‘The phrases that made me’: Dr Cameron Loy

Last month, Dr Cameron Loy was presented the 2021 Rose-Hunt Award,* the highest honour bestowed by the RACGP. Here, with Dr Loy’s permission, we are republishing his acceptance oration. The speech has been lightly edited for length.
 
It has been the greatest honour to receive the Rose-Hunt Award today.
 
A few weeks ago, I was at home in our incredibly messy middle room where our old textbooks rest but, hopefully, do not go to die. I found an old book by Talley and O’Connor.
 
These are books familiar to so many doctors. I had one volume, with yellow pages, an old hospital note from the late 90s lodged in between pages and a sticker in the front that we used to attach to one-litre normal saline bags.
 
In this book, Professor Nicholas Talley told trainees that success will be achieved if they can ‘be curious’. Even though the current RACGP President, Professor [Karen] Price also says it, I quickly formed an unsympathetic view of the author that was befitting an older time and a different era.
 
But that was unfair, as Nicholas Talley is one of Australia’s leading physicians. So it was worth sitting with it for longer. We hear phrases like this. We are told to keep learning, to not get complacent and to be aware that medicine always changes.
 
A few years ago, we saw on TV that ‘The Good GP never stops learning’.
 
We come across these phrases. We read them, or they are said to us across our lives and change how we think and act. I want to talk about a few of these. They are phrases that I now often use.
 
It was the late 90s and I was an intern in Mildura. The emergency department was old. There was a doctors’ desk, there were a few consulting rooms to the left, and to the right there were a few curtained cubicles and a resuscitation area.
 
I was struggling with a man with back pain in one of the curtained cubicles. I was getting irritated. I am still an easy read and would make a hopeless poker player. I was no different then. I went back to the doctors’ desk and a surgical registrar, who is now vascular surgeon in Geelong, Damien Holdaway, had seen the whole spectacle. He said to me, ‘The patients that irritate you are the ones you need to find something interesting about.’
 
What a great phrase. I still use it. There are so many parts to this.
 
Why am I feeling like this, why is the patient acting in that manner and what is the psychology behind it? A chance to think about the terms transference and counter-transference that we learn about. Is the patient a diagnostic challenge, or can I test the textbook descriptions of disease against this case? Is this a chance to experiment and try the management strategies we learn? What do I not know and what can I learn?
 
As an aside, I loathe the words ‘heartsink’ and the desire to change diagnostic labels such as personality disorders. The problem isn’t a label, it is how we react. The answer is to change how we react.
 
Our registrar this year had a rough start and copped one of these difficult presentations. It would have been hard and emotionally overwhelming for anyone. We worked through it and got closer to another axiom that what we do is an observational science.
 
We get to observe and describe illness and disease, we watch how people cope, what happens over time. ‘Over time’ is our big one in general practice and our unique place.
 
Along the way, we can do things that make people feel better and we get paid. This idea isn’t perfect, far from it, but it has helped me not sink under the weight of what we do. It has led me into parts of medicine that I would have otherwise hidden from.
 
Later, I was in the training program, talking to a medical educator, Dr Stephen Wilkinson. Stephen was around a long time and many of us would know him. When I was talking to Stephen, I was probably complaining about the patient load I had. He said, ‘You get the patients you deserve.’
 
Ouch. It sounded so harsh. But let’s unpack it.
 
On the one hand, we can think of a GP with a complex patient base full of challenging work with difficult medicine, difficult psychology and difficult lives. The GP feels it and she must work for her coin. That GP is likely practicing at the top of her game. She has high skills and elite knowledge. That GP is attracting the patients she deserves.
 
To that GP: come to my practice, we will give you all the support you need to work, because Medicare is not going to.
 
On the other hand, we can think of a GP who is disinterested and barely engaging their brainstem in their work. This GP is churning patients and inadvertently trying to see how much Clostridium difficile they can cause with antibiotics for everything. They give opioids and benzodiazepines to everyone.
 
I call it ‘crap-care’ medicine where I usually use a different word but I’m trying not to swear. That GP can stay far away from my practice and my community. But they are around in small numbers, and they get the patients they deserve.
 
Be the first GP, not the second. Your goal should be professional and not how many rubbish care plans you churned out or how much cash you stacked into a consult.
 
Be the first GP and you will get the patients you deserve. Be that good GP. If it is hard, it is because you are good at it.
 
The next one is easier. Dr Ric Milner is a GP I work with who has a canon of stories that he uses constantly. We mockingly call it, ‘the world according to Ric’. The stories are erudite reflections on medicine. He was GP of the year in Victoria a few years ago and has a phrase similar to the last: ‘Own your medicine’.
 
However, the one I want to talk about is this: ‘If you reasonably have time and there is a job opportunity – take it.
 
‘The worst thing that happens is you don’t like it or are no good at it. But you will have learned something.’
 
There is the test for us to which I have no science and it is all ‘feels’.
 
Go and find the GPs that you think are good and ask them about where they have worked and what they have done. You will find a group of GPs who have moved a lot early in their careers, especially the older ones, and others who have done all sorts of things.
 
As I was writing this my wife, who I think is a great GP, said that this wasn’t her. Yet she moved a lot, completed locums including solo locums in Apollo Bay, completed uncomfortable jobs in ICU and emergency departments, worked in Timor Leste, completed a Master’s in Public Health, led the drug and alcohol committee of the Victoria faculty.
 
I think her view was wrong. Do the uncomfortable jobs and give it a go. The worst outcome is that you are not good at it, or do not like it, but you will always learn something. The challenge is to join college committees, do side jobs and find unique experiences.
 
I have tried. I didn’t like the way I felt compromised and threatened in certain consults, so I started working in a prison. I turned out to be good at that. I don’t like the courts and legal part of our job, so I did forensic medicine for 18 months. I was not any good at it and I didn’t like it but I still learned a lot.
 
You are privileged to be able to do a lot in your career, so do a lot.
 
My last one phrase is from another GP I work with. Dr Anne Chirnside is another person who showed me that you can do this job well. She said, ‘Self-reflection is neither self-criticism nor self-hate.’ It is not exactly what she said, but it is close enough.
 
She said it after I thought I had made a big medical error and she suggested I use the time when it was raw to review what I had done. In this story, I arrived at work to find letters and results from the local hospital that told a bad story about someone I saw a day earlier. It was a distressing start to the day. After I reacted to the news, I sat with the file, went through it and tried to find anything I missed. Then, I went to PubMed and read. I went back to the file and read it again. I handed the file to two other GPs in the practice and asked them to find anywhere that I could have prevented the bad outcome.
 
I find it frustrating that we don’t have qualified privilege. As such, handing a file to a colleague is a trust exercise. Hospital meetings have qualified privilege, and it allows better peer review. It is also frustrating that general practice does not have mortality and morbidity meetings nor grand rounds. They just aren’t in our world, mostly because there is no funding mechanism for it.
 
The Medical Board doesn’t fully understand that we do not have conference leave in our contracts and there is not paid attendance at peer-review meetings. We mostly pay either directly or through lost time to engage in reviews and ongoing learning. It is such a loss in our specialty.
 
In the end, there was nothing I missed but I found a small series related to her illness reported in a journal. In an action I always do in these circumstances, I called her family in and went through every step and opened the file to them. It is always incredibly hard – incredibly hard.
 
As a positive, I did eventually find a rare disease, which needed super specialists to diagnose it, that was passed to one of the children. I could still be hating myself over this but I made myself the observer, the reviewer, used the science we have at hand and the scrutiny of peers. I turned self-criticism around into something productive. All the family still see me, so it must have been received well.
 
We are always doing better than we think but we can always do better. Self-reflection, audit and review are so important.
 
These few phrases are among the many that have shaped me and they are phrases I use relentlessly. In them, there is so much about who we are as GPs.
 
Who we are now and what we will become is entirely up to us.
 
It is for us to listen, observe and learn. Our skills and knowledge are unique. Congratulations on Fellowship but the work has just started. Never stop learning and be curious.
 
* Last December, Dr Loy was announced as the recipient of the 2021 Rose-Hunt Award. Due to COVID-19, the 2021 Rose-Hunt Award ceremony was cancelled last year, and in April 2022, RACGP President Adjunct Professor Karen Price presented the award.
 
Log in below to join the conversation.

general practice career RACGP awards Rose-Hunt Award