28/12/2013

Celebrate being different.

In his excellent book, Emperor of all Maladies, Siddharda Mukherjee traces the history of cancer treatment.  He covers the history of oncological surgery and notes that many surgeons are competent
musicians.  I am sure that is true but I know more  surgeons who are artists or photographers.

Basil Stathoulis, an orthopaedic surgeon in Durban, spends much of his free time taking photographs. If only for a second.  He sent me a link to a French video clip:

The clip takes a number of people who are having chemotherapy and makes them up with wigs and makeup.  A photographer (behind the mirror) takes a picture of their faces as they see their images.  It is fun.  They are made up to stand out from the crowd.
Many women who are having chemotherapy have told me that they cannot get away from being a "cancer patient".  Their hair loss and change in the shape of their face means they lose their identify.  Wigs resembling their usual hair style can help redress the balance but nothing can replace feeling "normal again".

There are a number of organisations who help women having chemotherapy feel better.  What was remarkable about this clip was, in typical French style, they were made up to be different.

I have recently been to Lyons: a wonderful city to visit.  Although it is the third largest city in France, incredibly well organised for tourists, has 22 museums, there is very little English spoken.  There is little attempt to conform to the generally accepted demands of international tourism.

Perhaps we should all take a leaf out of the French book and celebrate being different rather than trying to conform.

19/12/2013

Protocol driven medicine versus individual medical practices.

Mr Paterson worked in Solihul Hospital as a breast surgeon.  There have been a number of stories emerging about his practice.  Basically, he performed cleavage sparing mastectomies which resulted in a lot of breast tissue being left after a mastectomy had been performed.  Thereafter, a number of women  experienced recurrence of their breast cancer.  The question is whether that happened as a result of their inadequate surgery or whether the behaviour of the cancer determined the outcome.

I trained as a doctor in the UK and have worked in South Africa for the last 20 years. I have thought about the pros and cons of a protocol driven system on many occasions.  The NHS is an example of a protocol driven system.  There are clear guidelines set out for all health practitioners and they exist for almost all conditions.  In South Africa, outside the teaching hospitals, there are few guidelines although the health funders do apply some.  There are advantages and disadvantages in either system.

Protocols can be cumbersome and can result in many unnecessary investigations being performed.  They don't allow common sense to be applied.  They don't allow for the Art of Medicine.  My father was treated in Solihul Hospital and the seriousness of his condition (24 hours before he died) was not appreciated as the "score" being used did not reflect his illness.  No health professional looked at him and saw a sick man needing urgent intervention.  They saw a chart.

A system allowing individual freedom is equally wasteful.  Doctors who are not experts in their fields may treat conditions sub-optimally.  Patients get treated with unproven management.  Multidisciplinary approaches to treatment are not mandatory resulting in individual non-evidence based medicine being practised.  

However, although there are some individuals who do not benefit from protocols, the majority do.  Protocols save patients from our ignorance and arrogance.

I am not sure whether we will ever find out why Mr Paterson was able to treat women with unconventional surgery for so long and why no one in his team drew attention to the problem earlier.

Do you have any thoughts on protocols?










10/12/2013

Mandela: the listener

It would be impossible to blog from South Africa at this time without discussing the legacy and life of Nelson Mandela.  He was the world's most famous advocate.

In 2001, he was diagnosed with prostate cancer.  He made very few references to his illness.  The only quote I have found was "As a result of the treatment, the doctors took a blood sample and said "Your blood is clean of cancer"".  His disease did not seem to cause him further health issues.  There are millions of cancer sufferers who would love to be able to say the same about their disease.

Last week, I argued that the definition of ADVOCACY should include defining the problem before campaigning for a change.  Mandela spent decades in prison and used that time to study Afrikaans.  He stated that it was important to "Know your enemy and learn about his favourite sport".  His clear understanding of the issues dividing the population of the country made him such a successful negotiator for equality, reconciliation and empathy.

There are so many life skills we can learn from studying the lifetime of sacrifice of Madiba.   During his  imprisonment in Robben Island, he shared his cell with Dr Saths Cooper.  The two did not agree politically.  Cooper said "You could sense his resistance but he would listen anyway.  He was a very good listener and would try and insinuate his viewpoint through a carefully considered question of  clarification or positing another position.  But he listened, he may not have liked what he was hearing, but he listened none the less".

His famous quotes are in all of the newspapers.  What cannot be published is the silence needed to listen.


01/12/2013

The breast course for nurse: discussion about advocacy


On Wednesday, Thursday and Friday, we finished the Cape Town breast course for nurses.  The last 3 days consolidate the theory learnt over the preceding 6 months.  On Wednesday, we divided into 4 groups.  Biopsy and sonar techniques were demonstrated (and practised on chicken breasts and fruit).  Downstairs, there was a workshop on breast imaging.  In the afternoon, Sister Yvonne Jackman from St Luke's Hospice discussed terminal care cases with us.

On Thursday, the main part of the day was spent on lymphoedema management. Colleen Marco, Carola Schoonheim and Isla Muhl explained the theory behind lympheoedema management and showed us bandaging techniques to help alleviate the symptoms.


We started the last day with a gala breakfast at the hospital.  It allowed me the thank all our sponsors and all the health professionals who gave their time freely so we could run the course.  Our main sponsors were represented at the breakfast: Chris Tilney from Netcare, Dr Nauta from Care Cross, Jean-Claude from Blue Spier and Carol from WWD.  Bard spent the day with us on Wednesday.

The remainder of the day was spent discussing community activities.  Linda Greef, PLWC (People living with Cancer) led the discussion.  We spent sometime discussing what we mean by ADVOCACY.  It is a word that is used very freely without much thought a to what it means.

As defined by Linda, it means identifying problems and campaigning for changes to address the them.  As defined by Wikipaedia, it is: "political process by an individual or group which aims to influence public-policy and resource allocation decisions within political, economic, and social systems and institutions."  The free online dictionary defines advocacy as : "The act of pleading or arguing in favor of something, such as a cause, idea, or policy; active support."


I like Linda's definition.  Too much time is spent by many organisations trying to solve problems that either don't exist or will make no difference to the intended cohort.  TIME MUST BE SPENT RESEARCHING AND DEFINING THE PROBLEM before advocating for change.

Do you think the word advocacy should be redefined?