James Duthie

Posts

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.

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

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.

Creativity, Faster Horses, and Future Medicine

May 16, 2013/3 Comments/by James Duthie

I was at an international cricket match, when during one of the very few lulls in the action I noticed a camera operator. He was riding a Segway around the field in order to get close to the action and vary his angle for the viewers at home. After observing the function of this Segway-Human-Camera complex, it struck me that the only superfluous component in the system was the man with the beer gut and ill-fitting shorts. All he did was point, focus, and zoom a camera. This can just as easily be done by a director in a control room, or even independently by a smart enough camera. It is not a stretch to imagine a computerized mobile field camera that can track a ball, and “intuitively” widen and tighten shots. The only thing keeping our man on the ground in employment is that at present, he is cheaper than the technology to replace him. His days are numbered. Taking the example of manufacturing, human workers are already replaced or reduced when lifting, welding, or assembling robots become as cost-effective as their flesh-based competitors. Machines don’t fatigue, take breaks, or form unions, and so are an attractive alternative to, well, us.

With accelerating technology at declining cost, any job that is based around performing concrete tasks is at threat. Fast food restaurants are almost there, car wash services have been there for years, we only have pilots in aircraft because we don’t fully trust computers, and what next? Postal services? Car mechanics?

Lucky for us, doctors could never be replaced. Right? Actually wrong. There are already electronic systems that in some situations make faster and more accurate diagnoses and management plans [https://www-03.ibm.com/innovation/us/watson/]. Perhaps the role of the physician will soon be giving a “human” face to explaining why the computer has ordered this course of treatment. That is, until technology can generate an adequately “human” face.

We may be relatively protected in surgery at present due to such things as appreciating variable tissue structures, making complex decisions based on unexpected findings, and adapting the surgical plan based on our understanding of the patient’s priorities. Technology will get there eventually. Even now it is conceivable that a computer could control an endoscope in the collecting system of a kidney, identify and then vaporize a stone as well as a human surgeon. A computer removing an organ is surely just further along this same scale.

The best protection we have is creativity. At present, computers have mastered managing vast quantities of data rapidly, and performing physical tasks within specific guidelines. We just cannot compete in this arena. Our advantage is in the abstract. We are still better at thinking of creative solutions, unexpected improvements, and more pleasant alternatives. A quote attributed to Henry Ford points out that if he had asked his customers what they wanted, they would have said “faster horses”. A binary brain would have worked tirelessly to give them this.

In the long term, doctors may only be researchers, generating ideas for computers to assimilate data on, but even then machines will be snapping at our heels. Why can’t a computer generate combinations of chemotherapeutic agents for a randomized trial? Even our last bastions of humanity, the arts, are not guaranteed safety. A computer can understand the mathematics of music, learn what is and is not palatable to the human ear, and “create” music. The same could be said of agreeable angles and architecture. One has to wonder, however long it takes, if the era of the human healer is approaching its end?

Comments on this blog are now closed.

Surgery is Not Normal

February 21, 2013/4 Comments/by James Duthie

The man was unconscious on the operating table, in lithotomy position and fully prepped for the major extirpative surgery which he was about to undergo. Four of us from different surgical specialities stood around his nether regions with arms folded, having all done a very thorough bimanual examination. We were discussing whether his recurrent colorectal cancer felt mobile enough to get away with a posterior exenteration, or if all the pelvic organs had to go. As we considered the physical exam findings it occurred to me that this was not a normal situation. I looked at the patient and said to the head of Colo-Rectal surgery, “you know, in some workplaces people discuss things around the watercooler”. All of a sudden the stark reality of this bizarre situation was apparent as it might be to the casual observer.

Surgery is not normal, and neither are surgeons.

Surgical training is not normal. Much has been written about the unique legal status that medical trainees have, whereby they may dismember dead human bodies with impunity in the course of their education. As training progresses we are not only allowed, but expected to assault people with an array of sterilized weapons, so long as we expect that they will be better off for it. Only a fool would promise this will definitely be the case of course. Less has been written about the fact that it is not normal to be occasionally scolded in your workplace like a school kid and given “homework” in your thirties. It only seems normal because our colleagues seem to accept it.

That surgeons are not normal, I believe, is both self-selection and indoctrination.

Even the kindest, most humane surgeons have steel beneath the surface in my experience. At best, this is only revealed when advocating for a patient, such as demanding theatre access for an urgent after-hours case, but at worst…we have all met that surgeon. Almost all of us have surely had to grit our teeth late one night performing a procedure at the limit of our ability, unable or unwilling to call for help. Timid people do not self-select for surgery. In most countries the process requires an at least somewhat forceful personality to get through selection interviews. A certain drive is required to jump through the necessary hoops and survive the long hours and emotional trauma of the training. Once training begins, as is the case in the military, the majority of waking hours are spent with colleagues in the same environment, but sometimes in different locations. No-one on the outside truly understands the unique demands on the individual. Survival tips are shared, but competition is fierce even when unspoken. Even closest friends can be an obstacle to getting enough experience.

My non-medical father called me one evening some years ago and asked how busy I was. I told him “not bad”, I just had to knock out an appendix and I was almost done. He was taken aback by what seemed a cavalier attitude to what must be a frightened 18 year old about to undergo an anaesthetic for the first time and have his belly cut into. If you are a surgeon, it is understood that no-one has the emotional resources to care this much for every one of the endless multitude of people we treat. I care very much about doing my job as well as I can, but out of necessity I do not routinely involve myself in their personal drama. This would impact my ability to make them better.

Is that normal?

James Duthie is a Uro-Oncology Trainee (Robot Surgery) at Peter MacCallum Cancer Centre, Melbourne. He is interested in Human Factors Engineering, & making people better through electronic means. @Jamesduthie1

Comments on this blog are now closed.

Superstition

January 11, 2013/1 Comment/by James Duthie

In 1948 BF Skinner put a pigeon in a box. Unlike most of Skinner’s birds, this one did not have to learn a behavior, such as pecking a lever, to receive an edible reward. Food was automatically dispensed at fixed time intervals without fail, the pigeon simply had to wait. The fascinating development from this experiment was that after some few hours in the box the bird was performing an elaborate routine of behaviors; turns, head movements, foot raises, all presumably in an effort to bring about the reward. When a number of birds were placed in the same situation, each developed a unique routine to bring about reinforcement, that was forthcoming regardless. Whatever behavior they happened to be performing at the time of feeding was, by chance association, reinforced.

Skinner dubbed this phenomenon “superstitious behavior”. He extrapolated this to human activities that have no bearing on an outcome, but are nonetheless performed in an effort to bring about a favorable endpoint. Repeatedly pushing the elevator call button to speed its arrival. Using loved ones birthdates when selecting lottery numbers. Wearing lucky socks to a job interview. In these cases decision making is faulty due to misperceived information, that an extraneous behavior will make a significant difference to outcomes.

Much superstitious behavior is harmless, albeit futile. In surgery, we have the “Goodnight Stitch”. This is the added step in the procedure that maybe unnecessary, but makes us feel we have done something extra for patient safety, and will therefore sleep easier. If the patient does well, the behavior is reinforced. Equally we all know the power of a significant, memorable complication in influencing our behavior.

Real harm arises when, like a pigeon in a box, a surgeon becomes isolated. Sitting alone in the dark, relying on short-term patient outcome feedback, the surgeon may develop a dominant philosophy of “In my hands…”, or “Our experience is…”, that precludes service improvement based on robust evidence. It has been established since at least the mid 1990s that powdered surgical gloves increase the rate of symptomatic abdominal adhesions (Luijendijk R), but do any of us know a surgeon that persists in using them because “This has not been my experience”? At first glance, the geographically isolated surgeon would seem to be particularly vulnerable to this phenomenon, with few colleagues to provide a check on eccentric practice. Perhaps, however, the surgeon that separates themselves from the surgical community, regardless of geography, is of greater concern.

We have conferences, morbidity and mortality meetings, and audit to objectively assess our outcomes, and prevent us from becoming superstitious victims of anecdote. We can vicariously increase our experience through research based on thousands more patients than we will ever treat. If a surgeon avoids or minimizes these activities, they are vulnerable to systematic superstitious decision making.

As surgeons, we fiercely defend our right to autonomous practice, and rightly so. We must not become slaves to policies imposed by misinformed outsiders with agendas other than patient welfare. We must also seek to overcome undue internal influences on our decision making based on fear, lack of knowledge, and superstition.

Comments on this blog are now closed.