There’s a lot of it going around
— A GP'S ODYSSEY
Scoring a hole in one is an achievement for any golfer at any stage in life. What made Bessie’s achievement more noteworthy was that she was 84 years old and being treated for cardiac failure and osteoarthritis of her hips and knees.
Leon Piterman weaves many anecdotes about his patients into his critical account of contemporary General Practice. They are not mere case studies but show the compassion which is an element in the make-up of a good doctor as vital as medical training or diagnostic skill. “There’s a lot of it going around” has information, stories and advocacy. It is a book to enjoy and learn from.
I have often heard it said that whoever is in front of you is your teacher. If reading these fascinating, touching and often humorous tales from general practice is anything to go by, Leon Piterman has accumulated more than a lifetime’s wisdom from his patients.
Associate Professor Craig Hassed OAM
I loved reading A GP’s Odyssey. All doctors and medical students will identify with this precious book from an inspirational GP. It will make you laugh, cry and celebrate the unique and valuable role of the generalist in comprehensive patient care. You will love it too.
Clinical Professor Leanne Rowe AM
Sometimes poignant, sometimes hilarious the stories in this GP’s odyssey are filled with what makes general practice unique—pumpkin scones, family tragedy, those determined to live and the stoic humble elderly coming to terms with their fate. Ever the great educator, Leon Piterman’s stories has learnings for us all.
Professor Danielle Mazza
Monash Conference Centre, Collins Street, Melbourne
Tuesday 30th Jully 2019
“There is a lot of it going around.” A GP’s Odyssey
I have been a general practitioner (GP) for 40 years , 15 of these years in full time general practice and 25 in part time general practice, blended with an academic career, mostly at Monash University. I have estimated that during these 40 years I have engaged in some 140,000 consultations. My colleagues in full time practice over the same period will have engaged in over 250,000 consultations. I cannot think of any other profession whose members engage in this many consultations over a lifetime of practice. Knowing that I work predominately in an academic environment, I am often asked by friends and colleagues if I still see patients or if I do is it “just to keep your hand in”. I see patients because I need to be grounded in reality and in real life experiences which patients continually provide.
I enjoy interaction with my patients, many of whom I have known for more than three decades. Having worked in the same practice for most of my professional life I have had the privilege of caring for families over several generations. Patients who were in their thirties or forties when I first met them are now in their seventies or eighties. Those who were young parents are now grandparents. Continuity of care, an essential ingredient of general practice, affords us a unique opportunity to share in our patients’ life journey, and for some, to also share in ours. I also maintain that blending clinical practice with academic activities has prevented me from suffering professional burnout.
Patients continue to be a valuable source of learning. Not so much hard core evidence based biomedical learning, but deeper learning about the nature of the human condition. This happens when patients share their innermost thoughts and secrets as well their worries, fears, anxieties and apprehensions, whether it be in response to their own illness or illnesses that involve their families or close friends. In fact clinical consultations may not focus on illness at all but on changing social circumstances. Separation, divorce, job loss, bankruptcy, loss of a pet, all may occupy a considerable component of a GP consultation.
My patients’ emotional journey has been accompanied by my emotional response, be that overt or covert. I have laughed with my patients and I have cried with my patients. It seems only natural that this should occur. It is what we call in general practice “the connexional experience.”
General Practitioners , both established as well as those in training are encouraged to be reflective in their day to day practice. This involves reflecting on each consultation from a biopsychosocial perspective which includes asking some “meta-questions” such as “why him or her and why now”.
As I reach the twilight of my clinical career, I have had an opportunity to reflect on my time as a GP and recall patients and clinical encounters that have had a lasting effect on me at least to the extent that I have been able to readily recall the encounter and subsequently to make some sense of it. I believe I have been able to recall these events because they have generated an emotional response which has varied in nature and intensity, and has remained indelibly imprinted in my psyche. These responses (on the part of the patient or on my part) have included the following, for convenience, in alphabetical order: anger, acceptance, betrayal, confusion, denial, despair, elation, frustration, gratitude, guilt, happiness, hope, humour, indifference, joy, outrage, pathos, resignation, resilience, shame.
This book of short stories, based on real but de-identified clinical encounters, is designed to capture aspects of patients’ stories, their emotional response and to explore my own parallel response as their treating doctor. As GP readers engage with these stories I believe that they will experience a sense of familiarity and a sense that my emotional responses are by no means unique. All GPs will at some time experience similar responses triggered by a variety of clinical encounters. That is why I have given the book the title “There is a lot of it going around.” A GP’s Odyssey.. Not all responses will be the same. We are after all different.
These cases have previously been published on a monthly basis between 2016-2018 in “Medical Republic”. I wish to thank that journal and its editor Grant Holloway for giving me permission to publish them in this format. I also wish to thank my colleague, mentor and friend Professor John Murtagh for agreeing to write the foreword to this book.
Leon Piterman AM
1 Muscle Soreness?
Maria and Giuseppe had been long standing patients of the clinic. I took over their care when my colleague retired. They were in their 50s when I first met them. Giuseppe was a bricklayer and apart from occasional back pain and problems with an arthritic knee he rarely attended. He was a solid, burley looking man, seldom cleanly shaven, had the large roughened hands of a seasoned bricklayer and an evasive demeanor. Maria was a more frequent attender. She was slim, always neatly dressed, softly spoken. She ran a small clothing repair business from home. Her son and daughter were married and had left home. She had mild hypertension which required medication, had regular Pap smears, mammograms and flu shots. What troubled me most were her peculiar muscle aches and pains for which I could not find a cause. On some occasions when I examined her the pains were accompanied by bruises and I wondered if she may have a form of vasculitis. Repeated tests for inflammatory muscular, joint or vascular conditions were normal. She looked well, generally felt well and denied any emotional problems.
Having remained diagnostically destitute for over a year I suggested she see a rheumatologist. He was so impressed at clinching the diagnosis he felt compelled to phone me.
Maria was being physically abused by her husband and this had gone on for over 20 years. He had a drinking problem and when inebriated he became violent. The muscle aches and pains and occasional bruises were the aftermath of the abuse.
Maria was too embarrassed to tell me because I also looked after her husband and she thought I would raise the matter with him which would make matters worse for her. She felt comfortable in telling the specialist. She was unaware that I was bound by patient confidentiality. This was a secret she could not share with me.
So much for Family Medicine! I felt hopelessly inadequate. Should I have asked the right questions and even if I had been insightful enough to do so would I have received truthful answers?
“There’s a lot of it going around – a GP’s odyssey” by Leon Piterman
Review by Dr Andrew Pattison
St Vincent's Hospital 2020 Summer Newsletter
Professor Leon Piterman AM is a well-known and much published academic GP from Monash University. He is an expert in medical education and research and is internationally recognized in those fields. He has also been a practising GP for over 40 years – full-time for the first 15 years and then part-time, alongside his research and teaching commitments. In short, he brings a unique perspective to this book on the experiences of a family doctor.
“There’s a lot of it going around” is a small paperback book of around 80 pages. It has 25 brief chapters exploring some interesting case studies, with key observations and reflections. It is drawn from articles previously published between 2016 and 2018 in the medical magazine Medical Republic. It is just the right size to slip into your briefcase and browse through while having a coffee or to sit up in bed with at night. The separate chapters are short enough to read through easily and entice you back later for more. The stories are always authentic and readable, and at times poignant and confronting. There are a few amusing stories as well with some laugh-out-loud moments for the reader. The book has a refreshing honesty. It is not treatise of diagnostic triumphs; it also includes situations when things didn’t go so well or when diagnoses may have been delayed or overlooked.
GP’s are in an amazing position to observe what goes on in people’s lives. There is simply no other profession that offers this exquisite vantage point. As GP’s, we are inspired by people as they deal with illness. We share their happiness and their sorrows. And yes, we share a little of their grief and suffering too. Leon Piterman demonstrates all of this beautifully in his book. It celebrates the strength of the human spirit and how serious illnesses impact on other members of the family. Tough issues are also included in There’s a lot of it going around – sexual abuse, domestic violence, heart-sink patients, mental illness and elder abuse. The awkward situation of dealing with unwelcome advances from a patient is also discussed.
Over the years much has been said about the Art and the Science of Medicine. General Practice is a specialty where the two can and should work beautifully together. Evidence based medicine has been so important in refining our diagnostic processes and treatments but it should not exclude the humanity of being a GP. Leon Piterman’s reflections and stories illustrate this very clearly.
There’s a lot of it going around is an excellent read. It has something for everyone – medical students, doctors in training, practising and aspiring GP’s, and certainly any medical specialist who might want to know more about how patients wind up getting referred to them in the first place. However, it is a great read for anyone in the community to learn a little about what being “just a GP” is all about.
Dr Andrew Pattison OAM is a St Vincent’s alumnus, a GP in Ivanhoe and a published author.
Infectious and insightful
Phillip Siggins reviews There is a lot of it going around — A GP’s Odyssey
The Weekend Australian, August 10-11, 2019
If you are anxious about consulting your GP and looking for reassurance, read this book. It will allay your fears because it reveals how self-aware, alert and compassionate doctors must strive to be. Such competence only comes with courage, openness to experience and humility in the face of life’s complexities and mysteries.
This “GP’s Odyssey” is a short book. It contains 25 stories drawn from Leon Piterman’s practice as a doctor in Melbourne. Medical practice affords a remarkable view of the human condition: think Chekhov and his short stories.
Piterman estimates that in his 40-year career he has engaged in about 140,000 consultations. The vibrant stories he has selected from that breadth of experience resonate with what his colleague John Murtagh describes as “the buzz of the human encounter”.
In an introduction Piterman explains the stories are based on “real, but de-identified, clinical encounters... designed to capture aspects of patients’ stories, their emotional response and to explore my own parallel response as their treating doctor”. The target audience incudes his fellow GPs but I read the collection as a lay person and a patient and found it engaging, not least because the writing is vivid and accessible. There is also, of course, a certain voyeuristic enjoyment in reading about other patients’ lives.
Each chapter in There’s a Lot of It Going Around presents a story followed by Piterman’s response. His instructive commentary puts each story into context, framing the clinical encounter with serious, humane insights into diagnostic challenges, case management and problem solving.
The first story, “Muscle Soreness?”, sees Piterman confounded by the hidden reality of domestic violence. Maria and Guiseppe were longstanding patients, Maria attending the clinic more frequently than Guiseppe. Piterman is troubled because he cannot find a cause for her peculiar muscle aches and pains. “She looked well, generally, felt well and denied any emotional problems.”
Puzzled, he refers her to a rheumatologist who quickly phones back with the diagnosis. For 20 years Maria had been physically abused by Guiseppe. The aches, pains and occasional bruising were the result of that violence. Piterman’s initial response is one of sadness, frustration and regret. Maria had been too embarrassed to disclose the situation because she thought Piterman would raise the matter with her husband She was unaware of patient confidentiality, yet she felt comfortable in telling the specialist.
Piterman feels “hopelessly inadequate. Should I have asked the right question and even if I had been insightful enough to do so would I have received a truthful answer?”. This immediate reaction gives way to a calmer, more empathic response in which he seeks to understand Maria’s nondisclosure of abuse through considering her social, cultural and marital situation. There is something wistful in his concluding statement “I was left wondering how many other cases I had missed by not being attuned to the possibility of domestic violence. Current publicity has made me much more aware.”
Awareness is central and Piterman is able to identify child abuse and elder abuse in some cases. In “A Caring Grandfather?”, he has to deal with a spectacularly indifferent child abuser, one who, having been caught, is “more concerned about the emotional consequences he might suffer than any damage he may have inflicted on his granddaughter or her family”.
Shocked at the man’s lack of insight, guilt or remorse, Piterman is also frustrated by the abuser’s attempts to rationalise the situation to his advantage. After his trial the man presents himself for a check-up and he is a “shadow of his former self”. Yet, the shattered man is Piterman’s patient and in need of guidance and some help. Despite his personal feelings, Piterman must explore this patient’s medical and psychological needs. “When there is tension between personal feelings and professionalism or duty of care, the latter should prevail.”
Other encounters are equally compelling. A wide range of conditions is explored, from dementia to the intractable cases that Piterman identifies as “heart-sink” patients. And the cast of patients is various and fascinating. This is both an important medical text and a book that anyone can enjoy and learn from.
Phillip Siggins is a writer and critic.
Buy this book – or we shoot the dog
Grant Holloway reviews There is a lot of it going around — A GP’s Odyssey
The Medical Republic, June 13, 2019
ONE OF THE GREAT PLEASURES OF EDITING A PUBLICATION SUCH AS THE MEDICAL REPUBLIC IS THE INTERACTIONS WE HAVE WITH OUR DEDICATED BAND OF WISE, WITTY AND ALL-ROUND WONDERFUL CONTRIBUTORS.
None more so than with the peerless Professor Leon Piterman, who contributed a monthly column, called “There’s a lot if it going around”, to our magazine and website between 2016 and 2018.
Very few of the tasks beholden of an editor could match the delightful serendipity of being one of the first to read Professor Piterman’s entertaining and insightful articles.
And now the good folks at Melbourne’s Black Pepper Publishing have collected 25 of these contributions into a book, providing a handy repository of valuable information, anecdotes and advocacy for the critical roles GPs play in the healthcare of our society.
But don’t take just our word for it.
“All doctors and medical students will identify with this precious book from an inspirational GP. It will make you laugh, cry and celebrate the unique and valuable role of the generalist in comprehensive patient care,” writes Clinical Professor Leanne Rowe AM.
“Sometimes poignant, sometimes hilarious, the stories in this GP’s odyssey are filled with what makes general practice unique – pumpkin scones, family tragedy, those determined to live and thr stoic humble elderly coming to terms with their fate. Ever the great educator, Leon Piterman’s stories have learnings for us all,” Professor Danielle Mazza says.
By way of background, among other things, Professor Piterman AM, MBBS, MD Mmed, MedSt FRCP (Edin) FRACGP, is Professor of General Practice at Monash and Director of Monash China GP Training. He is also the Foundation Head of the School of Primary Health Care and past Pro-vice Chancellor of Monash’s Berwick and Frankston campuses.
He also maintains a part-time clinical general practice in Moorabbin, Victoria.
“General practitioners, both established as well as those in training, are encouraged to be reflective in their day-to-day practice,” Professor Piterman writes in the preface to this collection.
“As I reach the twilight of my clinical career, I have had an opportunityto reflect on my time as a GP and recall patients and clinical encounters that have had a lasting effect on me.
“This book of short stories, based on real but de-identified clinical encounters, is designed to capture aspects of patients’ stories, their emotional response and to explore my parallel response as their treating doctor.”