Currently Australia, or at least New South Wales and Victoria are in the midst of continuous or rolling, recurring lockdowns. For Sydney this is the first real surgery of the COVID-19 pandemic having largely been successful at transmission suppression in the time prior to Easter 2021. The reason is the emergence of the delta variant of COVID-19 just at the point when the Australian vaccination campaign was being implemented. Due to the tyranny of distance vaccine distribution in Australia was delayed whilst Europe and North America received their shots. During that time vaccine hesitancy, or more specifically Astra-Zeneca hesitancy, became common due to the emergence of a low probability but potentially fatal coagulation disruption called VIPIT. Pfizer was not yet available and the medical communicators were equivocating. Meanwhile the delta variant was arriving by plane and evading hotel quarantine. This variant seems more transmissible, possibly due to higher viral load in the infected, and appears to cause more serious illness in younger individuals than earlier variants.

The Australian Government and the NSW Government have indicated lockdowns will not be needed once 70% of the population are fully vaccinated. This should occur, with current vaccination rates, towards the end of October 2021. What is the significance of the 70% target. The United Kingdom is the example to note. At approximately 75% of the population over 16 years of age fully vaccinated the UK is still experience a surge of cases of around 30K per day – roughly half the peak at the start of 2021 and predominantly driven by delta. Most of the cases are unvaccinated or partially vaccinated although some breakthrough cases are occurring. Notably the risk of hospitalisation is reduced and the number dying each day is <100 (counting deaths that occur within 28 days of diagnosis. This is versus a daily death toll that peaked at 1800.

To date the Australian approach seems to have been to pursue freedom through perfection: tight border controls, zero local cases and zero transmission. This has been achieved with snap lockdowns, masking, etc. Even more perfect that Australia has been New Zealand, which is even more remote from the rest of the world.

Australia and New Zealand cannot remain islands unto themselves forever and they can’t stay locked down forever. From a practical perspective it is actually unknown at the current time whether or not the current lockdown settings or any lockdown settings are strong enough to suppress a delta variant outbreak. Based on the current situation in the UK and making a major assumption that the situation won’t deteriorate due to waning immunity or the emergence of a even more virulent and transmissible variant, Australia will need to get used to living with the presence of COVID-19 if it is going to relax lockdown.
Living with endemic COVID-19 means that despite high vaccination rates and herd immunity due to the combination of vaccination and infection/exposure individuals will become infected, most will have milder illness but there will still be, based on the current UK experience, hospitalisations and deaths.

Let’s assume 70% vaccination is by the end of October and true to the word of the politicians the lockdown is lifted and internal borders are opened – then what? Well in 10 WEEKS the Australian healthcare system needs to be able to accomodate a manageable number of hospitalisations and ICU admissions AND be able to conduct as much business as usual activity as possible. If we are unable to re-open the healthcare system then either the lockdowns don’t end or the whole situation needs re-thinking.

The other part of the mindset that will need to change is that we will need to accept that there will be some deaths. Australia is fortunate that there have been no influenza death for 12 months. This is not the norm and in a cyclical fashion Australia regularly has in the order of 1000 deaths per annum. This may be where we land with endemic COVID-19. The current influenza mortality rate is due to a combination of the local measures put in place to fight covid, rigid border control and ongoing vaccination programs. It is implausible that we will reach a state of no deaths from COVID-19 even after herd immunity is achieved so we need to learn to live with some poor outcomes.

Overall, and despite the current surge, Australia has been relatively good at responding to the pandemic. Where Australia has failed is planning adequately for the short and medium term future, implementing some of the plans (like vaccination) and in becoming complacent when things were going well. Now that things aren’t going well it is time once again to move at pace and scale to ensure the resilience of the healthcare system beyond October and to develop effective communications strategies to that the public knows where the ship is sailing to and that sometime we need to change tack.

America is in chaos.

Simplistically this is about a personality, Trump, claiming the priorities of his ‘populist’ base.

But this is too simple.

America was founded on a promise and a dream….truths self evident that all men are created equal.

And yet many of the people believed and continue to believe that all men are not equal. And in particular some men are inferior – those inferiors being blacks, women, gays, non-Christians, the impoverished and the like.

And yet, America also promotes the notion that it is the land of opportunity. Anybody can rise to success and wealth off the back of their own sweat and perseverance. This is not true. The USA has low rates of moving upwards in socioeconomic terms and the the reasons include a false meritocracy and a local of true equality.

I spent some months in the USA in the mid-1990’s and attended lectures at an esteemed mental health faculty. The message I took away was that America actually doesn’t care about the mentally unwell or to be more specific, the underprivileged, the poor.

And so, I can only conclude, that equality and individualism as ideals are incompatible bedfellows, especially when greatness is founded in bigotry.

And so we are left with a Capitol stormed by agents of chaos. They seek their own order but bring no organizing principles.

Ironically the Congress, House and Senate, are now tasked with recovering from COVID -19 and a brave new world where the ‘base’ is the underclass and they will and demand and the very same social supports that they deride as socialism.

I don’t know where the USA should go from here but it must re-invent itself and perhaps it should start by looking in the mirror and conducting a reality check.

One of the questions in response to the blog post https://winstonliauw.com/2021/01/01/what-will-a-covid-19-endemic-world-look-like/ was what would be the impact on oncology?

The impact on COVID-19 on oncology may vary quite a bit from country to country depending on the degree to which the healthcare system coped: in some countries there have been huge impacts on presentations with cancer and in some cases the ability to provide timely treatment. Where I work, in New South Wales, Australia, there has been negligible impact on the new cancer notifications and little reduction in the capacity to provide care.

The first major observation is that the pandemic acts as an accelerant driving change that was already happening in healthcare. The most obvious change is in virtual care including telehealth. When the pandemic starting impacting healthcare services activities in virtual care that had been trundling along with pilots and limited implementations over a decade were suddenly scaled up and implemented in a matter of weeks. In Australia, telehealth was ultimately catalysed and embraced by the medical community when fee-for -service arrangements were recognised after many failed years of lobbying. The systems aren’t perfect but they are now here to stay.

The acceptance and adoption of telehealth-related technologies including both software and (mobile) hardware enable a number of important activities that are useful in oncology. It can provide capacity for home-based care, particularly when monitoring is required. Being able to detect a deteriorating patient at home when they are being treated for specific conditions allows for rapid intervention. There will be increased capacity for shared care with primary care physicians and both in the treatment and survivorship phases of care more care can be delivered in a virtual fashion. Enhancing the ability to provide 24/7 care is particularly important for patients receiving palliative and terminal care.

Capturing patient reported outcome measures (PROMS) as well as patient reported experience measures (PREMS) is a high priority in the field of oncology as this has been shown to improve symptom management and oncologic outcomes, potentially reduce costs of care, and also can enhance the patient experience. In a virtual care environment PROMS and PREMS potentially become even more important as they can be incorporated into the workflow of a telehealth consultation to capture information that in turn guides the clinician as to how to direct the consult.

The response to COVID-19 in oncology/haematology led to rationalisation of care protocols for many situations. In oncology and many other fields a lot of unnecessary care was identified and suspended at least temporarily. The classic example is fractionation regimens in radiation oncology. Shifting to hypo-fractionated regimens is a much debated area of clinical variation in routine care but once there was a need to minimise patient visits to healthcare settings and to ration linear accelerator time it made instant sense to adopt such protocols. Whether or not these changes will stick will depend on time. Fortunately the impact in terms of outcomes can also be monitored via cancer registries.

One of the observations I made in my practice was that at the time there were restrictions on visiting hospitals and lockdowns were in place some of my patients re-considered their goals of care and decided against active treatment in favour of quality of life at home. The pandemic has re-ignited the need to have goals of care discussions and establish advanced care directives.

The biggest logistic challenge cancer services face is a consequence of the successes of new cancer therapies over the last 30 years and in particular the last decade. Essentially all common cancer types and many rare cancers have effective 1st-line and 2nd-lines of therapy and in some cases many more. In cancers like breast cancer screening, early detection and highly effective adjuvant therapy have increased the numbers in survivorship care. Many incurable/metastatic cancers now can be chronic disease with many patients living for years with cancer and the burden of treatment. Many of the treatments aren’t low toxicity treatments that can just be taken at home. Often the therapies are intravenous and repeats fortnightly to monthly for long periods of time. This has lead to a substantive increase in activity both in terms of visits to cancer specialists and visits for treatment. This growth in activity is not sustainable without having impacts on patient care such as increased waiting times which in their own right result in inferior outcomes.

Addressing the increased activity could be addressed by increasing resources but this is not likely to happen. Investment will be in physical infrastructure to boost the economy and the prospects of politicians. We will need to take many of the learnings from the pandemic to manage this problem. This will include development of novel models of care that exploit virtual care and in closely looking at what is necessary care versus optional care, how the care is delivered and by whom. Reducing arguably unnecessary follow-up of probably cured patients to free-up resources for chronic care cancer needs to be considered.

Oncology, as a subset of the whole healthcare system, will change long-term in response to COVID-19 but these changes were already happening and we haven’t been wasting the opportunity of a good crisis.

Everybody is hoping that towards the end of 2021 COVID-19 vaccines will have completed roll-out and we can hit the reset button turning back to life in November 2019. We’ve been through the initial panic then the realisation that the pandemic is a 1 to 2 year event. But wait, there’s more. Virologists anticipate that SARS-CoV-2 will become endemic. This means it will always be present in our communities. This is not unlike the many other coronaviruses that are endemic causing milder conditions such as the common cold.

The vaccines, to date, do not prevent transmission but do reduce the severity of disease if required. It is plausible that herd immunity will not be reached despite widespread natural infection and extensive vaccination programs. People will still become infected and the vulnerable populations such as the elderly, those with chronic disease and those with compromised immune systems will still be at greater risk of severe illness and death. So what should this mean for how we live in 2022 and beyond?

In considering this question we should consider viral influenza. Influenza as an illness poses a significant burden on the healthcare system due to the moderate symptom burden and some mortality in similar vulnerable populations as SARS-COV-2. SARS-COV-2 may have a higher case fatality rate although this may have reduced with improved understanding as to how to manage these patients. The greatest problem COVID-19 has created in regions with high rates of infection has been the burden placed on the local healthcare systems. Once intensive care beds are fully occupied by COVID-19 patients and less acute beds are also occupied the usual emergencies are competing for care and elective surgery and medicine is cancelled. Diversion of resources means other serious conditions aren’t treated.

So the endgame in a world for endemic SARS-COV-2 is to avoid shut down of the healthcare system. The caveat to this aim is that we must also find a way to avoid complete shutdown of the healthcare system without the trade off of completely locking down everything else – somehow daily life must go on. How is this to be achieved?

The first issue will be to change the mindset from crisis mode to a new business as usual mode. The current state of play in Australia is a very strong focus on public health strategies such as widespread testing, contact tracing, isolation of cases, quarantining of travelers and closed or restricted borders. The more extreme measures such as hotel quarantine won’t be sustainable if there is any intent to re-open for international tourism. There may need to be test-to-travel and proof of vaccination requirements if mass global movement is to resume.

Vaccinate as many people as possible and use every behavioral economic trick in the book to get people who don’t want to get the vaccine to do so. Altruism for the rest of society seems to be the answer. We also have to remember it is early days and there is uncertainty about the durability of the response to the vaccine but also whether there will be sufficient mutational variation to result in a COVID-20, not unlike the need to regularly update the influenza vaccine. Vaccination may need to be annual – we probably won’t know until next year

General measures to improve hygiene need to stay in place even if people are reassured that things are under control. This might mean that masking on public transport becomes routine: it was very common in Asian countries to use masks on a routine basis after previous coronavirus outbreaks. Perspex shields in customer service settings will continue. QR code check in, temperature checking and even facial recognition in less privacy concerned societies may become the routine as a way of facilitating contact tracing for positive cases. Risk minimization should prevail. Two hundred years after Semmelweis it might be time to take handwashing seriously. And other measures like proper use of PPE, not to mention the ability to make it locally.

There are going to be seismic societal changes. There are many displaced, unemployed workers around the globe. Sadly, the pandemic has taught us that many of these workers were not essential. Many work settings are getting by with fewer workers. Automation is coming into play: people still shop but they do it online and in turn the warehouses, despite some uptick in human employment, will increasingly rely on robot-based contributions to the supply chain. Drone or autonomous vehicles will start to appear on the roads. Initially these may simply serve as delivery services, replacing the e-bike powered food delivery services that currently navigate the roads with a death wish. Eventually autonomous vehicles will be driverless taxis providing a form of iso-public transport.

The lack of jobs for low-skilled and even some high-skilled people will mean a re-thinking of the welfare state. There may be a further decline in the middle class and an overall increase in inequality. Universal basic income may be not be imminent but more experiments with such societal support will occur. Regardless of the form it takes there is likely a need for increasing government supported social safety nets such as healthcare. This will mean governments will need to review and reform taxation. Note as well that society will be increasingly cash-less.

Work itself will change. Working from home will be increasingly accepted as an option for those whose jobs essentially involve screen time . Widespread broadband, 5G then 6G, team collaboration software and videoconferencing software and hardware are starting to come together to provide a more seamless experience. Working from home can provide a better work-life balance paradigm – providing of course the kids also don’t have to be at home to school (although more blended learning experiences may be offered). Productivity rather than hours may become a better metric for the output of labour especially as some companies move to modified working weeks like the 4 day week.

Live entertainment will also change. Film studios are moving to direct release to streaming and going to the cinema in person will mostly be for ‘event’ movies that benefit from the larger screen format. The trend to boutique cinema experiences will continue. For the theatre and live music, in particular for shows that are not long-runs or stadium events, there will be the public expectation that live-streaming will be available and that there will be the ability to replay at home for time-limited periods. Already such subscription services are rolling out. At at the classical concerts there will be less coughing between movements.

Other experiences like dining out may also change. Design of dining spaces to facilitate physical distancing will become more common and in places with favorable climates al fresco dining will become more common. This in turn will impact street design with broader sidewalks or other more pedestrian friendly designs.

Healthcare will be catching-up to other digitized service industries like banking. Virtual consultations and care via telehealth, remote home monitoring and many other innovations that have been brewing for decades have been given the challenge needed to implement them more quickly and in a more integrated way. The other change in healthcare will be more widespread use of rapid testing kits to diagnose many different types of infection. These will be important for rapid triaging to the right treatment and infection control measures. Rapid testing also has the potential to reduce anti-microbial resistance.

The pandemic and other natural disasters have been attributed in part to activities that result in climate change and it has also shown many people how the air can be cleaner when the world stops burning as much fossil fuel. As such the pandemic has become a catalyst for more rapid adoption of cleaner technologies. Housing has become more than ever a refuge for the world. New housing should be designed both mindful of the environment but also of the different needs of a society that goes into periods of lockdown. Having been forced to stay indoors many will have greater appreciation of the outdoors. This should prompt increased efforts to preserve and protect natural environments and also to improve urban design. Urban design will also increasingly accommodate pedestrians, cyclists, scooterists and other non-car based commuters.

Perhaps most importantly the COVID-19 endemic world needs to be ready to recognize and react quickly to the next pandemic. This is not a once in 100 year event. Pandemics or potential pandemics are occurring more frequently: think Ebola, SARS, MERS, Zika, etc. The ability for global co-operation, public/private partnerships and governments to move at pace and scale needs to be implanted in our memories and embedded into our systems. Vaccines were produced in record times. The next pandemic is most likely going to be a coronavirus sufficiently mutated and different to COVID-19 to garner it’s own name. If this is the case then vaccine development, building off existing platforms, should be even quicker, like the current status with the annual influenza vaccine.

We cannot keep living waiting for the 11 am press conference telling us how many cases there have been and what the next adjustment to restrictions will be. Now the vaccines are arriving governments need to turn to how they will manage endemic COVID-19 otherwise the light at the end of the tunnel will be the next oncoming disaster.

Citizens, based on retrospective judgement of historical figures character and actions, are actively undertaking cultural redaction by toppling sculptures, defacing monuments and renaming streets, schools, buildings and bases. Sometimes these changes are over-the-top and miss the point that you need to preserve some things, perhaps in museums, to maintain memory and learn from the past.

But retrospectively action is not enough. I propose the Memorial Test for determining whether prospective action is required to prevent the election of inappropriate officials and/or the erection of what might be in the future a culturally distasteful monument.

To apply the test imagine your current public figure had a statue. Would you as a citizen protester think it should be toppled based on the public figure’s actions? If the answer is yes then (1) don’t vote for them – assuming voting is allowed in your country and (2) don’t name anything after that person or build any monuments to them.

Donald Trump wouldn’t even unveil a portrait of Barack Obama. Don’t even paint a portrait of Donald Trump.

I think it is important that we get off-line now and again. Read a book. See your family. Go for a walk/run.

At one point today I was on one Skype call, receiving Skype messages, on a separate Microsoft Team meeting, receiving emails, taking phone calls and participating in WhatsApp conversations. And we are still to add comms methods.

Nobody has headspace for that much multi-tasking, multi-comms.

So take a break. Listen to some music. Do something else that downsn’t involve screen time.

I keep hearing the works never waste a crisis. The COVID-19 pandemic certainly fits the bill for the RACP Physicians Exam. In Australia the barrier for junior doctors to progress from basic physician trainees to advanced vocation trainees consists of a multiple choice examination and then for those that pass, a clinical examination consisting of short cases that assess examination skill and long cases designed to assess capacity to manage patients from a problem-based perspective. This year the clinical examination may not be able to be run. Normally held across July/August it could be postponed until October. The problem with this is that the practising for the exam takes months and is not possible to do with the infection control required during the pandemic. This is not to mention that the registrars themselves will be on the frontline and also will be emotionally and physically fatigued even if they don’t catch the virus. October is after the usual recruitment period for the subsequent year so there will be flow on effects. 2020 will be remembered as a lost year or 20/21.

The questions we should ask as a profession include: (1) does the exam ritual actually ascertain competence as a future physician, (2) is it really a good discriminator between those who can do the job and those that can work to the test, (3) does it really assess the knowledge-base, (4) does it assess ‘soft’ skills such as communication and team work, and (5) does it really assess readiness for vocational training.

It should be said that there are other assessments in play such as log-books, structured activities such as mini-CEX and case-based discussion, as well as supervisor reports. However, these assessments, in particular the supervisor reports, may not be very objective, and trainees not performing up-to-scratch can slip through the system. Ultimately the exam is the arbiter of progression.

The college should think of different approaches to assessment that spread out across training. These should address core competencies but with sufficient breadth to cover the key specialties including cardiology, respiratory, neurology, gastroenterology, geriatrics and endocrinology. Haematology, oncology and immunology are important but have boutique aspects that are not always necessary for the general physician to know. Viva exams that focus just on knowledge without necessarily having patient examination could be considered. (Video) observed practice and clinical audit could also be considered. Reduced emphasis on assessments that can be biased due to candidate performance anxiety is desirable. Additional focus on other contributions outside routine ward care should also be considered – for example leading innovation through RMO Associations or quality improvement activities. Alignment with the approaches to CPD that the college has implemented is desirable.

After the plague year we shouldn’t return to business as usual.

Yesterday the Royal Australasian College of Physicians @TheRACP held its’ annual written exam, a 5 hour long barrier exam for progression to the viva voice examination that progresses the candidates to advanced training in medical sub-specialities. For the first time the college chose to use computer-based assessment rather than written assessment and engaged @PearsonVUE to undertake the process. It went spectacularly wrong with the software essentially seizing up towards the end of the first half of the examination. The problem has been attributed to an as yet unknown glitch. The exam was called off and is now re-scheduled as a paper based test on the 2nd of March. This was also not the only problem with a process that included inconsistent supervision, inconsistent mobile phone policy, misinformation, failure to take into account the needs of the candidates (like expressing breast milk) and lack of a back-up plan. The consequences are manifold. Trainees planned holidays immediately after the exam and these are now put on hold, no doubt with financial loss. Extra time off the wards will be required. There may be interruptions to other training events scheduled a year in advance and recruitment that commences in August/September for the subsequent academic year could in theory be disrupted. This is all not to mention the psychological distress caused by the most important test of their lives (apart from the viva).

Can any good come of all of this?

All of these future physicians are entering an age of completely digitised medicine. In fact they are the first generation where all hospital based records and prescribing will be undertaken electronically and private practice is fast moving in the same direction. Some of these future physicians will hold titles in their healthcare organisation like Chief Information Officer and hold higher degrees in health data management and analytics. I think for those candidates who suffered the events of yesterday there is a teachable moment. Just as the RACP simply cannot afford for the digital assessment system to fail as health care providers we cannot afford for our digital systems to fail. Downtimes in the electronic health record (EHR) are a bit like the computer aided flight systems on a plane failing. Cyberattacks or power-outages might results in critical system failure. How can we look after a patient if even for short periods of time all their health-related data is not accessible? People will have infusions running when computers crash. Operations will be underway. Critical life-saving information could be unavailable. Patients lives might hang in the balance just as trainees sitting the exam might see their futures hanging in the balance.

Trainees who experienced the digital failures of 19/2/18 who go on to take responsibility for digital healthcare will reflect on their experience with terror. They will manage the risk and work hard to ensure that their digital health care environment is as safe as possible. Catastrophic failure is never 100% preventable but due diligence, user testing, good risk management and risk mitigation could have prevented these calamitous events.

Clearly marriage equality will lead to the end of civilisation through devastating disruption of the social fabric of society. This will be the final straw. After all think of all of the other things that have led to society’s demise (in no special order):

• The Pill
• Martin Luther’s list nailed to the doors of the Catholic Church
• The Steam Engine
• The Internal Combustion Engine
• Women voting
• Non-landowners voting
• Native title
• Rock and roll
• Jazz
• Atonalism
• The miniskirt
• The swim suit
• Abolition of slavery and apartheid
• Women in the workplace
• The forty hour work week
• Abolition of child labour
• Paid parental leave
• The old age pension
• Genetically modified food
• Solar power
• In vitro fertilisation
• Counter-culture
• Free love
• Divorce
• No more white Australia policy
• Nationalism (well that actually came pretty close -still might)
• Abolition of rule by hereditary monarchy
• Women on the battle field
• Dissolution of Empire

As you can see from the following graph – marriage equality is new to the game but we’ve been overcoming the end of civilisation for centuries.

Emerson String Quartet: Eugene Drucker, Philip Setzer, Lawrence Dutton, David Finckel