I want to be free of the folly, irony and paradox of modern medicine and walk on the sand and dipping my feet in the ocean.
I knew it was time for me to retire when I recently read a GP referral letter. A GP opioid agonist treatment provider had recently retired and was offloading his private patients to the public addiction medicine services (AMS).
This would ordinarily not be an issue except for the fact that public AMS employ addiction medicine specialists who are accountable to the public health system’s clinical governance and are expected to adhere to rigorous prescribing guidelines, unlike private GPs who have fewer external guardrails.
I had already prepared myself for retirement by putting in place a succession plan. I have trained two great addiction specialists to carry on my work. More recently I handed over the clinical directorship of the AMS to the more senior specialist. I reduced my hours from full-time to two days a week to ensure a smooth seamless transition.
I was awaiting a final instinctual signal to pull the plug. This referral was that signal.
I have pulled the plug before.
I graduated from medical school in 1977. I soon became a passionate cog in a wheel advocating that casualty departments should not be a place where unsupervised interns and junior doctors are “blooded”.
In 1986, I was grandfathered as a Fellow of the Australasian College of Emergency Medicine (ACEM).
In hindsight I regret that ACEM unwittingly created a medical supermarket called emergency departments (ED) that helped kill the corner-store (general practice). As growing numbers of patients flocked to public hospital EDs, managing winter attendance surges became increasingly nigh on impossible. This was well before ED ramping became a 365-day occurrence.
During the 1990s, all the NSW ED clinical directors convened top-level, high-priority winter strategy meetings each October, vowing to prevent the recurring winter surge chaos being experienced. The top strategists from medical administration and health economists all joined in.
The following year the same chaos occurred, only incrementally worse. The roadblocks were politically illusive.
In 1999, I convened my own personal winter strategy meeting. I pulled the plug on emergency medicine in NSW and moved to regional Queensland, where there was no winter.
Time spent in the trenches as an ED director both clinically and politically had inflicted a toll on me. I spent time in a private facility and received treatment for a “nervous condition” referred to as delayed PTSD from being “blooded” as an intern in casualty.
I had also lost a dear colleague to a deliberate suicide. A self-administered overdose of propofol was his only answer for a 10-year struggle with heroin.
I became curious about the neuroscience behind “addiction” and why the dux of his graduating year in medicine would succumb to such a fate.
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A position became available as a clinical director of a public drug and alcohol unit in regional Queensland and I grabbed it. No more winter surges for me.
Private psychiatrists were able to monetise treating alcohol addiction, but their public hospital colleagues had little knowledge or appetite for patients with substance use disorder (SUD) and seemed to hold a mostly nihilistic view and unconscious stigma against people with compulsive overconsumption of any substance or behaviour. This was not considered “core psychiatry business”.
In 2002 I was grandfathered as a Fellow of the Chapter of Addiction Medicine which was initiated by the adult division of RACP.
At this point, I wish to segue to my big-picture reflection of medicine.
I accept that “medicine is a science of uncertainty and an art of probability”, a famous maxim coined by one of the fathers of modern internal medicine, Sir William Osler.
Evidence-based (EB) medicine is a lovely idea, but medical paradigms are iterative and over nearly 50 years, I have witnessed giddying pivots, falsified evidence, every measure of bias and blatant self-interest put before patient care. Ultimately, research requires accepting theoretical models which reminds of the phrase “all models are wrong, but some are useful”, a famous aphorism by British statistician George EP Box. I take it as a given that doctors who succeed us will ask “what on earth were they thinking”.
The medical industry has also become far more fragmented with a proliferation of specialties and sub-specialties. Satisfaction survey reports from patients of their “patient journey” have nosedived. Medicine has simultaneously become increasingly politicised.
Activity-based funding ignores the humanitarianism of medical care and scope of practice debates are a buzzword for ease of access which ignores quality of care and human contact which is an imperative to good outcomes. Care became activity centred as opposed to person centred.
Osler’s other maxim: “The good physician treats the disease; the great physician treats the patient who has the disease”, was too thorny to include into an activity-based funding model. Efficiency-driven medical systems are where doctor-patient relationships go to die.
In medicine, like life, there are a fair share of mercenaries, missionaries, mystics and misfits.
The mercenaries are entrepreneurs with a medical degree, the missionaries are those who cannot maintain professional boundaries and are incapable of saying no, the mystics blend modern medicine with old style shamanism, and the misfits generally find niche habitats.
I’m generalising of course, but the latter two groups maintain prescribing habits that may be no longer contemporary.
This leaves us with a dual paradox. Medicine is too important to be left to clinicians, and medical bureaucracy is too important to be left to bureaucrats and politicians.
Let’s return to the referral letter.
In my clinical work with patients with SUD, the vast majority were affected by adverse childhood events. Factors contributing to SUD include predisposing factors (genetics, modelling, abuse, lack of attachment etc); precipitating factors such as the introduction to psychoactive substances from an early age, at times smoking cannabis at eight or 10, with normalisation of drug use and perpetuating factors such as early entry into the juvenile justice system and jails. Protective factors were minimal or non-existent.
For this cohort drugs were the solution to an awful childhood and early adolescence. It was only later that the solution became the problem. Addiction and non-addiction are non-binary but a dynamic moving spot on a continuum.
An unhealthy relationship with a substance or a behaviour is quite commonly associated with abuse of additional substances and unhealthy behaviours such as gambling, gaming, pornography and aberrant use of social media. Bidirectional “psychiatric disorders” are also common but generally over diagnosed. Persistent pain is the norm. This is not surprising when you consider that the pain and pleasure centres are neuroanatomically collocated.
Now for my disclaimer. All my views are formative. My current position is that the base elements of humanity are folly, irony and paradox. At its deepest level, my reflection explores how belief and perception can be manipulated, and powerful illusions can become reality for those who experience them.
Doctors are not exempt. We can all fall prey to self-deception, blind faith, and faulty science.
Perhaps my self-deception is that in complex chronic conditions pharmacotherapy alone, without insight, understanding, and the will to change behaviour, is unlikely to be a successful treatment.
Dr Anna Lembke in her book Dopamine Nation emphasises that the neuroscience of compulsive consumption is a matter of a pleasure-pain balance in which the prefrontal cortex acts as the brake and the nucleus accumbens acts as the accelerator. Treatment and recovery cannot be reduced to the pharmaceutical treatment symptoms alone. Sedatives such as diazepam, pregabalin and off-label antipsychotics used for their major tranquilliser effects progressively incapacitate the prefrontal cortex.
In my view the referral letter had come from a missionary who did not understand the aetiology of his patient’s compulsive overconsumption of polypharmacy, but had contributed to it via cascade prescribing, presumably in good faith.
He had inflicted a pharmacological frontal lobotomy on the patient. In my fallible view, his inability to put in place patient boundaries and say “no”, delivered me an individual with an appalling trauma history. I may well be wrong, but the enormity of his cascade prescribing was certain to have resulted in prefrontal cortical atrophy and permanent damage to her limbic reward pathways.
When I saw the patient, it was apparent to me that her pleasure-pain balance was now beyond repair. The neurotransmitter gremlins in her subconscious reward centres were in total control. She had iatrogenic opioid and other drug-induced hyperalgesia, anhedonia, hyper anxiety and was unable to interact with other people and the world with joy, curiosity and spontaneity.
I’m told that overall, our health system harms 10% of patients, provides low to no value care for 30% and improves outcomes in 60%. To me, the patient was in the first 10%.
Twenty years ago, my pharmacological intervention with opioid agonist therapy was the complimentary carrot that slowly allowed for meaningful human connection, education and direction towards change. The enemy was the drug dealers praying on vulnerable souls by selling heroin and other illicit substances.
Now the enemy has become my mercenary and missionary colleagues. I’m done trying to fight an enemy who won’t engage with present-day EB treatments.
The educated man fears being wrong. The wise man has simply made peace with how often he already was.
I’m tired of fighting in the trenches. I’m now noticing how people really do make time for the things they love. I want to be free of the folly, irony and paradox of modern medicine and walk on the sand dipping my feet in the ocean.
I will of course deeply miss my magnificent team who have sustained me, my patients whom I refer to as children of God, who have taught me so much about life and allowed me to walk beside them in their difficult journeys.
My aim will be to nurture my inner child and appreciate that both pleasure and pain are equally necessary and celebrate with gratitude the fact that I did enjoy great privilege in my professional life despite the challenges.
I hope the next generation of doctors and other clinicians can improve upon patient safety.
Associate Professor Kees Nydam was at various times an emergency physician and ED director in Wollongong, Campbeltown and Bundaberg. He continues to work as a senior specialist in addiction medicine and to teach medical students attending the University of Queensland, Rural Clinical School. He is also a poet and songwriter.
