolene cream for instance is high in water and can actually make dry skin and hence, dermatitis worse. There are lots of suitable brands (like QV or Cetaphil – we use both in our house) available in pharmacies. For kids with dermatitis I suggest parents apply moisturiser at every nappy change ideally!
    3. DO NOT vigorously rub the skin after bathing – rather pat it dry to avoid aggravating the skin further
    4. DO NOT scratch – easy to say, hard to do! The more you scratch – the higher the risk of permanent scarring and infection.

 

  1. Steroid creams are commonly used to treat dermatitis flares – we make choices (ointment versus cream, strength of steroid, duration of therapy) based on the severity of the flare and the location (some areas are more sensitive than others). If you take ONE thing from this – steroid creams are for SHORT TERM use; we use the steroid to get the flare under control. The steroid tells the skin to calm down, chill out, relax a little. Once the redness and itchiness have settled we STOP the steroid and manage the skin with the stuff in point 3 (no soap, moisturising like a crazy person etc). Long term steroid cream use has significant consequences – it can thin the skin and superficial blood vessels near the skin surface can become more prominent. So never self-treat with steroids, never use them for longer than advised! For patients with severe dermatitis there are other immune therapies available; we involve a dermatologist for these.

 

  1. Can you prevent your child developing dermatitis if they are high risk? (ie. You or your partner have one or many of the 3 of the allergic conditions I mentioned earlier). The answer is YES! There is evidence that in kids who are high risk of dermatitis due to family history daily application of the right moisturiser (as I mentioned above) as soon as possible after birth may reduce the risk of dermatitis developing or delay its onset. This is something we have done with our daughter from day 1 – and so far, so good (I say this with fingers and toes crossed!).

 

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Dr Preeya’s Fast 5: Middle Ear Infections in Kids

  1. There are 2 main types of ear infections – external ear infections (otitis externa) that involve the skin in the outer ear canal and middle ear infections (otitis media) which involve infection of the middle ear, behind the ear drum. Middle ear infections are common and 75% of children will have an episode before they reach school. Exposure to cigarette smoke increases a child’s risk of these.

 

  1. Most kids, when they get a viral infection (AKA a cold), get some involvement of their middle ear. In all of us, there is a structure called the Eustachian tube – it links the middle ear to the nose and ensures that the middle ear gets ventilated so we can hear properly. In kids, because they are smaller in every way, when they get a cold and mucous secretion ramps up the Eustachian tube easily gets blocked. Once it’s blocked due to mucous the middle ear can get a bit inflamed, with less air coming into it from the nose- as a result, the ear drum can look a bit red; that’s the bit I see when I look inside the ear. If I look in every child’s ear who has a cold I will often see a slightly red, flushed ear drum – but this does not necessarily mean they have a middle ear infection and need antibiotics.

 

  1. To diagnose an acute middle ear infection, we look for certain diagnostic criteria – the rate at which the symptoms came on, what we see on examination (we need to see specific features of middle ear inflammation like a bulging ear drum or fluid changes inside the middle ear). When we ask you to pin your child’s head and get the precious 2 seconds to look at the ear drum I am looking for 4-5 features rapidly to see what we’re dealing with.

 

  1. Even if a child has a class middle ear infection, antibiotics are not always required – and I find this is where parents get confused. If a child is over 6 months old and is otherwise well (no fever, eating, drinking, happy), we generally use the “watch and wait” policy and paracetamol to control pain. IF the symptoms are ongoing in 48 hours (the child has ongoing ear pain for example), THEN we treat with antibiotics. Why not use antibiotics first off? (I get asked this a lot) Because we know kids in this group do well without antibiotics and that for most children, antibiotics do not change the course of illness significantly (studies have shown that kids get better without antibiotics most of the time anyway). Also, antibiotics can cause more harm through side effects, so if we don’t have a clear reason to use them we tend not to. For kids who are under 6 months old (they are more vulnerable) or who are unwell with fever/vomiting, we do treat with antibiotics first off.

 

  1. LOTS of parents want quick fixes when their kids are sick – and being a parent, I am no different, trust me! BUT we are trying very hard now as a medical community around the world to try and only use antibiotics when they are essential and their use is backed by medical evidence. As a mother and GP I have tried very hard to limit my child’s exposure to antibiotics to reduce risk of side effects and resistance – I’ve seen now over time more and more of my patients align that way, reluctant to use antibiotics unless required (as opposed to begging for them!). If your child needs them I’ll give them to you I promise, but know that if I say they aren’t indicated it’s a well thought out decision backed by guidelines and research and that I’ll always review the ear again in 24 or 48 hours.

 

As I always say, you are the patient so ask questions, leave the room feeling reassured and in the loop; I hope background information like this helps you feel empowered to get the most out of your visits to the doctor.

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Breastfeeding – Time for the Truth

 

I would like to have an honest, non- judgmental chat about breastfeeding – a topic that can evoke a lot of anxiety and judgement. I feel I can speak with some standing on this topic being a GP who sees lots of mothers and their babies but also as a mother who has breastfed and ridden the engorged, leaking roller-coaster. My own experiences have given me a deeper level of empathy for my patients and all mothers.

 

As a doctor I am aware of the numerous health benefits of breast feeding – both to mother and baby. A breastfed child has a reduced risk of being overweight or obese. The child also has a reduced risk of middle ear infections and a gut infection called necrotising enterocolitis. The rates of conditions such as childhood inflammatory bowel disease and coeliac disease are also lower in breastfed infants. The breastfeeding mother also reaps rewards; she can reduce her risk of breast and ovarian cancer and evidence also suggests that by breastfeeding a woman can reduce her risk of heart disease in later life. Sadly, despite all the health benefits, an Australian survey in 2010 found that whilst 90% of women initiate breastfeeding, only 15% exclusively breastfeed their infant to the 5-month mark.

 

My job as a GP is to support pregnant women/new mothers/families to make an informed decision that suits them when it comes to feeding their baby; I am not in the business of forcing my patients to do anything. So, whilst I am pro breast feeding given the evidence-based benefits, I am also a realist and know that for some women, and some families, it simply isn’t feasible.

 

Let me take you back to 2 years ago, and you really need to envision this moment in your mind. I was a new mum, a GP and I had my own expectations weighing heavily on my shoulders. We had a traumatic birth with an emergency C – section and the psychological scars were far more gruelling than the physical ones. I was lucky my daughter (in the beginning at least) was great at feeding on the breast. We did it our way – she fed sitting on me in an upright position, we introduced a bottle with expressed breast milk early so that my husband could help with the feeds overnight whilst I recovered physically, and emotionally. Prior to becoming a mother, I had spouted the recommendations I had seen in some of the literature to my patients about not introducing a bottle early due to risk of nipple confusion, avoiding a dummy due to the same issues. Within several days I realised that survival was crucial; with the severe sleep deprivation, ongoing vaginal bleeding, engorged breasts, cracked nipples and constipation – I was doing what I could for both my baby and I to survive and the literature could quite frankly get stuffed.

 

Thankfully, though, breastfeeding worked really well for us. For a while.

 

We hit 6 months and things started to suddenly deteriorate. The wheels started to fall off and I, being a type A high achieving personality, tried everything to rebuild the very rickety and dysfunctional cart. I was taking medication to increase supply, expressing and doing all sorts of kooky positions to encourage my child to feed. I distinctly remember the moment it went too far; my husband walked into the nursery, which despite it being the middle of the day was pitch black. He found me holding our daughter in the reverse football hold (hugged into my side), standing up, swaying from side to side, loudly “shhhh-ing” (any new mother knows this sound well) tears strolling down my face, a child attached to my nipple, my whole-body jerking vigorously (like I was Shakira on steroids) whilst I delicately balanced our child around my torso. “Preez this has gone too far” was his exact response – I still remember the look of absolute shock on his face. The lactation consultant (the second one I had seen for help) agreed with my husband – it had, in fact, gone too far. The lactation consultant’s response to me was “Preeya you’re either going to drop your child or injure yourself; it’s OK to stop, you’ve done an amazing job.” The tears streamed and they continued to for 2 weeks as I slowly weaned.

 

I drowned in a thick pool of guilt for a good 2 months. Perhaps the only thing that saved me was a close friend of mine going through the same thing at the same time. My mother telling me that you can only do what you can do also helped– and I had done all I could. Sure, I could have expressed day in and day out and fed expressed breast milk to my child, but that wasn’t going to work for me emotionally; some mothers are able to do it and I take my hat off to them.

 

Women, new mothers, even partners (male or female) are flooded often with breastfeeding advice; the slogan “breast is best” was campaigned heavily years ago. Posters, midwives, friends, mother in laws, woman in the café sitting next to you – everyone has an opinion on breast feeding and there’s usually a thick smear of judgement as they serve their opinion to you. When you’re already questioning yourself and your abilities as a mother, someone else chiming in can tip the balance.

 

I’ll let you in on a hot tip – we mothers feel like a failure if we can’t measure up to the idyllic version of ourselves that we had envisioned. Being a mother and a GP I better understand the 1000 expectations on a new mother – hold it together, deal with vaginal blood loss after pregnancy, seriously painful engorged breasts but also smile, widely, and respond “it’s wonderful” when people ask you how the first 2 weeks have been. Be sure to prepare a cooked meal and start working on losing the baby weight. Oh, and breastfeed exclusively. Of course, in the ideal world yes, we would all do this. Certainly, the guidelines (and some of them do differ) advocate for exclusive breastfeeding until 6 months of age (newer guidelines now actually suggested the earlier introduction of solids to supplement this around 4-6 months when the infant is ready). But not every single woman can do this. Whilst this is ideal, and the health benefits are abundant, it isn’t always feasible. Don’t forget the infant born via surrogate or who is adopted; whilst donor breast milk can work this does not necessarily work for every new family. Is the formula fed child any less loved? No. Is the formula fed child less likely to make friends at school, share toys and have a fulfilled existence? No.  Some new mothers find breastfeeding a breeze, it works and continues to and, in those instances, I say go for it. Given the health benefits, breastfeeding is the ideal choice, but there is another side to the coin that isn’t necessarily wrong.

 

I have treated patients who stop breastfeeding within weeks or months of the birth when there are no issues, they never sought help or advice– of course, I feel a pang of “damn, if only I could have intervened maybe we could have kept it all going a bit longer.” By the same token, there are mothers who try literally everything – and it still doesn’t work. Let me share 2 stories so you can see better where I am coming from.

 

One of my patients despite taking Domperidone (a medication that can help increase supply) and expressing post feeds was struggling– her infant’s weight was not increasing as it should. Despite trying all efforts and involving a lactation consultant she couldn’t produce enough breast milk to meet the infant’s demands. I remember mentioning formula top ups to her when she came in for the 5th of 6th time exhausted, and I was now quite concerned she was struggling with postnatal depression – she broke down in tears, “I didn’t think anyone would let me.” Her words have stuck with me to this day, they rang in my ears when I was in the first few months of motherhood, “let” – we don’t need to “let” a woman “do” anything; it’s her right to choose how she feeds her child and it’s our job to support her. This mother was exhausted, not tired, actually “not a single scrap of energy left” exhausted because between feeds and expressing after feeds she did not have a single moment to herself. She started topping up her breastfeeds with formula – so she used a combination of milks- and a new, calmer woman walked into my office the week later.

 

After having my nephew and her second child, my sister in law developed a severe bout of mastitis– she was admitted to hospital with kidney failure. I was in another state with my newborn, feeling rather helpless, but spoke to her multiple times a day. I’ll never forget her devastated phone call from her hospital bed – she was alone, my brother in law had to take their new son home because she wasn’t well enough to look after him and herself. She was absolutely broken being separated from her children and husband and to add to that, she was told she shouldn’t continue breastfeeding as the health risks to her were too great.

 

Some women do not have a choice when it comes to breastfeeding. Some women try everything they can and it doesn’t work. Some women need to top up the breastfeeds with formula because they can’t exclusively rely on their own supply. And I don’t think it’s fair that these mothers be made to feel adequate or like a failure.

 

I have heard the people, sadly some in my own profession, who do not ever advocate for any formula use even referring it to “poison.” I’ve had a patient come up from the food court under my clinic in tears; someone had commented it was “unfortunate the child wasn’t getting proper milk” the child was born via surrogate; the mother did not have the option to breastfeed. I’ve seen my friends and patients scared to admit to people, even me, that they are topping up with formula – scared of the judgement. “Breast is best” can make mothers think if they are unable to do use their breast to feed their child they must be inferior or suboptimal.  Please know that as a GP I wholeheartedly advocate for breastfeeding – I try my best to support women and often involve lactation consultants (who are nurses, midwives or doctors) who are specialists in this area to help my patients – but sometimes you can try everything and the puzzle pieces still just don’t fit. And sometimes, after we have tried throwing the kitchen sink at the dead horse (yes, I’ve merged 2 analogies on purpose to demonstrate the energy invested), permission to stop breastfeeding, or top up with formula, can save a mother.

 

So, my advice is simply this. Breastfeeding has many health benefits to mother and baby and the bonding that occurs is truly magical. I remember often looking down at my daughter on my breast thinking how incredible it was that I was feeding my child. If you can do it, if it’s suitable – go for it. BUT – not everyone can do it. Breast might be best but it does not mean that everything else is wrong. I am the mother of a 2-year-old, I did not breastfeed for as long as I had hoped or envisioned but my child is articulate, kind, cheeky and creative – she gives me cuddles, says “love you Mummy” whilst she pats my face and burrows her head into my neck when she is tired or upset–how I fed her had nothing to do with any of that.

 

 

 

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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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