Protecting Kids

Working in a kids hospital is mostly joyful. Obviously it is sometimes sad. Then every now and then it is deeply distressing. While meeting families dealing with terrible illness and sometimes death very much features, the worst cases I recall have been those where children have been victims of some form of abuse. Whether through neglect, some form of inflicted harm or non-accidental injury these are the cases that send the teams retreating into silence.

New News of Old Deeds

In Australia at the moment, details emerge daily of horrifying child abuse within institutions stretching back decades as part of a Royal Commission into Institutional Responses into Child Sexual Abuse. Recently, cases involving homes run by The Salvation Army have been receiving coverage. Previously the Catholic and Anglican churches have been under the spotlight. More institutions will follow.

The stories of abuse revealed would shake most people. What is equally shocking is the response of the institutions involved at all points in the timeline when evidence of abuse emerged. The motifs emerging have become all too common. The most vulnerable targeted by those in whom no trust should have been placed. Evidence emerging but the focus being on support for the perpetrator who is moved on or protected from prosecution. Stories have even emerged of other people in positions to help, including the police, returning children to homes they’d managed to escape.

3 Wise copy

This poster was actually for those working on the Manhattan project [and stumbled on via wikipedia]

This spreads the taint far further than those few bad apples. The temptation, now that the various institutions are seeking to make the effusive apologies and payouts so clearly warranted, is to believe that this Royal Commission will allow a resolution of old stories so that everyone can finally move on. The hope seems to be that we are dealing only with a chapter of history, and we are taking the final steps to display that past behind glass cases in a museum.

The Here and Now

The stories emerging date back as far as the 1950s. Clearly times were different. It’s easy to think that people didn’t speak up at the time because that’s not how society worked.  Those of us who weren’t around have to use whatever available cultural touchstones we have to understand those times. Viewed through the haze of ‘Happy Days’ reruns or the lauded reconstruction of ‘Mad Men’, maybe it’s easy to assume it all arose from a different set of values.

However, we’re speaking of times over the ensuing decades too. This is a time well within the lifespan of my parents. Pondering that makes me wonder if values really have shifted so drastically. These cases of abuse happened within institutions that clearly harboured some disturbed individuals. They also counted in their number many people doing lots of good, and yet many of those people didn’t speak up. Would the shift in attitudes that has happened be enough to protect children now?

Actions and Words

When I look at the system I work in, the intent to protect is clearly there. As a health practitioner in NSW, there is  guidance available as to how to go about reporting any concerns of harm in children and I’ve been trained appropriately. The problem is recognised, spoken about and a framework is well and truly in place. The talk is all there.

I’ve actually had occasion to report a couple of cases. The reporting side is fairly straight forward and the system that is in place should ensure that cases are unlikely to be swept to a dark corner without concerns being raised. These are good steps to preventing future institutional abuse. Our problem locally seems to be that we haven’t set up a system that allows for action to be taken.

Early last year, an excellent (but sobering) series from Lisa Pryor illuminated all too clearly a system that cannot act through an overwhelming lack of resources. When working in medicine outside the hospital, we define a disaster as pretty much any situation where the number of casualties you have to deal with exceeds your available resources. That story covered in the link meets that definition many times over.

The benefits of intervening to remove children from risk are not disputed. The long term effects on individuals exposed to abuse are well known. The evidence is there that we are not providing the necessary resources to those prepared to take on this gruelling job and I don’t see much of an outcry. I’m struggling with why we don’t make the link between the horrors emerging in the Commission and the need to complete the construction of a system that can meaningfully prevent history repeating.

The staff of DOCS are seeing stories like this every day. We’re also hearing stories from staff in detention centres of significant concerns that treatment of children in those situations amounts to abuse (there’s more on that here). Staff there are already flagging the Royal Commission they expect to come. Is a system that can see and hear the evil but not act really learning the lessons from those old institutions?

Without the ability to act on concerns, without the capability to step in to stop things happening where a flag is waving, have we really done enough to prevent more stories emerging?

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No Hoverboard, but a Robot Doctor?

I was a big fan of The Jetsons when I was growing up. Well, who wouldn’t be? They had a talking dog and lived in the sky. Now that I’m bigger of course, I’ve had to deal with the disappointment of my completely earthbound car that refuses to fold into a briefcase. There are no robots dressed in an anachronistic maid’s outfit in my house either.

That particular fantasy comes to mind whenever I read something like this. Bit of a longread that one, but it actually describes the very real present day phenomenon of computers, big data and robots. There are some very cool projects covered in it, but to me it still reads like the insular hyperventilation of a zealot conveyed via the reporter’s typescript.

A Brave New World

Those raised on early sci-fi might find the notion of robotic health care a little unappetising.

Actually, they're not talking about the caring touch of this lump of metal. [via scifimusings.blogspot.com}

Actually, they’re not talking about the caring touch of this lump of metal. [via scifimusings.blogspot.com]

They’re really talking about something slightly different. The most interesting bit relates to the role of supercomputers in managing and responding to data. The example given is IBM’s Watson, famed for conquering the insular world of Jeopardy in the US (for a first person account of the experience check out this TED talk by Ken Jennings).

When discussing the possibility of these forms of computerised systems enhancing health care and safety, the article is on firm ground. Even allowing for the delays in cool ideas that are par for the course (*ahem* hoverboard soon please), you’d hope we’d see that within a decade in developed health systems. In fact, most of the cool ideas covered sound like the sort of thing I’d take a look at more than once.

That’s not where the problem lies. The whole article talks about revolutionising the world of health from an entirely American perspective. I get that it’s an American publication. But some of the folks in there don’t seem to get how ridiculous it is to focus on super expensive technological advances to try and save money in the world’s most overpriced and wasteful health system. It confirms the lack of insight in that whole discussion.

Rather than focus on a rich geek doctor’s wet dream, it would make a whole lot more sense to talk up stuff that would definitely improve outcomes and reduce costs associated with complications. Like making sure people wash their hands.

Not quite as cool, but effective and cheap. Far better to get the supercomputer I guess. It can probably stream your playlist at work and stuff.

Although it’s a little beyond the scope of this piece, it’s worth seeking a bit of context too. The vast majority of the world’s population isn’t dealing with problems that require a supercomputer or robots. They need drinking water. Or vaccines. Or food. Or antiviral medications for HIV. Or access to education. They don’t need better access to Angry Birds adapted for rehabilitation centres.

The Human Interface

My more general gripe with those breathlessly promoting the idea that doctors will be replaced by robots (and this isn’t about the Atlantic article now) is the implicit suggestion that it’s the technical elements of healthcare that are most important. Sure, you want anyone looking after you to be exceptionally good at the facts, but anyone can do the facts.

What I want as a patient, and what I strive to provide as a practitioner, is a shared recognition that at the centre of everything there is a person whose humanity needs to be acknowledged. I don’t want to be involved in a reckoning only of facts, figures and statistics. The doctors I admire are the ones who practice from the personal and apply the evidence correctly but with empathy at all times. Because as a practitioner, personal experience can be vital to being better at what you do. How about an example?

The Personal in Practice

Those who have had kids no doubt recall it as a profound experience.

I remember so clearly the drive to the hospital for our first son. I remember the sunlight cutting through the car. I remember the wait to be seen.

I remember the ultrasound, so large on the wall-mounted screen.

And I remember his heart.

Still. Resting.

In my memory I feel my wife’s howl, more than I hear it.

Then the long gloaming of labour. The final flickers of hope of some miracle finally dashed.

***

The full story of Alexander would require much more than this. What is pertinent to this discussion is how that experience colours my practice.

Weeks later I returned to work as a senior anaesthetic trainee. Inevitably, the middle of the night Caesarean section came up. I had prepared myself for this and the technical aspects of the job presented no challenges. It was a different situation anyway.

I remember acutely though that the Dad involved was horrible. In insulting everyone involved in the operation and more particularly his partner he provoked in me true quiet anger. I’d never experienced anything like that before. I have never had it happen again. And although there may have been reasons for my extreme internal response, I’ve not been able to do that sort of anaesthesia with the joy and generosity that the situation warrants. So I don’t do it anymore.

Patients deserve more than that. To have the trust of people as they hand over their very self is an extraordinary thing, and you’d better be prepared to turn up with all you’ve got. And while I’m no fan of the manner in which I gained the experience, I have ended up as a far better doctor through the insight of true grief.

It influences what I expect of my own doctors too. The time came when we needed to decide what to do for our next child. Change it all up and avoid any associations or return to the same obstetrician?

In the end, we went with the same doctor. Part of the reason was she understood us and took onboard the grief we carried. It’d be fair to say that she was the next most stressed individual to us throughout the pregnancy, and the next most relieved when it was done. It was a tough thing to do as a practitioner.

But that’s what I want from a doctor, and it’s why I think claims of robotic doctors being on the frontline are an overreach. I want a doctor to care about as much as Dr Ian Haines (look around the 5:20 mark) an oncologist featured as part of 4 Corners the other night.

Anyway, maybe I’ve got it all wrong. Perhaps I should welcome my robotic doctor overlords. Which do you prefer – Robin Williams in Bicentennial Man or Robin Williams as Patch Adams? Actually forget that, those are both horrible thoughts.

Let me know though – is a friendly face a key part of the equation, or should I get some qualifications in robot maintenance?