Wednesday, 1 June 2016

Racism, and why I'm Ashamed of what I Once Thought

When I was 18 I was often angry and often wrong.  I’m pleased to say I’m less angry now, though still very, very often wrong. Unfortunately, that mixture of anger and incorrectness lead to something that I’m not proud of. It’s not easy to talk about things we are ashamed of, but there’s one belief I used to hold of which I am now ashamed of that I feel I need to discuss.

One thing that I used to be very angry about was affirmative action, especially around Indigenous Australians. When I was 18 I railed against preferential selection into medical schools for indigenous students and what I saw as a disproportionate focus on Indigenous issues in the curriculum.

Last weekend I heard Brooke Boney (of SBS TV fame) talk about the health of Aboriginal Australians at the AMA National Conference. It was one of the greatest conference sessions I’ve ever been to, and it made me very uncomfortable. I was uncomfortable to think of the views I used to hold. They are not my views now. I like to think I am not a racist person, and that I don’t discriminate on any basis, so how did I so passionately oppose something so good? And was it racism?

Well I didn’t see it that way at the time. Working from the basis that medical school places are finite I saw it as something like this: An Indigenous student of a lower ranking getting in over non-indigenous students is an act of unfairness. I felt affronted for the applicant who missed out by one spot, it was their spot the indigenous entrant took in my mind. I thought I was being pretty fair and neutral about it in my mind, after all it wasn’t self-interest right? I had gotten in to my chosen medical school at the first crack so it couldn’t be, right?

I now realise I was wrong. I made two large errors.

The first error is to look at action in isolation. All affirmative action IS truly unfair when considered in isolation from the problem it is trying to address. When the fire department sprays only one house out of ten on a street with water that seems, and is, unfair if you don’t account for the fact that only one house is on fire. Of course, fire departments are not controversial, it is very easy to convince yourself that they are being fair, because you can see that only one house is on fire. Fire is eye catching.

What I had thought when I was 18 was that medical school selection starts in April the year before. What I now know is that it does not, it starts decades before. But disadvantage is not a fire. There are no leaping flames or cracking heat. Indigenous students finish year 12 a lot less than non-indigenous (around half versus around 4 out of 5), but you may not notice when you’re in year 12 because it’s hard to notice what isn’t there. No flames. Indigenous Australians are jailed 24 times as much as non-indigenous but this just doesn’t develop the traction it might otherwise because being jailed is seen as a moral thing, a simplistic single factor view prevails that simplifies jail as just a  punishment for being bad, and thus little outrage materialises. No heat.

These and other disadvantages are not left at the door when you put in an application to medical school. The slate is not wiped clean. There are two things that strike me now that didn’t before. Indigenous disadvantage is so prevalent that without the counter pressure of affirmative action or alternative entry streams we would probably have very few indigenous doctors with a poor representation of indigenous people in medical school for ever forward. Secondly that disadvantage means that that a merit based ranking simply is not merit based, it is a combination of merit, luck and disadvantage. Somebody with a lower score may not actual be less able, or less deserving of a place.

I have now realised the best way to sour your view of affirmative action is to look at the action in isolation. Ignoring the problem makes affirmative action seem unfair, acknowledging it makes anything less seem inadequate.

I said I made two errors. The first was how I understood affirmative action. The second was how I understood myself.

I touched briefly above on the fact I saw myself as a neutral observer, with the dispute between a lower ranking indigenous student and a higher ranking non indigenous student who missed out. I didn’t miss out on selection after all, so I was quite sure I didn’t have a bias in the way I looked at the issue. I was very wrong.

Sir Terry Pratchett wrote about “first thoughts” as instinctive responses, “second thoughts” as the counter argument and “third thoughts” as the thoughts that watch the first two. My first thoughts were that an indigenous student had taken the place of a higher ranking non-indigenous student. My second thoughts were “what if that non-indigenous student had been me”. The third thought that I never had was why I only pictured myself as the non-indigenous student and not the indigenous one.

While I didn’t miss out on selection myself I immediately identified with the theoretical non-indigenous student much more than the theoretical Indigenous one. My response was unconsciously biased because of it. I said at the start I like to think I’m not a racist. Part of the reason I responded so defensively was I saw this as something with the potential to harm, and was blind to the potential benefits at least in part because of what I saw as my race. It’s difficult to look back on that and the way I reached that conclusion and say then that it was not racist.

My views softened and changed and my perspective broadened both throughout medical school (particularly on indigenous placements, on elective in FNQ and particularly spending time with Andrew Macdonald, a paediatrician who was passionate about ATSI issues during paediatrics). I now think that what we do in indigenous medical education is not just needed but is in fact not enough. But it doesn’t take away how uncomfortable I feel about the views I used to hold, and how strongly I used to hold them.

It is in fact more than just discomfort, it is shame and I am sorry.

Monday, 28 March 2016

How to Pick a Good Surgeon in Three Questions

There’s been a lot of negative press around surgeons lately. Ranjana Srivistava described a very disturbing case of suspect (and what sounds like money-driven) decision making by a surgeon in a system that allowed for it. I don’t think what she describes is representative of all or even most surgeons, but I don’t doubt the veracity of what she describes, it’s a very believable story to me.

And all this is on the background of months of exposure for bullying and sexism in some quarters of the surgical profession.

It’s easy to see why somebody going to see a surgeon at this time might do so with a sense of dread or mistrust.

Choosing a surgeon is pretty daunting at the best of times. Doctor rating sites tend to be based around things other than the quality of a doctor’s practice. Most give as much weight to the visual attractiveness of a doctor’s room, the friendliness of reception staff and their punctuality as they do to a doctor’s knowledge. None that I know even attempt to measure a surgeon’s skill with the knife. Frankly I don’t put much store in them.

So how do you choose a good surgeon then? Well this is how I would do it. I’m not saying it’s the only way, but these are the questions I would ask.

The questions I would ask, more or less in order of importance are as follows.

Question 1. “Which M and M meeting(s) do you participate in?”

M and M (Morbidity and Mortality) meetings are the cornerstone of quality surgical practice. There’s an adage that only two kinds of surgeons don’t make errors, those that don’t recognise their errors and those that don’t operate. In a robust morbidity and mortality meeting the participating surgeons present every patient that has had a bad outcome, whether that be death, a disability, a wound infection or an unplanned return to the operating theatre and the case is discussed by the surgeons in the meeting. The meeting reviews whether the correct decision was made in deciding to operate, the type of operation performed and whether the outcome was avoidable, and suggestions are often made about how to prevent complications. Different surgeons will suggest a range of different suggestions for things they’ve tried that have or haven’t worked and whether they have found themselves in similar situations. Data is kept and surgeons who keep presenting with the same complications can be identified.

These meetings are usually held on a department/hospital level but for very specialised surgery (e.g. paediatric craniofacial surgery in NSW) they might be held at a state level to get sufficient expertise in the room.

Beware a surgeon that doesn’t participate in M and M meetings. M and M is the primary way surgeons get feedback on their performance and the primary way that surgeons keep an eye on each other to ensure everybody is meeting today’s standards for acceptable operating technique and decision making.

A surgeon who doesn’t participate in M and M doesn’t have that degree of feedback and to an extent is professionally isolated. “Self-review” is no substitute. There is nobody to check them if their approach is out of date and not in line with best available evidence, there is nobody to give feedback on how they manage their cases and nobody to challenge their decision making if it’s out of kilter. It also speaks to a surgeon’s priorities and how seriously they take examining their own shortcomings, and their self-perception if they feel they don’t need review.

By virtue of passing RACS exam it’s reasonable to assume every surgeon meets an acceptable standard of practice when they first start. But what is acceptable practice, as well as a surgeons technical skills can change over a 30+ year career, M and M helps ensure that surgeons continue meeting those standards.

This is the single most important question for me. I would be very hesitant about going to a surgeon who doesn’t regularly participate in an M and M meeting.

Question 2: “Is there anybody you would recommend for a second opinion?    

The answer should never be “no”. A good surgeon should support your right to be informed and comfortable in making decisions about your health. Many great surgeons I know will actively suggest a second opinion for all complex and major surgeries.

Beware the surgeon who suggests you don’t get a second opinion. It speaks either to a sense of professional isolation, unwillingness to have their decisions reviewed, an overly mercantile attitude or an unchecked ego. None of these are good things.

A good surgeon should be happy to suggest some names and facilitate a second opinion for you. If they’re not, that’s a red flag.

Question 3: “What will it cost?”

People don’t have limitless money. Surgery is important (often vital and life-saving) and a quality surgeon is important but it shouldn’t be used as a license to extort money. Surgeons charge a range of fees, as most providers do in a free market, but rates significantly above the AMA suggested rates should have to be justified.

Sometimes rates above what the AMA suggests are justified. Some cases are particularly and unusually complex compared to other operations of the same type. Some practices, especially in rural or remote areas with low patient volumes will have higher administrative costs without the economies of scale larger practices may have. All of these are good justifiable reasons to set a higher fee for a case.

Surgeons who charge many multiples of the AMA rate for simple cases just as a matter of routine because they can, either through reputation, celebrity or lack of competition show a degree of mercantilism that my bleeding left wing “healthcare for all” heart isn’t comfortable with.
If a surgeon can’t justify the fee they are charging that’s a red flag for me as well as my finances. I have to know that I am my surgeon’s first priority rather than my wallet, or else I couldn’t be comfortable placing myself in their care.

In summary:                

Like I said at the beginning these are just questions I would ask and this is just my personal opinion. I think if a surgeon answers those three questions well then it helps to establish that you’ve picked a surgeon who is not professionally isolated, who has colleagues checking their practice and knowledge is up to scratch, who is committed to quality and who has your care rather than your potential to earn them money as their first priority. That’s much more important to me than how attractively their waiting room is judged on a doctor rating site.

Sunday, 13 March 2016

Michael Gannon's Pitch for the AMA (Federal) Presidency

A note:

On 13/03/2016 I used the original version of this post to express concerns about Michael Gannon as a candidate for the AMA Federal Presidency.

On Sunday 29/05/2016 Michael Gannon was successful in the election for the AMA Presidency.

I have removed the original version of this post to give him clear air.

Saturday, 20 February 2016

Baby Asha

I'm not scared of politicians as a rule, they're generally understandable, most have good intentions and get into it for the right reasons. The remuneration (unless you're crooked) is less than what most of them could get in the private sector, and it's pretty hard work. But that's only most of the time, not all the time, there are two red flags for me that get my hair standing on end. Exclusion, and Bipartisan agreement.

For those of you that don't know, my Dad is a history teacher. Which is why it tends to surprise people that I don't really believe in "the lessons of history". I tend to think that people portray events to fit the perspective they already have, and fit the world view they've already accepted, rather than gaining any new insight, I see history more as a tool of argument than inquiry.

But there are a few exceptions. 

There's one thing I think is undeniable, that simply recurs too often, too consistently ignore: the most dangerous idea in the English Language is "other people".

Most of the great evils of the world, certainly nearly all perpetrated by governments, are predicated on portraying the victims as different and somehow other than ourselves. The watchword is "we" as a term of exclusion. Beware any politician who uses the word "we" to emphasise that the group of people he is talking about (and yes, it is usually a "he") is not part of a greater whole. That "we" and another group differ on a fundamental level.

Think: "it is we who order the State!" (Hitler, Triumph of the Will, 1935) or "we will decide who comes to this country and the circumstances in which they come" (Howard, Australian Parliament, 2001) or "We send a clear message... that those people will not be settled in our country." (Dutton, 2015).

Why is this? Because, invariably, we are being asked to tolerate and abjuration of rights for a certain group of people we would never tolerate for ourselves. It is only by separating a group of victims from the general population and casting them as being somehow different from ourselves that politicians are allowed to put them in situations we would never accept for ourselves. When politicians try and make people seem less human, it's generally because they want to treat them less than humanely.

If the government tried to take a white baby from Campbelltown and lock them in an island prison all hell would break lose. 

But language is insidious, if you say "we" and "those people" enough then other people start saying it too, soon there is a barrier or divide in peoples minds and you can get away with saying whatever you damn well like.

The second red flag. There's always part of me that thinks I might be wrong. After all politicians are pragmatic and hate each other more than it seems humanly possible to sustain right? And they agree on this? Surely if any other position was reasonable one of them would take it up simply to be contrary and score political points? Unfortunately history doesn't back up that ray of hope. If anything seeing the ALP and LNP agree wholeheartedly is more suspicious than it is a ray of hope. The White Australia Policy, the Stolen Generation and now island prisons for children we don't want have all been things the ALP and LNP (or forerunners) thought they could both get together behind. 

That's how we do evil in Australia, bipartisanly.

So I think about baby "Asha" and my colleagues in Lady Cilento and I wonder how we got here. That it seems likely in the next few days government agents will forcibly detain a baby (do they even make handcuffs that small?) and force them onto a plane to an island prison for the rest of their life. A place where sexual abuse against children has been alleged, where a simple cut foot has led to death from sepsis in another prisoner and where one has been beaten to death in a riot. Could I justify letting a parent willingly taking a child there? No, I have a duty of care. Can I justify the government forcing them there? Of course not.

Doctors treat children to help them. Whether they belong to a class of manufactured villains or not doesn't change that. A child is a child is a child.

Both doctors and parliamentarians take an oath. The difference is theirs is to "the crown" ours is to "people".

There have been two reports into shameful failures of compassion in Australian history in living memory. One called "Bringing them Home" (stolen generation), one called "Keep them Safe" (NSW's failure to care for kids at risk).

We are not bringing Asha home, we are not keeping her safe. We have learned nothing, evil marches on, our character blackens, and it means less and less each day to be Australian.

Monday, 24 November 2014

When Parents Hurt their Children

I’ve written before on the prevalence of tragedy in my line of work in children’s neurosurgery. One of the most painful tragedies to deal with is when a parent hurts their child. I’m not talking about accidental injury. Parents inflict injury on their children, that is the bare fact.  This is 2014 and babies are still shaken, older children are beaten and yes, some children are killed by those meant to be looking after them. I can personally attest to all the above.

 There’s something about children under attack that raises a protective and defensive streak in anybody warm blooded and fully human.  In a setting where harm has been inflicted by a parent, it is only natural for that to flow into hatred and a guttural need for retribution against the person responsible for that injury. It’s not something doctors are immune to either. For instance:

Our cup runneth over with those willing to seek vengeance for children who have harm inflicted by their parents.

I am convinced that parents hurting their children out of cruelty does happen, because I am sure I have seen it. I’m also convinced it is exceedingly rare. While I’ve seen cases that simply cannot be explained any other way they are thankfully memorable because they are so isolated. In a hospital that drains all serious head injuries in children for about half of Australia’s most populous state there would only be a couple that come to mind this year. To put that in perspective I can see more children with new brain tumours on a busy weekend.

And yet I have met very, very few cruel parents. The far more common parent is one at the end of their tether. I am in a luxurious position at work, I can play with happy babies, toddlers and children, and give them back when they won’t stop vomiting or won’t stop crying or won’t stop doing the exact opposite of everything you tell them.  There’s a lot of things kids just won’t stop doing.

There are people who will stop reading now, who will think this is going to be an apologia for child abuse. It’s not. There’s nothing a child can do that justifies the sort of harm we see, from death to permanent brain damage. I don’t think it’s unreasonable to say I probably see the effects of inflicted injury on children more than 9,999 out of every 10,000 people who will read this. I know the terribleness of this tragedy, and I’m not trying to argue that we should do less for child abuse and child neglect, quite the opposite.

What is also undeniable is that people have different capacities to cope with different things, every medical student learns that on their first trip to the emergency department. There are people who for whatever reason are not capable of coping with life’s challenges in helpful ways, or who cope and endure to variable extents.  Sometimes those people even get pregnant, or get somebody pregnant.
Without going into the specifics of how babies are made, the qualifications are neither particularly rigorous nor exclusive.

Some parents also have more supports than others. What is endurable with a supportive extended family, financial security and no other caring commitments becomes harder with the situation reversed.

For whatever reason the majority of parents I see who have shaken their baby, or neglected their baby, or abandoned their baby (in a hospital, or with the intention that it be found most of the time) have done so because they had nothing left to give not as an act of malice, but as an act of desperation.

Monsters are real but rare. Monsters are also easy, the truth of a parent who has passed their capacity to cope is both harder to hate and asks harder questions of us as a collective society. It’s easy to see why painting monsters is so much more attractive. The difficult realisation is that people like most animals are at their most dangerous when they are trapped with no way out. This is also when parents are most dangerous to their children.

As a society what I think we need is not just more supports for parents who struggle, but to publicise those supports that already exist. You can take a child to a hospital and say “I cannot look after this child any more”, there is no prosecution for this. I wonder how many cases of abandoned babies and infanticide would be avoided if people simply knew this?

Certainly more than will ever be avoided by harsher legal penalties. Anyone who has stared a mother who has shaken her baby in the eyes, or met somebody who has harmed their child because they felt so overwhelmed they couldn’t look after them any more can tell you: not one of them was thinking “well at least the jail sentence isn’t too long.”

Demonising parents who hurt their children and punishing them severely will sate our blood thirst. It does a lot for our collective need for retribution but it does little for our collective soul. It does even less for children, and nothing to keep them safe.

Deciding people are monsters is easy, but it’s no solution, and we need a solution.

Wednesday, 5 March 2014

Death, Tragedy and Suffering

I have taught a fair number of medical students over the past few years, which is something I have enjoyed a great deal. I can answer a lot of their questions, when they have questions I can’t answer we both end up learning something. It’s harder when they ask questions without definite answers. Especially in my new job (I am being a paediatric neurosurgery registrar this year) there are some life and family shattering situations. Why do these tumours cause hydrocephalus? Easy. Why did this little girl have to die? Hard.

I was talking to a crying medical student one afternoon after the very traumatic death of a little girl and, as I usually do, I found myself with far less answers than I would like. I wish I could have told her that this was a one off situation, a freak event and that it wasn’t part of the job, but that would have been a lie. Even diseases that don’t end in death can be tragic, the disabling brain injury, the miscarriage of a pregnancy or the slide into incoherence, incontinence and dependence of advanced dementia.

The truth is that illness, disease and injury are not nice things. To study or practice medicine is to enter a world with infinitely more suffering than joy. 

Why did this little girl have to die? There’s just no answer to that. But there are other, meaningful ways to ask the question. Anyway I took this medical student away from the throng of people that surrounds the death of a child in these circumstances, about 20 people all told: nurses; anaesthetists; intensivists; surgeons; paediatricians; radiographers; porters and others. We sat in the NUM’s office and we talked about one series of books and one series of paintings.

First, the series of books. I asked her if she’d read Harry Potter. She was a big fan (there’s something about medical students and junior doctors, every single one is a big fan). We talked about a few things. But mainly Dumbledore and the Sorting Hat. If there’s an overarching message to Harry Potter it is that who we are as individuals is defined by the choices we make, i.e. by what we do with what we’ve got. As Dumbledore says, “It is our choices, Harry, that show what we truly are, far more than our abilities.” When the sorting hat sorts students it does so not just by what abilities they have but by what they want and ask for. It’s the central point of the book, not just the heroism of the gifted (be it in ability or station) but the heroism of the ordinary. 

The series of paintings was more obscure. “The Vinegar Tasters” is a traditional subject in Chinese religious art. It shows three old men tasting a pot of vinegar, one has a sour look on his face, one bitter and one sweet. The man with the sour look is Confucius, the one with the bitter look is Siddhartha Gautama (the Buddha), and the one with the sweet look is Lao Tze. Each represents one of the religions of Ancient China: Confucianism, Buddhism and Taoism respectively. Confucius looks sour because life is sour and in need of strict rules, Buddha looks bitter because life is bitter and primarily characterised by suffering, Lao Tze looks sweet because life is sweet and while suffering exists in the world, for whatever taste the vinegar has, it is the taste of vinegar in its natural state, and things being true to their nature is fundamentally good, even if found subjectively objectionable by many or most.

It’s easy to see this as Taoist propaganda, designed to imply the superiority of Taoism over Confucianism and Buddhism, but it’s also possible to draw a more nuanced meaning from the painting. All three men are tasting from the same vinegar. That is the key point. All three religions try to interpret the same world, replete with suffering and tragedy, and yet come up with different interpretations and meaning, some would go as far as to say they are different presentations of the same wisdom.

The argument Harry Potter makes for the actions we choose as individuals, The Vinegar Tasters makes for the perspectives we choose as societies. Perspective, how we frame our questions is important.

Yes, we have a dead girl, a broken body lying in a bed. But zoom out for a moment to all those people we rushed past before: nurses; anaesthetists; intensivists; surgeons; paediatricians; radiographers; porters and others. All of them were there because a 5 year old girl was terribly, terribly unwell. We knew how, but not who. For most of the time, most of us did not know her name. 

We were not there because there was anything for us, because the little girl, or even her family had some sway over us or the ability to recompense us. We were not there because they were rich or powerful. We were there because a little girl was suffering. Because our society had chosen to do all that we could to eliminate and alleviate suffering as best we could, because the health and comfort and dignity of everybody in it is something we value.

There is unspeakable tragedy in the world, but if this, all these people and all this effort is how we respond to it, it says good things about us. The only way to extract meaning, for me at least, in situations like this is to focus not on the sometimes unstoppable and unlimited march of disease, but on the fact that with whatever limited abilities we have we respond to it in such a way as we can be proud of.

It is not the tragedy of our situation, our propensity for disease and suffering that defines who we are, but how we choose to respond to it. And as I look around at the dispersing throng of people, every person that could conceivably help, doing everything they could, we chose to respond to it the best we could. And we do, consistently. That is the perspective I choose.

It might not be the answer, but it’s an answer, and it feels like “meaning” to me.