Dermatology And The General Physician In Regional Australia
The skin is the largest organ of the body. A General Physician is a sub specialist trained in the holistic assessment of adults with acute and chronic illness that will not invariably involve the skin and integument, as well as internal organs. This paper details a personal series, over 5 years, of a variety of skin disorders presenting to a General Physician in Regional Australia and details the variety of diagnoses, the complexity of their management and the linkage and association with formal Dermatological services.
A systematic review was undertaken of all patients reviewed in a private General Medical practice in regional Queensland servicing a rural population of 500,000 persons. All cases from 2014 to 2018 inclusive were assessed. Cases identified where either a dermatological disorder was the presenting complaint or a key associated active problem in a patient under general medical care. Cases thus identified were then classified according to presentation, concomitant disease, final diagnosis and liaison with dermatological services.
The residential address of each patient was then matched to known available Dermatological Services as published by the Dermatological College of Australia. In addition Queensland Dermatologists were approached to determine if they also provided visiting services to regional and/or telemedicine. In addition Dermatologists were approached to determine if they offered inpatient hospital care, and or consultation.
Desquamating, erythroid, blistering and necrostising skin conditions were all represented in this series. Skin biopsies and liaison with Histopathologists provided an invaluable contribution to the final diagnosis. Formal consultation with Consultant Dermatologists occurred in < 20% of cases. There appears to be a maldistribution of dermatological services to meet the needs of patients in south western Queensland.
The General physician is likely to be the first point of contact for many skin disorders in patients requiring hospitalisation in regional Australia. There are very limited dermatological services in regional Australia and many of the available services do not provide inpatient care. The General physician is well placed with their training in holistic evaluation and multiorgan management to provide care to such patients, however attention should be paid to providing more formal education in general medical training in the area of clinical dermatology and postgraduate courses in clinical dermatology would be an adjunct in the further support of regional physicians.
“Medical Marijuana” And Palliative Care, Three Cases And A Review Of The Literature
The lay media has saturated the reading public with a perspective that “medical marijuana” is a major breakthrough in symptom management for palliative care, in particular for malignancy. Patients occasionally ask, but more often are accessing and utilising this preparation without the knowledge of the treating doctor. Here-in is presented 3 cases of surreptitious ingestion of “medical marijuana” with 2 adverse outcomes, followed by a review of the current literature. Specific areas to be addressed will include the science behind its utility, access, safety and ethical considerations in terms of patient contracts of care.
Three patients in the palliative phase of malignant disease ( 46 year old male with pancreatic cancer, 54 year old female with pancreatic cancer and 63 year old female with ovarian cancer) who used medical marijuana for symptom control without the treating doctors knowledge are presented. Two patients experienced serious adverse affects. One patient reported subjective improvement in pain, without any noticeable side effect.
Recent literature(1), suggests that in non-malignant pain, the NNT for any benefit is 24 while the NNH is 6. Inspite of this disproportionate level of toxicity, the public perception is still one of the right to utilize and try, though there is no regulatory control over the product ingested. The science, ethics and sociology of this phenomenon is presented for discussion.