What would you do with $30million?

Dear Mr Tattersalls,

I wrote to Santa Claus but he must have forgot what I want. My Dad says I can have anything I want if he wins tattslotto. The TV says we can get 30 million dollars. But only if we win.  If I had that much, I really could get anything I want, and the thing I want most is my Dad home from prison. 

You see Mr Tattersalls, Dad talks about you all the time, even though he never met you. When Mum and Dad fight he sometimes screams ‘George - tatts me out of here.’ And then Mum laughs. Other times Dad talks about all the things he would get for our family when we win the first dvision. Dad says its different to division in school cos Ms Anderson is teaching us that next year in grade three.

My Dad is not a bad man. Its true that there are bad people in prison cos my friend watched a show on pay TV about prison in America but my Dad never did any of that stuff. My Dad has the diabetes. It’s a condition my Mum says. But Dad calls it a disease and he says ‘condition’ is just a nicer way of saying disease that you have for a long time. Dad had it since he was my age and my older sister has it too. I used to want to have it. But now I don’t.

One day Dad went to work and never came home. Mum said he went for a holiday. But after a few weeks I stopped believing her. She thinks I still believe in the easter bunny too but everyone knows that’s not true, Dad puts out the eggs. He didn’t this year.  Then some kids at school started saying stuff about my Dad. I got mad and Mum had to come to the principals office. They sent me to speak to a counselor.

The counselor smelled like vanilla. She spoke too soft and some words I couldn’t hear. I told her that I knew my Dad wasn’t on holidays. So Mum came to the counselor with me the next time and they told me Dad was in prison cos of the diabetes. ‘But he is not bad’ I said to the counselor ‘so why is he in prison?’ She said that Dad drove his car to work and hit it into another car cos the diabetes made him pass out.  The man in the other car died, but Dad still lived.

I cried lots that night. I hoped that the man that died didn’t have kids. They would be sadder than me even. Mum said it wasn’t Dad’s fault. I believed her again now. She said his sugar went too low and that made him pass out. Like the time at aunt Glenda’s birthday party before I was born and they had to call an ambulance. I remember that story. When Dad tells it he says the ambulance woman gave him mouth-to-mouth and Mum got mad.

So you see Mr Tattersalls, it’s not really Dad’s fault. It’s just the diabetes that made him pass out. Plus, he said he was sorry the other man died. My Dad was a good driver and he never had any crashes. My uncle Jim did though. He was always getting new cars.  And he went on holiday lots too. So I asked Mum if uncle Jim had the diabetes. But she said he drank to much beer and that’s why he had lots of car accidents and holidays (but I think she meant prison and didn’t want to say it). She says uncle Jim can stop drinking beer if he wants but dad can’t stop having his diabetes. It’s not fair she says.

At Christmas lunch, its Dads job to do the cooking. Uncle Jim drinks beer and aunt Glenda brings cake. Dad says her cakes are too dry but she always puts a lucky coin in them. This year we got take away food and aunt Glenda didn’t bake her cake. Everyone missed Dad. Even uncle Jim cos Dad couldn’t drive him home. Mum cried when she gave us our presents. She said we spent all the money on trying to get Dad out of prison and she wanted to get us more. Mum said they might let Dad out early if we won tattslotto. So that's why we need your help Mr Tattersalls. Mum says our luck has to change. Last year Dad got the lucky coin.  


From,

Me (and Mum too)

Lines in the sand

A people that values its privileges above its principles, soon loses both – Dwight Eisenhower

‘Junkie’ is a word I detest. It's also a highly emotive word and has several different interpretations. Interestingly, it's used across the entire socio-economic spectrum and is almost universally considered derogatory. To a large number of people however, for whatever reason, it represents a line in the sand. Cross it and you're one of them. But is it really that black and white?  Who draws the line? And who controls the location of the line? Embarrassingly, I used to think it was pretty simple.

In 2005, a four year old boy from Mildura (VIC) died of a prescription drug overdose. Yes, four. The culprit – prescription opiates. His parents were both opiate dependent and the pill that ended his life was located in the family home.

Say opiates and most people think Heroin. But a much larger and more common problem is the prescription form of this medication - obtained from your local GP. With a street value of approximately one dollar per milligram, prescription opiates are popular items. Prescription opiates are also one of the best examples of the expansive grey area encompassing the line in the sand referred to earlier. 

On one side of the divide is ‘Steve’ a family man with a steady job and two children with chronic back pain requiring a prescription for ‘pain’ pills every two weeks from the local GP. 

The local doctor becomes uncomfortable about Steve’s opiate medication requirements and questions his increased use. Steve jokes heartily that he obviously isn’t addicted to them and clearly doesn’t look like a junkie. After all, he can control it, he holds down a job, tends to the needs of his family and plays guitar every weekend for the church band. The doctor nods, smiles and hands Steve a script.

A whole world away, on the other side of this line is ‘Eve’ - a woman who is unemployed, with no fixed address and presents to the local Emergency Department with vomiting and stomach pain. She soon discovers that she is pregnant.

There is both joy and shame as she informs staff of her injecting prescription opiate addiction. ‘Eve’ is keen to be a mother and is advised to commence methadone to ensure the safety of her baby.  ‘Just go and see your local GP’ the friendly staff member informs her.

The next day Eve enters the first GP surgery she can find and ironically ends up seeing the same GP as Steve.  Eve is very anxious and doesn’t want to sit down. She is acutely aware of the stares she received from the reception staff and shuts her eyes momentarily. Pleading with herself to ignore the perceived judgment, Eve makes a promise to no longer inject opiates.

‘I’m terribly sorry’ says the tired and sympathetic GP, ‘but I don’t prescribe methadone.’ Too ashamed and in a rush to end her discomfort, Eve neglects to inform the GP about her pregnancy. Instead she attempts to relay the gravity of her decision to stop injecting prescription opiates.

Remembering advice from hospital staff, Eve (choking back tears) asks about a tablet form of methadone. ‘Again Eve, I’m very sorry but according to medicare guidelines I’m only allowed to prescribe that medication for chronic pain and not for someone with opiate dependence such as yourself… tablet methadone is used for things like long term back pain for instance.’

Not exactly even stevens  - if you'll kindly excuse the pun. Prescribing opiates it seems, is not so simple, and has been described by some as a 'catch-22' situation. But putting prescription opiates in the too-hard basket is not the answer.

For too long our health system has danced around the multitude of issues associated with prescription opiates and definitions of dependence. At a recent inquest into the death of the four year old boy who overdosed on prescription opiates, coroner Jennifer Tregent called for mandatory GP education to ‘identify drug dependency and strategies to deal with it.’  

As a GP I welcome the mandatory education and training. It is long overdue. Maybe its time for all GP surgeries to reconsider the meaning of the sign in the waiting room that reads ‘we do not provide scripts for addictive medications.’ This clearly doesn’t help solve the problem. GP’s represent a privileged few that are able to have a major impact on prescription opiates... or we can keep pretending its impossible to shift a line in the sand. So next time you say the word 'junkie' - ask yourself what it means to you.

Choose your own adventure... Age 14

‘Take the blue pill the story ends and you wake up in your bed and you believe whatever you choose to believe… take the red pill and you stay in wonderland and I show you how deep the rabbit hole goes’ – The Matrix

I have always loved ‘choose your own adventure’ books.  It’s a simple yet delightful concept of multiple possible endings to a story where the reader is often the hero or central character in the book. Apart from confessing that I still occasionally indulge – the books were a large part of my world at age 14. The concept of being able to choose a different outcome fascinated me and formed part of my decision-making matrix. Despite this (or in part due to this) my ability to make decisions at 14 years of age was quite flawed.

A recent incident highlighted by the media (7/10/2011) involved a 14 year old boy who also made a rather poor decision. For whatever reason, he decided to purchase an amount of an illegal substance in Indonesia (where the substance is considered a narcotic).

There has been much attention given to this story as it involves multiple layers of topical issues. A 14 year old boy on drug charges. An Australian citizen overseas caught in possession of an illegal substance, held in detention.  Not to mention the political jostling it affords our ex-prime minister who is himself suffering from a touch of  ‘relevance deprivation syndrome’ (his recently quoted and quite apt descriptor of a media commentator).

Yet the most alarming point from my perspective is one that may not make the debate at all - what decision making capacity will this 14 year old individual have in four years time? Or ten years time? Whether or not the 14 year old individual in question is punished in Indonesia or Australia is irrelevant. More importantly – how does he develop his decision- making skills and avoid becoming part of our increasing prison population statistics?

Perhaps we can apply a ‘choose your own adventure’ analysis. Lets take the ‘red pill’ and turn to page 96 to see how our 14 year old hero fares in a hypothetical situation. After returning to Australia he is placed in juvenile detention. He serves his time and is released under the guidance of a mentor and case worker. Fast forward four years and our hero is faced with another choice of participating in a risk-reward scenario where the reward is now financial gain. He takes the risk. This time he can no longer be sent to juvenile detention. Accused of armed robbery he is placed on remand in a medium to maximum security male prison. 

Our hero (now 18 years of age) has not been convicted or sentenced. He finds himself in an environment where up to 50% of the population is Hepatitis C positive. Where substance use within the prison population is rife. Where he is subjected to threats, intimidation and physical harm multiple times per day.  Decisions inside the four walls of the prison are seemingly made for him – but are they? He is sentenced and released after time served and is now in possession of a permanent criminal record. This new classification (ex-prisoner) comes with all sorts of bonus prizes including – difficulty gaining employment or housing and a one in 10 chance of death within the first twelve months of release.  Not the happiest of endings for the red pill.

Take the blue pill, turn to page 84 and our hero is released from detention in Indonesia. He wakes up in Australia and is greeted with a horde of people outside his central coast residence taking pictures of his every move. He is verbally reprimanded for his crime and returns to school after an eventful holiday. Fast forward four years and he is faced with another choice of participating in a risk-reward scenario where the reward is financial gain. He takes the risk.  A big night of success at the casino (celebrating a friends birthday) – has resulted in our hero amassing a large sum of money. He gambles everything he has on the number 14 and loses it all.  So much for the lucky blue pill.

Clearly – not all choices have equal ramifications and not all circumstances are the same. The examples given were meant to be extreme and also to highlight that decision making is not a genetically pre-determined ability. It is a learnt skill and continually evolving. Human beings are all afforded the opportunity to obtain new knowledge and add to our decision making capabilities independently of age. Fortunately, my decision making skills since age 14 have managed to improve over time as a result of being taught by a number of different people, but also by being in an environment that was safe enough to allow for mistakes.

So who is responsible for ensuring that 14 year olds making poor decisions don't end up in jail at 18? If you think it’s the role of parents turn to page 54… if you think it should be part of formal education at a school level turn to page 76… If you think its up to the individual turn to page 87 …

Wolf and Sheep post 9/11

The world has changed since 9/11. As a society we are focused on notions of underlying threat in many aspects of our lives. Negative images and interaction founded on lack of trust and paranoia abound. As we arrived at the anniversary of 9/11, I was reminded of a common quote - ‘a wolf in sheeps clothing’ and how this might be applied in 2011.

Starting a new job can be a stressful experience. As a locum GP I change workplace locations every two to three weeks – by choice. It’s something I’ve been doing for about three years now and as a result, I’ve developed a keen interest in workplace profiling.

Many people are familiar with the first day scenario. It’s a seemingly endless array of unfamiliar names and faces. However, it’s also a great time to start gathering information. This is not about ‘playing games’ or ‘getting inside peoples heads’ – I think of it more as a protection mechanism. In reality, I’m trying to work out who is a potential threat and who is liable to make things difficult.

If you’re anything like me, you’d spend the initial few days at a workplace trying to uncover the ‘wolf in sheeps clothing.’ But who or what is the wolf exactly? The reputation of the wolf has been quite unfavorable in most work places and I think we need to take a closer look at how a wolf is classified. In Quentin Tarantino’s Pulp Fiction, the wolf (played by Harvey Keitel) was a highly efficient individual who solved problems - lets label that a Type I wolf. Traditionally, however the wolf has far more sinister connotations of someone who is cunning, deceitful and ruthless, stopping at nothing to get what they want - a Type II wolf.

In much the same way that Type I diabetes is often misunderstood and confused with Type II diabetes - so too is the fate of the workplace wolf. Personally, I rather enjoy the Type I wolf in any workplace. They are usually competent as well as confident and able to provide valuable information - as long as you’re not competing for their job.

The Type II wolf on the other hand, can be quite challenging. The Type II wolf will often attempt to make a significant effort on day one - the first act, otherwise known as deceit. This is followed by a period of superficial support and simultaneous slandering - act two, cunning. Eventually, this leads to a systematic smear campaign and the final act of ruthlessness - attempted character assassination. Surprisingly, the entire show (acts one to three) can occur in a relatively short time frame (less than two weeks).

One of the few things that may put a stop to the show after the first act is early identification.  Most of the power of the Type II wolf lies in their ability to create discomfort or unease in others discreetly. So be patient and eventually they will reveal themselves - the lure of self promotion is far too great for a Type II wolf.

But again, - this is not a call for hypervigilance on your first day at a new job. Not every workplace contains a Type I or Type II wolf for that matter, so approach the situation with honesty, humility and a measured dose of caution. As our ex-prime minister decreed in 2002 - you should be ‘alert but not alarmed.’

Flip_that...reverse_it

I’ve always been intrigued with Science Fiction. It allows people to take a look at their own world from a slightly different perspective and subtly challenge both individual and societal belief systems. Perhaps at times its fanciful and unrealistic, but it is also one of the most effective ways to stimulate analytical thought and confront our ideas of the status quo.

An interesting example of this is a Star Trek (Next Generation) episode on the concept of marriage. In this episode of the popular science fiction TV series – a society exists where the default option for married couples is mandatory divorce after a five year period. Instead of staying together – the couples are asked to prove to a marriage tribunal after the five year period has elapsed that they want to remain married. It’s a simple concept in reverse and yet the implications on our culture today are fascinating. A far fetched scenario perhaps but one that focuses change at a system level instead of an individual.

Leaving the science fiction world, I read an article in an Australian national news publication that made me ponder how we institute change on a system level when so much is at stake for an individual.

The newspaper article in question revealed that an individual had suffered a significant adverse health outcome despite presenting to a Victorian emergency department upon feeling unwell. The article went on to discuss the involvement of legal representation and the potential allocation of compensation for the individual who has been left with medical complications and ongoing care needs for the rest of their life.  In this age of accountability and transparency – the article intimated that an individual or individuals at the health service might have to answer to claims of medical mismanagement or negligence.

In the health service industry, the system for compensation is structured in a way that one party must prove the other was at fault. The only possible option for the individual at the heart of this issue to receive compensation is to commence legal proceedings, thereby attempting to blame another individual or group for the adverse outcome.

Now lets employ some science fiction to this scenario for a moment. Imagine this individual had not sought the help of their local health service. Yet the same outcome ensued. The individual was left severely impaired for the rest of their lives but had not asked anyone for help after feeling unwell. Does this mean they are not entitled to compensation? The cost of their healthcare needs will not change. The impact on their life and those around them will not change. But who is responsible for their adverse health outcome?  The simple answer is that any person who experiences an adverse outcome should be compensated (mandatory compensation). It is our obsession with accountability and allocation of blame in the health system that needs to change.

 If we continue with the concept of mandatory compensation – the individual has limited scope to commence legal proceedings. In fact, the process of litigation may be completely bypassed altogether if all individuals were entitled to seek compensation in some form. Government or tax-payer money could be allocated to individuals on a case-by-case basis so that everyone who suffers an adverse outcome receives a level of compensation on an equitable basis. Instead of allocating tax payer dollars to private legal firms who ‘win’ cases, our taxes could then be spent elsewhere. As tax-payers do we really need to be lining the pockets of private legal firms?

The money saved from expensive legal fees and court time could be allocated to the system at fault - the health service. Years of successive government funding levels have meant that Australian health services are overworked and under resourced – yet still perform relatively well on the world stage.  Unfortunately, despite the allocation of resources, adverse outcomes will undoubtedly occur and individuals will continue to be affected. Also, there is some scope for exploitation to occur in the context of mandatory compensation.  Perhaps this is where the role of private law firms can be reversed – and expend their energy in preventing such exploitation from occurring.

The process of finding someone to blame for a bad outcome is not the answer, both in the context of a marriage breakdown or an adverse health outcome. However, changes to the status quo need to occur by examining a situation from many different perspectives – not just science ficiton. Compensate those individuals affected as the default option and let humanity underpin our relentless quest for accountability.