Tongue ties, Lip ties. Frequently asked questions.

I sincerely empathise with the many mothers who are struggling with breastfeeding and who are confused about the role of tongue ties in breastfeeding, swallowing, sleep and speech. I hope I can write something of value to help you navigate this issue. This is written as an opinion piece, not a scientific paper. This is an evolving subject and as more evidence is gathered, my opinion and practice patterns will change. For those clinicians (ENT surgeons, paediatricians, neonatologists, dentists, myofunctional therapist, speech pathologist, lactation consultant, etc.) scrutinising my opinion, please be mindful that in the midst of this clinical debate, we have a parent and a child who needs information and support. This is my personal opinion and not those of any organisations I am associated with. I am neither “anti” nor “pro” tongue and lip ties. I am pro better understanding of the condition. I am pro better care for the parent and child. I am pro better treatment for the child.

 

Who Am I?

I am a Paediatric Otolaryngologist and Adult Head & Neck surgeon in Melbourne, Australia. I trained in Melbourne and went on to do 3 years of fellowships in Canada, Brisbane and Auckland. I trained in Adult Head & Neck Cancer, Facial Plastic & Reconstructive Surgery, and Paediatric Otolaryngology. My area of focus is the Airway, Sleep and Head & Neck Tumours across the lifespan. I subspecialise in assessing and treating conditions of the airway, breathing, swallowing, sleep apnoea, salivary glands, and head & neck tumours. I am part of the complex airway team, saliva control team and vascular anomalies clinic at the Royal Children’s Hospital Melbourne. I have an Academic Tertiary Hospital appointment and a private practice. I share this with you so you know my perspective. I do turbinate reduction, sinus surgery, rhinoplasty, adenotonsillectomy, airway reconstruction, head & neck tumour excision, tongue base surgery, mandibulectomy, neck dissection, salivary gland surgery, and other complex head and neck surgery as required. I see tongue and lip tie as a small part of the big picture. I am obliged to take a global perspective and treat the whole child, not just the tongue tie.

 

What’s the trend?

Google trend analytics shows a markedly increased number of search of the word “tongue tie”. The Australian Medicare Benefits Schedule code for tongue tie release under 2 years of age has gone from 702 patients in the one year period of 1998-1999 to 9,714 in the 2017-2018 period.  This is not even accounting for procedures done in private dental clinics and wards that may not be recorded under MBS. From a literature evidence point of view, the number of yearly published articles on tongue ties have gone from 0-7 articles per year in the 70s and 80s to 27-44 articles per year in the last 5 years. Most of them are case reports, reviews and opinions. Only 8 randomised controlled trials and 10 systematic reviews have been published in the last 10 years.

There is an undeniable exponential increasing trend in tongue tie diagnosis and treatment. Is this because we are giving birth to more babies with tongue ties, or is it because of overdiagnosis and overtreatment? Or is it simply a better understanding of the condition? Just like any medical trend, we go through pendulum swings of underdiagnosis to overtreatment before finally arriving at an evidence based reasonable practice. Sadly there are, in some geographical and online communities, an overwhelming push for tongue and lip tie release procedures. Certain practitioners are strongly advocating for tongue tie release and charging a high fee for these procedures that may or may not be necessary. Performing procedures that may not be necessary is harmful for the child. On the other hand, some practitioners are declining all tongue tie referrals and therefore undertreating kids who may need the procedure. This also is harmful for the child, the mother and the breastfeeding dyad. I have seen some amazing results from tongue tie releases, but I’ve also seen some ordinary outcomes. I’ve seen many who are referred to me after having several procedures.

 

Where are you in the spectrum between super-believers and super-skeptics?

Please, if you are a medical, dental or allied health professional, be mindful of your own biases of overdiagnosis or underdiagnosis. There’s a lot we know and a lot we do not know yet about tongue and lip ties. Some of our strong beliefs may be founded on limited evidence.

 

What is a tongue tie?

Tongue tie (or tongue frenulum or ankyloglossia) is a band of tissue (fascia) between the floor of mouth and the underside of the tongue. Dr Nikki Mills from Auckland, New Zealand has performed meticulous anatomical dissection on this anatomical region1,2 (Disclosure: Dr Mills is a friend and colleague of mine). Her study shows various different configurations of tongue ties, some superficial, others much deeper while the tongue musculature and neurovascular bundle are situated extremely close to the mucosal surface. The terms anterior and posterior tongue tie are confusing. Posterior tie does not mean it is inserting to the posterior surface of the tongue. It is a band of fascia that is situated more posteriorly than the anterior tongue tie. You may not see it but you should be able to feel it when you challenge the tongue. The grades of tongue tie (Corrylos grading) has not been completely validated, meaning, we have not studied if different grades (or class) is related to different functional limitations. It’s a description, not a measure of severity.

What is confusing about these labels and grades is that in practice we sometimes think in black and white. Does the baby have or not have a tongue tie? Is the tongue tie anterior or posterior? This black and white thinking is not helpful. We all have tongue ties to a variable degree. We all have this frenulum to a certain degree. The question is whether that tongue tie is restrictive or not. Can I use the tonsils as a comparison here? We all have tonsils. Some have bigger tonsils than others. Some big tonsils do not cause trouble. Some small tonsils cause trouble. The size of our tonsils has not been shown to accurately be related to the severity of sleep apnoea. If I removed every tonsil I see, including the asymptomatic ones, then I’m unnecessarily overservicing and harming patients. If I decline all tonsil referrals as I do not believe tonsils cause trouble, then I am also causing harm to those patients I have declined to treat. I cannot set up a Tonsil Centre to remove every tonsil referred to me, neither can I refuse all tonsil referral. The tonsil has to be assessed in the context of the whole patient. The presence of a tongue tie does not necessarily mean that it is causing harm to the child. We need to look at the impact of the tongue tie on the child as a whole. We also need to appreciate and accept that some tongue ties are problematic and need to be released.

 

What’s the Impact of Tongue and Lip Tie?

There is also confusion around the impact of the tongue tie on suck, swallow, sleep and speech.  I would like to divide and simplify the impact into 2 general categories based on age: the infant and the older child. In the neonatal and infancy period, breastfeeding and latching is a critical function of the lip and tongue. In the older child, speech articulation and some association with sleep disordered breathing has been reported.

The baby who struggles with breastfeeding may have a tongue and/or lip tie, or they may have nasal obstruction or other possible neurological conditions. Suck – swallow-breathe reflex is an inherent reflex in an infant, so if there are limitations in the first few months, an assessment of the swallow and breathing needs to be performed by trained maternal child health nurse, lactation consultant, GP, neonatologist, paediatrician, paediatric ENT surgeon, speech pathologist or anyone else with experience. Lip tie may cause an incomplete and ineffective lip seal suction around the breast, a tongue tie may restrict the suction effect of the body of the tongue around the nipple.

In the older child, tongue tie may restrict the movement of the body of the tongue and it is thought that it positions the tongue lower down on the floor of the mouth therefore over time, resulting in a tongue that is positioned more posteriorly, a mandible that is retruded and a maxilla that takes a high arched roof position. These craniomaxillofacial changes area associated with obstructive sleep apnoea. Tongue tie in this situation may be an association, not a causation. To reverse these changes, the complete airway need to be assessed, not just the tongue tie. Releasing the tongue tie without dealing with the turbinates, septum, adenoids, tonsils or tongue base is missing the big picture.

 

So my child has a tongue tie. Do they need their tongue tie released?

Well, it depends on whether your child has symptoms such as difficulty latching, myofunctional disorder, obstructive sleep apnoea, or speech articulation issue. Your child needs an assessment by a GP, paediatrician, speech pathologist, dentist, lactation consultant, oromyofunctional therapist or paediatric ENT surgeon. I’ve got a tongue tie. I seem to be doing fine (ok, ok, some of you may disagree).

 

So my child has sleep apnoea. Do they need their tongue tie released?

Is it simple snoring, or true apnoeas? Is it allergic rhinitis causing mouth breathing or central sleep apnoea? Is it the tone of the tongue, the size of the tonsils, adenoids and turbinates? Be assessed completely by a specialist. Tongue tie may be an association and a confounder, not a cause of sleep apnoea. I have had kids referred to me for tongue tie release when their main issue is laryngomalacia or floppy larynx.

 

So my child has a lisp. Do they need their tongue tie released?

Is it a lisp, a stutter, an articulation error, a VPI speech or a hearing-impaired speech? Have your child assessed by a speech pathologist, audiologist, paediatrician, paediatric ENT surgeon or a specialist in the area. Sometimes, speech therapy is all you need.

 

So my child needs a tongue tie and upper lip tie release. What is your technique?

There is no particular technique that has been proven to be superior to others. At the end of the day, the tie has to be completely released to it’s deep attachments. These deep attachments may be between the fibres of genioglossus or intrinsic muscles of the tongue adjacent to the neurovascular bundle. There have been reported cases of significant complications when the muscle belly or vascular bundle has been cut inadvertently.

 

My personal technique: under General Anaesthesia and with the use of magnifying loupes I use scissors and fine bipolar diathermy at low wattage to ensure accuracy and prevent collateral thermal injury to the submandibular duct, sublingual glands and neurovascular bundle. By vision and palpation I divide the tongue tie fibres down to the muscle. I palpate for a complete give or release. I then close the mucosa over the area with dissolving sutures. Local anaesthetic is then infiltrated. Oral intake and tongue exercises are commenced immediately. They will be a little sore for 2-3 days but they can eat and drink normally, return to daily activities and commence tongue exercises immediately.

 

I am concerned about my child, what do I do next?

Many specialists do care. I have listed many options: Family Practitioners (GP), maternal child health nurse, lactation consultant, oromyofunctional therapist, speech therapist, paediatrician, dentist, ENT Surgeons, etc. There is good evidence that in the right patient for the right reason, tongue and upper lip tie release is effective in treating breastfeeding difficulty, speech and swallowing difficulties, and even sleep disordered breathing. We have to be careful though as this does not necessarily apply to every patient. As parents you have the best interest of your child at heart. Sometimes you need to see 2 or 3 specialists before arriving at the right advice that you are comfortable with. At the end of the day, you need to decide what is best for your child.

 

Concluding remarks

I hope I have given you some things to consider. This is not a perfect article. I do not have the perfect opinion. Many will disagree and that is fine. Ultimately my job as a paediatric ENT surgeon is to provide safe care, information and education. We need to do a lot more research in this arena. In the mean time I have a duty of care to provide the safest care to the child and parent in front of me based on my training and expertise in Paediatric Airway, Sleep and Head & Neck Surgery.

 

References

  1. https://onlinelibrary.wiley.com/doi/full/10.1002/ca.23343
  2. https://onlinelibrary.wiley.com/doi/10.1002/ca.23410

Wellbeing Chair

You’re welcome to use this concept freely as a primer for discussion around the issue of wellbeing in your community.

Social Media in Surgery

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Some thoughts for Social Media Panel at the American Academy of Otolaryngology Head & Neck Surgery Meeting 2019, New Orleans.

Social Media is here to stay. The lines between traditional media, digital media and social media are blurred. Contents of traditional media are presented on social media platforms. Social media has become an acceptable entry point to digital and traditional media. The difference between social media and other forms of media is the social element. It is a two-way engagement with the information presented. The reader can engage directly with the content creator. In the past, a journal is published and passively read subsequently with significant time gaps in between. Today, an article can be presented at a meeting, brought up on social media and then discussed by various different experts from different countries each engaging in real time with the topic at hand.

How do you use social media in your practice?

In my mind I see 3 levels of social media use:

  1. Entertainment. This is where most people are and where the misconception is. Many people think that social media is a Weapon of Mass Distraction. And it’s true to a certain extent. This is where we watch cat videos, watch others getting pranked, and enjoy pictures of other people’s lunches. It’s a 2-way street. I get entertained, and I try to provide entertainment too, by adding terrible dad jokes and interesting pictures of my travels.
  2. Education. This is when we start to leverage the use of social media as an information highway. I read news, journal articles, opinions and thoughts. I curate who I listen to. Less of Justin Bieber or Kim Kardashian, more of ENT Journals and ENT News. I get educated, but I also educate by adding contents of value.
  1. Engagement. This is the part where you use Social Media as a platform for engagement, change and advocacy. Tweets can alter the reputation of others. Social Media articles can influence thoughts. The #MeToo movement was born from social media impetus. Several organisations, book publishers, medical conference panels have been brought down by tweets and status updates. You get engaged by topics you are passionate about, and you engage others in that area too.

My day to day use of social media is for those benefits. Notice that marketing or advertising is not part of my daily use. As an individual or corporate entity, you can use social media for those marketing purposes. The metrics and tools are different and there’s a whole professional industry group now established for that purpose. There would be many social media professionals available to help you with that.

How do you separate personal and professional social media?

Separating personal and professional social media is an individual preference. You can share as much private aspect of your life as you like. Totally up to you, but bearing in mind the issues with personal information and safety. I know that friends, colleagues, patients and strangers see my social media updates. I need to be careful not to overshare personal things. I have my private Facebook and official Facebook page separate.

How do I get started in professional social media?

Just do it. It’s going to get bigger and become more mainstream. Get your real estate address and slowly build up your property and presence over time. Grab hold of the 5 most common platforms: Twitter, Facebook, Instagram, LinkedIn & a website. Grab an easy handle on all, and create a similar content on all of them. I started off being an anonymous user during my residency training. I set up a WordPress blog and a Twitter account. I blogged my experiences as a surgical trainee. I linked the contents to twitter and engage twitter friendships. I learned quietly as an anonymous how to do it well. What to do and what not to do. Overtime it got big. So when I became an attending, I closed my anonymous account and set up my professional accounts. I use a similar content across all platforms and linked it to each other so it becomes a connected presence.

Some studies show that the vast majority of our patients have smart phones. They would have done their research prior to seeing you in your clinic. Many patients have researched their condition, their physician and they may even have found other patients with the same conditions. Our patients are coming to us engaged with both good and bad information. To me, having a social media presence allows my patients to get a feel for my expertise prior to them even seeing me face to face. I think it helps build rapport.

Common pitfalls?
A common pitfall would be wanting to go big too quickly. Social Media is social. It takes time to build relationships and presence. Another common pitfall is poor tone. Communication on social media is not the same as communication face to face. Lots of nuanced information is lost in social media. Misinterpretation, misunderstandings occur. Sarcasm and jokes don’t work too well. Be wary of engaging in heated discussions over social media. That’s another pitfall, engaging in long discussions over complex controversial topics. There are some topics that just don’t go well in social media. I have personally drawn some lines over religion and politics. Other things like gender equality and immigration are controversial yet I feel strongly about it so I engage in it. Just be aware and be careful of the tone you use in these discussions. You do not want to ever sound patronising or holier-than-thou. Much safer to ask questions than to make statements. Also, do not engage trolls or negative comments. There will just be a lot of to and fro shouting over social media. Lots of these negative heated discussions will fizzle out and be forgotten pretty quickly.

Legally speaking, there are rules around social media use in our professional practice. You are bound by HIPAA, I am bound by the Australian regulations. There are 5 things that we cannot do in Australia on social media:

  1. No false or misleading claims.
  2. No enticing of services with gifts
  3. No testimonials
  4. No claims of unreasonable expectation.
  5. No encouragement of unnecessary servicing.

I can talk about conditions, but I can’t talk about patients. I can talk about what I do, but I can’t say that I’m the best. I cannot entice them to come to my practice with gifts. No matter how good my patients think I am, I can’t put their reviews on my website. I can’t say “2 for 1 get two tonsils out for the price of one”. If your goal is to entertain, educate and engage positively, there are no rules around that. If your goal is advertising, then there are rules around that. I am also very careful about engaging patients on social media. The moment you identify as a doctor, you are immediately held to a higher standard. In fact, if a patient wrote on your Facebook page and you replied, you’ve already broken confidentiality rules as you’ve suddenly identified him or her as a patient of your practice. Be careful.

Pearls from your experience?

Be authentic and be respectful. If you’re likeable in real life, you’re probably likeable on social media.

You already have the content. You are the content expert. There’s no repetition of work, you put on social media the stuff you say regularly on a day to day basis. Re-write your abstract in lay terms and you’ve got a blogpost. Summarise your grand round presentation into a tweet or blogpost. Write down the controversies around your subspecialty are and you’ve got a discussion started.

Start small, and do it slowly over time. Watch, listen, ask questions, be funny, be human. The techniques of using twitter, facebook, Instagram are all slightly different.

Do I need to use social media?

It depends on what you’re using it for. It depends on your practice patterns. The short answer is no you do not need to use social media, but personally, social media has accelerated my career and opened up numerous opportunities that I did not plan for. There are bonuses of having social media. I am not using it for advertising, but I can report that I have had many patients referred to me through social media. I have had speaking invitations, collaborative projects, and international friendships made rapidly though social media. Social media breaks down the walls and silos that restrict communication channels.

Can you please explain what it means to be an influencer?

It’s not about the number of followers you have. It’s the value-added impact you have on others. Hard to measure. Perhaps you should ask an influencer.

Pick 3 topics close to your heart and tweet/write about it. Engage in that discussion. My 3 advocacy areas are social media in health behaviours, clinician wellbeing and leadership/cultural change. I try to engage in these topics in the hope of influencing the trend and discussion around these issues.

Saliva Surgery & Sialendoscopy

Saliva is good for your health. Saliva provides immune protection, chemical digestion and protects the teeth from dental caries. Too little saliva is debilitating. The mouth is too dry, tongue sticks on the roof of the mouth, taste is altered, speech and swallowing is difficult. Too little saliva carries a risk of dental and oral infections. On the other hand, too much saliva is also bad. Excessive drooling is incapacitating. It causes skin infection around the lips, social embarrassment and worst of all, risk of saliva aspiration into the lungs resulting in chest infections.

Saliva is produced by thousands of minor salivary glands lining your oral mucosa and the 3 pairs of major salivary glands (Parotid glands on the sides of your face, Submandibular glands under the angles of your jaw, and Sublingual glands just under the tongue).

Too dry.

Xerostomia or dry mouth, occurs when too little saliva is produced. There are many causes: nasal obstruction, infections, radiation therapy, medication side effects, physiologic aging process and systemic autoimmune conditions (such as Sjogrens Disease). An ENT surgeon will investigate the possible causes of xerostomia, including tests for autoimmune conditions. In some occasions, a biopsy of the lip to study the minor salivary glands may be warranted. Treatment of xerostomia depends on the specific cause identified.

Sialendoscopy and Saliva Stones

Saliva outflow from one of the major salivary glands can be impaired due to stenosis (narrowing), stricture (scar) or stones. One of the known causes of stenosis is radioactive iodine treatment for thyroid cancer. Any narrowing or obstruction should be thoroughly investigated. This can be done either through ultrasound, sialogram (xray picture with contrast injected into the saliva ducts) or sialendoscopy (camera scope into the saliva ducts).

Sialendoscopy is the minimally invasive method of inserting a 0.9mm or 1.3mm camera into the saliva duct to visually identify the narrowing or stone obstruction. There are only a handful of ENT surgeons in Melbourne performing this procedure. During the sialendoscopy, treatment can also be performed at the same time: lavage of the saliva duct system, dilatation, or stone extraction.

Too wet.

We produce 1.5 litres of saliva every day. Drooling (sialorrhoea) is a social embarrassment and a health hazard. This often occurs in patients with complex neurological conditions and cerebral palsy. There are medications one can take to reduce or thicken this saliva production. However, there are significant potential side effects of these medications. Botox injection to the saliva gland is beneficial but has limited efficacy as the botox effect wears out. For definitive treatment of excess saliva drooling, several surgical options can be offered. Saliva, swallow, speech, airway, breathing and sleep are all related functions. An ENT surgeon will assess and evaluate the condition and recommend the most appropriate treatment considering all other airway functions. This treatment may include: adeno-tonsillectomy, saliva duct clipping, saliva duct re-routing, submandibular gland excision, parotidectomy, tongue coblation, etc. Dr Levi works as part of the Royal Children’s Hospital Multidisciplinary Drooling Team to ensure that the most appropriate treatment recommendation is provided for each patient.

Get in touch with Dr Levi to discuss management of saliva conditions. Dr Levi is also available to provide educational talks on this topic.

Teaching is a privilege

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Teaching a privilege and an honour I hold deeply. I honestly believe we don’t do it well enough in Medicine. The didactic chalkboards and whiteboards have been replaced by the projector and millions of PowerPoint slides with the primary effect of numbing the brain. We may have killed dynamic thinking with the PowerPoint. It’s all cut and paste and data dump nowadays. There is enough information out there to suggest that teaching with PowerPoint is not necessarily teaching. Traditional podium teaching with focus on slides and data correlate poorly with retention and behaviour change. On top of that, we have the challenge of today’s contemporary methods of teaching including videos, audios, social media, Apps and other active mediums.

I have always been fascinated by the Art of Teaching and Speaking. Despite the amazing array of current technology that we have access to, there is something about Public Speaking and the use of the Spoken Words to deliver powerful engaging messages to large groups of people. Over thousands of years, nations and communities have risen and fallen over the power of Speech. Today, the Public Speech still moves and it is still the primary currency that is transmitted over videos, podcasts, social media and the like. Every single day on planet Earth, there is a conference, a meeting, a classroom, a hall where one person stands and speaks publicly to a group. The power of the Teaching and Speaking Platform.

I have been moved many times by powerful speeches. I am here today as a specialist surgeon because of thousands of hours of didactic teaching that form a significant part of my training. I can recall certain outstanding teachers who have taught me immensely and changed my practice. I still love attending lectures, because I sit at the feet of a Master and I get to do mental analysis and synthesis while they speak thoughts into my mind. Something about the human speech that trigger my mind to see and think things differently. I’m sure you can think of engaging speakers who have changed your life and your medical practice. This year I have got 18 speaking engagements locked in to various different groups and a few more in the pipeline. Every single time I get up there to speak, I know that it is sacred time. The fact that I am given time and attention is an exceedingly priceless honour and privilege. I want to do well and I want to know how to do it just a little better each time.

So what’s the secret to a successful teaching time? What is the secret to being a great teacher?

I wish I can simplify it and distill it to a few simple steps. You know better than I do that there are hundreds of books out there and resources that are available. A great example is a website by a friend of mine Dr Ross Fisher who have popularised his P3 (P-cubed) format. Check him out. He is legit. I have learned a lot from him.

May I add my own personal take on this? None of you need to adopt this formula. This is my own recipe. This is how I think about my presentations when I prepare them.

Teaching = Information + Inspiration

Information alone is impotent. Inspiration alone is infantile impetus without direction. Both information and inspiration are required to effect lasting beneficial change. Many of our medical talks are full of information, but we need to add inspirational ingredients in each of our recipes for our talks. Reducing information to essentials and adding inspiration may make your talk more powerful, memorable and effective. What’s a good example of inspiration: stories. Someone said that stories are data with a soul. Stories, ideas, imaginations are languages of thoughts that turn a data into a stimulus for change. I have seen this happen in many lectures and conferences. The moment a story is told, data comes alive and become memorable.

ABC of planning for a talk

When I plan for my talk, I think of

A: Audience

Who am I speaking to? A talk to medical students will look different to a talk on the same topic presented to ENT Surgeons sitting their Final Specialist exam. There is something in the audience that you need to connect to so your talk can be accurately pitched and be easily engaged. A talk to 5 people will look different to a talk to 5000 people. The needs of the group is different and you have to tailor your talk to each audience.

B: Behaviour

At the end of a compelling talk, there should be a behaviour change. Your listeners will need to be able to engage in a tangible change of behaviour. What is this change? Managing stridor. Treating asthma. Connecting with people. Leading a debrief. Recognising burnout. Mentoring others. Correcting hyperkalaemia. Starting ECMO. You know what I mean. What are the key messages? Limit these key behaviour change messages to 3 or less. Something about the human brain that can only retain a small number of information.

C: Connection

Return them home. Connect the dots of your talk to their native environment. You don’t want them to be you. You want them to act and be a better version of themselves wherever they are. Connect your message to the reality of their environment. Help them digest your talk so it becomes applicable to their workplaces and homes.

Those are my personal thoughts in preparing my talk. This is still all on a cognitive level. Next up are the 3 tools for the talk itself. The mechanics of my talk. What I call the Triple M: Message, Medium and Messenger. Yes I go to Ross Fisher’s P-Cubed for gospel truth and I refer you to his brilliant mind for the origins of these thoughts. He presents it beautifully. I go to him for practical tips on delivery. My simple mind retained it in my unique way, this way. He takes the limelight. I am leveraging his concept. I am only noting down personal ideas and thoughts to enhance my own future talks. (I don’t even know when I will get to pen them down, so we shall see when the next blogpost will be up.)

Surgeons vs Anaesthetists Debate

RCH Surgeons vs Anaesthetists Debate:

Actions speak louder than words.

OPPOSITION TEAM.

Good evening Ladies and Gentlemen. A very good evening to our esteemed judges.  It is an absolute honour to be here with you representing the surgical community. It is my promise that we 3 surgeons will continue to be here to support you the anaesthetists when you lose tonight. I am glad that we are debating here tonight outside the realms of the operating theatre because the only place we can beat an anaesthetist is outside the theatre. We all know that anaesthetists are powerless outside theatre. They can’t cancel cases or delay cases, or get help from all the other anaesthetists sitting quietly doing Crosswords in the tea room. An anaesthetist outside theatre is like a fish out of water, like a sleeping koala out of the gum tree, like a meerkat in an aquarium. They’re lost. They wear their helmets and tight lycra pants walking around click clacking in their cycling shoes, powerless.

Honourable judges and friends let me frame the debate properly. With their words, they want to convince you that Action speaks louder than words. That is so so so mistaken. What did you come here to do? You came here to hear us speak. You came here to hear clever words. We are using words to debate this motion. They’re using words to justify their actions. It’s like a surgeon using Propofol to make a point about surgery. It doesn’t make sense. If actions did speak louder than words, then we should be jousting or doing a charade competition. In fact, this debate is really not about whether Actions speak louder than words or vice versa. This debate is about who has the louder and better words.

Actions are speechless. You see, we are not saying that actions are unimportant. Actions are important. But actions do not speak louder than words. Words are louder. Actions, unless you hit something against another, are soundless. All human actions are quiet, except for 2 things. 1. Speaking – that is, the delivery of words into the space of humanity, proving to you that words are louder. And 2. Farting. Yes. This is a children’s hospital. We all know that farting can be louder than words. I guess the anaesthetists over there know all about farting, because they are experts at professionally passing gas every day.

Without words, appearance and actions can be misinterpreted. Without introducing myself using words, I could be mistaken for an anaesthetist. What do you call an anaesthetist in a suit? “The Defendant, your honour.” Their appearance, if not explained properly, can be misleading.

I am going to give you 3 evidence that words speak louder than actions. Evidence from history, evidence from biology and evidence from sociology. But before that, a story.

Recently the College of Anaesthesia held their Annual Scientific Meeting in Malaysia. On the flight back in one of the planes, there was reported a medical emergency. The pilot made an overhead announcement. “Ladies and Gentlemen, this is your captain speaking. We are cruising at 10,000 feet and will be landing in Melbourne on time. We do have a special request. There is a passenger with an urgent medical need in first class. If there are any anaesthetists on board, could you please make yourself known to one of our air stewards please.” So an anaesthetist from all the way back in economy ran up to first class and asked the air steward, “I’m an anaesthetist, what’s the medical emergency?”. The air steward said “Thank you for coming so quickly. There is an orthopaedic surgeon up there who needs her table height and light adjusted.”

That story has nothing at all to do with my argument. But it’s a good story and it shows you how words can transport your mind to a different place.

Words speak louder than actions: Evidence from History

All throughout history, the pen has always been mightier than the sword. Words are the crucible of actions. Words precede and supersede actions. Words are primary, and actions are secondary.

“I have a dream, that one day, this nation will rise up and live out the true meaning of its creed. I have a dream that one day on the red hills of Georgia the sons of former slaves and the sons of former slave owners will be able to sit down together at the table of brotherhood. I have a dream.”

Or what about this:

“Tell me somethin’, girl
Are you happy in this modern world?
Or do you need more?
Is there somethin’ else you’re searchin’ for?

In the shallow. In the shallow. In the sha-ha-ha-ha-hallow…”

Martin Luther King Jr, Lady Gaga, Nelson Mandela, Barack Obama, Bradley Cooper, the late Bob Hawke, Jacinda Ardern, Justin Trudeau and many other leaders have mobilised nations and communities around the power of words. Words ignite action. Words are timeless. Words are boundless. Words are powerful. Words speak louder than any action. The careful use of words could unite nations and tear down histories. Bad words result in war. Good words result in peace. Loose lips sink ships. History is written in words and is handed down generations to generations.

Let’s take you all the way back even more. What separated us advanced human beings from our action-based primitive ancestors is language. Words are a marker of sophistication and progress.

Words change history and history is recorded in words. That’s a compelling evidence from History that Words speak louder.

Evidence from Biology

I am an Ear Nose & Throat Surgeon. I am an expert at the important words in this debate. The element of speak and the matter of loudness. No one else on that panel is an expert at speech. They spend their days putting plastic tubes through the beautiful organ of speech. They get a 50/50 chance of getting it right down the right hole each time. Do not listen to the arguments of a non-expert. I am the very embodiment of a Level 4 Expert Opinion, on what speaks and does not speak.

As an ENT surgeon, I also know all there is to know about loudness. Again, listen to the only expert on this panel. Here’s an audiometric table of loudness that I took from our ENT Textbook. It shows that Anaesthetists are soft like a dripping tap 0-10decibels, while the surgeons are louder and more musical. The graph even calls us profound. That’s just who we are. We speak louder. Words speak louder.

IMG_0464

I love hearing. I love speech. And I love words. I wanna show you the most beautiful word in the whole universe. It is this word Otorhinolaryngology. It speaks louder than actions. Oto-Rhino-Laryngo-Logy. The word is made up of the word Oto, meaning ear in Latin. Rhino, meaning nose in Swahilli. And Larynx, meaning throat in Wakanda Forever. And The Logies. Compare that to the other word Anaesthetist. Anaes-The-Tist. I don’t know, I think Anaes may be Australian for Anus. I’m not sure.

What about Evidence from Sociology?

I did an extensive in depth research on the Sociology. I went to Social Media and Tweeted out this question. I got 48 great replies. Mostly from anaesthetists who are probably working while on twitter.

Here’s a few examples.

243

And here’s the scientific paper that supports my stand. Words Speak Louder. Published in Journal of Personality and Social Psychology 2015. I haven’t read the paper so I don’t know what it’s all about but the title supports my argument, so you just have to believe the evidence.5

So we use words in our day to day work. I can’t do what I do without the consent form. We can’t do timeout without communication in words, not in actions. Words are moving. Words carry power. Words carry hope. It happens for example, every afternoon at 4.45pm. When the wolf pack arrives at your operating theatre armed with their clipboards and blue phones, they ask “When will you finish?” I always, always give them hope. I always pull out a random number and say “I’ll be done in 5 minutes.” Just to give them hope. Words carry hope.

Let me finish, your excellency, with a simple experiment. I want to demonstrate to you that Words speak louder. Let me ask all of you in this auditorium to turn to the person next to you and just look at them. Don’t say anything. Just use your action. Awkward isn’t it? Now let me ask you to do that again, and this time tell them, “Oh crikey, you are the most beautiful thing on this planet.” Actions without words, are meaningless. Words speak louder than actions and move you deeply.

I think I have demonstrated to you, your honour, that words speak louder. Thank you.

Clinician Wellbeing Intervention Strategies

We have a complex problem. There really is not a single simple solution to the issue of clinician burnout and the poor wellbeing of today’s doctors. We need to accept this. The proponents of yoga and meditation need to know that no amount of mindfulness can fix an abusive hierarchy. Those who think good legislations can stop problems from happening must know of recent examples where unit leadership have failed to enact those regulations and allowed junior doctors to suffer from poor working conditions. The Royal Colleges feel that this is not within their jurisdiction, although in practice, Members and Fellows of the College are the standard bearers on the ground. Mental health of doctors is one of many specific challenges that need to be addressed specifically. Culture cannot be changed by legislations alone. Individual counselling relieves downstream effects but has little effect on upstream problems. Human resources and institutions are caught in a tangled web of limited resources and increasing demands placed upon doctors. Let’s agree that no single simplistic solution can fix this complex problem that has been years in the making. No one intervention is better than another. We need complementary approaches to the many elephants in the room.

There is hope. More and more we are realising that a multifactorial multipronged approach is needed. There are champions of change all over our institutions. The time is right and we are almost at that tipping point for change. We’ve heard of enough suicides and we have hurt alongside their families and communities. We have seen the data on doctor depression and burnout. We are agitated for change. The next few years will see an optimistic cultural change. There will be pockets of delay for sure. There will be small battles occurring everywhere. Change is not easy for many and a change of habit is hard for all.

Conceptually speaking, this is how I think about the levels of intervention that we can apply to our problems. All of us doctors are down at the pointy end of that pyramid: frontline, engaged with the patient and community. But some of us doctors and non-doctors are also at other levels of governance and can exert powerful influences. There are many interventions that can be applied directly and indirectly affecting the doctor at the front line. It would be so exciting to see these interventions applied at all levels.

1. Individual

Personal health and wellbeing. Family. Exercise regime. Meditation. Mindfulness. Pilates. Yoga. Spiritual health. GP. Counsellor. Psychiatrist. Holiday. Social activities. Hobbies. Debriefing. Personal coaching. Mentoring. Personal philosophy. Altruism. Humanitarian activities. Time management. Goal setting. Personal development courses. Nutrition & Hydration. Sleep Hygiene. Journal writing, practicing gratitude.

2. Departmental

Social networking. Leadership development. Mentor training & support. Admin support. Departmental activities. Crisis Leadership training. Media and Communication training. Leadership coaching and relief. Rostering support. The Department Head is a critical player in the wellbeing of doctors in the department. Studies show improvement in leadership has positive effect on staff wellbeing. Staff wellbeing should be a priority for the Head. Staff wellbeing should be a measure of efficiency of Unit Leadership Role. Leaders should be given training in this arena. Every doctor is accountable to a Unit Leader. Every Unit Leader has immediate influence on frontline doctors.

3. Institutional

HR roster support. Resources for relief and cover. Training and support. Staff development. People and Culture Development. Wellbeing Leads and Wellbeing officers. Wellbeing campaigns and programs. Wellbeing Lectures and Grand Rounds. Schwartz Rounds. Formal Staff Health and Wellbeing clinics. Debriefing and crisis timeout programs. Institutional Cultural Change. Investment on Unit Leaders. Organisational Science. Organisational Psychology. Systems thinking. EMR, Computers, Productivity systems. Remove technologies or systems that may reduce clinical efficiency. Empower doctors to rearrange workflow to enable interface with new technologies. Doctors lounges. Quiet Rooms. Align organisational values.

4. Regional and National

AMA, Specialist Colleges, Health Departments, Medical Schools, Medical Defence Organisations, Kindness and Change Campaigns. Doctors Health Clinics. Regulations, Legislations, Laws, Policies, Accountabilities. Big picture cultural standards and code of conduct. What is decided at this level affects and protects the individual doctors even if the authority has no direct jurisdiction. For example, The College of Surgeons may not have direct jurisdiction over the roster of a resident doctor, but The College may exert influence over their Fellows working within that institution. An MDO may not have direct jurisdiction over the working conditions of doctors, but they may exert influence from a legal risk point of view to effect change when a matter is notified to them. Consider effects of Mandatory Reporting on Clinician Wellbeing. Cultural Change from the highest levels of leadership.

This is a big picture conceptual thinking. We need to address this problem with a multipronged approach. We need champions of change at every level. Sometimes we may be coordinated, other times it takes too long to wait for coordination. We may have the resources, or more likely, it may take too long to wait for resources. Many of these interventions do not need to be expensive, exhaustive or intensive. The time is right. There are significant actions that can be taken locally.  It may begin with just a simple conversation over coffee amongst champions of change in your unit. Throw around some simple ideas relevant to your unit.

We need compassion, courage and collaboration for change.

The above is not a definitive list. What other interventions would you add to the list? What has worked in your institutions or country?

Reading Materials for Discussion:

  1. Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 2017;92(1):129-146.
  2. Callahan K, Christman G, Maltby L. Battling Burnout: Strategies for Promoting Physician Wellness. Adv Pediatrics. 65 (2018) 1–17.
  3. Beyond Blue. National mental health survey of doctors and medical students. Melbourne: Beyond Blue, October 2013.
  4. The Dark Side of Doctoring.
  5. Context of Clinician Wellbeing.
  6. Elephants in the Room.
  7. Put on your mask first.
  8. https://das.bluestaronline.com.au/api/prism/document?token=BL/0823
  9. http://www.massmed.org/News-and-Publications/MMS-News-Releases/Physician-Burnout-Report-2018/
  10. https://www.ruok.org.au/
  11. https://mhfa.com.au/

Rethinking Doctors Wellbeing Interventions

We have a complex problem. There really is not a single simple solution to the issue of clinician burnout and the poor wellbeing of today’s doctors. We need to accept this. The proponents of yoga and meditation need to know that no amount of mindfulness can fix an abusive hierarchy. Those who think good legislations can stop problems from happening must know of recent examples where unit leadership have failed to enact those regulations and allowed junior doctors to suffer from poor working conditions. The Royal Colleges feel that this is not within their jurisdiction, although in practice, Members and Fellows of the College are the standard bearers on the ground. Mental health of doctors is one of many specific challenges that need to be addressed specifically. Culture cannot be changed by legislations alone. Individual counselling relieves downstream effects but has little effect on upstream problems. Human resources and institutions are caught in a tangled web of limited resources and increasing demands placed upon doctors. Let’s agree that no single simplistic solution can fix this complex problem that has been years in the making. No one intervention is better than another. We need complementary approaches to the many elephants in the room.

There is hope. More and more we are realising that a multifactorial multipronged approach is needed. There are champions of change all over our institutions. The time is right and we are almost at that tipping point for change. We’ve heard of enough suicides and we have hurt alongside their families and communities. We have seen the data on doctor depression and burnout. We are agitated for change. The next few years will see an optimistic cultural change. There will be pockets of delay for sure. There will be small battles occurring everywhere. Change is not easy for many and a change of habit is hard for all.

Conceptually speaking, this is how I think about the levels of intervention that we can apply to our problems. All of us doctors are down at the pointy end of that pyramid: frontline, engaged with the patient and community. But some of us doctors and non-doctors are also at other levels of governance and can exert powerful influences. There are many interventions that can be applied directly and indirectly affecting the doctor at the front line. It would be so exciting to see these interventions applied at all levels.

1. Individual

Personal health and wellbeing. Family. Exercise regime. Meditation. Mindfulness. Pilates. Yoga. Spiritual health. GP. Counsellor. Psychiatrist. Holiday. Social activities. Hobbies. Debriefing. Personal coaching. Mentoring. Personal philosophy. Altruism. Humanitarian activities. Time management. Goal setting. Personal development courses. Nutrition & Hydration. Sleep Hygiene. Journal writing, practicing gratitude.

2. Departmental

Social networking. Leadership development. Mentor training & support. Admin support. Departmental activities. Crisis Leadership training. Media and Communication training. Leadership coaching and relief. Rostering support. The Department Head is a critical player in the wellbeing of doctors in the department. Studies show improvement in leadership has positive effect on staff wellbeing. Staff wellbeing should be a priority for the Head. Staff wellbeing should be a measure of efficiency of Unit Leadership Role. Leaders should be given training in this arena. Every doctor is accountable to a Unit Leader. Every Unit Leader has immediate influence on frontline doctors.

3. Institutional

HR roster support. Resources for relief and cover. Training and support. Staff development. People and Culture Development. Wellbeing Leads and Wellbeing officers. Wellbeing campaigns and programs. Wellbeing Lectures and Grand Rounds. Schwartz Rounds. Formal Staff Health and Wellbeing clinics. Debriefing and crisis timeout programs. Institutional Cultural Change. Investment on Unit Leaders. Organisational Science. Organisational Psychology. Systems thinking. EMR, Computers, Productivity systems. Remove technologies or systems that may reduce clinical efficiency. Empower doctors to rearrange workflow to enable interface with new technologies. Doctors lounges. Quiet Rooms. Align organisational values.

4. Regional and National

AMA, Specialist Colleges, Health Departments, Medical Schools, Medical Defence Organisations, Kindness and Change Campaigns. Doctors Health Clinics. Regulations, Legislations, Laws, Policies, Accountabilities. Big picture cultural standards and code of conduct. What is decided at this level affects and protects the individual doctors even if the authority has no direct jurisdiction. For example, The College of Surgeons may not have direct jurisdiction over the roster of a resident doctor, but The College may exert influence over their Fellows working within that institution. An MDO may not have direct jurisdiction over the working conditions of doctors, but they may exert influence from a legal risk point of view to effect change when a matter is notified to them. Consider effects of Mandatory Reporting on Clinician Wellbeing. Cultural Change from the highest levels of leadership.

This is a big picture conceptual thinking. We need to address this problem with a multipronged approach. We need champions of change at every level. Sometimes we may be coordinated, other times it takes too long to wait for coordination. We may have the resources, or more likely, it may take too long to wait for resources. Many of these interventions do not need to be expensive, exhaustive or intensive. The time is right. There are significant actions that can be taken locally.  It may begin with just a simple conversation over coffee amongst champions of change in your unit. Throw around some simple ideas relevant to your unit.

We need compassion, courage and collaboration for change.

The above is not a definitive list. What other interventions would you add to the list? What has worked in your institutions or country?

Reading Materials for Discussion:

  1. Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 2017;92(1):129-146.
  2. Callahan K, Christman G, Maltby L. Battling Burnout: Strategies for Promoting Physician Wellness. Adv Pediatrics. 65 (2018) 1–17.
  3. Beyond Blue. National mental health survey of doctors and medical students. Melbourne: Beyond Blue, October 2013.
  4. The Dark Side of Doctoring.
  5. Context of Clinician Wellbeing.
  6. Elephants in the Room.
  7. Put on your mask first.
  8. https://das.bluestaronline.com.au/api/prism/document?token=BL/0823
  9. http://www.massmed.org/News-and-Publications/MMS-News-Releases/Physician-Burnout-Report-2018/
  10. https://www.ruok.org.au/
  11. https://mhfa.com.au/