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Breaking the cycle

ONE OF OUR family treasures, kept on my parents’ mantelpiece, is a photo of me as a baby being held by my grandfather in the dappled light of a lemon tree in his North Adelaide backyard. As he held me in his arms, I’m told he whispered, ‘I am sad that I will never get to know you’. He died soon after from bladder cancer, caused by years of smoking cigarettes. My grandmother nursed him at home, dispensing drops of morphine elixir to ease his pain.

Fifty years earlier, he had been serving as the lieutenant colonel in charge of the medical division of the 2/6 Australian General Hospital. In 1941, during service in the Middle East, he was aboard the HMAS Farndale when it was struck by an aerial torpedo. He clung to flotsam in Tobruk harbour before being rescued two hours later.

Dr Mark Bonnin was a tall, gentle man. After returning to Australia, he became a well-respected physician renowned for treating all patients with absolute equality. He taught at the University of Adelaide for twenty years, and was forced into retirement from the Royal Adelaide Hospital at the compulsory age of sixty-five. Challenging the norms of the time, he continued to work well into his seventies privately treating all patients regardless of their means and mentoring junior doctors at the local college of physicians. His compassion inspired a generation of medical students in Adelaide and around Australia to be better doctors. He was the founder of the National Parks Foundation of South Australia and was recognised with as a Member of the Order of Australia in 1989, shortly before his death. Each year, the University of Adelaide’s medical school now awards the Mark Bonnin Memorial Prize for the best academic tutor in internal medicine.

While I have no memory of his presence, I followed his example and entered a career in medicine. It can be a challenging life, and sometimes, when I’m faced with difficult decisions, I imagine conversations we might have had, sitting under that lemon tree. Had he felt these pressures? How did he make decisions? From everything I’ve been told about him, I try to piece together what his advice would have been.

One instance I could have used it was on 9 November 2016 – a date the team of doctors, nurses and paramedics I work with in South Hedland will never forget. It was a fairly typical, warm afternoon, and a well-known patient was brought to our emergency department in cardiac arrest. I will always remember hearing those sirens racing towards the hospital, the adrenaline surging through my veins, the resuscitation team assembling. The strange silence that engulfs the doctors and nurses as we hear the deep rattle of a hospital bed rushing towards the door. The sound of bag-mask ventilation pushing air into his lungs, and the rising smell of faeces and sweat. Despite our best efforts to resuscitate him, we eventually ceased medical intervention and he passed away. The feeling of helplessness that followed forced some perspective on me, along with questions regarding our ability to prevent suffering.

I have spent the majority of my medical career in the outback. People often question why I am ‘settling’ for something ‘less rewarding’ than a city-based job. However, as all remote medical professionals know, when times are tough and distance is great, compassion is high and innovation thrives on necessity. Layers of bureaucracy in large hospitals trap and confuse susceptible patients, locking them into a cycle of dependence. In the bush, we start a patient’s journey with getting understanding their home, their family and their wishes in order to establish care plans together. This how I view medicine and my own work as a doctor – as the art of combining scientific knowledge and human empathy to make decisions.

 

THE FIRST LECTURE I attended at university covered the difference between disease and illness. To this day, it has proven to be one of the most important lessons for me. The dean of our medical school explained how disease processes affect our bodily systems, something taught from the perspective of the science of medicine. Illness, however, is a patient’s manifestation of disease and is the fundamental basis of the art of medicine, which cannot necessarily be taught.

In my work, I have discovered that patients are not motivated by an understanding of the pathology of disease, but rather by how improving their illness will improve their lives. As an intern, my first palliative lung cancer patient highlighted this difference. Mrs Tran, who was suffering from floridly active pleural pathology, understood her disease. She knew it was beyond surgical treatment and our team was temporising her shortness of breath with chemotherapy and painkillers, but she did everything to avoid letting the illness define her. I looked forward to morning ward rounds, when she asked us to sit on the end of her neatly made bed and explained the delights of various Vietnamese delicacies. Her positivity taught me the difference between having a disease and having an illness, and how to facilitate the treatment of both.

The importance of outlook isn’t the only thing my career path has shown me. Quality of life can be formally quantified through public-health calculations that evaluate the length of time spent in various states of health. As a resident working in an outback hospital, I once treated an eighteen-year-old Aboriginal man with obesity hypoventilation syndrome. Numerous, varied lifestyle choices had led this man to become so obese he was unable to stay conscious due to poor oxygen levels affecting his respiratory drive. In a constant state of drowsiness, he had very few quality years of life ahead of him. As I sealed an uncomfortable positive-pressure mask on his face and struggled to take blood tests through his subcutaneous fat, I wondered about the decisions that led him to this point. Some of these decisions would have been made well before he was born. The maternal and nutritional origins of disease have revolutionised my perspective on how we can create long-term, healthy change. When I was a medical student, my obstetric medicine professor, John Newnham, explained that the health choices mothers make in their reproductive years affect their offspring’s propensity for lung and heart disease. This means that, for us, targeting lifestyle is imperative for reducing the burden of disease on future generations.

While lifestyle choices are often just that – choices – they can also be inherited, ingrained physically and psychologically to the point that ‘choice’ becomes a questionable term. Evolutionary scientists hypothesise that ‘metabolic thrift’ – the theory that scarcity required early ice-age humans to increase their protein intake for survival – could help explain the underlying causes of modern fat accumulation, insulin resistance and obesity-related disease. After adapting in this way, the first and second agricultural revolutions afforded civilisations the ability to produce surplus supplies. As European societies began to consume more carbohydrate-rich foods, their bodily tissues promoted insulin responses in order to digest these foods. Other societies, including Aboriginal Australia, saw comparatively less simple carbohydrate consumption, and their relatively rapid transition to a modern diet has resulted in genetically higher insulin resistance.

On days when the Pilbara heat is unbearable, I sometimes retreat to the shopping centre in South Hedland. I am shocked at the range of affordable food available in the food court: donuts, hot chips, hamburgers, soft drink and processed juices. It’s a standard list of foods that contain unhealthy amounts of excess energy. Aboriginal populations in particular are primed to store this energy as adipose tissue (fat) for periods of seasonal scarcity. Health professionals know this, but educational programs targeting this high-risk population group are not easy to implement and sustain. We are faced with the challenge of making physical exercise and the consumption of fresh affordable food more appealing than watching television and drinking pre-mixed alcoholic beverages in the 40-degree heat.

To compound matters, a culture of low expectations from community service providers entrenches a practice of suboptimal treatment for more at-risk populations. If we know that the patient in front of us can’t afford the standard seven-tablet course of antibiotics to treat their urinary tract infection, why do we give them a take-home pack of only three tablets from the hospital? It is a reluctance to challenge established practice and evaluate the success of programs that leads to attitudes of complacency.

It is easy to grumble about the number of presentations to the emergency department and succumb to established habits of suboptimal and symptomatic treatment, but every interaction with a patient should be seen as a chance to improve their lives. We are not doing enough to connect with patients, nor to educate them and equip them with the tools necessary to make their own informed decisions, to establish an autonomy that will reduce the number of return visits to hospital.

 

TODAY’S MEDICAL GRADUATES are better poised to change the world than ever before. The democratisation of medical schools, rise of evidence-based medicine and the availability of online resources continue to improve patient-oriented care. By the time they graduate, armed with experience from international electives and nation-wide practicum placements, students are more practical and inclusive in their clinical approach than they were ten years ago, and the flexibility of rural hospitals provides fertile ground for experimenting with change and championing new best-practice guidelines.

For the last three years, my colleagues and I have been dissecting the processes in our hospital, questioning existing practices and then modifying components of care. We review every form and every process in an attempt to improve quality and safety for our patients. But our challenges to the status quo have been met with resistance.

The introduction of an electronic medical record system in our hospital is a good example. Engrained practice meant that practitioners continued to use patient file boxes, and uptake of the new technology was slow. One day, to widespread dismay, I removed the boxes. Nine box-less months later and patient management is far more efficient – the change just needed a catalyst.

In the United States, a 2015 survey of healthcare consumers reported that patient engagement can be improved through active partnerships with doctors, trustworthy online resources and technology that measured fitness and health. Given our understanding of technology and sharing knowledge across digital platforms, my generation of practitioners is best situated to facilitate this change. Similarly, the greatest levels of healthcare consumerism (or autonomy) are found in younger populations with a poorer baseline health status, which will result in life-long benefits for them. My experience mirrors this research. When explaining to patients their treatment options for an acute medical condition, I begin with ‘doing nothing’. This means the patient can elect not to treat their health condition if they believe the risks outweigh the benefits of treatments offered – let it be said, a valid decision. As savvier consumers of technology, younger patients are more inclined to align their expectations, personal preferences and researched understanding of a disease with what I am telling them. Indeed, some patients will choose to simply observe their condition, accepting that intervention may not be necessary. This approach, regardless of the chosen course of action, facilitates a sense of ownership and empowerment. In contrast, when discussing treatment with patients over fifty, I am often greeted with an open mouth, a puzzled look and a request: ‘You just tell me what is best, doctor.’

 

I OFTEN SEE children playing soccer in the car park of the hospital, kicking around rubbish in lieu of a ball. Sport plays an essential role in rural and remote areas, and can be linked to both the socio-economic health of a community and the physical health of its residents. It is a way to build confidence and practical skills in young people, empowering them to make their own healthy decisions as adults.

It struck me that if we wanted to break the cycle of poor lifestyle choices leading to an inherited basis for disease, replacing the rubbish these kids were kicking around with footballs, and a sense of insecurity at home with self-confidence through mentorship, would be a good place to start. Perhaps we could help the next generation of disadvantaged patients before they arrive at the emergency department with obesity hypoventilation at eighteen years of age.

In 2010, some friends and I founded Fair Game Australia, an organisation that recycles essentially worthless second-hand sports equipment into tools for inspiring healthy communities. Since its inception, Fair Game has developed training programs for more than fifteen thousand young Australians, with the goal of assisting others while learning about our collective culture. In 2016, our team of a hundred and seventy volunteers spent 4,952 hours in the service of under-serviced Australians.

Fair Game activities are uniquely crafted to impart health messages using team games. We use ‘no germs on me’ footballs in our skills development sessions as a catalyst to discuss the importance of hand hygiene. Our volunteers chat with children on the sideline about preventing the transmission of gastroenteritis, reinforcing that being unwell will mean they cannot participate in sports games; demonstrate correct hand-washing techniques; and donate ‘healthy communities packs’, which contain hygiene products such as antiseptic gel, bandaids and water bottles.

I am so proud of every one of our Fair Gamers; they exhibit the true spirit of volunteerism and generosity. After six years, we have become a reliable pillar of strength for many communities. Some of our first migrant participants, who were often from non-English-speaking backgrounds, are now setting up their own organisations and sports businesses to coach and mentor their communities. Each year, we support the Butler Falcons, a burgeoning African female AFL team in Perth’s north, with equipment and leadership sessions. The shared experience of culture and landscape has become a strong pull-factor for volunteers, compelling them to consider life outside of major urban centres when they graduate from university.

The possibility of giving back to the community while gaining professional experience has also contributed to a resurgence of interest in rural and regional areas. Government-led rural workforce development schemes have little power to influence long-term workplace trends because they offer short-term financial rewards rather than social benefits. Models like Fair Game’s encourage an emotional connection to work, which for many is ultimately more fulfilling.

There are many other types of innovation within the rural health landscape. For example, Lions Outback Vision, founded and directed by Dr Angus Turner, is a completely mobile, remote ophthalmological service with a mission to cure blindness in rural, remote and Indigenous Australians. Advances in technology allow regional hospitals to submit retinal photos and clinic notes to the off-road clinic ‘eye bus’, wherever it may be, enabling Dr Turner perform vision-saving surgery in even the most remote communities.

 

IN ADDITION TO the evolution of medical care, the past five years have seen the rise of what I call ‘second-sector’ healthcare. Frustrated with traditional medicine and a systemic lack of empowerment, an increasing number of wellness advocates are turning to what used to be termed ‘alternative practice’ for instant gratification. Second-sector healthcare is largely disruptive and disastrously unregulated, further complicates patients’ decision-making and dilutes their understanding of disease and illness.

While the approaches of second-sector services might give patients a sense of empowerment over their own health, the commercialisation of health and wellness continues without input from established providers puts long-term patient outcomes at risk. We need to consider whether consumers are best-placed to determine their future health needs if they are motivated only by short-term goals. My personal opinion is that second-sector healthcare regulation is needed to integrate patients’ immediate needs into a whole-of-life approach to improve outcomes for patients and providers. The future of the medical profession relies on such reimagining of clinical practices.

Fostering a happy medium between patient agendas and practitioner clinical expertise will be crucial for successfully implementing the concept of a ‘medical home’ – a care approach in which primary practitioners co-ordinate comprehensive, meaningful and continuous medical care. In 2017, in response to work done by the primary healthcare advisory group under the Department of Health, the federal government will provide $21 million to trial such a system of primary care. Medical homes will attempt to foster a culture of partnership and expectation as patients enrol in clinics with the personal responsibility to deal with illness by undertaking preventative health activities and attending appointments with on-site allied health practitioners.

This approach will present many challenges to the established system, and my generation of doctors has an essential role to play in it – harnessing the power of soft innovation, pushing for small incremental changes and continuous improvements. It won’t be an easy task, and could prove a reputational risk for people in their career infancy. But looking to the future, one of the largest threats to providing effective patient care is not questioning ‘the way things are done around here’.

 

THESE DAYS, WHEN I visit my family home, I love to sit on the lawn in the dappled light of the lemon tree. My mind drifts on the gentle breeze, and I wonder what I would tell my grandfather if he were still alive.

The world is a very different place. Having mapped the human genome, we understand more than ever before about the science of medicine. But the art of it, Granddad, the human element that you ceaselessly championed, hasn’t kept pace. This is not to sound too dire – all around me I see the tools and motivation to incorporate your forward thinking, and your lesson of compassion. It is still the most important aspect in our duty to others.

I hope I am doing it justice.


From Griffith Review Edition 56: Millennials Strike Back © Copyright Griffith University & the author.

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