Fear and Love: What Medicine Can’t Teach with Steve Robson

It's a real pleasure. I've been looking forward to it, Melissa.

Yeah.

It's a really good question. I guess on the side of my dad, he was an immensely practical man and he would turn his hand to building, fixing, etc. So he really was someone who encouraged a lot of hard work and industry and so on. My mum, who I've lost, was very, very interested in the performing arts As a young woman. She'd been a ballerina and in fact cut her teeth. It was the end of the Second World War when a lot of servicemen were in Brisbane from the US and they would dance to entertain the troops. They had a lot of things to keep the troops entertained. So she'd had a really, really interesting early life as well. And they found themselves in rural Queensland, which is probably as discombobulating for them as it was for me.

At the time. But there's a great sense of community in rural Queensland and so I think they worked together really well over their lives and won wanted the other. They were very, very different people. But like a lot of couples, it really worked.

Yeah, my brother is a doctor. He's a general practitioner on the Sunshine Coast. He and I, there's a bit of an age gap between us, but he took up medicine and is really interested in sports medicine and on the Sunshine coast there's a lot of sport. He was involved in surf life saving and would be the doctor at various beach events and things. So I think he's sort of had a more glamorous career being at the beach with all of this stuff going on than me. I think you've had a fairly salivary.

No worries.

Yeah. So I was flat broke at medical school and took the last couple of years of my medical studies. I was on a scholarship with the Royal Australian Navy. I'd had family members in the navy and after some time in public hospitals joined up full time as a doctor in the, in the navy. My very first posting was at the naval air station at Nara where the parachute training school is. So you spend a lot of time at drop zones dealing with people who've jumped out of planes. And of course I was asked immediately to do the training as a parachuter. So I'd grown up in the, in the country that was very flat, you know, hadn't been on anything high my entire life and was not very good with heights at all. Luckily I'm short sighted so I didn't, couldn't see where I was a lot of the time. That made it easier.

I have to admit at times I certainly totally appreciate that. I guess the military philosophy is it's not joy flighting or anything like that. It's getting soldiers out the back of a plane as quickly as possible. So as the officer I was at the head of the queue and the back of the plane would open and I remember the first time I thought, gee, I hope I've got the nerve to jump. But I needn't have worried because there were 12 soldiers behind me and the minute the door opened they pushed me out the back of the plane.

And you just get shoved out. I found that it was a real recipe for fear with me as someone with a fear of heights. And I think one of the things it really did across my subsequent medical career was gave me a great sense of what it's like to be really, really frightened and to also be able to pick that because I, you know, I spent the entire time trying to disguise the fact I was terrified of jumping out of planes. But it gave me a bit of a sixth sense and I in a lot of the work I've done, people are afraid and they don't necessarily want people caring for them to know that they're afraid.

They'Re afraid, they want their families to know. And I think being able to sense it and connect with people and say, look, I understand what it's like, let's talk about this. I think one of the things that also it gave me a very strong sense of is if there is some emergency playing out or something is going wrong, the worst thing you can do is arrive and panic. And I put a huge amount of effort over my career because often as the sort of senior specialist, you're called into something going very wrong to deal with it, to help to solve the problem, to provide whatever treatment. And it's so important to not show that you're afraid or anxious or anything, to appear calm because fear is infectious and it infects contagious. It's contagious, absolutely. So people come in and you look like you're panicking. It is a recipe for everything going to pieces. So coming in and saying, all right, this is happening, I'm here, we're all going to work together, we'll try to sort this out for you, we'll try to do this for you or solve this problem for you, I think gives people confidence, it settles the whole environment down and it's much better for patients and for their families, mothers.

I think you're absolutely right. And one of the things that I'm sure everybody who works in a public hospital, whether you are a doctor, a nurse, whoever you are working in that care team, is you see a lot of people, you see a lot of patients and families and you don't necessarily have a pre existing connection with them. So being able to encounter people for the first time at often what is one of the worst days of their lives. But do your best to connect with them, to assure them that you are there to help them to provide care is really important. And that's a skill that just takes time to develop.

Yeah, I agree. And it's often disorienting. You have this feeling of overwhelming dread and just meeting people who genuinely care for you, building that connection and saying, I am here to look after you and I will do that to the best of my ability. It just gives people confidence. And I think it's a really important thing. And it's so easy to miss that because everything's so busy and resources are stretched and things like that.

It's a good question. I tried to add this up at the start of the year and I probably a little over 5,000 babies over a career. I don't remember them all.

Look, I think a key word that you brought up is love. And I actually started doing some research into love in medical decision making a couple of years ago, and it got sidetracked, but it's rarely spoken about. A colleague and I went through the medical literature and we found that love rarely comes up, but it's fundamental to decision making in families. And I look at it right from the start. You know, having a baby is often something that love dictates. A couple will meet and love will dictate, you know, when they start their family, how big their family is. There's no doubt that when a child is born into a family, there is so much love. And if a child is ill, if a child has a disability, for example, love overwhelmingly affects decision making. But we almost never see it discussed in medical literature as though people are embarrassed about it.

It does not play enough role. And I think there are two key areas where love is so fundamental to the provision of medical care, and that's at the start of life and at the end of life. And I have seen many situations, both as a doctor, but also personally, where decision making at the end of life is so intimately tied up with love that you cannot disentangle the two. But I rarely read medical literature that explicitly says this. It might phrase it in other terms, but I think we should be completely open about this and so call it for what it is. You know, we do things for love that are inexplicable, important, and I think also for so many people, love underpins their satisfaction with life. And I think as a caring profession, one of the most important things we want to do is make people's lives better, and love is a big part of that.

Yeah, absolutely. And I think it's a really personal experience. My own mum, who passed away about over 15 years ago now, had a terrible end of life experience. And I think it was also isolating for her because they lived in a part of Queensland, it was a little bit inaccessible for other relatives. And my mum was diagnosed with a really terrible complication of her cancer on Christmas Eve. And it was a shock and I think it completely disoriented her. And I visited her and my dad on Christmas Eve when, of course, she was already sick. But she put a lot of stock in Christmas and the importance of Christmas as a family occasion.

And I get a little bit emotional talking about this, but we talked about what had just been diagnosed and she said, I'm really sorry this is going to muck up Christmas for you. I just was really taken aback and I gave her a hug. And of course, by that stage she felt a little skeletal. So you worried about breaking her when you give her a hug? I said, mum, all I want is for you to know that we all love you at Christmas. And I think that kind of broke the spell that she still had this mum sense that she wanted to manage Christmas for the family.

Yeah, absolutely. And I just said, look, all we want is for you to know we don't care. The main thing about Christmas is that you know, we all love each other. In fact, that was the moment that I realized that, you know, we often don't articulate love as an emotion, as a feeling, but it so profoundly affects how people feel, how they act, why and when they do things that it's really important.

Well, that was 17 Christmases ago. Coming up, this will be the. The 17th Christmas. It's one of those moments in life that we never forget. You know, there are some moments that are just imprinted.

They shape you, absolutely. And the two things from that that, again, were how fragile my mum was at the end, how it felt like by just hugging her, you could break her. And how despite all of this, despite her own travails and everything she'd been through in treatment, how it was still important to her that she sort of oversaw a Christmas for the family. And it puts a lot of things in your life in perspective.

Yeah.

Absolutely, yeah.

My mum got worse very, very quickly after that, and within a few months she had passed. And luckily, I think I say this in the sense of her not suffering. The end was quite quick, but she had this real sense that she didn't want to be a burden for the family.

It's so difficult to get past that and say, we don't care. We are your family, we love you and we want the best for you. We want you to be comfortable and as settled as you can be, and you are not being a burden and just put this out of your mind. But your mum can't get that out of her mind. And it's a constant dialogue about, oh, I don't want to be a burden or put you out, but at the same time recognizing that the end is near. I guess you would know this as much as anybody else. Everybody tiptoes around this fact, and it's a very difficult thing to admit. And I think another thing that came out for me would be that perhaps we need to think about how we can have conversations like this that are affirming, fulfilling, but still truthful. And it's not easy, but I think it's actually important for everybody in a family when they're dealing with the end.

I agree with you. And I think, speaking as someone who provides health care, it's often very easy for someone like me to retreat into that language to make what you are doing easier. It's hard. Sometimes it feels like you're going against your training to talk frankly and in language that everybody understands. It's easier for you to retreat a little bit into technical language when having difficult discussions. And I think if there's something that would be very, very useful for a lot of people in healthcare, and I know some people do it well, but not everybody does, is being able to help people think about how to have conversations near the end that are not crowded in jargon or as you say, you know, an exercise in getting technical legal documents right and things like they're people conversations.

I agree 100%. I think that's absolutely on the money.

So I think there are two aspects to this. I think there are anticipated deaths. There are definitely situations where a family anticipates that somebody will be lost. And you see this in older people. I've certainly seen it quite a lot dealing with people in a younger age group with cancer.

In my own area, ovarian cancer is something that takes the life of women, often in the prime of life.

It is one of those absolutely silent.

Yeah.

Yeah. So sometimes you will see an anticipated loss at somebody, and there is an overwhelming sense this person is too young to die. We get this. You know, they feel like they are gone too soon. The other is the unanticipated loss, the accident, the thing that comes out of the blue. And the wishes of the deceased often are not clear to family members. And I had this brought home to me a few years ago where a lot of the work I do is in fertility work. And of course that's about people starting a family, extending a family. It's about the start of life. But one of the things that not uncommonly we're asked to do is to take reproductive tissue from someone who's recently deceased because their family or their partner says, our family was not complete. And I don't want to lose that chance to have one more child with my, my partner. Now I've been involved where an accident has taken a life and family members are already overwhelmed with grief, with shock, huge trauma, horror in losing a young family member unexpectedly. Not only reproductive tissue, but often organ donation is a thing that is so important for the community, but often the conversation, conversations and never had. And it causes this conflict in family members. And some people will, will say, that's not what we want. Well, it's, you know, perhaps what your loved one would have wanted. And I think so. I, I think a lot of things don't occur to younger people to talk to family members about their wishes. Even, even things like, and I've seen this recently in people I knew very well about cremation versus burial. And it an issue that seems to me, I know it's really important to some people and it's culturally important, but the conflict it seems to cause in families at times, because the discussion was never had, blows my mind at times. So I think at a time of grief, people latch onto to some things. And at a time when everyone should be united in grief, you know, being divided by conflict is sad.

Number that has happened in my own family. I'm choosing my words carefully here, but there were situations where there was disagreement in my own family when my mother was very ill toward the end. And those issues have not been resolved 15 years later. And it is to everybody's cost. It is to everybody in the family's cost. And that statistic you quoted does not surprise me. And I don't think we should underestimate it, because at a time where a family can be united in grief and love, to see them divided and, you know, have permanent fallout is a real tragedy. And I suspect a lot of it is because conversations were never had when they should have been, and things lingered and were never resolved. And it can be a real blight on families.

I'm not the only one.

I couldn't agree more. And I would hate the thought that when my time comes, my family members and loved ones are divided in some way about some decision about me. I want it to be a time when everyone comes together and just, you know, connects. And I think the nature of families at the moment is a lot of family connection is lost these days. A lot of people, you know, on Facebook or social media and have a sense of connection, but they're not intimately, relationally connected. They're not relationally connected. And death grieving is the first time in a long time a lot of family members will come together as one. And it can unmask unresolved things. It can unmask things that people just didn't recognize because their connection was virtual or digital or whatever and not human. And I think that's a thing for society to think about.

Yeah, absolutely. It's often the person with the least direct recent connection who is demanding, you know, that everything is done. I have actually seen it in start of life care as well.

Yeah. So I have definitely seen it where in fact, not that long ago, where families are going through the trauma of harm to a young baby, often a preterm baby, and you will have a fairly peripheral but influential family member demand or expect things or be difficult with staff, even though it's clear they haven't had a lot of direct connection. And I'm sure that plays out as well at the end of life. I suppose it's human nature, but it just makes the dynamic difficult. It makes it difficult to provide care. And again, I suspect it's one of the things that contributes to these family fractures, fractures that you talked about earlier on, that coalesce around difficult times.

Oh no, I agree completely. And you know, there is a sense that people want to be seen to be doing everything possible, even though you know in your heart this will achieve nothing. And in fact, in, in many cases, a lot of end of life care actually makes things worse for people. It prolongs things, it improves, involves discomfort or adds to suffering for what is, you know, minimal, if any, quality gain. Look, I would never presume to tell anybody else how to think or how to act, but for myself, I think I would like the end to be about love, about connection and about comfort. And a lot of things that people like me do as doctors are the opposite of all of those things. So I think we need to be really mindful and I can only speak for myself and I totally respect if somebody has a different view, but I think in the end we need to Be aware that exactly as you said, it drives an enormous amount of low or no value care.

So I think it's an incredibly rich area to talk about. I think as a system, and like health systems around the world, doctors and healthcare workers tend to view their job as making people better rather than making people comfortable. And we all wrestle with this impulse that, you know, we need to, as we said before, do everything we can to try to prolong life by a day or, you know, whatever. And I think the really great people involved in palliative care or other end of life care get the fact that to be, for example, like my profession, a doctor, you don't have to treat actively or offer, you know, some sort of therapy to do the right thing by somebody for whom you're providing care. And I certainly see it all of the time. People are afraid of criticism or they're afraid that if they don't do something, one agree family member will put in a complaint that, you know, something wasn't done. And it's very, very hard to. And particularly in a system where we may not know the patients that well, the people we newly encounter, people just want to say, look, we, we did this, you know, you can't criticise us. And I think getting the paradigm where your responsibility as someone who provides health care is to actually make people's lives better. And I think we have enormous opportunity to make what is left of a life better.

Be, the best it can be. And in fact, I don't think we should say, well, look, you don't have a lot of time left, so we're going to give up, say, actually this is an opportunity where we really can find, fulfill our role and make what is left of your life better, as good as we possibly can. And focusing on that, I think would be good for as, you know, thousands and thousands of people.

I think as a society we do our level best to avoid talking anything about end of life. A lot of the time, even healthcare workers uncomfortable talking about it. So families will often arrive in these situations, have had few coherent conversations, haven't been guided to thread their thoughts together on this. And I think it's actually a huge responsibility because it's not rare, you know.

I mean, it's the opposite. I mean we're all going to hit this, this, hit this point. So it's inevitable for every one of us. And I think this huge opportunity community wide, have really important conversations early to mainstream these sort of conversations and for people to understand just how important they are because there's a sense, oh, it's a bit, you know, a bit out there or whatever, but it's not, it's really important and we should focus them on mind, on these things. So I think that's a really admirable pursuit.

Look, I think we go through stages in a career and early on you are absolutely obsessed with being, you know, the most knowledgeable, the most skilled surgeon, the most thoughtful and considered in my profession, doctor that you can be. You go through a phase of consolidation where I always remember one of my early surgical teachers said there are three ages of a surgeon. The first age, you take out every appendix you can see. The second age, do you get excited.

Yeah, you want to take out every appendix you can find. The second age you realize, oh, I think I can pick the ones I need to take out and the ones I don't. Then you realize you're wrong. And the third age, you go back to taking them all out again because you realize you can't actually pick them. I think in the middle of your career you often are consolidating. You're finding that one of the hardest things is understanding when not to do an operation or not to offer a treatment or something like that. And I feel I'm in a lucky sort of situation now where I don't feel I've got to be prove Anything in terms of my skill or ability or whatever anymore. In fact, you know, I recognize all my limitations. I think you reach a phase where you want to pass on the most difficult thing of all, which is judgment, and trying to pass judgment on to the people with whom you're working, the younger people with whom you're training. But one of the things I've really recognized is that we need to be great stewards of the resources of the health system. That they are limited, that we can't just have everything all the time. And a way that you can make sure you squeeze the most benefit for the most people out of the resources, the money, the resources available is great policy. So I've put a lot of, I guess, thought over the last decade or so into less about treating the individual patient. Not that I don't think about it, but I mean less about thinking about things as the individual person in front of you and more about the system as a whole. And how do we get a great system? How do we make sure that every, every Australian, no matter who you are, where you are, where you came from, has the best, the best access to healthcare possible, that we, we do really great healthcare in this country. So a lot of what I've done's really been around that for the last few years and it's, that is an endless, endless thing. There's no easy answers.

Yeah. Look, I hate to say this, but judgment often comes from getting things wrong.

I know, absolutely. And you spend a lot of time at medical school and in your specialist training with textbooks and papers and learning. But some of the most valuable things that we learn are when things just didn't go right.

When you made the wrong call, you learn an enormous amount. And. And I say, look, we need to see failure in. In many aspects as the opportunity to learn how to do things better. Now, the stakes are high. You know, if you get something wrong, it can harm patients or not make them better. So I'm not talking down the stakes, but I think a lot of the real experience I've gained is as much from getting things wrong, making the wrong call, not interpreting something correctly, as it is about having the knowledge. And there's another saying that, you know, 80% of making a diagnosis is just listening to a patient. Most of the time, people will tell you what's wrong with them if you listen carefully enough. And I think, as I said, a little bit around the sort of slightly frivolous thing about taking out appendices, you know, we learn how to treat things and we are proud of our ability to do an operation or manage a treatment. And it can be the hardest thing to say, actually, this is not right for that person. The best thing I can possibly do is not do this operation, not offer this treatment. And that can be a hard thing to shake, particularly for people at the start of their career who are so proud of what they can do and have mastered skills, tools. Saying, actually, the right thing is not to do it takes a bit of a mindset shift, and I think that's something that only comes with time.

Absolutely.

Yeah, I agree with that. And I think one of the other things, and this is probably slightly off piste a little bit, but I can.

But I say to my trainees, sometimes the really great surgeons, for example, don't look like they're doing much. It just seems to be just flowing along and something wonderful is done. And other people, there's a lot going on and it's not going right. And talk about off piste, like skiing. Some people just make a skiing look effortless, so graceful. I know you just see them and.

Wow. I wish I was like that. They just look great.

Yeah. And they don't look like they're putting any effort into this. You know, they're incredibly skilled.

Yes.

Yes.

Yeah. I think one of the really important things is the demographic change we see globally. We certainly see it in Australia, where we're going to have an increasing proportion of the population is older people like me, and we'll have a smaller and smaller proportion of young people not only providing care. We know that the caring professions, whether it's aged care, health care, disability care, will be the growth area. There'll be increasing demand, fewer people to do it. And we face that dilemma of should a high income, highly developed country like Australia take healthcare workers from countries that have fragile health systems anyway, to accept the fact that we train those countries train people, we take their best and brightest. Such an important point to Australia. We leave countries with the most need, often with the most fragile health system. We need to think really carefully about that. There's a lot of talk about artificial intelligence, for example, virtual care, picking up the slack. I'm skeptical about that. And I also think that when we are at our most vulnerable, when we are sick, when we are near the end of life, we want human connection and we want touch. And people say to me so often, oh, I was so sick, it was so wonderful to have the nurse come in and just spend time with me. It felt so good. You know, he or she cared so much about me. And I think when we are at our most vulnerable, the thing we want most is human connection. And AI will never provide that. I mean, it's fine, get an AI chatbot or something.

Is it morally okay? It's a complex question. I would imagine every single Australian who's had healthcare has had encounters with people who did their training overseas, often in lower income countries and abort here. And we are, you know, in, I've heard it said, we're really stripping the resources from countries who need them the most. So I think we have a lot of really important questions to ask ourselves in this country.

I recognize that many of the things that affect the health of Australians do not occur out of the blue at the end of life. They are the end of a lifelong process. And I think if there's one thing I'd really love all of us to learn is to say things that affected us at the end of life, whether they are conditions, diseases, cancers. Could we have perhaps done things earlier in life that might have ameliorated or prevented this? And I think it's an opportunity for families to understand the critical importance of prevention. I was at the Public Health association conference and this came up that so much of the burden of disease in Australia is potentially preventable. And we know that exercise, great dietary choices, moving, staying out of the sun, all of these things set you up for much better end of life. Even if they don't necessarily prevent you getting something, they can make the progress of a condition slower or less impactful. So I think the end of life, we shouldn't forget that it's an opportunity for us to learn about prevention and for the next generation to understand choices. You know, I've had plenty of relatives who drank too much, smoked too much, ate the wrong things and suffered for that. And in some ways, I think that's that circle of life that the young can learn a little bit from the older generation. And I think the other big thing is the critical importance of compassion in everything we do and the art of putting yourself in somebody else's shoes. And I have seen some absolutely abominable online discourse. And it's very easy to be a keyboard warrior and judge people or make terrible comments. And it's very easy not to put yourself in somebody else's shoes. And I think the opportunity for young people to understand the critical importance of compassion, of taking a journey in somebody else's shoes or Seeing things from another perspective is really important, and I think it gives us yet another opportunity to do something great for the next generation.

I think I would say take the opportunity to not treat the person you're caring for as a patient, but to put yourself in their position and say, what would I want in this person's situation? Now, it's not always possible and each of us have different things, but I think sometimes just putting yourself in that person's position would temper the way that you manage things, and it would make you look afresh. I mean, I said before, look, as I see it would rather be comfortable, you know, affirm, love, and reconnect with people at the end of my life than be having all of these treatments that I know in my heart won't work. So I think my advice would be take the opportunity, if you can, to just do what you can to place yourself in that person's position and ask yourself, would I really want this myself? And to be honest with yourself and with the. With the person you're caring for.

Very common.

It's been a pleasure. And similarly, thank you for everything you do.