The Inevitable Blog

A new and exciting step forward

It’s been a while since I last got on my electronic soapbox, however things have been extremely busy and some changes have come about.

Healthcare providers get into their particular fields for various reasons, however there is one underpinning principle that binds them; care. In addition to this, there is the 

The view from the other side of the doctor’s desk.

Something happened a few weeks back. I had somewhat of a whoopsie. You see I had been ignoring the pain in my back for about three weeks. Even after the altered sensation in the left calf and foot kicked in, I figured that with some tried and tested physiotherapy and McKenzie exercises all would come good in 6 weeks or so after the pesky disc had learned to behave itself. Well, maybe not. After successfully removing a small phone charger from a socket at Townsville Airport something went horribly awry and two days, and two less than comfortable flights, later I ended up flat on my back.

This meant a few things. Firstly, I realised that my own company sucks as I am nowhere near as entertaining as I thought I was, and secondly; I had to see a doctor. Or two.

Whilst I could probably have utilised a network of colleagues to sort it out, I though it might be time to get a GP. As I preach the advantages of such a thing to the patients I see, I thought I might as well do the same. So off I trotted to the local clinic, the only one that happened to be open on a Sunday.

My new GP was kind and spoke softly. He asked me what I was taking for the pain and I told him that I had run out of Panadeine forte and NSAIDs and would like to discuss a regime for treating what was no doubt a combination of disc pain and neuropathic pain. He looked at me strangely (though he did know I was a doctor according to my brand new and shiny medical record), and asked me what I would like for the pain. I’m not a fan of self prescribing, so I asked him to make suggestions. He did make suggestions and then kindly called that magical service to check if I was recorded as a ‘drug seeker’. 

At the time I was a little taken aback by this, and borderline offended. However, on reflection I now admire that my GP did this. Its not easy to make difficult decisions when there is someone in front of you asking for help. And there is a significant problem in our society regarding the use and misuse of opioid based analgesics. And just because someone is a doctor doesn’t make them exempt from potential misuse. So well played, sir! Anyway, script in hand, off I trot - well stagger like an old man actually.

Then to the dreaded MRI. I had avoided this for the previous three weeks as I ‘knew’ what it would show. Like nearly 70% of men my age, there would be some disc bulges, and one of them would be misbehaving and I would just have to suck it up until the physio etc did its job. I didn’t want to know if it was worse than that as pure vanity prevents me from believing that I am no longer 25 years old. In my mind, I’m still ready to jump the fence and fill in as Centre Half Forward for the Melbourne football club at a minute’s notice. Also, but to a lesser extent, if I didn’t get an MRI my GP would not prescribe me any more medication, so off I went. Long story short, the MRI result required me to go to see another doctor, one with a scalpel.

Fortunately, I deal with many of these in my day to day work so I knew who I would like to see, and they had a spot available. I thought that I could take an alternate approach this time and state my case a tad more proactively - “I reckon a nerve block will do the trick and then I can fly to Cairns tomorrow, and from their to Darwin and back home again as I have a lot of people to see and if that doesn’t work we can discuss other options.” Again, my doctor smiled at me whilst looking at the MRI and, speaking softly, knowingly said ‘Sure, give that a go, and if it doesn’t work we can always talk about surgery as I don’t think this one is going to settle.” Sweet, a win for Dr Sid and all other ignorami out there!

The nerve block was great. I hobbled less and was even able to sit for more than 2-3 minutes for the first time in a week. Look out Cairns, here I come. Or not. Two days later I’m joking with an anaesthetist and wearing paper underwear and a gown whilst awaiting my microdiscectomy.

The rest isnt that interesting. Great surgery (thank you Dr Paul Licina), out of hospital three hours post op, walking around normally the next day and able to be back at work three days later, including interstate travel. Modern medicine - you rock!

What did I learn from this little adventure? Quite a lot really. Being a patient is not fun. Pain that stops you doing simple things like riding your bike, or seeing patients without having to get up and stand every couple of minutes, or sitting down, or walking, is bloody frustrating. And sometimes its easy to forget that when it has been a while since you’ve experienced it, or if you never have. Doctor lingo is great when talking to doctors, but can often fly over the heads of others, including patients. I discovered this when trying to explain to my family what was going on. I resorted to drawing pictures and will do this for patients now. Or use an App. There’s surely an App for that.

Making hard decisions regarding a patient’s health (in this case, pain management), is challenging for both the doctor and the patient. Communicating the reasons for making the decisions and undertaking the actions that you must do is vital to reduce the likelihood of creating a barrier between the healthcare provider and the patient. Actually communication is the key to all aspects of healthcare, and it is the main differentiator between an excellent and a poor practitioner.

I learned how important it is to keep an injured person’s mind active. I was going bonkers when I couldn’t sit to type or lie in a position that allowed me to read my notes and dictate. And daytime television is atrocious (BTW - 'Dr Oz’ and ‘The Doctors’ does not constitute health education any more than looking stuff up on Wikipedia does).

I learned that assumptions and ingorance are, well, stupid. Assumptions about what the pathology is. Ingoring the clinical signs. Assuming what the MRI would show based on the clinical picture, after ignoring the clinical signs, so avoiding it for 3 weeks. When asked what I would have done if a patient presented in front of me with identical symptoms, my answer was completely different to what I had done to/for myself. 

I learned the benefit of having something to aim for post op, it is a vital factor in recovery. For me it was getting back to work to put food on the table and do the things that I love doing. Different people have different priorities and its important to identify these and mold them into achievable steps to facilitate a return to normal living.

I learned about professionalism in a way that can only be done by observing how a colleague goes about their job. Occupational Physicians generally do not have the benefits available to them of the collegiate atmosphere that a hospital or group practice can facilitate, as we tend to work in relative isolation. This can also be true for others in the Occ Med sphere; health and safety reps, return to work co-ordinators, and site based nurses, physios and medics. Any opportunity that you have to discuss cases that went well or poorly, or where there was difficulty getting your point across to the injured worker, you should take it. And if there aren’t any opportunities, create them.

Now I have to go a wrestle my shiny new swiss ball back from the children and do my exercises, just in case my physio reads this. 

Health Surveillance - Why & How.

Health Surveillance can be confronting for an organisation. There are a number of groups that offer it, and there are just as many opinions on what is required for your organisation to meet its legislated and ethical requirements.

Health surveillance is used to identify those at increased risk of developing an occupational health disorder,  and detect adverse health effects at an early stage so the worker may be protected from further injury, either by control of the process or by removal from exposure. Health surveillance is not a control measure in itself, though it is a very important component in assessing whether an organisation’s control measures are effective. 

There are specific chemical exposures that have legislated requirements for surveillance under Work Health and Safety laws throughout Australia. Most of these, and the recommended tests, are listed here. This is prescriptive and advises on the minimum requirements. The tests that are recommended are based on best practice .

How do you determine which tests are used as part of health surveillance? You use relevant and validated screening tests. And this is the important factor, the tests must be screening tests, not diagostic tests. What’s the difference? In simple terms:

  • Screening test - a test that is used to identify potential indicators of illness or disease
  • Diagnostic test - a test that is used to confirm the presence of disease.

In other words, a diagnostic test is used by a doctor to confirm what they already think is going on. If a person has retrosternal crushing chest pain and the doc is pretty sure its an AMI , they will get an ECG to see if there are ST segment changes that confirm the AMI. 

A screening test is a different animal. Its purpose is to see if there are changes in the individual’s body that could be due to the exposure in question. And there are important things to consider when you design a screening test. It needs to fit the following criteria:

  1. Safe and acceptable - it MUST be safe and something that society will accept. No one would accept performing a brain biopsy on all workers to ‘check’  if their mercury exposure had caused structural changes in the brain. It’s also not safe to do this en masse in a clinic or on-site. 
  2. Simple and cheap - You want to be able to do it without specialised equipment that requires years of training to be able to use. And each test cant cost thousands of dollars or it will be too prohibitive to do the test on workforces across the country.
  3. Accurate - Speaks for itself.
  4. Sensitive and specific with reasonable PPV - It has to be sensitive enough to pick up the changes in the body, and specific enough that you know that the changes it shows are due to the exposure. To achieve this, you need to know what the exposure does to the body and at what level of exposure it has the effect.

All of this is important because there can be serious consequences if the test that is chosen is wrong. If the test is not sensitive enough to pick up changes in the human body from an exposure you could miss a problem and make workers sick. If the test isnt specific enough then you could incorrectly think that a worker is sick due to an exposure at work, when they either aren’t actually ill or the test results are due to another cause.

This is a problem when a ‘scatter gun’ approach is taken to health surveillance. Someone has advised an organisation with workers who are exposed to isocyanates that every worker should get a chest Xray and a blood test. Now, isocyanates can cause respiratory disease, namely asthma, but a Chest Xray will not show this. And a blood tests are also of no value in diagnosing asthma. 

For the organisation, this is a waste of money. For the worker it is exposure to harm (radiation and being stabbed for a blood test) that is unnecessary. Worse still, what about the poor worker who is found to have a minor change in there Full Blood Count and is then further subjected to a barrage of tests to make sure that the changes aren’t dangerous? What about the worry that they go through thinking that they are sick, and blaming their workplace or colleagues for it? As doctors, we are supposed to follow a set of rules, the first being "Primum non nocere” or "First do no harm”. By doing the wrong test, we are potentially harming people.

So, what seems like a simple process of doing some tests because you have to, becomes quite a specialised process. And that’s before you even get to the stage of interpreting the test results.

The people who are best trained and qualified to advise you on Health Surveillance are Occupational Physicians. Look them up and see what they have to offer.

What is an Occupational Physician and Why do I need one?

It is not often when I see patients for the first time that when I ask them if they have heard of an Occupational Physician that they say ‘yes’. In fact, when they do say ‘yes’, it is usually an indicator that they have been involved in protracted Workers’ Compensation  processes. Or, alternatively, they have misunderstood what I’ve asked, and think that I am an Occupational Therapist.

So, having said that, what is an Occupational Physician? If you think of a cardiologist, they are a specialist doctor who advises people about the managment of conditions to do with their heart. An Occupational Physician is a consultant specialist doctor who advises people on how their work can affect their health, and how their health can affect their ability to work safely. This is the role in a nutshell, but it incorporates so many facets. They are experts on injury management. They are experts on safe levels of exposures to chemicals and hazardous substances, both at work and in the community. And that’s where the ‘Environmental’ component of the specialty comes into play. You see, the correct title for an Occupational Physician is actually an ‘Occupational and Environmental Physician’, though we often use the title ‘OP’ to keep it simple. We hold a Fellowship with the Australasian Faculty of Occupational and Environmental Medicine within the Royal Australasian College of Physicians.

Unfortunately, there are some doctors who call themselves Occupational Physicians who are not qualified through the Australasian Faculty of Occupational and Environmental Medicine. Whilst this is not against the law, it is unfortunately misleading. It also places them and those who rely on their advice in a precarious position in that the advice provided and relied upon is not backed up by formal training, qualification, and continuing professional development that is required for Consultant Occupational and Environmental Physicians. It means that this advice would be difficult to defend if it was ever questioned. The message here is; check the the qualifications of any doctor that you rely upon for advice.

The upside is, when you do have a qualified OP, the advice that you receive is evidenced based risk management advice.

So what do we actually do? Take a look at the video below which I will use as an attempt at a metaphor…….

See how much easier it is to appreciate a situation more completely when you sit back and take in the entire picture? All of those things that we each missed when we were focussed on one particular aspect (the detective in the video and what he was saying) become apparent when you can see the situation in its entirety. 

That is what an Occupational Physician does. They take into consideration more than just what is directly in their focus, but stepping back and assessing the individual, their environment, the mechanism of an incident, and the evidence base to assess the likely causation of an individual’s injury or illness, and determine the best way to manage the situation to maintain the health and safety of the individual.

"But I’m a Heath and Safety representative or Return to Work Co-ordinator in an  Insurance / Mining / Aviation / Transport / Tourism / Recruiting / Government / mum and dad small business / health provision organisation? How do OPs help me and my organisation? 

Well, again, look back at the video and see how the external perspective allows for a better understanding on a situation. An OP can help you organisation to identify key areas of risk for the health and safety of your workers. This will reduce injuries and illness, leading to healthier and happier workers, as well as decreasing the costs of insurance premiums. And, if the unfortunate does occur and a worker is injured, then an OP can advise on the best treatment for the worker to return them to normal living as soon as safely possible, and assess them to determine any ongoing risks for their health in the workplace.