Rwanda Day 4: We didn’t bring a robot

Day 4 and we’re 10 operations in. A few challenges along the way but that’s sort of the nature of the game. Although it’s been easy enough to mention the stuff about all the fancy gear and big machines, it’s actually probably more important that we brought people.

There’s more than just those you might have guessed as well. In addition to anaesthetists, physicians, nurses and physios, there is someone just to look after all the technical equipment, someone to manage pathology, a pharmacist and someone providing all that excellent info over at www.ohi.org.au.

They’re all vital and none of them could be replaced by machines. I wouldn’t even trade in the surgeon for a robot.

But Robots Are Cool

Well, robots are sort of cool. Or sometimes freaky. This self-folding origami one is kind of freaky.

In medicine though they’re getting popular and that includes in surgery. For an aid trip they are a bit big and cumbersome and expensive (like millions of dollars too expensive). We’re also not talking about fully autonomous humanoid things with temperament chips that happen to cut. The robots involved in surgery are mostly of the variety where a human still operates them.

The advantage that gets mentioned is that superior control for the surgeon can mean less tissue trauma to impose on the patient and that means less pain and better recovery for the patient. Sounds good, right?

I’ve mentioned before that I’m not convinced robots have found their niche yet. Part of the reason is that for every clinical situation where evidence appears to be mounting that they are of benefit, as in prostate surgery there are other areas where people have been overzealous. Situations like some forms of gynaecological surgery (see also here), or where there is evidence that lots of complications from robot-assisted surgery go underreported.

There are people already using these machines for cardiac surgery and examples of researchers trying to figure out if there might be benefits. What I am fairly confident of is that we are a long way off robots being able to do much without the input of the human brain (not that many are suggesting that really).

The Upsides of the Human Brain

You’ll have to gather that I am effectively whispering this online, as it’s not traditional to spend too much time telling the surgeons they are impressive at what they do. And having humans involved in stuff comes with issues with the way humans think and act in challenging situations. On this trip I’ve even heard a couple of stories of people behaving colourfully in healthcare situations that left me with this look…

Yep, pretty wide-eyed.  [Via reddit.com]

Yep, pretty wide-eyed. [Via reddit.com]

The things I find super impressive about the human brain are demonstrated in the way the surgeons repair the heart.

For some of the repairs there might be holes in the heart to fix, or valves to repair or replace (we’re not doing so much in the way of replacements here). When the surgeon is doing that though they’ve already put the patient onto the bypass machine, drained it of blood and given a dose of a solution to stop the heart from beating at all.

So surgeons work in an empty, blood-free heart to produce a repair that has to work in a heart that is pumping away and full of blood. In the meantime they also fundamentally alter the way the heart has been working.

That’s partly a testament to the impressive ability of the heart to adapt to the new state of affairs (in most cases pretty easily). The surgeon though has to judge how to do their repair to deal with an entirely different set of conditions once they get that heart going again. It’s a bit about experience and a bit about the ability to see the structure in front of them and visualise it under a different future reality and a lot about judgment.

So we’ll all be saddled with old jokes, occasional interpersonal challenges and some fairly ordinary musical choices for a while before robots can do all that.

And most of the time we’ll be quietly impressed.

But definitely not mention it.

Honestly sometimes I think it's better not to ask.

Honestly sometimes I think it’s better not to ask.

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Things That Doctors Do Terribly

At the same time as articles hyperventilating on the robot future that will replace squishy humanoid doctors appear as regularly as each new moon, it has never been more apparent to me that I will be seeking personal interactions in my own care for a long time yet. When I visit a doctor I value the recognition of all of me that is beyond my ailment just as much as their accuracy in guidance and diagnosis. I hope I offer the value of shared humanity when I care for patients too.

The robots we have just don't seem that caring. [via flickr.com]

The robots we have just don’t seem that caring. [via flickr.com]

The need for humanity as we look out for each other was driven home by an entirely different story this week. The death of Robin Williams and the ensuing grief and reminiscence has brought much to light. The need for a deeper understanding of depression has been a recurring theme in coverage. And when I read this coverage I am embarrassed at how poorly I understand something that is so common. Anyone with medical training should leave their undergraduate training with a deep and useful knowledge with which to provide help to those in need. I’m pretty sure that is not the case. I’m sure because doctors don’t even look after their own who are struggling with mental health issues.

 

The Invincible Doctor

A culture of denial of health problems or any form of weakness is a big hurdle to doctors seeking help when they need it.  But more and more evidence points to significant issues with anxiety, depression and substance abuse in doctors everywhere, including Australia. A survey released by Beyond Blue in 2013 revealed around 10% of doctors responding had suicidal thoughts in the preceding 12 months. Doctors reported substantially higher rates of psychological distress than the general population and other Australian professionals. The difference was most marked in doctors under the age of 30. That’s our next generation of healers in distress.

This is not unique to the Australian medical landscape. Similar problems are being reported in the UK. Medical training is no defence against the grim dog of depression or any other mental illness. It does not guarantee insight into what is going on. Nor does the medical training of those around you guarantee that they will understand what it might be like to be drifting inside that cloud. I have heard too many doctors make the mistake of expressing depression as just a matter of ‘getting over it’. Point them at any other disease and those doctors would try to understand the underlying pathology that leads cells or systems to malfunction. Until physicians truly accept that this is a disease like any other that inflicts real pain and disability in all its terrible manifestations, how will we get close to making our responses better?

 

Big Hurdles

The barriers to doctors seeking help are easier to understand. The stigma attached to mental illness clings just as stubbornly inside medical circles as outside. Doctors voice fears that their career will be over if they confess to mental health issues, a worry made all the more pressing as you imagine what would happen if patients or colleagues found out. Add a temptation to self-manage and doctors are just as likely to need multiple approaches to seek help as any other affected individual.

What is steadily improving is access to help. Most societies and specialty colleges provide resources addressing this and guidance as to what can be done. It is not hard to find confidential help and treatment from groups like the Doctors’ Health Advisory Service. From medical school onwards, the importance of having a relationship with a general practitioner is strongly emphasised.

But we’re failing each other. At a personal level we’re not doing a good enough job of helping colleagues who need help. I sat down and counted. Almost every year of my professional life I can recall a story circulating of a health professional in distress. Too many of those stories have ended with suicide.

We’re too often failing colleagues and we’re too often failing patients. So it is well and truly time I tried to gain some of the understanding I should have left university with.  I plan to start by listening to those who can teach me. I aim to absorb as much advice as possible from those who have been there. And then I hope to be ready to help every time I can. It is surely the least a human doctor should do.

 

More reading:

In trying to explore this, I’ve found all of the following bits of writing (in addition to the link above) extremely helpful. I’d be very happy to be shown more. 

http://www.kingstribune.com/index.php/weekly-email/item/2070-quarantining-depression

http://blogs.telegraph.co.uk/culture/jamesrhodes/100075913/robin-williams-dies-depression-is-a-cloak-of-lead-a-toxic-second-skin/

http://junkee.com/we-need-to-talk-about-mental-illness/39402

http://hyperboleandahalf.blogspot.co.uk/2011/10/adventures-in-depression.html

http://www.lettersofnote.com/2009/10/it-will-be-sunny-one-day.html

 

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?