Angelina Jolie, every adolescent man’s (read every male given brain development) video game fantasy woman declared earlier this year that she had undergone a double mastectomy and breast reconstruction as genetic testing had determined that she had a very high risk of developing breast cancer. Her own personal story includes a mother who died from her own hereditary risk of cancer which she unknowingly passed to her daughter.
Angelina essentially cited the evidence (let’s call this science), common sense and a strong desire to protect the future of her children. In the latter case it was the ability to raise them to adulthood and seeing their own destinies unfold.
Let’s compare and superimpose these arguments on the debate around climate change.
The science says the planet is warming and it is our fault. If the planet keeps warming then there will be increasing numbers of climate related disasters, sustained food and water insecurity and economic failure i.e. planetary cancer.
Common sense says that even if these predictions aren’t 100% accurate (Angelina’s chances of cancer are not 100%) then at least it takes reasonable steps to mitigate them. In the case of climate change the common sense argument is even stronger: we can see with our own eyes the current effects of man on the environment and we can take active steps to reduce our so called carbon-footprint.
Finally, Angelina acted to on behalf of her children. In the case of climate change let’s consider our children and future generations. I saw a great mock advertisement today of an ever thinner iPad being handed to an ever thinner African child. Perhaps, if we don’t act on climate change then this will be our legacy. Angelina acted, maybe society should too?
It was nice to read the article Michael Mosley’s Five Biggest Health Myths this weekend. On the same weekend I was in a store and overheard a conversation between customers about managing their common colds – they related their remedies of high doses of vitamin C and echinacea and were disappointed that it was still too cool to indulge in salt water. The first two methods are unproven in randomised trials and well, the latter, who knows.
Although I didn’t agree with all of Mosley’s advice (and he admitted some of it was based on early data) his underlying point is correct. We use our health knowledge (or health literacy) to inform our health choices.
Unfortunately many people really have poor health literacy – a lady I’ve treated for ovarian cancer for 18 months recently asked me where her pelvis is. The problem is aggravated by a proliferation of health myths. A lot of common information about diet and exercise is basically wrong or was ill-formed and made part of wide-spread public health initiatives.
One of the things we need to do to promote preventive medicine is actually provide accurate health information about diet and exercise rather than old-fashioned myths.
After that we need to know how to nudge people to follow the advice but that will be part of another blog post.
“Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat.”
― Sun Tzu, The Art of War
So a bit of brainstorming / mind dump ahead of a lecture on Saturday.
Oncology has come a long way in the last two decades. Some cancers, even when metastatic, have become chronic diseases. In particular this is the case for beast, colon and prostate cancer, and in some selected cases even lung cancer. This raises some important considerations about how oncologists approach the treatment of cancer.
In the past a die was cast and essentially the patient chose to take the poison (chemo) or not and if they took it and it worked then fantastic, and if not, well that’s the way it was meant to be.
Now, for many cancers, there are multiple lines of therapy. There are options for intermittent and maintenance treatment. And the paradigms are changing. In the past ‘systemic diseases’ were not treated with locoregional therapies but now it may be appropriate. We are moving to an era where the combination of targeted therapies and selective surgical cytoreduction, regardless of cancer type, becomes the norm rather than a situation where the rules are being broken.
So for the oncologist we must start thinking strategically about the goals of treatment.
If the aims change from achieving tumour response or prolonging life to cure (in the case of metastatic colorectal cancer) or achieving 5 year survivals in the metastatic setting then fundamentally different strategies are needed. Specific tactics we might pursue are maximal cytoreduction whether by chemical or surgical means, maintenance therapy, toxicity reducing therapy, planned treatment interruptions, immunotherapy and other maneuvers. Thinking not just what will be first-line therapy will be but looking ahead to the long-term strategy is required. Do you hold some treatments in reserve?
It is also important to think about chronicity and the effect it has on the whole person. I find my patients are stunned when I run out of conventional treatment options an yet they remain well, apart from the toxicities already inflicted. In this case there must be a lot of preparation for the eventual physical but not psychological surrender. It must be understood that many battles will be fought and won but the overall war could be lost but it doesn’t constitute giving up.
It must also be remembered that strategy is created in the midst of conditions of uncertainty. This can be communicated but only addressed by making life as normal as possible.
In addition to setting
When something adverse happens in hospital, for example, a patient is given the wrong medication, then we are supposed to log a report in the Incident Information Management System or IIMS. It is especially the case that this system should be used when harm to the patient is the result of the error. This is a good system but under-utilised and poorly designed – nonetheless we should continue to promote it.
We should in fact promote it’s extension to medical administration. If we really want accountability about the health care system, and in particular management of the budget, then we need an incident management system for the administrators. Let’s take the human resources department as one example. I have a potential employee for whom I could offer a job, No offer has been made even though the interview occurred 3 weeks ago. The hold up has been with the HR department and their need for more paperwork, etc, etc…..none of which was communicated as advice prior to the advertisement being released. Overall the whole process has been f’d-up, not to mention slow and expensive. So why shouldn’t I log this to IIMS.
Health care management in the Australian public health system is littered with examples of poor practice for which we should have an IIMS system……this is the way to achieve health care reform.
It’s been a while since I did a “Things they didn’t teach in medical school” post but this week has prompted some introspection so let’s give it a go.
Two years ago my dad said he was retiring. Dad is a GP who, for as long as I can remember, worked 10-12 hour days, often 7 days a week. When he said he was retiring it meant he was moving from solo practice to a group practice and possibly working as few as 40 hours a week, but still doing on call well past standard retirement age.
But can this happen in speciality practice in 2013? A surgical colleague 10 years my senior (I’m about to turn 4) and I had a chat about this recently. The conclusion…..it’s hard.
The issue is maintaining the churn. This isn’t meant to disrespect our patients but the reality is we see a lot of them and it’s demanding work – physically, mentally and emotionally.
I look around at the people senior to me and the reality is that many of them, across many specialities, not just my own specialty of oncology, wind back their day-to-day clinical activities as they enter their fifties – a time which is really only in the waning part of their second decade of practice as a specialist. The combination of repetition and stress take their toll over time.
Now I don’t mean to say that this happens to everybody but I suspect it applies to a lot of practitioners.
So what to do about it – I think diversification of interests and practice is important. This doesn’t mean get a hobby but find a role in your profession that doesn’t rely on just seeing more and more patients. Find a research interest, become good at (and interested in) management or simply make enough money to retire early. Find something to keep you going to work in the morning.
And to the future registrars I’ll be interviewing on Monday……start thinking about these things early. Those that don’t will just burn out.
Australia is in the midst of a Federal Election and for the next 3 weeks we are going to be hearing a lot of promises being made.
Reflecting on this election I’ve been thinking about the similarities between some of the medical consultations I conduct and electioneering.
Many patients come to me wanting be to impart hope. I might get them to live just that little bit longer by giving a new chemo or drug treatment. In political terms this is the promise of money. If you re-elect me I’ll give your electorate/community/organisation X million dollars to build Y & Z. Or I will cut a tax and reduce an expense.
But we (the electorate) are not iterate about these matters. We aren’t prepared to accept the real story…..that throwing some more dollars into the ring isn’t going to change much..it could ecen be wasteful. In the same way many patients are pursue the path that offers hope even though, in reality, the solution offered has little chance of changing the overall situation.
The politicians probably do actually understand the reality of the situation but they choose to play politics. The doctors also understand the reality of situations and either choose not to or are unable to communicate it effectively to patients.
The underlying problem in both circumstances concerns literacy. The economically literate would say you can’t increase spending without increasing revenue (aka taxes). Likewise the health literate individual would be able to acknowledge you sometimes run out of options.
So I have a close working relationship with a surgeon where essentially I play bad cop to his good cop. The whole Hood Cop/Bad Cop concept is a method of interrogation. In our practice it is ostensibly around the good cop sending a positive message with hope and the bad cop (supposedly me) giving the bad message.
Well this is all around want people want to hear. It happens to be the good cop message.
But let’s recalibrate this. I probably am more pessimistic but the actual attitude I take is not of taking the ‘bad’ side but of being realistic. The statistics I quote are grounded in fact. I can’t and nobody can predict the future and some people have to have a good outcome and some have a bad outcome. Neither the good cop or the bad cop can predict the future but that can be honest about the chances even if they can’t tell who will do well and who won’t.
The realistic message needs to be heard when there is a situation where the gains can be modest and the trade-offs are high. Not everybody will take the odds offered: some people will end up hurt.
Physician trainees having just completed their viva examinations are anxiously awaiting results and are deciding they want to do for the rest of their lives: they are about to embark on what is called vocational training. This is supposedly training for which these individuals have a special calling – like the priesthood.
In reality many of my peers and my juniors seemed/seem to have no idea what they have a vocation for and in fact base their sub-specialty on a variety of factors including exposure (it was the best of a bad bunch), lifestyle choices (financial , overtime/shift-work), brains/brawn (physicians vs. surgeons), and even parental expectation. As a consequence I often see fully qualified professionals who are not suited for their ‘chosen vocation’ for a whole variety of reasons ranging from technical incompetence, through to boredom and burnout.
I ultimately went down two vocational training pathways: medical oncology and clinical pharmacology. Notably I had always thought my vocation was psychiatry. I did a consultation-liaison psychiatry term for my option term in a New York cancer hospital and loved it but when I returned to do a general psychiatry term it really didn’t gel – I didn’t hate it but at the time I thought it was (and perhaps remains) flawed both in philosophy and science.
As it happened I did 2 terms each in medical oncology, haematology and gastroenterology and a term in palliative care and thoroughly enjoyed them: so what to I do now? – gastrointestinal oncology. Oncology lead me to drug development and an interest in quality care and this in turn lead to clinical pharmacology as a second specialty.
I could tell you why I like these specialties but I can’t actually tell you why I ended up here rather than performing cardio thoracic surgery (although I do often tell patients I could take them apart I just couldn’t put them back together again).
Unfortunately many trainees don’t get broad enough exposure to different disciplines in order to find their calling. In addition their modes of practice often don’t reflect what it is like as an actual consultant. For example many doctors get put off oncology because of the death and dying aspects as they only do inpatient work and no outpatient work – this is not a unique problem.
What I can tell you is this: get exposed to as much as possible and then do what you really enjoy and have found satisfaction doing. The success, career-wise, will follow-on and hopefully you’ll never get bored. In medicine never view the practice of medicine as a view to making money: if you take this pathway you need to remember the only way to make money is volume (i.e. lots of work). You’ll make more than enough doing what you really like and perhaps more than you expect. But if you really view financial gain as the reason for your ‘vocation’ then you chose wrong.
Finally don’t view a ‘vocation’ as being a singularity. First and foremost physician sub-specialty trainees need to remember that being a physician brings skills and opportunities to do things in the same way that law or commerce does.
The Wiki Leaks Party is proposing to promote ‘scientific policy’; decision-making based on research, evidence and clear, transparent principles. It is also supporting Internet freedom: “the WikiLeaks Party will be fearless in its opposition to the creeping surveillance state, driven by globalised data collection and spying agencies, both state and corporate controlled. We will demand that all information on data seizure and storage of citizens’ data by government agencies and allied corporations be made public.”
Both of these are laudable aims.
Now explain to me how the Wiki Leaks Party will operationalise these actions in relation to health care and health care data. Over the last few decades best practice in health care has been driven by the evidence based medicine (EBM) movement so the Wiki Leaks Party has a solid platform to base its’ promotion of scientific policy making. Interestingly EBM is now coming into collision with the era of big data. The problem is that we don’t have enough access to the data we already have and we aren’t collecting and using enough of the data we need to really inform the decision making process. By we I mean health care providers both Governmental and private.
I guess the trite response is that the approach to health care data will be through the principle of transparency. Well there are already many claims about transparency from the existing powers and health care providers. So lets have some detail about the the Wiki Leaks Party will handle big health data.
One of the commonest questions I get asked as an oncologist is “what would you do doc?” or “what would you do if it were your mother?”
The more I get asked this question the more I wonder about its’ relevance as more often than not the patient/family goes with the option I wouldn’t necessarily recommend.
Usually this question is asked in the context that I am discussing the pros and cons of nth-line therapy for a incurable, metastatic cancer. The option of palliative care is always available and in many circumstances, in my view, is the best option. A lot of nth-line treatment options have statistically significant but clinically marginal benefit and being the expert who as looked after a lot of people I’d usually go the palliative care route as my own preference.
But this is my preference and it is informed by my world view. I think the flaw in the “what would you do doc?” question is that the real question is “what would you do if you were me?”….well the answer to that is I’m not you and I don’t actually know what your preferences are. I encourage patients to try and work out what kind of patient they are and what their preferences are: are they a “do everything possible person” or a “quality of life is my priority person”. Sometimes I already know the answer to this as I have known the patient for a long time.
The most important thing, providing you stick to the ‘do no harm’ rule, is that there is no medically correct answer but there is a right answer for the individual.