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Rehumanising

March 8, 2016/by Jim Duthie

We live in a dehumanizing world. Out of a need for efficiency, convenience, and reassurance, we both dehumanize and are dehumanized routinely in our commerce and relationships. We are not a three-dimensional human being of unique genetics and experience, forte and frailty, preferences and peculiarities to our bank, public library, or insurance company. Out of necessity, these structures diminish us to a number or barcode. We are grouped by age and demographic, measured by our internet clicks, targeted according to our income by corporations. To those profiting from our consumption our individuality is irrelevant; the big money is in exploiting groups. Whether you support a free Tibet does not concern the people selling cheeseburgers, unless enough people agree with you that some marketing leverage can be generated from this fact. In medical research we reduce people to “female between 40 and 75 years with chemotherapy naïve metastatic ovarian carcinoma”. Not “Julie, mother of three boys (one with cerebral palsy), who put up with her vague abdominal symptoms for too long because she was preoccupied by supporting her younger sister out of an abusive relationship”. While logistical limitations do not allow for the statisticians to enter into every individual story, we reassure ourselves that the depersonalized and homogenized data from these studies is for the greater good. Indeed, sometimes it just isn’t any of our business.

We can accept that on this macro level there are faceless amoral corporations that care only about how to alter our spending patterns, but on an interpersonal level we can be equally guilty of dehumanizing attitudes. Thanks to the heuristics developed by our ancestors, which I for one am grateful for, the human brain is very efficient at mentally grouping things under such headings as “dangerous” and “delicious”. This has allowed our continued survival. Having a general suspicion of things that looks like snakes means a reduced risk of envenomation. Being suspicious of strangers by default means that we are less likely to be on the back foot if someone pulls a spear on us. It would be nice to think that we have largely put this simplistic cognitive process behind us, but we tend to fall back on bad habits. Every time we mentally label a person we are trimming their humanity in order to fit them into a pre-existing cognitive category. When we think “young hoodlum”, “old codger”, “drug addict”, “liberal”, or “health nut”, we are in fact extracting what we deem to be the most salient point of person and making it the sum total of their identity. There is obviously expedient for us, as we continue to do it. It makes it easier to ignore the “derelict” on the street, and not feel too bad about the “foreigners” affected by natural disasters. Our bias is routinely exploited by our leaders, especially in times of war. We are not killing people very similar to ourselves, we are fighting “scum”, “heretics”, “commies”. While studying for a degree in psychology I came across a study that demonstrated that people attribute more negative characteristics to people groups if they are referred to by nouns rather than adjectives. People were more mistrustful of others described as “Poles” or “Jews”, rather than “Polish” or “Jewish”. The objective label nudges people into a category, with the adjective reminds us that these are complex individuals, who happen to have a given ethnicity or faith.

We have a reflexive discomfort at being dehumanized ourselves. We don’t like being treated like cattle by airlines or sports stadiums. We despise being written off as nothing more than the town we came from, the school we went to, the era we grew up in, or our gender. We know from personal experience that we are unique, and attribute value to this, at least in ourselves.

Surgery is dehumanizing. We take frightened people, anaesthetize them so that they cannot resist, and then disassemble them. The intention is to reassemble them in an improved way, but we are reducing people to a collection of organs and meat in a way that strips them of usual dignity. Until the Renaissance, disassembling the dead was considered too shameful to tolerate. Indeed, to begin with only executed criminals, considered sub-human (already dehumanized), were considered suitable candidates for anatomical dissection. It was too much to imagine a person opened up for the world to see their insides, their dignity stripped in an extreme form of nudity. I have already written about how not entering into the full experience of every human drama is what makes surgery a viable career (https://www.bjuinternational.com/bjui-blog/surgery-is-not-normal/), and I don’t think it is helpful to focus on the bigger picture beyond the operating theatre while focusing on the technical steps of an operation, but a few points are worth considering.

Firstly, those of us who have had human dissection as a part of our training tend to share a common experience. While in the thick of a dissection, occasionally rewarded with the discovery of a familiar structure, it is normal to forget that the prosection was once the residence of a functioning person. Typically it is the glimpse of a uniquely human feature; the face, feet, hands that triggers a moment of shock at what is going on. I still recall looking down to see that our cadaver had painted toenails. Instead of being a learning resource, it struck me that this woman had spent time days before her death, tending to her toenails fastidiously, unaware of what was to come. This placed her in a room in her home, at a time of day, perhaps before leaving to attend a social event. The full experience of her humanity was infinitely greater than the tutorial aid she had been reduced to. The strict procedures governing the use of human tissue made sense, lest we forget the gift of the donor.

One of the more moving experiences I have had in a hospital is watching Intensive Care nurses managing comatose patients. My observation is that these patients are treated more gently than necessary, and there is a constant one-way conversation from the nurses explaining that now, they are going to reposition the legs. They are going to brush teeth. They are adjusting the pillow. Calling the patient by their name, as their words fall on deaf ears. While logically this makes no difference to medical treatment, it protects the nurse from dehumanizing the patient, making them more than an oxygen trace on a screen.

Ultimately, the effort to re-humanize is what makes us fully human. The unconscious patient or cadaver is not affected by our attitude towards them, but we sacrifice our own humanity whenever we revert to applying broad heuristics to other people. A cat knows to be frightened of snakes, but it takes human intelligence and will to deliberately consider that a person is more than something to fear, ignore, or desire. It is an act of overcoming base instinct. When we apply the appropriate reverence for a person as we prepare them for surgery, care for them in their unconsciousness, our respectfully use their dead body to improve the treatment of future patients, we affirm our own humanity. It is more for us than for them.

Jim Duthie is a Urological Surgeon/Robotic Surgeon. Interested in Human Factors Engineering, training & error, and making people better through electronic means. Tauranga, New Zealand. @Jamesduthie1

A Medical Voyage of Discovery

October 9, 2015/by Jim Duthie

I am still getting used to being able to stretch out in bed. For the last two weeks my nights were spent in a wooden bunk designed for trainee Japanese fishermen, none of who apparently exceeded 175cm in height. Or 50cm in width during any point in their nocturnal contortions. Combined with a roaring generator, constant motion, four roommates, and another person in the same situation on the other side of the thin plywood wall from me getting up for their daily four o’clock watch, nights were not a highlight on the ship. The ship was the Pacific Hope, a (mostly) refurbished training trawler with a new career in humanitarian outreach.

My day job as a Urological Surgeon mostly involves lasers and robots, but for this two-week period the peak technology available was a blood pressure cuff. I had not looked in an ear since I was an undifferentiated junior doctor, or taken anyone’s blood pressure, or diagnosed knee arthritis. One thing that I was confident of, was that I was better than no doctor at all for the inhabitants of Ambrym Island, Vanuatu. In the event I enjoyed the collegiality of an Irish Junior doctor who was hard working, quick to learn, and most importantly hilarious company. Between us we solved most problems, and had the bail out option of referral to Port Vila hospital for blood tests or imaging if we were completely baffled. As well as tuberculosis, a yaws, and an elephantiasis, we were saddened by how widespread hypertension was becoming, thanks to the introduction of low quality, high-salt canned beef to the islands. I managed to rescue a man with a rotten diabetic leg, sepsis, and uncontrolled blood glucose (no insulin) with a bedside debridement and urgent transfer to the mainland. We followed up a week later and surprisingly, it looked like he wouldn’t need an amputation. I couldn’t do anything for a woman with early Parkinson’s disease, as medication would never be reliably available for her. I even saw one case of BPH, but didn’t have any alpha-blockers.

It was a cheerful, positive environment, with grateful patients and hard working team mates. There were no managerial reviews, waiting lists, or funding approval involved in treating the patients. We didn’t order unnecessary tests to rule out the miniscule possibility of an alternative pathology, as we knew no one would sue us for trying to help them.

I swam a lot, ate coconuts, had no phone or internet access on ship, and the world still turned. I won’t get any publications out the trip, and had to pay for the privilege of working, but it was actually a privilege to do the work.

I climbed a mountain and looked into a lava lake, watched dolphins play and flying fish fly, swung off a 10 metre high crane into the ocean, and walked an hour through jungle to do a house call. I don’t usually get to do these things as part of my job.

The Pacific is an area of high medical need that is comparatively safe and accessible for a third world region. Most of us train to be doctors because we want to make people better, and volunteering is a way of really feeling like you are achieving this. Taking two weeks off work will make little difference to my career development, was good for my mental health, and allowed me to stare at the horizon more than I otherwise would have. As doctors, we have portable skills; our tools are our hands and brains, and they work well in remote areas. Have you been finding work a bit “samey” lately?

I’m going back next year.

Kenny Rogers’ Law of Surgical Practice

February 3, 2015/1 Comment/by Jim Duthie

Although not a Country Music fanatic, I would like to acknowledge the contribution that Kenny Rogers, elder statesman of the genre, has made to the practice of modern surgery. I refer to his insightful song, and subsequent film, The Gambler. For the uninitiated, the song describes a chance meeting between a world-weary professional card player and an aspiring young gambler. If you are gambling lover then you may know Bitbola is a sbobet88 Mobile Indonesia site that provides a variety of online gambling games such as Sportsbook, Online Casino, Agile Ball, Online Poker, Online Togel, Cockfightingand many more, with a minimum deposit of only 25 thousand. There are so many benefits to be gained when you join Bitbola. For now, Bitbola is the Official SBOBET Mobile site in Indonesia which is well-known among all online gambling lovers. People are loving to play w88 games. The older man gifts the younger with pearls of wisdom on winning at cards, culminating in a chorus stating that a player needs to “know when to hold ‘em, know when to fold ‘em, know when to walk away, know when to run”. I am not for a minute condoning the practice of surgeons literally running away from their patients, however strong the urge, but I do think some of the other sentiments are instructional in our practice.

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The revelation came to me as a student, staying in the hospital late with the senior surgical trainee on call, hoping for something exciting to come through the door. Late that night, a very elderly, frail woman arrived shocked, in agony, confused, combative, and in multi-organ failure. The CT showed a significant portion of her small bowel was ischaemic. The trainee drilled me on management options; thrombolysis or endovascular techniques were impractical here, leaving only extensive resection; anastomosis with proximal diversion. Of course this would be a high-output stoma with associated high loss of fluid and electrolytes, difficult to manage, she would be a poor candidate for elective reversal… It did occur to me that this was going to be tough on the poor lady, and probably even futile, but a student can’t say “let’s just keep her comfortable” on a surgical rotation. The trainee had the experience and humility to suggest it himself. He confirmed my predictions of failed extubation, a prolonged ICU admission with worsening multi-organ failure, debates about whether to dialyse, increasing vasopressor and inotrope support, undying hope from the family that she would “turn the corner”, until finally a wrecked shell of a human being would succumb to an unavoidable complication of her treatment. “Sometimes, you’ve got to know when to call it quits”. This inspired me. “You’ve got to know when to hold ‘em, know when to fold ‘em?”. “Exactly”, he replied, and Kenny Rogers’ Law was born.

A mentor of mine once said, “there is no medical condition that can not be made worse with a poorly conceived operation”. This is the doctrine I cling to when feeling pressured to “push the envelope”, or attempt “heroic surgery” in the face of good sense. The most important factor influencing surgical outcomes is patient selection. Poor substrate results in poor results. The problem is that complex surgical problems often come wrapped in the most sympathetic, heart-breaking packaging. The delightful lady with a neurological disorder who is really fed up with the urinary diversion she had twenty years ago. The poor old fellow who can’t bear his nephrostomy. The tearful wife who asks if there is anything, ANYTHING you can do for him? At a departmental meeting it might be easy to assess these cases in a cold academic light, and rightly recommend against intervention. But then you don’t have to face the desperate human face of suffering at the meeting.

A surgeon I know who has a million useful platitudes once told me that if I was planning to do a surgery, but was not sure of the wisdom of it, to say out loud what I was going to do in the past tense with the preface, “well, Your Honour…” If you have never done this, I recommend it. “Well, Your Honour, I know she was morbidly obese and had had multiple laparotomies in the past with significant adhesion disease, and was admitted to the ICU with profound sepsis each time, but even though her dexterity is too poor for her to effectively self-catheterise, I thought it would be worth trying to reverse her ileal conduit and perform a clam cystoplasty. She was really sick of her conduit.”

As doctors, rather than just surgeons, sometimes our role is to convince a patient that however bad they think things are, we could certainly make things worse for them. Undoing an operation and its complications is usually not easy, and often impossible. Better to know when to fold ‘em.

Staring Into The Abyss

July 22, 2014/by James Duthie

I was surprised at the referral in the first place, but baffled after seeing the patient in the flesh. It was someone else’s clinic, and the note read that this 94 year-old man on androgen deprivation for asymptomatic low volume metastatic prostate cancer for many years had a climbing PSA. About 8. Please discuss combined androgen blockade with him. I began the talk about how combined blockade has a pretty weak benefit at the best of times, and that in a 94 year-old it almost certainly would not make him live any longer. He was asymptomatic, so he would not feel any better, and he may have a worsening of his side effects. I wrapped it up by telling him he was old enough to make his own decisions about his treatment, and if he didn’t want another pill to take, he could certainly say no. He said yes. I clarified the points about limited or no benefit, and possible exacerbation of side effects. He said if it would give him a few more years, he’d take it. I told him it wouldn’t. He wanted it anyway. I could not promise the treatment would not make him live any longer, and that was good enough for him. At the end of the consultation he was well counseled, and had made his decision. You might think of an 80 year-old you have seen who seemed more like a 60-year old, and think I was being unfair to the man, but I can confirm he was a 94 year-old who seemed very much to be 94.

I tend to assume that when people get to a certain age, they have come to terms with a few things, including death. This is not always the case, and I think running from death is becoming more popular. While research confirms that doctors have few illusions about treatment leading up to their own demise, and plan to refuse much of it, laypeople are hungry for all the invasive treatment they can get. As doctors, we don’t always help with this. We have pills and procedures that make statistically significant improvements in cancer specific survival, and what cancer sufferer would say no to that? We spend a lot more time studying how to hold failing anatomy together than we do learning to let entropy take its course. We have treatments that hint at immortality, nobody needs to die of Condition X anymore, now that we have Drug Y. What if this patient in front of us is the one in a hundred that has a durable remission? What if we kill them through inaction? What about the guilt-ridden estranged son who wants “Everything Done”?

Popular media have kept up a sustained and determined campaign for cardiovascular resuscitation in particular. Having an intelligent, sensitive, pragmatic talk to a family about not resuscitating the palliative patient due to the invasive, undignified nature of resuscitation for a virtually negligible chance of durable success is not as convincing as James Bond being defibrillated in his Aston Martin.

What is the definition of “good survivor” if not continuing to drink, gamble, and assassinate day zero post-resuscitation? Sadly, days or weeks of vegetative decline is much more common.

So what of the 94 year-old, who has already outlasted his cohort’s life expectancy by over 20 years? Who lived through two world wars, the rise and fall of the Soviet Communist state, the invention of Rock ‘n’ Roll, space flight, and electric foot spas? Objectively, he made an informed decision about his health care, prioritizing his values and concluding that the chance of increased quantity, however tiny, trumped quality. I can’t help think that in reality he kidded himself that he was beating death once again. He had evaded those cruel icy fingers, and secretly maybe thought he could live to a hundred and fifty. If he was my Grandpa, maybe I could have talked to him about embracing the end as a part of the natural cycle; not fearing, but accepting. But then, I was just his doctor.

Brown Sauce and honest reporting

May 2, 2014/6 Comments/by James Duthie

The British are fond of a condiment called Brown Sauce. The product itself leaves me unmoved, but the thing I find interesting about Brown Sauce is that it purports nothing about itself whatsoever, other than a description of its colour. It claims no link to any known product of nature, just a factual statement about its appearance. Consider, for instance, tomato ketchup. If an independent lab discovers that a ketchup is, in fact, only 5% tomato and 95% starch, sugar, salt, and flavor enhancer 621, people will be justifiably irate about the “tomato” claim. If, on the other hand, Brown Sauce is eventually proven to be made from asbestos and drowned kittens, the manufacturers can quite rightly state that they only said it was brown.

The same kind of plain speech is often missing in surgery. The truth has often been a casualty in the patient consent process due to a combination of ignorance, fear, avarice, or ego on the part of the surgeon. Whatever the motivation, when we explain rates of risks and benefits to the patient before us, many of us are not giving an honest report of our own outcomes. In the case of the battle between robotic and open radical prostatectomy, for example, real-world complication rates are often ignored in favour of Walsh’s rates on one side, and Patel’s on the other. Surgeons are certainly not all the same. If you have ever considered who you would allow to perform surgery on yourself the chances are you have written a very short short-list. When we tell a patient that the rate of complication x from procedure y is only 5% and we have not audited our own outcomes, we are likely giving the rates produced by the high-volume specialist centres that had the expertise, numbers, and clout to get their rates published in a reputable journal. Most surgeons do not work in those centres.

There is an on-going debate on whether hospitals should be compelled to publish their procedure-specific outcome data, so that the public can make informed decisions about their surgical care. I think this misses the point. Yes, there are potential hazards to compulsory publishing; centres of excellence may have worse outcomes than others due to operating on the sickest patients with the slimmest hopes of success, one major complication in a lower volume centre can skew the data, and there is the potential to develop a culture of suspicion and dishonesty, but the real point is more personal. We should honestly report to the patient in front of us from our own results as a matter of honesty and ethics, regardless of hospital policies. We can then (hopefully) reassure them that our outcomes are comparable to those published, and they can expect good quality care from us. If we cannot reassure them of this, our audit process will inform us of our shortcomings and we can seek to address them. We might even consider leaving certain procedures to a colleague who is better at it than us. A bitter pill, maybe, but arrogance is the enemy of improvement.

It can be a nuisance to collect and collate operative data. It can be painful to discover that we are not as good at something as we had assumed. Thankfully surgeons are mature adults who can take these challenges on the chin, and use the results to make our patient care better. Can’t we?

Otherwise, the information we give our patients is “pork-pies”, which is Cockney rhyming slang for lies, and no amount of Brown Sauce can make those pies palatable.

James Duthie is a Urological Surgeon/Robotic Surgeon. Interested in Human Factors Engineering, training & error, and making people better through electronic means. Melbourne, Australia @Jamesduthie1

Stunned

February 27, 2014/2 Comments/by James Duthie

If you needed inspiration to pursue cognitive ergonomics as a career or hobby, you could do worse than starting with the book “Set Phasers On Stun” by Steven Casey. Presented as a series of bite-sized real-life vignettes, the book illustrates the inherent fallibility in humans who design and use systems in a very engaging manner.

The most relevant story for doctors is the titular tale about a man receiving radiation therapy for a tumour on his shoulder. Ray lay on the treatment table. The tech in the next room attempted to set the machine to an appropriate radiation dose, but accidentally turned it on to full power. She noticed her error, and reset the machine before firing. Unfortunately the software was not sufficiently powerful to acknowledge her rapid typing, and the setting stayed on full. Furthermore, after firing, the screen told the tech there was an error and that no dose had been delivered. She tried twice more, inadvertently dosing Ray each time, unable to hear Ray’s screams from the lead lined treatment room. He only avoided further doses by running away. As Ray died from the treatment over the ensuing weeks, he jokingly told people that “Captain Kirk forgot to put the machine on stun”.

As clinical doctors, we should acknowledge the fact that individually, we do not make that many people better. Disappointing though this is, as it is the Raison d’être for many of us, I think we understand on some level that it is the “Big Picture” people, the Epidemiologists and Public Health physicians that really make the difference. However many cancers I cut out in my career, I’m still likely to make less of a difference than one well in Sub-Saharan Africa. Many of us are prevented from entering the “Big Picture” career paths due to the fact that they are interminably boring. It is much more interesting to counsel and educate patients, and certainly more exciting to perform complex (and at times terrifying) operations than to sit in a small office in the medical school’s worst-funded department crunching numbers. And who is more likely to be invited to appear on Dr. Oz? The Robotic Surgeon? Or the Epidemiologist with meticulously gathered records of malaria rates in South East Asia? The sad truth of the world is that glamour and excitement are usually more revered than self-sacrifice for enduring positive change.

It took a tragedy, and software engineers to solve the problem that killed Ray on the radiation table, but fortunately, there are simpler avenues for clinicians to make a difference beyond the patients they personally treat. This does not necessarily mean being involved in research on expensive new drugs that often have an incremental (or even arguable) benefit over the existing standard. And you don’t have to be Atul Gawande, creating the WHO surgical checklist, but it helps to use his approach. Devoting some time and mental resources to identify problems that affect a large number of people, even if only in a small way adds up to a significant total benefit. This week I was sent a review article on inadvertent diathermy injuries. These are uncommon, but can be debilitating, as in the index case where a patient essentially lost the use of his right hand due to thermal injury-induced tendon contractures. A consistent problem was a loss of contact between skin and earthing plate. Sweat and traction can loosen the plate and result in occult burns, particularly during prolonged cases, or emergency cases where the plate was applied in a rush. Maybe another surgical check should be done at four, or six hours into an operation to assess the need for a second antibiotic dose, and check diathermy plate. If the case is taking significantly longer than expected, should we take the opportunity to ask; “Why is this taking so long? Do I need help, or a second opinion here?”

The electronic age has given us unprecedented opportunity to reach patients with quality information on the nature of their disease, what to expect from their surgery, and advice on when to seek urgent help. In many cases it just takes a person to assume responsibility for writing content for a web page. The more quality health content we write, the more we drown out the snake-oil merchants and charlatans that prey on credulous patients.

My challenge to you in the coming week is to devote some time to thinking of a “Big Picture” issue that could benefit more patients than those you see yourself, or alternatively dig a well in Africa.

Face to interface

February 6, 2014/by James Duthie

Cast your mind back to college physics and recall that an interface is a boundary between two phases of matter, for example gas and liquid. The interface is where interaction occurs between the disparate parts, there may be an exchange of molecules, or a conversion of molecules from one state to the other such as evaporation. Information, such as light or sound is always upset when it reaches an interface and some of the message may be bounced off while some is transmitted across the interface to the other state. This is why we might see our reflection in a pond, as some of the incident light bounces of the liquid interface and back to our eyes. So far, so dry and irrelevant.

If we think about interfaces between people, the equivalent to phases of matter is two disparate minds attempting to transmit information across the interface of human communication. It seems logical that minds that are more familiar and perhaps similar due to experience and level of sophistication lose less information due to reflection (think of the ease of communication between close family members versus explaining theoretical physics to a three year old).

There is always an interface with communication, be it speech, gestures, semaphore, or Twitter. Our intention is to effectively get across sufficient information to understand and be understood. Each modality has pros and cons, for example a letter allows a distillation of thought and a poetry that is absent in a phone call, while Skype allows you to see a loved one in real time. Due to a lack of vocal inflection, facial expression, and physical gestures, many public figures have claimed a misunderstanding after making inflammatory statements on social media.

We certainly are getting used to communication through physical separation. The ability to keep in touch when you want to while geographically apart is undoubtedly a boon, and in the medical sphere isolated patients are benefiting from teleconferenced and video-linked consultations, along with podcasts, tweets, and YouTube videos that make medical advice more and more accessible.

But here is the problem. The interface between a doctor and a patient has a very high surface tension. That means that information struggles to breach the membrane from doctor to patient and vice versa. Without conscious effort, by default information thoughtlessly spouted will bounce off and be lost. The minds of the doctor and patient are usually disparate, with one an expert in their own experience of a disease, and the other an expert on pathophysiology and evidence based practice. Both are complex subjects, difficult to communicate to the non-expert in the conversation. With the addition of a screen, or phone line to the interface, we have to beware of the surface tension becoming impenetrable. As medicine becomes increasingly electronic, we need to remember that dispensing advice to the internet is different from communicating with a patient. Every communication interface has its weakness, and we need to be aware of avoiding pitfalls that compromise care. Humour often does not work as well in an email as it would in person, accompanied with a cheeky grin. Speech over an internet connection may be distorted, intermittent, and as a result, irritating to listen to, making us want to curtail conversations prematurely. To shamelessly direct you to my other work on the role of technology in medicine and life we need to add value as doctors above what a digital algorithm can provide to justify our work.

Why? The usual arguments (it is good business to keep the client happy, specially if you use Salesforce help, the prestige of being a preferred doctor, the opportunity to expand ones sphere of influence), but also I think most of us sacrificed our youth training in order to make people better, and we cannot do that if patients cannot hear us.