[Comment] The fate of medicine in the time of AI

What does it mean to be a doctor? Is it still medicine we practise when a machine knows better than us our patient’s diagnosis, treatment, or fate? Would the hand we hold at the bedside still be reassured by our words and care? It remains hard to predict when artificial intelligence (AI) will become so powerful that it outreasons human beings. Some see that day arriving soon, and extreme predictions see whole disciplines like radiology or dermatology disappearing, replaced by AI.1 The truth is much less clear.

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.

[Department of Error] Department of Error

Willer H. Breast cancer in Venezuela: back to the 20th century. Lancet 2018; 392: 461–62—In this World Report, a procedure incorrectly reported as being radiology should have been radiotherapy. This has been corrected online as of Aug 17, 2018.

[Correspondence] The future of radiology: adding value to clinical care

The practice of radiology needs to change for three reasons: subjective decisions about tests are a major contributor to the overuse of services, images are often inconsistently obtained and analysed, and radiology reports often include vague descriptions.

Your patients’ health in their hands

Information for AMA Members from the Australian Digital Health Agency about My Health Record.

By Professor Meredith Makeham

Australians are being offered an important choice over the next three months about how they want to interact with their health information.

By the end of 2018, all Australians will have a My Health Record created for them, unless they choose not to have one.

The decision, importantly, is theirs to make after considering the benefits of having immediate online access to their health and care data, and being able to share it with their clinicians.

They will have access to information such as their medicines and allergies, hospital and GP summaries, investigation reports and advance care plans which could not only save their life in an emergency but also help their clinicians find vital information more quickly so that they can make safer health care decisions.

Trusted health care providers – GPs, specialists, pharmacists and others – are likely to find their patients want to talk to them about their decision. The My Health Record system is here to support better, safer care – not to replace current clinical record keeping systems or professional communication. Neither will it replace the patient-doctor relationship and clinical judgement. It is simply a secure online repository of health data and information that wouldn’t be accessible otherwise.

The data flows into the record from securely connected clinical information systems in hospitals, general practices, pharmacies, specialists’ rooms, and pathology and radiology providers. It also provides access to Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data, the Australian Immunisation register and the Australian Organ Donor registry.

People understandably want reassurance that the Australian Digital Health Agency (the Agency) holds the privacy and security of their health information as its first priority. The system’s security has not been breached in its six years of operation. There is no complacency however – My Health Record system security operates to the highest standards, working with the Australian Cyber Security Centre and others. It is under constant surveillance and threat testing.

The legislated privacy controls are world-leading and easily accessed on the consumer portal. They include features such as a record access control – similar to a PIN – that a person can apply to their entire record so it can’t be viewed unless shared with their clinician. In an emergency, the legislation allows a clinician to ‘break glass’ and see vital medicines and allergy information. However, all instances of this are audited and people can choose to receive a text or email informing them if this happens.

The steps required for a healthcare practitioner to view a My Health Record require a number of security authentications to take place. For a provider to access the My Health Record via their clinical information system, they must be a registered health care provider – for example, registered with the Australian Health Practitioner Regulation Agency. They must also have a valid provider identifier and work in an organisation with a valid organisational identifier.

Software must be conformant, with a secure and encrypted connection to the My Health Record system. In addition, the patient must have a record on the provider’s clinical information system as a patient of the practice.

The Agency has not and will not release documents without a court/coronial or similar order. No documents have been released in the past six years and no other Government agencies have direct access to the My Health Record system.

We know 230,000 hospital admissions occur every year as a result of medication misadventure, costing the Australian taxpayer $1.2 billion annually. Many of these could be avoided if people and their clinicians had better access to vital medicines and allergy information.

The ‘Medicines View’ is a recent addition to My Health Record. It provides a consolidated summary of the most recent medicines information from notes entered by GPs, hospitals, pharmacies and consumers.

Over the past 12 months, the system has enriched its clinical content. Public and private pathology and imaging providers are now connecting and a vast increase in connected pharmacy systems as well as hospitals has occurred. This will accelerate the realisation of benefits as clinicians find they can access a more comprehensive source of information within the My Health Record system.

This month, a national communication plan was launched to ensure Australians are well informed when making their decision. Almost 20,000 My Health Record education kits were distributed to GPs, community pharmacies, aboriginal health services, post offices and public and private hospitals.

Our role as health care providers is to be our patients’ advocate, to support them in making the decisions and choices that will lead to better health outcomes and ensure that they have access to safe and effective care. My Health Record isn’t here to solve all of our problems, but it is an important step forward in our ability to deliver a safer and better-connected healthcare system.

Clinical Professor Meredith Makeham is Chief Medical Adviser of the Australian Digital Health Agency.

Candidate profile – Dr Jill Tomlinson MBBS(Hons), PG Dip Surg Anat, FRACS(Plast), GAICD

Nominating for the position of AMA Vice President

We are at a critical period of change in health. We are asked by Government and the community to do more with less. Healthcare costs are rising. Technology is changing how we practise, offering opportunities but also challenges. Our profession faces significant cultural change.

The AMA must remain relevant and engaged in this time of change. It needs a strong leadership team who will deliver advocacy, political representation and passion to do better for our patients and for the profession.

If elected, I will make digital strategy a key priority. Within the AMA, this means improving communication and engagement with members by expanding digital services and addressing barriers at State and Federal levels. The AMA must be where doctors are, and must support a strong AMA in every State.

Within the health system, a focus on digital strategy means strong advocacy for systems and programs that work for doctors, not create work for doctors. This is not just about My Health Record, it’s about real time prescription monitoring, secure messaging, data use and security, accessibility, interoperability, care co-ordination, the digital determinants of health and the regulatory and administrative burden on doctors. We must get digital systems right, or else – as we’ve seen with hospital constructions across the country – billions are spent but the final product doesn’t address the needs of patients or doctors.

Preventable illnesses associated with obesity are literally killing our patients. We need a radical, whole of community approach to the problem – one that drives meaningful change. We must advocate for public health improvements and make real investment in general practice, which is the most efficient part of the health system and has been neglected for too long. We must improve mental health care, aged care and veterans’ services. We must reduce inequality, and Close the Gap. We must be inclusive, and support equity and diversity. It’s the fair thing to do but it’s also in the best interests of our patients and the profession.

We must address workforce issues, including doctor and training position maldistribution. We must support medical students and doctors-in-training who are increasingly struggling to manage the overwhelming demands of training and service delivery. We must improve access to flexible training and end discrimination on the grounds of pregnancy, mental illness, disability, parental leave and return to work. We must advocate for marginalised individuals and groups that cannot speak for themselves.

We must fight for an independent profession. Patient care suffers when health funds control access to care or make decisions for patients; corporatisation increasingly affects general practice, radiology and pathology.

I seek your support and your vote at National Conference. I seek your advice and insights into how we can improve health in Australia as, while I have a vision for the AMA, I do not claim to have all the answers. And most importantly, I seek your enthusiasm, passion and engagement – only by working together will we achieve the best outcomes for our patients and the profession.

* See other candidate profiles on thios site.

Candidate profile – Xavier Yu MBBS/BA FRANZCR GAICD

Nominating for the position of AMA Vice President

Yes, I am a radiologist. But one who actually enjoys engaging with patients and fellow clinician referrers….

I began my medical career 18 years ago, but only recently gained my FRANZCR two years ago. My 16-year doctor-in-training career included stints in general surgical and orthopaedics training programs, while working in hospitals across New South Wales, Victoria and Tasmania, before joining the world of radiology. My current public and private practices include inner city, outer suburban and regional Victoria, as well as interstate through teleradiology.

My credentials include graduate qualifications and advanced training though the Australian Institute of Company Directors, and being involved in AMA committees forever, including as Council of Doctors In Training Victorian representative, and AMA Victoria Board member for six years (including the past two as Vice President). A transition from one VP role to another seems natural enough!

We must unite and rebuild, with collaborative and respectful engagement of the most important asset – you as the member. Our organisation faces increasing challenges with membership recruitment and retention, provision of membership services and assessing our vision: what and where is the future in advocacy for the AMA?

The role of the next AMA Vice President is threefold:

* support act to the President;

* bring good modern governance credentials to the Board, Councils, Committees; and

* listen to the voice of the membership.

My five ‘passions’ include:

* General Practice.

You might find this strange coming from me, but my frequent professional discussions with GPs has highlighted the powerlessness they feel about being able to effect genuine change – and continuing to fight the escalating war on punitive over-regulation and intrusions by threats from task substitution like ‘superpharmacies’. I also hear loud and clear the anxiety from GPs about talk of changes in regards to Health Care Homes, outcome based practice incentives and e-PIP.

* Membership engagement.

To say we have a lack of engagement ‘on the ground’ is an understatement. I want to ‘close the gap’ between President and the ‘normal’ doctor, fostering better member engagement and networking opportunities, and being the person behind the scenes to whom you can freely talk to and get stuff changed. The State and Territory AMAs must be at the forefront of advocacy activity, and therefore be suitably better resourced.

* Culture and systems change.

We have to end the ‘blame game’ in hospitals and workplaces, by lobbying for better mechanisms to improve work-life balance and doctor well-being, assist colleagues in distress without vilification or victimisation, and promoting equity to give opportunities to all our colleagues, regardless of gender, ethnicity, religion or orientation.

* The ‘maldistribution mess’.

Medical school, prevocational and vocational training settings all need to work together better.

* Regional, rural and remote recruitment.

To whom are the doctors going to hand the keys of their practice when they retire?

Follow me on LinkedIn (search “Xavier Yu”) and Twitter (@docxy75) leading up to National Conference for more: I’m more than ‘just a radiologist’….

* See other candidate profiles on this site.

Make a student’s week

BY ALEX FARRELL, PRESIDENT, AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION

For a medical student or junior doctor, one kind word can get you through the week. This year, as students start clinical rotations, remember that you have more influence than you think.

Placement as a medical student is a strange and wonderful world. It’s where we are finally exposed to the reality of practising medicine, and meet the doctors whom we aspire to be like one day. It is here that we set our expectations for the culture of medicine. We learn that medicine is a place of mentoring, compassion and respect. But it can also be tough, most students will recognise the near universal experience of feeling like a burden to their team.

Students want to work hard, but sometimes it is hard to know what is expected us, or how we can be of use to our team. You’ll recognise the almost painful amount of enthusiasm a student will put into a job you throw their waY – from grabbing a bluey to calling radiology, most students just want to be a helpful member of their team.

As medical students, we are very aware that teaching us takes time from doctors’ already packed days. We understand that treatment must be the first priority, and how frustrating it must be when students slow clinicians down. But like all doctors before us, we have to learn. Supervisors explaining a process or saying that a student did a good job only takes a second, but it can make a big difference to a student’s day.

Medical students will, invariably, get answers wrong. They will make a mess of simple procedures and they will take up time on days when the doctors on their team have none to spare. The supervisor who can tell them not just what they did wrong, but also how to improve, will be the teacher that they remember.

Positive experiences are important. I have heard many students extol an “incredible day”, simply because they felt like they were part of a team or that they could ask questions. Passion for medicine is infectious. In fact, many consultants have told me they are in their specialty because of a particularly influential mentor.

No doubt, it is high pressure being a doctor. Some days, circumstances make it tough to be the best supervisor, but never doubt the amount of good a quick acknowledgement can do for the medical student on your team.

There are great role models and teachers in every ward and clinic. For that we are grateful. Every one of you plays a role in shaping the doctors and medical culture of the future.

So this year, as medical students rotate in and out, keep in mind the doctors whose teaching made you the clinician you are today. Never underestimate the power of some thoughtful advice, a clear explanation, or a kind “you’ll get it next time”. We use your words to guide us, help us start off down the right path.

Technology advancement – not always the panacea for making your life easier

BY DR ROD McRAE, CHAIR, AMA COUNCIL OF PUBLIC HOSPITAL DOCTORS

I hope all have had a splendid and refreshing break with family and friends. 2018 is set to be a busy year around the nation related to industrial relations. Victoria has just settled its Enterprise Bargaining Agreement under extenuating circumstances, but which has exacted an unbelievable cost which will soon be widely discussed, akin to what transpired some years ago in the upper echelons of Victoria Police. For those continuing with their jurisdictional discussions, my strong advice is to develop a strategy and adhere to it.

Beyond pure, old-fashioned industrial relations, there is to be a Senate inquiry related to the emergence of new technologies in Australia, and their impact on the future of both work and on workers (it reports in June). The AMA is making a submission and your CPHD will be working to consider how we can minimise perverse outcomes arising from rapid change.

You may recall the early prediction that the introduction of a computer-based, ‘paperless’, office would cause a conundrum for society: how would it manage a consequent huge increase in a workers’ available leisure time. I observe that this was staggeringly inaccurate. Instead, an explosion of intra/inter-organisational communication occurred, along with profoundly new work methods, which then created significant additional workload and response pressures, not to mention more paper.

Medical practice is not immune from such implications, but we can prepare to ensure both quality patient care and professional sustainability. To preserve our well-established (and evidence-based) norms, we must establish significant ownership over such mooted technological change. This will enable us to guarantee that patients, and thus the community, will benefit from effective and efficient implementation / integration of technologies, and will ensure medicine remains a safe, attractive and useful career. Like all workers, we too seek job satisfaction and security; reasonable work time commitment; observing good effects arising from our work; having clear purpose when at work; having opportunity for professional growth; having a family and recreation time and receiving a fair day’s work for a fair day’s pay.

So, what might be the effect of revolutionary technology, including artificial intelligence, for us in the public hospital setting? We are already observing a US model of care outsourcing radiology/medical imaging reporting and analysis all the way to India (teleradiologists). That’s perhaps all very well superficially, but what about: the de-skilling impacts locally; quality assurance; uncertain medico-legal liabilities where there is further intervention underpinned by reporting error; and consideration of the patient being properly served when off-shore analysis might not have access to all pertinent records and information?

There is also another more sinister side to this. In our domestic public hospital context, AMA has already had some industrial experience of representing radiologists who, while rostered On-Call but in fact basically through incremental hospital request over time, have ended up working from home as if on duty, all thanks to current IT capabilities. Home computers (and employer installed equipment) have made activity possible that was previously only ‘in the hospital’. This makes it easy for many of us to fall into the trap of never being away from our work. There is incentive for an employer to increase their expectations on us while we are left with our vocational challenge of being unable to stop serving our patients.

Concerns about exploitation and fatigue management are very real, but also our existing payment compensation entitlement framework about On-Call, Recall or overtime have not been design to accommodate such new ways of “doing things” now enabled through use of new technology. This is an indication that we need to stay on our toes to prevent unfair and unpaid (over)work direction. Remuneration and rostering methods for our enlarged workforce will need modernisation to account for our anticipated expanded work value contributions and requirements.

Medicine and medical practice has always evolved with the expansion of scientific knowledge, and its translation to medical care. In the modern environment of rapid advancement and transformation, the frequency, pace and unpredictability of the consequences of change will likely increase, yet be of a different character to previously experienced adjustment processes. Managing the integration of new technology/artificial intelligence is a new challenge. Technology necessarily changes behaviour, which brings with it a new set of requirements to coordinate new systems of work. We want to guarantee effective communication between us, apply the new technology, and manage the implications for our teams and hospital administration. Employers will need to work with us with early respectful dialogue to ensure there is careful introduction of the new ways of doing things; this so that patient care is not undermined and we are appropriately rewarded.

For CPHD, the challenges we face in response appear to be about ensuring employment rules keep pace and useful new technology/artificial intelligence are effectively implemented/integrated. Both of these fundamentally relate to us being enabled to maintain the high standards of presently enjoyed patient care.

Are Australian prostate cancer patients getting a raw deal?

Australian men with a recent diagnosis of prostate cancer that require active treatment, as opposed to careful monitoring, are often not given all the options available to them.

This means not all men are getting the necessary information and support to make a decision on what treatment is best. A growing body of evidence and treatment guidelines support the fact that less invasive radiation therapy is equally effective in curing or controlling cancer as surgical removal of the prostate, known as radical prostatectomy.

While all patients see a urologist – the specialist surgeon who does the biopsies and gives the diagnosis – they only see a radiation oncologist if the urologist or GP refers the man on. In this way, the urologist is the gatekeeper to men receiving optimal (or sub-optimal) care. The fear of cancer and a natural emotional response to get it out may lead to a less than fully-informed decision for surgery, and to possible regret of this decision later on.

Bias in medicine is a reality, and it is not surprising doctors favour familiar treatments. But it is problematic when bias creates a hurdle to men getting accurate, balanced information. There is plenty of evidence men aren’t getting the chance to hear about their radiation therapy options. A recent US study found that men seeing both a radiation oncologist and urologist were six times more likely to choose radiation therapy compared with men seeing only a urologist.

In Australia, the proportion of men receiving radiation is much lower than research on effectiveness of radiation therapy would predict if men with prostate cancer were exhibiting truly informed choice. Meanwhile, prostate surgery rates are higher and continue to rise, especially in the case of robotic surgery.

Prostate Cancer Foundation of Australia.

The gold standard of care

The gold standard of care for prostate cancer begins with the patient and his support person talking with the experts – the surgeon (urologist), a radiation oncologist and a specialist nurse. In doing so, the man is provided with the relevant information and impartial advice he needs to make an informed decision about his preferred treatment.

Virtually all specialist doctors who treat cancer profess to be part of a multi-disciplinary team, that includes surgeons, medical and radiation oncologists and other experts, and attend meetings where the relevant health professionals discuss patient “cases” to decide on management. These team meetings are valuable, but they are only one aspect of a high quality service. Meetings do not include the patient, the man with prostate cancer, who is integral to the decision-making process.

The multi-disciplinary team model has been successful in the treatment of breast cancer. There is nearly always more than one good treatment option available for men with prostate cancer, sometimes several. For men with low risk cancers, many may not require active treatment up front (or ever) and are appropriately managed by active surveillance or careful monitoring.

But other men with prostate cancer require active treatment to reduce the chance of dying, or suffering symptoms, from cancer. Alternative treatment pathways are very different for the individuals involved, in terms of patient experience, potential side-effects, the need for additional treatments, and potential out-of-pockets costs. This is why the man with prostate cancer has to be the most important member of the team who decides on the treatment.

Putting the patient at the centre

Only the patient can weigh up the trade-off between the risk of bowel problems (with radiation therapy) and the risk of urinary incontinence (with surgery). Likewise, the choice between attending the cancer centre for radiation treatment every weekday over several weeks versus hospitalisation and time off work for recovery after surgery. There are many other pros and cons that may sway a man to prefer one approach over another.

As already mentioned, the ideal model for decision-making for prostate cancer treatment is that the man has a consultation with a urologist and a radiation oncologist. As the two types of prostate cancer specialists have distinct expertise in different areas, seeing both is the only way men can get complete, up-to-date information.

The man can then consider his options and discuss these with his family and GP if he wishes. The good news is that men can take time to do this, as most prostate cancers are relatively slow-growing.

In the United Kingdom, Canada, and select centres including some in Australia, prostate cancer teams do place the man at the centre of decision-making. But this must become the rule rather than the exception and Australian men should be strongly encouraged and assisted to see all experts.

Ultimately, men need to be empowered in their decision-making through being part of a process that enables and supports them in making fully informed choices. Until then, men who require active prostate cancer treatment need to insist on seeing all the specialists in the area, including a radiation oncologist.

Sandra Turner, Associate Professor, University of Sydney

This article was originally published on The Conversation. Read the original article.