RAPRIOP
RAPRIOP
Education is never wasted. Sometimes though it is badly timed. Most of what we need to know to safely practise medicine is learnt long after we graduate, and long after we have been first let loose on an unsuspecting public. We learn mainly from our patients. There are also various postgraduate courses that are targeted to our interests, and to gaps in our learning that we may have identified from reflection or from experience. The profession now recognises this need, and has invented the idea of vocational training, not just for specialists, who then learn (in the words of Konrad Lorenz), "more and more about less and less and finally know everything about nothing", but also for generalists, before they are allowed to practise independently.
It was not always so. When I was a medical student and junior doctor in the 1970s, we were less regulated. There were fewer of us, and we were always being asked to fill gaps in the level above by acting as a house surgeon or working without a registrar. We learned quickly by our own mistakes, rather than having the comfort of learning from the mistakes of others. I remember as a newly registered doctor agreeing to fill in for a local GP while he indulged his passion for motor racing. As I might have expected, he crashed his racing car, and broke his jaw. I arranged to take time off from the hospital so that I could cover his entire practice for two or three weeks. I made many mistakes in those few days.
General practice training at the time was optional. Experienced GPs could meet the requirements for vocational registration simply by adding their name to an indicative register. Others who wanted to work as GPs could do so without any particular postgraduate training. We are only just now coming to the end of that era. Vocational registration at the moment is required for fully independent practice, but doctors who have not yet achieved this can effectively work on their own in various scopes if they have a "collegial relationship".
I have recently been peripherally involved in the development of vocational training in New Zealand for rural hospital doctors, which is now recognised as requiring different knowledge and skills from other generalist scopes of practice. A majority of the fellows and trainees are trained or are training in related fields such as general practice or emergency medicine. This has brought about the creation of a new section of the workforce that allows for succession planning, in a previously poorly staffed area of medical practice, and will do a great job of keeping rural people safe for years to come.
As a junior doctor, probably aware, from my locum attempts, of the difficulties of practising well as a GP, and back in New Zealand after an extended period of hospital practice in England, I opted for a year in the Family Medicine Training Programme in the Manawatu. This was a revelation. At medical school, we had had almost no exposure to general practice, or to the skills required. It was a privilege to work with experienced GPs who understood the importance of their work and were committed to passing on their craft. Later, I went into practice on my own and eventually completed the requirements for Fellowship.
In the meantime, before going into practice in New Zealand, I took up a position for two years working as a primary care and rural hospital doctor on an outer island in Vanuatu. I have since got to know colleagues who have done similar work and have had some training in tropical medicine, some of them going so far as completing the postgraduate diploma available from Liverpool, or one of the newer equivalents. My lack of knowledge in this area, as it turned out at the time, was not too much of a disadvantage. The common clinical conditions I came across in Vanuatu were in fact similar to those in New Zealand. There were also well-structured programmes already operating in the country and in the region that helped us to take care of the various tropical conditions that might be encountered.
Unexpectedly, after I returned, all those years ago, from my time in the islands, solo rural practice in New Zealand was in many ways more difficult. There was so much more to know about (that in Vanuatu I think I had been happy to leave to others). Patient expectations were higher. Again, I found that my formal training in general practice was valuable. One piece of advice I found useful, from one of my former GP teachers, when I found myself baffled by a patients' requests, was "You don't have to have the answer, but you do need to have a response."
After a few more years as a rural GP and rural hospital doctor, I got the chance to teach at the Auckland School of Medicine. This allowed me to explore in more depth the formal basis of general practice. Our Professor, Brian MacAvoy, as an example, had been instrumental in developing a mnemonic elaborating the type of response to patients' requests, which we taught to the undergraduate students, and they also found helpful. It was called RAPRIOP.
The first R is for reassurance, which is fine, but in real-life practice is probably the one that contains the most potential fishhooks. First, it is important to take a good history, something that the medical students, in spite of all the training they now have in communication skills, were often not very good at, in order to know what it is that the patient is afraid of and wants to be reassured about. Also, without thinking carefully about what other steps in the process might be required, reassurance is often inappropriate.
The A is for advice; the first P is for prescription; the second R is for referral; the I is for investigation. One or all of these might be expected to meet most patients' expectations. The O is for observation, something that has become more familiar to me, especially for children, working in hospital practice. The second P, the one that is hardest to remember, and hangs lamely on the end, is for prevention. It is as if when all else fails, and as a doctor you can't think of anything else to do, you can always try to prevent something.
Some years later, partly with the idea of doing some work back in Vanuatu, I completed a postgraduate paper in Wellington on tropical infectious diseases. This is part of the travel medicine suite of papers, which are deservedly popular, not I suspect because they relate to a major unmet health need within New Zealand, or are useful to work in less-developed countries, but more because they allow health professionals in primary care to take an informed approach to the health care requests of the more affluent and well-travelled members of the New Zealand population. Some of the students in the course, to be fair, also had patients who were refugees or migrants, or were themselves looking to work in tropical countries.
The content of the course was surprisingly detailed. My experience in the field was useful but there was a lot of information, such as the huge range of related virus infections spread by mosquitoes in different parts of the world, that I hadn't previously needed to know. The coverage of the diseases with which I was already familiar, from my experience in the tropics, was much more thorough. I don't think I had realised, for example, that patients with malaria, as well as malarial parasites in their blood, typically have a low platelet count.
After starting work as a rural hospital doctor, with the requirement that I spend some time working in other hospitals, I did get to work back in Vanuatu, at the base hospital in Port Vila, the capital. I spent a week as a volunteer doctor in Outpatients, which is like their Emergency Department, then a week observing the specialist teams on the wards. Primary care in Port Vila, as in most of Vanuatu, is provided mainly by nurses. There are only a few doctors, most of whom, especially in the public system, are specialists or are in specialist training. There was another volunteer GP helping out in Outpatients, the wife of a visiting British paediatrician, but she disappeared within a day of my arrival to accompany her husband on a medical tour to the outer islands.
The staff did their best with limited resources. None of the auriscopes worked, because their batteries could no longer be recharged. There were new colourful posters hanging in each room, from the World Health Organisation, encouraging us to wash and dry our hands between patients, but there was no soap or hand-gel, no hand-towels, and some of the taps did not work. The Japanese at the time were building a brand-new hospital on a nearby site. There seemed to be aid money available for capital items but not for infrastructure or consumables.
All of this of course brought back memories of my time in the smaller more remote outer-island hospital that I had worked in 30 years earlier. But, with further experience and further training, I was seeing it through different eyes. One ten-year-old boy who presented with fever illustrates my new understanding.
Just before I arrived, there had been an epidemic of dengue, which seemed to be waning. People with symptoms, mainly fever, were still turning up to Outpatients, or bringing their children, to be tested. The problem was that the blood test for dengue is a PCR test, which is expensive and is not available in Vanuatu. The ten-year-old boy I ended up seeing had a blood test anyway, arranged by the nurses, then was sent to me, which when I thought about it was an appropriate response. The nurses, by ordering an investigation, without specific training, but with years of experience, were applying the RAPRIOP formula that my former academic boss, in a British context, had helped make more explicit.
Reassurance was inappropriate: the child was quite sick. There was no advice that would have helped. A prescription was not indicated: there is no specific treatment for dengue. The hospital did not have the resources to observe the child. So, the child had been sent for an investigation, a complete blood count, and had been referred to me. I reviewed the history and examined the patient. Apart from the fever, there were no particular findings. I glanced at the blood results, thinking how I would explain to the child and his mother that the results would be unhelpful, and that dengue is a clinical diagnosis. The blood count was not normal: the platelets were low. I thought back to my training in Wellington. Low platelets, although they can be seen in dengue, are best known as a sign of malaria.
Malaria in Vanuatu is less common than when I worked in the country previously, but still sometimes causes illness and occasionally death, especially in children. In Port Vila, because of spraying with insecticides around the city perimeter, it is rare. This child however, on further questioning, turned out to be from a rural village in a swampy area elsewhere on the island. Apologetically, but secretly satisfied with the opportunity to apply my newly-acquired knowledge, I sent him back to the laboratory for another blood test. His blood was full of malaria parasites. A prescription was required after all. I checked with the nurses as to what was the current standard treatment for malaria, gave him that, and sent him on his way.
What about prevention? The persistence of malaria in poor countries like Vanuatu is an international disgrace. Other places like Hawaii, with similar climate and geography, have eradicated it years ago. There is no reason for the fact that a common condition, with a life-cycle that is understood and can be effectively interrupted, and for which there are effective treatments, continues to kill people around the world.
Apart from successfully diagnosing and treating the child, I had also added to my medical learning and experience. A few months later, at a meeting in Dunedin, I caught up with the convenor of the Wellington paper and told her the story of the boy in Vanuatu. We did a high five across the table. Education, we concluded, saves lives.