Issue 2 / 29 January 2013

IT has not been a good start to 2013 for my town of Coonabarabran in the north-west of NSW.

Bushfires encircled our town, with about 60 families losing their homes. Even as I write, the fire rages on, predicted to burn for many more weeks.

Just like in any tragedy, the fire brought out the best and worst in people. The good greatly outweighed the bad, with so much generosity from our own and outside communities. The concern shown by so many has been very encouraging (including many readers of MJA InSight — thanks for the emails, calls and faxes.).

As I watched the drama unfold — thankfully without fatalities or serious injuries despite the intensity of the blaze — I got thinking about the firefighters and the victims, and how this compares and contrasts to doctors and patients.

The victims and patients clearly have much in common — some are in their predicament simply due to bad luck, some due to bad planning and some due to a refusal to accept the risks associated with where, or how, they live. Some are fully insured, some partly insured and some not insured at all. In an emergency all get treated equally, but down the track insurance will have a big effect on access and outcomes.

Just like doctors, firefighters are now ruled by the centralised government masters, even though at the local level they do have a little autonomy. Like doctors, local firefighters are often frustrated that their knowledge and experience is sometimes overridden by a top-down approach — such has been the case with respect to back-burning and other fire prevention measures.

But what about “lifestyle” and what about “identity”?

Although not subject to fires every day, firefighters work by the rule that fire and its victims take priority irrespective of what they may otherwise be doing.

As for doctors, many of us, and many members of the public, think we are the same. But are we really?

The medical profession has become increasingly focused on work–life balance. Reasons for this include a generational shift, concepts of safe hours, the feminisation of the workforce and the emergence of a team approach to how things are done.

An article on this topic in The New York Times a couple of years ago rang true as I looked into employing doctors for my practice. Working hours and on-call come up all the time.

General practice is especially seen as a lifestyle specialty, where you work less and earn less for a “lifestyle”.

Patients are shifted to second place when such thinking dominates. General practice, more than any other specialty, relies on continuity of care to achieve its best results. Patients do not choose when they get sick and most prefer to see a doctor they know.

I often hear GPs moan about patients not following up, patients doctor-shopping or other GPs “stealing” their patients (often within their own practice, mind you!). A critical question for these GPs is: “Were you there to put out the fire when it was burning?”

Another thing about firefighters is that they are instantly recognisable. All the Coonabarabran firefighters were in uniform. It was easy to see who they were and who was in charge. The same can no longer be said of doctors.

While much was made of the Garling report when it was released in 2008, few people referred to recommendation 62.

Garling was concerned that for the patient in hospital (but I reckon you can extend this to many other settings), it is difficult to know who is who. Is that young chap who just saw me a nurse, a physio, a radiographer or a doctor? And if he is the doctor, is he my doctor or a trainee?

The report recommended that a uniform system be put in place to identify health professionals, including doctors. The uniform we need is fairly straightforward — the white coat. It makes a doctor instantly recognisable, has history behind it and is cheap and convenient.

Concerns about hygiene have been greatly dispelled, and are well summarised by Sara Fraser, a Queensland medical student.

So in 2013, let’s be more like firefighters and put the patient first and identify ourselves clearly.

Wearing white coats again might also do one more thing —if the patients can see who we are, maybe we’ll remember it ourselves.

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.

Posted 29 January 2013

7 thoughts on “Aniello Iannuzzi: All fired up

  1. Firefighter says:

    Hmmm. Firefighter clothing is all about Personal Protective clothing, being visible to others and staying safe in a hostile environment. I really don’t think white coats for doctors come into the same league.

    Howwever I do have a beef about the trend to health “professionals” all wanting to wear scrubs – as if wearing your pyjamas at work makes you look more professional??

    On a related note, the stethoscope was once the doctor’s badge of office – now most nurses wear a stethoscope too. I fail to see how this contributes anything to nursing care – especially now that nobody takes a manual blood pressure any more. Perhaps it’s just the current fashion accessory?

  2. WA GP says:

    Or just a name badge? With title, surname and “job” description eg. Sr. Suzie Citizen, trauma nurse or dr A. Somebody; general practitioner. That may serve a double purpose of identifying the health professional clearly and make it clear what you would prefer to be called. eg if you want to be Mr Important, let your name badge state Mr. S. Important, head of department. If you prefer to be called by your first name, then leave out the title, but still put the job title eg Johno Person, cardiology registrar, etc.

  3. Anonymous says:

    Thanks for the interesting article, I hopefully you aren’t facing the other end of natures fury with the recent rains?

    Firstly, in relation to the idea that “firefighters are always there to put the fire out” and the implied idea that Doctors should do the same. Firefighters (whether career or volunteer) are required to take regular breaks out of firefighting during major fire events and are not capable of being on the fireground for days at a time. I would propose the Doctors are not capable of the same either, regular breaks from the work environment reduces fatigue, improves wellbeing and enhances our interpersonal relationships, all of which are vital to keep us going long term. All too often we hear of rural towns loosing a Doctor, or practitioners who are reluctant to commit to rural practice due to lack of support and long hours. Sometimes we just can’t be everywhere at once.

    In relation to the discussion about identity, as a medical student, I often find it difficult to work out
    “who is who”, I can only imagine what it is like for patients who are fortunate enough to have a short stay in hospital.

    To add an extra layer of complexity, older medical students can be mistaken for doctors, especially in bigger hospitals, where VMOs are commonplace.

    In teaching hospitals, students are required to wear name tags clearly identifying them as such. In practice though, name tags seem to become less common as students progress through their studies and confusion reigns.

    Rather than the suggestions of white coats and a perceived position of superiority, I would support senior staff and specialists wearing name tags (with their position)to clearly identify themselves (not only to patients, but family and other staff).

    As someone who has had the opportunity to sit on both sides of the fence(as a career firefighter and medical student), identifying the most senior person on a team is a very real need, but there is also an understanding that the team (regardless of profession) is working together to a common goal, and I for one, struggle with any move that widens the gap between Doctors and other health professionals.

  4. Ian Hargreaves says:

    Christine Nixon might agree about some similarities, having been pilloried for having the temerity to have dinner while directing the Victorian Black Saturday bushfire command.
    We are all used to seeing the weary fireman on the news, trudging from a solid three days at the blaze.

    Yet if he tried to drive his semitrailer for more than a regulation period, he would be charged and probably lose his licence.

    As doctors we swing between being the loved and respected fireman, soldiering on interminably in unbearable conditions, and the heavily regulated truckie, where a few ks over the limit or a lack of a meal break is an offence.

    Had Dr Iannuzzi treated 100 patients, locals and fireys, in a horribly busy day of burns, breathing difficulties, and eye foreign bodies; he would have automatically been the subject of a disciplinary review by Medicare and the Professional Standards Review Committee. Woe betide him if he failed to maintain comprehensive clinical records. A wound infection when treating while fatigued could lead to a lawsuit, a death certainly to an inquest. A high-speed drive past a speed camera to save a life would guarantee a charge.

    Perhaps our white coats were surrendered along with our professional pride as we meekly acquiesced to all the regulators. It is little wonder today’s doctors want to keep a low profile, and not stand out.

    Thankfully the PM and Premier only come around after the fire is out, and don’t stand behind the fireman, telling him how to hold his hose.

  5. Rhys Goodey says:

    A very well written article by a real doctor in the middle of an embattled community that I have grown to know and to whom I am very grateful. What a contrast with “Anonymous” who seems to think that white coats might import “superiority” and interfere with her interaction with her cliched “team”. You’ve got a lot to learn about being a doctor, Anonymous. As I used to say to her ilk when they were dealing offhandedly with my late GP father in hospital in his last illness “My dad was delivering babies before you were even thought of, so you can drop the Christian name and call him Doctor”

  6. Greg the Physician says:

    I agree with Rhys Goodey. When I ring the Emergency Centre at my hospital now, the person who answers the phone only ever gives their first name – I don’t know if it’s a doctor, nurse, receptionist or whoever. After my elderly mother was discharged recently, the young intern who had been involved in her care telephoned her to adjust her warfarin dose, but only identified himself by his first name; she had no idea who he was and so was understandably reluctant to accept his instructions.
    So I say yes, bring back the white coat, but even more importantly, bring back the title “Doctor” and accept that not all members of the health team are equal in knowledge, skills and responsibilities.
    One of my senior colleagues, having introduced himself to a new patient, as “Dr …”, was asked by the patient “What’s your first name?” He replied “my first name is Doctor”. I’m very tempted to follow suit.

  7. Down to Earth says:

    Rhys Goodey: ” You’ve got a lot to learn about being a doctor, Anonymous. As I used to say to her ilk when they were dealing offhandedly with my late GP father in hospital in his last illness “My dad was delivering babies before you were even thought of, so you can drop the Christian name and call him Doctor” “.

    You sound like a delightful chap both to work with and to have as a patient’s relative, Rhys!
    And Dr “my first name is Doctor” Greg: that better-than-thy attitude is exactly why society judges us so harshly.

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