#004 Prof Mark Brown - Renal Medicine, Patients you'll never forget, Life and Mortality

In this episode of Doctors Getting Coffee, I interview Prof Mark Brown, a renal, obstetric medicine, and homeless health physician with an incredible career. We talk about what it was like to be an intern, we spoke about patients that will stay with us forever. The highs and lows of medicine. We spoke of the good life and how to speak to patients about death. It was truly wonderful, I hope you enjoy it.

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Transcript

hello and welcome to another episode of doctors getting coffee dr sill here junior doctor from sydney australia

0:23

today i have the pleasure of speaking with professor mark brown mark brown is a senior renal physician at st george

0:29

hospital and a professor with unsw mild university now um mark or prof brown mark will be

0:37

good thanks yeah um the reason i wanted to speak with you today actually is because you gave me a tutorial when i

0:43

was uh in sixth year and i'm sure you don't remember because you you are you've been teaching for decades

0:50

and it was one of the most moving tutorials that i've ever had it was uh

0:55

not a lecture it was a story and you shared with me a story with the class a story about a patient who

1:01

um had kind of acute in kidney injuries and chronic kidney problems

1:07

and we traced her life or their life and we you talked about the different insults and we measured the creatinine

1:14

of the different stages and how sometimes it would get worse it would get worse and then kind of go back to a baseline make a bit worse and every and

1:21

we talked about the different illness processes along the line and um it kind of led to the point where

1:27

dialysis wasn't working as well and and we had to talk about palliation and

1:32

eventually the patient passed away and then you know we had goose bumps we thought it was i thought it was a fictitious

1:38

patient but then at the end of the tutorial you say the reason i'm telling you about this patient is because i've just come from her funeral

1:46

and that has sat with me for a long time and i've spoken to other students from that tutorial and it moved us a lot

1:53

because being a doctor is more than just a job right you have this uh lifelong connection with patients

2:00

and um yeah so thank you for that it's good that it's stayed with you yeah

2:09

[Music]

2:19

but i wanted to know what kind of led you to becoming a renal physician

2:24

of all the organs well i was going to be a surgeon actually

2:29

i when i was at medical school i had this fantastic surgeon who

2:35

i'm not even sure how he and my father were connected i think they'd played golf together or something at one stage

2:41

my dad wasn't in medicine and he took me under his wing

2:47

and i would go to either sutherland hospital or carina hospital with him every wednesday

2:52

morning and assist him in theater and i probably did that for about three

2:58

years wow and he was a brilliant man he and he taught me i could tie knots and all

3:05

those things i can't do anymore and he told me a lot about surgery but he taught me a lot about life as well he

3:11

was just a very kind um gentle man and

3:17

you know it didn't kind of pull any punches you know he was still very sensible but he was a very kind man um

3:24

and at the end of all of that um uh i do remember one of the things he

3:30

taught that has stayed with me was we had a registrar walk in in the middle

3:35

of one of the cases and was saying something about so and so another consultant and

3:42

he said oh look he's very experienced and it was almost like a bit derogatory and a lot of people can be around doing

3:49

things for a long time but they have to keep their eyes and ears open to be experienced

3:54

and i thought it was a really pertinent comment it's just not the length of time you're in medicine or engineering or

4:00

whatever you do it's how observant you have remained during that time

4:07

if i think about the terms that i've been a part of the ones that work best are the ones with a pretty open feedback

4:12

culture and companies too by the way and there's a lot of examples i can think of in like

4:19

engineering where where if people don't have their ears and eyes open for feedback yeah things can go go wrong yeah um so

4:28

that's a piece of advice that's stuck with you how does that change your practice today you how did that uh yeah bit of advice

4:35

affect you yeah i've been conscious of that i think right from medical student days because because of him and

4:40

interesting how you learned from people was and so i've been conscious of that the whole time i've tried to stay a bit

4:46

aware of that although when i was a registrar i had a physician a general physician

4:52

that i was working for at the time and i was about to sit my exams and you know you kind of think you know a lot of

4:58

stuff and and he you can get a bit ahead of yourself i think in retrospect

5:03

and he said to me mark do you know why we have to have uh medical registrars

5:10

i didn't know where this was going but i said oh no he said it's to keep us consultants

5:15

absolutely up to date with the newest information and i chuckled and then he said

5:20

so why do we need consultants i looked at him and he said to me

5:26

to protect the patient from all the harm that might do and i thought

5:31

that's right it was another kind of you know who put me down quite nicely

5:36

because i thought you know i thought i knew a bit of stuff at the time um but it was again another comment that

5:42

i have remembered because it just again it's that reflection of integrating knowledge and experiences

5:49

is quite important i think it should go on and i think having a role model

5:54

like no matter what people want to do in their lives like good role models are really key because they can provide

6:00

insights that you can't learn from a lecture [Music]

6:14

so going back i was going to at the end of medical school i thought i'll be a surgeon yeah so

6:20

how old were you when you were assisting in these cases oh how old was this like high school or were you ready no no i

6:25

was in medicine right you had already started medicine but we were in the we

6:31

did a five-year medical course went straight from school into medicine so i think i was 18 or

6:36

something when i started medicine it was crazy um and we were the first of the five year

6:42

course at unsw which later got scrapped and returned back to six years

6:48

probably reflective of how we turned out i don't think so

6:53

so but and interesting talking to some people along the way it kind of turns out i think they were making that course

7:00

up you by here as yeah

7:05

so it got changed um now so it's probably not no more than you know 21 22

7:10

or something like that going so you were going for surgery and um and then what happened

7:17

then i did um i was actually an intern here at st george wow yeah in fact i've spent

7:23

39 years of my career at st george fantastic um so i was doing an

7:28

internship here and i did a surgical term first in urology and i really enjoyed that that was great

7:34

um but then little into the year i did a a he i did an orthopedics term

7:40

and they were great there's a one of the surgeons i won't name he's he's a surgeon in sydney now an orthopedic

7:46

surgeon he used to let me do pins and plates and things with him supervising as the registrar

7:52

until one night we actually he came in the next morning mark that woman we did last night last

7:58

night i said oh what happened and he said no she's done well he said she's fine but it turns out it's

8:04

matron's mother there we used to have nursing matrons back in those days like the director of nursing equipment and

8:12

well none of us here said the register and an intern had been doing a pin and plate on matron's mum which wasn't a

8:18

good look nice so we had to kind of cover that up but we had that was a good term but i got

8:24

very interested in the medicine during that term because as a junior doctor you're somewhat left

8:30

on your own just sort out the medicine in that term yeah for those who don't know when you're a medical when you're

8:36

the junior doctor on a surgical term you kind of run the the ward while uh more

8:41

senior people are doing the operations so all the parry operative complications the pre-op repair preparations and the

8:47

post-op complications pneumonias clots all that kind of thing sometimes you're the first person there to sort it all

8:53

out yeah so you gotta you gotta know the medicine yeah so that was interesting us and then i

8:59

did hematology and again you know you're lucky in life i worked for a wonderful man called bob

9:05

pitney the pitney and he was just a remarkable man an

9:12

astute physician as a student hematologist but just a good song

9:18

and he took me aside at one point and said i really think you'd be suited

9:24

to be a physician and i don't know what clicked that it was

9:31

at that point i thought yeah this is where i need to head were you were you conflicted at the time or

9:37

before that conversation about what you were going to do with your career or were you looking for a kind of kind of a

9:43

permission from a kind of a role model to get to open up that option to you or

9:49

because i can imagine that if you've had like someone who's you look up to and who's guiding you telling like building

9:55

you up for surgery you would have felt like that's kind of what you had to do but also what you wanted to do

10:01

but maybe having another role model open up a second door did that change your mind or was it

10:06

something that was more internal than external that's probably a bit of both i i really

10:11

don't know i didn't feel particularly conflicted at the time i think that sometimes in life things just go down a

10:18

pathway and then eventually the door opens and you you may not have seen that door coming for a while yeah um and i

10:24

think there was more more that but also too i think to have someone senior

10:30

and someone you respected probably more to the point you know so i think this is a pathway

10:35

you could go down makes you think a lot more about it so that was the turning point i think when

10:41

i decided on physician style of work and then renal i just did a renal term

10:49

found it very interesting thought there were a lot of um even then thought there were a lot of

10:55

opportunities of things that could be developed oh yeah um and

11:00

um it was kind of exciting seemed to be at a very early phase and um did some obstetric medicine in that

11:08

term and um well not really did obstetric medicine but had a look a couple of disastrous cases

11:15

and um thought you know that's another kind of angle to this job

11:20

with the eclampsia and the high blood pressure issues that come with yeah i don't think yeah yeah we i can

11:27

still remember back the kind of cases we saw we didn't get called much to

11:32

delivery suite or maternity but when we did it was a nightmare of a case it was

11:38

usually in a late presentation uncontrolled hypertension

11:44

um bleeding disease renal failure the whole bit right and at that stage if you couldn't

11:51

get a baby past 34 weeks they didn't survive so it was pretty horrible so

11:58

yeah but with dr pitney him being a just a good man i find that a lot of physicians like

12:05

a good people do you think that doing this job um working with people who are unwell

12:11

during the worst times of their life do you feel like that makes you a good person or do you feel like it's good

12:16

people that kind of go into medicine i feel like people who go into medicine are very young and and you know their

12:21

identity is still developing a lot of the time by the time they they get in and uh over the course of their their

12:27

life they they kind of you know become more compassionate and kind or burnt out and go the other way but

12:33

yeah do you think like for example with dr pitney it was the fact that he was a good person intrinsically before

12:39

becoming a doctor was it being a doctor that makes him a good person you suspect he was always

12:44

a good person yeah but i think medicine gives you the opportunity doesn't it too to actually explore that in your nature

12:51

you you know a lot of people have that intrinsic

12:57

capacity but might not either find or be given the opportunity to

13:03

utilize that as their life goes on and whereas medicine is a blessing to

13:09

allow us to do that um but if i look most of the doctors that i know you know

13:15

95 of us are good people yeah and i have some very close surgical friends

13:21

and they're they're very good people very you know the same i don't think it's physician surgeon

13:28

obstetrician or anything they're just yeah there's a lot of stereotypes that are so unfounded yeah yeah i agree

13:38

[Music]

13:50

throughout all your training like i know burnout's a big issue these days uh i'm

13:55

sure it was as well in in your in your training days did you ever experience burnout what was uh some of the tougher

14:02

times during your training yeah the terminology is a bit tricky but burnout yeah

14:07

tougher times definitely absolutely we when we were medical registrars

14:13

there weren't many of us for a start and there were no specialty registrars so

14:20

the plus side of that was that you did everything you'd you know you'd be on night a night shift

14:26

and you'd do your own lumbar puncture you put in your own pacemaker you do whatever you know so

14:32

you you got a lot of experience but number one it wasn't directly supervised so

14:38

that wasn't great i can remember the first chest drain i

14:43

put in was as a jmo i was in the canterbury emergency department

14:49

after hours and there was only two of us on five entire hospital and the other jmo was in maternity stuck

14:56

there and i had a young kid come in there with um after an mva

15:03

ruptured spleen which we diagnosed in those days by putting a a needle into the abdomen and seeing

15:10

blood um we didn't have the ultrasounds and things and a pneumothorax and um

15:16

i hadn't put a chest chain in before and there was no one there to do it and no one coming in so i rang a surgical

15:23

registrar said george who i've done a term with here and who was just

15:28

a godsend and he took me through it over the phone wow and that's how it was done

15:34

now things have changed so much for the better since then but i still remember that case and the fact that i remember

15:40

it means that it's had some effect on me um but so the supervision is much better

15:46

now so those sort of cases are hopefully non-existent but then yeah the hours were terrible we

15:53

would do the mid-red shift was the weekend one was saturday morning you'd start at

15:59

eight and you finished monday evening at six or whatever and you hoped you got some sleep along

16:05

the way um and that you know that wasn't good and you were studying for your exams as

16:12

well and you were trying to you know carry out relationships in life as well and

16:19

there was a lot of collateral damage well really so it affected like personally affected your personal life

16:24

yeah those are those out there i can imagine yeah it did and then by the time you get home what energy do you have after

16:31

72 hours of that and then you've got to put that into study yeah

16:36

so that was they were difficult times to be honest um there were good times too

16:42

because you know you form very strong bonds at work it's a camaraderie rather than just a

16:47

colleague you know i really admire that absolutely

16:53

so there was the plus side to it but um i'm glad it's not that way anymore

16:58

it should it's much better [Music]

17:20

one of the questions and you've alluded to it already is um what i wanted to ask is about how

17:25

patients stick with you throughout your life um you're you're you're talking about a young

17:31

patient you saw as an intern as a result of the president um

17:37

yeah um do you often think about patients from when you were younger in your internship

17:44

and resident years because i'm a resident now and i've been seeing

17:49

i've seen a couple of tough cases and they definitely stick with me yeah yeah

17:54

um probably less so from those years than from say early consultant years um

18:01

because then the responsibility is yours but you're a early consultant yeah kind of is that is that the issue

18:08

well i don't know i hadn't actually thought of that along those lines but that's probably correct um

18:13

but i particularly remember a pregnant woman who died and

18:22

that you know that was tricky yeah right you know i'd actually back in

18:29

those days i was very junior consultant and um i came in and went to theater with her

18:35

the surgeon in the obstetrician we decided we had to deliver she was 28 weeks

18:41

a terrible program so we had to deliver um and i went into theater and tried to

18:48

help with the blood pressure control of things and so on that was about 2 a.m

18:54

and then i came back and saw her about 6 30 a.m

18:59

and she was you know pretty stable i thought baby had been transferred out to a

19:05

neonatal intensive care unit was doing okay and um

19:11

i went back to start my clinic um about eight o'clock

19:17

and got a phone call about an hour later to say she was dead

19:22

and you know i worked with the coroner to try and find an explanation we couldn't but

19:28

that was the medical side of it which is almost irrelevant um well not irrelevant but because finding

19:34

a cause would have been great and we never did but um having to sit there with the husband and

19:42

tell him what happened so that's um yeah that's still difficult yeah

19:48

and um i went to tanzania for an emergency medicine elective yeah and

19:53

there's no antenatal care where i went uh small town and i saw a couple of pregnant uh young women die from what

20:01

was certainly eclampsia and you know very pregnant and you know they're thinking of perimortem c-section

20:07

kind of things during recess and um they just don't have the they didn't really have resources for like for a

20:14

neonatal intensive care for that kind of a situation and it's yeah it's it's horrible to see someone pass

20:20

away it's horrible to see a pregnant woman pass away and it's horrible to tell the husband that you know one day he's got a wife and a

20:27

baby on the way and the next day um he's alone yeah and bizarrely i got an email from a

20:33

fellow consultant recently did i know so and so a woman who'd died in pregnancy all

20:40

these years ago because they're just seeing a relative of theirs who's now pregnant

20:45

wow just keeps coming around yeah but i think with all those cases so it's

20:51

kind of what you learn from them um i think what's kind of amazing

20:57

and not necessarily in a good way about being a physician is because you have to go from that conversation with the husband to your clinic or to your next

21:04

thing now it's like an e.d there's now they do hot debriefs and

21:09

cold briefs so hot debrief sorry a couple of things just to take a step back for everyone watching

21:15

eclampsia which is um you know what happens when you're pregnant and i have high blood pressure

21:21

your blood pressure gets so high when you're pregnant it damages all it damages the brain you get stages it

21:27

ruins your kidneys and blood pressure comes higher and so it can kill people in australia it's

21:32

luckily usually caught early um because most people go into antenatal care but some people don't um

21:40

from a mix of reasons so that's what we've been talking about here um

21:46

and yeah sometimes you see horrible things and then like you you do an after-hours shift someone dies you have to update the

21:53

family and then you get a rapid response you've got to go to the next patient so you know there's views around

21:58

repressing feelings and actually i think when you're at work sometimes you have to to be functional

22:04

yes and you process it after work yeah yeah do you have a good support network

22:09

personally to to talk to and and that kind of thing or yeah my poor wife [Laughter]

22:18

i think the beauty that she's she did nursing and so she understands the

22:25

the discussions um i suppose you know phrased correctly anyone can understand the discussions because they're more

22:31

about your feelings and emotions than technicalities of the case but i think

22:36

it has that's also been helpful but yeah the burden's been on her a bit to

22:42

hear all his stories over the years um but that's that has been a great support

22:49

but i've also been really blessed to work in a fabulous department all this time and

22:54

you know we we can chat yeah amongst each other and you know

23:00

about a range of issues amongst our colleagues whether they be a case

23:05

um or whether they be a personal issue you know we are actually good friends in our department as well as good

23:12

colleagues and that's wonderful um that's been such a blessing yeah yeah

23:17

something you said earlier that's kind of just hitting me now because it's uh something i do

23:23

was around how um the medicine was the irrelevant part of it and it was the emotions that that was

23:29

the kind of core focus or just the interpersonal situation with families

23:34

around hard situations i just realized that's actually my defense mechanism is

23:39

to over intellectualize horrible things and try and describe the pathophysiology or you know try and

23:46

describe what's happened medically and to try and protect myself from going towards that so that's an interesting

23:52

one yeah that's it anyway that's just something i need to be aware of myself because you know i think we at the end

23:57

of the day i don't know if that's the right way to process it but we all have our defense mechanisms

24:03

we do and i think in medicine that's pretty universal and i think that we still do that i mean

24:08

i know i still do that right but i'm more conscious that there are

24:14

that there's much bigger issues at play than just the mechanics of what the case

24:19

was all about [Music] whereas i'm not sure i was as conscious of those

24:25

early on and in your junior or i shouldn't say junior in your early consultant years

24:31

what uh what was the reason that those patients stuck with you longer is it was it because you hadn't had the kind of

24:37

experience you have now uh the kind of sense of control that you might have now was it a

24:43

um i don't think so i think it was just that um

24:50

this there wasn't it wasn't the experience back then i think and so you felt more

24:57

what should i have done that i didn't do right the what-ifs yeah and i think you can get to a later stage where

25:04

you can more objectively see that you've tried the right things

25:10

but i think to coming back to having a good department to work and you can

25:15

actually then discuss that case with your colleagues to make sure that

25:20

there wasn't a step you missed and you know what doctors are human and

25:26

mistakes happen and there aren't guidelines for everything yeah yeah it is up to your you know that's that's

25:33

sometimes there's no right perfect answer yeah and hindsight is 20 20. yeah yeah

25:39

but even in later career i think you still get cases that are going to stay with you i mean in my

25:46

recent years i had a lovely man older man on dialysis that

25:53

i've been looking after for the best part of 25 years i think on and off since he started his chronic kidney

25:59

disease right through but he had a family relative who just

26:04

talked to me and did not like me at all and just kept at me and she'd fly in

26:09

from overseas and go straight to the patient complaint unit and it just went on and on it was

26:15

relentless and yet he was a very nice man and he and i had a

26:21

good relationship and and i could see that his life was his

26:26

was deteriorating his medical conditions were worsening and i'm generally conscious these days of

26:33

wanting to make sure people have so-called good death yeah and

26:38

i tried to put you know systems in place and padded and palliative care connections and advanced

26:45

care plans in place for him and none of that worked with with that person and that relative of

26:52

his and he ended up dying pretty horrible death pretty well and bleeding out

26:58

in a in a radiology department and you know

27:04

i won't forget that for a long time either i'm i'm not sure what i could have done

27:09

differently um but you know maybe i should have had different ways

27:16

of establishing a better relationship with the family i'm not sure but um but that case will stay with me for a

27:23

while as well so i think throughout your whole career

27:28

yeah there's going to be particular cases that stay with you but to keep the perspective i mean

27:35

they're vastly outweighed by the fabulous yeah and i feel like we focused on negative cases in the chat but i do

27:43

that because that's you know what's something i'm interested in at the moment but um i also think it's a

27:49

privilege to be one of the people during a horrible time like that makes the thing better even if it's a you know the

27:55

terrible cases the fact that you're one of the people during those cases you know that's that's uh an honorable

28:02

and admirable thing to to make a bad thing even a little bit better prof

28:07

when you're working with people with renal disease and they go towards the end of their life and you're you work closely with palliative care and

28:14

dr brennan you see a lot of death and does it change how you feel about your

28:20

own mortality uh yes it does i think

28:26

i don't think i've been as conscious of my own mortality

28:31

except maybe in the past 15 years or so doing the renal palliative care stuff

28:37

[Music] but not in a negative way at all but just more in a way of

28:44

you know trying to live out you know the best life you can

28:52

but i hope i can maintain my own principles when it comes to end of life and you know and that is

28:58

not to have prolonged suffering and not to inflict

29:04

prolonged suffering on those around me so i hope that i can carry that out but you know we'll

29:12

see hopefully not for a long time of course yeah yeah i think it's a

29:17

marker of maturity of a society to start going towards palliative care and accepting the idea of a good death and

29:24

not just fighting death which it's a win-win because it's also better for doctors like

29:31

obviously it's better for patients and patients have to come to that their own way um and kind of that's a different

29:37

conversation but it it means that there are limits of care in place from a doctor's perspective and we're not just

29:42

fighting a futile fight which is a horrible thing to try and do when you're just treating you know

29:49

putting chest strains in someone who's just won't be like adding to someone's

29:54

suffering which yeah i i've been involved in resuscitations of people that really should not be resuscitated

30:00

and um and that stays with me and yeah it's uh it's a it takes a bit of

30:08

maturity to society to get to a point to accept that like death is a part of life

30:13

and we're not at that point in society yet and i think right partly the reason for that is we haven't had strong

30:19

societal leadership about those discussions you know you can see

30:25

politicians for example are very nervous about having these discussions because you know it could be seen as a negative

30:32

thing to do and puts them in a tricky situation but we do need to have you know societal

30:39

discussions about it's really a discussion largely about medical technology you know i mean what

30:45

do you mean a slide that i use at the end of my talks on renal supportive care which

30:51

says that there's what you can do but then there's what you should do

30:57

right and so from renal we can put anyone into a dialysis machine more or less

31:04

not 100 but more or less but you shouldn't always do that for the patient and families say you

31:11

know and similarly you know the technology and cardiac medicine and chemotherapy and everything has just

31:18

advanced so much but we have to just take a deep breath

31:23

and go okay that's fantastic but what is the right place for that

31:30

for this patient and it's the families that are

31:35

as affected as the patient really i mean the families will often through love

31:42

want every everything done for their elderly parent yeah you know who

31:49

you know from a medical perspective meets the criteria that they will not go well

31:54

yeah they'll ask and that's a common thing that registrars have to talk to families about where you know in

32:01

their case we do things called nfr forms or resuscitation forms i've got the

32:07

exact term of it um but we have to talk to family about what they wish what the patient would want in a cardiac

32:13

event or the patient themselves and often you know i've seen families

32:18

advocate for cpr on a 95 year old and it's like if a heart stops a cpr is not

32:25

going to change that outcome in a 95 year old with these comorbidities it's always a case by case basis but

32:32

it's it's this attitude of let's do everything we can to get them even an extra day

32:38

but in a sense it's anyway that's a bit um extreme but it's

32:43

a form of harm um to to over yeah do this stuff i think the tricky

32:49

thing in the discussions that i've come to learn is com is trying to understand where that family is coming

32:54

from and it is very often out of love it's just

33:01

misguided understandably because they're not coming from the same

33:08

understanding of the case or what the harms might be as as you you're coming

33:13

from um but if you can tap into that aspect of the discussion with them

33:18

um that i can see that you love your dad and i can see why you want what's best for them which is not always

33:25

but i can tell you what's going to flow from this and that may not be you know the right thing for for them

33:34

and i think one of the ways to turn it around then is to say to them look you're loving your dad and wanting to

33:39

get all these things done for him put him on dialysis or whatever

33:45

but really the best way to love your dad now is to help us look after him and keep

33:51

him really comfortable and you know that he has a peaceful life from here on

33:56

and that's it it takes time with those discussions

34:02

yeah yeah you can't change someone's mind in one chat no definitely

34:09

[Music]

34:21

now you've done a bit of work in homeless health as well haven't you which i wanted to ask you about and how

34:27

you see the future of homeless health and how that's going what has been your involvement

34:33

um so just over 10 years ago my wife and i established a medical

34:40

clinic at the mission australia center in surrey hills which is a

34:45

shelter for homeless men um so

34:50

the guys come in from various places they'll be referred in there or they might be

34:56

referred through mission beat from you know living rough or they'll come from jail

35:02

to there because there's nowhere else to go right and around that time

35:08

we've had some connections with the mission australian society and there was a medical report that had come out

35:14

basically showing that something like 80 of them had never had a medical assessment in their life

35:20

like never and so yeah that so that opportunity came up

35:26

to set that up and um we've been running it since then and we've now got

35:32

it's through this george hospital again the camaraderie and collegiality in this place is fantastic yeah you know we've

35:39

got um another physician now that's joined us we've got nurses who'll come and do

35:44

vaccinations there we've got a nurse will come and do the fibro scans to look for the chronic

35:50

liver disease we have had a mental health psychiatrist come

35:55

that's not happening at the moment but you know all of that has has developed

36:01

over over that time and um it's been been good to be able to

36:07

i'll share do you have is there a website for it or anything like that no no it's just a walk-in kind of yeah

36:14

and you work directly with services okay yeah we published published it in one of the journals some of the outcomes but

36:20

yeah and is that funded through the state government or through st george the hospital that funds it or i don't talk

36:27

about it i'm the only person with a department that has no cost center

36:33

we have no money for this at all so everyone does it off there

36:38

yeah there's a little bit towards the psychiatrist money but not very much

36:43

um but the rest the rest of it is unfunded and you know you mentioned in that question

36:50

the future of homeless health it's a long way behind the eight ball

36:55

it's pretty neglected outside of it there are very well-meaning people

37:00

trying to help out at certain levels in the district and at

37:05

ministry and other ngos and that but oh yeah it runs on a

37:12

you know it runs on a prayer it runs on no money and you're always looking for people to

37:19

volunteer to do this sort of work [Music] which is

37:25

great if you can get someone to commit long term but these are not the sort of clinics where you can just

37:32

come in and go out and not establish relationships right so that's a bit tricky as well but

37:40

i'm hoping to spend a bit more time trying to escalate the profile of that problem yeah

37:46

statewide at least because it's got to be better managed than it is now in terms of

37:52

an approach to health care it's it's pretty terrible yeah it needs as much mental health input as physical health

37:58

input and i don't know why then yeah don't get you started hey

38:03

it does but i mean at the moment our psychiatrist is on secondment for six months or whatever and i cannot get a

38:10

replacement to do a clinic of one clinic a fortnight that's all we're asking

38:15

and i can't get it and i think that reflects i mean partly reflects the shortages in

38:20

mental health in general but it also reflects the

38:26

approach to homeless health i mean if there's a shortage in the renal department or the cardiology department

38:32

you just advertise and get someone right you know the shortage in this and it's

38:38

not that easy it's just not seen as one of the uh sexy things to do in your career kind of thing right yeah that's

38:44

sad and these are guys with terrible life stories you know yeah just

38:49

amazingly bad life stories you know for my

38:54

one of the guys was so early on in the process he'd um he'd come from a drug and alcohol

39:01

background but when you got into it he'd been abused as a kid it's for his 13th birthday his dad

39:07

thought he'd shoot him up with heroin for his birthday present for his fourteenth birthday is his uncle gave

39:14

him a job selling cocaine at the cross well what hopes the guy got you know and

39:19

then he ends up there and so you're starting from scratch when he's you know 21 just out

39:24

of jail and you're trying to you know start from scratch and work through all those things um he had hep c

39:30

that he didn't know about a whole range of medical things um but then the much bigger issues for him

39:37

was trying to get him back on track lifelines yeah well that's right and how much can you do as you know one

39:44

appointment a week with a doctor kind of thing it's uh they've got great counsellors of course yeah yeah so it's

39:50

it's a multi-disciplinary yeah i think so you yeah you're involved in the medical side of things but they have other yeah

40:08

because this is really wonderful stuff so

40:13

in the next 10 years of your career what are your kind of what are you hoping to achieve in the next 10 years is that

40:19

things it sounds like you're working on like working on this clinic a bit more is

40:25

that the main thing or is there other things as well you're working on i think the two areas i'm now

40:31

mainly working in is is that in terms of systems side of things not so much

40:38

more i'll continue doing the medicine but more on trying to get the systems changed

40:43

and just still working on the renal supportive care renal palliative care stuff with frank brennan and

40:50

we're currently in the midst of a international collaboration on developing a curriculum for that

40:56

um so that doctors worldwide can have a standardized learning process

41:02

about real supportive is that care the format of a online course they can

41:07

do we we're heading towards something like that yeah so um

41:12

i'd write a section on nephrology for the non-nephrologist because i like that you know then the pal care person who's

41:20

doing most of the supportive care work in you know south africa

41:26

is not a nephrologist but then there'll be a nephrologist who'll learn the pal care side of it all

41:33

working in some other country palliative care is it feels like such a young specialty um

41:40

and i yeah it's something i'm actually thinking about a lot i've never i haven't gotten a palliative care term

41:45

yet as a jmo um but i'll yeah i look forward to talking to frank more about

41:52

life as a physician in imperative care i think the opportunity for a lot of young doctors now is the opportunity to do

41:58

dual training for example in our department we've got a fabulous nephrologist who's dual

42:05

trained in renal medicine and palliative care oh great yeah she's just brilliant yeah um and i think those

42:12

opportunities are going to open up i think palliative care is now evolving more into what it always wanted to be

42:19

and that is not just about the last week or two of life

42:24

but the chronic trajectory exactly you know the second you get diagnosed with that

42:30

uh you know life-limiting illness even if it's a year or two years yeah you know multiple uh um als can take years

42:37

and getting involved early yes that's the way to go yeah exactly yeah and

42:43

so you know with if you want to be a any any doctor really but if you want

42:48

anyone who's dealing with chronic care but even to be honest even critical care i think

42:55

there's opportunities for dual training really if you think about

43:00

critical care a lot of my senior colleagues in critical care will say to me oh you know we had someone come in

43:07

and we spent a lot of time going through the family with them about you know palliative

43:13

approach to things and what we would do from here on and they're not all going to die in that emergency department

43:19

you know and sure they'll be handed on to another team but i think if you've got

43:24

expert background training yourself you know you might maybe a diploma is all

43:29

yeah you would have needed to do rather than a whole specialization

43:34

but that sort of thing i think it's an enormous benefit in that setting um but

43:39

you know if you're doing neurology or cardiology or respiratory or anything like that if you're dual

43:45

trained with palliative care the opportunities to really look after people and their families

43:51

just opens up enormously that's right yeah look yeah i i will definitely do a term

43:58

in my planning on it so mark you've had a lot of leadership roles uh

44:03

in your life and you've worked with junior doctors that are good and maybe some that are not so good what are some of the attributes that you you find are

44:10

really important in a good junior doctor i think the main thing is having an interest

44:16

and being you know excited about being in the role um i don't mean you have to jump up and down about it but um

44:23

if someone's interested in that job and what they're doing i think just human nature is you'll be more interested in

44:30

helping them develop as well so i think that's a first key element and i think secondly that

44:37

they want to learn that's really important and again that bounces off you and

44:44

you're really keen to help them learn this goes for medical students too absolutely yeah yeah absolutely and you

44:51

can tell a lot by someone based on the questions they ask yeah i think yeah that shows how interested

44:57

they are and what they're thinking about while they're next yeah right no that's very true and then i think the third thing is how

45:04

they interact with the patients the families and everyone else on the team so

45:10

you know the the cleaner that's cleaning on the ward you know the allied health team the

45:17

nurses the doctors their colleagues you know are they all on a whatsapp group that they've formed

45:23

together because they actually like each other uh all that i think they're really key elements um

45:30

we've been pretty lucky i must say i actually see a increasing maturity

45:38

and an increasing um goodness in the

45:43

junior doctors that we've that we've been getting great um i think

45:48

it's never been bad but i just think it's better and i think you guys are much better

45:53

than i ever was at sorting out your your life and some balance in your life

46:00

i think that's very admirable um yeah we get given the opportunity to

46:05

have a bit more work-life balance though i have never done a friday to monday 72-hour shift for example yeah um yeah

46:14

but i think you handled it well anyway i think i think is it you're a lot more cognizant of it

46:20

i mean i i don't think i matured earlier you know early enough to be

46:26

honest whereas i think the junior doctors now far more mature than i was

46:32

at the same stage and i think you're therefore thinking a lot more about life and

46:38

you know the complexities of it and the balances of it and much better than

46:44

i think what i did yeah yeah

46:50

so um on that note now do you have like systems in place in

46:56

your life like a morning routine because you do so much you're extremely productive do you have a morning routine that uh you use to kind of get ready or

47:03

a night routine or uh systems in place um a lot better now yeah

47:09

i mean early in early in my career i did too much on the work side of things

47:16

and you know come home and still work at home and um and that went on for too long in

47:22

retrospect [Music] so time again i wouldn't do that

47:29

and i would just achieve goals a bit later than i achieved them before

47:34

i think that would have been a much more mature approach a worldly approach to it

47:40

what slowed you down what was because it takes um a lot of

47:47

and like a insight to to not just go gung-ho

47:53

on the career pathway um and something depending on your career you can't like you can't do it you can't do part-time

47:58

neurosurgery no matter what you are yeah it's doing that yeah but uh yeah

48:04

for you what made you kind of take a step back um it's interesting i'm not entirely sure

48:10

of the answer to that question but one of the things that's happened is along the way

48:16

you'll get certain recognitions you know you you made professor or whatever

48:22

and it's all great and you go out for dinner and you have a champagne and whatever but the next day you kind of wake up and

48:28

you're still the same person and so i think you kind of realize that

48:33

these milestones that you might have set yourself um and not

48:39

that fantastic compared to other parts of your life and so i think for me a little

48:44

bit of it has been that um just coming to the realisation that these different milestones you know

48:50

publishing this paper or you know getting to this point in your career or whatever

48:56

they've all been good but you know they weren't this the most important thing so probably so what was

49:02

the most what because you know we've talked about you wanting to live life as good as possible given all the exposure to the

49:08

end of life you've had and and uh and now kind of realizing that sometimes

49:14

the academic achievements aren't everything although very important in a meaningful career

49:19

what do you find is the most important parts of life to live a good life

49:25

um i've got a very good friend who summed this up for me quite some time ago and

49:31

he said and i think he's right he said the first thing is you've got to have strong relationships

49:39

and secondly you do things for other people and thirdly have a spirituality

49:48

and if you think about those three things in medicine relationships

49:53

we're so blessed i mean i'm i'm lucky i've got great relationships with my family i've got

49:59

a fabulous wife but the kids are great we've got four and another almost one on the way

50:06

grandchild wow we see them all the time that's great we you know the families together a lot

50:12

you know and that's just been fantastic i've got friends who i went to school

50:18

with um friends who i went through uni with and lots of friends that i've met since

50:24

then inside and outside of medicine the relationship side of it

50:30

at a personal level has been so helpful at you know different crisis

50:35

times along the way and on a day-to-day basis is great

50:41

and then in medicine we're even luckier because it's such a privilege to be a doctor and

50:46

we can have relationships with all these people that you haven't met

50:52

until last week you know um and you can continue those relationships in

50:58

many aspects of medicine for 30 years or more um so that relationship side i think is

51:05

important doing things for other people i think i'm more cognizant of that

51:10

since he talked to me about this um but again you know that doesn't have to be

51:16

running a clinic somewhere or going to tanzania it has to it can be as simple as

51:22

being cognizant that i'm a doctor whether i'm an intern or a senior consultant

51:28

and i've got a patient and family and and other staff and students and things

51:36

that i have to care for and do something good for them like a

51:42

nice conversation and i'm deeply grateful that you've taken the time to do this

51:49

thank you so much for your time sorry last question uh and it's about the spirituality how did you find your

51:54

spiritual because as a as a bit of context i kind of wish i was religious i um and i was raised catholic

52:02

and and i kind of am not um i just like when i think of the probabilities of

52:08

whether humans kind of came up with these um stories versus whether they're real or

52:13

not to me the probabilities don't play out uh in favor of the kind of

52:20

supernatural or whatever you would use to describe it but um i also

52:25

think that i haven't been tested on that because it's it's all like as a agnostic

52:31

or atheist it's all good to say that when life's going well but it's a different thing when my life

52:36

gets tough and i haven't been challenged by life in a way that challenges

52:41

you know like what's my meaning kind of thing because things have gone very smoothly i'm very privileged and

52:47

grateful for that but for you how do you like what is your spirituality how did you find it

52:52

later years just 20 years ago really came back to christianity as

52:58

and i think what i would say to you is there's a vast difference between spirituality and religion

53:05

religion is very much constructed and that's why there's so many religions

53:13

but everyone's got a spirituality frank brennan taught me this that

53:18

you know that innate um questioning of who am i

53:24

where do i sit in the universe or the spirits

53:29

um you know what is my purpose in life this is not

53:34

human so much as spiritual and that then can dovetail nicely with

53:42

some religions uh and not so nicely with others and i but i think

53:48

frank's right everyone's got an intrinsic spirituality and for some

53:55

you know there might be christianity or buddhism or whatever there's a religion that can then

54:02

intertwine with that and enhance so um mark what a what a beautiful way to

54:08

finish what has been a very insightful and wonderful conversation so my pleasure thank you so much thanks so

54:14

much