Beating the Drum for the Country Docs

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It can be lonely out there

Rural Health - the real challenge.

As you may know, I took a few years off from clinical medicine as the emotional strain from caring for patients was hard enough, but running a practice was even harder! Now I've chosen to return to Family Medicine, but this time as a Locum GP, and I've chosen to help patients in the rural community. And it's been great!

Firstly, country people are different and have different problems. They're different in that they're more 'forgiving' and they're more thankful:  I had four 'Thank You' cards from one practice after just one three week Locum! But they face their own challenges too. Obesity is a big issue - excuse the pun - and is only compounded by the sense of inertia that occurs in small country towns. With the obesity of course comes Type II Diabetes with all it's insidious complications. 

Then there's a big issue with Chronic Pain Syndromes and the use of powerful analgesics that are being used to control them. It's a real challenge in such a short period of time to educate such patients on pain modulation, alternative treatments and the ancillary lifestyle modifications availabe. The resources needed are limited - professionals such as myself, clinical Psychologists and dieticians are nearly all FIFOs which makes continuity of care a real challenge.

And that leads to the one constant gripe of so many rural patients - with the inevitable question being asked "How long are you here for?" They feel that they are constantly having to repeat their stories to new faces (and despite computerised medical records, getting up to speed in 15 minutes in a complicated history is a tough gig even for someone with years of experience)  and many patients have literally given up trying merely limiting their consultations to requests for 'a new script'!

Our full time GP colleagues are bearing an enormous load in very isolating circumstances. I can fully understand why a female GP graduate with a young family would find it daunting to embark on a career in a remote rural practice. She would face so many professional and domestic stresses for which there are few practical answers. One may be to utilise the skills, knowledge and experience of those retired GPs who are looking for that something extra in life rather than playing bowls or embarking on another cruise, and developing an efficient, effective mentoring service!

Another would be to support groups such as the Australian Doctors Spouse Network that's been established to support Fellowship spouses in their un-ending merry-go-round of moving from hospital to hospital over their 6 to 10 year training. This group are aware of the challenges their partners face - perhaps Rural GPs Spouses can work with them to build support for their craft too.

Because at the end of the day, we're there to supply Health and Wellness information to our patients. We're there to support our patients when they're struggling. We're there to be their advocate when they have nowhere else to turn and to constantly remind them how special they are and why health is such a valuable commodity. 

At the end of the day it's all about our patients, and we can't do that properly unless we look after our Rural Doctors too.

Stop calling me Skinny!

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You’ll often hear it said that approximately 50% of the western world are either overweight or obese and that this can lead to serious health issues. And I agree with that. But I’m in the other 50% and am starting to get a bit fed up with being told that I’m getting skinny, or that I need a good feed to fatten me up.
Now, although I frequently write about the huge health threat that comes with obesity, what I do not do is go round telling people to their faces that they are fat and, why don’t they cut down on their eating.
The reasons behind this reversal of fortunes is that with so many people now being overweight or obese, half the population now think that their body image is normal and that the skinny ones are the abnormal ones.
As you all know, this year it’s 100 years since the start of that terrible first world war, and there have been lots of film footage of troops signing up and going to the front. So far I haven’t seen one fat person signing up in all that archival footage. Fair enough, smoking was more prevalent and cigarettes part of a soldiers rations, AND they did a great deal of marching up and down. But if they introduced conscription these days ( and heaven help they never do again) then there are going to need an awful lot of XXX large uniforms for over half of the troops.
Being overweight or obese is not the norm, but the pattern for it can so often be laid down in the first five years of life and that’s where we need to focus part of our efforts to fight the trends toward obesity related Diabetes, heart disease and cancers.



I was reminded of this after reading an article in the past on “Risk factors” for heart disease and in particular a study in the US which has been going on since 1972, and which has followed a community of people to study the incidence and causes of heart and blood vessel disease. This study, which is called the Bogalusa Heart Study and which has been an ongoing study for over 40 years now, has not provided any revolutionary results but some of the conclusions need to enter the mainstream thinking of every family, every school and every community.

But first a look at what we know, and you’ve heard it all a thousand times, but Smoking remains the No 1 bad guy when it comes to vascular disease - the type of disease that leads to heart attacks and strokes. Second comes Hypertension, or high blood pressure, which needs to be measured if you want to find out whether you have it or not. Then comes Diabetes, which if poorly controlled often leads not only to heart attacks and strokes, but also to disease of blood vessels supplying the legs, and when they get blocked gangrene and amputation may follow! And finally comes raised Cholesterol, obesity, age and being white - the Bogalusa study being run in a mixed biracial American community.

In this particular study the finding that neither obesity nor raised cholesterol rank highly as a risk will be of interest to the experts in those fields and will be the subject of intense, ongoing debate. But what we do know is that:

Since the introduction of ‘Statins there has been a 30% reduction in developing the risk for atherosclerosis - the plaque that leads to heart attacks and strokes. And that people with a Cholesterol level lower than 160mg/dL do not get heart disease irrespective of what their HDL, LDL cholesterol are or their Triglycerides are.
Obesity is linked with diabetes and diabetes is a significant risk for developing blood vessel disease. It is also linked to cancers and other medical problems and remains a real focus of necessary life style changes.

In fact one of the glaring outcomes of this 40 year old trial is that childhood nutrition and obesity should be the main focus of all preventative programs. If it’s left uncorrected then it’s linked to life long health problems that are not only physical but mental, educational and social too. So that’s why the childhood nutrition story needs to be told loud and clear and repeated in new ways year in and year out. If we give our children a healthy start in life then not only are they going to be able to make the most of their opportunities, but they are going to be healthier and get less disease. And what this means is that they are not going to need the services of our fantastic, but very expensive hospital services, which are paid for out of our taxes and our insurances. So the “price” of investing in getting our kids to eat healthy nutritious food is going to be a wonderful investment in their future and in our Nations too.

So where do we begin? Well in most places the machinery is already in place and beginning to work really well.

Smoking. Nearly every child I meet hates the smell of smoke, but sadly there are a great number of teenagers to take up the awful habit and unbelievably, cigarettes are still sold as Duty Free items in airports around the world. But in most developed countires, the good guys are wining and the percentage of smokers continues to fall, but we must never relent!
Childhood obesity requires serious, sensitive handling. Childhood obesity leads to a plethora of life long health problems. The key factors of teaching, showing, sharing better ways to eat need to be tailored to the individual and to be creative. The involvement of Chefs in school programs that allow children to try foods - and these are foods that they would normally “hate” -  prepared and presented in different ways so that the kids actually enjoy eating them, does have a huge impact. The widespread appearance of school vegetable gardens is another creative way of involving kids in making nutritious food choices and understanding how a healthy food chain operates..
Physical activity. Whilst not really impacting on weight itself, the direct benefits of physical activity in so many areas of life - heart disease, cancers, mood disorders and so on - mean that being active must always be an integral part of our education system.

Reducing risk is a lifelong health education challenge. We should not wait until mid-life to try and correct things that need not have occurred in the first place. So lets give our children the best tools available to build healthy lives, so that when their turn comes, then they will know how to build a great world for their children too.

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Driving me crazy!

Tweet I've just driven from the centre of Ireland to the city of Galway and back again to catch up with a friend of ours who has been doing an intensive English course there. And although I want to concentrate on posture in this article, I first must make a few observations of what I saw in that lovely city: 1. So many people were smoking that my heart sinks for their future health, because so many of these people are young people. 2. The number of seriously overweight people was remarkable. But as we know, this is not just an Irish problem, but a universal challenge. But yet again it was the number of young people who are literally carrying 40 to 50 kilos of extra fat around on a daily basis that must inevitably lead to serious health consequences. 3. Being a tourist area there is an added emphasis on alcohol, and yet again it's the young who are at the pointy end of the problem. In all these situations there are those who are putting in a huge effort to promote a healthier alternative, but to the average punter, they are not having the required impact. One obvious casue of these problems is the ease of availability of cigarettes, fast foods and alcohol. I do not advocate prohibition, but perhaps we should look at reducing the number of outlets for each of these products within each community. Naturally there would be a screetching outcry at such a suggestion, but tough decisions need ot be made if we are not to end up paying billions of dollars in the years ahead to combat the health and social impacts of the negative consrquences of these three challenges. Meanwhile, back to the problem of posture. Maybe I am deformed - a suitable pause for ribald comments - but at my age I find that the driving seats in cars eventually will cause me neck and shoulder pains. I find that they cause me to bend forward in the seat with rounded shoulders resulting in my cervical spine (neck) being in an uncomfortable position. Unless I force myself to constantly tighten my lower abdominal muscles to fix my lumbar spine in the correct position, to stick my chest out and push my shoulders back, then after an hour I find myself with tense shoulders and the onset of a mild headache. Perhaps all the creative geniuses out there who deal with ergonomics can give me some good advice!

Poor mother toddler bonding linked to teenage obesity.

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I read an article today from Ohio State University which appears to reinforce my belief that the first five years of life are so critical for the normal development of a toddler.

The researchers there looked at the quality of parenting in early life and then looked at the rate of teenage obesity: as you would unhappily expect, those with weak mother-child bonding had a higher rate of obesity - in fact it was over a quarter of them, or 26%. This compared with under 15% for those with observed better bonding skills.

The knee jerk response is then to blame the parents for "causing" their kids to be obese in their later life, with all the associated medical problems that can be associated with it - diabetes, heart disease and some cancers. But the findings highlight the fact that changes must be ocuring in the toddlers brain to account for the metabolic responses to these early life experiences. According to Sarah Anderson, Assistant Professor at Ohio State, “Sensitive parenting increases the likelihood that a child will have a secure pattern of attachment and develop a healthy response to stress. A well-regulated stress response could in turn influence how well children sleep and whether they eat in response to emotional distress – just two factors that affect the likelihood for obesity.”

So instead of just focusing on eating healthy food and getting adequate physical exercise - which is necessary for all children anyway - systems need to be developed to support and improve the parenting skills of those who currently lack them. This is easier said than done and cannot be left solely to government agencies to find solutions. This is something that everyone who knows someone with kids needs to be aware of. Bringing up kids is tough; doing it by yourself is even tougher; doing it in an environment where unemployment is high and making ends meet is a never ending struggle, would just about make a saint weep.

An offer of help, a word of encouragement: maybe even taking the child to the park whilst Mum has a break, or reading stories to the little one whilst she takes "five" - there are many small ways in which we can make a big difference. As Professor Fiona Stanley here in Perth said many years ago, "It takes a village to raise a child".
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