Thursday, 16 August 2018

Re-writing the language.

   Here's a piece of 'educational research' that I  continue to get because  I  used to be a physician.    It is so tainted with 'political correctness' as to being  not only an opinion as to how a physician relates to  patients, but to suggest a whole new dictionary as to how physicians should record their interpretation of their interview with their patients.  George Orwell could hardly have dreamed up this piece.  
   Medical history taking is a highly skilled art, an art most physicians downplay today, because it is time-consuming and not rewarding.  Both the scientific community and the  masses grossly underestimate it, because in the long term, we all die.  History taking is not glamorous and much  of the time is routine grunt data collection, which is why in  our present health care system is almost exclusively done by medical students  and residents and even they realize that it is considered the 'scut work' and barely valued at all.  Although it is the bottom of the totem  pole, it holds the structure aloft.  I know the high tech stuff is much more exciting and achieves incredible results (sometimes!) but when the bottom of the pyramid is unstable, the whole damn thing is likely to topple.
   Remember, before Christ, the Romans were building bridges  that lasted a thousand years.  ( The Ponte Vecchio built in 1345 is still functioning today).

 
  

Stigmatizing language in chart notes creates negative impressions
Clinical question
Does negative language affect residents' and medical students' attitudes toward specific patients and influence their treatment decisions?
Bottom line
Think of how antagonistic common medical jargon is. Patients "complain." They "admit" or "deny." They "refuse" or are "noncompliant." The words we use can transmit, via a hidden curriculum, implicit bias to medical personnel in training. This study compared stigmatizing language with neutral language used to describe a patient with sickle cell disease that cast doubt on the patient's pain ("still a 10" vs "still a 10/10"), portrayed the patient negatively ("hung out at McDonald's" vs "spent the afternoon with friends"), or implied patient responsibility with references to uncooperativeness ("he refuses his oxygen mask" vs "he is not tolerating the oxygen mask"), Medical students and residents had more negative attitudes toward the hypothetical patient when described with stigmatizing language and suggested less aggressive management of the patient's pain. It's time to revise the medical scripts that convey negativity and bias about the patients in our care. (LOE = 1b)
Reference
Study design
Randomized controlled trial (double-blinded)
Funding
Foundation
Allocation
Uncertain
Setting
Other
Synopsis
In this study, medical students (n = 233) and emergency or general internal medicine residents (n= 180) were randomly assigned, concealed allocation unknown, to read 1 of 2 chart notes with medically identical information about a hypothetical patient with sickle cell disease: one using neutral language (eg, "He has about 8 to 10 pain crises per year, for which he typically requires opioid pain medication in the ED") or stigmatizing language (eg, "He is narcotic dependent and in our ED frequently"). After reading the note, both the residents and medical students completed the Positive Attitudes toward Sickle Cell Patients Scale (range 7 - 35) and the residents selected a treatment for the patient from 4 options. Attitudes were significantly lower, on average, for participants presented stigmatizing language (25.1 vs 20.3; P < .001). Attitudes were progressively lower with years of training (correlation coefficient -.95). Residents were more likely to select less aggressive treatment (eg, a low-dose opioid or a nonsteroidal anti-inflammatory drug instead of higher dose opioid, along with less likelihood of redosing) if exposed to stigmatizing language (P <.001). Participants reading the stigmatizing note also were more likely to identify the physician who wrote the note as having a more negative attitude toward the patient.
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Friday, 10 August 2018

Canadian Medical Scavaging.

  The recent decision of the Saudi-Arabian government to withdraw funding of students being educated in Canada, although not admirable, is certainly understandable.  The present Canadian Government, lead by a multimillionaire capitalist pretending to be a socialist, trading on his father's name and who has never had a productive job, is a poor recommendation for the intellect of the less than half of the Canadian population, who voted for him and his wealthy elites.  He hopes to continue to buy power, and it is all about power, by changing the electorate of Canada.  His millionaire socialist father, and his millionaire socialist cronies, knew well that the way to fool the poor and needy and many others is to pretend to give them all they need, courtesy of the hardworking and creative segments of our society, that lifted us and them out of the poverty that was so ubiquitous in previous generations.  Scientists and physicians were penalized for their efforts and as a result many have undergone a fundamental attitude change.
   The withdrawal of many postgraduates in medically related fields won't go without consequences.  Students and residents play a much greater part in keeping the health care system running than most people realize.  In addition, foreign governments pay the Canadian government substantial sums of money above and beyond what it costs to train their residents.  We are not doing it out of the goodness of our hearts!
   Canada, as well as Britain and the U.S. have a shameful history of scavenging second and third world countries for their badly needed newly qualified physicians, not because we need them, but because it is cheaper than training our own.  In addition, they are much more easily controlled by the  University hierarchy, because they have control over the licensure of Foreign Medical  Graduates.   Incidentally, even the term 'Foreign Medical Graduate' is deemed politically  incorrect today.  I can  comment on  this because I am one!  Now the term is 'respectabilised' into INTERNATIONAL Medical Graduate.  They vary in quality from excellent to dangerous and often are not very carefully screened before being given positions in our health care system..
   Anyway the FMGs are at the mercy of the  University, who can pull their license if  they don't do as they are told!  They are certainly much more easily manipulated than Canadian graduates.   I was a medical educator for much of my life.  I know!
   For once our tweeting Foreign Minister got the message right as to how foreign countries should correct their deplorable human rights record but has done serious damage to the resources of the health care System in Canada and to the economy.  In our declining health care system which was only capable of giving mediocre care to citizens even before the intake of thousands of immigrants, the loss of funding and manpower resulting from the present fiasco can only do more damage. 
   Let's hope the Liberal  government puts their money where their mouths are and that Canadian health care is not going to accelerate its already rapid decline.  This government will not even allow Canadians to spend their own money in quest of better health care, without leaving the country.
   The government's first job is to look after the people who are paying their salaries. 
 Don't be afraid to comment.  I won't tell anyone
   

Friday, 27 July 2018

Great Canadian Physicians -Sir William Osler.

Dr.William Osler.

    Long long ago when I used to interview applicants for medical school I was often amazed that when I asked a candidate to name one great Canadian physician, how many of them started at me blankly and could not even make a guess. There have been many greats, but Sir William Osler, internationally renowned for changing the face of medical education in Canada, the United States and Great Britain and in the world, should surely have been known to any candidate aspiring to become a physician in Canada. Those giants of medicine on whose shoulders we stand, , of which Osler was certainly one, must be turning over in their graves at the direction their beloved profession has taken. I am, and I'm not even dead yet!
    Let me quote Osler to attempt to convey to you what embarking on a career in medicine meant in those days and into the days when I chose medicine as a career.
"The good physician treats the disease, the great physician treats the patient who has the disease". That, some hundred years before the College of Family Physicians began touting that concept as though it was something new.
    Another: "The greater the ignorance the greater the dogmatism".
    "Medicine is learned by the bedside and not in the classroom. Let not your concepts of disease come from words heard in the lecture room or read from the book. See and then reason and compare and control."
    Well, I venture to think this exceptional man, who established the Department of Medicine at McGill, who was a founder of Johns Hopkins Hospital, world famous for treatment, teaching and research and later professor at Edinburgh and and then Oxford, would have been finished before he began, had be existed in our time.
He said this: "The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.".
    This is a time in which everyone considers themselves to be an expert, no matter how little they know about a field, under the egregious misapprehension that all opinions are equal and should be treated with equal respect. Anyone who is not a total moron knows that isn't so. Unfortunately, the fear of confronting ignorance and the desire to re-write history politically correctly is a major contributor to the accelerating decline we are experiencing in the developed world.
Sir William said many wise and true things some of which today would bring about the rapid termination of his career, no matter how brilliant he might have been.
    "The uselessness of men above 60 years of age and the incalculable benefit it would be in commercial, political and professional life if they were to stop work at this age ....the plot hinges on the admirable scheme of a college into which at sixty, men retired , for a year of contemplation, before a peaceful departure by chloroform. "
    "The desire to take medicine is perhaps the greatest feature which distinguishes man from animals."

    Many today, think  that medical eponyms (naming a discovery or  a treatment after the discoverer) should be abolished, that they just complicate medicine.  I am strongly opposed to such action.  The giants of medicine deserve to have their names and their contributions respected. 

Friday, 20 July 2018

The Ex-Doctors Dilemma. Pt 2.

   So, the next morning, (see previous post if this needs explanation), I started off at Pen Club.  The London, Ontario, Pen Club is a rather remarkable club.  Its only rule is that there are no rules and that any attempt to introduce them will immediately result in expulsion from  the club.   So far there have been no expulsions.   Since we meet every Saturday morning without exception unless Christmas day falls on a Saturday morning (even Yom Kippur does not qualify  in cancelling a meeting!), there is usually adequate time to philosophize and  solve the world's  problems after the Pen  discussions.   In fact, I  have suggested on many occasions that we should extend  our title to 'The London Pen Club and Philosophical Society'.   None of the other members of the club seemed enthusiastic about that,so we left things as they were.   Nevertheless,  I continue  to regard the club as my 'ex-doctor medical lab' and listen to the comments, complaints and sometimes praise of the health  care system.
   A couple  of weeks ago one of my club co-members and friend, whom I will call PC2 was concerned about having an angiography and stent placement.
   " You've had that done, how was it?"he said to me.
   " I wrote a piece in the "Medical Letter" describing it in  what I hope was as humorous a way as one can.  I'll post it in my blog or re-write it  for  you." 
      I did and I hope it brought him a little enlightenment and humour.
    In  the meantime he'd had and survived the procedure and felt better now  that the stent was in place..  We discussed details.   My stent has lasted ten years.  Then we discussed pens because PC2 knows more about Pens than I ever knew about stents!
     
   That evening, I received a call from a relative, we'll call her FM3.  Shortly into our conversation she asked me,  "What do you think of this whole Valsarten issue?"
   Me: "What  Valsarten issue?"  
   Valsarten is a blood pressure and cardiac medcation.  It was even around when I was practicing full-time and considered an effective medication as it is today.
   FM3: "Some batches of it have been found to cause cancer.  Not the actual stuff, but something used in its manufacture, by some companies."
   All my family think I'm brilliant and know everything!
   "News to me.  I'll have to look it up."
 FM3: "The pharmacist phoned and told me to bring the remainder back and to talk to my doctor about a new prescription."
   I looked it up in the FDA site and there it was.  A list of formulations containing NDMA, (look it up) apparently used in the manufacture or somehow appearing as a contaminant in some of the formulations.  
   " I'll certainly have to follow up on that one!"
            I'll follow that one carefully!

   Later on, my lovely bride said to me, 
      " Oh I've got this funny pain in my elbow.  Want to take a look at it?"
     Me,"Oh it's probably old folks arthritis," I diagnosed glibly.
     MLB, "It sort of feels like a splinter.  Want to take a look at it?'
     Me, "I can't see anything there."
     MLB, "You don't have your glasses on, feel it!"
     I grudgingly admit I can feel something.                  
   "I'll get my magnifying glass."
      I find a tiny splinter that could have been a speck of glass.  I get some alcohol (not to  drink) and a needle and sterilize the needle and the operation site,  I'm pleased to report the surgery was sucessful!
     It's almost like being a doctor again! 
     God help me!!
     - and my poor patients!!
  
     
   
  

Saturday, 14 July 2018

The Ex-Doctors Dilemma.

The Ex-Doctors Dilemma.

    When I retired from practicing medicine three or four years ago after a satisfying lifetime in medicine I thought I had had enough. There were a host of talented young men and women ready to take up the mantle. They were well trained state -of -the- art physicians When I made new friends or acquaintances, unless directly asked I carefully avoided bringing up my erstwhile occupation. Indeed, since I was an academic I could honestly give my profession as being a university professor rather than as a practicing physician. Nevertheless, there were frequent leaks, as they call them nowadays and medical issues sometimes dominated the conversation when that was not my wish. I was not insensitive to the fact that the exchange was not always 'story-telling', but sometimes reflected a real need for information that should have been conveyed to a patient by their physician. As a teacher for many years who emphasized the importance of communication between physician and patient I was disappointed how frequently that communication and the understanding that it brings is lacking. In this era of episodic care, it often barely exists, if at all and I frequently encounter people who for whatever reason need to be heard and informed . I suppose it is partly the consequence of the ten minute consultation (impossible!) imposed by government when it interprets the fee schedule and of other cost-cutting measures like abolishing the Annual Medical Examination, that golden opportunity when the patients got to know the physician and the physician got to know and understand the patients and their problems. So now that I have unlimited time to listen (I was always a good listener) and no patients, I try to shed a little light or whatever it takes to help when I think I need to. There is rarely a shortage of customers to listen to my unlicensed, non state of the art, pro-bono medical opinions or explanations. I rarely give advice.!
   In the past twelve hours .....................................
   Last night,my wife and I went out to dinner with some friends. The husband requires two canes to walk and keep his balance. After dinner, as we walked back to our car, I noted they were parked quite a distance away from the restaurant, although there were handicapped parking spots sitting empty right outside.
I remarked that he should have had a disabled persons parking pass and told him he should ask his doctor to compete the form. His wife told me he had done so and the doctor refused. I considered this unreasonable and told them so. I hope they will take some action. When I asked them the name of the doctor they wouldn't tell me. 
(Later she told me she was mistaken and that it was something else that the doctor refused.).  Regardless, I think it is the doctor's responsibility to firmly recommend a parking pass to someone who would clearly be at risk traversing an icy parking lot in the Canadian winter. Obviously, the ten minute consultation time often allows only the most pressing needs of the patient to be addressed.
  My wife mentioned I had been having a little knee trouble and that I had bought a elastic compression sleeve from Amazon which was very effective. His wife had a sore knee too. I sent her the link! God bless Amazon!!
   As we pulled up to our own door I saw an elderly man (i.e. about my age) shuffling around and looking lost.
   Irene: "That old man looks lost."
   Me: "Yes, I think he is."
   I go over to the well groomed old man. 
"Are you lost, Sir?"
   "Yes, I think I am." "He points up a rather steep hill in the condo complex. "I think I live somewhere up there.".
  "Hey, I don't think I could walk up there right now. Hop into the car" I say.
  "Oh, I'm okay.". He shuffles on.
  " What number do you live in?"
  He looks puzzled. "Er, I think it's 56."
  "Hop in the car and I'll drive you up there."
  We drive up there. There's a car in the driveway, otherwise the place is dark. He gets out of the car, knocks on the door. No answer.
  "Do you think it's where you live?" I ask.
  "Well, that's not our car in the drive."
  "Do you have a phone number?" Yes, but he didn't know what it was.
  "Do you have a wallet?" Yes, but he left it at home.
  "I'll just get out of the car and have a look around." he said.
  "Not a good idea, stay in the car and we'll cruise around." He had already told me his wife would be getting worried as it was getting dark.
   We drove around the complex. It was getting dark and I saw a young woman finishing up her gardening. I pulled into her drive.
  "Miss, " I said,"this gentleman is lost and I'm trying to find out where he lives. Do you know where he lives? "
    She knew who he was, knew he had Alzheimer's and knew approximately where he lived.
   "Jump in the car and let's take a look."
   That's what we did and found his wife frantically looking for him. She was very grateful and I spent a few minutes educating her as to how to prevent recurrences in the future by making sure he was identifiable.
   The number of his house actually turned out to be 65. If he had wandered out of the condo complex it could have been dangerous.
   As one of my friends says when I tell him I'm not a doctor, "Once A Doctor, always a Doctor".
  "No," I say, "but for those with the vocation once a doctor always a Samaritan!"
I didn't have another case to deal with until the next morning at Pen Club!
   

       

Saturday, 7 July 2018

Old Cabbage - Coronary Artery Bypass Surgery. Pt2.

A personal story!

When I sprung it on relatives, colleagues and friends that I was planning to have bypass surgery, the first response tended to be reassurances as to how healthy I looked, and questions as to how long I was ill.    Funny, because I never considered myself ill at all.   After all, all I had experienced was a bit of breathlessness and a little tightness in my chest when I exerted myself.  I could swim laps indefinitely, as long as I used commonsense and didn’t try to break records.   And after all, I was sixty-nine, no spring chicken in anyone’s language.   How was that to be equated with illness, I was never ill a day in my life.   Never missed a day of school or university or work.   Ill indeed, I thought indignantly!  In fact, quite honestly, I was really only proceeding with surgery prophetically, because the genetic scales were so heavily weighted against me.  Was I just going to sit around and wait for those obstructed coronaries that I had looked at on the angiogram to totally plug and kill a huge chunk of my myocardium, or even me.  I was determined to get those obstructed coronaries before they got me.    So I carried on going to work every day, waiting to hear from my surgeon’s office as to when I would be having my surgery.   Meanwhile, I was daily fielding a litany of phone calls from relatives and other well wishers, including dutiful nephews and nieces who no doubt were responding to their parents exhortations and gracefully did their duty.


The operation. 
     Thursday was a fairly normal day at work although I did finish a little early in order to complete my paper work as Friday was 'coronary artery bypass surgery day'. I had my martini (of course) and a light supper and a visit from David, a great support as always. 
     11/19 /04 up at 5 am And David picked Irene and I up at 5.30 for our morning apt.  In more civilized times patients were admitted the night before surgery to get acclimatized to the hospital environment and to get rested up before the surgery.  "The system" (i.e. the administridiots who have destroyed it) no longer concerns itself with such things as long as it saves a few bucks.
     At 6 am I was through the admitting area hardly noticing all those other poor souls with their problems small and great but none I was sure, as  great as mine. 

     A kiss goodbye to my wife. A word of encouragement: clothes deposited in a plastic bag; then on to the stretcher in to the OR .

      The Anesthesiologist greeted me at the door

So you are Davids  dad?'' he smiled effortlessly sliding the IV needle into my vein.

     "Yes, that's me,” I managed to smile back, trying to think of  some smart answer.

     The lights went out.  

      I opened my eyes.  The lights came on! The anesthesiologist was gone. The operation was over and I was surprised at how little pain I had. Just like my niece Maureen had said describing some recent surgery - 'lights off, lights on.'

     Now I had to get the damn breathing tube out of my throat.   My God, I couldn't talk!   I made as much noise as I could to attract attention and look as though I was really suffering, - maybe that way I could get rid of it!   The Nurse leaned over me.

          “Are you having a lot of pain?” she asked sympathetically.

          I shook my head - no, but harrumphed and coughed as much as I could to make it quite clear I wanted this tube out of my throat.    Maybe if I coughed hard enough I'd manage to propel the thing across the room. 

          I could hear the machine behind me, but couldn't see anything.    Where the hell was I anyway?    Alive, at least, and no sign of any stroke or paralysis or anything else horrible as far as I could determine.    I seemed as sharp as ever!   I tried to cough up the tube.   The nurse injected something into the IV tubing and I drifted into some pleasant place.



         I woke up with vague pain everywhere, and a horrible nauseated feeling.    A nurse strolled by.   “Something for the pain?” she said, deftly depositing a little cardboard container with two pills in it, into my hand, and launching the whole shoulder, arm, hand unit in the right direction.   I swallowed them and soon dozed off again.

          “Are you on these pills too?” I politely asked the woman just to the right of my shoulder when I woke up.   I couldn't figure out why she was wearing the pretty bonnet right in the ICU.  I managed to twist my neck around, to get a better look at her and saw this was an electric fan that somehow looked like a woman's face, framed in a bonnet.   I gave a little chuckle to myself, as I realized my delusion- no wonder the poor old geriatrics got wingy after a few days on narcotics.   I had at least one other similar episode.   I looked at the clock, 11.10, must be at night, I thought.   I drifted off to sleep again, and had a long deep sleep.   I woke up again, and looked at the clock.   11.20!

Maybe I had slept right around the clock and it was twenty four hours later.   Then I noticed people all hustling around and going somewhere!    It looked like some sort of a set from the movies, something funny was going on here.   Everyone was leaving.   Nevertheless, someone was offering me pills again.

          “I think I'm going to throw up,” I said.   

          “Hold on a minute,” the nurse said, a large basin appearing from nowhere.

          I felt horrible, retched and threw up a large amount.   The relief was immediate and wonderful.   I closed his eyes and drifted into a deep sleep.    When I looked at the clock a long time later, it was 11.30.



          Somehow, the night crept by, a nanosecond at a time, but at least I could see that the morning would come eventually.
    Two days later I was back on the ward.

Note to myself on Dec 2.  2004

Apropos of nothing, but in the light of some of my recent thoughts, I was interested in this paragraph I just read in the NY Times Review of Books, from the review of the book by Harold Bloom entitled " Where  shall wisdom be found?"

     Bloom: "It reminds me of the experience of a friend years ago, when, awakening from major surgery, she heard in the recovery room a faint voice reciting the Easter soliloquy in which Goethe's Faust comes back from the brink of suicide to the joy of life.    Through her anesthetic haze, she wondered to whom the voice belonged until she recognized it as her own; speaking a poem she had known by heart in childhood and somehow retrieved from deep memory during induced sleep." 

          Now if only I had known Goethe's Faust so well........



My notes from a few days later:


A bath!   Oh, what a pleasure, oh what a joy!    And, oh, how much muscle power it takes to get in, wash yourself and to get out!     Amazing how much leverage, torsion and other forces involved in just sitting up, pushing yourself on to your feet, while praying that your feet don't slip away from under you, cracking your cracked thorax on the side of the tub, and ending back in the hospital.



And where does all that disgusting dirt in the water come from, when you haven't been out of your house and barely out of your bed since the last bath?    Anyway, it confirms that the simple joys are great!


Monday, 2 July 2018




Some belated Father's Day thoughts.






    My father was a conversationalist, a communicator, a wit and a punster, and a bit of a philosopher, who loved his family and his country. He was born in and loved Dublin and had some very close Irish friends in all walks of life.. He used to say to me, “Son, you may travel the world you’ll never find a finer place”. (In fact I couldn't wait to get out of that tight little island!)
    For a man whose formal education ended when he was fourteen he was very well-informed and I remember as a child seeing the National Geographic and a journal called Psychology Today lying around the house. There was no topic he was unwilling or unable to discuss. He was a master of the allegory, always ready and able to illustrate his point with an anecdote, a story or a song (and he had a collection of songs both sad and funny that no oneelse seemed to have heard of).
   I have quoted him freely and still do. Indeed we were
suspicious that some of his songs were made up, until we managed to find a number of them on the internet. In retrospect, many of his stories and jokes, had a profundity that I didn’t really appreciate until adulthood and which resonate until this day, when I am thirty years older than my father was when he died.
   He was an upholsterer by training and built up a small business. He was truly an artisan of the old school and loved to restore old period furniture which he did painstakingly himself, sure that it was too delicate for even his most competent employees. He had magic hands, he could repair anything and even singlehandedly, built a fair-sized room onto our house, doing everything from the brick-laying to the electrical work and the final decorating himself. A wonderful gift, it seems to have skipped my generation, though I see the same painstaking preoccupation with perfection in my son. I spent some time as an orthopedic house officer assisting very capable orthopedic surgeons, and feeling sorry that my father’s superior manual skills were not applied to surgery.
   
He taught me about respect for others. His friends were either honorary aunts and uncles, or Mr. or Mrs. No first name addresses by seven year olds to adults.   No cheeky, smart-ass retorts. He also taught me about respect for myself and for the young girls and boys I associated with..
   When all the other teen-agers (I’m talking about 1 7 or 1 8 year olds) were sneaking into their homes quietly to avoid discovery by waking up their parents, I knew I was going to find my father sitting reading the newspaper waiting for me no matter what time I arrived. He would look at his watch and say, “You’re late tonight, where were you?” Then, “who were you
with?”   I'd tell him the truth (usually!) and then he’d offer me a cigarette and we would sit chatting, in front of the fire, often for a long time, about every topic from world politics to scientific developments. Sometimes my mother would wake up upstairs and call down, “are you two going to sit up all night?”
   The Conversation, the conversation was all, I knew how he thought, and he knew how I thought. We shared love, rapport, respect.  I never, ever, remember my father raising his voice to me. Sometimes, when there was something on his mind, something worrying him, he would tell me about it. Often it was about financial issues, as mass production drove him out of business.  Invariably, he would finish by saying “don’t worry, it will be alright, and you needn’t worry your mother about it”. My parents never yelled at each other. The closest they
came to that was when my mother would say to him, in exasperation at me, “Talk to him, Davey,” and he would say ‘Hello Stanley’. That’s about as close as it got!
   They're not making his kind anymore.