Today I was again reminded how nonsensical some OTC combination products are. The thought was sparked by a prescription I received for Hydrozole(R). It's a non-PBS item and can be Pharmacist prescribed. Hydrozole is one of those annoying combination products; hydrocortisone 1% w/w and clotrimazole 1% w/w. According to television advertisements, of which there are many, it's apparently good for sensitive, inflamed skin conditions. I think it's crap, and most texts agree.

You see, if indeed the problem is a fungal infection then treatment, with an azole antifungal is required for 14 days after the lesion resolves (AMH, 2010). Moreover, if the 'rash' is eczematous and a steroid indicated, then a "5 days on, 2 days off" regimen is the usual treatment. Now, it's quite likely that an inflamed fungal infection occurs. And here's the kicker; at every pharmacy I work at, you can get both a steroid cream and an antifungal cream together for less than you pay for hydrozole.

What I suspect happens is that a prescriber is asked about a 'rash', and odds are, it's one of the two. Instead of suggesting the patient purchase one or t'other, they cover their bases and bow to he pressures of 6-minute medicine by writing a 'script; the prescriber's seen the TV adverts, too. I'd be impressed if most prescribers knew the cost of antifungals or steroid creams; I suspect most would pick the combination cream as less expensive. This presents an interesting challenge for those patients who "Just want what's on the prescription."

In short, hydrozole is a medicine that survives on its media profile. It's not appropriate for a simple fungal infection, excessive for an eczematous-type rash and cannot be used to treat anything for the appropriate time. Pretty much, there's no good reason to use Hydrozole(r) and even less reason to prescribe it.

So, it's now the end of my second week of O&G. Despite a holiday on Australia Day, I'm exhausted. One overriding impression I've gained so far, is that there's a great mix of ways to have baby.

I'm not talking about positions, methods or even situations; I'm talking about philosophies. For some, having a baby is about walking a certain path, with or without certain inputs or stimuli. Others simply want a healthy baby at the end, no matter the methods.

As with any philosophy, there are extremists; mothers-to-be with training in hypnobirthing and aromatics who refuse interventions or medical assistance even with triplets on board, or expectant mothers who at the twelve-week mark, plot out a date for an elective caesarian. In fact, I was getting a little frazzled by all the demands and requirements of O&G patients.

Then, as a patient was being admitted, I saw the most sensible thing I've seen all rotation. An answer to a question on the birthing plan;

It was right there, in the mum's handwriting; a raw, honest, pragmatic look at birthing. I think for many people, exerting such enormous amounts of control over the journey is to compensate for the uncertainties about the destination, both for first-time mums and multips. A healthy baby is indeed a wonderful thing.

For Christmas, Batman gave me a Rubix cube. In Dunedin my flatmate Sandy taught me how to do one, and I could remember a few of the steps, but solving it outright took some practice. After memorising the solving algorithm, I've been able to do it pretty quickly since early January. This week, I taught someone else how to do it; he's down to under 4 minutes.

Rubix cubes are one of those beautiful enigma puzzles. The average Joe suspects that the first step is to make one whole side and then loses their way. The cube when mixed up appears horrifyingly complex, yet once the method, the system, are locked away in the memory bank, it becomes a case of applying several steps of an algorithm.

Sometimes, it feels like this is the way medicine could be done. First, orientate the patient cube in the correct manner. Find the white side and ensure it faces up, and the yellow side faces down.

Step One; make the cross. Ensure you know what it is you're moving. Where you're moving it from and to, and in which order. Make a plan. After you think you've done the steps, check your work. Do the next step, the corners. Gather information, make a plan, action it, check the results.

This routine continues whilst all the steps are performed. And, in most cases, it'll work. The challenge comes in picking the cube that's had the stickers pulled off and put on in the wrong place, or the cube that can't turn in certain ways.

So, it's not really how medicine can be done at all. It's a good safe way for students to learn, to apply a system, to check results. It may not always be the quickest, but for most cubes, they'll face up just right.

But down the track, you don't want to be twisting for hours some poor cube whose stickers are just on wrong.

Five new things I've learned in the last twelve months;

1. Pharmacy isn't really at a crossroads. It just thinks it is, and has done for a good quarter of a century. In truth, the profession often struggles to define its true purpose, torn between finance, health, community and hospital. Within the profession, the best we can do is to pick our path and cop the flak that comes our way.
   
   
2. Failure is not fun. Although, it's a good learning experience, but certainly not something I'd want to experience too often.
   
   
3. Rural doctors are the true all rounders of medicine. The basics of General Practice, surgery, medicine, obstetrics and psychiatry are standards in their armoury. They are, in my experience, well rounded humans and excellent teachers. Best of all, they know when to ask for help.
   
   
4. The joy of 'returning' to competitive sport. I haven't played Grade Cricket since I was fifteen, and the feeling of standing in the field, appreciating a fine day in the fresh air, clouds wandering across the sky and physical exercise in healthy amounts is something I've gained new respect and appreciation for. The art of mastering orthodox spin bowling has provided an extra challenge.
   
   
5. Fabien Cancellara is awesome; this guy is one of the strongest cyclists on the planet, and boy, can he time trial. He's the Contre la Montre monster. In fact, this whole road cycling gig is a helluva lot of fun; you'll doubtless hear more about my cycling escapades into 2010; I even have an encore to the Razorback Challenge lined up.
   

Of course there are many more; it's back to Uni next week, whereupon medical anecdotes and insights will continue; first up, Obstetrics and Gynaecology.

It's not purely self-indulgent, either. The pair are raising money for The First Tee New Zealand charity; a crew that's about developing strong morals and ethics in young 'uns through golf.

The guys have, by themselves, mobilised their skills to create a wonderful marketing machine, and they're having a great time doing it. They're on facebook and at @puregolfchap, although I strongly suggest you check them out at puregolf2010.com

I'm in New Zealand, visiting family and friends and truly enjoying a holiday in the area I grew up. I even managed a drive past my old schools.

A friend from said school had an aversion to fingernails, or the inappropriate disposal thereof. His grandmother, as grandmothers do, had chastised him for cutting his nails onto the floor and kicking them away. She told him that if you didn't put your fingernail cuttings into the rubbish that upon your death, you would become a ghost, stuck in limbo, forced to wander the earth until you had found and disposed of your offcuts.

I loved this story. Not because I believe in ghosts or that I have a fanatical concern for my fingernails. Quite the opposite, in fact.

What better way to ensure one's return to a place than flicking blackened fingernail offcuts into the ether; a guaranteed second look at that beautiful beach, serene bushland or windswept mountain. Now, where did I leave those clippers?