Category: Uncategorised

Seasons come and go. Life is a journey with many detours. The big story of my life has many chapters in it yet to be written. Just when I thought I had climbed one summit and sat down to rest, a voice inside tells me, “Stand up, pick up your mat and go. I have something else for you.”

With great excitement and trepidation, I am making a big jump to be a business owner by setting up my own private practice. This is an easy move for many, but a massive move for me. You see, I am a clinician at heart. I am not a business person. I don’t have an entrepreneurial bone in me. I’d rather be caring for patients, than dealing with ABN, ACN, TFN, accounting, legals, etc. This move is the scariest move ever (besides moving my whole family 3 times in 3 years to 3 different countries!)

So why am I leaving the comfort and safety of a group surgical practice? Why take such a massive risk to go solo? I spend so much of my time in academic, elective and emergency public work at RCH & St.Vincent’s. I have very little time in the private. I only consult 1-2 days a week in private. The majority of my mind and time is spent in teaching, training and public service. It makes no financial sense to go alone.

Ever since I came back from my subspecialty fellowship training I have been an associate in a group practice. The surgeons at ENTV have been the best mentors and colleagues I could ever have. Dr Bernie Lyons, Dr Ben Cook, Dr Patrick Guiney, Dr Sor Way Chan, & Dr Lisa Wun have been my role models and my sponsors. I would not be where I am today if it wasn’t because of them. They have been the most gracious of colleagues and supporters. They have given me the best start as a surgeon. They taught me during training. They nurtured me during early years of surgical career, and they are still teaching me to be a better surgeon. I continue to work with them at St.Vincent’s. They have my deepest respect and gratitude. I would trust them to care for any of my family members.

So it is after months of decision agony that I have decided to leave the comfort and safety of this group practice that has been a circle of protection and safety. I needed to jump out of the boat to learn to walk on water.

Instead of going big, I am going small and personal. My mantra that most people seems to know by now is “Go low and go slow”. That’s exactly what I’m doing. I’m “shrinking” my practice and I’m taking a slower pace. My new practice is 8 minutes from home. It’s hidden in a little inner north-east suburb of Bulleen. It’s not in a flashy medical tower. It’s hidden in a residential area behind a lush garden. When I walk into my office now, I get to look outside at a green garden. I feel I’m home. And that’s the feeling I hope many of my patients will experience too. I sincerely hope they will experience a sense of healing and hope as guests. Because this clinic was built for them.

And for the many others who will come with me on the journey. If council approves, I am building a glass box just outside of the clinic. This future glass room set under the trees may well be a place of conversations. That’s still a dream waiting to be realised.

I hope it will truly be a place of Welcome.

Well. Come.

Wominjeka.

Nose bleeds (epistaxis) is extremely common. Not every patient requires cauterisation. About 97% of all nose bleeds occur at the front of the nose on the septum (midline) as there are major vessels that arise from the floor of the nose to supply the septum. The nose at that part is extremely dry due to the constant airflow (breathe from your mouth and see how quickly your mouth dries up). This means that any abrasion due to nose-digging or any trauma to the thin lining of the septum can cause a dry rupture of the blood vessels. Of course, some patients are at much higher risk due to previous surgery, trauma, bleeding disorder or blood thinning medications (fish oil, aspirin, warfarin, clexane, rivaroxaban, dabegatran, etc.) So the key is to apply pressure to the specific spot and keep the nose as wet as possible. If this bleed happens on your knees or elbows, you can all easily put your finger on it. The only issue with the nose is just its location.

Here are a few tips: 
Do not look up to pinch the bone bridge. This does nothing to the bleeding spot and could cause aspiration of blood into the throat/airway.

Tilt head down, check which side is bleeding and put a gentle pressure on the nasal alar on to the septum (the soft outside pressed in).

Wait for 10minutes and most bleeds will stop.

Do not put any tissues up the nose as all it does is dry the blood and rips off the scab when the tissue is removed.

Blood clot or scab is the body’s natural bandaid solution.

Wet wet wet the nose for the next week or two.

Saline sprays, vaseline, sorbolene, saline gel, Nozoil, and anything else that keeps the nose wet so the scab doesn’t dry up while the septum is healing.

Some studies show that there is a higher carrier rate of bacteria in the nose of those with nosebleeds, so your GP might start you on chlorsig, bactroban or kenacomb ointment. Apply it 3 times a day to the inside of your nose for 1-2 weeks.

If you’re on blood thinners, your blood thinners will always win no matter what we do to the nose.

If the nose continues to bleed despite these basic treatments, then perhaps cauterisation is needed. Some kids won’t tolerate cautery depending on age.

Cautery is basically silver nitrate chemical burn to the area of bleeding. There is no magic. It’s just chemical burns in the hope that the big vessels are destroyed. But the body will form a new scab and new blood vessels, so cauterisation is never 100% successful.

Ultimately, keeping the nose wet wet wet is the best preventative method while the nose takes time to heal.

In extremely severe situation, we can do electrical cautery, septoplasty, closure of the nasal cavity, nasal endoscopic keyhole procedure to clip the sphenopalatine artery at the back of the nose or do a radiological interventional embolisation to the blood vessels. 

But the vast majority of patients do well with simply keeping their nose wet.

This talk was presented on the 13th of September at #CODA22.

Wominjeka. Welcome. We make hundreds of decisions every single day. What you wear, who you speak to, latte, piccolo, magic, soy, almond, oat milk, lactose free, or if you’re not from Melbourne, black or white coffee.

We also make hundreds of decisions on behalf of someone else who trust us voluntarily, or involuntarily, the patients under our care. These clinical decisions are based on clinical judgements. These clinical judgements are based on knowledge, experience, and ethics. Being human, unfortunately, our judgements which influence our decisions can be coloured by our biases and experiences. Ethics should be our guiding light, but sometimes when we’re in under pressure, the light is a little faint.

Ethics in clinical practice must be practical, otherwise it’s just rhetorical philosophy. We’re not all ethicists, but we all need to practice ethical decision making daily. Ethics has to be practical. Ethics cannot be esoteric.

Not every story ends well. Not every story begins well either. This talk is dedicated to the many mothers, parents, carers and babies who have had challenges at the beginning of their stories. Some have great outcomes, others don’t. Some survive, others don’t.

A long time ago in a galaxy far, far away lives a 45-year-old Padme. She’s a Senator. She has been trying for years to have a baby, and she’s finally successful on her last round of IVF. Yay! Her first trimester went smoothly, her only complaint was missing out on soft serve ice cream and sushi. The first sign of trouble was written on the ultrasonographer’s face during her 18-week gestation scan.

Oh, oh. Something is not right around the baby’s head & neck. I can only imagine the sonographer continuing to work scanning the foetus while maintaining professional composure. “We don’t know what we’re dealing with. We need to do more scans.” Sometimes it’s not what is said, but what is unsaid that leaves a mark. As clinicians, do we know how to care for patients with both the things we say and the things we do not say?

Off to the MRI scanner a couple of weeks later. This is a maternal foetal MRI showing the uterus with a foetus that has a neck mass the size of her head. The head is down, the foetus is hugging the mass. For me, this image triggers a whole lot of cognitive excitement. Differential diagnoses of the mass, anatomical distortions, airway challenges, procedural complexities, simulation, training, problem solving, etc. For the clinician, this is a foetus with an airway obstructing neck mass. For the mother, this is derailment of a dream.

Let’s take a pause. Time out. Ethics in medicine occur in 3 contexts: Timeline, Teams and Time pressures. When it comes to timeline, treatment options for this foetus differ between 14 weeks, 24 weeks and 34 weeks of gestation. In some countries, access to US and MRI is not a reality. Is this a benign lesion or is this a malignant lesion which may end up being incompatible with life? What is the future trajectory if this mass was already present right now in utero? Should a termination of pregnancy be offered in this situation? But none of our tests are 100% accurate, so what do we base treatment decisions on? Any interventional biopsies will risk the child’s life as it may trigger rupture of membrane and premature labour in a foetus with airway compression. The ethics, law and regulations around termination of pregnancy differ from state to state from country to country. Decisions made at this point of the timeline on the basis of limited information will affect future decisions. Does the ethics become clearer with time, or does it get even more muddy with each decision made along the timeline? Will mum hit the first month of life with this child and look back to say, “I wished we had decided differently?”

I respect many of our obstetric colleagues who routinely deal with high risk pregnancy and high risk foetal conditions. They would have these conversations often. Ethics occur on a timeline. Sometimes you delay, sometimes you decide. Decisions made today will affect decisions made tomorrow. Often it’s hard to detour or U-turn 10 weeks down the track. The burden of decisions at every point in the timeline is unique and I think we always need to extend grace towards other clinicians who have made decisions before us. You think you would have advised things differently, but you never know. You might still decide the same thing.

Grace for past decisions, evidence for current decisions, and hope for future decisions. Ethics in a timeline.

Let’s fast forward 14 weeks. We’re now 32 weeks’ gestation and the MRI shows the mass has gotten bigger. In the interim, mum has seen maternal foetal medicine specialist, geneticist, ENT surgeon and many other specialists. The more teams involved the more confused and conflicted the advice and plan is. This is the reality of complex care in many places. Fragmented and siloed.

This is where the clinical journey becomes more exciting. We have 2 patients, one completely dependent on the life of the other. We have a foetus with a mass the size of its own head obstructing the airway. How do we deliver this child? I am not an obstetrician and I do not identify as female, but I have been reliably informed that delivering one head is hard enough. I was present on the delivery of all 3 of my kids and boy it looked like hard work. And once delivered, how do we secure the airway in a neonate with an obstructing neck mass?

Yesterday at the SAS we heard the terms CICO, RSI, THRIVE-HI, EFONA, VAFI, FARSI. Well let me throw you even cooler abbreviations. This is CHAOS. And we have 2 options for CHAOS: EXIT or OOPS.

CHAOS is Congenital High Airway Obstruction. A foetus with an airway obstruction. Somehow we need to secure the airway. EXIT is Extrauterine Intrapartum Treatment. The foetus is outside the uterus, but still connected to the placenta. Uterine contraction is suppressed. We have up to 60minutes, high risk of haemorrhage to the mother. OOPS is Operation on Placental Support. Just like EXIT, but the uterine contraction is not suppressed. We have less than 20minutes.

Let’s go into a bit of details. Some of your clinical brains are ticking away already. For the C-section, we need to know the position of the head, the tumour and the placenta. If the placenta is low lying, we may have to approach the uterus from the top to get the baby out. If the mass and the head is big, we need to turn the head and body around to prep for intubation or tracheostomy. The obstetrician has got all these maternal factors to consider. The obstetric anaesthetist need to anaesthetise and suppress uterine contraction, and yet be mindful of possible significant bleed, massive transfusion, disseminated intravascular coagulopathy.

In my mind, I’m the one in charge of the Airway. But in reality, and rightly so, I am just one of the many involved in this mother & child care. Once we get the baby out, while still connected to the placental circulation, what’s our airway plan? And this is where the paediatric anaesthetist, the neonatologist and the ENT surgeon huddles around a 3kg baby over the mother’s open abdomen. Space is very limited. The foetus is not going to come out with sats of 99% breathing. The A is blocked. The B is not established. The C is connected to mum.

We met, planned, simulated, rehearsed. This is the practical ethics of having 5 microteams who don’t normally work together. We meet together and we created a bespoke plan for these 2 lives. Who leads. Who calls the shot. Where do we stand. Who makes the first moves. We decided that neonates was the overall leader. Anaesthesia will get a line in and make 2 attempts at intubation before handing over to ENT. Videolaryngoscopy, flexible laryngoscopy, rigid endoscopy and other intubation techniques were considered. Exact position of the baby and every team member was mapped. How do you get into the right intubation position on an open abdomen? One thing I noticed in the meetings is that initial awkwardness. We don’t want to push anyone else. We don’t want conflict. We don’t’ want to offend anyone. We don’t know how to disagree well with strangers. This is the teams ethics. We bring different values, different skills, different assumptions to this big team. Practical ethics and human factors at play. Sometimes the best option of therapy may be hidden with the most quiet team member. If human factors does not provide a platform for psychological team safety, we may not arrive at the most appropriate decision.

Ultimately, we can plan till the cows come home, but on the day itself, work as imagined may not be work as done. When timing and time pressures come into the picture, our decision-making process get affected. How long do we tolerate sats of 70-80%? Most babies come out with low sats and gradually increase with oxygenation and spontaneous breathing. The longer they remain hypoxic the higher the risk of ischaemic encephalopathy. But where do we draw the line? Different people in the team may have different opinions here. When do we move from plan A to B to C? When do I insert that tracheostomy. Will I be able to do a trache on the belly with the mass was in the way? What do you think is the worst case scenario here? A dead mother and a dead child. A review of 235 recorded cases of EXIT reported that there’s a 5% rate of PPH, and a 17% foetal mortality rate. Mother needs to know these statistics. Though there are no records of maternal death in the literature, it does not mean it has not happened. It’s just not written. The consensus is to prioritise the life of the mother, but that in itself is an ethical judgement that all teams and the mother has to agree to.

Practical ethics and decision making in context of Timelines, Teams and Time pressure.

I’m thankful that this does not happen too often.

In the context of Timeline, I’m learning to extend grace for past decisions, evidence for current decisions and hope for future decisions.

In context of teams, I’m learning to extend kindness and respect.

In context of time pressures, I’m learning to extend trust. I’m trusting that our prior planning and stimulation training will help us land at the right decisions despite being under cognitive and time pressure.

I am thankful that as I see these kids grow up as they become my long term patients as I look after their head and neck tumours. Whenever I see them, I see the delightful success of a 5 microteams working together. Be part of a team that changes the world. We may not have changed the world, but as a team, we did change their world.

Writing is my therapy. I am not a mental health clinician. I am just a surgeon who grapple with these issues within myself, my colleagues and the patients I see daily. Many of you are much more experienced and better trained to speak into this space. I will not do justice in this blogpost to the breadth, depth and complexity of the spectrum of human mental health conditions. We will never be able to delineate and break things into neat compartments, because we’re humans and that’s what makes us unique.

The words “mental health” have been used a lot during this pandemic. Sometimes to the point of being used as a political weapon. When I ponder and meditate on my big emotions during this pandemic, I realise that there are differences between stress, exhaustion, burnout, moral distress, compassion fatigue & mental illness. What do I mean?

Stress

Stress is a natural physiological and psychological response to a challenge. Work is stressful. COVID is stressful. School is stressful. Weightlifting is episodic stress on muscles to build muscle resilience. Life is full of stresses. There is a spectrum of normal stress. Some stress is good for you. Exam stress and work stress train your mind to excel.

Exhaustion

Exhaustion is a natural physical side effect of working hard. Training and exercise, long working hours, consecutive shifts, lack of breaks, prolonged exercise, etc all result in physical exhaustion. It’s normal to be exhausted after a marathon at work. You can be exhausted, but be absolutely satisfied as I often experience after a whole day of operating.

Burnout

Burnout is an occupational psychological state characterised by cynicism/disengagement, emotional exhaustion and lack of efficacy. This is often due to poor work environment or toxic workplace culture. You can be stressed and exhausted, but be happy at work and not burned out. Similarly, you can be burned out in a low productivity job if there was significant prolonged negative culture.

Moral distress

Moral distress (moral injury or anguish) is the state of knowing the right thing to do but the inability to do it because of restrictions. You want to help a patient, but you can’t because there’s no ICU bed is moral distress. Not burnout. Needing PPE but having none is moral distress. Knowing the horrible state of affairs in your institution but being unable to change it is moral injury. Seeing a patient needing oxygen but being unable to offer higher level of respiratory support is moral injury.

Compassion fatigue

Compassion fatigue is a condition characterized by emotional and physical exhaustion leading to a diminished ability to empathize or feel compassion for others, often described as the negative cost of caring. Sometimes referred to as secondary traumatic stress. This is many of us who have seen hundreds of COVID patients turn up in Emergency, ward or ICU. We plug them on oxygen and we move on to the next one without compassion because we know the next patient just needs the same thing again and again.

Mental illness

Mental illness is a medical/psychiatric condition with strict categorical definition based on DSM-V and ICD10. This is a diagnosis made by a mental health professional or a GP/Family Physician much like other medical conditions. I cannot define depression, anxiety, PTSD for you. It is the domain of the GP and mental health professional.

Interconnected

Of course, the above experiences are all valid and interconnected. You can be stressed without having compassion fatigue. You can be diagnosed with depression and not have burnout. You can be burned out but not have moral distress. They are different shades of the human experience. COVID is stressful for all. Health care workers are experiencing stress, exhaustion, moral distress, compassion fatigue, burnout and some even reach a diagnosis of depression.

The solutions?

Stress: manage the amount of work and consider breaks. Exhaustion: rest, sleep, nutrition, exercise. Burnout: occupational cultural change. Moral distress: ethics of resources. Compassion fatigue: rest, social support. Mental illness: mental health professional. The solutions to these challenges are unique. Antidepressant will not fix a toxic workplace. Lack of PPE will not fix compassion fatigue. Cutting workload down will not completely fix depression. Target the right solutions to the right challenge. We’re all humans. The solution to one isn’t the solution to the other. When I’m exhausted, I sleep. When stressed, take a break or call for help. Last year having proper airborne PPE gave me a massive boost against my moral distress. Having close colleagues with similar values and many others who work in the space of cultural change protected me against occupational burnout. We worked collectively to improve occupational health, and I saw purpose at work. My colleagues & team replenished me and protected me against compassion fatigue. Pandemic was stressful, exhausting and pushed us to moral distress and burnout. But these things in themselves did not meet the criteria of mental illness diagnoses.

Grief

One other big emotion that we do not often talk about during this pandemic is grief. Grief is mental or emotional suffering or distress caused by loss or regret, usually the sorrow from a death of a loved one. Millions of lives have been lost, and the grief is truly global. In addition, there is also the grief of losing your plans, hopes, dreams, jobs, routines, aspirations, and the fundamental grief and sorrow of losing normality. All of our plans have been cancelled by COVID. That’s been one of the hardest things for many of us to articulate.

Mental health

I share these non-professional thoughts as a human being on the same journey with all of you. There are many causes of our negative emotions and there are unique solutions. Being able to articulate accurately what we are feeling is the first step to finding an appropriate solution. Stress, physical exhaustion, burnout and compassion fatigue affect our mental health but they are not considered mental illness.

Chair of Wellbeing

A simplified way for me to think about my personal wellbeing is considering that my wellbeing is supported by a 4-legged chair. These 4 legs need to support my overall wellbeing. Do not disregard the importance of any of the other legs. These 4 domains and the listed suggestions are the things that have helped me stay healthy. You may have your own unique stool to stand on.

And one more thing,

This blogpost was initially a series of tweets on a Sunday morning. Following the discussions, Dr Nathalie Martinek PhD added her wisdom in this space. She suggested that there are also other things worth considering: Trauma, Moral injury, Burnout, Vicarious trauma, & PTSD. I have attached her article here which brings out some really important concepts of care. Pages 38-39.

Hope this has been a primer for your consideration. Please reach out to your local helpline if some things here have triggered you. I am not a mental health professional so this article is not definitive or exhaustive. I really sincerely just want to share the journey with you. As I have alluded to, there are many things we can do formally and informally to improve our general wellbeing. How are you feeling today? What changes would you implement this week to improve your wellbeing?

• 

Do I need an online presence?

Short answer: Yes.

Long answer: It depends on the purpose.

Asking if any clinician needs to have an online presence is akin to asking in the 1970s if one needed a fax machine, in 1980s if one needed an email address or in 1990s if one needed a mobile phone. Online and social media engagement is the natural progression of communication technology and media interaction. It is now the norm not the exception. Of course when it all started we did not have a manual, so some of us used it effectively and others poorly. Institutions, legal entities and patients were also learning how to draw boundaries around the use of social media and online communication in the sacred doctor-patient relationship. Social media was once since as a frivolous marketing façade amongst clinicians. We now understand its powerful effect to inform and even influence health outcomes.

As of Jan 2020, 3.8 Billion people use social media. Facebook reports 2.45 billion users, YouTube 2 billion, Instagram 1 billion, TikTok 800 Million, Twitter 340 Million. If you are not a citizen of any of these online nations, you will lose real estate and therefore you are not searchable by your current and future patients. Worldwide average of daily internet use is 6 hours and 43 minutes (!), and 2 hours 24 minutes of that is spent on social media platforms. How do people access the online world? 53% of the time through smart phones, 44% via laptops/desktops, the rest through tablet devices and others. Full article here.

So, do I need an online presence as a clinician?

Short answer: YES. Because your patients are already there. Your patients are likely to have a social media account, spend hours daily on social media and by the time they walk into your office, they would have googled you, your institution and their medical condition on their smart phones. Embrace that. Being aware of the average patient online behaviour prepares you to be a better assistant to their health needs. If your patient cannot find you anywhere on the internet to check your credentials, then you may well be considered less accessible than another clinician who details their expertise.

One of my biggest reasons for being online is this: my patients and my trainees are already there. I need to understand where they’re coming from.

On the other hand, the longer answer to that question is: it depends on what your purpose is in having an online presence. As clinicians and human beings, we can all have a social media account for personal use. That’s where we connect with our high school friends and relatives. However, if we were going to use our online presence and social media activity professionally, then can I suggest 3 levels of social media usage that you can consider?

Basic

At its most basic, your online presence is your virtual real estate. It is to be used to inform patients and other health care providers of your presence. You can have a basic website (free from many website providers), or homepage (linked to your University Departments, Institutions or Private Practices) or a Facebook page (A Facebook personal profile is different to a Facebook public Page). The contents simply need to include your prior training, current practice and specialty interests. You just need to show the world that you are a legitimate clinician expert who can be contacted in real life. The contents can be similar across several platforms (Facebook, Blogsite, Website, Twitter, Instagram, etc.). This is to help patients to find you when they google you. The information is basic and static. For most clinicians, this is sufficient, depending on your geography and local referral processes.

Intermediate

For those who want to take it up a notch, you can turn your static presence into a more dynamic engagement. You can be an educator who could engage the community. Your website can be regularly updated with information specific to your specialties. You can have an interactive dialogue on the Facebook page. You can comment and like, retweet and engage with others. Facebook, Instagram, TikTok, LinkedIn and Twitter all have unique target audiences and therefore require different strategies of engagements. There are pros and cons on using each platforms. Your specialty and your patient will define your method. Doing social media well takes time. Putting up information and expecting the engagement from the community takes time. But the rewards are also great because you will find that as you connect with others, you gain knowledge and network. If you are an educator, putting up good information online would be important for our trainees and our patients. As doctors, we have the privilege of our training and position. Our presence online matters and in this day and age of fake news, I sincerely hope more and more of us would stand together online as a scientific community to continually present reliable and practical information. Whenever there is information vacuum, bad news tend to fill it. We have a moral obligation to our community to be present in this online information market to represent clarity and certainty.  

Expert

Finally, a few of us over time will end up being expert users of Social Media. This does not happen overnight and require long term strategy and time investment. You know some people with such great presence online who are powerful influencers. They have refined their presence over many years and reliably present clear information and therefore they become influencers and the go-to individuals. It is not how many followers you have. It’s how you influence them that matters. You can be followed by a handful of news reporters or other specialty clinicians and you can become the point person to connect and mobilise experts. The online connection crosses specialty boundaries, geographical limitations and timelines. You can connect with clinicians from other countries to collaborate on projects. You can be invited to speak at conferences or collaborate on manuscripts through the online networking. Social media is a catalyst and an accelerant when used well.

Some Practical Ground Rules to Note

You are a clinician and therefore the community holds you to a higher standard. Everybody’s watching and recording. Nothing gets deleted. The internet, like taxes, is forever permanent. So total RESPECT has to be first and foremost. You can provide opinions, but the information you provide online and the discussions you engage in has to be guarded by total respect because your words can be printed on the local newspaper and they can be sent to your Department Chief. This also means that jokes on other specialties or stereotyping people has to be done with care.

Never ever talk about patients. You can talk about conditions, but you must never talk about patients. Patient confidentiality rules in any country will be identical. Never break confidentiality, unless of course there is an expressed written permission. You can discuss, applaud, encourage a generic patient, but I would strongly advice against any specifi identifiable entries.

Be human. Be a social and a professional one. You do not have to reveal anything personal at all. You define your limits. Social media is a place where doctors can reveal their human side and engage in some non-medical interests and causes.

What about advertising?

Many clinicians would actually have an online presence for the primary purpose of advertising. In some countries that is normal and expected. In other countries, it is legally not allowed. I have worked in Australia, Canada, and New Zealand. When I flew for several conferences in the USA, I was surprised to see the inflight magazine full of medical advertising from big Institutions and personal doctors. That was foreign to me, but normal and accepted in the US. For the US clinicians where advertising is accepted, having a social media online presence is even more critical for your career. Check your local regulations and you might even engage an advertising company to design an advertising campaign for you. There are multiple measurements and return of investments measures that can be applied.

For those of us in Australia, on the other hand, here are the boundaries set for us:

Section 133 Health Practitioner Regulation National Law on Advertising

A person must not advertise a regulated health service, or a business that provides a regulated health service, in a way that–

(a) is false, misleading or deceptive or is likely to be misleading or deceptive; or

(b) offers a gift, discount or other inducement to attract a person to use the service or the business, unless the advertisement also states the terms and conditions of the offer; or

(c) uses testimonials or purported testimonials about the service or business; or

(d) creates an unreasonable expectation of beneficial treatment; or

(e) directly or indirectly encourages the indiscriminate or unnecessary use of regulated health services.

It’s all fair and logical, in my words:

• Can’t fake your service. You can’t say you’re the best.
• Can’t offer gifts or enticements. Can’t say “do facelift and I’ll throw a discount rhinoplasty.”
• Can’t use testimonials. Can’t get your mum to say nice things about you.
• Can’t say this surgery or medicine will fix everything.
• Can’t offer unnecessary treatments.

How do I maneuver around these reasonable practical limits? Education. In health industry, education is the best form of marketing. You can’t talk about patients, but you can talk about conditions. You can’t say how awesome you are, but you can talk about the procedures you do for certain conditions. Ultimately the more educational materials you put up on your Facebook, YouTube, Twitter, LinkedIn, Instagram and even TikTok, the more likely it is for the google algorithm to discover you. All these things are generally free. The main cost is time and effort. The internet records activities. The more active you are on any platform, the more likely you will rise on search engine rankings.

So there you go. Do you need an online presence?

The answer is “yes”. But what for?

I hope the answer to that is “for my patients and my trainees.” Our greatest satisfaction is seeing people get better. Help them get better information and better health.

See you online.

Thanks to COVID19, we now live in a physically-distanced virtual world. Online virtual conferences and meetings are becoming the norm. This is a great opportunity to increase our worldwide connectivity across geographical lines. Virtual meetings mean that more people can attend and less unnecessary travels are undertaken (good for the earth!). Of course the social connections are missed but with every major change there will be positives and negatives.

Here are 5 pointers to help you increase the value of your online presentations. These are by no means exhaustive, prescriptive or conclusive. These are things I’ve learned as I have spent hundreds of hours in meetings, conferences and listening to talks. Virtual conferences are different to real live conferences and therefore we need to modify our techniques: Ready, Set, Lights, Camera, Action!

1. Ready. Get ready by simplifying your content. Focus on 1, 2 or 3 key points. Most of your listeners are listening in an office between activities, lounge room, or even while they’re driving. No longer do we have the full attention of a conference hall. Most of us are juggling parallel activities while listening to talks. So leave one big message if possible. Keep slides to a minimum. Keep words on slides to a minimum as people may well be watching on a phone. (Seriously, no one is going to remember your talk details in 3 days.)
2. Set. Set your timer. The most respectful thing you can do for your listeners, meeting organisers and other conference speakers is to stick to time. Speaking beyond your allocated time is basically rude. When time is up, speak forth the big message and drop the mic.
3. Lights. Have light shining on your face from the front. Background lighting results on your face looking dark. Either have your desk light behind the computer you’re speaking to (like my pictured set up above) or get yourself some cheap “selfie” light you can buy and attach to your computer.
4. Camera. Keep your camera level with your eyes. Elevate your computer on a platform or a box. Looking down to a camera below your eyes means that your listeners are going to look up at your nostrils. Also watch your background and sound. Headphones/earphones may improve the clarity and gain of your speech. Careful with bluetooth headphones and virtual background as it adds workload to the computer processing, which may delay connectivity or quality of your presentation.
5. Actions. Maintain the tone of your talk as conversational. The elevated public speaking volume that we use when we speak on a big podium will not work too well on virtual conference. Remember that you are now talking directly to one person sitting in their lounge room, office, or car on their headphones. Facial expression matter even more now as they are almost face to face with you. Speak not with the tone of a quiet chat but that of an excited conversation so as to maintain engagement with your listener. Make them feel that you are talking to them directly.

Hope that helps!

Tell me if you have learned other helpful presentation tips too.

Artwork on my screen is a mural at the Royal Children’s Hospital Melbourne by Elizabeth Close.

This article was published on the Australian Society of Otolaryngology Head & Neck Surgery Newsletter Summer 2020 Edition.

It was eerie. After finishing up an emergency case at 8pm, I said goodbye to the anaesthetist and the nursing staff. The usual relief of finishing a difficult case was absent. We looked at each other quietly not knowing what’s ahead of us. In my mind, I wasn’t sure if I was going to see some of them ever again. I drove home under the cover of the dark wet windy winter that is Melbourne. Carlton, Fitzroy, Richmond and suburbs that are usually alive with lights and cheer are completely empty. The curfew has begun and my beautiful Melbourne is a ghost town. Its soul has gone. Fear is now locked behind doors.

At its darkest days in July-August, Victoria had 700+ new positive COVID cases a day. The hospitals were starting to get full. At St.Vincent’s Melbourne our PACU is converted into a clean ICU while the formal ICU is the “hot” ICU caring for COVID patients. Anaesthetists get daily briefing on the list of COVID patient in the building and their resuscitation/intubation status. A COVID theatre team is set up daily for emergency intubations or emergency SCOVID (Suspected Covid) cases. On the other side of town at The Royal Children’s Hospital, the NICU is dealing with their own COVID positive inpatient and outbreak, requiring the swabbing of every baby, every parent and every staff member who was in NICU for more than 20 minutes. I had to reflect on how long I was there accumulatively in the last week and which mask I was wearing.

How did Victoria get here?

COVID has certainly revealed where the cracks in the system are. The Chief Health Officer who is responsible for public health is not responsible for hospital responses. Hospitals, PPE and Health Care Workers are under the portfolio of the Chief Medical Officer through Safer Care Victoria. The Aged Care Facilities are the responsibility of the Federal Government, not the State Government. The Hotel Quarantine? Well, we’re still not 100% sure whose responsibility that was. We know a few people have lost their jobs over that. Chronic underfunding of the Public Health Unit at VIC DHHS also meant that only a handful of people were actually employed to manage this pandemic. The system could not bear the load applied to it. In the first wave back in March, the Premier cancelled the Melbourne Grand Prix and we dodged a bullet. The second wave, or the first tsunami, came about through cracks that, on hindsight, were pretty obvious.

More than 95% of all infections could be traced genomically to a family in quarantine. COVID came through a family from overseas, then a hotel worker was exposed. In a casualied work that is hotel quarantine, with lack of proper training, it was easy to see how COVID could leak through hotel staff to community. These workers are often from lower socioeconomic backgrounds and live in large households where there are others in the household who work in health care. Some religious holidays were occurring at that time which translated to very quick household to household transmission. The pandemic highlighted the structural inequities, the lack of coordinated response and the underfunded system.

Two weeks is a very long year in a pandemic. Multiple families across different suburbs were infected. COVID entered aged care facilities and hospitals, and because there was a lack of appreciation of aerosol spread at that time, PPE guidelines and ventilation were less than ideal. Once in a facility, COVID spread was rapid due to the nature of our physical contact. Delayed response to aged care outbreak meant that we had high morbidity and mortality situation occurring in that context. Aged Care workers were getting infected and the Government had to move Aged Care Residents to Private Hospitals. It was both scary and amazing to see the hospital response in Victoria.

Private and Public as one.

The COVID tsunami also occurred with a corresponding email tsunami. Every public and private hospital sent out their own version of COVID modifications. In one hospital, nametag lanyards were bad, in another hospital cloth surgical cap was bad but lanyards were cool. It was easy to see that so many of our protocols were made up along the way. It was a significant period of change. In fact, opportunistic leaders used this opportunity to make good changes within their departments. Private hospitals cared for COVID, SCOVID, and NOVID aged care residents. As elective operations were reduced, many of the theatre nurses I work with were deployed to aged care facilities or to the wards. I must confess, I am deeply impressed by the stories of care they provided. Theatre nurses who are usually in clean environments had to alter their practice and had to manage sick patients and quite a number of deaths, which is not routine business in a typical private hospital. Health care workers just rolled up their sleeves and did the job that was required of them.

In the hospital, universal masking, splitting of teams, routine pre-op swabbing, telehealth, zoom meetings, 50% elective capacity plus emergencies, 3-tiered PPE based on procedural risks, zoning of hospital facilities and many other changes occurred. In the community, 5km bubble, 8pm to 5 am curfew, school closures, stay at home directives, leave home for essentials only, and 1 hour exercise outside home were the enforceable norm. As I write this, South Australia has just entered and finished their mini lockdown. They had a brief taste of queueing for toilet paper. Today, masks outdoors in Victoria are off. We have had 23 straight days of zero transmission. The real test is when the borders are re-opened.

The role of the ENT Surgeon in a pandemic

It has been 6 months since I saw my colleagues’ smile and since I shook hands with my patients. The roller coaster ride meant that things have changed, some for good. Scrubs and masks are becoming the universal norm. Telehealth is well utilised. Meetings are more brief and many voices are better heard as everyone has the same “muteability” on zoom. Information exchange is rapid (How many WhatsApp groups are you in now?). The typical clinician nowadays can pretty much attend any Grand Round and conferences in other hospitals, other countries and other specialties from the comfort of their own home. As an ENT Community, we have also done much advocacy around the protection of our staff. The International ENT Community has published on mortality figures amongst ENT surgeons, which almost certainly influenced the protocols in many places and provided support for our colleagues in Dentistry, Maxillofacial surgery, Respiratory and Oral Cleft Surgery. At the national level, ASOHNS have been in close discussion with Federal Health Officers. At the local level, VIC ASOHNS and ENT Heads of Units advocated for protection.

And at the individual level, despite the heterogenous group that we are, ENT Surgeons have provided the necessary steady leadership influence around our workplaces. Turning up day after day both in public and private, modifying surgical approaches, rearranging clinics, sharing 3D-printed face shields, adapting to new PPE changes, communicating respectfully and many other simple acts that keep us and our community trusted. The fear amongst health care workers were palpable. The porters, theatre technicians, nurses on the ward and even cleaning staff were fearful. Though masks have covered their faces, their eyes speak of fear of uncertainty. Every time I spoke about the changes and the possible future, every eye and every ear was turned towards me. I soon realised early in the pandemic that speaking hope and perspective to my health care colleagues were just as important as talking about PPE and surgical modifications. Hope is a critical PPE armoury in this pandemic.

One theatre nurse said, “You know, I realise that ENT is the worst hit specialty this pandemic. You’ve got a high risk profile. Yet every ENT surgeon I have worked with has remained calm and unflustered. Thank you for being steady. We nurses appreciate that.”

If there is one other big thing I learned this pandemic, one surgical trait I wished I had more and in abundance, it is the lesson of humility. Scientific humility is knowing that we do not know everything about this virus, appreciating that airborne spread is a continuum with droplet, and changing our protocols rapidly based on new evidence. Surgical humility is adapting our surgical approaches to changes, respecting the concerns of every team member and being open to inevitable disruptions in workflow. Corporate humility is knowing that we need to advocate for our team and our patients, and that we need to listen to others (Infection Control, Occupational Health & Safety, Aerosol Scientists, Epidemiologists, Ventilation Engineers, Wellbeing Officers, etc.). Many colleagues and many in our communities suffered heavily through the lockdown. This pandemic showed that although we were all in the same storm, we were in vastly different boats depending on the pre-pandemic resources one had. As ENT surgeons, we are in a very privileged position and we have a moral and a community obligation to use whatever resources we have to support our communities. 

As other countries manage their COVID waves, we do have a good story to tell from Australia. Perhaps we can be that voice of support that other countries need. Many Victorians will not take for granted the freedom we now have after a difficult lockdown. There is still much work to be done in fixing our structural inequities and protecting health care workers but I for one will from now on treasure every Soy Chai Skinny Latte I enjoy with my colleagues face to face.

Talk presented at #NotYoga2020 Symposium Dec 2020.

I have a question for us. What do you think is our greatest asset in this pandemic?

What is the most important asset that we need to protect during this pandemic? If you’re in leadership positions, you may consider that the team or the institution as something you need to guard. Today you will hear many brilliant ways of engaging the whole system for change. But for you personally, you probably know that the greatest asset in this pandemic is yourself.

Of course, your experience of this pandemic is dependent on where you are, when you are and probably even more importantly, who you’re with. We’re all experiencing different phases of the pandemic. How Melbourne feels right now is different to how Brisbane, London, New York or Warrnambool is feeling. How Melbourne feels right now is different to how Melbourne feels back in August when we were in lockdown. Perhaps most importantly, your team, your leaders, and your institutional authorities determine how you are feeling at this moment. You’ve heard it before: we’re in the same storm, but we’re in different boats, different waves and we’ve got different boat crew members.

In this day of big talks, we are not going to gloss over the little big people, or big little people. This is a private talk. We process this pandemic differently. My experience of this pandemic is very unique to me. I work in several institutions and teams. In one hospital I feel completely protected and appreciated. In another I feel lonely & lost. In one hospital, name tag lanyards are ok, surgical cloth caps are not. In another, surgical cloth caps are ok, but name tag lanyards are not. It’s wild. No wonder it’s been a roller coaster of emotions. I still remember the betrayal & anger I felt when I needed to justify a request for N95 mask for my aerosol generating ENT procedure. We experience & process this pandemic differently on a personal level.

A recent study published last month looking at “Psychological distress, coping behaviours, and preferences for support among 650 plus New York healthcare workers during the COVID-19 pandemic” reported that 57% screened positive for acute stress, 48% for depressive, and 33% for anxiety symptoms. And what were their biggest concerns? Lack of control, lack of testing and PPE, and transmitting COVID to family.

How are you feeling at the moment? You might well be feeling burned out, because this pandemic is a chronic occupational stress causing us to feel emotionally exhausted, depersonalised and less efficient. You could be feeling a sense of compassion fatigue: an emotional and physical exhaustion leading to a diminished ability to empathize or feel compassion for others, the negative cost of caring. Or perhaps it’s moral injury, moral distress, moral anguish, or moral conflict. In 1984, the term moral distress was first conceptualized by Andrew Jameton in his book on Nursing Practice, to describe the psychological conflict nurses experienced during, “ethical dilemmas.” He wrote that “moral distress arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.” I bet many of us here know that feeling.

You may not be able to accurately delineate where burnout, compassion fatigue and moral distress overlap, but I’m sure that you can recognise the primary emotions underneath. Those definitions are scientific, while our emotions are raw and real. Our emotional responses to this pandemic are native and inherent to who we are as human beings and health care workers. May I help you define some of those things you’re feeling right now? Can I confess that I have felt mad, bad, sad and scared?

I have felt mad. I was angry at the state we found ourselves in. I was mad at certain protocols. I was angry at some decisions made by our leaders. I have written emails I should not have, and tweeted thoughts I should not have. Has anyone else done this? Or is it just me?

Because of that and a few other things I also have felt bad. A sense of shame that I wasn’t good enough. A feeling of guilt that I did not do more for that patient who died or that colleague who got infected. I felt bad I did not advocate more.

Of course, I have felt sad. I’m sad that I see worldwide carnage from this virus and yet many who still deny its existence. I am sad that I have not seen some of my colleagues’ smiles for a long time or hug some of my patients and my family members. This sadness can explain some of the days when I just wake up feeling blue. When will this marathon end? When will this pandemic be over? When can I hug my patients again?

Perhaps the one emotion that has driven a lot of actions during this pandemic is fear. We are scared. The uncertainty of the future makes us feel scared. The words “toilet paper” has triggered some primitive emotions and actions. When I’m doing rigid bronchoscopies on my tracheostomy patients, I feel close to danger and I’m scared. When I’m holding the face of my patients and examining their noses and throats, I’m scared & anxious. It only takes one breath for the patient to pass on their covid to me when we are that intimate in an ENT examination. That’s why my psychological safety is strongly linked to my physical safety.

I’m not so good at writing cards. So you know when you look for a greeting card in the shops, you are looking for one that encapsulates how you feel about the recipient. Perhaps the emotional confusion you feel can be defined by one of these words? Am I feeling mad, bad, sad or scared? This is not an attempt to belittle these emotions or its impact on the individual. This is my way of simplifying and clarifying how I feel. I need simplicity to help my simple surgeon brain to comprehend my complex emotions.

Here’s the thing: are these emotions negative, positive or neutral? None of the above. These emotions are not negative, positive, or neutral. These emotions are human. These are human emotions in a pandemic. Feeling mad, bad, sad or scared is human in this unprecedented year we are experiencing together. The challenge is how we navigate and manage these fundamental emotions for positive impact. My anger is a trigger that something does not sit right me. I need to find a solution. My shame or guilt is a mirror to remind me to be humble and to accept that I am good enough where I am. My disappointment is a reminder that I do not have everything under my control. I should focus on things I can influence. My fear is a reminder that I need to redirect my excitement for advocacy work. Use these basic emotions to reorient your thinking and response.

When I look back carefully at the last 11 months, I admit that beside feeling mad, bad, sad or scared, I have also felt glad. I have changed. I learned new ways of doing things. I learned stuff I wouldn’t have learned. Listen to the speakers before me and the speakers after me. I am glad I get to learn from them. I have been impressed by many leaders. I have been touched by the resilience of many of my patients. I have seen the faithfulness of my colleagues. I have seen ordinary people doing extraordinary things. Librarians calling up the elderly in their membership books. Restaurants feeding frontline workers and the marginalised. Airline crew working in aged care facilities. The pandemic has shone a light on social inequities and broken systems, but that light that broke through the cracks mean that we can start fixing things. Like a mosaic art, light will shine through the cracks, and all those colourful pieces can be put together for a better vision.

This pandemic has decluttered my life and reorganised my values. I am learning the art of tidying my life. I have decluttered my possession, my profession and even threw out some friends in the bin. I am learning to focus on things that spark joy. You know, I basically Marie Kondo’ed my way through the pandemic. Marie Kondo says you need to touch every item in your life and keep it if it sparks joy, bin it if it doesn’t. The first thing my dear wife did after reading her book: she laid her hands on me. She said, “I’m just checking if you still spark joy.” For many of us, this pandemic year is a year of re-setting. Pandemic decluttering is good for you.

Feeling mad, bad, sad, scared or glad is not wrong. It is simply being human in this pandemic. Reorienting those emotions for positive effect is what we should strive for. Decluttering our lives, reducing the noise and focusing on things that matter will help us significantly.

One more thing. So by now you know how to don and doff your physical PPE. What’s your emotional and mental PPE? Your mental PPE will look different to mine. It could be exercise, books, meditation, art, spirituality or yoga. My personal PPE include humility, heart (empathy) and hope. To my surprise, one of the greatest emotional PPE I’ve discovered through this pandemic is other people. My colleagues help me debrief. My family helps me see purpose. My team mates make me realise that I’m not alone. We get through this pandemic together.

So perhaps my opening statement is incorrect, or at least, incomplete. Perhaps the greatest asset we have in this pandemic is actually each other. Jump into each other’s boats.

Stay safe. Stay connected. Take care.

This article is posted on Healthcare Workers Australia.

“We’re over it.” Many of us, health care workers or not, have overtly or covertly expressed this state of being. The ever-changing protocols, the hybrid telehealth clinics, the endless zoom meetings, the cancelled conferences, the restrictions, the distancing, the lack of human touch, the masked smiles. Our day-to-day work and living have fundamentally changed as managers dictate what we can or can’t do. We thought it was going to be a short sprint. It’s turning out to be a marathon that we did not sign up for. And we’re over it.

A mutated RNA virus measuring a mere 125 nanometres infected a host and went viral. Horror pandemics that made great Hollywood movies suddenly became our story. We’ve lost loved ones. We’ve lost jobs and businesses. We’ve lost our dreams and plans. We’ve lost a sense of control over our personal and professional lives. 

My patients tell me that they’re scared. The theatre technician tells me she’s confused. Fear & confusion spread rapidly in a pandemic. What drives the R0 of fear? As I reflect on the times that I feel fearful in my work as a surgeon, I fall on these 3: lack of cognitive understanding (I don’t know what’s happening), lack of emotional support (I feel alone) and lack of physical protection (I feel I’m at risk). These are real human concerns that many of us have felt internally behind the heroic narrative bestowed unwillingly upon us. So, we put on that mask.

Knowing that there is still the long journey of COVID normal ahead, what can we do to resolve some of those hidden fears? Waiting for surveys, research grant, program approval and administrative intervention can take a long time. What can we do tomorrow for our colleagues, our team and our patients? What antidote can we offer for this pandemic of fear and confusion sometimes manifested in anger and frustration?

Humility

In Dr Anthony Fauci’s widely viewed Grand Round Lecture to Harvard Medical School (at 1:02:20), he underlined humility as something that he has learned and has underpinned his approach. Humility is not just an esoteric conceptual idea, it is a courageous practical reality. Not knowing everything there is to know about this virus. Being willing to put aside dogma in light of new evidence. Being quick to admit wrong. Being prompt in changing protocols and guidelines. Considering the alternative view. Listening to those outside of the specialty. I have been wrong. I have criticised my managers. I have been rebuked, corrected and critiqued. We all need to embrace this humility espoused by Dr Fauci. We are not looking for perfect leaders in this pandemic. We’re looking for authentic leaders willing to accept errors and embrace change. I think we could easily trust leaders who are genuinely interested in hearing every voice and who make efforts to adapt and adopt change. Humility starts with us whether we have a position of leadership or not.

Heart

What do you do when you feel you don’t know what’s going on, you feel unsupported at work or you feel you are at risk? You go to your leader. At this point in the pandemic your wellbeing is strongly tied to your leader/manager/supervisor. If you work under a poorly performing leader (I do not have to define that, you know what that would look like), you would not bring up your concerns. But if you have a leader with their heart on their sleeves, you will speak up. A compassionate, competent and collaborative leader makes you feel safe at work, in the midst of all the pandemic stress. Mayo Clinic has shown this to be a fact. They ran 2 studies that linked staff wellbeing with leadership scores of their manager. In 2013 they surveyed 2,813 doctors and in 2017 they surveyed 39,896 Mayo Clinic employees, excluding doctors, reporting very similar outcomes. The immediate supervisor leadership score was strongly associated with burnout and satisfaction of individual employees after adjusting for sex, age, duration of employment and job category. Each one-point increase in composite leadership score of the supervisor is associated with a 7% decrease in the likelihood of burnout and an 11% increase in the likelihood of job satisfaction. What does this mean for us? This pandemic is a long-haul journey to COVID normal. If you’re in any position of leadership, have a big heart. Your team depends on you being a good leader. Your leadership influences their levels of burnout and job satisfaction. No fancy campaigns or expensive programs, be a good person. Have heart and humility. If you do not have a formal position of leadership, lead from within. We all have influence on our workplaces.

Hope

Stephen Hawking gave this piece of advice to his children during a June 2010 interview on ABC News: “One, remember to look up at the stars and not down at your feet. Two, never give up work. Work gives you meaning and purpose and life is empty without it. Three, if you are lucky enough to find love, remember it is there and don’t throw it away.”

Beyond the pandemonium that is this pandemic, beyond the science and epidemiology that is pursuing this virus, beyond the fear and confusion, are 7.6 billion human hearts that beats with hope. We have seen the cracks in our health system. We have seen the true colours of leadership. We have seen the dark inequities that exist within our society. The fatalistic, nihilistic, catastrophising view is to say “it is what it is.” The clinician scientists with a hopeful world view would say, “let’s rewrite the story beyond the curve”. Let’s build a new normal. Let’s focus on and fix a few things. You say we can’t change the world. Well, the world has already changed. We now have a pandemic momentum to change a few things. For hope to be realistic, it has to be tangible and measurable in the present. We can start by writing down the top 3 things in our workplaces that we can change. How do we support frontline non-clinicians? How do we improve HCW protection? How do we empower team leaders? How do we better communicate the science? How do we reduce inequities?

So today, how can we and our leaders practically apply Humility, Heart & Hope in our workplaces?