Steve Leeder's Better Health Blog

Tuesday, September 25, 2018

TB and HIV - still miles to go

Published in Australian Medicine September 17 2018 https://bit.ly/2pja5uY

Tuesday, September 18, 2018

Providing primary care for refugees

Published in Australian Doctor August 20 2018 https://bit.ly/2pja5uY

Tuesday, August 14, 2018

An important reminder that we must never forget Nazi doctors

THE LAST WORD

Dr Hans Asperger (1906-1980), the Viennese academic paediatrician best known for his contributions to our understanding of autism and related conditions, has been revealed as a Nazi sympathiser.

The revelations were contained in the results of an eight-year study of Dr Asperger published in the April edition of Molecular Autism.

The research was carried out by Dr Herwig Czech, a Holocaust scholar from the Medical University of Vienna, who concluded Dr Asperger failed to protect his young patients from the Nazis’ euthanasia program.

In fact, Dr Asperger frequently referred children with what we now call autism and similar problems to a Nazi clinic for children with disabilities, who were judged to be a burden to parents and the state.

Somehow, Dr Asperger managed to sidestep criticism for his close association with the Nazi regime and continued practising as a respected clinician for decades after World War II.

However, his actions and those of other doctors who carried out medical atrocities in Nazi Germany led to a global movement among doctors to stop this from ever happening again.

The result was the establishment of the World Medical Association, which aimed to restate the ethical basis for the practice of humane medicine. It achieved this in the Declaration of Geneva published in 1948.

The declaration provides doctors around the world with a code of ethics. They pledge not to permit “considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient”.

The declaration also demands doctors “respect the autonomy and dignity” of their patient. But has it worked? Since it was introduced, we have not heard of anything on the scale of the human experimentation and euthanasia carried out by doctors working under the Nazis.

However, there have been cases. The so-called enhanced interrogation techniques, including waterboarding, were widely used on terrorist suspects rounded up by the CIA in the aftermath of 9/11.

While the torture methods were developed and inflicted on detainees by psychologists (contracted by the CIA) rather than doctors, groups such as Physicians For Human Rights claim doctors were complicit in what was happening by monitoring the health of those being tortured.

This included using a pulse oximeter to track the effectiveness of respiration during waterboarding. The group suggests this was a way for doctors to “calibrate physical and mental pain and suffering”.

More than a decade on, no medical professional has been held to account for their involvement in this dark chapter of American history, the group says.

With this in mind, rather than curse the medical ethics committees that delay research, we should be grateful for these necessary checks and balances. And remind ourselves of the reasons why they came into existence.

Published in the Medical Observer, 8 June 2018

Why we cannot allow machines to take over

The digitisation of medicine is having a negative impact by eclipsing the human side of medicine, writes Professor Stephen Leeder.

"There are times when the diagnosis announces itself as the patient walks in, because the body is, among other things, a text,” says Professor Abraham Verghese, professor for the theory and practice of medicine at Stanford University Medical School, California.

Writing in the New York Times (16 May), he adds: “I’m thinking of the icy hand, coarse dry skin, hoarse voice, puffy face, sluggish demeanour and hourglass swelling in the neck — signs of a thyroid that’s running out of gas. This afternoon the person before me in my office isn’t a patient but a young physician; still, the clinical gaze doesn’t turn off and I diagnose existential despair.”

The state of the US healthcare system, which means doctors no longer care for real patients, is the root cause of this young doctor’s despair, Professor Verghese says.

Similar cases of burnout are not uncommon in Australia where heavy workloads, long hours and administrivia are increasingly taking doctors away from the essential task of meeting and treating people, not printouts.

His essay, ‘How Tech Can Turn Doctors into Clerical Workers’, goes on to describe how patients sat in hospital beds are just “place-holders” and the work of doctoring now occurs with virtual patients who reside inside computers.

“Old-fashioned ‘bedside’ rounds conducted by the attending physician too often take place nowhere near the bed but have become ‘card flip’ rounds (a holdover from the days when we jotted down patient details on an index card) conducted in the bunker, seated, discussing the patient’s fever, the low sodium, the abnormal liver-function tests, the low ejection fraction, the one of three blood cultures with coagulase negative staph that is most likely a contaminant, the CT scan reporting an adrenal ‘incidentaloma’ that now begets an endocrinology consult and measurements of serum cortisol,” he writes.

“The living, breathing source of the data and images we juggle, meanwhile, is in the bed and left wondering: Where is everyone? What are they doing? Hello! It’s my body, you know!”

This is how the disillusioned young doctor before him has ended up as the highest-paid clerical worker in the hospital, says Professor Verghese, adding that for every hour a doctor in the US spends with a patient, they spend nearly two with the electronic medical record. I doubt these figures are much different in Australia.

Of course, we can’t blame the rise of electronics solely for the rise in doctor burnout. There are other factors at play, such as the increasing load of older and complex patients that our health system, with its strict divide between hospital and general practice, is struggling to adapt to with the necessary means for integrated care.

But it’s clear the digitisation of medicine is having a negative impact by eclipsing the human side of medicine.

In a recent edition of the ABC’s Life Matters, two anaesthetists who had had cancer were interviewed about their experiences as patients.

They spoke of the shock of diagnosis, the high-quality therapy they received and their eventual return to practice.

Both identified sensitive care as the most important element in their journey to recovery. They also noted how the time pressures of modern medicine easily exclude it.

Not having time to listen and interact closely with patients can lead doctors to emotional exhaustion, cynicism and resignation.

“True clinical judgement is more than addressing the avalanche of blood work, imaging and lab tests; it is about using human skills to understand where the patient is in the trajectory of a life and the disease, what the nature of the patient’s family and social circumstances is and how much they want done,” Professor Verghese points out.

“So let’s not be shy about what we do and ought to do and must be allowed to do, about what our patients really need.”

It is more important than ever for doctors to speak out about the caring element of the profession. For, if patients come to us for technical help and care and we skimp on one because we are so pressed for time, they will eventually seek help from a different health professional.

Just look at the billions of dollars Australians spend on alternative medicine each year, which suggests that they are already seeking treatment, and care, from others while we busily attend to machines.

Related reading:

Published in The Medical Observer. 19 June 2018.