AAN 2019 Living Well

A

I arrived in Philadelphia on Thursday to attend the 2019 AAN annual meeting. The programme of this year continues much of what was started in 2017 and 2018 around burnout and its opposite wellness.

The AAN states: “Neurology is the only medical speciality that has both one of the highest rates of burnout and the lowest rates of work-life balance. AAN leadership is well aware of your daily challenges and how emotional exhaustion can lead to the loss of interest and enthusiasm for practising medicine. It’s important to remember that it is possible to prevent burnout as well as restore well-being. Your health matters to the AAN and we’re here to help. Each day AAN staff and member volunteers are working on your behalf to decrease regulatory hassles to make it easier to be a successful neurologist. Additionally, we’ve compiled the following resources to provide you with tips, tools, and strategies for cultivating well-being and resiliency in your life.”

After last years meeting, I penned the following which I posted on Medium. Little has changed but is clear that neurologists and clinicians, in general, are facing an existential crisis.

Is the art of medicine, and by inference neurology, in terminal decline? Reflections on attending the 2018 American Academy of Neurology meeting in Los Angeles.

The most important part of attending large International conferences is the time for thought, reflection and importantly introspection. The AAN 2018 was no exception. The programme was informative, in a disturbing sort of way, in that a lot of the teaching sessions were dedicated to survival in the workplace; i.e. dealing with burnout, mentorship, work-life balance, mindfulness and meditation, giving and receiving feedback and many issues related to private practice.

When I was a trainee I was expected to be resilient; I simply had to get on with the job at hand. I was too busy to think about or identify these sorts of issues. I am not even sure if ‘burnout’ was an identified problem back in the late ’80s when I started my clinical training. For me, and most of my colleagues, internal medicine and neurology was a calling; ‘our vocation’. Being a doctor was more than simply doing a job. What has changed? My wife tells me the millennials have changed things; they are not as accepting as we were of the status quo and want something different out of life. Play and leisure define the millennials and not their work. Is this true? If yes, maybe I need to play more and work less hard?

The millennials demanding something different from life doesn’t explain it all. Something more seismic is happening to society and medicine. In the current era, often referred to as the post-industrial era, technology has democratised knowledge and the medical profession’s power base of asymmetric knowledge has been eroded. This is leading to an existential crisis for the profession. Unless you have a technical skill that you have honed over years with practice, for example, a surgical skill, our knowledge-based skills are being challenged by the crowd and algorithms. This is leaving the average neurologist frightened and bewildered; like a rabbit caught in the headlights. In the past, my colleagues used to get excited about major advances in medicine. Now what seems to excite them most are reminiscences from the past, from the era when our seniors seemed to be the masters of the universe.

Gone are the days of the clinical anecdote. Big data is now king. I heard a talk at the AAN2018 on pathogen discovery using deep nucleic acid sequencing of clinical samples (blood, spinal fluid, biopsies, etc.) and clever bioinformatics; unsurprisingly, it outperformed the clinicians. Gone are the days when an astute well-trained clinician would have the edge over their colleagues. In the current era technology and big data trump clinical skills and human knowledge.

Another example of a threat to neurology is the revolution that is happening in relation to gene therapy and RNA interference. Both are creating an unprecedented need for presymptomatic genetic diagnosis. Why waste time screening for single genes? Why not simply do whole genome sequencing on everyone at birth so that we can identify treatable genetic diseases, risk profile everyone for common diseases and then let algorithms analyse and reanalyse the genomes of the world’s populations as new information becomes available? It won’t be doctors that will be making diagnoses or treatment decisions it will be algorithms.

Neurologists still cling to the neurological examination claiming it is too complex for a machine to do and interpret. This is clearly not true. Data is emerging that the way we use our smartphones and how we interact with the web tells tech giants, such as Google and Facebook if we are depressed or have signs of early Parkinsonism. Image analysis using artificial intelligence of pictures taken of suspicious skin lesions and the retinae of diabetics are outperforming dermatologists and ophthalmologists at diagnosing skin malignancies and diabetic retinopathy. The same goes for image analysis in radiology and pathology. Why wouldn’t machines get better than us at interpreting physical function?

As we enter a world of smart wearables and other smart technologies it is only a matter of time before a robot will be able to perform and interpret a neurological examination better than we can. I have little doubt that the neurological examination will be deconstructed, improved on and ultimately performed by machines.

So how are we physicians and neurologists going to ensure our survival? Dare I suggest we redefine our role? Clearly, the part we play as diagnosticians will become less important as the algorithms take over this role. Treatment of disease will increasingly be delivered by assistants using care pathways and standardised protocols. IT systems linked to the electronic record will analyse variance. Any variance from the protocol will trigger an investigation into our practices. I am already aware of this happening in multiple sclerosis in relation to possible over- and under-prescribing of highly-effective disease-modifying therapies or DMTs.

To survive in the brave new world neurologists will need new skills, particularly in relation to sifting, curating and communicating information. We will increasingly be called upon to fight fake news and anti-science movements so as to protect our patients from harm. To be effective in this role will need to actively engage with the new media and acquire new digital skills. Neurologists will need to become better listeners and better communicators. We will need to shift the focus from a disease-centric worldview to a preventative and holistic worldview. Treating disease will become a smaller part of our work. We will need to train and support teams of assistants and nurse practitioners who will do the majority of the hands-on work. We will need to become knowledgeable and skilled in lifestyle and wellness counselling. More importantly, we are going to have to walk the talk; we are going to have to live our lives the way we want our patients to live theirs. Neurologists who lead by example will become the pioneers of a new type of neurological practice. Based on my experience at the AAN2018 I would call this Wellness Neurology.

Are you prepared to retrain as a wellness neurologist?

I am still haunted by the concluding lines from The Great Gatsby that are as relevant to me today as they were when I read them as a 16-year old: “So we beat on, boats against the current, borne back ceaselessly into the past.”

About the author

Gavin

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.

7 comments

  • The point of singularity is fast approaching. All professions are under threat. Once Machine intelligence reaches human intelligence. Within 5 years AI will become the dominant life form. Its inevitable.

    • I agree. Why shouldn’t an inorganic life-form based on binary code take-over from an organic life-form based on triplet code? Life is really only information and who said one form of information storage and transmission is superior to another. What is quite staggering is the pace of evolution of digital life.

  • “Neurology is the only medical speciality that has both one of the highest rates of burnout and the lowest rates of work-life balance.”

    Poor old neurologists. I’m guessing their patients with MND, Huntington’s Chorea, Parkinson’s etc. etc. are having a much easier time.

    Every profession (police, teachers, firefighters) moan and moan about the stress they are under. Perhaps they should think about the stress faced by our young men in the trenches of WW1, Spitfire pilots in WW2 or those who worked in the mines in the 19th century.

    We live longer than our grandparents’ generation, have better medicine, homes, travel experiences etc. etc. but moan and moan how awful it is. You’d hate my suggestions – people need to toughen up, deal with issues internally rather than constantly sharing experiences (in groups or on social media), and be grateful for what they have. During my schooling / university (40 years ago), there was no self-harming, ADHD, gender reassignment etc. etc. Having stress, mental health issues, other issues are now a badge of honour. We need some old school doctors and teachers who tell people to toughen up and get on with it. If things continue as they are we are going to end up with a generation on anti-depressants. People were a lot happier in the 1950s and had a lot less (and had lived through one or two World Wars).

    Doctoring was (and should be a calling). Unfortunately over the last 40 years money has corrupted it. Too many doctors in the UK moan about stress and workload, but find the time for their private practice work or paid consultancy for pharma. Doctors need to focus on why they joined the profession, ditch chasing the money, and their stress and work life balance will be greatly improved.

    • As a person with Ms who understands you completely. Sick people should not expect nonsick people to prioritise them over their lives. If we weren’t sick would we do the same? If that was true then God really had it in for good people for making only righteous sick. But we both know that isn’t true!

  • Thank you for the all the work, your tolerance and knowledge serves you well.
    Greetings from Croatia!

By Gavin

Translate

Categories

Recent Posts

Recent Comments

Archives