The true value of preventative medicine lies somewhere between a patient's own self care activities and their proactive practitioner's screening processes.
Today we are joined by integrative GP, Dr Penny Caldicott who is long-term champion of team-based, multidisciplinary healthcare, having founded her practice on these principles. Dr Caldicott joins us today to take us through her views on some of the forgotten aspects of self care in modern society and the many important ways a GP, or health professional(s) support patient wellbeing through screening and assessment.
Covered in this episode
[00:47] Welcoming back Dr Penny Caldicott
[01:25] Developing multidisciplinary team-based care
[04:07] Self care: prevention or early intervention?
[08:44] General practice: guidelines for screening
[10:12] Smoking and alcohol: risk assessment
[13:36] The complexities of mental health assessment
[24:33] Refining the patient presentation of anxiety vs. heart attack
[29:10] The value of teaching breathing techniques
[31:21] Crafting professional referrals
[34:15] Assessing for cancer
[38:08] Assessing sexual health
[44:47] Recognising the diabetes patient
[47:05] Assessing for sleep apnoea
Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line today is Dr. Penny Caldicott, who's an integrative medicine GP and the founder and director of Invitation to Health, a multidisciplinary clinic on the central coast of New South Wales.
Dr. Caldicott is the current president of the Australasian Integrative Medicine Association, that's AIMA, and she believes that the integrative medicine focus on prevention of disease can play a significant role in turning back chronic disease in Australia.
Welcome to FX Medicine, Penny, how are you?
Penny: Thank you, Andrew. Very well, thank you.
Andrew: Now, Penny, you've developed a truly multidisciplinary clinic. Tell me how that all started first, I think? What was it that you weren't quite happy with just the orthodox sort of box, the orthodox method?
Penny: Yes. So, I became a general practitioner and went out into conventional general practice. It was actually a very good, very comprehensive general practice. But I started to get a whole lot of patients who were coming to me with conditions that, at the time, some doctors weren't taking so seriously. And these were things like chronic fatigue, people presented with chronic fatigue and fibromyalgia. And, at the time, there was a lot of talk about how these things weren't real diagnoses, or that these people were just stressed, or anxious, or had a mental health disorder.
Penny: And so, when I started to look after these people, you know, I certainly believed them, but my problem was more that I didn't have any training to look after them. And so that's when I started looking into what was going on. And at the time, there wasn't so much structured education as now. And so I just went to as many conferences as I could and talked to as many people as I could. And started to bring in different ways of talking and hearing these people, and different things that we could do to alleviate some of their symptoms.
But then I realised that actually you need a team approach to help people with complex problems, and that I was limited in what I could offer, but if I was working with other people, we could offer more as a team. And that's when, 15 years ago, we set up Invitation to Health, which is a multidisciplinary centre. And, really within, you know, within weeks, you know, our learning just changed so dramatically, and working together was just so much richer, not only in terms of our own learning, but in terms of patient outcomes.
And then, over 15 years, we've just developed that into a model where there's just more and more communication, more and more transparency, and now we work in teams where we see patients together. So naturopaths, nurse or health-care coordinator, and doctor, and we're working on developing that even further. So, it is really kind of a very rich way of working. We feel like our outcomes are quite different, and we're starting to measure those. So, you can work co-located, which is pretty cool, you can work in a team together, but you can also work in different locations and care for patients by really communicating.
Penny: Yeah. That's interesting. So, I think that there seems to be a lot more initiatives out there for self-care than there used to be in the past. I mean, there's a lot around obesity in children, and talking about diet and nutrition in a very general way, and exercise, and you know, screen time, and all kinds of stuff that's starting to happen out there, kind of, in the mainstream. But I think we've kind of lost our intuition for self-care. You know, we're growing up in and working in, and being in internal environments so much now that people have, kind of, lost their connection with nature.
So, as people get more unwell, so our environment and our world gets more unwell, and vice versa. It's like we've lost connection with our roots and where we come from. Because we know that getting out in nature makes us feel good, makes us feel more connected, and does all kinds of things, even biochemically to our bodies, particularly when we're walking and exercising.
Penny: So, I think we've, kind of, lost our intuition, and then we've been fed all this rubbish and advertising about eating, and you know, and people have forgotten that you actually have to eat food that looks like it's...
Penny: ...come from nature, and that has nutrients in it, you know, rather than stuff that's been manipulated. There's sugar in about 70% of the things you find in the supermarket.
So, I think people have, kind of, lost their way, and the next generation really has been exposed to such a different way of being that...you know, yes, I think we're a bit lost in terms of health now. I mean, in that lots of people are starting to get sick. There's lots of people out there doing their own research and going, "Well, I don't want to just go to the doctor, and get a diagnosis, and be on medication for the rest of my life."
I'm not saying all doctors do that, but we're trained to make diagnosis and manage illness, and so they're starting to look for their own solutions. And I think that this drive for looking at what's happening to us in terms of disease, and syndromes, and illness, and health is being driven by the population, even more so than by therapists and doctors.
So, people are starting to wake up and go, "Wait a second, this doesn't feel right to me. You know, what else is out there?"
Andrew: Yeah. I've often thought like, if we subscribe to the healthy weight, the healthy blood pressure, the healthy whatever, the normagraph says we are in our early years, aren't we just programming ourselves to then, therefore, fall into the diagnoses that are ‘usual’ in older age? Like, aren't we just accepting of what bad is sort of thing?
Penny: Yeah. So, all of those things are just indicators of well-being right? And of course we know that...we're realising more and more that each person is totally individual. So there are variations there that we have to take into account for each person that we're with. But they are only indications of what's going on, you know? So, if you've got a raised cholesterol, the question is...
Penny: ...why have you got a raised cholesterol? And what's not working well in your environment that you've created or in the environment that you're in with your genome to express like that?
So, really it’s, yeah, I think that a lot of the things that we talk about as prevention in general practice really have got to do with screening.
So, you're screening for problems, and then when they arise, either the person is heading towards a diagnosis and it's seen like that. Or some people will be saying, "Okay, so why are we face with this, and what's going on in that person's life as an individual that is causing the genome to express like this, or causing them to have this type of phenotype?" And, I think, in conventional medicine we're trained to do that, but we're not trained necessarily in all the things we need to look for, particularly dietary and environmental, nutritional stuff. But I think, in integrative medicine, doctors and other practitioners are trained to look at that quite differently.
Penny: Yeah. So, the RACGP, which is the College of General Practitioners...and this is for practitioners. Obviously, many other doctors look at prevention as well. But the College of GPs has a Red Book, and the Red Book is really all the parameters and recommendations around prevention and encouraging healthy lifestyle for prevention of disease. And this includes all the kind of screening that doctors are meant to do at each stage of a person's life.
Andrew: What would be the main areas that the Red Book would concentrate on?
Penny: So, they concentrate on each age group, so from the prenatal advice, the pregnancy advice, the infants, all the way through to the elderly. But they define a healthy lifestyle, or the things that you need to do for a healthy lifestyle to prevent disease, in seven categories.
So, one is, "Do not smoke. Maintain a healthy weight. Be active. Eat a balanced and nutritional diet, including eating minimal sugar. Limiting alcohol consumption. Being sun-smart, and protecting against infection." So, that's how the actually Cancer Australia and the RACGP define the, kind of, more general advice that we would give for disease prevention.
Penny: Yeah. I mean, definitely the smoking one, but I think the key about anything that has become an addiction is you've got to work out why that addiction is taking place in that person's life at that particular point in time, and work on that. And it would be the same with alcohol as well.
So, look, I think that there are general guidelines about alcohol. There's a general thought that people should drink probably no more than four nights a week, or have at least three nights a week off drinking. There's a different amount of alcohol for men and women. And technically that should apply to, kind of, weight, as well. So a smaller woman should drink less, you know, than a bigger man, proportionally.
But I think that it's also very individual, so that we know that there are people who can only drink one glass of alcohol and already start to have the effects of it. So we're all different in ways that we metabolise alcohol. We ask, every doctor would be or should be asking, about alcohol intake on a regular basis. And we would be talking to our patients about that regularly. So I think that that's really a big part of any initial consultation and ongoing care of a patient in general practice.
Andrew: How do you cover this with regards to the Australian cultural acceptance of alcohol, particularly, you know, we're the highest drinkers per capita? How do you then talk to somebody on a personal level about, "Hey, this level of intake may not be good for you?"
Penny: Well, again, it's a really individual thing. I think that there are the generalised discussions, but if you get the impression that someone's really, kind of, struggling with it, or it is a big kind of cultural thing amongst their group of friends that they're with, well, then you have to really personalise it. Sometimes it takes a long time.
So, I've had people, like particular men, who live alone, and they're on these...their real social contact is at the pub every night, and that's where they hang out with their mates. And so, it's quite a journey to morph that behaviour, in terms of drinking, into something that may be suiting them better.
So I think you've got to use what's going on in their life, kind of, find out how it might be affecting them in a negative way. If it is. And it probably is if they're drinking, you know, five, six stubbies a night, or more. So you've got to find a way for each individual. And so, I guess that's why, in general practice, and probably for naturopaths, nutritionists, other people who look after patients on an ongoing basis, that you have time. And so, while, you know, you might have these discussions, you know, even over a period of a couple of years before you get behavioural change.
But I think it's really about listening to and finding out how that kind of behaviour is integral to their, you know, their social aspect or their loneliness, or whatever else is going on for them so that you can work out, you know, other ways for them to feel connected or to be able to change behaviours within the same social context.
Andrew: You mentioned loneliness there, which, of course, has been in the news of late...this is mid-2018, that, you know, we've never felt more isolated, more lonely in our existence as humans. I think there was something from London a few weeks ago that I listened to. And, of course, that branches out into mental health.
How do we as health practitioners, how can we be more aware of our patient's mental health? And, indeed, what can we teach them to be more aware of their own mental health, to go, "Hang on, this ain't right?"
Penny: So, that's interesting. Because, again, I think that the most important thing when you're with a patient is to really listen to their journey.
So, very often people present with very physical symptoms, and those physical symptoms are actually telling us that they're having a problem with anxiety, for example, or depression, or loneliness. But you have to spend the time to listen beyond the symptoms, and to find out what's actually going on in their lives. And I think that people are lonely even within families actually. And I think that we have a culture that's changed so much probably in the last 40 or 50 years, maybe even more so in the last 10 years or so, that we've actually forgotten about social connection as being really important to us.
So, I have this great example. I was watching a show years ago about a group of people who were interviewed before the Berlin Wall came down in East Berlin. And before it came down, they said that, well, they didn't really have that much to do, and so what they would do, you know, when they had time and they weren't, you know, at work, would be to hang out together. And they'd just be at someone's house, they'd spend heaps of time talking, playing games, drinking cups of tea, whatever they were doing, and that after the Wall came down, and they got more integrated into the culture of West Berlin, that they just didn't find they had time anymore to do that.
Penny: So, I think it's like, you know, that they'd really miss that. The fact that there is so much to do means that we're so busy. And the fact that we now have all this information at our fingertips means we can spend...and we all do this, you know, spend too much time looking at things online and thinking that that actually connects us to the world.
Penny: But in a way, it kind of...I mean, it can, in some ways, but in a way, it does the opposite. And so, I think that, you know, those, kind of, long afternoons and days of just hanging together are something that we maybe do less and less.
So, I think that people find themselves alone, so they're working hard, they may have, you know, one full-time job, or they may even have a couple of jobs, they've got kids, they've got...their life is just so busy that that social connection is just not there. And not only that, the connection with all the things that are happening in the world, all the things that are so distressing, I think, put us in a permanent state of distress, or stress.
So, like we were talking about it this morning at breakfast with our young-adult children, and, you know, you see 70 people have died somewhere from an earthquake, or from a mudslide, or something, and it's just like common, right? Or there's horrible things happening in Syria and, you know, kids dying, and families being distressed, and it just becomes commonplace. But it also creates a level of distress...a collective distress for all of us.
And so, I think we have to be really on the lookout for that distress manifesting in people's lives, and it might manifest as symptoms like...we can talk about in a sec, or just, kind of, really obvious mood things. And I think we need to be really alert for that all the time. And working with people to find ways for them to reconnect. So reconnect to nature, reconnect to family, if that's appropriate, reconnect to other people in their lives. Become involved in communities where they feel like they're making contributions, that kind of thing.
So, I mean, you know, people can present with...I know we were going to talk about the, kind of, red-flag things, but chest pain, for example. Now, of course, that's an issue that you have to take medically very seriously. But some people just are so stressed that they're having, kind of, low-grade panic. And they might present with palpitations, you know, "I feel like my heart's fluttering. At the same time, my chest feels a bit tight, and I'm finding it hard to get a full breath in," that kind of thing.
Or it may be presenting as digestive symptoms. So, you know, "I just, you know, have all these IBS-like symptoms. You know, I'm getting diarrhoea, or I'm getting tummy pain. I'm finding it difficult to digest my food." I mean, there's many ways, and, of course, all of those things you've got to investigate in other ways.
But there's many ways that people can present with stress-related kind of symptoms. And we know that, anyway, stress changes you biochemically. You know, noradrenaline, and cortisol, and adrenaline, you know, all make you use lots of micronutrients, for example. And so, in times of stress, you might present with cold sores, or viral illnesses, or chest infections, or whatever. Because of that level of stress and what it's doing physiologically and biochemically to your body.
Andrew: I think one of the best programs I've seen was the R U OK? Day. However, delving into that, I'll always remember Hugh Jackman talking that it's not just going, "Are you okay?" "Yeah, sure, mate." "Oh, okay. No worries. We'll get on with the day then." It's not as easy as that. It's, "No. Seriously, I know you and I've noticed something about you. What's wrong?" And there's this real...it's a care, so it's a connection. You can't just walk up to somebody and expect them to tell you about their depression.
Conversely, the person who is suffering that mood doesn't want to be seen as being a drag on their friends, on their peer groups, indeed, on their workplace, if that be the case, and so there's this real resistance to accept to admit that, "Yeah, I'm not in a good place." How do you overcome that as a health-care practitioner?
Penny: So, that's interesting because that's the kind of conversation I'm having with people a lot of the time. So I mean, firstly, they may have felt this way for so long that they think it's normal. They see other people feeling a bit like this, so they think it's normal. And so, sometimes it's, kind of, teasing out what's going on for them and helping them to see that that's not actually normal and that they've had other times in their life where they've felt much better than that. So, I mean, even just putting a context around how they're feeling.
There is a very strong...particularly amongst the, kind of, Anglo-Saxon culture in Australia...and I know we're much more diversified than that. But amongst that group of people, a whole thing around, "Well, if there's something wrong, then I should be able to fix it. I shouldn't have to rely on anyone else to do it. It's my thing."
And those people...you know, it takes quite a while, and a real, kind of, time to make connection with them so that they can trust you, and stuff. To help them see that, "Actually, we're not all here together to do it alone."
Penny: That actually asking for help and going and getting help is something that many people can do, and that it's okay to do that. Because we're so trained...you know, certain groups of us is so trained to think that we should be able to fix this up ourselves.
So, that's part of it. I talk to people about that whole collective distress that, you know, it may not even be, you know, certain things in their life, but there's a, kind of, collective distress at how distressed the world is, and how distressed so many people are around the world. And that that's okay and normal to feel that pain, as well, but to acknowledge that it's not just your pain, that all of us are feeling it, is sometimes really helpful for people.
Part of what you brought up before is also really important, and that is, you know, everyone's busy, and everyone's stressed, and so I don't want to stress anyone out with my problem. And so I had a conversation with a patient about that yesterday. And she's been through a very difficult time and really isolated herself from everyone around her. And I'm trying to help her how she might maybe reengage just gently with a few people, and the comment which is common is, "Well, you know, everyone's got their own thing."
So, I often say to people, "Okay. So, if you had a friend who'd been distressed, and disconnected, and, kind of, gone off on her own, and came back to you and said, 'Look, you know, this is what's happened to me, but I'd really like to catch up with you for a coffee, or go for a walk together,' I mean, would you say no?" I mean, almost nobody would right? So, when you say that to people, they go, "Oh, no. Of course, I wouldn't have a problem." And so I say, "Well, then you could probably imagine that most people...you know, unless you've had a terrible falling out with them, would be happy for you to approach them like that, and would make the time. Because it's something you would also do."
And so, there's lots of different ways of helping people to see that they're not as alone as they feel. That other people are feeling similar things. That this connection is really vital for our well-being. And that asking for help is not a terrible thing or an unreasonable thing to do. But I guess, with each person, you just need to spend the time to see where their own limitation or blockages in terms of reconnecting...and it might just be severe anxiety, "What would I say? How would I say it?" Maybe they don't feel good enough about themselves, you know, to feel worthy of making that connection. There's all kinds of different reasons why people get isolated, and how that isolation just fuels all that, kind of, inner distress.
Andrew: And, that's not just from the sufferer's point of view, the person who might want to be helping them might also have their own issues and might feel unworthy. And so, I totally take your point that just saying, "Hey, you know, you want to grab a cup of coffee, or do you want to go to lunch?" Something innocuous, that's social, that you would invariably talk at is a great way to break the ice and hopefully uncover some sort of issue that might need further help.
I picked up on what you were saying earlier about anxiety, and you're talking about, "I can't get a full breath. I've got palpitations," and that sort of feeling of a weight on your chest. And then you were talking about digestive upset, and I guess I'm concentrating more on upper GI upset here, the heartburn. But that smacks very closely to me, very hard to tease off between anxiety or heart attack. How do you do that?
Penny: Okay. So, again, you've got the context around how it presents. So, interestingly, you know, when people in general practice just come in and you have this whole consultation, and just before you're about to turn the door handle to go out, they say, "Oh, yes," and, "I've had a bit of chest pain." And, you know, so, in the context of what you've already talked about, you might have already got that there's a whole lot of stuff going on in their life, or they're really stressed. But as a doctor, I always go back to, what are the kind of classic presentations of chest pain that might be ischemic, or show that they, you know, may either be having or may have a heart attack?
So, I usually go back to those classic questions which we can talk about now. But with a realisation also that ischemic heart pain or heart attacks can prevent very atypically, so it's a really tricky kind of area. And if there's ever any concern, as a non-doctor practitioner, you should always, always get that patient to see someone else urgently. And even if that would involve you making a phone call and facilitating that. Or making sure they get to a hospital or calling an ambulance. And, you know, your only risk is not doing it.
Andrew: That's right.
Penny: But it's worth, kind of, teasing it out a little bit, you know, if you have the skills to do that. And if you don't, someone else would need to do that for you.
And so, typical kind of ischemic chest pain...first, "ischemic" just means, you know, you're not getting enough oxygen to a part of your heart, but you're not necessarily yet having a heart attack. Or you may be on the way to having a heart attack. So, that would be things like shortness of breath on exertion. So, sometimes people present and they go, "Oh, you know, I'm really fit, and usually I'm doing really well, but nothing's changed in what I'm doing, except that now I get short of breath when I walk up a hill, or upstairs, or something else."
And so, then, to tease that out a bit further, you might say, "Okay. So, when you're getting short of breath, do you have any tightness or heaviness in your chest?" And you can go through that. Heaviness is like, you know, that you've got a real pressure on your chest or something’s like, sitting on your chest. So, if they had that, you'd be quite concerned. "And with that tightness or heaviness, do you get any sweating?" Because when people are having ischemic chest pain, usually they would get sweating as well. And then, sometimes there's a referred pain that goes either up into the neck or down into the top of the left arm.
So, they would be the classic kind of symptoms of ischemic chest pain, and sometimes people will also get that at rest. They suddenly get chest tightness or heaviness, they get shortness of breath, and those other symptoms that I've just talked about. So, it doesn't always have to happen with exercise, and the person doesn't have to look unwell. I mean, they might in that moment, but they could be a really fit person as well. It's not always the, kind of, classic person that you would think would have a heart attack.
So, those are the things that I would check, and then I would do a physical examination. But, if anyone presents with those kinds of disturbing symptoms, and they have them at the time, then urgent help is required, like an ambulance or something. But if they've been having symptoms like that, but don't currently have them, they need to get to a doctor very quickly to work out whether this sounds really like an ischemic thing or not.
If they're not having any of those symptoms, but their symptoms are nevertheless, kind of, quite intense, and getting more frequent and worrying, they still need to be assessed. But, people can present with all kinds of other symptoms like that, kind of, not seeming to get enough breath, and that's a really interesting one to tease out. Because I find a lot of people present like that. So, if they're presenting like that, and they've got, kind of, major stressors in their life, I ask them about what that feels like, and often you'll find that they are able to actually get a deep breath in, but they actually feel like they're not getting a deep breath in.
And then, I'm talking to...and I'm sure many practitioners of all types are doing this and talking to people about their breathing. So, when we're in a state of stress, often we get, kind of, that tight feeling in our epigastrium, or where our diaphragm is. Because when we're stressed often, we get, you know, the diaphragm, kind of, contracts and we do that upper airway breathing, or upper lung breathing.
Penny: So we're not really taking a deep breath in. And after a while, that can often feel like you're not getting enough breath. And so, sometimes, if I feel pretty clear that it doesn't look like there's a heart problem, I will talk them through some breathing exercises to relax their diaphragm. There's many different ways of doing breathing exercises, and if, for example, they have that in the moment, to see whether that goes away when we do those exercises together.
And so, that's, kind of, quite a common presentation of stress that, you know, "I just don't feel like I'm getting enough air in." And I often refer to that as something like ‘breath hunger.’ So, they are getting the air in, and they can take a deep breath, but it just feels like they can't.
And then, people often present with...and I don't know whether...I guess I'd have to ask naturopaths and Chinese medicine practitioners, and others about whether they present to them with palpitations. They often present to us with what they would say is palpitations, and then it's really a matter of finding out what does it feel like? When is it happening? How often is it happening? Is it getting more frequent? Those kind of things.
Penny: And I suppose, you know, to really delve into what kind of symptoms they have, that's probably something that...I mean, that is something that needs to be done by a doctor. But many people present with, kind of, like, a little missed heartbeat or something like that. That's worse when they're stressed, worse when they're drinking coffee, sometimes worse if they're having more alcohol, those kind of things. But it's often another manifestation of someone who's feeling overwhelmed.
Penny: Okay. So, the first thing is to get the permission to do that, because clearly you'll need the patient's permission. Some patients will have, you know, quite a good relationship with a long-term GP that they know that they can get into. But I think it's really important for some communication to happen, as well, in terms of some formal communication.
So, in the circumstance where someone tells you they have a history of something, you've, kind of, teased it out, but it's not something that's happening right now, then a letter would be a good way to communicate.
So, I'm president of the Australasian Integrative Medicine Association, and we've had an inter-professional working group that's recently put together some referral letters, and we're going to be setting up some training to how to write these referral letters. So, some of these referral letters are just like, "I'm seeing this patient, and this is what I've been doing, and this is the rationale for it, and this is what's happening." But amongst these referral letters that we're going to be using in AIMA, and training people to use, is a red-flag referral letter.
Penny: And the point of the red-flag referral letter is to say in a language that the doctor would be happy with is, you know, "I've seen this patient. They've presented with these kind of symptoms, and I'm a bit concerned that there might be something like X happening, and I've emphasised to the patient that it's very important that they come and see you as soon as possible."
And so, that kind of letter, you could write, but then you would just have to negotiate with the patient with, "Take that letter along to the doctor.” Whether you would pop it in the post if you felt like, you know, it wasn't urgent-urgent. Or whether it might be a letter that you might fax to the doctor, or communicate in some other way, either through the doctor's receptionist or directly to the doctor depending on what the circumstance was.
But, yeah, it's very important that the patient is on-board with the communication that you're going to have with the doctor, and that they understand what you're communicating.
Andrew: Unless, of course, it's an acute coronary syndrome in which it's an ambulance call, and, "Get the hell to hospital now."
Penny: Well, exactly. If someone was having that right in front of you. And, I mean, it's true that, you know, early on in our career, sometimes a panic attack can look like that. I remember being a very young GP and sending someone to hospital and the ambulance coming and looking at me, going, "Yeah, she's a newie."
Andrew: But who cares?
Penny: But who cares? Right. So, the person is safe, and you've taken care of making sure that they're safe. And that is the most important thing. That you make sure that the patient is going to be safe, and that you're not missing something.
Penny: I think, in general practice, we're probably, kind of, hyper-vigilant about cancer because there's so much of it around. And, you know, the stats now are, like, one in three people in a lifetime will have some kind of cancer. And so we do lots of screening and lots of education about screening. But, you know, as another practitioner there, you'll have some patients who are not that happy about seeing doctors, and may not be seeing them regularly. So it is really good to encourage the patients to have screening, regular screening with doctors, or other services like mammograms and stuff like that. But also, you may have to, kind of, guide them a bit if they're really reluctant to see someone or they refuse to see someone.
So, in general practice, we would do yearly skin checks, and we'd be encouraging and educating patients on what to look for if they get lesions that are different from other spots on their bodies, that are changing, that are growing, that are irregular, that might get crusting, bleeding, pain, that kind of stuff. That if they get anything like that, that they need to go to a skin clinic or come and see their doctor, or get some help in working out whether this new lesion is dangerous or not.
So, we talk to them prevention-wise, you know, there's the Slip-Slop-Slap campaign that people would say is very successful. I often talk to people about getting that little bit of sun every day in summer and winter. So 10 minutes in summer and 15 minutes in winter depending on your skin type, obviously longer if you've got darker skin.
But then, other than that, kind of, maybe, you know, covering your body rather than using lots of sunscreen, using sunscreen when you can't do that. So, that's something that, I guess, we probably do on a really super-regular basis with our patients. And if you've got someone who's not seeing doctors, then that would be the kind of advice that you'd be wanting to give them apart from encouraging them to get a regular skin check.
Andrew: It's something that I think we really need to be aware of, that patients may not have the knowledge that we do about what the significance of lumps, bumps, and bleeding is.
Penny: Yes, absolutely. And, interestingly, when we started doing our combined clinic with naturopath and doctor, we had a number of patients who came to that clinic who would normally not see doctors. And in the first six months we diagnosed three pretty serious progressed cancers. Because these people, despite symptoms and knowing that they were a problem, would not come and see doctors.
And so, yeah, it is really important for people to be aware that the patient may, A, not be aware, or B, avoiding looking at the obvious problem. And so, asking some of the questions, you know, they've got bowel issues, but some of the other questions like, you know, "Are there changes to your bowels recent?" Because that could mean that there could be something going on like a tumour or something. You know, "Is there blood in your stool?" You know, do they have signs of anaemia? Other kinds of things to, kind of, work out.
I mean, I guess, as doctors, we always, kind of, go, "Well, what's the worst-case scenario? And, let's rule that one out."
Andrew: Yep, yep.
Penny: But then that's, kind of, a different way of thinking maybe than other practitioners. But we probably all need to do that to some degree, to cover the patient and also to cover ourselves while we're looking after them. To make sure that, you know, we're not looking after something really serious as...and calling it irritable bowel syndrome, for example.
Penny: It's interesting because, you know, we all remember, those of us that are a bit older, when HIV first came on the scene, and how hyper-vigilant everyone had to become about sexual health. And, I mean, it's not that HIV doesn't exist anymore, but it is kind of, for the most part, kind of quite well-managed when people do get it, however awful it is to have that diagnosis.
But, that hyper-vigilance about protection in terms of sexual health has changed, and people aren't as careful as they used to be. And interestingly, one of the groups that we find who are not very careful are the people who've been married and get divorced, and they're in their 40s, and they're having a new relationship..
Penny: And it's almost like they've forgotten that it's really important to protect. I mean, sexual health in terms of prevention starts in school. Hopefully, GPs, they're, kind of, encouraging those messages. And peers, and there's plenty of stuff that goes out on social media and public education campaigns.
But, despite that, the STIs are, kind of, becoming more, not only more frequent, but we're also getting resistant cases of gonorrhoea and other things like syphilis, and stuff like that. So, it's still very important that we frequently just recheck that with our patients. Particularly patients who are not in a long-term cohesive relationship. Because even a long-term relationship doesn't guarantee anything, and that's also something to remember.
Andrew: I was having a conversation with Moira Bradfield regarding sexual health, and I just thought about if somebody isn't comfortable with visiting their normal GP because of their social relationship with them, if you like, because maybe the rest of the family might be there visiting that same GP and the person might have had an affair, whatever the reason. Practitioners can teach their patients that it's quite fine, and safe, and accepted, at least in Australia...I know this may well be different in other countries, but in Australia, you have the sexual health clinics, and so patients can go and see these clinics as well.
Penny: Yes. That's right, Andrew. So, sexual health clinics are a good way to go for people who don't want to disclose behaviours and symptoms to their GPs. And, you know, any practitioner can talk about sexual health clinics and encourage people to go there if they're concerned that the patient may have a sexually transmitted infection or some concerns about that.
And I think it's also reasonable to ask patients about their sexual preferences and sexual practices. It's not an easy thing to ask about, but I think that it's also reasonable because it's a way of kind of assessing risk. Sometimes you ask...you know, some of the times people will give you a little bit of information, they go to parties and they mention something about sexual practices at parties. It’s worth, you know, if they give you that opening, it's worth going into that. You know, "So, when you're at a party, you know, would that being with a man or a woman, or, you know, could it be with both?" Or something like that to, kind of, elicit whether there's risk associated with the types of behaviours that they have.
And it's worth knowing that there are all kinds of behaviours that are happening out there. That people segregate into a part of their life, but that they don't share with anyone else. They might not consider themselves homosexual, for example, but they may have MSM, or men having sex with men, may be doing that, and see that as another part of their life that doesn't relate to their you know, their other partnership.
Penny: So, you know, there are all kinds of issues that are worth if people give you an opening to go in and ask just a couple of questions to see if there are some risky behaviours, and you can always ask about, you know, symptoms.
Andrew: And, just moving a little bit further on from there, obviously a medical practitioner is going to have different responsibilities and different things that they're allowed to do with regards to examination. But what about things like vaginal and penile health?
Penny: Yeah. So, it's interesting, I remember having a case, well, a few cases actually, of women who had been to another practitioner, and they had said, "You know, I've got this terrible thrush, and it keeps coming back, and it’s really, you know, it's really painful, and we've done all this stuff but it doesn't work." And I've got the symptoms down, and I have a look, and they actually got herpes.
So, it is tricky, and, I mean, what would have alerted me in that circumstance was the fact that they were saying it was really painful, because thrushes generally can be uncomfortable, but it's not necessarily...and really irritating, but unnecessarily painful.
But, yes, so it is that people are having recurrent symptoms, and it's a part of the body that, as a naturopath, or a nutritionist, or another practitioner, that you wouldn't normally examine. It's important to get them to someone who can examine them and do some swabs because it may be something totally different than you think. And although thrush is common, there are many other things that could be going on at the same time or instead of something like thrush.
So, the examination stuff is really important, particularly if they're recurrent symptoms or severe symptoms.
Andrew: And changes in exudates and things like that, anything from NSU to bacterial vaginosis?
Penny: Yes, exactly, exactly. And so, I mean, you can learn a little bit about different discharges, what they are. So, in women, you know, a white cheesy discharge is, you know, almost always going to be something like thrush, if the symptoms, you know, correlate with that. Whereas a discharge that might be yellow or green is going to be something different than that.
And the same for men, you know, penile discharge is clearly not normal, it needs to be sorted out. Men can also carry sexually transmitted infections with no symptoms at all, as can women, to some degree, as well. And any young person should be regularly screened by their GP for chlamydia because chlamydia is an STI that's quite prevalent and can cause big problems for women in terms of fertility.
Andrew: Okay. So, what about things like...we mentioned insidious, often undiagnosed things. Things like type 1 diabetes, that don't often present until something weird happens, you know, whether it be behaviour or something like that?
Penny: Yeah. Type 1 diabetes is a really tricky one because it happens, kind of, relatively quickly, like often over weeks, and stuff. And they can present in really funny ways. Like, I remember someone presenting just with...you know, the presentation was constipation. Actually, the practitioner at the time was treating them for constipation, and it was a young girl. But at the time when she presented with those symptoms, there wasn't the insight to ask for other symptoms that may be coming along with that, so she had fatigue and...okay, so heaps of people have got fatigue, but the fatigue and the constipation were new, and really out of character for this young girl. And she also had signs of dehydration, weight loss, and the other symptoms that you would always ask for are polyuria and polydipsia.
So, polyuria means that you're passing a lot...you might go frequently, but you're actually passing lots of urine. And polydipsia is thirst. So, these people can become very thirsty and be passing lots of urine, even at night, so you're not getting up to do a little wee, you're getting up and passing a whole lot of urine, and that's because of the high level of glucose in the blood.
And so, type 1 diabetes is a tricky one, it presents...but what you're really looking for are symptoms that have presented suddenly that are totally out of the norm for that person. And if you get a constellation of symptoms and signs that are like that, so fatigue, dehydration, weight loss, abdominal pain, polyuria and polydipsia, you'd be definitely looking straightaway to exclude type 1 diabetes. Which, of course, is different than the type 2 diabetes that comes from metabolic syndrome that develops over a longer period of time, and can present with some of those symptoms, but definitely not the weight loss, unlikely to have that kind of abdominal pain. And the symptoms, you know, are gradually presenting over time.
Andrew: Right at the beginning we were talking about fatigue and chronic fatigue, but what we skipped over then was something like sleep apnoea. How do you twig to be aware of it, and indeed, what should you teach other practitioners, and indeed patients, to be aware of it?
Penny: Sure. So, sleep apnoea seems to be diagnosed more and more now. There are, of course, many reasons for people developing sleep apnoea. You start to be thinking about sleep apnoea and asking more questions when people present with specific kind of symptoms. So, fatigue. Again, we've talked about fatigue as such a common symptom.
But when someone's really tired, I mean, of course, we're going to ask about sleep, aren't we, because if you're fatigued and sleeping well, it's a very different issue than if you're fatigued and not sleeping well. The problem is that some people with sleep apnoea, you know, aren't aware of not sleeping well. They just wake up unrefreshed and are tired a lot of the day.
So then, the next question is, you know, "Have you been witnessed to be snoring?" And people who live alone sometimes don't know that, but they might say, "I went away on a weekend with a friend, and I was told that I was, you know, really snoring a bit." And so, the next question you would ask if someone has been snoring, and is tired, and wakes up unrefreshed, is whether anyone around them has witnessed them, kind of, waking up choking a bit..
Penny: Or have had spells where they've actually stopped breathing.
Andrew: Stopped breathing, yeah.
Penny: And, many people, you know, have had that witness...so people who sleep with them have witnessed it. But even yesterday I was talking to a woman and she said that her husband sleeps so heavily that he's never noticed, but she went away with some friends and they noticed that when they were sharing a room with her.
One of the other presentations in these people is microsleeps. And I had someone yesterday, as well, who presented and said, "Look, I've had a couple of microsleeps where I've just found myself in the bushes. I've been driving, you know, a couple of hours and I just veer off the road and found myself in the bushes." Or even that pre-microsleep where it's, "I'm so tired, I don't even know whether I'm going to get up to the next place on the highway where I can pull over."
So, I mean, the important thing with these people is to say, "You cannot do long drives until we sort this out. Like, you have to only do short drives…
Penny: And where there's a place you can pull over." But sometimes microsleeps happen so quickly that people don't even realise they're coming. Or even they can be in the middle of talking to someone when they're tired in the evening and just fall asleep mid-sentence. That would really alert you to possible sleep apnoea.
Morning headaches. So, some people present with morning headaches, and that can be a sign of poor sleep and sleep apnoea. Insomnia. So, some of these people, they don't realise that they're actually having apnoeic spells, but they find they're waking up a lot, and they have presented with that typical, kind of, waking up, kind of, choking and gasping for breath.
Waking up with a dry mouth and a sore throat every morning can be another symptom, and the frequent need to urinate at night. And that might just be because they're waking up and then they're going, "Oh, I need to pass urine," or it might be all part of the picture for them. So, they're the kind of symptoms that you would be asking for to try and put together a picture of whether this looks like sleep apnoea. And then, of course, refer them to the GP, or if you're a GP, refer them to a sleep clinic, of which there are millions now all over the place.
Andrew: Yeah. I got to say you said a very important word there, "picture." I think it's interesting that, in their isolation, just waking up and voiding urine could be diabetes, could be BPH, could be sleep apnoea. It could be a presentation of so many issues, could be diabetes. It's, of course, our training which forms that picture of what you think the most likely suspect, or suspects, would be, and then you treat or test to confirm that, and then move on with a treatment plan.
And I thank you so much for taking us through… obviously, there are so many that we could cover. We've covered a few of the more important ones. I'd just really like to thank you for joining us on FX Medicine and taking us through the responsible way to take care of somebody, and indeed, to refer on when the need arises. Thanks, Penny.
Penny: Thank you, Andrew, and thank you for covering these really important topics.
Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook.
|Dr Penny Caldicott|
|Invitation to Health|
|Australasian Integrative Medicine Association (AIMA)|
|The Royal Australian College of General Practitioners (RACGP)|
|RACGP: The Red Book|