How do you start your morning? I think my idea of having the sunscreen next to the toothpaste reminds met to Slop up each day, because I always, well nearly always brush my teeth! Thankfully, I am yet to brush my teeth with Sunscreen…..

When I do a Skin Cancer Check, I will run through the Sunsmart message. You know slip slop slap. I see that  the Cancer Council has added a couple of extra hints in addition to the original Slip Slop and Slap. I have to confess that I have only realised today that Sid is a seagull. I think the yellow face threw me.

Slip on sun protective clothing that covers as much of your body as possible.

Slop on SPF 30 or higher broad-spectrum, water-resistant sunscreen, at least 20 minutes before sun exposure. Reapply every two hours when outdoors or more often if perspiring or swimming.

Slap on a broad-brimmed hat that shades your face, neck and ears.

Seek shade.

Slide on sunglasses.

I think we are doing a much better job of protecting our skin in these sunny latitudes. I remember my Dad at work laying bricks in the Perth summer sun with just a pair of shorts and boots. He added a hat a bit latter. Now more workers are choosing or are required to wear long pant and sleeves. Long sleeve fishing shirts are trendy. My kids remind me to cover up.

A few statistics from Australian Institute for Health and Welfare to encourage you protect yourself.

  • In 2016, an estimated 13,280 new cases of melanoma will be diagnosed in Australia, and 1,770 people will die from this disease.
  • The rate of melanoma is increasing; from 27 cases per 100,000 in 1982 to 49 per 100,000 in 2016.
  • Some good news is that for those under 40 the rate has dropped from a 13 cases per 100,000 in 2002 to an 9.4 per 100,000 in 2016.


  • Between 1982 and 2016, the mortality rate rose from 4.7 deaths per 100,000 to an 6.2 deaths per 100,000.

If you are too busy to see your GP for a skin check, have at a look at this guide melanoma, basal cell or squamous cell cancer. But really make the time to have a skin check.

PS Not endorsing Colgate, Oral B nor Galderma in their post – just the concept!



Helpful hint to make your GP consultation run smoother #2

What to wear to a Medical Consultation

I have never worn a white coat as a doctor, but in some countries this the is the expected “uniform”. Really, I mean white is not my colour, although back in 1985 there was a pair of white jeans. They didn’t last long as I seem to attract dirt. It would be even worse in a world of blood, pus, poo and urine!

The aptly titled TAILOR study (that is, targeting attire to improve likelihood
of rapport) was a review of published papers to find out if patient preferred their doctor to wear formal attire. The authors were American but they did review papers from a variety of countries. They concluded “the influence of physician attire on patient perceptions is complex and multifactorial.” And suggested that “patients harbour a number of beliefs regarding physician dress that are context and setting-specific.”

One of the Tailor study authors went onto a write a commentary for The Conversation. His final comment was “While scrubs are appropriate for operating or emergency rooms, we suggest changing into more formal attire to visit patients in the hospital or the clinic. Regardless of the occasion, flip-flops, showy jewelry or jeans simply don’t belong in the hospital, just as scrubs do not belong outside the hospital environment. Especially not in the grocery store.”

In another BMJ article a microbiologist berated junior doctors for not wearing ties.  And heaven forbid facial jewelry. This was frowned upon by the authors of this study. The majority of American patient surveyed gave such jewelry a big thumbs down; “negatively affects perceived competency and trustworthiness.” 

I will stick with comfortable shoes, pushed down socks, shorts and a casual shirt with absolutely no tie. And I may just see if the stud still goes through the hole in my ear.

Now moving onto patients!

Are there any rules?

Should there be any rules?

What are the expectations?

Doing a PubMed search revealed very little on the subject. Amongst lots of articles (1120 to be exact) they all focused on patient’s perceptions of what health care professional should wear and not visa versa . Maybe there is a PhD in that?

So, here is my thoughts on what will make the consultation run smoother based on experience and chatting with colleagues.

First may I state the obvious,  make sure you are wearing clothing.  Turning up to the consultation naked will have you transported to the nearest psychiatric unit for an assessment of your mental health.

Secondly, don’t feel obliged to wear a suit and tie or even smart casual. Dress comfortably as we may be chatting for a while. I don’t work in a 3 minute appointment clinic and I like to get to know my patients. But you remember all those studies mentioned above, well I am human and despite my intensive training, I will sometimes lapse into making a judgement about you if you turn up in smelly torn jeans, odd socks, and NSFW emblazoned t-shirts.

Now I am not suggesting that I make my patients wear gowns for an examination as is the case in other countries,

My suggestion would be wear what would you to visit your Gran?

Here are some other logical practical suggestions.

1. Consider having a shower on the day of the consultation.

2. Consider wearing underwear and if you do make sure they are also clean.

3. Consider leaving your muddy boots at the front door of the clinic, but have fresh socks available.

4. Consider loose clothing. This is especially important if you have knee or hip pain or have come in for pap (oops… cervical screening test).

5. If I have to listen to your chest, the stethoscope works best on the bare skin. If you have several layers of clothing, some will need to be removed.

6. If you have booked a skin check be prepared to remove shoes, socks and at least some other clothing. Not wanting to make anyone paranoid, but melanomas can develop on places which may not get a lot of sunshine.

7. And, although strictly not clothing, please bring in your glasses and hearing aids.

Have I missed anything??

Helpful hint to make your GP consultation run smoother #1

Do you think you may have a Urinary Tract Infection?

Symptoms of a urinary tract infection can include needing to pee a lot more than normal (frequency), stinging or burning when you do (dysuria), seeing spots of blood in your urine (haematuria), have belly or lower back pain and having a fever.


If you arrive early or are waiting for your doctor, please ask to see the clinic nurse to get a clean-catch urine specimen.

It may sound like I am may be telling you to “suck eggs” but if a urine specimen is contaminated by skin cells it the laboratory may report the presence of bacteria there were never in your urine. This may lead to unnecessary use of antibiotics and all its attended problems and cost.

For women
Open the sterile jar and hold it in one hand. Sit on the toilet with your legs wide apart. Use the fingers of your other hand to hold your labia apart. The urine should not touch either your labia or your fingers. Start passing urine directly into the toilet. After a few seconds, catch your urine in the container. Once the container is half filled, screw the cap on tightly.

For men
Open the sterile jar and hold it in one hand. Retract your foreskin if you have one. Start by passing urine directly into the toilet. After a few seconds, catch your urine in the container. Once the container is half filled, screw the cap on tightly.

Kids who are toilet trained can also do this.

For kids who are not yet toilet trained you need patience or some special techniques to get a uncontaminated urine specimen. The Quick-Wee is a interesting and less invasive alternative. As is the bladder tap and back massage techniques. Failing that, suprapubic aspiration or a urinary catheter


Trying to understand Medicare #1

Referrals to Specialists

In Australia you don’t need a Referral to see a Specialist. So, say you wanted to see a Plastic Surgeon about a skin lesion, you can just find a Plastic Surgeon on the internet or ask a friend and make an appointment and off you go. But be prepared for a bill – sometimes a really big bill. This is because, you won’t be able to access a Medicare rebate for the Plastic Surgeon’s fees. To do so you need to first have a valid referral from your GP. But it is not as simple as just calling your GP and asking for a referral.

What is a Referral letter?

It is a legal requirement to have a valid referral to access Medicare for the care provided by the Specialist. In Medicare speak, the referrer must first “consider the need for the referral.”

A referral is a written, signed and dated request to a Specialist to assist with care of your medical problem. Often the Referral is to a specific Specialist, but this is not necessary. From DHS

“Referring practitioners don’t need to address a referral to a specific specialist or consultant physician. Patients should also be given the choice of where to present the referral, including where the referral is submitted electronically.”

This however can be an issue for referrals to public hospitals (that is a story for another time).

In the Referral letter, I usually would explain the problem, what I would like the specialist to do and provide a list of your medications, allergies, previous medical problems along with a copy of relevant investigations that may have been done. I find that this is best done face to face in a consultation to avoid miscommunication.

A specialist may run a triage system; a way of sifting through referrals to pick those that need more urgent care.

There is an expectation that a letter of reply will be forthcoming following your consultation with the Specialist.

How long does a Referral last?

A standard Referral is for 12 months of care. This starts when you first see the Specialist, not form the date the Referral was made. This makes sense as you are unlikely to see a Specialist on the same day as seeing the GP.

Referrals can be made for an indefinite period. but this is generally used for conditions that are unlikely to go away. For example, you could be referred to an Endocrinologist for help with managing diabetes indefinitely.

What is a Referral for?

A referral is for a single course of treatment of the specified problem. If a new problem arises then a new referral is needed. Therefore, if you see an Orthopedic Surgeon to manage your broken arm you will need a new referral to deal with your hip replacement.

The Specialist can bill more for a for a first visit, then less for subsequent. Unless a new problem arises, which requires a new referral, you shouldn’t be billed for a new visit after that.

Who does Referrals?

GP can refer to all Specialists.

Opticians can refer to Ophthalmologists. Midwives and Nurse Practitioners are also able to make Referrals under Medicare rules. Dentists can refer to Dental or Orofacial Maxillary Surgeons.

A Specialists can refer to another Specialist but these referrals only last 3 months. An example here could be a Paediatrician may refer to a Paediatric Neurologist to help with management of problematic epilepsy. For ongoing care by the second Specialist a GP’s referral may be needed.

Backdating Referrals

As a Referral is a legal document, Medicare does not permit backdating a Referral.

A Specialist can see a patient without a valid referral only in an emergency. Apparently, if your dog ate your referral, or another good excuse, there is a exemption available for you to claim your rebate if the Specialist notes that the “Referral is lost”. I am sure that Medicare would get suspicious if this happened a lot. Medicare do audit what GP’s and Specialists get up to make sure the rules are being followed. There are fines for not following the rules!

If you need a Referral make sure you see your GP before seeing the Specialist if you wish to get a Medicare rebate for the service. Asking your GP for a backdated Referral is like asking the Specialist to forward date your consultation so you can get a Referral. Both are not permitted under Medicare.

One final thought

Surprisingly, your may find that your GP may actually be able to fix the problem you want a Referral for and save the inconvenience of seeing a Specialist.

Medicare rule can be found here

Here is a summary from the AMA

For more details you may wish to read the Health Insurance Act 1973 and Health Insurance Registration 1975 but it isn’t easy reading with its subsections and subregulations, respects and accordances. Lots of Legal speak.



Medical Podcasts

Where to find Medical Podcasts?

I’ll avoid the Podcosts which I don’t do because the “F” in FOAMed is free.

Well  you could go to iTune for your medical podcasts, which include some “podcosts” here

Or if you prefer Android or PC and if you don’t want to contaminate your PC with Apple stuff then click on the Podcaster’s website to link to the podcast.

Be warned iTunes catalogues a lot, an awful lot of podcasts, more than enough to turn your brain off and makes you walk into a passing bus.

So here is a much shorter list of stuff that I have listened to from time to time.

Australian Prescriber podcasts

Bit’s and Bumps for women’s health from Penny Wilson and Marlene Pearce

Broome Docs by Casey Parker. Currently there are almost 100 podcasts to enjoy. I haven’t listened to them all.

Dr Daniel Aranov’s EBM Podcasts These are easy listening and good humoured. I like these Daniel, keep up the hard work.

Don’t forget the Bubble for paediatric stuff

EmCrit by Dr Scott Weingart an ED Intensivist from New York.

ETM as in emergency trauma medicine

GP Skeptic by Dr Justin Coleman being educational and well skeptical

IM Reasoning Drs. Art Nahill and Dr. Nic Szecket, have a passion for teaching clinical reasoning.

Life in the Fast Lane with a lot of other stuff

Reach MD really sounds like a radio for medical stuff from the US

St Emlyn’s podcasts on academic emergency medicine

The Health Report by Dr Norman Swan

Therapeutics Education Collaboration Canadian’s promoting healthy skepticism and critical thinking

The Good GP from Drs Tim Koh and Sean Stevens, in collaboration with RACGP WA.

The GP Show by Dr Sam Manger

This one will have stuff interesting for GP’s too

The Purple Pen Podcast is a fortnightly discussion about clinical pharmacy in Australia.


If you think any should be added please let me know at

Most of the major medical journal offer a podcast on recent articles with author interviews.

Australian Family Physician

America Acedmy of Family Physician



Medical journal of Australia


The Lancet


There are a lot, what is your favourite?


Would you take seal oil?

In a recent Diabetes Management Journal that ended up my desk. “Could seal oil reverse diabetic neuropathy?

This article refers to a study done in Toronto, Canada on just 40 type I diabetic patients whose peripheral nerves have been damaged by their illness. This was an open label-study, proof of concept study. So not randomised nor blinded. The authors used corneal confocal microscopy to look at the changes in the corneal nerve fibre length as a surrogate for more peripheral nerve damage, thus avoiding the need for a nerve biopsy.

The study has been taken up by a number of web and print medical news journals,

I wonder if the editors of these news journal, or indeed the authors of the research paper considered the ethical dilemma of harvesting oil from species protected in many countries around the world, including Australia.
The oil used in this study was sourced from Auum who according to their website are at the forefront of omega-3 supplements. Further, it claims to be “dedicated to developing and manufacturing superior nutritional products to support the health of all.” That is of course unless you happen to be a Canadian seal.

The Harp Seal (Pagophilus groenlandicus) appears on the IUCN Red List as an creature (some would say resource) of “least concern”. Canada’s seal hunt remains mighty controversial even within Canada. National Geographic asks why Canada still allows a seal hunt. And there is more emotive posts about Canada’s seal hunt, for example The Dodo website. Obviously there are proponents of seal hunting, and you can buy seal products, such as Canadian Sealers Association. Another proponent of seal oils suggests that the cute cuddly white coated variety are no longer hunted. It is okay to harvest these older seals as they are able to swim on their own and have left or been abandoned by their mothers. So that makes it okay if they are “abandoned”. Kerthunk…..

A problems with seal oil is the potential for contamination. One product blurb for seal oil appears to suggest that their product is safe as it is bio-filtered fish oil. As seals are much higher in the food chain than fish, “seals use their digestive system to filter out the many natural impurities found in fish.” Conversely biological dogma suggests the further up the food chain you travel, the more likely you end up with more contaminants, such as mercury, PCBs etc, not less. Dr Ho, who can sell you seal oil overcomes this problem through a process molecular distillation. His process removes all the impurities, such as mercury, metals and PCB’s from the oil and makes it a purer product that is safer for human consumption.

Interestingly, I found on DPAGold another Canadian seal oil distributor’s website this paper written by researchers at RMIT, Melbourne and supported by Meat and Livestock Australia. The authors suggested that taking 10 seal oil capsules a day “may be more efficient than fish oil at promoting healthy plasma lipid profiles and lowering thrombotic risk”.  Thankfully, Meat and Livestock Australia will have to keep their hands (or clubs and harpoons) off Australian seals through federal legislation.

Personally, if I need more omega-3 in my diet I would be using the Australian Heart Foundation list of natural dietary sources and thankfully omits seals, which are protected in Australian waters.


Emergency at 30,000 feet.

Three hours into an intercontinental flight, the dark blue waters of the Pacific ocean pass below. A cloudless azure sky offers contrast. The remains of another airline lunch has been collected. Postprandial heads began nodding. A few fellow passengers have already succumbed to slumber assisted by duty free spirits.

 “Can a medical practitioner please make themselves known to a member of the cabin crew, please”

A few people steal quick looks around. Maybe hoping someone else may volunteer, maybe just curious.

Finally, a hand reaches for the call button, a red light came on with a ding. Dave stands, sweeping the remains of crumbs from lunch from his shirt front. He adjusts his glasses and steps into the aisle. A flight attendant strides up with a serious professional look on her face. “Come this way please” and he follows her to the rear of the aircraft. There, a young lad lays curled up looking like he was in some distress. A plaintiff cry intermittently escapes his lips. Next to him a woman, obviously his mother, is worriedly mopping his brow, saying “shhh”. The Father similarly worried, is in the next seat to the the pair.

“Are you a doctor?” the Purser inquires “Do you have some identification?” she continues, demanding polite but firm.

Taken a little aback Dave mutters “Yes, just a minute” he fumbles his wallet from his jeans. Chuckling as he looks through his wallet for some form of identity, “Maybe I should have worn my stethoscope around my neck?” Finally he pulled out his RACGP ID card and offered it. “Hmmm, okay that will do”, the Purser accepted. “Can you help with this young man. He has pain”.

Dave takes the empty seat next to the lad and asks a few questions of the lad’s parents. He lays a confident palm onto the lad’s belly, skilfully feeling, discerning the pain and its possible causes. He nods, knowingly distilling the information. He stands to talk to the Purser, “Where’s the nearest place we land to get the lad to a hospital?” In the blue emptiness of the Pacific there was no where closer than from whence they came. Dave rubs the quickly developing stubble on his chin. He knows there is but one thing he can do.

He turns back to the parents to explain what he must do. Colour drains from the Mother’s face, the Father just nods, silently shocked. Dave looks into the offered medical kit then turns to the Purser, whispering a few requests. The pair heads to the first class galley.

Dave returns, having marshaled his resources and equipment from what he could find. He gives the lad a large tot of first-class OP rum, splashing more onto his own hands and the remainder onto the now naked groin of this stoic young lad. He directed the two burliest cabin crew to hold onto the lad’s arms. To the parents he whispered “its going to be okay, just breath”.

The father solemnly nods to Dave then looks into his son’s eyes, which are now tightly shut unaware of what is about to happen.

Dave pulls on the latex gloves, flicking the cuffs. There is a hush only broken by the noise of the jet engines outside. Armed with sharpest steak knife Dave could find, still warm from its dunk in boiling water, he skilfully cuts into the lad’s tense scrotum. Linen serviettes soak up the blood. He picks up a pair of nail scissors and eye brow tweezers and continues his artful surgery.

The lad gives a rum tainted groan and gratefully lapses into unconsciousness. A young lady in seat 25E quietly vomits into a sick bag. Her partner grimaces and crosses his legs.

Adroitly, Dave untwists the dusky organ on its stalk. A flush of fresh blood fills the testicle. Those watching burst into spontaneous applause.

Finally Dave uses the Purser’s stapler to close the wound and wraps the scrotum in a clean silken scarf.

The young lad’s Father gives a weak smile knowing his son’s future progeny has been saved. Dave wipes his hands on a fresh first class serviette.

The Purser directs Dave to his first class upgrade, hands over a card for lifetime membership of the airlines Gold club and cracks a bottle of Moet. “Well done Doc, I’d fly with you any day”

Behind, the final smart phone camera video light flicker off awaiting an active wifi link.

The pilot announces that the planned emergency diversion to Kiribati is no required to the grateful passengers.

– A work of fiction


And if you thought this impossible and not too sqeamish…