more_vertGrowing up, Santiago Ramón y Cajal (1852–1934) wanted to be an artist, but his father, a physician, wanted him to be a doctor. A gifted painter, sketcher, and observer of nature, he found his way to medicine through anatomical drawing, which led to a career in histology and neuroscience. In 1906, he shared the Nobel Prize in Physiology or Medicine with Camillo Golgi “in recognition of their work on the structure of the nervous system”. Golgi’s famous staining method had enabled visualisation of individual neurons, facilitating, among other things, Cajal’s thousands of iconic drawings, about 80 of which are the centrepiece of the touring exhibition The Beautiful Brain: The Drawings of Santiago Ramón y Cajal and the elegant companion book.
Preference: Physiology and Anatomy
894
When the doctor becomes the patient
Former Federal AMA President, Dr Steve Hambleton, fell ill suddenly and unexpectedly last week in Canberra.
He flew in to Canberra early on Wednesday, November 7 for a meeting of an MBS Review Committee. He made it to the meeting, but not for long. By midday, he was in the ED at Canberra Hospital.
After tests and care and an overnight stay in Canberra Hospital, he was on a 6.00am Thursday flight home to Brisbane and straight back in to hospital in his home town.
He underwent surgery later that day, and remains in hospital recovering.
In a brief window of opportunity during his transition from robust doctor to vulnerable patient, Steve found time to write a ‘Thank You’ note to all his carers, which is also an emotive account of his patient journey.
Thank you all …
Dr Steve Hambleton
Thank you to all the people who made my stay in the Canberra Hospital a little more bearable.
Thank you to Dr Eleanor who, when I asked for help, was decisive and supported my need to seek help. Thank you to Dr Andrew for making that call to the hospital to smooth the way for me.
Thank you to the staff at the triage desk, to whom I was just another person. I was treated with care and compassion. I was not that well, and not at my best, but very grateful. I wasn’t the only one there. Around me were people from all walks of life, with a bandage here or there, and their own personal stories to tell. Some were impatient. But if it bothered them, they did not show it.
Thank you to the cleaners. Your work behind the scenes makes a huge difference. My body told me it was time to vomit, which is always a bit awkward when wearing a suit and tie. On one knee on the floor in a clean toilet rather than a soiled one made all the difference to me. I am sorry if I made your next run a little bit harder.
Thank you to the triage nurse who kept me informed while I was in the waiting area, and for showing me to my bed.
Thank you to the emergency nursing staff. You don’t know how much comfort the sight of you in your uniform brings to those of us feeling helpless.
Getting changed out of my suit (which makes me feel important) into that gown confirmed that I was truly the patient on this occasion, totally dependent on the kindness and skills of others.
Thanks to the Emergency Physician who took a history from me. You asked me to describe my pain and I could not. It was pain, bad pain. It was waxing and waning every few minutes, and I was struggling to find an adjective that would help you. You smiled and were patient as you gently probed and questioned.
I was not a very good historian. In that moment there was a lot of my history I could not remember. Certainly not dates and times, and what happened in what order, and I don’t really have any chronic diseases. It made me think about how much harder it must be for those that do.
Thank you for putting in that intravenous line, which sort of validated for me that I was not a fraud and did need to be there.
Thank you to the student nurse, who recorded my observations and administered the first of the medications. I was not well, and probably did not express my thanks all that well.
Thank you to your Senior, who was quietly guiding you as you administered the analgesia. The pain did not go away immediately, but the warm feeling on my skin was reassuring that something was being done.
I wondered how the meeting that I left was going, and what my colleagues were thinking about my sudden departure.
Thank you to the wardsmen who transported me to the radiology department on two occasions. For your light-hearted banter as we weaved our way along the corridors in my bed, which seemed to have lost its steering. We need to get that trolley fixed – it just wouldn’t go straight. Sorry about the rubbish bin. It was a welcome distraction to take my mind off the way I was feeling.
Thank you to the ultrasound operator who was gently efficient – his job was to be in that darkened room, applying his knowledge of anatomy to help answer the clinical questions.
Thank you to the CT scan nurse and the radiographer for your part of the diagnostic journey.
I spent a long time in your emergency department. I love the reference to the flight deck, which is your central point. I was there long enough to hear shift changes and the handovers.
I heard you gently managing the patient with the mental illness, whose understanding and connection with our reality was tenuous at best.
I heard you keeping the patients’ relatives informed about the next steps on their journey.
I heard you manage the man with dementia who was someone’s brother/husband/father. He was loud, and he was angry as he fought his demons. Despite that, he was treated with the same kindness as all your other patients. Do you remember telling me that by the time he left the Department that he was “the nicest old man”. I hoped that you would be around if ever I was that man in the future.
I wanted to go home but needed to stay. I needed help and you gave it to me willingly and I am so grateful. When I leaned on the call button accidentally or when I needed extra help, you were there quickly.
Did you know that if you hold your breath you can watch your oxygen “sats” go down and make the alarm go off? The machines beep to tell you when things are going well, and when they are not.
Thank you for letting me use the phone to keep my family informed. It seemed every time you came into my room, I was talking to someone else.
Thank you for letting me go home when you knew that I was still not quite right. I know you worried about whether it was the right decision. Thank you for tolerating that uncertainty.
Nothing in medicine is absolute – it’s all about trade-offs.
As I walked through the Department on the way out, I could not believe the patient load you were facing.
Thank you to the night registrar who, even at the end of his shift, had a smile for me.
Dr Steve Hambleton is a former President of the Federal AMA and AMA Queensland.
[Comment] Patient education and engagement in treat-to-target gout care
Gout is the most common inflammatory arthritis worldwide, affecting 4·0% of adults in the USA and 2·5% of adults in the UK.1 The pathophysiology of this crystal arthritis is well understood, and inexpensive urate-lowering drugs that address the underlying cause of the disease are widely available. Yet gout remains poorly managed, with 70% of patients experiencing recurrent gout flares2 and substantial burden from tophi and joint damage, which lead to functional limitations and diminished quality of life.
BOOK REVIEWS
REVIEWED BY CHRIS JOHNSON
Rescue Paramedics
By Brett Stevens
New Holland Publishers
Sub-tiled True-life stories of front line paramedics, this book is a riveting read about the often unheralded work of those first on the scene of so many tragedies and accidents … as well as some of life’s most uplifting experiences.
Births, deaths, rescues, burns, overdoses, stabbings, shootings, crashes, and crash-throughs are all described in these pages with humanity and powerful insight.
Extremely well written and easy to read, Rescue Paramedics is a fitting tribute to those who put themselves on the line to be there when duty calls and people need help.
Scrublands
By Chris Hammer
Allen & Unwin
A page turner! This crime, thriller, suspense novel is simply brilliant.
Set in a dying rural town of the Australian Riverina, this is more a “why-done-it?” than a “who-done-it?”.
The crime is revealed in the first paragraphs of the book and the rest of the journey sets about trying to untangle what seems to be a very messy web.
Hammer’s prose is beautiful. And he defiantly wraps up myriad sub-plots just when you think the task impossible.
You can feel a part of this tight-knit community that has more dark secrets and seedy characters than any town should.
There is a very good reason that Scrublands hit the bestsellers list immediately and has stayed there.
The Incidental Tourist
By Peter Doherty
Melbourne University press
Nobel Prize winner Peter Doherty has written an amazing travel journal, weaving his knowledge of science and medicine with his love of far-flung destinations.
A very enjoyable read, this memoir crosses the globe as well as the decades and all the while posing the deepest of questions, such as “What the hell am I doing here?”.
Doherty won the Nobel Prize in Medicine or Physiology 1996 for discovering the nature of the cellular immune defence.
His intellect, humour and good nature are all evident in these pages.
[Editorial] The Nobel Foundation needs to check its privilege
Of the 216 Nobel Prizes for Physiology or Medicine laureates to date, only 12 are women. It could be argued that some of the bias is due to historical imbalance; the scientific community has only started to recognise that poor diversity limits the breadth of scientific findings in the past 10 years. But that is discounting that institutional discrimination, which still affects scientific institutions, might also be pervasive in the Nobel Prize for Physiology or Medicine’s selection process.
Video game physiotherapy could help with back pain in older patients: research
An Australian study has found that a unique video game physiotherapy program is effective in improving pain and function in older patients with chronic lower back pain.
The randomised controlled trial, published in Physical Therapy, is the first of its kind and recruited 60 participants, aged 55 years or older, with chronic lower back pain. Patients were randomised to receive the video game exercise program or to continue their usual activities for 8 weeks. The video game operates through the Nintendo Wii Fit U.
The authors measured the primary outcomes of pain self-efficacy and care seeking, in addition to the secondary outcomes of physical activity, pain, function, disability, fear of movement/re-injury, falls-efficacy, recruitment and response rates, experience with the intervention, and adverse events.
Participants receiving the video game intervention practised flexibility, strengthening and aerobic exercises at home for 60-minute sessions three times a week, without the supervision of a physiotherapist.
Physiotherapist and post-doctoral research fellow from the University of Sydney’s School of Public Health, Dr Joshua Zadro, led the study and told doctorportal that the results were encouraging. The research revealed that total adherence to the total recommended exercise time was 70.8%, and no adverse events were reported.
“What our trial showed was that a video game exercise program, performed in the comfort of older peoples’ homes, reduced their pain and improved their function.”
“Participants on average experienced a 27% reduction in pain, and 23% increase in function”, he said.
While those completing Wii Fit U exercises demonstrated significantly greater improvements in pain efficacy and function, and were more likely to engage in flexibility exercises at 6 months, there were no significant between-group differences for the remaining outcomes.
The benefits of video game physiotherapy – compliance, convenience and cost-effective
Dr Zadro said that one of the benefits of this program over conventional approaches to back pain is that video game exercise is interactive and provides patients with video and audio instructions. While playing the video game, participants also get feedback on their technique and scores on their performance.
“So, these patients are quite good at maintaining adherence to the exercise program over time, which is often a limitation of existing programs where people are asked to self-manage.” Similarly, the program would have a great advantage for patients living in rural and remote areas, where service access is an issue.
Dr Zadro said another benefit of the program was its potential to effectively operate within the MBS, which currently covers only five physiotherapy sessions – despite traditional exercise programs generally requiring many more sessions.
“As you’d need only one session for the physiotherapist to set up the video program and teach how to use it, participants could then manage their exercise independently, in the comfort of their own home, without needing regular follow up.”
“They can really do as many video game sessions as they feel is necessary to get the benefit.”
Looking ahead, Dr Zadro is keen to investigate how effective the video game approach is in different groups of patient populations.
“It would be good to see if this same program could be applied to other patients – maybe younger people or even the very old people with chronic lower back pain.”
[Correspondence] Young Frankenstein and The Lancet
Medicine has become an attractive theme in entertainment, including medical dramas such as House, Grey’s Anatomy, Chicago Hospital, ER, and Charité. References to medicine, however, can also be found in cult films such as Young Frankenstein (1974), which is a parody of Frankenstein; Or, The Modern Prometheus by Mary Shelley (1797–1851). The novel contains several references to historical neurological practices such as electrostimulation (this technique has become useful again in modern times), which is also mentioned in the film.
[Perspectives] John Keats’ apprenticeship
Visitors to Keats House museum in London, UK, are often surprised by the first display case. A small leather notebook, containing lecture notes on physiology and anatomy, is flanked by medical instruments—pharmacy jars, forceps, amputation saws, a leech urn. Labels explain that the notes were made by John Keats during his 2-year stint as a medical student at Guy’s Hospital, which followed his 4-year apprenticeship to an apothecary–surgeon. The poet was, you learn, soon promoted to surgical dresser at Guy’s, a position which involved “the first management of serious incidents”, 24 hours a day for 1 week out of every 3.
[Comment] Helping children with hearing loss from otitis media with effusion
Otitis media with effusion occurs during viral upper respiratory tract infections in around two-thirds of infants and young children because their Eustachian tube anatomy and function do not provide adequate ventilation and drainage of natural mucus production during a cold until the age of around 5 years. Children are also much more prone to develop a middle ear infection during an upper respiratory tract viral infection. Even with the introduction and widespread use of pneumococcal conjugate vaccines, acute otitis media following an upper respiratory tract viral infection remains common in childhood.
What use is the high moral ground when you are being eaten alive?
BY AMA VICE PRESIDENT DR CHRIS ZAPPALA
GPs’ livelihood and ability to practise are being attacked on many fronts. Dubious role substitution creep from usurper health care practitioners must stop. Does the fight need to come to their doorstep instead of doctors always being in defence?
The Acting President of the Pharmacy Guild recently likened the AMA to a “salivating and barking dog,” following a perceived “onslaught of abuse and derision,” in a response to broader scope of practice for pharmacists. The hyperbole was rousing!
It was suggested that prescribing medications, being able to capably understand and diagnose a patient’s medical problems without appropriate training or ability to garner a full history and examine, and to provide health prevention advice is within the scope of pharmacy training? Clearly not true. The aircraft engineer doesn’t pilot the plane, serve the drinks, or unload the luggage. Being able to work a sphygmomanometer and having a basic understanding of physiology does not make you a doctor or capable of giving medical advice while standing in the middle of a retail pharmacy. The benefits of an enduring, familiar family doctor who knows you well and can provide wide-ranging advice and treatment is well evidenced and the appropriate cornerstone of our health care system. Pharmacists are not required to do any part of this job.
It was also asserted that self-defined broader scope of practice for pharmacists will also save money and time for patients. Not really if outcomes are inferior. Where is the evidence that pharmacists behaving as quasi-doctors achieves anything? Regular interactions with general practitioners is crucially important in developing an enduring bond, discussing risk factor modification, and so on. Government cannot ‘de-fund’ general practice, then attempt to remove the more simple work, and expect the system will still work given growing patient complexity and potential risk.
If you want to be a doctor – go to medical school. Australia is graduating just under 4000 doctors this year – there’s no lack of space! Please, do not abandon doing the job you are actually trained to do. Patients need direction in how to use their inhalers every few months (or their technique degrades), explain the purpose of medications (both prescribed and over the counter), clarify dosing regimens for patients, make sure warfarin interactions with diet are understood by patients, sort out pill boxes or Webster packs to reduce medication errors, and so on. This unequivocal in-scope pharmacy activity is performed far less than it should. If it was done frequently and properly, it would be far more useful to patients and contribute more robustly to the safety and quality of the system, compared to the constant attempts to do a doctor’s job in a rudimentary and inferior way.
The AMA has always decided it is morally and ethically more appropriate for doctors to not dispense medications as a system- wide policy (bearing in mind it has usefully occurred in rural areas for a long time). It would actually be very convenient to patients if doctors did dispense medications (to use one of the Guild’s main arguments for role substitution), and we could make it cheaper to the system as a whole if the costs reflected the dispensing fees only, without profit being generated, and/or any profit being retained within the practice for other patients’ services. If doctor dispensing of medications became a reality, individuals would not have to do it, if they didn’t want to. If patient convenience and cost are paramount in the system, whereas training, evidence, and professionalism do not matter as much to decision-makers, then we perhaps need to recognise this.
Offence might serve us better than defence. Is the AMA position due for a re-think?