A lack of rules is not our problem. A lack of open mindedness to the existence of an issue is our problem.Read More
This Tuesday, I'm so excited that everyone will finally get to see Heartbeat: The Miracle Inside You on ABC Catalyst. The show, written and directed by documentary filmmaker Anna Broinowski, lets you follow me around the operating theatre, visiting patients and exploring some exciting new developments in the science of the heart.
I spend a lot of time trying to get people excited about their hearts. Or more specifically, looking after their hearts. Many years ago, as a junior doctor, I got so drawn in by this magnificent organ that I committed my career to taking care of them. As a medical student, I was always going to be a surgeon, although at that time, I was going to be a plastic surgeon or an orthopaedic surgeon.
Women surgeons were uncommon when I was a fresh faced new doctor. And they still are. Women make up just under 10% of surgeons in Australia. While unconscious and systems biases still exist, I was lucky enough to be mentored by some incredible surgeons who were largely male and taught me to be a hard-working and highly skilled doctor. To me, it never crossed my mind that being female would hold me back. And with the support of my seniors and my own tenacity, it didn't. My gender is the least interesting part of who I am and what I do.
When I was given a rotation in cardiothoracic surgery, at Royal Perth Hospital, it was hard not to get sucked in to the beauty of everything that is held in by our rib cage. Our hearts and lungs are so incredibly clever, so strong and yet, I was beginning to understand how fragile they could be. I think one of the turning points came for me when I went to visit a lung transplant patient in ICU and I asked him how he felt. He looked at me and said "you have no idea how good is to be able to breathe." That right there, took my own breath away.
I never left heart surgery, and finished my specialist training to become a cardiothoracic surgeon after many years training, including getting extra training in transplant surgery and congenital & paediatric heart surgery. While staring at hearts is now very normal for me, I can honestly say that I never ceased to be amazed by what our hearts can do.
Despite their brilliance, hearts get sick. Sometimes we're born with problems in our hearts. In fact, every day in Australia, eight babies are born with a heart problem. Sometimes, it happens out of the blue in fit and healthy men and women. Sometimes, our hearts pay the price for what we do to them, like smoking or inactivity. And that's where we come in. A huge team of doctors, nurses and allied health professionals that I am lucky enough to call my colleagues are ready to help however we can.
Heart surgery and medicine in general is truly excellent. We are always pushing though to work out ways to tackle diseases of the heart in ways that are better, safer and more effective for patients. In an ideal world however, we'd get in long before you needed to be on an operating table.
It's my hope that we can all get better at taking care of our hearts. Whether it be breaking the code for the genes that cause heart disease in children, or developing even better mechanical hearts, I am so excited at where the future of our hearts is taking us. As part of Catalyst, I was lucky enough to meet some amazing scientists who are doing just that. From Prof Sally Dunwoodie and Prof Robert Graham at the Victor Chang Institute to Professor Stuart Grieve at University of Sydney, these tireless researchers are helping make a future for our hearts brighter than ever before.
As I said, I don't usually get to meet this wonderful minds. While I call them colleagues, they're the ones doing the hard yards behind the scene, sometimes over many many years to get a breakthrough that will help hearts everywhere. At the end of that process, I get to be the lucky doctor who uses their hard work, sometimes to save a life.
All in all, it's inspirational. And that's what I hope you all see from Catalyst this week. But rather than just be in awe of the clever scientists, the brave patients or our wonderful heart team, think about how wonderful you are. Because on the inside, you have this incredibly beautiful pump that starts beating before you're born and never stops until the day you die. It's such an amazing thing that we all have and I hope that this inspires many more of us to look after it in the way it deserves.
Day of the Girl. Sounds like a Terminator film title. 'Day of the Girl: Rise of the Ovaries'. Now, as you may have guessed, I spend quite a bit of my time thinking about, talking about and trying to improve gender equality in my little chunk of the world. I want the girls and women I come into contact with to see what they can do but also how it happens. I want to show them my flaws and mistakes so that they might learn from them. I want to create a collective voice that stands for all women reaching their goals, living a life where they can see their potential and fulfil their needs. I want women to have choice.
I grew up not really understanding that gender is a barrier. I never knew that because I was born a girl, that some people would see that as a weakness. I never understood that my intelligence would be both questioned and somehow demeaned if I was not pretty. And I definitely did not appreciate that even in a modern time, I would be required to work twice as hard as some of my male counterparts and I would be judged much more harshly for behaviours considered normal for boys but unbecoming of girls.
That being said, I am a middle class white woman. I am educated and I had a safe home with good role models in my life, some male and some female. I was not shot in the head for going to school, I was free to marry who I chose and I was free to do things in life that others might take for granted, like walking alone into the city. When I was born, my birth was celebrated not mourned. In fact, I was born when many girls are never given that chance when fetacide still occurs.
October 11 was declared by the UN to be International Day of the Girl Child in 2011. It aims to promote leadership and change so that girls around the world can lead full and safe lives. The very important message that we need to take from this day is that when we nurture and educate our girls, our whole communities improve. Health and welfare improves and violence abates.
I am very proud of what I have done in my life. Being a woman is a gift and I hope that I can use that to inspire and mentor those around me. It's a tough gig sometimes but we are tough and resilient and resourceful. However, today, I want to take a moment to be thankful for the great opportunities I have had and mindful of those that others do not. It is so vital that for us girls and women who have privilege and a voice that we fight for girls everywhere.
Happy International Day of the Girl x
My fellow tweeting-surgeon-friend, ENT surgeon Dr Eric Levi, tweeted these two thought provoking messages today.
There were lots of replies. A few identified with the fact that medicine is not 'just a job' but a vocation, a calling and defines who we are. Some talked about the importance of having hobbies outside of medicine. Others talked about leaving medicine and how scary that can be. It seems that Dr Levi hit a sore spot. He certainly did for me.
I like to think that in my daily dealings with life's big moments such as death, survival, fear, anger and caring for another human that I have learned what is really important in life. I have. I know that a wife desperately wants to see her husband get better after a long hospital stay. I know the raw emotion when a mother passes away. I know the sound of elation, relief and thankfulness when things have gone well. Yet, in putting that into practice, like many of my colleagues, I have fallen short of the mark.
Last year, I read the phenomenal book by neurosurgeon Dr Paul Kalanithi, When Breath Becomes Air. Paul was just about to complete his neurosurgical residency when at the young age of 35, he was diagnosed with metastatic lung cancer. Paul wrote the book as he battled this horrendous disease which ultimately took his life. I read it as a doctor who deal with lung cancer but also as a doctor who like Paul, had given up so much to pursue this 'calling'.
As I read about Paul's life and career, I found it echoed my own and that of many of my colleagues and friends. Upon diagnosis, he wanted to get back to work until the realisation dawned upon him that life was not the many hours spent in the operating theatres. While I was so sad that this young man lost his life to an aggressive cancer, what also saddened me was that why had it taken such a crisis to cultivate appreciation for what truly matters?
I have struggled with my own identity as a surgeon first and everything else second. One thing I can say without hesitation is that is the wrong way around. Surgery is indeed a vocation. Medicine is a calling. It is not something you do when you have luke warm feelings about it. It is not however, all of who I am. It is not even the most important part of who I am nor of my life.
Recently, a patient about to undergo a major cardiac operation had a wedding in the hospital. It was love that mattered. And that is exactly what matters and defines us, not our occupations. It is the love of your spouse, family, children and friends that is who you are. It is the things you love to do with your time whether that be watching the sun rise, long runs on the weekend or a nice glass of red wine that matter. For all the times I got my priorities and identity backwards, I am sorry. I am sorry for those who fell down the ranking and I am sorry for myself.
I do look like a surgeon and I am a surgeon. A surgeon though, is not all that I am nor all that I want to be. I want other facets to my career and I want the important people and experiences in my life. I want to cultivate a life that is not made up of sutures and blood and ward rounds. And I want to share that life with the people who mean the most to me.
So to answer Eric's proposition, who would we be if our careers were taken or perhaps freely given? We would be just fine.
I met a delightful colleague recently who introduced me her term 'kindfulness' which I immediately fell in love with. Her idea that so much toxic culture and therefore toxic outcomes results from a failure of kindness, both towards ourselves and towards others. She advocates for the widespread, indiscriminate practice of kindfulness.
"All I know is that my life is better when I assume people are doing their best" - Brene Brown, Rising Strong
I thought about what she said and realised how much truth there was in this. We are geared up to think that people are doing their worst, that we are doing less than our best. We have become so judgemental and focussed on evaluating and critiquing what everyone else is doing. All this is breeding is toxicity. We judge ourselves for not going to the gym or doing the washing and then berate ourselves to the point where we equate not meeting a task as a reflection on the very fabric of who we are. We missed a workout or didn't make the bed snowballs into 'I am an inadequate person'.
Likewise with those around us. The guy who cuts in front of us on the motorway is an idiot and can't drive. The coworker who constantly leaves early is lazy and useless. It becomes so much a part of our moment to moment conversation, thinking and perceptions that everyone around is not living up to some imaginary standards. Their behaviour escalates into a reflection of all of their behaviour and then everyone else's and as a consequence, we do not bother to show them any kindness or compassion.
It may not come as a surprise that doctors are a competitive bunch but we're also tribal. Surgeons hang with surgeons, physicians with physicians and so on. The tribalistic behaviour has given rise to some hilarious jokes and stereotypes. Such as my personal favourite, what's the difference between God and a cardiac surgeon? God doesn't think he's a cardiac surgeon. (Boom tish) These jokes are a reflection of how we judge each other without compassion, kindness or understanding and say all heart surgeons are arrogant, all orthopaedic surgeons are dumb, another specialty is useless at something and the list goes on.
What these jokes, then stereotypes and harsh judgements actually foster is an inability to be kind to each other at times. And when we can't be kind, we get judgemental. When we get judgemental, we get frustrated, angry or aggressive and significantly less tolerant of others, their behaviours, their flaws and even their successes.
Being kind to ourselves and each other is not just about cultivating the manners our grandmothers spoke of. Being kind and compassionate to ourselves and to each other is good for mental and physical health. Training people to be more compassionate increases their well being, alleviates anxiety and improves their ability positively contribute in a social setting. Being kind to others also increases a sense of self-kindness and wellbeing about oneself. We can happily teach people to be kind and compassionate and in the school setting, this can have positive effects on school safety and development of young minds.
At work, where we are subjected to sometimes long hours of toxic culture, being kind is the correct antidote that we should be using. Showing compassion to others difficulties, whether they be in the office or outside of it increase a sense of well being and therefore productivity. Workplaces that are rife with bullying see an increase in the number of sick days taken and employee turnover, not to mention the development of depression and anxiety in those subject to bad behaviour. Self-compassion is associated with less burnout and anxiety at work, all good for the office but also good for the humans involved.
Kindness is not about being a door mat or standing for poor behaviour, performance or systems; letting that slide is probably going to make you feel worse about yourself and more resentful towards that person and therefore less likely to be kind to them. But perhaps we need to stop confusing strength and aggression and vice versa.
It's fairly safe to say that what we're doing to ourselves and each other isn't exactly working, with rates of burnout, depression and anxiety much higher than most people feel comfortable with. Toxic workplaces are miserable and road rage is a term that is now part of the modern vernacular. So let's try something different. When someone cuts you off, when someone forgets to do their work or when you have a burger instead of a salad, be kind. Notice it, give them and yourselves a break and carry on.
Or even better, practice 'kindfulness' actively. Smile at the person opposite you on the train, wish the barista a good day when you get your morning coffee or offer some help to someone who looks like they might need it. It's not a massive amount to ask and the dividends may be great.
"Picture me standing on a floor made entirely of glass. If something good happened to me, or if I had a good day with a friend or family, the glass I was standing on would become a bit thicker, meaning that my resolve was stronger and I was less brittle. But if something bad happened, or if I had a setback, cracks would start to appear in the glass. If those cracks ever became numerous enough, the glass floor would shatter and I would fall" - Jerome Doraisamy, The Wellness Doctrines
I have written about mental health (or lack thereof) in doctors on several occasions. The upcoming week or so has two very significant events for mental health. Firstly, September 8 is R U Ok? Day, a day that we are encouraged to ask the people around us if they are doing okay and if they're not, act on it. Secondly, the AMA(WA) Doctors In Training Wellbeing sub-committee has a symposium coming up on how we can facilitate keeping our doctors well and help those who aren't overcome their difficulties.
Depression, anxiety and suicide in doctors is rife. US data suggests that 400 doctors per year commit suicide which is the equivalent of losing an entire medical school every twelve months. Beyond Blue has determined that the risk of depression and suicidal ideation is much higher than that of the general community and higher than other professionals. Doctors face an enormous amount of stigma if they suffer, especially openly from the public and their colleagues alike. Despite existing to fight disease, doctors are blind, ignorant or dismissive of this disease in themselves and in their colleagues.
The factors contributing to poor mental health in doctors are numerous. Obviously, a number of doctors who experience depression have pre-existing traits, genes or personality structure that sees them prone to this. When we add into this equation the incredible stress faced by doctors, it's hardly any wonder. I personally feel like the stress in medicine is increasing, despite the fact that as a registrar, I worked many less hours than my most senior boss, who trained 20+ years before me.
Doctors are now faced with new and difficult stressors including an increasingly competitive training environment, layers of bureaucracy and unnecessary paperwork and exposure to increasingly sicker patients. This in addition to the 'run of the mill' stress of long hours, social isolation, long training times as a specialist, relocation, personal cost of training to name just a handful. While hospitals and specialty colleges are offering access to support services such as counselling and moving to combat stressors like bullying, this in itself is not enough.
Most of us do actually realise the significance of these major bodies coming out and saying 'we understand you need support from time to time' but we are doing very little to prevent mental illness, target stigma and facilitate meaningful recovery.
A doctor admitting they are unwell is still such an incredible taboo and can be an enormous barrier to seeking help in a timely fashion. There is the ever present threat of having conditions placed on your practice by the Medical Board and having your colleagues be made aware that you are not up to scratch.
Prevention of mental health by truly taking steps to reduce the common stressors in the life of doctors is also an area that needs improvement. Access to part-time or interrupted training may be beneficial to those who are unwell but do not want to leave their training program. Truly developing no tolerance policies when it comes to bullying hospital-wide, not just in surgical circles may relieve some of the stress experienced by our doctors. Successful implantation of wellness programs have taken place in Stanford General Surgery in the USA where surgical residents are given time to go outside, play games and generally destress.
Finally, as a profession that strongly identifies themselves as their vocation, facilitating return to work programs and allowing time off and other access to mental health professionals and programs can help validate the doctor as useful contributor, even in the face of their illness.
The irony of all of this is that whenever I see a patient who to me, is depressed, I have no problems being a compassionate listener and offering the help that they need. As do my colleagues. Doctors, ourselves, prefer to live in a 'Do as I say, not as I do' fashion. While we stand silently and let ourselves, our friends and our colleagues be consumed by illness, we fail to offer the help we vowed to take. We also fail to stand side by side with those who need it and let them know that they are not alone and that things can get better.
Nobody really wants to suffer in shame and silence. And so, this Thursday, ask those around you if they are okay. And take steps to be a loud voice for you and everyone around you and demand that as a profession, we start taking care of each other in the same manner we take care of our patients. Mental illness is not shameful, no matter who you are. It's time that doctors start to take proper care of themselves and for those around us to say that it's okay to need a little looking after.
I came across this interesting article, shared by excellent podcast The Doctor Paradox. Published in the Wall Street Journal online, the article alerts readers to a very real problem for the profession and the people it lives to serve.
Today medicine is just another profession, and doctors have become like everybody else: insecure, discontented and anxious about the future. In surveys, a majority of doctors express diminished enthusiasm for medicine and say they would discourage a friend or family member from entering the profession. - Wall Street Journal
The article very nicely pinpoints several issues that are perpetuating this disillusionment within the profession. A feeling of being under-valued by society and our governing bodies or employers, a never ending stream of bureaucracy and paperwork linked to that and most worryingly, impacts on patient care.
Despite concerns about income, autonomy and professional satisfaction being a part of this problem, doctors are by and large, quite altruistic people. We hate seeing our patients short changed by an increasingly burdened health care system. And we hate that the burdens being forced upon us are passed along to patients. For example, the WSJ article speaks about administrative tasks directly diminishing patient contact time. In Australia, we have concerns over government funding of health care that will lead to a passing on of costs to vulnerable patients. Our profession exists to serve people. And it is a service we glean much satisfaction from.
That being said, it is time to take this problem seriously. These days, we are trying to make sure everyone feels valued but doctors seem to be getting a slightly different message. The implications for our society as a whole are great if this intense job dissatisfaction continues.
The profession obviously needs to look inwards at itself to see what it is doing to aid such disillusionment. Factors in the workplace such as bullying and discrimination, lack of flexible training options or high degrees of mental stress will not only tarnish our existing doctors but word will get out and we will lose the best and brightest to come other profession. Despite what many of my senior colleagues have said about 'quitters' over the years, this is not weeding out the weak. This is our great loss and society's great loss.
During tough times in our lives, my fellow surgeons often turn to surgical training as a yardstick. 'If you made it through surgical training, you can make it through this'. And 'this' can take many forms; relationship breakdowns, deaths, financial troubles and so on. Becoming a surgeon should not be used as the yardstick by which we measure all of life's problems.
As a profession we also need to take charge of our destiny. Take a look at the great efforts by the doctors of the NHS in the junior doctor dispute. They came together as one profession and said that they were no longer going to be taken for granted and most certainly, they were not going to put their patients at risk for the sake of politics. Health systems the world over have a lot to learn from this dispute.
Perhaps the most serious downside, however, is that unhappy doctors make for unhappy patients. Patients today are increasingly disenchanted with a medical system that is often indifferent to their needs. - Wall Street Journal
We are altruistic and we do care about our patients. We also care about ourselves and our own families and the extraordinary sacrifices we have made for our profession and our patients. The fact that we are not alarmed as a society by the breaking of our health care workers is a sad indictment on our approach to modern life.
Our medical students and young doctors need to be mentored authentically to demonstrate professionalism but also learn about career planning and self-care. We should examine our training processes to ensure that we are doing everything we can to retain people even if that means moving away from trying to break our trainees. And lastly, the profession needs to bring our goals together and ensure that we have a strong hand in shaping a system that works for patients and doctors alike.
Our system is approaching breaking point and the dedicated health care workers from all fields who prop it up won't be able to for too much longer. So now is the time for action to sustain our health care system into a long and caring future.
"It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat." - Theodore Roosevelt
We would all like to describe ourselves as strong, tough or resilient. We would like to think that when life gives us lemons, not only do we make lemonade, we do it with fortitude. We look the problem in the eye and we go for it. We take no crap and suffer no fools. And in the end, the triumph is ours.
I have been reading the most fantastic book recently, 'Rising Strong' by Brene Brown. In it, social worker and PhD researcher Brown talks about the value of vulnerability in strength and overcoming adversity in life. In both the big moments and the day-to-day hiccups. The crux of Brown's approach is exactly as Roosevelt states. Courage is not winning, courage is 'being in the arena', it's dusting yourself off and starting again. It's turning up even when you've been beaten down.
The concept of strength to me has always been that typical Type A response. Attacking the problem head on with huge amounts of gusto. Now though, I think that most of human achievement actually comes from the moments in the arena. It comes from the moments when we have to show faith or hope or vulnerability. That kind of exposure of yourself is much greater than the exposure of grabbing a bull by the horns.
"Vulnerability is not winning or losing; it’s having the courage to show up and be seen when we have no control over the outcome" - Brene Brown, Rising Strong
The concept of strength being about brute force rather than the gentler vulnerability and quiet, persistent courage is a barrier to real happiness and real success, both personally and professionally.
It is the falling short of our need to win that creates a dangerous workplace culture when we take our shame and frustrations on someone with less power than us. It stops us from seeing what our emotions truly tell us that we want. It stops us from asking for what we need and want in life. It's the pride that lands us in more trouble when we don't ask for help. It's the isolation from our family and friends when we don't communicate what really matters to us.
The real strength lies in compassion. Compassion for ourselves and the hurt that we experience. Compassion for others so that we might see that they are trying their hardest or are imperfect, even when they fall short. Their best may not be our best or even in our best interests, but when we look at what has happened with compassion, life is a little easier. And rather than pure anger or some other Type-A response, we can grow ourselves and maybe even help with the growth of others.
I wish I had known more about just being in the arena before now. About the power of vulnerability and compassion. I think it may have made me a better person, a better partner, a better friend and a better doctor. In our society, we might earn to grow together if we start seeing the world not in terms of winning or losing but of the power of showing up and being real. We can act from a place of authenticity and integrity and I don't know about you, but I think that will definitely help me sleep at night.
Gap (noun) A break or hole in an object or between two objects:he peeped through the gap in the curtains1. A pass or way through a range of hills:2. A space or interval; a break in continuity:there are many gaps in our understanding of what happened3. A difference, especially an undesirable one, between two views or situations:the media were bridging the gap between government and people
Chasm (noun):1. A deep fissure in the earth’s surface:a chasm a mile longfigurative he was engulfed in a chasm of despair2. A profound difference between people, viewpoints, feelings, etc.the chasm between rich and poor
At a recent gathering of colleagues, we were discussing the upcoming meeting of a women in surgery craft group. A few said they would be attending, some could not but one voice said something I wasn't exactly expecting. A similarly aged female colleague said 'I never go. It's just a room full of whinging women'.
This isn't the first time I've heard someone say this and certainly not the first woman I've heard say this. I have to be honest, it always shocks me a little. Although my surgical workplace remains a male-dominated field, some women have better experiences than others, some a lot worse. However, using the term whinging implies that those bad experiences are being blown out of proportion or imagined.
The bold statement that implied women’s craft groups are nothing more than a group vent made me think, are they really relevant or are we just whinging?
Surgery is not alone in the presence of female-orientated craft groups. Virtually all professions where men have traditionally held those positions have one or more. Women in Surgery, Women in Media, Women in Engineering, Women in STEM, Women in Law,Women in Aviation and even the defence force has a section dedicated to encouraging women into their ranks. On numbers alone, you would have to imagine that these organisations must exist for a reason and do function in a positive manner.
In these diverse fields, women are particularly underrepresented, especially at the higher echelons. Women make up around 10% of surgeons and in a very public investigations, around half of women in the field reported some form of bullying. Others reported discrimination and sexual harassment. Only three women have been appointed to the Supreme Court, loss of women in STEM during their 30’s and 40’s sees them underrepresented at higher academic appointments and across the board, difficulties with breastfeeding, parental leave or career progression are common.
Strength in numbers is so useful to women who may want guidance or mentoring. It is great to be validated by someone else in a similar position that the problems or successes you experience are not just limited to you. You are not alone. Women’s professional groups have the ability to share advice and offer support. At the risk of sounding a little but of a hippy, at the very least, within these groups a safe space can exist to share some of the not-so-good times.
They can explain how they manage child care with work, or how to make a workplace breastfeeding friendly. They can share advice on how to break the good old glass ceiling and support, mentor and facilitate the advancement of women through their ranks. Personally, I think they are an excellent resource to network, mentor, support and even socialise.
Women’s professional groups do have some distinct advantages for their members. This includes locating a mentor that the mentee can identify with, providing both guidance and inspiration in navigating the workplace. When used appropriately, this can be of great advantage in an increasingly competitive workplace where connections matter. These groups often advise overseeing professional bodies on matters that effect everyone including workforce diversity or flexible working hours and leave policies. Whether you be male or female, member or not, a lot of positive improvements in the workplace have come as a direct result of the influence of professional women’s groups.
That’s not to say that these groups sometimes underperform. Especially in workplaces where gender equality is not as advanced, these meetings can indeed have a tendency to become all about venting the problems we all encounter. In addition, just by existing or having a large group, that in itself won’t change systems weaknesses or unconscious biases. Women’s professional groups also have to develop achievable action plans that can actually perform at work.
Professional women are also very adept at keeping their heads down, so as not to create any trouble that might hamper their career. Associating yourself with your women’s section may wrongly identify you as a feminist, troublemaker or ‘humourless bitch’. Regardless of the fact that we have every right to have our concerns heard and changes made. Nobody wants to be seen as a troublemaker and troublemakers are at risk of not being employed or looked over for promotions. Whether it is true or just, women’s professional groups can indeed seem a little scary to those of us who are just trying to survive.
That being said, I don’t think that we should stop voicing our concerns. Perhaps a meeting of women in surgery or engineering or any other group is full of ‘whinging’ because we have along way to go. It may be a sign of disempowerment of women as individuals at work, in society or as a group as a whole.
I don’t buy into the philosophy that we should support other women, at all costs. The saying ‘there’s a special place in hell for women who don’t support other women’ is just another way to exclude someone who may have a different opinion. We should support each other and not pull the ladder up behind us, however, disagreeing and having the tough conversations will only improve things for women. Nodding along with whatever is said, including the existence of women’s groups, can lead to us missing the important and uncomfortable topics that need attention. However, blanket labelling of feminists and women’s groups as ‘whingers’ belittles the experiences that some women have had at work.
I strongly believe it is important that these groups exist and continue to undertake the excellent work that they do, not just for women or its members, but for our entire workforce. A diverse workforce is without a doubt, a more efficient and productive workforce. Instead of choosing our doctors, lawyers or pilots from a proportion of the population, we get to pick them from the whole population. Imagine the talent we could discover!
It is also important that women’s professional associations do not become echo chambers of professional women listing the vast number of problems faced by them in the workplace. To be honest, I don’t think many just do that. They have absolutely been positive vehicles for change, not just for women but for entire professions. Continuing to use our collective voices, women’s professional groups can lead the way to create workplaces of the future that are inclusive, productive and successful.
Just when you thought it was safe to turn on your TV...
Just when you thought your TV show had hired a medical consultant...
Just when your neighbours thought you had stopped yelling at the screen...
It's time for part II of 'Meredith Grey is not real life'.
House MD: Where are the nurses, allied health professionals and ward clerks?
I have already given House a hard time in my last article but considering it's a repeat offender, it deserves a repeat mention. Aside from the fact that House and his team of ultra-talented doctors appear to be the only physicians working at Princeton-Plainsborough, they are flying solo. The nurses portrayed in this series are not only few but they seem to only serve to give House dirty looks. Real life is much more diverse. We all work in multi-disciplinary teams where each professional brings a special set of skills. the nurse for example, may not do surgery, but equally luckily, the surgeon will not demonstrate physical therapy. It takes a village to heal a patient.
The book 'Blindsighted' by Karin Slaughter: Not everyone cracks a chest
In this series of books focussing on small town coroner/paediatrician where an unnerving number of murders take place, the drama seems to win out over accuracy. In the first book of the series, the protagonist opens a young woman's chest to give internal cardiac massage. Of course, she survives. TV shows, films or books often make it sound like we are all ready to give anything a go. In reality, doctors are not. We make calculated, educated decisions not just based on knowledge but our own skills and specialties. And when a situation is above our skill level, we call someone who knows what they're doing.
Every TV show/medical movie ever: If the supply closet is rocking, don't come knocking
Just no. There are rumours of hospital staff shall we say letting off steam, but most definitely not with the frequency of TV shows. If we were all at it as often as the doctors of Grey's Anatomy are, there would be no time to get work done.
Every TV show ever: We all hangout after work at the pub over the road from our major teaching hospital
Going back to this concept of time, we are tired. Most of us at the end of the day just want to go home, eat food that is not from the hospital cafeteria and sleep. Before you are a fully fledged specialist, we race home to study for specialist exams. Basically, we are boring and responsible. However, when the time does come, we do know how to have fun and hang out with the people you spend most of your life with.
Grey's Anatomy: Relationships with patients are frowned upon. Especially if they leave you a large inheritance.
Back to Izzy and her drive line cutting, doctors are held up to a very strict code of conduct and having a relationship with a patient is a major no-no. We are in a particularly privileged position, the patient in a very vulnerable position and these rules exist to protect the patient from being unduly influenced. In Australia, even receiving gifts from patients is subject to strict rules and require reporting of the gift to your hospital.
House MD & Grey's Anatomy: You can't be rude to patients or other staff and expect to get away with it
From the time Cristina Yang screwed up and organ donation request to every time Gregory House interacted with another human being, the tolerance for being rude is pretty low. Especially to patients, no matter what the circumstances.Patients (rightly) complain about doctors (or other staff who are rude to them) and increasingly, within the medical profession, we are becoming less tolerant of poor behaviour from our colleagues. Whatever the situation or reason, the patient suffers when behaviour is poor and that is just not okay.
Catch Me If You Can: I concur, you can't pretend to be a doctor.
Ironically, one of my favourite TV shows is Suits about a guy pretending to be a lawyer which I'm sure is pretty unlikely. Pretending to be a doctor would be tough. Even as a fully qualified doctor, any time you want to work somewhere or perform a new procedure, boards or committees scrutinise you very closely to ensure that you are who you say you are. Rocking up and nodding along sagely with a senior clinician will net you a trip to the police station.
Casino Royale: After a cardiac arrest, James Bond is back to saving the world
Mr Bond, it pains me to tell you off. Especially after that scene in that film. And you always get your man. But let me be clear here, people do not have a cardiac arrest, shock themselves (sort of) and then just clean up and carry on with their day. If you survive a cardiac arrest, you can be sure that you have booked yourself a hospital stay to find out what happened and how to stop it from happening again.
Heartbreakers: Melissa George was never covered in bone dust
To be fair, I have not yet watched Heartbreakers, based on real-life transplant surgeon and author Dr Kathy Magliato. In her interview about how she saw real-life heart surgery, George says that she was covered in bone dust after a tough day of scrubbing in. No she wasn't. I promise you, she wasn't. Heart surgeons in particular pride ourselves on being neat and tidy for one. Secondly the sternum opens without much fanfare at all. Maybe she was gunning for ratings? Either way, it's generally not as glamorous, dramatic or messy as TV and TV stars make it seem.
Tell me what else drives you mad - I'm sure there are hundreds of them!
Many years ago, I was working as a registrar in plastic surgery. In this unit, we did a lot of complex head and neck reconstructions for cancer. One case I remember especially well was a wonderful lady who had a particularly nasty cancer on the floor of her mouth. She was scheduled for surgery on a Thursday. Thursday was reconstruction day. We started her operation around 8am, finished around 5am on Friday morning. I raced home for a quick shower, got changed and came back to work. No sleep. A lot of make-up. I came back into the ICU to see our lady and the free flap reconstruction was not looking great. It was likely that there was some problem with the blood supply of the tibia, muscle and skin we had borrowed to reconstruct the defect. An hour of trying things like manipulating blood pressure, taking pressure of the neck and heparin to dissolve any clot didn't work and so we headed back to the operating theatre to revise the flap. It was about 5pm on the Friday when I realised I had fallen asleep on the operating microscope.
This is not the first or last time I had been awake for several days. I am overly familiar with the reasons sleep deprivation is used as a form of torture. It is awful. In surgical literature, there has been a growing body of evidence that suggests sleep deprivation can be associated with mistakes made, especially by junior doctors. They are also at risk for traffic accidents, needlestick injury, burnout and other mental illness. Work-life balance is undeniably important.
In Europe and in the United States, working hour restrictions were brought into place to try and improve the safety of patients and doctors. In Australia, we have shift length restrictions and minimum breaks but in my experience, some hospitals play fast and loose with these areas of the award. 24 hour shifts still exist.
The European and US restrictions do have some drawbacks in surgery. Firstly, the increased number of shift changes may mean that a patient's care is 'handed over' to doctors resulting in the potential for Chinese whispers of the medical variety. Errors can be made each time we tell the story again, things forgotten. For training purposes, the reduced time on the ground may decrease training numbers and exposure to emergency cases.
An ambitious study was released today in the New England Journal of Medicine where investigators looked at the ACGME-compliant group versus a group with more flexible work hours. The main differences was that the conservative group couldn't have shifts over 16 hours (24 hours for more senior doctors) and had to have 14 hours between shifts. The flexible group could work over the 16 and 24 hour limit and did not have to have a 14 hour break.
Flexible working hours were not associated with any increase in adverse events, which is very reassuring. The flexible group residents did also not report any dissatisfaction with educational opportunities and were less likely to leave during an operation. The residents didn't report any adverse personal outcomes to working more hours.
What is very interesting about this paper is that the residents involved were not aware nor were they consented. Neither were patients, when care may have been affected. In my opinion, this is an ethical whoopsie. It may have changed outcomes as doctors changed behaviour or perception, but medical research is not in the business of not consenting its subjects.
Other data which would be great to see was not picked up would be incidence of needlestick injuries, a validated burnout scale or longer term well being or skill acquisition data. I think these things would make for a fascinating look at the effects of the things we do to ourselves.
I think work hour restrictions are actually important for training doctors. The weight of evidence to suggest that tired people are sad, burnout, dissatisfied, potentially error prone, divorced, unhealthy and so on is quite strong. We all know someone who has had a near-miss or actual accident being so tired after work. I had a bike accident one day, coming home from a long shift. I was too tired and didn't see the car pull out in front of me. An obstetrics registrar was killed in an MVA, a plastics registrar hospitalised. I don't know many surgical trainees or surgeons who haven't woken up in their cars, nearly underneath a bus.
That being said, I also believe that it is important to know how to operate when you're tired. Someone's life is going to depend on that one day. The first time you're doing an emergency procedure after a long day shouldn't be when you're out on your own. I also think that handing over mid-operation is not good for patients or doctors learning. Some flexibility must be afforded to experience emergency, tired and middle-of-the-night surgery. It should not, however, be the norm.
As with most scientific literature, we don't usually change practice based on one study alone. That should be the case here. More information is needed so that we can find a 'sweet spot' where the needs of both doctors and patients are looked after.
Back again in my plastic surgery days, those hours were long. We operated most nights, not just on true emergencies, but on urgent but not emergent cases. We needed to get the work done because there was no other time. On call for plastic surgery rarely meant home before midnight and back at 5am.
One night, I went to see a patient with the senior registrar. This man had been waiting to have a second operation on his hand after an injury. It was around 7pm and we were hoping to do him around 9 or 10pm that night. My senior told the patient this and he refused to consent.
"I've seen you here after midnight every day this week, mate. You're too tired"
The senior was seriously jacked off that his competence had been called into question.
In all likelihood, had he had his operation by the tired registrar that night, it may have gone well with no problems. In medicine, we try not to play too much with 'may have' or 'she'll be right mate' because when it comes to people's lives, close enough is not good enough.
Close enough is not good enough for our patients or our doctors. It is incumbent upon us to work out what is good enough.
This is a copy of a letter I am sending to the editor of the UK Newspaper The Times following an editorial by a Dominic Lawson. The article is available at http://www.thesundaytimes.co.uk/sto/comment/columns/dominiclawson/article1656813.ece Dear sir (or madam, because I hold hope that a woman may be employed by The Times),
As you may know, social media has been quite intrigued by the article written by Mr Dominic Lawson entitled 'The one sex change on the NHS that nobody has been talking about'. Mr Lawson's article is placing the blame for workforce issues, including the current junior doctors' contract dispute, squarely at the feet of the female doctors in the NHS. I am writing with both a strong rebuttal but also to express my extreme offence at the article.
My background is that I am a female doctor and moreover, I am a female heart and lung surgeon who practices in Australia. The shockwaves of this article have reached that far. In this country, our own regulatory bodies including the Royal Australasian College of Surgeons have gone to great lengths to investigate and move towards a medical workforce where opinions in the style of Mr Lawson are regarded as discriminatory and antiquated. 2015 has begun an era in Australia and more specifically in surgery when we will no longer tolerate sexism.
It is remiss of anyone to think that women alone are responsible for any issues related to work-life balance. Men also wish to be a part of their children's upbringing just as much as their wives. Both male and female medical graduates make informed decisions about their career choices based on this. Many professions are now pushing for safe working hours and balance in one's life. This balance is so important for the physical and mental well-being of employees and is much more likely to yield productive employees. It is extremely inaccurate to say that this solely an issue of 'feminisation of the workforce'.
'Piling up' in accident and emergency wards has very little to do with doctors and a lot to do with the health workforce at large. Casualty is subjected to enormous pressures with patients who are increasingly complex, unable to access their overworked and under resourced general practices and hence overflow to emergency departments. Understaffing of orderlies, laboratories, radiology, wards and bed numbers at capacity are a real problem. Citing this as a side effect of graduating more female medics suggests that Mr Lawson has failed to grasp the actual issues that face a modern workforce and more specifically, that are faced in health care today. I would suggest that these issues are not only more real, but much more deserving of an editorial.
The general tone of the editorial is insulting to doctors like myself, who are consummate professionals, who are highly skilled and would get out of bed at any time for a patient who needs our care. It is an insult to the hours we have all freely given (in a financial and social sense) to the practice of our craft. In 2016, there is absolutely no place for editorials that are inflammatory and sexist. Maintaining a healthy and balanced workforce must be discussed. We should discuss how to accommodate maternity leave in a professional manner, not in the pages of a newspaper, with approaches for real workable solutions, not blaming one group for a problem.
Mr Lawson has mentioned that his daughter may take issue with his opinion. I honestly hope that she does. More importantly, I hope that Mr Lawson keeps in mind how he would like someone to speak of his daughter's skill, commitment and achievements in such a fashion as he does to mine. I doubt many fathers would truly be happy with their offspring being spoken of as he has done to me and my female colleagues across the globe.
In case you hadn't got it, the first part of the title of this blog should be sung. You know the lyrics:
Sugar, sugar (da da da da da) Oh, honey, honey. (da da da da da) You are my candy girl...
Apologies, I digress.
I am going to let you in on a trade secret. Doctors eat crap. Well most doctors do. Especially younger doctors. It's a multi-factorial problem that is ably aided by long work hours, lack of time to develop decent culinary skills, every ward in a hospital having treats, hospital food tasting like a foot with very little nutritional value and being really bloody tired.
I had very busy couple of days of work recently where I think I only slept single digits over the course of 48 hours. So I was shattered. And when I'm tired, I eat awfully and usually in my car. On my return home, when I had finally left the hospital, I was forced to remove the bags of empty take-away from my car.
The funny thing is that I live in the health-nut headquarters of Australia, where kale juice and superfoods reign supreme. So in front of slim, anti-oxidised passers-by, I very shamefully took the evidence of my crime to the bin. If they knew that I was a doctor, I wonder if the shame would have resulted in an emergency admission to a health food retreat for immediate reprogramming?
Anyway, as a heart surgeon, I deal with the consequences of our lifestyle choices day in and day out. I look after patients who meet the criteria for morbid obesity, who have blocked coronary arteries or who have lost limbs due to peripheral vascular disease. Not only do I indulge in foods that I shouldn't more than is recommended, my own understanding of nutrition is frankly, dodgy.
Medical school did cover some nutrition but not a lot. I get that. When you have to cover an entire human body and all of its functions, some stuff has to go. Plus, we have our extraordinarily learned colleagues, dietitians, to steer us in the right direction and give sage nutrition advice.
But what about me? What about me and my nutrition? What about the fact that I should know how to advise people when they ask what to eat after bypass surgery to make sure they don't meet me again? (Most don't by the way) What about my own health?
This week, I saw that iTunes' weekly 99c rental was That Sugar Film made by Australian actor, Damian Gameau. So I decided to watch it, with the hope that it would start 2016 out for me with a good change in my own diet and more knowledge about what we should all eat.
I accept that as a society, we eat too much. We also probably eat too much sugar. Along with saturated fats and low levels of macronutrients and micronutrients (vitamins, minerals). That aside, I find the whole no-sugar, in fact a lot of 'diet' movements to be distasteful. I find their science to be quite shaky, they often advocate removal of foods or food groups that have good nutritional and medicinal value and their claims outside of maintaining a healthy weight lack evidence. So I went hunting for more information, specifically on sugar. While this a very simplistic view point, I hope it might be a starting off point for my own sugar and diet knowledge.
What is sugar?
Sugar is not just the stuff on the table you add to your coffee. The term sugar encompasses glucose (found in carbohydrates), lactose and galactose (found in milk), fructose (found in fruits) and in combination with glucose, sucrose, a disaccharide. When sugar consumption is being regulated, we are looking at that which is added in excess of naturally occurring. There is no good evidence to support that sugars occurring in foods such as fruit in a natural unprocessed state is the devil.
Glucose is a very important substrate. It is the cells' currency for energy production. The brain in particular, is highly dependent on glucose for normal function.
What is the problem with sugar?
Energy excess, whatever the source, is not great for our health and wellbeing. However it happens, whether it be from too much fat or too much sugar (of any form), if you have too much of it, the body will store it as fat. Consuming too much sugar is being increasingly recognised as an independent risk factor for cardiovascular disease, diabetes, hypertension and liver disease.
The argument is ongoing as to what forms of sugar are truly naughty. We also have not locked down whether all calories are created equal. That it is, is sugar truly toxic or is it just an energy excess that excess sugar consumption causes that hurts?
What about fat?
Fat has generally been blamed for all of our health woes in the past. It's likely that this was an over simplistic view of things. It's generally well accepted that saturated fat is linked with increasing levels of cholesterol and tryglycerides in the blood (not good). The recommendations now support using monounsaturated fats such as olive oil, seeds, avocado, fish to make a patient's blood lipids more in line with health. Fat can also help us feel fuller for longer as fat delays gastric emptying.
So how about fructose?
Poor old fructose. Fructose is the naturally occurring form of sugar that we eat in fruits. Fructose is getting a seriously bad rap at the moment, bearing the weight of all, well, our weight issues.
The movie That Sugar Film points out that naturally occurring fructose in fruit is accompanied by fibre. Say an apple or some berries. The fibre aids in making us feel sated, and fibre is important to regulate bowel health. (Ask someone who eats loads of protein and no fibre about their poos.)
Some evidence (from rat and short term human studies) have placed the blame for "toxic" sugar effects squarely at the feet of fructose. It has been linked with diabetes and insulin resistance, gout and obesity. The science behind this is thought to be due to the liver's handling of fructose. It may more readily convert it into fat.
The fact is with regards to fructose, the studies are not based on super strong science. The levels of fructose in some studies are much higher than the 'average' person consumes for example. I also have a real problem with the promotion of quitting fruit to reduce fructose consumption as fruit had many excellent benefits to health. I'm eating a punnet of blueberries right now! Not only are they tasty, they're stopping me attacking a block of Dairy Milk. Win, win.
How much sugar should we eat?
A few months ago, the WHO published guidelines to suggest that total energy intake should not have more than 10% of free sugars - that is added sugars. Not sugars found in fruits, vegetables, carbohydrates. However, for optimal health, we should be aiming even lower to 5% which equates to 25g of sugar or 6 teaspoons of sugar per day.
That is not much (bye bye Giant Freddos)
Nope. It's pretty small really. But bear with me. Here's some sugar contents of popular foods.
Can of coke (375mL): 39g (oh my goodness)
Light strawberry yoghurt: 14g
Clif Bar: 21g - damn. I loved these for emergency breakfast.
McDonalds Cheeseburger: 7g
Tomato sauce: 4g (for a 17g/tablespoon serving - I use more than that)
Strawberries (punnet): 7g
So all in all, what's the deal?
- Obesity sucks big time in terms of getting sick
- Our understanding of nutrition is constantly evolving, so this may change again in the future
- Sugar is not the only lifestyle problem - we eat too much in general
- Smoking and inactivity also are strongly linked to cardiovascular disease
- Too much sugar is not great for you
- Fructose - the jury is still out
- Fruit is good for you so don't give it up
- Evidence for mood swings or depression and sugar is not great
- Superfoods are non-essential food items, eat them if you like
- I am going to miss Giant Freddos
I am going to be much more conscious about cutting out excess sugar in my diet. And excess take away. However, I have a major problem with the terms good and bad when referring to food. I think the psychology behind it, for me at least, is harmful. And I like food, I like sugar. I want to have an actual birthday cake, not one made of kale. Yes, I really have it in for kale, I do not like the taste one bit!
I think it's important to get our information on diet and exercise from reputable sources. I mean no malice in this statement, however, a lawyer/actor/wellness blogger may not necessarily have the tools to correctly identify the plethora of information about this kind of thing. We have seen countless examples of how these people can miss the mark a little. Or more than a little.
For me, I am going to continue my research into food and sugar. I'm interested in it for my own well being, my patients and I think I can make a good go of the literature. That Sugar Film has prompted my reading and noted that excess sugar probably has a role to play in obesity and disease. But the science is lacking. If it helps people rethink their choice, great. But this just ain't gospel I'm afraid.
For further reading:
This great blog from Scientific American: http://blogs.scientificamerican.com/brainwaves/is-sugar-really-toxic-sifting-through-the-evidence/
Wendy Zuckerman's great podcast Science Vs. did an episode on sugar: https://soundcloud.com/science-vs-season-1/sugar
Q&A on Fructose: http://bmcbiol.biomedcentral.com/articles/10.1186/1741-7007-10-42
Full disclosure - I have unashamedly stolen "Mirenagate" from Dr Eric Levi. (@DrEricLevi) He has also written a great blog on this piece, specifically as it relates to social media. Aussie medics on twitter especially, would be aware of the article posted in the Australian newspaper on the 2nd of January relating to obstetrics and gynaecology trainees. The article related to a debate topic at a college branch meeting in the next month about women in training and how they should manage their fertility. As one might expect, the suggestion that childbearing should be regulated for the course of specialist training was not taken very well by a lot of people. In fact, it was so badly received, it left a lot of people asking why in the world someone would let the debate topic exist in that form.
I should take this opportunity to point out that a number of obstetricians suggested that the debate topic was supposed to be a humorous way of talking about a serious topic. The RANZCOG president was quoted as saying he wasn't aware of the topic, thought it was tongue in cheek and will address it. Even with that in mind, people were still not exactly impressed. And remain so; this has really struck a nerve.
"Mirenagate" has really brought to light a few issues, all of which are very important and some of these issues have failed to been addressed not just in this scenario, but by medicine for years.
Women have long suffered innuendo or genuine discrimination in medicine due to their reproductive choices. I know of women who lied about their children existing, were bullied when they fell pregnant during training, have been given no consideration due to illness during pregnancy, have worked heavy rosters up to the late stages of pregnancy, been asked about their intentions with children for references/training intentions and so on. And let me very clear, not all of this happened in surgery. It is rife in medicine, I'm sure in a lot of professions, that women may be perceived as having less entitlement to a career or a position due to pregnancy.
Now I understand that this is not always the case and that employers and colleges have been understanding to some groups or people. But to women who have suffered bullying or discrimination by virtue of their gender of their children, it's not hard to see how even in jest, this suggestion could be very offensive.
My friends and colleagues who have undertaken training with RANZCOG have spoken highly of the support they have received when they have had children. The RANZCOG policies are more robust than other training institutions for part-time and interrupted training. If they are going to truly talk about the difficulties for trainees, employers and the college alike when interrupted training exists, then that is a good thing. However, the choice of topic title may have been better stated to take into account the large numbers of women who have been the subject of bullying and discrimination in medicine. The very public RACS investigation and media coverage on this same matter in 2015 should have taught us that we have a group of doctors who have been terribly treated and harmed in the pursuit of their profession.
The other issue that Mirenagate uncovered was the importance of being the master of one's own domain. As often is the case, this story was all over Twitter very quickly. Unfortunately, it seemed that RANZCOG did not have a social media presence here and missed many of the issues raised and the extreme disappointment at this issue. I tweeted my own disappointment, especially in the setting of my perception that RANZCOG was doing better than most. This topic also started off a conversation online of the difficulties many women have faced in training, not just in obstetrics but surgery, medicine and other professions. Not all of the backlash online was directed at RANZCOG but was a sharing of other's experience with pregnancy in medicine. Being online, RANZCOG may have understood what all the fuss was about.
Having a social media presence I feel is not only important for individual doctors, but this demonstrates how important it is for RANZCOG or other colleges. They may have been able to mitigate some of the damage early on. They (and other colleges) could get a strong sense of what a difficult issue this is for a lot of doctors and hear some of the stories women were sharing. Being involved or observing the conversation can allow important change to take place. It is important to be a part of the social media sphere to control the conversation people are having about you, to you or that involves you.
I hope that RANZCOG have a great meeting with meaningful discussion about issues their trainees face. I would also hope that we all learn from this experience. Some of us will learn that obstetricians, by and large do not want their registrars to have Mirenas. Some of us will understand that the media love a headline. Some of us will learn about the struggles faced by trainees and how we can provide better training for our doctors. And definitely, I know RANZCOG will now be tweeting a little more.
In case you have missed it, the Australian government is undertaking a review of Medicare, or more specifically the Medicare Benefits Schedule. The MBS is a list of codes for procedures or consultations, delivered by health care professionals that have a cost associated with them. Social media has been quick to pick up on a slightly underdone news report by the SBS about some procedures that are set to be axed. Let's be very clear about something. Medicare is sick. This country is in desperate need of a wake-up call that the public (and to a lesser extent, private) purse is not a bottomless pit, even for vital services such as health care. The MBS desperately needs to be properly and thoroughly reviewed with appropriate values assigned to procedures and delisting of procedures that have no scientific basis. We need to start rationing the health care dollar in order to get the best from it.
We are all healthcare consumers and we should all care where our money is being spent. Think of it like this. While we are wasting money on one thing, say a procedure that may not work, that money could be missing to find a procedure that does work. It's like buying a pair of jeans that don't fit properly, then when you go to buy some that do, the cash is not available. Our entire country should start thinking about how we spend our money and ensure we get bang for a our buck.
The MBS has been around since 1984 and currently lists codes for around 5700 procedures. Some procedures that are still listed are no longer utilised as they have been superseded. Not all procedures are what we call 'evidenced based' where the best possible scientific evidence has been examined to determine when, where and for who we are supposed to use a certain intervention. Some procedures are grossly overpriced and some procedures are grossly underpriced. The MBS has become a matted tangle of codes for procedures that have not been revised since their addition. At the same time, medical care has been advanced and refined. Medicare is also poorly structured to account for the complexities of chronic care and the increasing complex problems doctors manage in modern times.
The review is long overdue. Doctors are commonly heard to be lamenting the complexities, inaccuracies and redundancies in the MBS. It is important that this review becomes an important tool in modernising our medical system and maintaining a high level of care to patients. It is also important that this serves as a reminder of responsible use of the healthcare dollar; that is to say that we as a community spend an appropriate amount on procedures that are both safe and efficacious. I hope that review continues to be strongly influenced by clinicians, those with much more experience and knowledge than I have. Doctors are very happy to be a part of system that reflects the excellent health care that we can provide our patients.
You may or may not be aware about the upcoming, likely, strike by junior doctors in England over a contract that would compromise the safety of patients and doctors and cause severe financial penalty. All this to a vocation that gives so much of itself, for the service of humanity. It is with interest that I read this article written by Simon Jenkins, lamenting how society will be held to ransom by 'militant doctors and angry lawyers' over a contract that Judkins feels is more than fair. I mean, why should society bend over backwards when in the NHS "consultants worked to their own schedules of convenience and remuneration"?
Well, aside from the mythical skills that professionals are using to befuddle the public, according to Jenkins, doctors are a bunch of whiners who are taking up arms on social media and are the new unions, being held to account by nobody and resorting to workforce crippling tactics.
Why is it that professionals, like doctors and lawyers, are not allowed to negotiate and make demands for pay, like any other worker? Why are we not allowed to stand up for a true worth? Is it acceptable that a doctor could be rostered on for 24 hours or more and be responsible? People like Judkins are more interested in their pilots sticking to safe work hours than their doctors.
Medicine is a fundamentally altruistic profession. I'm not sure people realise to what extent doctors sacrifice and go without in order to do their job - helping other humans. It is a lifelong sacrifice and a labour of love for the people and for the profession. Unfortunately, a proportion of the public will always see doctors (or any other professional) as elitist, golf playing, champagne drinking snobs who have it good. Nobody would deny you for a second that by and large, people who have had the means to obtain a professional degree have had a degree of privilege, but make no mistake, that means squat without hard work and extreme dedication.
Irrespective of whether you believe that doctors are kind hearted souls, the fact remains that we have rights as workers just as anyone else does. It is also important to remember that these rights also protect the rights of the patients. Safeguards for working hours are meant to protect doctors from being too tired and therefore making mistakes. Or killing themselves. As a junior doctor, I remember a young obstetrics registrar being killed in a car accident after having worked some unholy hours. I participate in rosters where doctors are rostered on for 24 hours. Back to the pilots, they can't fly this long. Are we more afraid of flying than of not surviving a heart attack? Because statistically, the later is more likely.
Worker's rights are not just for tube drivers in London, or nurses or train drivers in Melbourne. They're not just for blue collar workers who are going to be exploited by their fat cat employers (extreme sarcasm). Workers rights are for everyone. And in the case of junior doctors, they really are for everyone, because who wants a tired, unhappy and undertrained doctor?
It's time we stopped cutting down tall poppies. Professionals are people too and deserve as much protection as anybody else. And in the case of doctors, your life just may depend upon them one day.
Disclaimer: This is a broad and sometimes, personal overview of the medical workforce problems. My views do not represent any professional body I am associated with. They also do not even scratch the surface as to the gravity of this issue. I was recently hearing about the growing concerns over graduate unemployment with only 68% of university graduates finding full-time employment within four months post-graduation. This number excludes those doing research or further study. It does include people who may be termed 'under-employed', people who are available for and want to work full-time but are unable to secure full-time employment.
Medicine has always had an aura of being a very secure job. In fact, we are being constantly told by the government that we don't have enough doctors. And while that may be partially true, it is not the whole story. We have a doctor distribution problem, not just a major shortage. We have doctors in towns, in tertiary hospitals but not in rural towns, or certain specialties are under-subscribed.
We are fast heading to be following in the footsteps of our tertiary educated colleagues, where doctors will be unemployed or underemployed. And I'm not referring to a graduate in their early twenties. This problem is going to affect people who have finished specialty training, who are in their mid-to-late thirties and have families and other commitments. We are turning our future doctors into future Centrelink customers because we can't seem to get the balance right.
Rural doctor shortages
One of the major reasons the government wishes to train more doctors is to address the shortage of doctors in rural and remote towns. As a young medical student and junior doctor attached to rural towns, the pain the residents felt at not having a regular doctor or long waits (weeks) to see the GP was incredible. A number of initiatives have been undertaken to try to get doctors to rural towns, including bonded medical positions, increasing medical school intakes for rural students and financial incentives. A number of doctors have also called for the creation of a permanent rural medical school to encourage those graduates to stay in the area.
Rural doctor shortages are in effect, a maldistribution issue. We simply cannot under the current system, staff doctors for all rural towns. It is a very complex problem and has significant concerns for inhabitants of these areas who feel underwhelmed by the medical care.
Do we train too many medical students?
At medical school, my graduating class was approximately 100 strong. That number tripled within a few years. When I went back to university to teach anatomy as a graduate, instead of the few students we had in a group when I did the same unit, there were now sometimes over 10. In 2005, there were 1320 graduates. In 2013, there were 2944 (from Medical Deans data). There are predictions of a doctor shortfall in the range of 2500 in the year 2025. And so, there is ongoing and mass increases in medical schools, not just by numbers at the same university but new medical schools. The most recent addition has been of Curtin University in Western Australia, which will commence in 2017, much to the distress of young doctors everywhere.
I believe that decreasing reliance on overseas trained doctors to fill spaces is important. However, it takes up to ten years to train a specialist doctor, a little less (but not much) to train a GP. With the increase in graduating medical students, we have created a serious bottle neck at the vocational level. Another maldistribution. We don't need more interns, we need more specialists, especially in under-serviced areas like psychiatry and radiation oncology.
The intern crisis refers to the fact that every year, the government struggles to find intern positions for medical graduates. To be fully and unconditionally registered as a medical practitioner, a doctor must complete one year as an intern in a supervised post. So if you could not be employed as an intern and therefore not meet this requirement, you would not be registered and therefore be able to practice as a doctor. The government is always super pleased with themselves when they announce that they have found jobs for all interns. But they fail to mention that we now stick interns in every nook and cranny of the hospital, in jobs that did not exist before or in huge numbers in one speciality, thus risking diluting experience. The job guarantee ends here. Following this, a junior doctor can find themselves unemployed or underemployed as further vocational positions are not made available.
Without taking steps to increase the number of vocational training positions, we are creating a bottle neck for these junior doctors. Again, unlike counterparts from other tertiary degrees, are significantly older and caught in a system that they cannot do anything about. We have not increased training positions for these young doctors to go on and become specialists (including GP) to solve our workforce shortage. But it keeps happening throughout training too, because on the other side of specialist training, things are not at all rosy.
Our medical specialists are underemployed
In the past few years, my friends and colleagues who I have studied with at medical school have completed their specialist training. They are anaesthetists, surgeons, physicians and so on. I am also in this group. We suffer similar angst to medical students, because a number of new specialists are coming up against another bottleneck; the fight for a consultant position.
For surgery, workforce planning has been done on working out how many surgeons we need per 100,000 people (amongst other variables) and taking into account a retirement age of 60. Which is ridiculous to be frank. Any workforce planning, except maybe professional sports, that believes the retirement age is not going to increase is kidding itself. People are living longer, working longer and financial interests have changed. For instance, the GFC saw a number of previously retired doctors return to work as superannuation losses hit home. Our senior colleagues are not retiring, private practice is nearly impossible to break into and we have not at all accounted for this.
We are going to see an increase in junior doctors applying for training positions that simply do not exist. And I believe that we are currently training too many specialists. How can we justify the personal and community expense on training a specialist and have them underemployed or forced overseas at the end? Just to put in perspective, for surgical training, I spent anywhere between $10,000 to $20,000 a year out of my own pocket. And this does not take into account the societal cost of training a specialist. What a waste if we can't actually employ these specialists. There is a significant maldistribution between specialities and as such, some of us specialists are facing uncertain futures, with nobody stepping up to the plate to better plan and coordinate training in this country. The HWA workforce planning document alludes to this problem in 2012. In 2015, little has changed.
So what next?
I don't know. This problem is so complex and it seems we are in an incredible mess. But I think we owe it to our graduates (of university and specialist training) to sort some of this out. Some solutions may have more than one benefit, such as the introduction of part-time or interrupted training. This would allow flexibility that people now desire for families or research whilst allowing us to train more specialists over a longer time frame. Revising workforce planning so that the specialist colleges get a handle on what they're setting its Fellows up for. We need to better incorporate the presence of IMG's into workforce planning. Although we wish to decrease reliance on overseas trained doctors, this will not stop them from coming to and working in Australia. The senior consultants may need to look at ways of adding their younger colleagues to practice in a way that is financially, intellectually and clinically sound for all concerned.
I am also a firm believer that we need to give doctors (especially young ones) more strings for their bows. I think we should encourage doctors to pursue other avenues of study including law or business to allow them the ability to take on management roles for example. And this can only mean good things for hospitals who will benefit from well-rounded physicians and better run hospitals.
I wrote to my local MP (who is now our current Prime Minister) to express my concerns earlier this year. I received a pro-forma email back entitled 'Education' because clearly my concerns best fit into an 'education' problem. The email spent more time talking about women in STEM (also identified as a feminist from first email clearly) than about why improving doctor training issues was important. The email closed with an invitation to get in touch again if I desired. I did reply, and funnily enough, my second email has not been responded to.
I think it is time for the doctor maldistribution problem to be tackled in a meaningful way. Or else the next time you get a taxi, it may be driven by a doctor.
Despite being what most people would call extroverted, I actually find it quite tricky to meet new people. Especially when I’m not sure if we have anything in common. I’m not sure they will find me at all interesting or will we have anything in common to talk about. So, these past few days, I made the trip to our nation’s capital for a little thing called an un-conference known as Junket. Junket has been organized by Junkee, an online magazine who wants to serve politics and culture in a way that respects the intelligence of it’s readers. They invited 200 of young Australia’s best and brightest minds to talk about issues that mean something to them and put it to the brain trust to solve.
The Junket delegates comprised of Aussies across the nation who are from every field imaginable; tech, healthcare, science, engineering, arts, politics, skateboarding and robots even. And the conference was not in any way like anything I ever go to. There were no suits, no planned-months-in-advance schedule. Just inspiration.
I have met some incredible people. I met Young Australian of the Year Drisana Levitzke-Gray, who is deaf and an amazing advocate for the deaf community and introducing AusLAN far and wide. We chatted about the use of AusLAN interpreters in healthcare. There was accountant student Chloe, who wants to teach financial literacy and get doctors to the country. Bridi is a post-doc fellow at Black Dog Institute who is tackling suicide by connecting people. Amrita is an incredible dancer and choreographer who taught us how to dance like Beyonce and wants to preserve Aboriginal culture in a digital age. Mikey is the first professional skateboarder I've ever met and he wants kids to get active, preferably through skating. Jessica who is a paralympian (in two sports, no less) and is trying to get people to look after their precious eyes. I ran a session with the delightful Laura, who organizes TEDxSouthbank and is heavily involved in philanthropy. And there's Sophia, a super clever Women in STEM champion, Olli who uses her day job as a model to publicise important political messages and Neil Ackland of Junkee who wants us to switch off to get connected. And that list doesn’t even scratch the surface.
This is a group of people I may not have otherwise met. Whose ideas and diverse day jobs, skills, hobbies and opinions I may have never gotten to hear. I think if I go away from this with a broadened view, that is wonderful. I had never even considered some of the solutions opened up by talking to other delegates. While our politics and opinions won't always match up, what the two days taught me is that mismatching is okay, sustainable and necessary to progress. Broad representation is the key.
This is precisely why this is an incredible place to be and an incredible idea. As I heard someone say here, when we put the same people in the same room, they will come up with the same ideas. With different people in different rooms, we have changed the conversation already. We may even be able to change the progress we make with all the very, very important topics we presented. We were so lucky to access each others' networks, expertise, ideas and experience to keep our ideas and solutions headed in the right direction.
The thing though that will stay with me, is that Australia is in very good hands. Passionate, intelligent, motivated and unwilling to accept the same busted ideas. Just here, there is a group that just wants to make the world better. I am so inspired to have just been here. And I am thrilled to have been thrust out of my comfort zone to meet some incredible people.
Still can’t dance like Beyonce I’m afraid.
At the moment, our counterparts in the UK are under attack from the government regarding their contracts. In case you have missed it, the government is forcing a new contract on 'junior doctors' which will lead to:
- Reduction in pay of around 30%, in part due to normal working hours including evenings and weekends
- Financial penalties if time is taken off for say, having children or performing research
- Loss of protection from unsafe working hours
Although half a world away, the battle hits very close to home for all doctors. The health minister, Jeremy Hunt, has been bending statistics and scaring the public to make them think junior doctors are lazy and money hungry. It would appear that it is the other way around, as while the NHS is figuratively starving to death, the MP's have still received a 10% pay rise.
Australia has a better but still very imperfect system. You would be hard pushed to find a doctor in Australia who hasn't had a problem with pay or working conditions. We have been unpaid, refused overtime pay or rostered for unsafe hours. However, at the moment, we're not in the terrible predicament the NHS docs are. Half of the problem, I feel, comes from calling it a 'junior doctor' problem. Referring to any doctor as 'junior' is a misnomer and belies the countless financial, personal, professional and educational contributions made not only by the doctors, but their families too.
A junior doctor refers to anyone who is a fully qualified doctor but is still in the process of attaining a qualification in a specialty. It covers wide ages ranges from doctors in their mid 20's to well, the sky's the limit. It covers doctors one year from medical school or doctors ten or twenty years from medical school. It covers doctors who have attained their specialist qualification and are fully registered with medical boards, specialty colleges or Medicare as specialists but haven't got a permanent consultant job yet, either because we have a bottleneck for positions or because they are continuing to gain experience in super sub-specialised areas.
If you come to hospital with a heart attack in the middle of a night, the first person you might see is a 'junior doctor'. If your heart stops beating, it will be 'junior doctors' who will start it again. It may be a 'junior doctor' who takes you to the cardiac catheter lab and starts performing the lifesaving procedure to restore blood flow to your heart, while the consultant makes her way to the hospital. They are helped by another 'junior doctor' who gives an anaesthetic and keeps your body in optimal condition. It is the 'junior doctor' in intensive care who will be monitoring your heart rate and blood pressure, talking to your family and reassuring them and informing them.
It takes at least ten years to train as a specialist but during that time, a 'junior doctor' is no less valuable to society, to patients and hospitals. They are still accumulating expert knowledge and spend many, many unpaid, unrecognized and unforgiving hours honing their craft, performing teaching or administration all to one basic end. We all got into this because primarily, we like helping people. We love technical and intellectual challenges too, but we really just want to take a disease and kick its butt.
I think the term 'junior doctor' is a serious understatement of how important 'junior doctors' are. I would prefer something like pre-specialist. Or specialist in training. Or down right legends. Because that is what junior doctors are. They deserve respect and protection like any other occupation or person in society. They deserve to be able to pay their mortgages and their training fees. We seem to have lost our way as a society with where our respect goes. Put out a sex tape and become 'Instafamous'? Money and fans and respect are yours. Study for over ten years, work like a dog and sacrifice? The bureaucrats will ensure that your are undervalued and underpaid.
Superstar doctors of the NHS - we are with you 100% of the way. Good luck!