A half-finished lemonade tells me all I need to know about yesterday You had a name for this, didn't you? Well I was gonna, I was just, the working title was Miller vs Berger and me challenging your nonsense basically We'll see how we get on Berger, do you mind if I call you Berger? No, no, go ahead What's your general at work, how do people refer to you? Do you get Dr Berger in your phone?
I get, increasingly the junior residents are calling me Dr Berger I can ask them to call me David however many times I like but I think I've become more grey-haired and more fierce so now they feel they have to call me Dr Berger but yeah, no, whatever, you can call me Berger lots of people call me Berger All right Berger, so when was the last time someone thought that you might have been too young to be their doctor?
I was reflecting on this myself the other day Yeah, well that would be never when I was a medical student they thought I was the registrar so yeah, no, that's never I had more the other problem where I used to be asked for the newspaper when I went in to see my patients and have the newspaper but there are more recent times I can imagine you looked pretty baby-faced Andrew I did, yes, and underdeveloped and I in fact these days are disappointed with how
reassuring my arrival is to patients when they see me and they realize I'm not the new doctor on first sight but I take it as reassuring I've got the double whammy in Australia in that I have aged grey hairs a certain amount of convective gravitas and a British accent which actually confers another level of status actually which I didn't realize when I moved here It gives that standard British accent does give a lot of reassurance to those of us in the colonies
that you must know what you're talking about because you're the ones who walk Exactly Yeah, okay So there's a lot of people who know who you are and a lot of those will be listening to the podcast but who've never had a conversation with you and so I thought it would be useful to do so and I suppose my first question first proper question will be what's the point of view? What is it that you are for?
Yeah, I mean I'm pretty bolshy in the sense of I've always been a grumpy old man but allied with that I'm quite the idealist and actually went into medicine for very just naively idealistic reasons which I think I've kept The point of me is that I have a fairly wide ranging knowledge and vision I have a wide experience in medicine and I have no vested interests or at least no position to protect within the medical hierarchy I'm effectively a medical nobody So I don't have an academic position
I'm not a medical politician and yet I'm able by dint of sometimes being outrageous and being categorical to say things that many other people would like to say and that's the point of me That's the point of me to be an annoying thorn in the side I was accused yesterday by a very or not yesterday, last week by a very senior Australian doctor very very prominent of just being somebody who throws grenades Well in any war you sometimes need a grenade thrower
Yes but you're not normally throwing them at the generals of your own army are you?
So you've found yourself in a position of needing to I guess come out from a comfortable position that we're all in in the profession which is that we're down in the trenches we're getting on with our daily job Sometimes I feel like a medical degree is a bit of a franchise that gives you a monopoly and an income and a trade to work So how uncomfortable has it been for you to be having to get up and make your morning coffee and go out and make life difficult for the authorities?
Yeah I mean it's been very uncomfortable at times as you well know because you've been a staunch defender of mine which I really appreciate You're dead right when you say that the profession the medical degree is essentially a franchise and it's a hell of a money-making franchise it confers status, it confers wealth, respectability it's the acme of achievement for many parents to see their child become a well-respected wealthy doctor But like I said I am an absurd idealist
and actually we were brought up when I trained in medicine in London in the 1980s I didn't appreciate it at the time but we had a strong inculcation of the great of the works of the great physicians of the past I went to St George's hospital I trained at St George's hospital which was where Jenna first conducted a smallpox inoculation an unsuspecting nine-year-old and so we were really brought up in that heritage and one of tremendous idealism
and I'm so old-fashioned that I forgot to forget the idealism and so I find myself in a situation where I have very strong beliefs about the role of the profession towards the public and in public health and those in fact do not chime with the majority direction of the profession which seeks a route of accommodation and expediency with the prevailing forces and medicine is political and there's the great quote from Virkhoff about medicine being politics by another name and it really is
and everything we do is political every prescription we write has a political aspect to it every just simply everything we do and there's a tacit agreement that will ignore that aspect and I can't ignore that aspect and so I feel very strongly that the duty of the physician is to present to the public a vision of health and a vision of public health that serves them and not for instance corporate masters so I mean one of the I don't want to descend into the cynicism of Chekhov
who I think it was said that you know he hates doctors more than lawyers because lawyers are thieves but doctors are thieves who also want to kill you and so what proportion of the jungle organism of the healthcare system do you think is going about things in goodwill towards patients with one eye on the cash register and making sure the business works and what proportion is simply self-promoting do you think it is the same as or worse than other industries?
I think there's a very shining brand that has to be protected I think there is a degree of hypocrisy that is much much greater than in other industries you know doctors are not they're not they're not they're not thieves and bastards who are you know just out to scam the public a few are but not the majority but there is an underlying willingness to compromise on principle for the sake of an easy life and to keep the cash rolling in and the lifestyle flowing
I think that's true every aspect of society so I suppose the notion that we're challenging is this reverential status have been given unquestioningly yes and that's the brand that's we trade on the brand of we are these selfless noble heroes with a higher calling and we trade on that brand but really the reality is a bit different in that the only self here are actually you and me and the rest of them are exactly the rest of them are not to what degree is it simply following the leader?
Well I think if you talk to the medical leaders they say well you know this you know like when I talk to the medical leaders they say well you know this is the only way to do it and I talk to medical leaders they say well you know you're right David of course but our membership won't support that so the leaders would say that they're following the membership and so I think you get into this vicious circle whereas actually true leadership is to inspire people
to go to a place that they didn't want to know that they wanted to go to and I think we see very little of that in medicine I think we see very little of that in general in politics in society. Absolutely. These days. Politics is the art of the achievable. I don't see any great objection to for example the dropping of masks in health care at the moment which seems to me to be problematic how do you analyze that?
And again that comes back to my this this challenging this notion that that we doctors are somehow these special beings with higher morals higher values I don't think we are I also don't think we have higher insight. So I think that's what you know multi we're as bad as multi-step reasoning and following through on the consequences of that multi-step reasoning as the rest of society.
So what would you do to improve that because it seems to me we have a regulatory system which is exactly to me analogous to the legal system in general society and that in that we live in the shadow of it rather than ever really interacting directly with it. I think that that comes back to the massive gap between work as imagined and work as done.
So the things that we do and have to do on a daily basis to deliver the most appropriate care to patients are very different to how for instance the regulator would understand what we do. I mean the mayhem of an emergency department at times it just has to be seen to be believed.
I mean we had a riot in the waiting room a couple of weeks ago a literal riot and in this it was the patients on that occasion but you know so in that context delivering care is extremely difficult and those kinds of considerations the considerations in the real world are very, very different. So yes you're right there's a huge amount of theatre and there's a huge amount of people simply doing what has to be done irrespective of what regulations are.
I mean just the concrete example of this so people can understand we're not allowed to send photos of patients by insecure means. So if you've got a patient with a burn. That sounds like a very good idea. It sounds like a great thing. I'm in the committee now and I'm voting with all the other committee members. Actually we're not even having a vote at the safety committee. Somebody just suggested this. We're all going yeah that sounds about right.
It's absolutely obvious that you want the most secure means of transport of confidential patient information but it's one o'clock in the morning. You've got a patient with severe burn. You've got a multi-trauma. You need advice. You've got a bone sticking out of the leg.
The orthopedic surgeon wants to see a picture of that leg right now and we're not allowed to send for instance by mobile phone by a text message and there's supposedly some kind of secure mechanism by which these photos can be sent etc. In practice that does not exist in any way that I have ever come across. So every time that a doctor sends a photo of a patient in a critical situation to enhance the patient's care with the consent of the patient they're breaking the rules.
So they stick their neck on the line every day to do that. And that's the gap between work as imagined and work as done. I mean I think the thing to say is people are inherently good and that's the I do believe that and they inherently want to do the right thing.
There is an element of idealism for anybody who goes into a health profession and they want to do the right thing by the patient but it's a question of surviving within the organization and I think it's you that's referred to the large health bureaucracies as self-healing organisms and indeed they are such that if you want to get on you have to behave in a way that supports the functioning of the organism.
Well what can a patient do someone who's out there who's got long COVID at the moment what's their best hope in approaching this sort of Kafkaesque how do they find the people who will do the best for them in the face of a difficult system combined with a difficult patient problem.
Relentless questioning and relentless advocacy and that will piss a lot of people off but it is the squeaky wheel that gets the noise and if you find that you're being fobbed off ignored you simply have to put the case more strongly.
I do not think that we have for all the rhetoric a patient centered healthcare system and there is no doubt that many people get marginalized for the sake of the smooth running of the system so for the individual patient I'm afraid there is no alternative to being polite but firm and going this is not what I need I've got more questions can you please answer them blah blah blah. That's all you can do.
Perhaps it's best that patients come in a bit a bit skeptical about their healthcare provider rather than assuming from the get-go that the first doctor they see is going to know what they're talking about and going to take their problem seriously particularly if they have a complex problem like long COVID that doesn't necessarily fit yet with medical dogma a contested area.
Yeah no question and if you look at the level of knowledge of many ordinary people about the nature of airborne transmission of not just COVID but other respiratory infections now it's way higher than that in the medical profession and there's an enormous problem which we've seen in the pandemic with knowledge translation in other words the latest knowledge and understanding being translated into everyday medical practice we've known that's a problem for years but we see you know it
can take 10, 15, 20 years sometimes never for relevant information to get into medical practice and now with the availability of information with people able to Google able to see on Twitter what the latest studies are that contrast between what is known and what is being practiced is ever more dramatic and I mean just on a personal level my dad just to show how difficult this is my dad many years ago about 20 years ago now he was in his early 80s he developed he got
flu he got he then got a septic arthritis of his knee he had a staff arthritis of his knee was admitted to hospital perfectly correctly was started on high dose IV antibiotics flu floxacillin he then went into renal failure this was in the UK he was in his early 80s he was okay he wasn't in the best early 80 year old but he was wasn't bad and the doctor said in the hospital they knew they all knew me I was low for GP they all said well poor old boy his time's up and I said his
time isn't fucking well up because he's got interstitial nephritis from the flu floxacillin that he's just had and he needs high dose he needs renal biopsy and he needs high dose steroids and then it will get better and they said no well we'd have to transfer him to the regional unit you know it's not really appropriate blah blah blah so I insisted so sure enough what happens he's got interstitial nephritis from the antibiotics he goes on to high dose steroids he gets better he
lives another five years so now I had very specialist knowledge there and was able to insist and was prepared to insist so I do think it's important for people to be well informed and to approach with a degree of healthy and polite skepticism you know when when when doctors roll their eyes about the patient coming in with printouts from Google and they go oh Dr Google you know actually that's great you've got an engaged person you've got somebody who understands what's
going on who wants to understand about their illness and who can be a good partner in that you know you can be a good partner to them in that journey I think we're much too defensive and I think we have to be much more open to people part of the challenge is finding the voices that you trust and my view has been that the voices to trust other humanitarians it's the ones who actually you know are trying to look after people rather than necessarily sell them something and there's
there's no shortage of doctors out there trying to sell things but how did you find who to listen to during the pandemic I mean you've become a famous some might say infamous social media scion now what are we talking upwards of 50,000 yeah hang off your tweets occasionally and yeah you you have good presence and you've also become known to the to the wider stream media as a result how did you find what people to listen to at the start of all this um I mean that's a really interesting question
uh I I don't I I I've certainly developed a very good bullsh nose for bullshit over the years um and there is uh I think it comes down to as you said those who are humanitarian who speak plainly and who cite uh both evidence and reason it does seem to me that there is I mean there is a knowable reality some things are more true than other things um and people who make reasoned deductions on the basis of both evidence and scientific thinking where the
evidence is lacking and rationality underlying a humanitarian uh with an underlying humanitarian voice it seems to me those people relatively quickly uh show themselves to be trustworthy um now by contrast you have like the people who say well you know the shadow pandemic uh lockdowns caused all this trauma uh and uh all this you know immunity debt and so we're seeing enormous consequences of this uh over the years and they will evince humanitarian uh aspirations and humanitarian
ideals and they say well we're just looking out for the wider people but actually there's nothing underlying in terms of evidence in terms of rationale uh so those voices are false those who say you know we're concerned about studies that show a 36 times incidence in pulmonary embolus in the two weeks after contracting covid or we're looking at an excess death rate of 13 percent uh those uh seem to me much more trustworthy so i think it is it is a process um uh but you're
right i mean it we have been brought up to believe that people who are professors and have lots of letters after their name are the people to trust and of course the people who are professors with lots of letters after their name also push that uh notion and we would like to think that everybody who is in the academic sphere in the medical sphere in the scientific sphere is good and has noble aspirations and noble ideals uh and a conscience as pure as
driven snow uh but the reality as we've discussed before is that we are all human and i do not automatically trust somebody with lots of qualifications because we all have agendas i think that's a that's easier for those of us who have dealt firstly in the clinical area because we know that i'm sorry to say this the professor isn't necessarily the best surgeon um the one who's i was going to say that i as there was a pancreatic surgeon when i when i there was
a professor of biliary surgery when i trained and like everybody in the hospital went just don't go and see him just don't send any of your relatives to him and we all know that we all know those people it doesn't mean they're not the best surgeon because they are the professor but the but the converse is also true it's yes it would be more often than not that the person who hasn't devoted a large chunk of their time to academia but who has in fact spent most of their time
operating whilst being aware of the literature living in the shadow of what's happening academically that's most likely the person i think it is it's really hard for the general public uh to detect who to listen to and who not to um but as i say you know there is some degree to which you have to go with your gut you know is this person does this person actually sound like a humanitarian are they making sense uh and is there some kind of scientific basis to uh to what they're
saying um i think the reality is that the regulatory uh system cannot uh cannot guarantee that uh the people who uh are appearing as your talking heads on tv etc are actually telling you the best information and that's that's the reality you know we have bullshit in medicine and and we're just like any other we're like any other profession any other branch of humanity they're a bullshit artist and they're really good at it and you just have to try and sniff them out well one
way unfortunately they're very beloved of they're very beloved of executive producers on some tv shows but well that's that's uh that's true but you one way of sniffing them out is to to see how many times they've been wrong or how many times they've asserted the wrong narrative yes even if they didn't yes didn't know that it was wrong and and i think so you want a doctor who's humanitarian you want someone who's cautious so in the face of an
emerging risk not someone who's saying don't worry about all this it'll be fine it's all a bit of a fuss when then we get 20 excess mortality and then they go and try and deny that at the same time but uh you know that is it that is an unlock blame it on lockdowns in south australia which had like three three days of lockdowns or something i think wa was less you know yeah exactly we had exactly and tasmania we had travel restrictions we could only go as far as karnanara and esperance so
there was there was a lot of people in school parts of western australia they'd never seen before but certainly there was no uh there was no degree of lockdown and that's a whole another question that we'll approach another time but but yeah i did want to ask you um uh where you are at the moment and uh because you you have a peripatetic um kind of uh i i sometimes think of you as philius fog from um around around the world in 80 days
just uh yeah it's been to be around the world so where are you at the moment so at the moment i'm on the uh north new south wales coast on the mid-north coast and sort of hippie near the hippie town of bellingham which was where we first moved when we came to australia but we pretty soon decided that we didn't want to that we wanted to do this is my wife's also a doctor's gp like me uh that we wanted to do more interesting medicine than being in a suburban general practice so
we since we arrived actually in australia just over 10 years ago we've been working at the hospital in broome working in the emergency department on the ward and in the high dependency unit now that's not just down the road from where you are at the moment though no no it's a long it's about as far as you can get on the other side of australia so uh so we've actually just driven back uh in a in a land cruiser we came back it took us 10 days of hard driving we
came back mainly on dirt roads from uh from broome which was good you took a shot spent about half a year we took a shortcut across the middle which is a bit of a long car long cut we didn't see another car for three days so this is an amazing country here so uh uh yeah we spent about half the year up there working in the emergency department which is uh about as challenging in so many different ways uh as i imagine medicine can be anywhere
so really interesting work uh very heartbreaking sometimes uh and really rubs you up against the uh question of uh of of treating downstream results as opposed to upstream causes we're totally downstream and uh medicine needs to be upstream or at least a lot of it needs to be upstream so you're suggesting that prevention is better than cure horrors yeah the best quote the best quote is which i have which i've just been repeating all the time from archbishop
desmond tutu he probably got it from somebody else so he said there comes a point where you have to stop fishing bodies out of the river down at the river mouth and go upstream to see who's kicking them in you know and we're just fishing the bodies out of the bottom of the river upstream prevention it's a bit dull because nobody gets ill and then people go well maybe he's ill so why do we need to do all this stuff uh but that's really where the big gains
are to be made it's not in you know trying to get the hba1c down by another 0.5 percent by adding in another diabetic drug into somebody who's got a body mass index of 50 you know that's that has a degree of futility about it that's yes so um do you find that uh you are able to sustain this sort of by this lifestyle of spending six months immersed into that emergency department because you can then uh spend a bit of time outside of that and do you think it balances with the
advocacy work that you do trying to improve the upstream or or are they both incredibly taxing uh well i i i couldn't just do the that work probably 75 80 percent of our patients are indigenous aboriginal australians uh and seeing dealing with that on a day-to-day basis relentlessly uh is uh uh results in a very high degree of moral injury to health care workers it's very hard to do that work and not get burnt out uh so does it make you does it make you angry
it it really makes me angry about you know the false promise of medicine medicine is so the medicine that we have today is so powerful and so incredible and we are seduced by it i mean as humans as hunter gatherers we are tool makers you know the history of our species the history of of the genus homo since a million years is a refined tool making the history of our species as homo sapiens over the last 200 000 years is refined tool making and and an increased
communication and the ability to cooperate to make amazing tools and our drugs are the most amazing tools and we are so seduced by them but in fact you know we we we do so much that is self-defeating we create the illness that we then go on to treat in this kind of virtuous loop or non-virtuous loop um uh and that's that's what makes me angry is the futility of what we find ourselves forced to do people don't mind working very hard but they they do not like doing work that
is futile no exactly exactly and you just look at you go i can put a sticking plaster on this today but the damage was done so long ago um but so but you have to do it right someone has to be there for that of course you do yeah absolutely and that's the that's the beauty of medicine you know that you're there you've got the patient in front of you you have this very clear moral duty to do your absolute best to help that person in the best way possible for them
taking into account everything blah blah blah uh so that's that's easy so actually standing there on the day you know you don't give somebody a lecture on the uh you know the importance of avoiding ultra-processed food and not drinking four liters of coca day etc you just got to treat their mi or whatever so that's easy um but it does there is an accumulated moral injury from that over time and i don't think i could do that uh every every week of the year without getting extremely burnt out so
advocating so i'm just on for my personal well-being advocating for humanitarian uh uh aspects is very important i spend a long time advocating for a better treatment of refugees uh coming to australia um and uh as you know more recent against uh health care corruption particularly in the world medical association um and now as you know i've been a vocal proponent of safety in the pandemic for all of us but most especially those
who are most vulnerable who have no uh who are so much more at risk and who i think have been grotesquely introduced uh during the pro during the pandemic and and are now being exposed to unacceptable risks in our health care system and that that's what makes me most upset and most angry uh is that we are no longer uh even paying lip service to first do no harm we don't care um it seems you have these two all us sort of um activities that you throw yourself into and one of them
in a way cures you of the other and the other it does you spend your time in the emergency department putting the band-aids on because you know what to do for that person right in front of you and there is a real satisfaction in the immediacy of dealing with your father's interstitial nephritis and fixing a problem that is fixed in medicine like in politics like in law like in everything we want a problem that's fixable so that we can
have a victory exactly there is it yeah i mean look it's fun you know it's it's a really interesting i mean i i partly i went into medicine because i absolutely love medicine i mean it's absolutely fascinating uh and the power the sheer power of what we can do is incredible i do think uh i mean here comes a bit where i i kind of lament about the young doctors of today but the young doctors of today i'm not even that old but they don't understand how things have
changed even in 30 35 years hiv has become a chronic manageable condition i mean these are incredible things and so when you do something when you you make a great diagnosis you manage to cure somebody you put in a chest drain you know to relieve a pneumothorax whatever these are all incredible things to be able to do and there's some sometimes in the emergency department where we're going yeah we are the champions we figured it out yeah and so that's that's really you know
that's really fun i mean it's of course we need that medicine the fact is a lot of it we shouldn't have to be doing i mean we'll always have to do some of it but so much of it is like we don't have to be doing this so you're like a firefighter who gets a real satisfaction out of putting out a fire but every now and then you kind of want to make a fuss about why don't we have better fire safety why are we getting so many damn fires because who's who's making and the fact that there are
some people making money out of this and there are other people wandering around going exactly don't worry about all the fires don't listen to Berger you know he's trying to impinge on your freedom by saying that you need to have a fire extinguisher exactly and yeah exactly it's ridiculous to advocate for zero fires what a ridiculous idea you know it's bizarre but it's so weird isn't it the way you know we can advocate you know that we
have this manifest these manifest targets for like zero road deaths which is totally unrealistic i mean they'll never be zero road deaths but but the government's spent billions trying to get to it presumably partly because that you know there's a lot of money in its motor manufacturers to build safer and safer cars so there's this kind of coincidence of of aspirations but in other things it you know there really isn't any there really isn't any interest so
like the notion that we should have zero hospital acquired respiratory infections for instance that we should make our hospitals safe if people go well that's just ridiculous you know we can't we can't even what an absurd aspiration and yet the history of humanity is that we are cunning clever fiendish and we accomplish everything we do the most amazing things and yet the simplest things if they're not politically expedient we are indoctrinated to believe that
they are impossible and that's where i'm most upset about what i see is the failure of leadership in the medical profession that the medical profession should not be doing the bidding of the pharmaceutical companies or a government whose only short term our main short-term aim is to get people back into city center business properties cvd business properties and to get coffee shops running again at full capacity that's what really annoys me
when our privilege gets revealed to us we then have these constant moral judgments to make about how much do we go down into the abyss and look into the abyss trying to help because you can give away all your wealth tomorrow walking through the streets of africa and make no difference at all and on a substantial sense whatever how much life are you entitled to reserve to yourself to enjoy do you think it's possible to to have a
balance where you're not beating yourself up too much you're not getting in too much trouble you're still doing your job but you're actually making some sort of progress or is this as people like falcon might suggest a long defeat where we're just seeing sort of some some nice pushback occasionally but in the end things sort of get tending towards entropy yeah i mean i think that things obviously you know all the nature of entropy is that everything tends tends towards the
less ordered state and that is the nature of the universe but and life and particularly humanity we are the entropy reversing process particularly you know we reverse entropy on this local scale we per capita command more and more energy we control more and more of the solar energy that's reaching the planet i do think that one can get terribly bound up with this kind of obsession with purity of motive you know how pure am i am i doing enough should
i be doing more etc and i used to get very tortured by that you know this kind of absolutist view of things and i think it's a very western way of looking at things i mean i i you know i think you just do what you can you just try not to be a shit in your personal life and you try to work the best you can for others given the limitations that you have and none of us are perfect and i don't yeah personally i don't feel the need to kind of strive for protect
perfection which is a good thing because i'm so far off it but i think i think i think just understanding that that the quest for purity of motive is a quest but you don't necessarily have to follow it you can just try and do the best you can and it's better than not doing the best you can and it's okay to make a holiday from it and enjoy yourself exactly because you're only human and you there's only so much you can do and beating yourself up is it's another
kind of vanity in a way you know it's like you know i should be so perfect i could be doing this and it's just like come on just listen yeah i think that's been a good orientation uh to my provocative uh question is what's the point of you um i think i'm gonna have to interview you and i'll see what's the point of you no no that's not the premise that's a very interesting question as well it's nothing it's not the i'm not ready for that question maybe when i get to
your your esteemed seniority then i'll then i'll be ready of course uh if we do anything by sharing these chats i want people to not feel alone because there are people who don't have our privilege of having a pretty still a pretty reasonable immune system being able to get out yeah and people who find it difficult to access their health care at the moment there are people who have split up from their families at the moment because there's no understanding about
what it is they're going through so if in having these chats people can uh understand that there are those who have not just sympathy for them but also strategy also connection also potentially some influence uh on on the way people think about things if not explicitly then maybe um we we influence the way that people um thought leaders or decision makers do think even though they might never want to admit it then i suspect we can repeat
the same conversation next time and just say it in a slightly different way perfect I'm back here again, I told myself I'd stay a while away Solutions ahead but don't carry on Blinded by nothing, we'll wait through it all Hold on to the dark There's a grace in the fire and the flames Thoughts drifted so far In this room I've lost my way All trees are clad So far below me now And where do I go when the signs aren't so bright And I'm weighed down by feeling I don't have much time
It's okay, I suppose, let's just hope that it goes No need to stress over a failure to cope I'll take my anguish and go