Steve Leeder's Better Health Blog

Tuesday, September 6, 2022

Doctors don't know everything - sometimes we need help

Ages ago, following an election, I had a call from a staffer in the new Minister for Health’s office. He was breathless with excitement.

“I’m new to this job,” he said.

“If I came and met you,” he continued, “could you fill me in about Medicare and everything about how the health system works?”

I replied that I would be pleased to meet but that I laid no claim to knowing everything about how the health system worked.

He had not heard of Heath Robinson, the English cartoonist who drew complex inventions that achieved absurdly simple results around the time of World War I.

I suggested that he study Heath Robinson’s art as a clue to what the health service looks like, with its multiple disciplines, specialties, facilities, cultures, management practices and more, linked together optimistically to serve the patient’s needs.

It is hard enough for a novice nurse or doctor to understand the nature of the ‘system’, let alone an uninitiated staffer or journalist.

The complexity of the system means that an understanding of it is fragmented and widely distributed among many groups ⁠— providers, users and managers.

As a hospital inpatient, I gained a comprehensive view of what goes into hospital care. You see it 24 hours each day and night.

You value clear communication, quick response to calls for help with toileting and pain, the value of regular ‘obs’, the pressures on the nursing staff, the perspective and world view of physios, occupational therapists and others. You learn to admire cheery porters taking you for an X-ray or scan. All these experiences are educational.

For us doctors, the insights gained from our studies are enhanced by our experience.

A recent 6minutes article on Dr Ben Bravery’s experience as a patient with colon cancer that led him to a career in medicine shows just how valuable this is.

The widespread acknowledgment in recent decades of the special insights patients bring has led to advocacy from patient groups ⁠— frequently successful ⁠— for there to be patient representatives in all major governance instruments in healthcare and research.

Human research ethics committees have lay members who bring a community perspective to discussions about proposed studies ⁠— be it clinical trials of new therapies, or descriptive qualitative surveys.

Having chaired a research ethics committee for many years at Sydney’s Westmead Hospital, I appreciate the immense value that lay members, who are not involved in the care of patients, bring to its discussions.

They hear the story from the perspective of users rather than providers. They can challenge the value of research.

More from Professor Stephen Leeder:

The Consumers Health Forum of Australia tackles many thorny topics: for example, it has participated strongly in Australia’s response to COVID-19 and in demythologising mental health problems.

Medical education has progressively included consumers to provide their unique perspective

An important feature of consumer involvement in medical education is to demonstrate how varied the experience of illness can be.

Our teaching inevitably focuses on the mean, the average; however, consumers remind us that we all see and experience the world differently ⁠— there is no one-size-fits-all.

Consumers may place quite a different value on health, define it differently to providers and value other things more.

In 1979, when it was still something of a novelty, we ran a diabetes session for students in Newcastle University’s new medical school, with the late Dr Paul Moffitt (who died in 2019, at 92), a local physician with a major interest in managing patients with diabetes.

Published in the Medical Observer, 3 August 2022

Tuesday, June 28, 2022

Are we heading for a 'Great GP Resignation'?

About 40 years ago, I shared lunch at a restaurant in London with our then federal Minister for Health. He asked me how I felt things were among Australian doctors.

I told him of two disaffected colleagues who planned to leave: one to pursue a career in IT, the other in macrame.

The minister, a staunch adherent of the ‘dry’ persuasion, set his cutlery aside and smiled.

“That’s splendid news! Now they’ll be doing something productive instead of draining the national budget!”

Of course, flexibility has always been hailed as one of medicine’s splendid features, allowing doctors to pursue interests beyond clinical practice — in research, education, politics, journalism, the law, ethics, religion, administration, management, commerce, literature, art and music.

Positive opportunities for diversification have always been there. But what we are seeing now is a different, worrying shift in medical careers.

After two years of highly stressful work in the pandemic, doctors are voicing discontent, with a growing number recognising they are burnt out and need to stop and change direction to protect their own health and wellbeing.

Read more:

GPs are cases in point. In fact, if I were the new federal Minister for Health, I would be focusing on whether we’re heading for a ‘Great GP Resignation’.

The specialty has been central to Australia’s successful COVID-19 response, especially in managing widespread community anxiety and depression, as well as the rising burden of long COVID.

A refreshed awareness has come to us of the damaging health effects of marginalisation and inequity in our communities.

However, GP numbers have not grown alongside demand, and many areas of the country (not just rural ones) are reporting serious doctor shortages.

This is owing to a combination of fewer medical graduates opting to train as GPs and the Federal Government’s slow squeeze on the overseas doctors’ pipeline.

This double hit has been compounded by a pandemic-forced stressful IT evolution in primary care, which has seen GPs coping with a wholesale shift to telehealth and other digitally altered practices.

The impact of telehealth alone has been huge. A recent study by a University of Sydney Master of Public Health student estimated that more than a quarter (28.8%) of Australians aged 15 and older had had a telehealth consult between July 2020 and June 2021.¹

That’s a whopping 5.8 million people, according to the Australian Bureau of Statistics Patient Experience Survey.

Many of these consultations have been with GPs. But while patient satisfaction has been found to be high, we do not know how acceptable they’ve been to GPs; we have no peer-reviewed research.

However, a recent AusDoc survey found experiences during the COVID-19 pandemic had negatively affected three-quarters of GPs’ enthusiasm for their job.

Of the almost 500 GPs and GP registrars who took the poll, 75% said the pandemic had sapped their love for general practice, with only 5% saying it had improved their enthusiasm for the role.

And two-thirds (64%) said working during the pandemic had negatively impacted their personal relationships, including with their family.

You wouldn’t blame any GP if, after all this, they upped and left — or at least reduced their hours.

There are other worrying anecdotal indicators too.

Writing in AusDoc in May, Professor Simon Willcock recounted how a group of young GPs had told him they were planning to leave face-to-face general practice because the demands and expectations were unsustainable.

Many older GPs who are nearing retirement are not planning on hanging around either, as revealed in the blogs and comments on AusDoc.

Meanwhile, GPs and doctors in other countries who are under the same immense pressures have already started to respond with their feet.

According to the chair of the British Medical Association England, Dr Farah Jameel, 400 full-time GPs have left the nation’s health service in the past year.²

That may not sound like a lot — given there are 28,000 — but the trend is concerning.

More from Professor Stephen Leeder:

And around one in four US physicians intend to leave their current practice in the next two years, with almost one-third (31%) planning to reduce their clinical work in the coming year, revealed a survey of more than 9000 doctors in December last year.³

The situation has triggered big global questions about the future of the general practice workforce and what changes are needed to ensure it remains sustainable.

High-level queries include, what do we, as a society, expect from general practice? What can it uniquely provide? How well suited are our various forms of care? How do we organise primary care to meet the needs of different communities?

Also pressing is how will the specialty evolve to satisfy the legitimately changing expectations of new generations of medical graduates?

The pandemic and new technologies have unfrozen established patterns of professional and business behaviour in general practice — what ways can it adapt and innovate?

Resilience will be required in spades to manage more disruption, and coming at a time when GPs are already burnt out, this is going to be extra tough.

But if rethinking what it means to be a GP is required to ensure the job is attractive — and so sustainable — for the future, then we must be ready and prepared to confront it and lend energy to finding the right answer — for patients and practitioners alike.

Professor Leeder is an emeritus professor of public health and community medicine at the Menzies Centre for Health Policy and School of Public Health, University of Sydney.

Published in The Medical Observer
20 June 2022

Tuesday, April 26, 2022

War: The inhuman cost of medical progress

With Ukraine certainties are few.

A family flees a village in Mykolaiv district, Ukraine, 7 April. Photo: AAP.

We cannot predict how far the mass destruction will spread, nor for how long. We cannot confidently assess the chances of a diplomatic fix or even a nuclear escalation.

Beyond the catastrophic effects of bombs and artillery on human life, this war will have an insidious impact on millions far from the battlefields.

The shaky public health and clinical care systems in Ukraine, a country that struggled to prosper after the collapse of the Soviet Union, are now being crippled.

Damage to surgical supplies, electricity, clean water, food, supplementary oxygen, medications, hospital records and IT systems has been so extensive that hospitals and clinics near the front lines have been abandoned, the staff relocated.

The stress experienced by frontline medical and nursing staff is visible. We see the scenes of heroism, as doctors and health workers continue to care for the sick and injured in those underground shelters.

Then comes the damage less easy to see — the effect of the sanctions and embargoes imposed on Vladimir Putin's regime.

As a war waged by alternative means, there is no question that they are designed as a response offering less carnage than the West’s direct military involvement. But they carry huge implications for ordinary Russians.

Read more:

There is also the global issue of food. Across the Middle East and parts of Asia and Africa, some 800 million people depend heavily on Russian and Ukrainian wheat.

And you can throw in the other dynamics. Inflation, an economic illness afflicting those least able to adapt, is expected to spread rapidly in the coming months.

But there has always been that dark truth when it comes to war. Medicine benefits as a by-product of its horrors.

The familiar example that comes to mind is the rapid developments in plastic surgery after the First World War, much of it through Dr Harold Gillies, the New Zealand-born otolaryngologist, and his revolutionary use of tubed pedicled flaps.¹

A paper published in the New England Journal of Medicine at the beginning of the COVID-19 pandemic, listed just a few other examples.²

The authors (both doctors) referred to George Washington who successfully inoculated his army against smallpox. This helped to demonstrate the value and efficacy of a public health intervention which can be marked as one of medicine's greatest achievements.

There was also the US army physician Dr Walter Reed who elucidated the epidemiology of typhoid and yellow fevers during the Spanish–American War.

Then comes penicillin, another medical wonder. Alexander Fleming’s chance discovery in 1928 that the mould penicillium appeared to kill bacteria was publicised around the world at the time, but then it lingered untapped for a decade.

It was only in 1941 when the US government responded to the imploring of Oxford researchers Howard Florey and Norman Heatley about what this drug could do, and created a system to produce and deliver it in industrial quantities.

In their paper, the authors described this as an undertaking on the scale of the Manhattan Project.

They add “By D-Day in 1944, there was abundant penicillin for wounded soldiers, and by 1945, both service members overseas and civilians at home had ready access to the drug.

“The requisite scientists, laboratories, and production facilities would never have joined together in peacetime or through private industry alone.”

Other therapies, such as chloroquine and radioisotopes, have similar histories, they say.

The sudden acceleration of medical progress through war usually benefits most those of us who only experience conflict as distant history, read about rather than suffered.

I think of how many lives penicillin has saved — it runs to millions, of course.

But ultimately your heart can’t escape what war does to the individual life.

The following comes from Sasha, a long-serving health worker with MSF.

He's talking about the Russian attack a few weeks ago on Mariupol, the city where he was born that has been so severely battered.³

Read more from Professor Stephen Leeder:

“In the beginning, things almost seemed more or less normal, even though we knew that nothing really was normal anymore," he wrote on the MSF's website.

“But then the bombings started and the world we had known existed no more.

“Our lives became weaved between the bombs and missiles falling from the sky, destroying everything. We could think of nothing else, and we could feel nothing else.

“The days of the week stopped to have any meaning, I couldn’t tell whether it was Friday or Saturday, it was all just one long nightmare. My sister tried to keep count of the days, but for me it was all a blur.

“In the first few days, we managed to donate some of MSF’s remaining medical supplies to an emergency department in Mariupol, but [then] the electricity and phone network went down.

“How can one describe one’s home becoming a place of terror?

“There were new cemeteries all over town, in almost all neighbourhoods. Even in the little yard of the kindergarten near my house, where children should be playing.

“Each day is like losing your whole life.”

I am grateful to Dr Peter Arnold, OAM, for his editorial assistance and suggestions.

References:

1. Cal West Med 1930; 1 May.

2. N Engl J Med 2020; 29 Apr.

3. MSF: Ukraine: how long will this disaster continue?; 24 March 2022

Published in the Medical Observer 7th April 2022

Should we reopen schools or not? It’s more complicated than that

The dozens of passionate comments left on the AusDoc website as to whether schools should open shortly reveal how difficult it is to make wise decisions in an emotionally fraught setting (as when the health of our children is at stake) without a solid base of facts.

It is a terribly complicated matter, unlikely to be resolved painlessly.

Children, parents, teachers, and workplaces will all be affected one way or another. What might be workable in one locality may not work in another – making a ‘one-size-fits-all’ solution an awkward fit.

We know that COVID-19 thrives in areas of low-socioeconomic privilege, and we should attend especially to the needs of schools in poorer areas when considering closing them.

The Australian Bureau of Statistics compared the distribution of deaths reported as due to COVID-19 up to the end of July 2021 in five equal groups, or quintiles, of the population according to socio-economic status.

It found 155 deaths occurred among men in the least privileged quintile – compared with 43 among the most privileged. And 156 deaths occurred among least privileged women – compared with 40 among the most privileged.¹

So, I wonder if it might be possible to have different policies with regard to school opening for different localities depending on socioeconomic status?

But hang on, let’s suppose we did make school closure or opening a local decision, what would follow?

The decisions, if taken locally, would be fearsomely difficult to administer because of their sheer variety. They may overload the bureaucratic system and we have quite enough confusion as it is.

The US has been criticised for taking this local approach with the choice to open left to 14,000 or so school districts.

This had “splintered the conversation about school closures into thousands of noisy arguments”, according to The Economist in its 15 January edition.²

If we closed schools in line with the death statistics just quoted, then those schools in poorer suburbs would be shut while those in the more affluent suburbs would be open.

Read more:

These latter schools may bear the hallmarks of privilege in other ways too including better building stock, less crowding, more health-literate parents, high rates of vaccination and with easy access to healthcare.

In the poorer areas, if schools remained shut, who would look after the children and enable home learning? Probably parents or other carers who may really need to work to maintain the family income.

The educational and social development impacts of school closures on the children would be greatest in the areas least able to compensate. Damned if you do and damned if you don’t.

An international declaration advocating an approach to COVID-19 that favours herd immunity in concert with protection to the most vulnerable and signed in October 2020 by 916,000 epidemiologists and infectious disease specialists, has strong words about lockdowns.³

“Keeping students out of school is a grave injustice,” the Great Barrington Declaration says.

That was before Omicron.

I’m afraid you run into some hard and uncomfortable truths here relating to health and social inequality.

The significance of inequalities – which we always knew were reflected in health and disease differences – is revealed starkly in the death data related to COVID-19 just quoted. The well-known association of poverty with illness has been amplified greatly.

It’s as though the virus has stimulated a ‘PCR’ or ‘polymerase chain reaction’ on a substrate of social gradients in health and disease.

For the moment though – tough as it may seem to say it – we may be left to ‘muddle through’ with regard to school openings.

If schools do open, so should the windows. If open spaces, indoor and outdoor, are available, use them.

If the kids can tolerate masks, then they should be encouraged to wear them (I have a profoundly intellectually impaired grandson and he will never wear one).

Highly effective masks for teachers and administrative staff should be readily available.

If vaccines are available, let’s jab.

COVID-19 is not over, and we should be prepared for more mutations and more anguish.

In the process of that preparation, let’s refresh our thinking about the principles of good health promotion as the basis for effective prevention.

In 1974, Marc Lalonde, the then Canadian Minister of National Health and Welfare, commissioned a report called A New Perspective on the Health of Canadians.4 It received international acclaim. It aimed to answer Lalonde’s question about why, with all the money Canadians spent on health, things weren’t better.

At the time a vast amount of that money went into the hospital system, but as the report went on to show, many of the health problems Canadians experienced where potentially preventable if action was taken on the determinants of health way beyond medical care and hospitals.

It offered the Health Field Concept as a basis. Take for example road deaths: lifestyle, environment and healthcare organisations contribute to traffic deaths in the proportions of something like 75%, 20% and 5% respectively, the report said. Yet this is not how Canadians (and us) had been splitting the money.

If we adopt this approach to COVID-19, we will not only ensure that our hospitals can cope, but do more about the impact of poor lifestyle and environment on seriously affected communities.

Schools in less privileged areas are more likely to be of poorer construction. Ventilation may be inadequate.

The prevalence of Omicron may be higher in the community and vaccination rates in the community lower.

The communities have less reserve to cope with home schooling – think home computers and quiet spaces for students. These are all things that we can do something about!

We need short-term solutions such as these to the vexed question of school opening, allowing space for different opinions because we don’t have the data to be definitive. But it is surely better to do something beneficial than nothing.

COVID-19 has torn into the most vulnerable of our communities in a shocking manner.

We need to think beyond the current pandemic to the widening gap in health between the haves and have-nots in our society.

It would be sad if we do not, as Australians, take this opportunity to consider what kind of humane society we want for our future in which we can all flourish – and invest accordingly.

References:

1. The Australian Bureau of Statistics, COVID-19 Mortality, COVID-19 deaths that occurred by 31 July 2021

2. The Economist, 15 January 2022

3. The Great Barrington Declaration, October 2020

4. A New Perspective on the Health of Canadians, 1974

Published in the Medical Observer, 19 January 2022