This session is led By the People, For the People! Two cases have been submitted for discussion by our local GPs, which are certain to provoke robust conversations and empower you in your care of patients and your self.
GPs should urgently perform, or urgently refer, for an excisional biopsy with 2mm margin of lesions suspicious for melanoma. A thoughtful approach to size and alignment of the biopsy is important to minimise disruption the lymphatics.
If a melanoma is confirmed on histology, GPs need to consider if a Sentinel Lymph Node Biopsy is indicated BEFORE performing a wider excision.
Current WAKMAS guidelines recommend that SLNB be considered for all patients with melanoma >1 mm in thickness and for patients with melanoma >0.8 mm in thickness with other high-risk pathological features. Generally, if the nomogram risk is over 10% in a healthy patient, SLNB would be recommended.
The pitfalls of the SLNB were discussed with the take home message: The only thing you can take away from a SLNB result is that a positive result means the disease has spread to the lymph node. The opposite is not true. A negative SLNB is not an “all clear”. Melanoma can also spread through the haematogenous route and there is a false negative rate for SLNBs of up to 20% on the head and neck. Learning about an unexpected patient death creates a lot of emotions, thoughts and questions for health practitioners. An objective review of the case, self reflection and discussion with colleagues can help. A series of debriefing conversations can be very helpful for a grieving family – but also for the grieving GP. Being aware of the bias you can carry as a result of a patient death is important for future practice.
Call Kirkbride Melanoma Advisory Service.
Morton, (2014) NEJM. Final trial report of sentinel-node biopsy versus nodal observation in melanoma
Melanoma Institute Risk Calculators
ACD guide sentinel node biopsy.
The rollercoaster of rural general practice
Richard shared the joys of working with and for people who were with him as he grew up, as well as some challenging situations – socially and clinically.
When someone has a poor outcome, the gravity of the situation is amplified by years of history and ongoing deep connections.
AI knows ‘Coping with mortality as a doctor requires actively separating your role as a healer from the inevitability of death. It involves reframing existential anxiety through routine emotional reflection, building strong peer support systems, and finding personal meaning outside the hospital to prevent burnout.’
RACGP says ‘Self care is ensuring that you look after yourself without being your own doctor, and involves looking after your physical, mental, emotional and social health. It is both a preventative and therapeutic action’.
Further excellent points are included in the attached Powerpoint presentation – the knowledge of such facts is insufficient: the difficult part is putting them into practice, especially when we are most vulnerable. At a minimum:
- Ensure you have your own GP, and see them regularly.
- Do all the things we tell our patients to do: eat well, sleep well, exercise regularly, find things you enjoy and make time for them.
- Find people (cats/dogs?) with whom you can be vulnerable.
- Know when it is OK to be vulnerable with your patients.
