the change in medical practice over the last 40 years,

Key points

Thanks to Gavin Pogue  for inviting me to speak today at SCR, ALSO TO President Danny Hogan and Roy Hill for inviting me along to Rotary

My theme today  is the change in medical practice over the last 40 years, particularly for GP’s  and their patients in the country towns like Shepparton.

A bit of background
In 1981 Shepparton was a thriving metropolis of  24,000 people and Carlton had just sneaked a grand final. Seymour won the local grand final.  Malcolm Fraser was the PM  and Rupert Hamer was Victorian Premier. Locally we had Bruce Lloyd as our federal MP, Bill hunter as mayor and Peter Ross Edwards as the local MP. Suede flares were just out of fashion except for Shepparton weddings.

I arrived on Dec 15 1981, new baby, into a new practice and new life. General Practice then was an apprenticeship, building up patient numbers, learning from the older GP.’s as one became a family doctor. Reports were written on 5×8 cards with the barest of illegible comments. Failure to give an antibiotic to a sick child led to reproval from the others when they had to do a call out later that night when the child became more unsettled.

GP’s then were jack of all trades expected to do moderate surgery, deliveries and anaesthetics. Melbourne was over 2 1/2 hours away by road and the new Base Hospital had only just opened. Up until then GP’s had run the local hospital which had been based in Mooroopna,Ron Gwynn was the medical director.  Shepparton offered 4 small group practices which was better than the solo practice in small towns  usually working from a converted house. We were expected to do long hours on call, deliveries during the night, home visits and emergencies needing plaster or suture that dominated the life style. Wives were receptionists, backstops and substitute doctors when the doctor was out. No mobiles then , no computers,  billing systems based on trust with payments being made up to 3 months late, Patients had their own doctor and had to be sent back to them after being seen for an emergency. We had to buy into the practice with a large goodwill component and some bricks and mortar.

Roll on the years!
Every year would bring new advances in medical treatments, surgical procedures, obstetrics and psychiatry.
Plus the introduction of computers from 1980 onwards in many different ways. Epidemiology and recording and communication.
Mobile phones and faxes were introduced then the curse of e mail.
Equal opportunity and government scholarships opened the way to greater female participation in the medical workforce. Changing societal values led to shorter working hours and greater emphasis on personal values and freedoms for the general population which then moved into the medical field.

Some of the good

Medicare initially. 1975
One flew over the Cuckoos nest effective treatments 1975
Ulcer surgery replaced by Pills. 1981 Barry Marshall and Robin Warren 1985
Christian Barnard and open heart surgery. 1967 leading to CABG’S
Test tube babies and IVF. 1978
Caesarean sections.
Cryotherapy and diathermy
Good preventative medicine
Stop smoking campaigns.Skin campaigns, PAP testing.

and the bad
HIV IN 1979
Greater accountability led to the growth of specialization and the decline of active general practice. Freezing of rebates led to poorer services being offered and the growth of government supported after hour services and casualty attendance for emergencies. Economics dictated large clinics and a loss of the family doctor role which will be gone in the next 5 years.

The ugly
increased litigation.
Increased recording and regulatory demands without commonsense.
The privacy act.
Medicare

The funny.
Acupuncture.  BB story.
A patient was having an acupuncture session with her GP who was newly trained. He had put 15 needles in when called away to a phone call. As he was locking up at 6.00 he heard a plaintive cry from the acupuncture room Can I go home now. Well yes as soon as the needles were out and no a long visit was not charged.
Going halfway to Dookie to give a painkiller injection to a man with severe back pain immobilized on the kitchen floor. then finding he had a Benalla doctor who had refused to come out.

The dramatic
Real home doctoring
Out to pick up B boy after knocked of bike on cnr Balaclava and Wyndham St, beat the ambulance.
Attending a psychiatric emergency when police called to ask if I would talk to patient who had barricaded himself in his house with a gun. On arriving in the street the two policemen put bulletproof vests on and we edged along the house to the front door. The sergeant and I asked if we could come in  and talked him into putting down the gun.

The sad
For a GP. Some things never change ,having to give bad news on diagnosis.
For patients the loss of the family doctor. I saw a lot of second and third generation patients over that 35 years and built up rapport both ways. Some of you probably still have your family doctor who is nearly always there but this is becoming a rarity in Shepparton.

Life lessons
The patient is always right .
people who call late at night are genuinely sick.
You can never tell over the phone how bad an injury is.
Get a doctor who gives you time [hint they are always late and it hurts waiting but you will get the attention you need].

I retired after 35 years in general practice and had a medical career for 50 years. I would still be involved today if the regulations had not become so onerous and unwieldy. Something that affects most careers these days.

Lastly I would like to remind Rotarians that health is a field that can offer opportunities for us to help the community in.

Thank you all for listening

lovely lemon tree.

When I was just a lad of ten, my father said to me, “Come here and take a lesson from the lovely lemon tree.” “Don’t put your faith in love, my boy”, my father said to me, “I fear you’ll find that love is like the lovely lemon tree.”

Lemon tree very pretty and the lemon flower is sweet But the fruit of the poor lemon is impossible to eat. Lemon tree very pretty and the lemon flower is sweet But the fruit of the poor lemon is impossible to eat.

One day beneath the lemon tree, my love and I did lie A girl so sweet that when she smiled the stars rose in the sky. We passed that summer lost in love beneath the lemon tree The music of her laughter hid my father’s words from me.

One day she left without a word. She took away the sun. And in the dark she left behind, I knew what she had done. She’d left me for another, it’s a common tale but true. A sadder man but wiser now I sing these words to you.

“Vieni qui e prendi una lezione dal delizioso albero di limone.” “Non mettere la tua fede nell’amore, ragazzo mio”, mi disse mio padre, “temo che scoprirai che l’amore è come il delizioso albero di limone”.

Il limone è molto carino e il fiore del limone è dolce, ma il frutto del povero limone è impossibile da mangiare. Il limone è molto carino e il fiore del limone è dolce, ma il frutto del povero limone è impossibile da mangiare.

Un giorno, sotto l’albero di limone, il mio amore e io abbiamo mentito. Una ragazza così dolce che quando sorrideva le stelle si alzavano nel cielo. Passammo quell’estate perduti nell’amore sotto l’albero di limone. La musica delle sue risate nascondeva le parole di mio padre.

Un giorno se ne andò senza dire una parola. Ha portato via il sole. E nel buio che si era lasciata alle spalle, sapevo cosa aveva fatto. Mi ha lasciato per un altro, è una storia comune ma vera. Un uomo più triste ma più saggio ora canto queste parole per te.

the boat has a problem.

luciferro bearer of the light or knowledge implies as does GOE that knowledge and insight is bad and belongs only to god.If we are characters in a play written by a god and even if he uses a tabula erasa the story cannot be untold. Do the characters, if sentient have a pre knowledge that they would go through these fates willingly and volunteer for it [The fair way] hoping to gain real death, loss of knowledge, Or are they just a story line whose pain and emotion an disintegration, while conscious of it was merely visitated on them by the author. in full knowledge of the effect that it had? Worse if a story, It can be read from both ways.

The boat that floats. a biased view of life, and people.

The premise is simple.

A boat is floating in the sea. So, on the durface, waterproof and coping with its surroundings, engine going and able to cope with problems as they arise.

But now we are told that the boat has a problem. A hole below the water line big enough to sink her in 6 hours and no way to repair it. Engines not working and no pump on board.
We are unable to help though we can communicate with the boat.
6 hours pass and the boat is still floating at the same level. Two days pass, a yera passes and still the boat floats.
What is going on?

This analogy has many real life situations. In personal relationships, politics, health , sports and life in general.     Analogies +++

So what is really going on?
The simple answer is that

+

 

 

 

5 Balls/points

Conundrums  Observer or observerless

1 ball no space no time no weight no dimension no colour, no taste no vibration

2 balls seperate so introduces notion of space or distance in a straight line between them

3 balls Triangle relative distance, angles 180 degrees.

Memory Input
Information through sensation
We can only memorise what we observe or imagine but we can only imagine after we have observations to work on, otherwise our memory is a tabula rasa. Observation is through our senses. We can input auditory visual tactile taste and smell, the 5 senses. We also have proprioception a sense of orientation. These allow us to perceive the world about us through the medium of our senses. We also have a perception of time based on the changes in these perceptions.
The world can be observed through other senses that we do not have but are able to piggyback onto by re evaluating them in terms of the senses that we do perceive.

Hence microscopes telescopes Infra red [predator] U Violet radio waves etc as we have learnt from our science talks. Magnetic fields and electrical signals are used by birds and fish and bats used high pitched sounds that we cannot hear. CT scans and MRI and USS are other mediums we use.

Our input is only as good as our receptors [senses] allow. Visual problems, hearing problems reduce our capacity  to assess and store information. .

The observations are assessed and recorded in specific areas of the brain, visual cortex, auditory cortex. but also go to all areas of the brain for further consideration, organisation, action and storage. The scope for this central processing room is a little beyond the remit of this talk though it is vital for our talk today on memory.

Memory storage by the brain is still controversial. There is no one site in the brain that it is stored in. Medical studies have shown that multiple variable sites all over the brain are active and activated when using ones senses. The main theory is that the neurons in the brain set up multiple  interconnecting pathways and  some have the plasticity to store the inputs and retain this as information that can then be used. More recent studies suggest that memory information is actually stored in the cells themselves and is able to be recovered.
Conceptually we liken our brains to computers. This is actually truer than you think but it is not yet proven or understood. [Why explain later re nature of inputs* binary].

Memory is classified partly by storage and partly by the input system.
Visual memory
Auditory, etc.
But also by the use we make of it through our CPU. to organise both our thinking and our emotions. Different areas of the brain help control our different types of thinking and our emotions.
Hence we have a speech [Broca’s] area usually on the left side of the brain where we organise our languages.
Here we have emotional memory, map memory, photographic memory,
Many of these areas have been shown by MRI techniques whereas in  the older days brain mapping was done by observation on the changes in thinking people had with brain injuries like stokes.

Why do we have memory, what is it used for and what advantages and problems does it cause?

Evolutionary wise memory was something that developed accidentally in self replicating proteins that helped them survive better. Life itself is memory in that the RNA is a memory code that makes more RNA , a self explaining loop. Humans like to look for reasons for behavior but here none are needed, By definition ongoing replication must have built in mechanisms to do so [cue Aliens again], Evolution dictates that if a better way of doing so comes along it will be incorporated, not that it needs to be.
Hence if a sense developed that was protective it would be incorporated. Sensing food, seeing danger and reacting appropriately were not necessary, just useful improvements., The protobrain was the cell and its cell wall. The memories of pain, heat, thirst and actions to alleviate them improved over time and were coded for by the RNA and developed in the cell.

Some of memories are stored in a special memory organ, the brain. Needed by a gigantic billion cell organism.But every cell in our body had both cellular memory and RNA memory and DNA memory and can react without central nervous involvement. Our immune system has an Immune memory which develops and improves throughout our life without any need to be involved with our brain.Our bodies develop under the remembered response of hormonal and time influences to dramatic changes from birth to adult hood then senescence. Our organs react to food input in the appropriate manner and as humans we have a diurnal lifestyle imposed on us by remembered  evolution.

There is a lovely Frank Sinatra song, “Memories are made of this”

(The sweet, sweet memories you’ve given me
You can’t beat the memories you’ve given me)
Take one fresh and tender kiss,
Add one stolen night of bliss,
One girl; one boy; some grief; some joy:
Memories are made of this.
Don’t forget a small moonbeam.
Fold it lightly with a dream.
Your lips and mine,Two sips of wine:
Memories are made of this.
Then add the wedding bells;
One house where lovers dwell;
Three little kids for the flavor.
Stir carefully through the days See how the flavor stays.
These are the dreams you will savor.
With His blessings from above,
Serve it generously with love.
One man, one wife, One love, through life:
So what is a memory, what is memory.
Memory is the ability to store and recall the past events of our life.
To remember words and language rules in a way to think clearly and communicate
To find our way around our world and identify those persons and things we come in contact with. It is the gift that enables our CPU to think clearly and also to plan and think ahead or fall into a muse and remember.
But it also a psychological aide, for good or ill to help us through our lives.
It allows us to develop and express our emotions and helps form the base of our conscious, consciousness and the person we will be through life.
When we are young we have no time for memory we are too busy developing it, When we are old we spend too much time using it and the one thing we fear is losing it.
Memory loss is built in to mist of us like aging. We need all the brain cells we can have even though we do not appear to use them at anywhere near their fill potential . We lose 200,000 a day from birth but this 6 billion over 90 years is only a small part of the 42 billion available.
Nevertheless losing a big chunk of the brain by repeated damage as in boxing or concussion injuries with LOC or strokes is not a good thing. Some people have a sensitivity to alcohol damage to the brain instead of the liver [Wernicke’s encephalitis]. For most of us this is not a problem. B12 deficiency can cause problems. Meningitis, encephalitis and syphilis are infections capable of causing brain damage. The most problematic is Alzheimer’s disease or presenile dementia which is the early onset of dementia. The cause is still unknown though there is a genetic tendency to early disease in some people. MRI has helped diagnosis but it is usually best diagnosed post mortem..
Senile dementia is related to vascular damage from atheroma  over many years and usually occurs at a later age. Other rarer conditions exist. Parkinson’s, Huntington’s, etc
Prevention.
I will be controversial here and merely say that I have never been made aware of an effective strategy for countering Alzheimer’s disease.
It behoves all of us to reduce our risk by living life in moderation and avoiding Bungee jumping.
Early diagnosis can make a big difference to the sufferer and their partner.
The best clue is a sudden change in simple tasks by an otherwise reliable person.
Putting plastic dishes in the oven [more than once], Forgetting appointments regularly, losing things or repeated “thefts”.  Putting dints in the car and for doctors in the audience people repeatedly asking for lost scripts and what the medicine is for. It is very hard to diagnose but quite obvious when the diagnosis is made.
Should we attempt to improve our memory?
Yes. Old dogs can learn new tricks. One of the secrets of staying younger physically and mentally is to try new challenges and new activities. We still have a capacity, so many brain cells left, that we can easily improve our brains and enjoy life more.
Crosswords, Sudoku, Board and card games, Trips, Trivia and U3A.

Memory tricks.
The secret to improving your memory is to want to improve your memory.
The tip to improve your memory is to write things down, not necessarily a diary, even a scrap of paper will help

The Zeigarnik Effect

When you start working on something but do not finish it, thoughts of the unfinished work continue to pop into your mind even when you’ve moved on to other things. This can be useful as a counter to procrastination.

Language is difficult. Basically all language is asking or answering a question.
This can be internal or external as to whether the person being addressed is self or other.
Communication and understanding are the motifs, the reason for using language.

We can only understand what our particular mindset lets us understand.
Hence some truths and understandings are not available to everyone.

[Digress second and third body problem, Einstein, No channel to the other person[s]].

 

verbs

Understanding Transitive and Intransitive Verbs
Intransitive verbs are verbs which cannot have a direct object. If you add a direct object to an intransitive verb then you get a sentence which doesn’t make any sense.

Examples:  I swim the purse.    I go a pizza. , “swim” and “go” are intransitive verbs. At least, in English…

As a general rule, consider the English tense of any verb (my examples here all use past tense), and then ask the question “What?”, using the same tense of the auxillary verb:

  • I drank. What did you drink? Drink is a Transitive verb (it takes an object– I drank beer, for instance).
    I wrote. What did you write? Transitive.
    I saw. What did you see? Transitive.
    I came. What did you come? That makes no sense– Come must be Intransitive!

It is most often verbs of Personal Motion/ Action or States of Being that are Intransitive.I was born. What did you born? Nonsense; State of being; Intransitive.
I sat. What did you sit? Motion. Intransitive
I laughed. What did you laugh? Action. Intransitive.

In Italian, it seems that there are always some irregularities. But, for the most part, the English definition holds true.
In Italian, Transitive verbs use the auxillary verb form of AVERE, while Intransitives normally use the auxillary verb form of ESSERE/ STARE when combined in the past participle tenses.
You just have to memorize certain Italian verbs because some of them can be used in both Transitive and Intransitive forms, while others are Intransitive in English but Transitive in Italian. For example:
Abbiamo corso per dieci minuti (We ran for ten minutes). Intransitive, but using AVERE in Italian.
Ho lavato la macchina (I washed the car). –What did I wash? The car. Transitive.

Note  Mi sono lavato la faccia (I washed my face). –Reflexive verbs are (edit) usually Intransitive.

Imperative fun

Let’s try to use the expression let’s do things a lot today in many ways.

I will give everyone a list of verbs and we will make as many sentences and ideas as we can.

Let’s go, where and why   Intransitive

andiamo al negozio per compare un giornale di leggere.

andiamo al cafe di bevere  una tasse di cafe con nostri amici.

Prendiamo il autobus finale alla citta stasera per videre I fuochi d’artificio.

let’s eat what and how Transitive

let’s sit down where and why  Reflexive hence Intransitive

Dimmi Dammi shimmy shammy

give me your name or tell me your name?

Dimmi il tuo nome. Tell me your name is the right way to say this in Italian.

Though one could say Dammi il tuo nome it is wrong hence not used.

Here the verb Dicere is used, it means to say or to tell-

Sensodione

The attack, when it came, was unexpected, high level and no holds barred.

As the saying goes, no plan survives the first contact with the enemy.

Hosie was in bathhouse, in the pool, in the fast lane and in good spirits.  Savannah was walking briskly in her white, golden clasped high heels, wheeling the communication trolley when the glass doors at the end of the atrium exploded inwards shredding the palm trees and cyclid pots protecting the entrance. Matt the security guard at the eastern entranced  was knocked to the ground, blood flowing from his face and nose into the pool waters as he lay limp and drowning.  Savannah screamed and collapsed on her knees hol ing her right shoulder.
Hosie hit the red duress alarm on the pool side and grabbed a speargun from the recess flipping on to his side to watch the door. Three men burst through the shattered door glass, wearing goggles, masks and holding  laser  light .394 Glocksheims. Hosie let the first spear loose ripping through the air and lodging in the upper chest base of the neck, Pivoting his aim he took out the second man through the right eye, dived as bullets cut up the water towards him from the third.

His thoughts went back to the plan, to Ritchie’s paranoia and concern re his reflexes. Your’e getting old mate, nearly 25, Why bother with the risk?.He smiled. Ritchie was the dork, the true computer geek bought to life. he could no more fire a gun straight than ride a skateboard.

s

Infection occurs when skin comes in contact with contaminated freshwater in which certain types of snails that carry the parasite are living. Freshwater becomes contaminated by schistosome eggs when infected people urinate or defecate in the water. The eggs hatch, and if the appropriate species of snails are present in the water, the parasites infect, develop and multiply inside the snails. The parasite leaves the snail and enters the water where it can survive for about 48 hours. Larval schistosomes (cercariae) can penetrate the skin of persons who come in contact with contaminated freshwater, typically when wading, swimming, bathing, or washing. Over several weeks, the parasites migrate through host tissue and develop into adult worms inside the blood vessels of the body. Once mature, the worms mate and females produce eggs. Some of these eggs travel to the bladder or intestine and are passed into the urine or stool.

Symptoms of schistosomiasis are caused not by the worms themselves but by the body’s reaction to the eggs. Eggs shed by the adult worms that do not pass out of the body can become lodged in the intestine or bladder, causing inflammation or scarring. Children who are repeatedly infected can develop anemia, malnutrition, and learning difficulties. After years of infection, the parasite can also damage the liver, intestine, spleen, lungs, and bladder.
Common Symptoms

Most people have no symptoms when they are first infected. However, within days after becoming infected, they may develop a rash or itchy skin. Within 1-2 months of infection, symptoms may develop including fever, chills, cough, and muscle aches.
Chronic schistosomiasis

Without treatment, schistosomiasis can persist for years. Signs and symptoms of chronic schistosomiasis include: abdominal pain, enlarged liver, blood in the stool or blood in the urine, and problems passing urine. Chronic infection can also lead to increased risk of liver fibrosis or bladder cancer.
Epidemiology & Risk Factors

Schistosomiasis is an important cause of disease in many parts of the world, most commonly in places with poor sanitation. School-age children who live in these areas are often most at risk because they tend to spend time swimming or bathing in water containing infectious cercariae.
If you live in, or travel to, areas where schistosomiasis is found and are exposed to contaminated freshwater, you are at risk.

Areas where human schistosomiasis is found include:

Schistosoma mansoni
Distributed throughout Africa: There is risk of infection in freshwater in southern and sub-Saharan Africa–including the great lakes and rivers as well as smaller bodies of water. Transmission also occurs in the Nile River valley in Sudan and Egypt.
South America: Including Brazil, Suriname, and Venezuela.
S. haematobium
Distributed throughout Africa: There is risk of infection in freshwater in southern and sub-Saharan Africa–including the great lakes and rivers as well as smaller bodies of water. Transmission also occurs in the Nile River valley in Egypt and the Mahgreb region of North Africa.
Found in areas of the Middle East.
A recent focus of ongoing transmission has been identified in Corsica.
Diagnosis

Stool or urine samples can be examined microscopically for parasite eggs (stool for S. mansoni or S. japonicum eggs and urine for S. haematobium eggs). The eggs tend to be passed intermittently and in small amounts and may not be detected, so it may be necessary to perform a blood (serologic) test.
Safe and effective medication is available for treatment of both urinary and intestinal schistosomiasis. Praziquantel, a prescription medication, is taken for 1-2 days to treat infections caused by all schistosome species.

Page last reviewed: June 22, 2018
Content source: Global Health, Division of Parasitic Diseases
Schistosomiasis