Bashar al-Assad trained as a doctor. How did he become a mass murderer? | Ranjana Srivastava

Preparing dinner, I bite my tongue as images of the latest atrocity in Syria flashes on the screen.

“Isn’t he a doctor too?” my daughter asks.

“Yes,” I cringe at the “too” and rededicate myself to the carrots.

But she knows that conversations about medicine are usually far more animated in our household and immediately sniffs out my reticence.

“I don’t get it. Aren’t doctors supposed to help people?”

Since it’s too late to switch channels, I say something benign. But the footage continues, leaving her to conclude, “I guess not all doctors save lives.”

The heart-wrenchingly succinct statement goes to the heart of my own dismay at the appalling crisis in Syria. More than 400,000 dead, most recently in a nerve gas attack. Six million citizens internally displaced. Five million refugees fled to neighbouring countries. An entire country in spasms. And to add to the unspeakable tragedy, at the hands of a president who used to be a doctor. Not just a theoretical doctor, not one of those who enrolled in medical school but never touched a patient. No, Bashar al-Assad was a proper doctor who by all accounts was personable and polite.

A doctor who studied first at the prestigious Damascus University, then committed to post-graduate training and finally went to London to gain further experience in ophthalmology, a niche medical specialty with many aspirants and limited places. A doctor whose boss recalled him as humble and whom nurses thought exemplary in reassuring anxious patients about to undergo anaesthetic.

To his medical class he was unassuming, seemingly unaffected by his status. Perhaps he had secured admission in the way of other entitled offspring, through power and privilege, but he seemed to be at ease with the responsibilities of being a doctor.

Some classmates kept their distance, wary of the dictator-father’s long reach. Some suspected he didn’t have it in him to be a leader, but then, the world needs good followers and it would have been quite normal for Assad to have settled in a leafy corner of London and practised his craft. Not necessarily groundbreaking stuff, but solid, dependable, everyday medicine that relieved the suffering of many. No one thought he would turn out a mass murderer.

Upon becoming president, he returned to London with his glamorous and accomplished wife, herself a cardiologist’s daughter, who presumably possessed insight into a doctor’s obligations. At his old eye hospital, he looked longingly at a slit-lamp and fondly recalled his medical training.

When he was recalled home, Syria was in the grips of a rebellion, Sunni fighting Shia against a backdrop of roiling tensions in the Middle East. Perhaps Assad, the urbane, London-educated ophthalmologist who spoke of Syria’s “own democratic experience”, would be the people’s advocate, the agent of change. But alas, the Damascus spring didn’t last and Assad the kindly doctor transformed into Assad the feared killer.

Revulsion at the horrific abuses perpetrated by the Nazi doctors – Josef Mengele most infamous among them – led to the development of the Nuremberg Code, which govern the ethics of human experimentation. Radovan Karadžić was a psychiatrist and a poet before being convicted of genocide in the former Yugoslavia. British doctor Harold Shipman injected lethal drugs into more than 200 patients, and American cardiologist Conrad Murray was convicted of homicide after injecting Michael Jackson with the anaesthetic agent, propofol.

History has witnessed other doctors turned rogue but Assad’s attack on his own people is staggering by any standard. He has gone from bombing civilians to destroying entire hospitals, and whatever and whoever lies in their wake. Nearly 800 medical personnel have been killed and many others detained and tortured. Four hundred medical facilities lie in ruins, their hapless occupants either dead or badly injured.

Doctors around the world regard Assad’s deeds with dismay and horror

Entire cities have been left without medical aid, turning treatable injuries into fatal wounds. The United Nations has pleaded that “even war has rules” but experts say that no previous war has witnessed such deliberate, systematic targeting of medical facilities and health professionals.

It defies belief, but in a way it makes sense, that a doctor who once felt the pulse of people, knows that the way to still that pulse is by aiming his strongest weapons at the hospitals that keep people alive and give them hope. It would take a doctor to predict the psychological devastation and desperate surrender of a people robbed of gauze for a bleeding wound, antibiotics for a festering sore, surgery for a lodged bullet.

There are interesting views on how someone who once pledged to save lives could so wantonly destroy them. Perhaps he is striving to prove himself to his dead father who had openly favoured his older son who died in a car accident while Assad was becoming an ophthalmologist. The younger Assad was teased for being interested in human blood rather than the blood of politics – this is the revenge of the bullied.

Or more chillingly, all that medical training was just a show and behind the suave specialist lay a murderer who always had the measure of his power. Medical training necessarily inures doctors to pain and suffering: imagine how inefficient a doctor would be if he faltered at a patient’s every tear and cried over every wound. Part of becoming a good doctor is to learn to stand back enough to help, but most doctors experience a continual tightrope in maintaining a professional boundary while being empathetic. Perhaps Assad just dumped the empathy while fortifying the boundary.

Doctors around the world regard Assad’s deeds with dismay and horror. They know how many of their colleagues leave medicine for far, far smaller reasons than killing a patient. Most doctors can’t bear having a stain on their conscience for missing a diagnosis or misprescribing a drug, never mind that the patient wasn’t even hurt. Doctors take their own lives at the mere thought that they did something wrong. It beggars belief that someone who was once one of them could so systematically and remorselessly kill his own classmates and their patients.

History will diagnose Assad one day but in the meantime, when I see my Syrian patients I can’t help wondering whether to just treat their illness or acknowledge their deeper wounds. Their fragility is obvious as is their concern and shame.

Assad’s crimes against humanity seem distant until they are personalised in the form of a son, a mother, a neighbour. The easiest answer is to feel helpless and stay silent but it just doesn’t feel right. Another is to express solidarity with our fellow human beings even as they live unrecognisable lives in distant lands. This, too, can feel inadequate in the face of punitive government policies. A third is to support the courageous professionals and the organisations that are determined to stay put in Syria against the odds. Most of us won’t go to Syria because we are not skilled or capable of working in dangerous and impoverished settings. But we can be effective through donating to credible charities, such as the Red Cross, The White Helmets and Médecins Sans Frontières, who can channel our aid where it is needed.

Our gestures can seem insignificant in the face of so great a tragedy but I hope it says to the Syrian people that while their own doctor president has given up on them, the rest of the world has not.

Bashar al-Assad trained as a doctor. How did he become a mass murderer? | Ranjana Srivastava

To stop doctors ending their lives, we need to hear from those suffering | Ranjana Srivastava

The ceilings soar impressively high, the stained glass windows are exquisite, and the satin-adorned pews stretch majestically to the dignified altar. Amid the silence punctuated by the barest of sobs, I spot doctors whom I have long lost track of. And row upon row of nurses, still tight years later. As we wait for the service to begin, we imagine we are all silently interrogating our memories about each other. Time parted us for decades before we have gathered in such dreadful circumstances.

“I wanted you to hear it from me,” a colleague had said, audibly upset on the phone. I nearly collided with the pavement when I heard.

She was wonderful, the speakers confirm that morning. Her boss delivers an impassioned eulogy about an inspired clinician and a devoted mother to the children who sometimes tagged along on weekend rounds. Her best friend recalls their last conversation that ended with the doctor saying to the nurse, “Go home, don’t work so hard.”

Her husband quietly expresses gratitude for their years together and grief for the stolen ones. Her parents sit mutely, heads hung low, suddenly and irrevocably aged. A slideshow of pictures, depicting ordinary things – licking ice cream, dropping of the kids, medical graduation, the first day of internship – suddenly turned unmistakably poignant. The audience is frozen in a horrible dream.

Outside, there is more heartbreak. “We have to say goodbye to Mummy, just us,” the children’s father says softly. We, the gathered, hold our breath lest it makes a sound. Gently, under the flowers she so loved, she is lifted into the car. It’s soon a mere dot on the road. There are refreshments but the crowd disperses awkwardly, wordlessly, not trusting ourselves to speak.

We had known each other well enough in our early days, biding time on endless night shifts, watching dawn break, praying that the nurses would save the next page for the day crew. Later, our lives diverged, each assuming the other was successful, busy and content. The final time I saw her was shortly before she died.

It had been a fractious day; I felt brittle, from a distance she looked happy. What would have happened if we had stopped to talk?

If she had asked, “How are you?” I’d almost certainly have smiled, “Fine.”

And if I had asked, “How are you?”

Could she conceivably have replied, “Suicidal”?

After the gut-wrenching news of her suicide starts the inevitable soul-searching. It was a bad boss. No, a troubled marriage. Parenting had taken its toll. Or her disagreeable colleagues. She seemed so normal in the days leading up to it. No, far from it. She was upset, anxious, disillusioned. The only thing you learn is that for someone who was surrounded by observant and intelligent people, no one really knew much at all. No one knew what went through the mind of a vibrant and capable doctor in the prime of her life, who one day decided that life wasn’t worth living anymore.

Unfortunately, this isn’t the first time I have encountered the suicide of a colleague. Some I had known personally; others were brought close through mutual patients, and still others I would never get to meet because they had ended their life before starting a new rotation. In every instance, other doctors did not realise the depth of their colleague’s mental anguish. “I wondered about her but didn’t want to intrude,” someone ruefully recalled. “I didn’t think it was possible,” reflected another.

Four junior doctors have taken their lives in the past six months in Australia.In my busy hospital, I observe a roundabout of students, residents and specialists in difficulty. But how much difficulty? When they say they’re having a bad time, is it a bad week, a dreadful year, or a tortured life? Are they upset about a rejected grant or do they deem their very existence worthless? Forced smiles and tough hides abound in the workplace, where always being “fine” is a badge of honour. This is why it can be so difficult to distinguish doctors who will indeed be fine from those who need help.

There is ample evidence for the high rates of mental illness in doctors, several times greater compared to other professions and the general population. These figures are quoted so frequently at every orientation that awareness should not be an issue. Practically every institution has an employee assistance program that offers confidential help. Some offer free psychiatric evaluation and counselling. And as with other informal medical consults, many psychiatrists will help a colleague in distress, making access to high quality help less of an issue for doctors than many others.

Armed with knowledge and surrounded by advice, why do doctors commit suicide at an alarmingly high rate?

I sometimes fear it may be because as a profession, we are reluctant to swallow the evidence. And if we can’t accept the evidence we can’t help ourselves or others. We can have an intellectual discussion about anxiety, depression or suicide and we can apply the knowledge to our patients but but identifying vulnerability in our own self is altogether different. No matter how many times we hear it, it still doesn’t seem possible that we, or someone like us, could have a mental illness. The consequences seem so vast, the repercussions so numerous that perhaps it’s better to not know the truthful response to “Are you OK?”

Doctors say that the disclosure of mental illness poses a real threat – to license and insurance, career and reputation.

Discrimination, bullying and harassment in medicine are unfortunately never far from the headlines but thanks to brave people who have risked their career, a victimised doctor has more support than ever before. Nonetheless, a career in medicine means always having to keep up with something, whether it’s the latest research, the newest drugs, the next exam or the upcoming promotion. Doctors would like to be perfect at all of these and are genuinely puzzled when life deals them disappointment. It seems ludicrous now but I was dumbfounded when I got my first mark that wasn’t a distinction. Twenty years later, I realised nothing had changed when my registrar failed his specialist exam and told me that “even the walls” were laughing.

When doctors are depressed, their sense of personal failure is compounded by the suspicion that they somehow lack the ability to pull themselves together. The “well” among them can’t understand how the same stressful hospital ward, the same demanding colleagues, the same rocky tenure track can make some of us angry, others sleepless, and yet others suicidal.

In these pressured times, few doctors would be strangers to a variation of the message, “Heard you’re sick. There’s no cover so let us know whether to cancel your patients.” There is no call more disheartening than one that professes to care about the doctor but can seem like a veiled complaint that says, “If you’re sick, we all suffer.” But while it’s quite easy to tell your colleagues that you have pneumonia or a migraine, doctors say that the disclosure of mental illness poses a real threat – to license and insurance, career and reputation. The diagnosis invokes not only sadness but also ignominy, which may be why there are so few well-publicised stories of doctors with mental illness.

For much of my career, I have watched policies, promises and campaigns about combating mental illness and suicide in doctors. Our knowledge is evolving and with it, ways of managing mental illness, but with many lives lost each year, we don’t have the luxury of time.

Since we can’t always read the suffering of our colleagues, humanity in all our professional dealings and concern and compassion for every colleague must be a priority. As well as this, a healthy dose of introspection about how we judge doctors with a mental illness and why we judge them differently, arguably more poorly, than our patients.

When it comes to mental illness, we hear a lot from the experts but not enough from the sufferers. But in fact, nothing would be more welcome than the insights of doctors who have endured mental suffering and worse, been on the brink of suicide. What healed them and who helped them? What could their colleagues have said or done differently at the time? What workplace adjustments would have meant the most? These stories are clearly among us – hearing them could illuminate the dark corners of our understanding and help link theory and practice.

As a profession, we must do more than lament our dead colleagues. Dealing effectively with mental illness and halting suicide among doctors requires curiosity, compassion and practical support. Most importantly, it requires the humility to realise that in the long span of a career, none of us is immune and that those doctors whom we help today could end up saving our life tomorrow.

• In Australia, the crisis support service Lifeline is on 13 11 14. In the UK, the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Hotline is 1-800-273-8255.
  

To stop doctors ending their lives, we need to hear from those suffering | Ranjana Srivastava

The real quest of cancer treatment: dispensing the right mix of hope and reality | Ranjana Srivastava

“I just need a letter to say I am fit to fly,” he says, my young patient who has gone from being a paragon of fitness to needing a walking stick in a space of only two years. Today, he is on an unscheduled visit, promising not to stay long, not that I mind. I’m fond of him and have grown to admire the way in which his family has coalesced at a difficult time. His wife left her job, his pregnant daughter has moved in to help, and his two sons are always around for appointments.

But fit to fly? I’m alarmed.

Fly to where? He is pale and gaunt, his eyes magnified on a cachectic face. But his spirit seems valiant as ever, which sends me scrambling to wonder when we had discussed this impending trip, how it slipped my mind, and most importantly, why I had not encouraged it well before these final days of his life.

A flight from Melbourne to Sydney perhaps. Easy and short. Or further maybe, to Alice Springs – difficult but not impossible. Several times I have stopped palliative chemotherapy to honour a patient’s wish to take a trip.

“Where are you flying?” I ask.

“Asia.” he says, and I do a double-take. “They have curative treatment there.”

I should have guessed.

“There is this famous hospital where they give special therapy to kill cancers that have stopped responding to chemo. They sound amazing.”

Every oncologist spends time drawing a distinction between useful adjunctive therapies including reflection, meditation and exercise and dangerous extreme alternatives like exclusion diets and vitamin overdoses, but judging by his tone I calculate that my time would be more wisely spent trying a different approach.

“I am worried about you deteriorating while overseas in a country that has poor hospitals and no palliative care services. I’d hate for you to be stuck”

“I’ve spoken to them, they can fix me,” he says.

“They can’t fix you,” I gently respond. “I know this is really difficult but stay here and let us help you. At least give it some thought.”

Brandishing a manila envelope, he says, “The flight is booked, we leave tomorrow.”

Many retorts, pleas, and memories of misadventure cross my mind, still I hold my tongue, understanding that the measure of grief and the promise of hope amount to much more than the weight of my frustration.

“Doctor,” says my patient. “You have nothing further to offer me, please don’t block my way.”

We arrive at the impasse we had to have.

“I won’t change your mind but I can’t declare you fit to fly,” I say.

At this, I think of the times I have been called to assist ill patients on long-haul flights. Many were emergencies but some not. An elderly lady had felt unwell throughout that day’s dialysis and subsequently suffered an arrest on the plane. “Who cleared her to travel?” I plaintively asked her husband as she drifted in and out of consciousness.

Her situation had stressed hundreds of passengers, distracted the pilot, and put a nurse and me in the impossible situation of resuscitating a patient with bare resources and deafening noise.

I regard my desperate patient with something of my own desperation as I ponder my duty of care. Is it to my patient, reliant on me for a final morsel of hope? Or to all the unseen travellers who may be inconvenienced if by chance he falls ill on the flight?

To temper my pessimism, I remind myself of the grateful patients who didn’t succumb to my dire predictions. The breathless Greek patient who had lived his entire life in Melbourne but who got hold of oxygen and begged to die on home soil. The grandmother who decided that the only way she could make amends to her estranged daughter was to embrace her grandchildren who lived in Egypt. The patient who braved a trip to India by ingesting extra morphine and whose wife wrote to say his final weeks with his whole family had been the most consoling.

This man’s reasons were different but who was I to be impatient around, and judgmental about, people whose decisions departed from mine? So with my patient watching I write the most honest letter I can. It states his wish to seek treatment in a foreign country, my opinion that patients like him can deteriorate unexpectedly, and my sincere hope that he remains safe. He deems the letter fair; his family is clearly displeased.

I feel rattled until I hear that the flight was uneventful. But then the heartache continues because the treatment centre “took one look at him and told him to turn around and go back home”. Which he manages to do before plunging into further decline and succumbing to his illness a short time later in a trajectory that had been predicted.

In the ensuing months the family resists all contact, perhaps feeling angry and let down by all the people who failed their loved one. Meanwhile, the team, too, lacks closure and feels inadequate at not being able to prevent preventable suffering at the end of life.

We muse that perhaps the hardship would have felt worse had they not pursued this last avenue of hope. And maybe the only thing left to give a vulnerable patient is the gift of autonomy. These and other thoughts swirl in my mind, no doubt to be tested in the case of another patient and another patient after that, with every outcome testing and unsettling in its own way.

So many advances in cancer, so many protocols, but still missing is the protocol that says, dispense just this much fact, mix just so much optimism, offer precisely this much warning, infuse just so much hope and things will turn out fine.

For doctors, it’s about how to stand up to – and stand by – our patients to give them the very best of medicine but shield them from the worst. For patients – when to question their own discussions and when to place their trust in ours.

On many days, this seems to be the impossible quest.

The real quest of cancer treatment: dispensing the right mix of hope and reality | Ranjana Srivastava

The three questions that every patient should ask their doctor | Ranjana Srivastava

An unimpressed nurse summons the oncology fellow to the chemotherapy chair. “I am not prepared to treat him with chemo. He can barely stay awake.”

“But his oncologist wants to push on,” the fellow responds.

“The patient doesn’t seem to understand how sick he is or how chemotherapy is doing harm. You’ll need to sort this out, I am afraid.”

The fellow sighs, caught on the horns of a dilemma.

Elsewhere, an elderly woman has taken warfarin, a blood thinner, for some time, and now presents with a massive cerebral bleed. She was going to the kitchen one moment and unconscious the next; she is expected to die shortly. As I console her stricken son, it emerges that she had sustained 50 falls that year leading up to the fatal one. There had been many doctor visits but no one had asked specifically about falls.

At the desk, as I solemnly write a note, I overhear the same exchange that’s going on in my head.

“Fifty falls!” one dismayed resident says. “Why would you put her on warfarin?”

“Because someone wanted to reduce stroke risk and someone else watched her heart disease but no one thought of the whole patient.”

“What were they thinking?”

If you listen to doctors and nurses, this is one of the most common questions you will find them grappling with and grumbling about. It reflects part genuine puzzlement and part exasperation that what one doctor has recommended seems ill-advised or even inappropriate to another.

The Grattan Institute estimates the cost of wasted healthcare dollars to be in the order of a billion dollars and the figure stings clinicians but as a disillusioned young doctor sighed, in the age of super-specialisation, it seems expedient to let every doctor manage “their own organ”. Except the practice harms patients who are after all, more than a collection of organs.

If highly trained doctors don’t understand their colleagues’ intentions it stands to reason that most patients feel even more hapless, caught in an endless tangle of tests and explanations but the knowledge and power asymmetry is such that it’s impossible to question the doctor, who must surely know better (if not best).

Physicians overestimated the effect of some interventions on life expectancy by as much as 30%

Unnecessary and expensive medicine is at an all-time high and the usual reasons given are patient expectations, financial incentives, therapeutic uncertainty, medico-legal fears and the sustenance of hope. Now a new study in JAMA Internal Medicine authored by two Australians points out that when it comes to unsound medicine, there is another element at play. It turns out that when prescribing a drug or ordering a procedure doctors are actually quite bad at estimating the benefit and harm associated with it.

In a systematic review of 48 studies performed in 17 countries and involving more than 13,000 clinicians, they found that doctors rarely had accurate expectations of benefits or harms. The inaccuracies were in both directions but more often, harm was underestimated and benefit overestimated.

No group of doctors fared well. As a result, children with acute ear infections may be overprescribed antibiotics and women with troublesome postmenopausal symptoms may be deprived of hormone replacement therapy. Obstetricians and neurologists underestimated the risk of birth defects from antiepileptic drugs and GPs overestimated the benefit of prostate cancer screening and underestimated the benefit of warfarin for atrial fibrillation, a common heart condition. Transplant surgeons were biased towards an inaccurately low estimate of graft failure and all types of doctors were unaware of the risk of radiation exposure from imaging.

Physicians overestimated the effect of some interventions on life expectancy by as much as 30% and for elective but by no means inconsequential surgery on the thyroid, lung, prostate and uterus, there were clinicians who believed that complications “never occurred or had a rate of zero”. Dermatologists couldn’t agree on psoriasis treatment and psychiatrists differed on the risk of harm from long-term antipsychotics. There was a reluctance to convey a numerical estimate of benefit and worryingly, clinicians “overwhelmingly recommend the interventions they provide”.

This study is a wake-up call for doctors because it speaks to our collective failure to appreciate that in prescribing more for our patients we don’t always help, and indeed, commonly inflict harm. The goal of good medicine is not only to avoid harm but also to provide actual benefit, a distinction that’s commonly blurred, including in oncology. Chemotherapy at the end of life improves neither quantity nor quality of life. It leads to more invasive procedures and greater likelihood of dying in an intensive care unit but patients continue to receive it.

In the reign of evidence-based medicine it is discomfiting news that doctors may not understand the data in the form of hundreds of thousands of studies poured upon us.

First, as any patient knows, the art of medicine matters as much as its science. Evidence applied without tact, consideration, empathy and an understanding of the patient’s perspective can be as harmful as evidence not applied at all. Doctors are increasingly exhorted to provide collaborative care and practice shared decision-making. The catch is that both art and science suffer when we don’t know the facts or struggle to convey them.

Part of the problem is the sheer volume of publications. Entwined in increasing bureaucratic demands many doctors lack the time and also the confidence to interpret academic research so we turn to (commonly paid) expert opinion, “peer influencers” and biased pharmaceutical advertising.

Medical schools run the obligatory statistics course but don’t ingrain in doctors that their interpretation of a journal article or more commonly, an “advertorial”, and their participation in marketing disguised as “literature” peddled by pharmaceutical representatives has a direct impact on patient experience, the cost of care and wasted healthcare dollars. Hospitals who should care even more about such education virtually ignore it and when it’s volume, not quality of care that’s rewarded, it all but extinguishes the desire to do better.

Meanwhile, what should patients do? The JAMA study suggests that doctors frequently don’t know and certainly, don’t know best. This is vexing but not all doom and gloom because doctors now have at their disposal an unprecedented number of sound guidelines, robust protocols and genuinely plain-language information for patients, not to mention easy web-based access to experts. When it comes to doctors seeking advice the world really is a global village. In a world of rapidly evolving information, patients should be prepared for a doctor to say, “I don’t know” provided this is followed by, “but I’ll find out.”

Here are three questions that every patient should ask of every new proposed drug or intervention:

• What are my options?


• What are the specific benefits and harms to me?


• What happens if I do nothing?

If patients asked these questions more often and doctors took it upon themselves to answer faithfully, medicine might yet experience a new dawn.

The three questions that every patient should ask their doctor | Ranjana Srivastava

If I have cancer will I die? You asked Google – here’s the answer | Ranjana Srivastava

On a Sunday afternoon, a relative calls. She is at a party and wonders if I can help a friend of a friend.

“Her brother is having cancer treatment and wanted to talk to you.”

“You know I don’t like doing this, especially if there is another oncologist involved.”

“I know,” she says contritely. “But she is so shocked and I thought just your words might help.”

Suppressing a groan, I ask: “What kind of cancer does he have?”

“It’s some form of blood cancer.”

“He needs a haematologist. I can try to suggest one.”

“Oh, that won’t do,” she says. “He lives in Germany.”

“Germany has really good healthcare! He doesn’t need my advice, especially on a disease I don’t even treat.”

“But people like us, we hear the word ‘cancer’ and freak out.”

The friend of a friend is a wreck and I can’t bear to turn down her request. So although there is very little I will say, I patiently hear her out. Her brother indeed has cancer and has met his German oncologist, commenced chemotherapy, and seems to be doing OK. He has young children and the family is anxious about prognosis. The friend asks me many times if he will die from his disease. I tell her as many times as I can that he seems to be in competent hands and that the question about prognosis should be directed towards his treating doctor.

I long to tell her that he has a highly curable disease but without knowing all the details, this wouldn’t be right. I end the call feeling somewhat like a politician, having batted away every meaningful question with a platitude but my hands feel tied.

“If I have cancer, will I die?”

As an oncologist, it’s both interesting and poignant to know that this is one of the most common answers people seek from Google. Dispensing with the obvious, “Everyone must die”, the answer I hope Google would give is: “Tell me more.” Google should ask for not just the type of cancer but the colour of your skin, the language you speak, how much you earn, what country you live in, the distance to the nearest cancer centre, and crucially, if you are married.

‘The disparities in cancer outcomes based on the socioeconomic gradient are significant and sadly familiar to every oncologist.’ Photograph: Enrique Castro-Mendivil/Reuters

In the developed world, cancer survival rates are increasing. An Australian patient diagnosed with cancer today has a 67% chance of being alive in five years. Cancer Research UK states that cancer survival rates in the UK have doubled from 24% to 50% in the past 40 years. A recent American Cancer Society report calculates five-year survival for all cancers as having risen from 49% to 69% in the past 40 years.

If you have survived the first five years, the chance of long-term survival is increasingly optimistic, more than 90% for all cancers combined. These improved outcomes are attributed to early diagnosis and better treatments. Modern chemotherapy and radiotherapy regimens are unrecognisable compared to earlier decades. The march of immunotherapy continues, with new drugs able to delay cancer progression and extend survival in traditionally bleak scenarios including melanoma and lung and bladder cancer.

We now know that cancer is actually many different diseases, cancer cells are extraordinarily smart at outwitting the body’s defences, and a reasonable goal ought to be keeping cancer patients better for longer rather than expecting to banish cancer altogether. Amid the high survival rates for common cancers such as bowel, breast and prostate, detected early, the outcomes for brain, pancreas and stomach cancers remain dismal, with most patients expected to live for only a few years.

But apart from tumour biology, what else affects survival? Being male, an ethnic minority and being non-English speaking confers poorer outcomes as does social disadvantage, illiteracy, poverty and living far away from the full suite of services that modern treatment demands. The disparities in cancer outcomes based on the socioeconomic gradient are significant and sadly familiar to every oncologist, who nonetheless spend most of their time prescribing drugs because this is what they feel best equipped for.

Interestingly, marriage (but not living with a friend or a child) conveys a consistent and substantial impact on cancer detection, outcome and survival. Married people seek earlier attention for concerning symptoms, are more compliant with treatment, and die with greater psychological support. Married men benefit somewhat more than women but in the case of five common cancers, the overall impact is greater than published results of chemotherapy, leading the Journal of Clinical Oncology to state baldly: “Marriage is as protective as chemotherapy.”

It’s fair to say that if you are a cancer patient lucky enough to live in the rich world, you can be increasingly optimistic about your chances all along the continuum of cancer care, from diagnosis to terminal care. But what if a person living in a poorer country asks the same question? Unfortunately, the answer is more likely to be a straightforward: “Yes, you will die.”

Have scientists found the cure for cancer?

There are 14m new diagnoses and 8m cancer deaths each year. A staggering 70% of deaths happen in Africa, Asia and Central and South America. Poverty, poor governance, inadequate infrastructure and scarce specialists all play a role. Many countries have pockets of excellence but there is no comprehensive and easily accessible programme of cancer education, screening, treatment and palliative care.

Globally 20% of cancers are related to tobacco, use of which remains common, cheap and unregulated. Another 20% are attributed to vaccine-preventable infections such as Hepatitis B and C and the human papillomavirus. Patients suffer from the twin curse of living in cancer-promoting environments and lack of access to help when they need it.

But even if one took the sanguine view that everyone must die of something, it is the abject state of palliative care that should jolt us from complacency. While we may be occupied by opioid abuse, access to morphine remains a pipedream for most people around the world. Fully 90% of the world’s morphine is used by patients in the US, Canada, Europe and Australia.

Meanwhile, the vast majority of cancer presentations in developing countries are with advanced disease, where effective palliative care is not only the most practical but also the most compassionate intervention. But oncologists there have stories, such as the dying patient with a bleeding, infected and painful cancer who has travelled hundreds of kilometres in search of pain relief only to be sent home with paracetamol or ibuprofen, or nothing at all. Morphine is arguably the cheapest and most effective drug for palliation and is on the World Health Organisation’s list of essential medications but due to health illiteracy, stigma, misguided fears and misinformed government policy, dying with dignity is no more than an aspiration for most patients around the world.

As an oncologist, I am regularly humbled by patients’ disclosure that they lost track of everything else I said after the word “cancer”. Treatable or not, the very encounter permanently alters the lives of those who suffer and those who must watch on. No one, no matter where in the world, is “lucky” to develop cancer, but the next time you turn to Google and ask “If I have cancer, will I die?”, it may help to know what a loaded question it really is.

If I have cancer will I die? You asked Google – here’s the answer | Ranjana Srivastava

When pain persists: what makes hospital patients really unhappy? | Ranjana Srivastava

A ninety-year old woman has lain shrivelled and uncomfortable in her bed for forty hours, awaiting an operation. She has become heavily constipated as a result of an over-enthusiastic prescription of anti-diarrhoeal tablets and is now at risk of a bowel obstruction.

The surgeon says that the hardened faeces need to be manually evacuated under anaesthetic but it’s the weekend and only one operating theatre is open, with a bevy of surgeons desperate for the same limited resources. My patient doesn’t speak English and I don’t speak Polish but the language of starvation and defeat is universal.

No words of consolation will relieve her of the suspicion that she has been abandoned because she is old. Her bleary-eyed, septuagenarian son, wants her to taste a piece of her birthday cake because today might be her last birthday.

“Doctor, can my mother have cake?”

If she fasts, the surgery might happen. But if she eats, it definitely won’t. If she has the surgery, she might die. But if she doesn’t, she might also die. I wish he didn’t have to ask the question and I wish I didn’t have to answer it.

I have already argued with the surgeon, who is a trusted friend, and who is even more upset than I am, asking me to imagine how he feels when patients and doctors blame him for delaying surgery when he spends entire weekends biding his time to get into theatre.

“But you’re the surgeon,” I say. “Who has the authority to open another theatre?”

“Bureaucrats, who don’t work weekends.”

I am driving home hopeless and helpless when a colleague calls. “My hospital says patient experience surveys rate me as being in the bottom percentile of providers. How can this be when I give my heart to medicine?” This from a woman whose greatest concern during a difficult pregnancy was who would look after her patients when she took maternity leave.

She is surprised when I laugh, “You can’t be at the bottom because I am!”

Soon, we are swapping stories of doctors who are equally stumped by surveys that call into question their approach to patient care and seem to put the blame at their feet for not doing better.

One might have thought good medicine was always about the patient but patient experience surveys are the latest trend in healthcare. Done at significant cost and with good intention, they seem reasonable enough. After all, in order to address the matter, it’s important to know what makes patients unhappy.

As the saying goes, a happy patient can still be a dead patient

But poor patient experience surveys must be an executive’s nemesis. Pleasing political masters means performing magic and making the problem vanish, preferably before an election comes around, but addressing the cause is a lot like peeling an onion, uncovering layer upon layer of challenge that makes one weep.

Firstly, patient experience is not the same as patient satisfaction. A patient who is shaken awake every four hours might be in a rotten mood the next morning but those neurological observations might just have saved her life.

A patient denied jam on his toast might say the service stinks but better a grumpy diabetic than a comatose one. As the saying goes, a happy patient can still be a dead patient. But patients aren’t naïve and many understand the clinical imperatives that determine their experience.

Whether it’s waiting hours in the emergency department, being stuck on a trolley, facing delay in surgery or awaiting chemotherapy, very few patients make an actual fuss – because they see that doctors and nurses are doing their best.

Indeed, the neediest patients tend to complain the least – perhaps because they are tired but also because their experience of chronic illness has taught them patience and empathy. No, this should not be an excuse for provider complacency.

For most patients, a genuinely poor experience results from a lack of communication and a failure of compassion. Combine deferred surgery, lying in a trolley, a cancelled appointment and a hurried consultation with a lack of decent explanation and no acknowledgement of suffering and you have a real problem with patient experience.

A poor patient experience is leaving an incontinent patient wet because there is a shortage of nurses and when a confused patient can’t be fed because the nurse has two hands and five patients. It’s when you can’t reach your water jug, and when you do, it’s empty. It’s being desperate for a hot tea, a warm shower and a working call-bell. When patient dignity suffers, there are no winners – a bad patient experience is a guilty provider experience. Realising this isn’t rocket science but ushering change is really hard.

Hospital medicine is increasingly conducted amid apologies

Every frontline clinician knows that no amount of ward redesign, geographical shuffling of patients or imaginative rebranding will solve the fundamental problem of having fewer doctors and nurses on the floor to deal with increasingly complex patient needs. Studies show that extra staffing of registered nurses improves patient outcomes. Nurses flag early signs of deterioration, help patients mobilise safely, and step in when doctors don’t or won’t communicate effectively. Having good nurses on the ward transforms the environment – interns feel secure, specialists feel supported, and patients benefit from earlier discharge and lower readmission rates.

An ageing population has placed an unprecedented demand on allied health services like physiotherapists and social workers but it seems as if no one saw this coming. Try finding a service on a weekend and you could be waiting all day.

“If your patient isn’t homeless or destitute right this minute, I can’t get to it,” apologised one lone, harried social worker covering an entire hospital.

Heart and kidneys don’t wait for a quiet weekday to fail. An appendix doesn’t wait for an available theatre to burst. Tottering patients don’t know not to fall on a Sunday. Clearly, infrastructure and planning are not for an individual doctor to fix but when hospitals perform poorly, the spotlight shines inevitably on doctors.

Hospital medicine is increasingly conducted amid apologies. I am sorry you can’t have your operation today. I am sorry the morphine took so long. I am sorry you have vomit-stained clothes. I am sorry your son left before a doctor could get here.

The apologies are necessary and it’s humbling that they heal more than mere words should, but apologies without action slowly erode us because we know that tomorrow will be filled with more apologies and so will the day after and the day after that. Those who engage with patients know that you can’t soothe and trick people into thinking they are getting better care – you actually have to provide it. But as long as bureaucrats answer to politicians and clinicians answer to patients, the tension will remain.

Some people just leave. “I get paid better for a different headache,” says one surgeon, who quit the public system after ten years of battling a dysfunctional outpatient system. But many others stay, in part due to a philosophical belief that their exceptional training should benefit the least well-off in society. It is especially these doctors and nurses we want to shield from disillusionment.

Having observed healthcare delivery in some of the best institutions in the world, I have been struck by one observation. It’s when executives regularly make time to visit the wards and interact with patients, families and all manner of providers, from physicians and nurses to porters and aides.

They peer into a decrepit bathroom, pick up a flimsy frame, sit in a wobbly chair, taste the tepid tea – and discover what makes for a poor patient experience. A clinician leader who doesn’t see patients frequently loses touch with their most human concerns. A non-clinician heading finance, operations or human resources, is never exposed to the daily realities of human suffering yet is charged with making far-reaching decisions that impact all our lives. The best leaders make it a point to keep their finger on the pulse – and society is better for it.

Patient experience surveys are here to say, and in time, to financially reward organisations and individuals who do well on them.

But to truly improve patient outcomes organisations will have to do more than probe patients and fault doctors. To borrow from the drug advertisements, when pain persists, organisations will need to talk to their doctors.

But then, they will need to listen.

When pain persists: what makes hospital patients really unhappy? | Ranjana Srivastava

To sustain hope while preserving honesty is the greatest challenge in oncology | Ranjana Srivastava

“You know I am going to beat this.”

“No, you aren’t,” I think despondently.

“With a positive attitude and determination,” he adds.

“Then you’d be the first,” I silently retort.

A successful retired engineer, he is one of those who don’t fall ill until catastrophe strikes.

He had gone to the doctor feeling vaguely unwell and inherited a cancer diagnosis, and with it, an endless series of investigations. For a while, his surgeon sat on the fence – although the primary abdominal cancer was technically operable he had a hunch that the tiny, indeterminate nodules on the lung represented metastases.

“Why won’t my surgeon operate?”

“Because he doesn’t think he can cure you.”

“Do you think he is being too cautious?”

“No, I think he is looking after your best interests.”

His dogged determination refuses to consider the nuances I keep putting forward.

“I’ll do everything in my capacity to help you,” I say.

“I know you will. We’ll beat this together.”

“We may not be able to,” I respond, running away from the battle metaphor.

Unlike other patients, he doesn’t question my judgment or warn me off discussing bad news. He isn’t aggressive or demanding, in fact the opposite. Being a logical man, he doesn’t believe in miracles. But he just has an unshakeable belief that I am his companion in the fight of his lifetime and with me on his side, he can win.

I look across the desk at my well-dressed, thoroughly organised, thoughtfully spoken, impeccably mannered patient and ask myself how I am going to convince him that he has months to live.

I look at his wife searchingly. How does she regard his maniacal self-belief?

He starts chemotherapy and the remarkable response surprises everyone. Moreover, he suffers none of the anticipated toxicities, prompting him to grin, “Are you sure it’s not placebo you’re giving me?” Patients ask this from time to time, belying a real fear that their doctor has given up, so I answer seriously, “I promise you, I am treating you with the most intensive cocktail available.”

“Then why am I not sick?”

“Isn’t that great?”

“We will overcome this!”

I look at his wife searchingly. How does she regard his maniacal self-belief? Will she help me inject reason into the conversation? But she doesn’t utter a word, as if reminding me that the doctor-patient relationship is between me and her husband.

The surgeon calls me to say that he has finally ruled out the prospect of surgery. “He does realise he is having palliative chemo, right?” The surgeon’s mild exasperation mingles with mine, threatening to overflow at the next visit.

As I take a minute to collect my thoughts, I find myself wishing that my patient would say just once, “Yes, I understand I have an incurable disease.” We don’t have to talk about prognosis, compare patients, or dwell on anything other than how great he feels but the acknowledgement would take a burden off my shoulders. 

As these thoughts toss through my mind, my vague discomfort suddenly finds form in a single question, as if posed by an outside observer who is fed up of my attitude.

“Why does his relentless optimism bother you so much?”

I answer my invisible interlocutor with gusto.

“It bothers me because it makes me feel like I haven’t sufficiently explained things to him and maybe, he has taken my silence to mean assent. It bothers me that one day, when his disease inevitably progresses, he will blame me for concealing the truth. It bothers me that his death will be fraught because how will we cross over from joking about placebo to accepting mortality?”

The invisible interlocutor retorts, “But how you deal with your fear and conflict isn’t your patient’s responsibility.”

Stung by the realisation, I face my patient again.

“I’m determined to beat this,” he repeats.

“You know what, that would be truly wonderful,” I answer with a smile, suppressing all my dread and discomfort.

Something in me relents and something in him revels. The next few months are blissful, devoid of rancour and competition. He directs the conversation; I lose the urgency to say anything to tip our fragile balance. When I feel a stab of anxiety about the future, I remind myself that my greatest value to him may be in not undermining hope.

To sustain hope while preserving honesty – this is the greatest challenge in oncology. 

Oncologists attract much disdain from other doctors and patients for withholding bad news, twisting facts and distracting patients from dying well. Studies show that the majority of patients with advanced cancer don’t know that their life is limited and that treatment is not curative. 

Other studies highlight the anxiety and distress faced by patients and their carers when there is confusion surrounding the future and when oncologists don’t play a role in helping shed the uncertainty. But just like cancer represents many different diseases, cancer patients represent many different kinds of people, each with their own needs, longings and expectations. To address them all in one tone would be as pointless as treating all cancers with one drug. Grief has no arc.

Just as I’d feared all along, the cheer dissipates but what takes away my breath is how quickly it happens. One week he is well and the next week he’s glowing yellow with liver failure and in pain. I am dismayed.

“I can do a scan if you want but clearly things look worse.”

I brace myself for the onslaught of protest with a reminder that this is the price of the preceding months of bonhomie. But I am wrong again. He regards the numbers, looks at me, and says as calmly as if discussing the weather, “So this is it, then?”

Tears prick my eyes. Looking at his pale face and sleepless eyes, I yearn to have his old, ebullient self back, the self that wanted to challenge nature itself. I am tempted to lend him some of his hope back but all I can muster is, “I am really sorry.”

He sits there for a while, his face a kaleidoscope of emotions.

“I can’t thank you enough for the way you have held me up,” he finally says. “I’ve always appreciated your honesty.”

He’s got the wrong person in mind, I think dully as I recount my endless quest to save him from his delusions. His humility astounds me, giving rise to a tide of frustration at yet another death at the hands of some invisible, unrelenting process that neither my patient understood nor I could genuinely explain.

The next week, at an unscheduled visit, he looks terrible.

As I write a morphine prescription, he mentions he is pleased to have the beehives sorted.

“What beehives?” I ask, wondering what else I don’t know about him.

“If I can manage the travel, I’ll show you.” He hesitates, then hugs me. I know I won’t see him again.

Defying progressive symptoms, he assiduously ties up loose ends and gives away various belongings. Then, he surprises me one last time by making a final trip to hospital.

I stare at the gleaming jars of honey, pale gold, painstakingly decorated and wrapped, finally understanding just how hard he must have worked to finish the intricate undertaking.

It turns out only one of us was in denial and it wasn’t the patient.

To sustain hope while preserving honesty is the greatest challenge in oncology | Ranjana Srivastava

Statins: Patients are allowed to make poor choices but the media shouldn’t help them | Ranjana Srivastava

It’s clear that her symptoms are advancing and that she was right on the futility of further chemotherapy. She is having trouble staying awake, her appetite is deteriorating, and she is weaker by the day. This may well be our last appointment.

“We can get rid of a number of your medications,” I say, frowning at the long list that her daughter says is proving increasingly difficult to administer.

“Let’s do that,” she says joyfully.

So in one of my favourite acts, I slash half her list, explaining why as I go along.

But she stops me at the statin, an anti-cholesterol drug she was prescribed 20 years ago for a barely elevated cholesterol detected on an insurance test.

“I need that so I don’t die from a heart attack.”

“Not quite,” I say soothingly. “Statins exert their benefit over many years and we agree that now, it’s more important to maintain comfort.”

“I can’t imagine my day without my statin,” she declares, leaving me to wonder somewhat enviously how her cardiologist managed to evince such devout compliance for a questionable cause.

Just then her husband pipes up. He is a sprightly 74, still working, and unlike his wife, detests medications, including the statin he was prescribed after a serious heart attack some years ago.

“Well, I’ve decided that at 75, I am swapping the statin for sausages. From what I hear, the two are as bad as each other.”

She has heard this before because the wife adds with a smile, “At 75 or when I die, whichever happens sooner.”

I urge the husband to discuss his decision with his doctor before stopping treatment, I tell my patient to stop her statin and I bid them both a fond goodbye.

As they leave, I find myself thinking about many recent conversations I have had with patients about statins. With cancer patients who have a limited life expectancy, stopping the statin is both safe and right. But during my stints in general medicine, where we treat heart attacks, strokes and dementia, the answer is more nuanced.

Does everyone need a high-dose statin? How many will experience side effects? Is lifestyle modification a reasonable starting point or should every patient be commenced on a statin? The reality of most hospital management is that a drug is prescribed and the patient finds out as an afterthought. But if a statin, once started, is likely to become a lifelong drug, what considerations are important beforehand?

Many patients have heard of statins but awareness does not mean familiarity and it certainly does not mean being informed. For every person who trusts a doctor’s recommendation to take a statin, someone else suspects a conspiracy theory fuelling the prescription of the world’s highest-selling drug.

For the patient who wants to know more, things can get complicated. A cursory internet search warns that statins make women (but not men) more aggressive, accelerate ageing, damage stem cells, worsen heart disease, cause dementia and are “unhealthy and unethical” to prescribe.

Alongside are studies asserting that statins significantly reduce the incidence of heart attacks and strokes and improve mortality. Their benefits are evident within the first year of intake and accumulate over time, making them among the few drugs to have a dramatic impact on health outcomes. Considering that heart disease is the number one killer in many parts of the world, this is no ambit claim. But pity the hapless patient trying to make an informed choice – it’s hard to know which “expert” advice to heed because everyone sounds knowledgeable.

Very few patients needed to stop statins due to adverse effects.

When I recently prescribed a statin to a young woman with a heart attack and a host of coronary risk factors, she expressed concern. I explained that no drug was without side effects but a new, rigorous, non-industry funded, meta-analysis by the clinical trial service unit of Oxford University, shows that the benefits of statins have been underestimated and harms exaggerated. The results were published in the Lancet medical journal.

Treating 10,000 high-risk patients with a low-cost, generic statin for five years prevented 1,000 strokes and heart attacks and treating 10,000 lower-risk patients prevented 500. Of 10,000 patients, five might suffer muscle aches, up to 100 may develop diabetes and five to 10 may suffer a brain haemorrhage but these side-effects have been included in the estimate of the absolute benefit.

Very few patients needed to stop statins due to adverse effects. It may not be the absolute final word but the meta-analysis concludes that many problems have been misattributed to statins, therefore planting fear in the minds of those at high cardiovascular risk and dissuading them from taking a potentially life-saving drug.

But how did these rare toxicities garner so much attention in the first place?

In October 2013, the British Medical Journal, as part of its mission to promote rational prescribing, published a paper quoting the incidence of statin-related side effects being as high as 18% and thus concluding that statins did not provide an overall health benefit to those patients deemed at low risk. But the 18% figure was based on flawed research and it was apparent that even in the quoted research, the figure was closer to 9%, but without the inclusion of a placebo-controlled group, which meant even the 9% could not be genuinely attributed to statins. (The meta-analysis says that statins are “no less well-tolerated than placebo”).

Seven months later the BMJ corrected the erroneous statements but did not retract the entire paper. Sir Rory Collins, the lead author of the Oxford meta-analysis, warned at the time that without full retraction, doctors and patients would continue to be misinformed. It turns out he was prescient.

Medical journal editors … owe it to society to publish papers that “first do no harm”.

Misleading media reports followed and led to increased reticence among doctors to prescribe or even discuss statins and increased unwillingness among patients to take them. Statins were already being under-used but a new wave of adverse media meant a further reduction in use.

In the UK, 200,000 patients stopped taking statins. 60,000 fewer statin prescriptions were dispensed in Australia following a now-withdrawn television program. If those patients avoided statins for the next five years, researchers estimated that a few thousand would suffer a fatal heart attack or stroke. For a disease that kills 17 million people around the world each year, an ounce of prevention is not to be sniffed at.

So what does the statin saga teach us? For one, it underlines the power of the media and in turn, the responsibility of health reporters and newspaper editors to think twice before exploiting health news to suit their audience.

“Beloved grandma loses mind to cholesterol drug” and “How statins ruined my life” might be guaranteed click-bait but responsible reporting might instead discuss the dreadful statistic of one Australian dying of cardiovascular disease every 12 minutes and how to prevent it. Statins are no panacea but combined with diet, exercise and curbing cigarettes and alcohol, they have a role.

Second, it reminds medical journal editors that they owe it to society to publish papers that “first do no harm”. If Big Pharma can’t be trusted to provide unbiased data and to base advice on sensational tabloid fare makes a mockery of medicine, doctors must put their faith in someone to provide credible information.

There is an old joke that the majority of academic papers are read only by the author and the editor – this may be a little harsh but busy clinicians mostly flick through abstracts and note key points rather than read even a fraction of the million scientific papers published annually with an interrogating mind. It is up to journal editors to simplify the task and spell out the difference between interesting research and findings that transform patient care.

Finally, better health arises from better health literacy. In a free society, patients are allowed to make poor choices but the media shouldn’t facilitate it. Just this week an acquaintance asked me what I thought of her daughter’s “courageous” bid to not vaccinate her child for fear of “giving her autism”. I reminded her that the fraudulent data had long been exposed and retracted but she said she had seen it on the net and that was that. Dashing my hopes, she next took on statins.

“What do you make of the controversy?”

“There is no controversy,” I replied. “Read the report.”

“You would say that, wouldn’t you?”

Then, after a pause, “But seriously, did you see the story about the old lady who went mad on her statin?”

No, I didn’t. But newspaper editors, please take note!

Statins: Patients are allowed to make poor choices but the media shouldn’t help them | Ranjana Srivastava

Do I really need "the test"? Too many tests could do patients more harm than good | Ranjana Srivastava

“How are you doing? It’s nice to see you again.”

“OK,” she replies, unusually tersely.

“How was your daughter’s wedding? I thought of you when the sun came out.”

“Yeah, it was good.”

And then, she burst into tears.

“Is everything OK?”

“Look love, I don’t mean to be rude but can you just tell me what my test showed? I haven’t slept all week and am nauseous with worry. I can’t take this anymore.”

“You had a test? But I didn’t order one. Your breast cancer has been stable for some years.”

“My GP did, and said you’d have the results. You mean you don’t know?”

Conventional medical training teaches doctors to start with perfunctory questions and build rapport before delivering significant news. After all, patients, especially in the public health system, don’t always see the same doctor and it’s important to cover or recap important details.

I used to greet patients at the door, ensure they were comfortably seated with phone turned off, hearing aid tuned in and notebook ready. I’d exchange a few pleasantries to humanise the interaction. But frankly, I am surprised it has taken me so long to appreciate that no oncology consultation goes far without first relaying the news of “the test”. “The test” is an umbrella term encompassing all manner of bloods and x-rays – haemoglobin, biochemistry, liver function, tumour markers, CT scans, PET scans and the rest. From the moment of their cancer diagnosis, patients are wedded to “the test”.

It’s different for brand new patients who are resigned to repeating their story multiple times to multiple doctors but when long-term patients return for their regular check-up they have one thing on their mind. So I have learnt to get to the point fast.

If the news is good, I tell the patient as soon as we’re out of earshot: “Your tests were fine, come and sit down.” Grips loosen, shoulders relax and some days you can feel the hiss of dissipating tension. When the news is bad, I escort the patient to a chair, make eye contact, and say, “I’m afraid the scans found a problem – we’ll have plenty of time to discuss this.”

Everyone does it differently but over time, I have decided this is kinder than, “How are you? Let’s go over any symptoms before we get to your results.”

Every patient has a story about spending sleepless nights and nail-biting days, fearing the worst but praying for a reprieve. When someone cries with relief at a scan that I’d always expected to be normal, I can’t help reflecting on how automatically scribbled test slips have the power to govern people’s lives.

“Your bone scan was normal again. There was no sign of cancer in your spine, only arthritis,” I recently reassured an elderly man with prostate cancer. He suffered from chronic back pain but the moment he mentioned it to a new provider, he scored himself another test. This time, a chiropractor had encouraged him to ask his GP for a scan.

Tests crowded his life – he rued that there wasn’t an event in recent times that hadn’t been disrupted by an appointment or a test, from his nephew’s wedding to his sister’s funeral. Knowing that I’d played a part in his misery, I suggested, giving him a break from tests. “They don’t really help nearly as much as talking to you and seeing how you are doing,” I said. But his wife was quick to squash his glee, “Oh no, I’d go mad not knowing! You must do a blood test at least.”

As cancer patients are living longer, they are seeing their oncologists more and many visits are accompanied by some sort of test. In the case of breast cancer, but also others such as prostate and colon cancer, blood tumour markers are used to track tumour activity, with changing markers often triggering costly scans. Patients regard painful and inconvenient tests as the cross to bear if they are to stay alive. After all, without tests how will their oncologist know what’s going on inside their body? For oncologists, writing test slips is as routine as breathing.

But the evidence suggests that cancer patients who are not receiving chemotherapy and are not enrolled in clinical trials do not need frequent testing. Depending on the disease, professional guidelines have long recommended against so-called “routine” testing in cancer surveillance but patients continue to receive them. Not all tests are ordered by oncologists – in a fragmented environment, patients see multiple providers. They order a test hoping it will reveal something that a good history won’t but this is seldom the case.

Tumour marker measurements in a range of advanced cancers altered management in a mere 2% of patients.

Pathology and radiology tests have grown by around 10% each year. The Grattan Institute estimates the overall cost of wasteful healthcare spending to be as much as a billion dollars.

It might seem intuitive that early detection of disease progression through tests might be helpful in instituting or switching therapies, avoiding unnecessary toxicity and guiding therapeutic choices but there is no evidence that a particular test done at a particular interval alone determines a change in course.

On the other hand, there is evidence that more tests cause more anxiety. Up to 65% of patients with advanced cancer are said to suffer some form of psychological distress. Undergoing frequent tests, not clearly understanding why and waiting weeks, even months, for results traps them in an unenviable situation. Patients who are preoccupied by test results have been shown to have a worse quality of life.

A recent study of more than 2,000 American women with metastatic breast cancer published in the Journal of Clinical Oncology found that more than a third of their providers were “extreme users” of blood tests and scans. (Here, extreme use was defined as more than 12 tumour marker tests and more than four scans per year.) Patients who were cared for by these providers had a 60% higher cost of care, more hospital-based care and later use of palliative care. A previous study found that tumour marker measurements in a range of advanced cancers altered management in a mere 2% of patients.

The overuse of pathology and radiology tests is by no means a problem specific to oncology but cancer patients are among the most heavily investigated, with the direct cost of cancer care in Australia reaching over $ 4.5bn.

Entrenched physician practice is hard to change through guidelines alone. In one study, over 90% of oncologists reported that repeat tests were ordered by someone simply copying the previous order. Without being constrained by rigid rules, doctors must be accountable for the tests they order. Making doctors aware, individually where possible, of the cost of tests, has been shown to influence practice, at least in the short-term. Awareness of the myriad costs of over-investigation must begin early in a doctor’s career. Good clinical practice means asking with every test ordered, “How will the results change my management?”

Patient expectations play a role in the prescribing habits of doctors. Comparisons in cancer are rife. “My neighbour with the same cancer gets a test every time, why don’t I?” is a common question posed to oncologists. The answer is not to order the test, rather to educate the patient. Patient surveys show a willingness to understand and avoid the harmful effects of indiscriminate testing. A key motivation for enduring tests is a feeling of security but patients need to understand that a good doctor-patient relationship, where concerns are promptly heeded, is no match for a battery of tests.

When I tell patients I’d rather not order tests that don’t provide meaningful results in their clinical context, they often ask what else they can do to look after themselves, as if submitting to tests were a proxy for self-care. I tell them that there is growing evidence that they should maintain a healthy weight, eat everything but in moderation, get some form of regular exercise, stop smoking and nurture good relationships.

Frequent testing improves neither quality nor quantity of life but these other recommendations nod to the foremost tenet of medicine, first do no harm.

Do I really need "the test"? Too many tests could do patients more harm than good | Ranjana Srivastava

Should you take your children to visit sick relatives? | Ranjana Srivastava

During the final weeks of her life, all spent in an Indian hospital, my grandmother deteriorated peacefully, and gracefully, until she slipped into a coma and breathed her last. My 10-year-old self remembers a thing or two about this time.

The hospital’s egg curry, a much-loved north Indian dish, was amazing. The tiny cakes with real butter icing that defied all dietary guidelines weren’t bad either so my cousins and I, gathered in the small room, took turns selecting the menu and outwitting the nurses, who sweetly played along, praising the voracious appetite of our fading grandma. Enveloped in grief at their mother’s impending death, the adults couldn’t bear to look at the food – if our mirth seemed out of place, they never said so.

As we wolfed down the food and settled down to another game of Scrabble, my diminutive grandma would open her eyes to peer at us. We often sat within her line of sight and sometimes when she wasn’t tired, she would lift her hand in blessing. She didn’t have any last-minute advice for us neither did she say goodbye. She never cried and she never complained. In fact, she barely spoke but she smiled when possible. The kind of quiet, contented smile that said she was at peace with life even though she was dying far too young. I remember thinking how much she loved her grandchildren – the feeling was so powerful and visceral that it never struck me there could be suffering behind it.

But my grandmother’s skin had turned bright yellow and explanations were called for.

“Why is she yellow?”

“They say it’s jaundice,” the adults replied.

“Why does she have a drip?”

“The doctor ordered it.”

“Why is she sleepy?”

“She is tired.”

“Is she hungry?”

“No.”

“Then, can we have the egg curry?”

It was through incidental observations that as children we became witness to life drawing to a close.

There were no doctors in our family and there was no sophisticated understanding of the process of illness and dying. Since the adults didn’t know much, there were no customised, careful explanations for the children. In fact, as loss stared us in the face, there was very little to say. But what we lacked in words we made up for in another way – we stuck together to observe the ritual of dying.

Alongside our parents, we watched our beloved grandmother sleep, awake, groan and smile. We watched her totter to the bathroom and then confined to her bed. We watched her eat half her food and then none at all. We learnt to scrutinise the doctors’ expressions and understand that our sorrow wasn’t their fault. We saw how hard the nurses worked and came to fill in their gaps without rancour.

Thus it was through incidental observations that as children we became witness to life drawing to a close. It was a gradual and real schooling so that when our grandmother finally died, we were sad but neither inconsolable nor traumatised. Years later, as grown-ups, we find ourselves helping our own children navigate illness and loss – as the cycle continues, we summon our own memories about the importance of just having been at the bedside.

I found myself thinking of all this when I looked after an elderly patient who came for an elective procedure which went horribly wrong. As organ after organ failed, my patient retained an uncommon spirit of optimism, expressing hope that he would get home to see his grandchildren whom he greatly missed.

In the week he became irretrievably ill, his daughter came up to me, wringing her hands.

“What should I do about the kids?”

I waited, sensing there was more. As it turned out, her children, 8 and 13, had not been in at all. She had protected them from his temporary problems and when his condition took another downturn, she was grateful that they were occupied at school. She maintained an anxious vigil over him but kept hoping for a day to come when her father was well enough to greet his grandchildren like his old self.

“What are you afraid of?” I gently asked.

“That they’ll have lifelong nightmares. Isn’t it better if they remember him being well?”

I felt a stab of regret. It’s true that her father looked pale and gaunt but the warmth in his eyes was unmistakeable. And he could still speak, telling me he didn’t have long and thanking me for my care. He didn’t want to burden his daughter but I longed to fulfil his final desire without compounding her dilemma.

“What would you do if you were me?” she tearfully asked.

GPs report meeting adults … who fall apart when a parent falls ill because they have never encountered illness

There, she had asked the question I had dreaded. I believed that although there had been better opportunities, a visit to their grandfather’s bedside would still be meaningful and provide an opening to a later unavoidable conversation with the children about illness and mortality. I thought the children were old enough to be left confused by the turn of events and wondered what views they might form of what happened in a hospital. I feared that their mother, coping with bereavement, might struggle to find reasonable explanations later. And I fretted that the emerging disagreement in the family over the children would test adult relationships. So I told her sincerely, “I would find it heartbreaking but I’d try to bring them in.”

When it comes to children visiting sick or dying relatives in hospital, every family decides differently. Granted, hospitals aren’t designed for the ease of young (or old) visitors. There is a maddening lack of space, chair and amenities and visitors can feel conscious of getting in the way. It’s unlikely that these deficiencies will disappear anytime soon though people do find their way around them.

Studies show that childhood bereavement alone is unlikely to be related to adult outcomes. Rather, factors such as parental support, open communication, age-appropriate explanation and the presence of other adverse social and psychological events may have more impact than the fact of the death.

In hospitals and nursing homes, there is a stark lack of young visitors to the bedsides of their elderly relatives. When children do visit, they are nearly always parked on a device, making real engagement impossible. We seem happy to let our children Google illness, just not let them near it. But making illness and mortality invisible to our children has unexpected consequences. GPs report meeting adults in their 40s who fall apart when a parent falls ill because they have never encountered illness up close and don’t know how to deal with their own emotions, let alone their children’s.

There is an epidemic of loneliness among our elderly population as they trudge from residential care to hospital and back again. For staff, the loneliness is in plain sight – every doctor has met a patient who begs to stay an extra day because “it’s nice here, people talk to me.”

Addressing loneliness is hard when there are a dozen other priorities even though a visit from a loved one is worth a dozen pills. And the comfort of strangers is no match for the consolation of family, so every day we convince and cajole relatives to visit, until it becomes a job as routine as checking bloods.

Patients cheer up when anyone visits but when children come they have an unfailing effect on lifting the mood and alleviating the loneliness of patients. Occasionally, I’ve needed to take one of my children on a weekend ward-round and felt bad about it. But my misgivings have melted at the sheer delight of patients. Nothing banishes the dreariness of being in hospital than an innocent banter with a child. The food tastes nicer, the pain seems bearable and life itself seems more hopeful. Indeed, children inject a kind of optimism and happiness in patients that it’s hard to replicate. Countless patients have thanked my children, saying, “You remind me of my grandchildren,” prompting one green medical student to ask me, “Then where are their grandchildren?”

Unfortunately, for my patient, time ran out and his grandchildren didn’t come in. But the encounter was another reminder of the therapeutic benefit of young visitors to the bedside.

We cannot forever shield our children from the realities of life. It’s normal to feel apprehensive but there are steps parents can take to prepare everyone for a visit. We need to protect our children but we also need to spare a thought for our elderly who have often given years to building a bond with our young only to be deprived of it when they most need it. Being sick is hard enough, they don’t need to be lonely too.

Should you take your children to visit sick relatives? | Ranjana Srivastava