The Toilet Paper Revenge & Jailbreak.

 The Toilet Paper Revenge.

A visit to the psych centre.

 Our visits soon became routine. we had regular clinics 3 times a week and responded to calls twenty-four hours a day. One or more students or residents attended the clinics to learn how to deal with these difficult and often manipulative patients. The variety of patients were extreme ranging from the xxy ( the bad guys in old monster movies ) who you wouldn't want to meet in the back alley on a dark night, all the way to clean-cut, well-groomed even in prison garb, inmates. All the usual complaints that occur in any practice presented, as well as a large number of manipulators who came to the clinic with some ulterior motive that could range from the desire to get hold of some illicit medications to getting hold of some item of clothing that had become popular (and 'fashionable') among most of the prison population. For instance Nike runners were a high prestige item and inmates often demanded them for painful feet or low back pain. They were often aggressively specific in their demands and they were loyal to brand names so that a cheap trainer would be quite unacceptable to them. Their response, when they were not given what they want could sometimes be violent. Such demands could run right through the institution and if an inmate managed to manipulate such a prescription there would be an avalanche of people with foot pain and lower back pain all needing Nike shoes. Eventually, when I was presented with such requests I had a cover story that they could only be prescribed by a specialist in Orthopedics and I would be glad to arrange an appointment for them but that the waiting time would be about a year. That worked very effectively and usually stopped the request.

  One of the common situations was an attempt to obtain narcotic drugs by feigning symptoms. They thought that would result in a prescription for what they wanted. They had other schemes to obtain drugs that they could not get prescribed for them. Visitors entering the institution were screened very carefully because they sometimes smuggled in illicit medications. Indeed the inmates were so successful at getting medications illicitly that the staff carried out searches from time to time. The inmates were cleared out of their cells and a spontaneous search would sweep through the institution looking for narcotics and other drugs. Many drugs were discovered on these searches and on one occasion a search revealed a partially completed homemade still to distill alcohol. Although it never actually succeeded in producing any alcohol, its manufacturer's had made significant progress in its construction before being discovered.

  Some of our students were attractive young women and in an all-male institution of this sort, this naturally aroused considerable interest and necessitated careful security precautions

   Some of the inmates were only temporarily remanded while a psychiatric assessment was carried out. Those individuals were sometimes released into the community. When they did not get what they wanted, some of these inmates would level threats at the psychiatrists, physicians and or nurses. I recalled one such individual who issued a threat that when he got out he would ‘get’ me. As he was only being held on remand and it was likely that he would be out soon, it left me feeling a little uncomfortable. Shortly thereafter he was discharged. Not long afterwards, I came home one night to find that the trees and bushes in my front yard were draped with toilet paper and my front room windows were smeared with toothpaste spelling out some obscene words. After cleaning up and considering who was responsible, It occurred to me that it might be the individual who had previously threatened me. I went along to our local police station to report damage and danger. I explained the background and that I worked in a maximum-security prison. The police sergeant said, " They didn't do much damage, you were lucky they only used toothpaste and not paint.”

  I pointed out that it was not the property damage I was concerned about but the potential danger to my family and myself.

 “ Oh well, we'll have a patrol car cruise around your cul-de-sac once in a while and keep an eye out for anything strange.” He didn't seem worried at all. The end result was that my neighbour who had a trailer parked outside his house on the street in our cul-de-sac found a fifty dollar ticket on it a few days later.

 "Strange "he said to me.`` It's been parked there for ages and I never got a ticket before. "

  I didn't tell him it was because I'd asked the police to keep an eye on our house. I guess they thought they might as well ticket his trailer and have something to show for their trouble. Fortunately nothing ever happened and I never did find out who the perpetrator was, but when my colleague suggested that he lend me his shotgun for a while in case any murderers or rapists break into my house I gave it serious consideration.

The Break-out. (Almost).

  As I entered the RPC one morning, there seemed to be a lot of commotion at the entry gate with a line up of individuals with various business to complete waiting to get in. By this time I was well enough known to the guards to push my way ahead to gain entry. There were a lot of officers there.

  "What's up," I asked. "What's the big hold-up?"

  "One of the guys tried to break out and he managed to get into the area between the inner and the outer fence. He was just starting to climb the outer fence when Gil showed up with a shot-gun, lined him up in the sights and told him he better get down or he'd be shot."

  "I'll bet he did as he was told" said I.

  "He did," said the guard.

    I walked across the courtyard and entered the building. As I approached the clinic I saw Gil, sitting at a desk, typing earnestly with two fingers.

  "What are you doing there? " I asked.

  "You heard about what went on this morning ? I'm just writing up my report."

  I started reading over his shoulder.

  "the prisoner had managed to get over the inner steel chain fence and had made his way to the outer fence and had begun climbing it to make his way to freedom. I pointed the shotgun at him and said 'please step down immediately or I will have to shoot you.'

   I laughed because I knew that Gil didn't talk like that. "Okay, what did you really say?"

   Gil laughed right back and said, " I said 'drop, fucker, or I'm going to waste you! He dropped!'"

  I attended the RPC for seventeen years and that was the closest we ever got to a jail break!

   

Corrections Canada. Pt.2.

 The Regional Psychiatric Centre. Corrections Canada.Pt.2.

Walking the Walk.

 After passing through the metal detector, the metallic clunk of the lock being released on the inner door, allowed the visitor to begin the long walk across the courtyard to the main building. As I walked across the courtyard I noticed a pretty cozy-looking tiny house to my right that spiked my curiosity. I had to find out its purpose. It seemed all pink and fluffy.

     "What's that little fairy tale cottage over there all ?" I asked.

   The guard, whose name was Gil grinned. "We call that the 'Fuck Hut', er I mean the 'Love Hut'" he said. "That's where the poor deprived prisoners, er, I mean inmates - they don’t like the erm prisoners here,spend the night for a cosy little interlude when the wife or as they say nowadays ‘significant others’, comes to visit. They can't be denied their conjugal rights, you know."

   He laughed again. "One guy's wife phoned a couple of weeks ago to know why he was being allowed to bring in a hooker who swore she was his wife. It's not a bad life here once they get used to it."

   As I approached the second set of security doors, I wondered if I was going to have to go through the same routine again but they were expecting me and a loud clunk sounded as someone in security who had been following our progress on multiple video cameras, sprung the release. The tightly controlled security nerve centre, to which I was only admitted once by a friendly guard, was very high tech and any part of the institution could be monitored in detail or locked off, if deemed necessary. Once inside the building, the guard behind the desk said, “Hold on a minute doc, and we’ll take you on a guided tour of the institution and wind up in the clinic where you'll be working.  I’ll show you around and introduce you to the clinic nurse who'll be working with you.”

 

   The circular corridor was divided into sections so that any area uprising could be instantly isolated to prevent spread.   The large steel gates unlocked noisily as we approached each section and locked equally noisily after we had passed through.

  " Very smooth," I said.  Canadians were efficient in those days and did what had to be done.

  Inside the circle of the building was a large central area where the prisoners were allowed to exercise and in the centre of that area was a beautifully landscaped cultivated area. I noticed one or two men picking daintily at the edge of the turf.

  "The prisoners do a really nice job of maintaining these gardens," I said to Gil.

   Gil laughed at me again. "This place is maintained by the biggest and best landscaping company in town, Doc. I wish I could afford them. The only prisoners who work in the garden are those who request to do so, provided they are not considered too dangerous. Prisoners can't be coerced into working and those who volunteer have to be paid."

  We stopped at a point in the corridor where a locked door on the left had a sign that read 'General Medical Clinic'.Gil pressed a button and spoke into a speaker. "Okay, we're here at the clinic. Let us in."

  Again the loud clunk of unlocking. We walked in. I looked around the clinic area. This clinic looked better than my family medicine clinic at University Hospital! The clinic itself was well laid out, no intrusive security precautions apparent and better equipped than my office at University hospital. Corrections Canada is federally funded never seemed short of money, whereas health care provincially funded was always in need.

     "This is your Nurse, Doctor Smith,” said the guard, introducing me to Heather, a pleasant young woman who looked about fifteen years old and who wouldn't have weighed a hundred pounds soaking wet. I have a daughter who is a nurse and I couldn't help thinking I wouldn't want her working here. It was a hazardous job but Heather turned out to be a fearless young woman who seemed to manage two hundred and fifty pound six foot two giants comfortably.  Thought I, she’s a better man than I am!

  "I hope That you always have adequate security when you're working in this Clinic.

  “ Oh yes, I have my belt alarm,'' she said, indicating the gadget attached to her belt. “All I have to do is press this button and there's someone here right away. Most of the time there is a guard right in the room with me."

  "I think that we'll have to change that a little and tighten up the security. When we are seeing patients there will be a guard in the room at all times and if it is a patient with a violent history there will be two guards in the room and another just outside the door in case we need it.”

  "Well there is patient confidentiality to consider, some of the guys don't want anyone hearing about their personal problems," Heather said.

  You bet they didn’t!

  "In this situation I think our safety is more important than patient confidentiality so the guys will just have to suck it up. If there's any problem with that then we need a meeting with management.  Further,if there are investigations or treatments that can't be done here at this institution and patients need transfer to university hospital, facilities will have to be developed to move them promptly, observing all the appropriate precautionary measures necessary. Because these guys will have to be handcuffed and ankle cuffed when they're being taken over to University Hospital and two guards and a driver will be necessary to undertake the journey safely.” 

    After inspecting the clinic, the team, which had now grown to include a couple of administrative bodies, continued on to inspect the living quarters of the inmates.  Each prisoner had what we in the competitive outside world would call a studio apartment.  Some of my patients who worked hard trying to make a decent living did not live as well as these inmates.

  Next, the nurse shepherded us into the dining room which was more like a middle range restaurant than a jail.

  "The staff can eat here too, so if the clinic runs on a little late you could save a little time and then go on to your office, "  said Heather, and then added,   "You should try to make it on a Thursday," she smiled, "because on Thursday we get steak!  That’s a rule.  Steak once a week”.

 

Who said 'crime doesn’t pay?'.

Corrections Canada.

 Corrections Canada.

   Following a modestly successful career in training young physicians in family Medicine in an era when superspecialization was the solution to all the world's problems, I was offered the Headship of the Department of Family Medicine at University Hospital in Saskatoon, the site of the College of Medicine at the University of Saskatchewan. Generalists In a territory the size of Texas, with a population of 1000000 were desperately needed. The opportunity was too good to turn down and eventually led to becoming the Chair of the Department of Family Medicine and a full Professorship. When I was forty I had taken an academic position as Assistant Professor of Family Medicine which involved teaching undergraduate and postgraduate students and developing a residency training program in the newly built teaching hospital, The Plains Health Centre. It was with mixed feelings that I left the community based partnership that I had enjoyed for fourteen years. My partners were of a caliber I don’t seem to encounter very often nowadays. Hardworking, caring and rugged individualists. We all took our own night calls, did our own deliveries and made house calls. All without whining about how hard we were working and what facilities we could access for burnout!! (What was that, anyway?) We kept our post-partum patients in hospital for five days, because we knew that new mothers needed the rest and weren’t likely to get it at home. When a patient pressed for early release we would reluctantly let her go home on the fourth day and feel we were exposing her to stress.

       In those days our heart attack patients stayed in hospital for several weeks and weren’t even allowed to get up to go to the bathroom for the first week. We would look after the elderly at home, making house calls as necessary to monitor their progress. Those were the days before the ‘Health Care Industry’, when being a physician was naively thought to be a noble profession.

 I had only been in my new position a few days when my nurse knocked on my office door,.

 “Dr. Smith, there are two Mounties here to see you, they say it’s personal,” she said apologetically.

 “Oh, they’ve finally caught up with me,” I said laughingly, “show them in.”

 Two young RCMP officers came into my office, looking a little uncomfortable.

 “We’ve come to pick up your RCMP special constable pass, doctor,” the shorter of the two said, awkwardly.

 “Oh, you mean you’re firing me?” I asked gravely.

 “Oh, nothing like that, sir. It’s just that our headquarters are in Regina. I’m sure that if we have any medical needs in Saskatoon you’d be the first person we’d be contacting.”

 I reluctantly handed over my RCMP Special Constable pass thinking of all the story-telling mileage I’d gotten out of it over the years. Little was I to know, however, that before long I was to be offered another position with the Justice System that would be more interesting, more lucrative and more dangerous than the one I had just given up.

 

 Soon after we had moved to Saskatoon where the Medical School was, I was approached by an old friend of mine from my Regina days. Dr David Williams was a graduate of Cambridge University, who had come to Canada, possibly to escape two ex wives and two sets of kids who’s maintenance kept him permanently impoverished, to the extent that he found it difficult to maintain the lifestyle he preferred. That included wining, dining, skiing and travel. Fortunately his current lady was also a physician, who was well able to support herself. He was a very competent and busy family physician whose itinerant lifestyle was prompted more by personal preference than by any professional shortcomings. In any event, he ended up in Saskatoon as the Medical Director of a maximum security Corrections Canada Psychiatric Institution. (Prison!)

             He sat in my office, “So how are you enjoying being the big boss at the Regional Psychiatric Centre?” I asked him.

 “The job is actually quite interesting and pays well too!” he responded.

 I interrupted, “How the heck did you get did you get a high level administrative job like that, you hadn’t had much administrative experience, had you?

 “No, not formally, at any rate. As you know, I did a term as President of the Provincial Medical Association and did interact quite a bit with Health Care Politicians and bureaucrats, regarding various issues. Being fluent in French didn’t hurt either.”

  “I wanted to talk to you about a couple of things, Stan. As you know, I’m the medical director of the Regional Psychiatric Centre. I’m quite enjoying the job but I have a couple of concerns. The first is that I don’t want to get so far out of medical practice that I can’t get back into it. I don’t want be an administrator for the rest of my life. I know that you have some community based physicians come in to the clinic and do some teaching, as well as farming out residents and students to community based practice. So, I’d like to offer my services to your department one day a week, doing anything that you feel would be useful in the department as long as it involves patient care. I have done some teaching in the past and had students do a month rotation in my office when i was in private practice. Actually, I got some pretty good evaluations from the students. So do you think there may be something I can contribute that will allow me to continue to have some exposure to patients on a weekly basis. Of course I don’t want any remuneration and any fees that I generate can go into the departmental slush fund or whatever.”

 “I have no doubt that you would be a valuable asset to the department. If you can firmly commit to coming on a Monday, which is our problem day to get teachers to come into the unit, I can definitely facilitate you. You say you had a couple of issues you wanted to discuss, what else do you want to talk about?”

 “We have a whole phalanx of psychiatrists at the Psych Centre, but we have as yet, no clear-cut mechanism for providing general medical care for the inmates. We wondered if the department of Family Medicine would provide that care.”

 “That’s going to provide a considerable time commitment, Dave. There’s no way we could do it on a fee for service basis.” I said.

       “We don’t expect you to do it on a fee for service basis.” He mentioned a figure that quickly removed any doubt in my mind as head of a university department with an unhealthy deficit. The Department needed the funds.

I looked impassively at Dave for a moment and wondered what all the wives and mistresses saw in him.

       “I’ll have to discuss this with members of the department, but we’ll certainly give it serious consideration. I could see that it could have some very valuable advantages from a teaching point of view,” I said. I didn’t add that it would also have some very valuable advantages from a financial view for a teaching department that was having difficulty maintaining its mission while functioning in the black. Let me talk to the department and think about it for a day or two and I’ll get back to you.”

       Experience had taught me never to say yes or no to any idea, no matter how good or bad it seemed at first blush, until one had a chance to think through all its implications.

My decision to follow such a policy had served me well over the years and avoided embarrassment on a number of occasions.

 It didn’t take me long to convince Staff and Residents that providing the general medical care for the Regional Psychiatric Centre would be a valuable teaching service as well as providing the financial means to provide some much needed improvements within the Department.

 And so it came to pass that Dave became a regular Monday afternoon teacher in the Department of Family Medicine and the Department of Family Medicine became the official care providers of the Regional Psychiatric Centre. We negotiated a start date a couple of months down the road and it took all of that time to get the necessary security clearance and complete the contract. Two of my departmental colleagues and I would alternate coming out to the centre on a weekly basis accompanied by a family medicine resident to hold a clinic and the physician or resident on call for the department would manage out of hours calls.

 On January the second nineteen eighty-eight, I showed up at the RPC Saskatoon, federal maximum security institution of Corrections Canada and walked up to the perimeter fence.. This place was for males only - the really dangerous guys. The entire complex was protected by a double ten foot high fence broken only by a single entry point that served as a check point for anyone or anything entering or exiting the centre. Sensors secured the area between the two fences which were sufficiently sensitive to be triggered on occasion by birds or small animals.

The entrance was protected by a checkpoint that was an office with an outer and inner door between which was a security desk and a scanner of the variety which we have all become familiar with at every airport. The security doors were glass in their upper part so that any prospective entrant who rang the bell to gain entry could be observed and questioned as to the nature of their business. Once admission was considered appropriate the visitor was questioned regarding the nature of his business and prior to gaining admission to the institution proper was required to turn out his pockets and empty any briefcase or other baggage to avoid the possibility of anything being smuggled in or out or of being stolen by the inmates. After passing through the metal detector the metallic clunk of the lock being released on the inner door, allowed the visitor to begin the long walk across the courtyard to the building.

 

 

 

The Holyland. Pt 3.

 Monday 29th Jan.

Met with Dr. Ben-Basud, head of the clinical decision making group at BG . A very interesting man who moved here from Jerusalem to head up the decision making group. We talked about changes in medical education, (he is about my age) and the change from traditional histo - pathologic based diagnosis and treatment, to 'evidence based medicine', which attempts to encourage professionals and decision-makers to pay more attention to statistic -based evidence to inform their decision making and to eliminate traditional or outdated practices. unless to some of the recent Russian emigrants who had been accepted into the FMR program. The Residency here is a four year program, the last of which is, more or less a social service year in which the resident practices independently for the most part, with some general supervision. This usually occurs in the various outlying clinics in the Negev. These immigrant physicians are faced with the task of trying to learn Hebrew and English at the same time- no easy job. Incidentally, they are among the best dressed people I have seen in Israel, where most of the physician are in jeans or cords and shirts. Afterwards I was driven back to the hospital by one of these residents, who was driving one of the nicest cars I've seen in Israel.
Irene has a bad cold so we didn't go out once I came home. I tried plugging in the modem, and though I didn't manage to make the connections I wanted, it didn't fry the modem. So I'l have to experiment a bit. Meanwhile, I will continue to use computers around the hospital.

Tue 30th January.
This morning I went up the the shopping centre to have a haircut, while waiting for Irene to wake and see how the cold is and whether we would be able to make the trip to Jerusalem or not. Went into an Israeli salon where they didn't speak much English and I said I wanted it short. And boy, did I get it short, in a very military sort of style! At least I won't need another haircut for a long time! We still haven't become used to the manner in which Israelis invade your space, quite unlike Canada and the US. As I sat in the chair, one of the female stylists came over to talk to the young man who was cutting my hair. She leans over to talk to him, her bare midriff right in my face, totally oblivious to my presence.
We left for Jerusalem at about two p.m. and made our way across the countryside enjoying the rolling hills, the very green fields, this must be the greenest time of the year, the trees and the sights. Just coming out of Beer Sheva, the Bedouin Shanty towns, followed by nice new permanent Bedouin housing developments. Took some photos of both of these to illustrate the contrasts. Once onto the main Tel Aviv Jerusalem stretch, the traffic was horrendous, and we observed the Israeli phenomenon of turning a normal human into a lethal driving machine. As we get into Jerusalem and the traffic slows down before the ultimate gridlock, the other Israeli compulsion of honking the horn incessantly becomes evident. Israelis sound their horns insistently and incessantly, for reasons that are often not clear. Sometimes I think its just to let you know that they are there. They also pass on single lane highways in situations that most sane N.Americans wouldn't think of.
Jerusalem was far busier than when we were last here in 1989. As we were driving in we recognized the area where we were living then, and drove and walked around a little 'til we found 18 Mitudela where we had stayed, a big stone apartment block that was always cool - without air conditioning. It was so designed that the cool evening air blew gently through. We then drove downtown and after much hunting around managed to find a parking place. Ambled around King George street and Ben Yehuda St. and finally found a nice outside restaurant and had fish and chips. Thought it time to start heading back to Beer Sheva as I had no idea how to start back. Stopped at a gas station for some directions and they advised me to head the most direct way which was through Jericho. Now even we are not so poorly informed that we don't know that this is a dangerous place, and since the attendants at the gas station seemed a bit vague perhaps they were underestimating the dangers. Since we remembered that we came in on the Tel Aviv road we headed back out that way to look for the turn off to Beer Sheva, which we somehow seemed to miss. We soon found ourselves almost at Ben Gurion Airport, and I decided to turn into the airport for further direction. As we turned into the airport there was a sort of obstacle course, which quite obviously, was to stop any would- be car bomber from getting in to the airport. As I came through the path, three heavily armed soldiers, came out and. waved me down. I stopped the car immediately and jumped out. They had me pull the car out of the traffic lane, but quickly seemed to rule me out as a serious terrorist threat, despite my military haircut. They could speak hardly any English, and I just kept saying in my very few words of Hebrew "Where is Beer Sheva?" They told me in very simple Hebrew how to get back on the road, and sent us on our way. Later discussed our avoidance of the Jericho route with some of our local acquaintances. They assured me it was the right decision.

Wed 31 Jan 1996.
Went to Research meeting on Bedouin Health and their perceptions of their health care. Main coordinator of the research program is Maroud, a medical resident who speaks Hebrew, Arabic, Czech, English and Russian. He is carrying this project almost single-handedly, because acceptance of researchers of other ethnic origins would not be acceptable to the Bedouins. The research project calls for many meetings involving all the different communities and requires separate meetings for men and women, and Maroud attends almost all of the meetings. In addition he attends to his duties as a family medicine resident on his one year rotation of Internal Medicine. Many of the issues are similar to those of our Canadian Indians, to provide continuity and comprehensiveness of care in the rural areas. One of the differences is that the distances are so small in Israel, that even from the most remote areas it's at the most a couple of hours drive to a major centre. Anyway, after the meeting I had an interesting chat with Maroud, and he suggested I might like to go and visit some Bedouins and drink some coffee in the tent. I said I'd love to. He said he would arrange it.
Later I went to a meeting of the Family Medicine Dept, during which time all the peripheral teachers come in to have a department meeting and a continuing medical education presentation. When I came in to the meeting the Chairman asked me if I could follow the meeting in Hebrew. When I answered no, he said, "Dr Smith does not speak Hebrew, does anyone have any problem with changing the working language to English?"
Nobody had any trouble with that.



Thur 1 Feb.
Spent the morning in the Family Medicine Unit seeing patients with some of the staff physicians and residents. Some of the residents were experienced physicians who had emigrated to Israel and were working towards full licensure. Most, but not all had a working knowledge of English. Several were from South American countries including one from Cuba and several were from Russia. There were quite a few Americans and Canadians. Very few were fluent in Hebrew.
In afternoon went to old part of the city and sought out another well of Abraham. Seems to be several around here. This one was a tourist centre with information handouts and a women in the office who was delighted to have someone to talk to. This area had four wells and were not as old nor as impressive as the much narrower, deeper well at Tel Beer Sheva. This was in a part of the old city that we had not seen before, and had an interesting looking market and shops that would stand a little exploration.
In the evening we go with Mickey and Sid, the couple we rent the apartment from, to a social gathering a friend of theirs is hosting to present a lecture on the 'Alexander Method', a sort of alternative therapy ', aims to re-educate the mind and the body through a series of movements so the body uses muscles more efficiently'. The relationship between the head and spine is the key. The talk is given by an Israeli therapist, a fortyish, lean man who is the therapist of the aging hostess. He delivered the talk with some difficulty in English. It turns out to be another worthless, crack-pot theory but being the only physician there among the converted, I managed to keep my mouth shut and look thoughtful. Something I don't easily accomplish.

Sat. 3rd. Feb.
Got up at a respectable hour this morning and headed to Ein Gedi, a kibbutz on the Western sore of the Dead Sea. Ein Gedi was an ancient Oasis Settlement of great significance during the First Jewish Rebellion against Rome (66CE). The drive was incredible involving a drive through Arad and on to the Dead Sea, which goes through very picturesque sandstone mountains, up and down winding narrow roads, some overlooking dramatic precipices, the crazy Israeli drivers passing blindly on the dangerous curves. When the Dead Sea comes into view, 400 meters below, it does so as a glorious panorama of intense blue and white, overshadowed by the monumental Jordanian mountains. We drove on to Ein Geddi, where we stopped at the Spa, had some lunch, (an interesting salad bar, which included one of my favourites, egg-plant - known as hatzilim here.) walked on the beach, for a while and then went on to the En Geddi beach. Ein Geddi, has been an Oasis in the desert for thousands of years, across the Sea from which is the Moab mountains, where Moses was buried. Here is one of Israel's most important archaeological sites, which we did not go to see nor even know about. We will have to go there again.

February 5, 1996
Meeting in morning re Inf Hepatitis Study. Pesach is very good at getting drug Co. money for acceptable research studies.
Went over to library to do a lit search on stroke incidence in Israel. Librarian from California. In the afternoon met with Vice Dean Carmi Margolis. Talked to him re computerized medical record. Very interesting. Need to spend more time with him re CPGs. He's from NY. He told me the story of how he and others developed an electronic medical record for Kupat Cholim, complete with all the bells and whistles, and that it needed updating and K.C. pulled their funding and decided to go with another system - that the clinics involved are now back to writing records manually. He referred me to someone else for further information. We talked for about an hour about emr. My diagnosis is they were shooting too high, and should have extemporized and tried to hang on to what they had, but there may be factors that I don't know about. We never did get on to talking about CPGs, and will have to schedule some further meeting to discuss this and other issues. Carmi's explanation for Israeli behaviour-Israelis got their country by fighting relentlessly, winning the war, and estalishing the state-and feel every issue has to be won in the same way, by fighting a war there is no such thing as resolution by compromise.

February 5, 1996
Today went to Ashkelon to the K.C. Clinic to spend the day working with David Tobin, a physician from Ottawa who has been in this area for about ten years. The clinic is very busy and David sees from 40 to seventy patients per day. This is a bit hard to understand in view of Israels very high ratio of physicians to patients. There seems to be some very real competition between family physicians and various specialists, and perhaps between the various managed care groups, of which there are four or five. A great cultural cross section of patients, varying from Ethiopians (very difficult to diagnose because of cultural differences and somatization), to new Russians, many of whom don't speak Hebrew. Patients tend to be pushy and tend to push into the Drs office without invitatiion, so Dr. Tobin locks the door between the examining room and the waiting room once he shows his patients in. Although part of Israel is extremely high tech in some ways, this clinic which could be very easily computerized at little expense, has an archaic record system. David seemed glad to have someone to confer with and I think must feel a bit isolated practicing alone. I saw a few interesting patients, David interpreting for me. I think I could pick up 'medical hebrew' pretty quickly. David stated he feels aware of the booming Israeli economy. His analogy of Israeli life is of the person getting on the bus getting trampled by the other passengers running over him, but when they see the poor fellow cannot get off the bus they carry him on their backs to the hospital.
Tonight we were invited to Noga Porter's for dinner and met her son, ready to go into the army, and her husband Basil, a pediatrician. He is very interested in CPGs and I think we shuld meet in the business setting to discuss this and other issues.
Basil is a S.African who immigrated to Israel years ago.

February 6, 1996
Met with Dr.Haim Belmaker, a transplanted American psychiatrist who is the head of Psychiatry here. An interesting fellow, who recently co-authored a paper entitled:
Dopamine D4 Receptor (D4DR) Exon III Polymorphism Associated with the Human Personality Trait of Novelty Seeking.
This made Time Magazine in January.
Of more mundane interest is that Dr. Belmaker holds the Chair of Ortho- Molecular Psychiatry, endowed by the Vikars family, brother-in-law of Abraham Hoffer. Dr.B. has been active in O-M research, recently publishing a paper entitled, "Double-Blind, Controlled Trial of Inositol Treatment of Depression," which was reported in a newspaper that came to the notice of Hoffer, who was not at all pleased that the research was not directly concerned with the use of vitamins in the treatment of schitzophrenia. He wrote quite a nasty letter to Dr. B. saying how displeased he was with the direction of B.s research, and that they would have done better to give the money to a Canadian or American University. He hasn't replied to this letter yet, and he states that he will show it to me before responding. Apparently the whole endowment brings into Psychiatry $3000/yr. I'll be iterested in the follow up. We have arranged a meeting between Dr. Elana Belmaker and myself for later, as she is some sort of a public health physician.
Walked round old BeerSheva and had a light supper at a side-walk cafe.
Rena phoned at one am, just after I had dropped into a nice deep sleep. She sounds great.

February 8, 1996
Met with Jeff Borkan this morning to talk about a possible low back pain project and made a few notes.
Also found an office that has word perfect, where I hope I will be able to print up some of the stuff I have written.

February 9, 1996
Dimona to meet with Dr.Alan Bitun, a graduate of BGU practicing in a Kupat Cholim Clinic. He lives at Sde Boker, Ben Gurion's clinic, and invited us to visit him at the Kibbutz, which I hope to do. I had a short but interesting takl with him, which covered the fierce competition between Israeli Family Physicians and other primary care specialists. Interestingly he very definately distinguished between 'specialists in Family Med, and other primary care physicians. Irene came withme and we went on to Mamshit, a city built by the Nabotheans two thousand years ago. A really impressive site and sight, of which i took many pictures.
Dimona is interesting apart from its Nuclear reactor. Noga told me that a large black commuity had come there to settle from Chicago years ago

The Holy Land. Pt2.

 Wanderings in the Negev.

Once on the road again we started heading towards Dimona, a modern Israeli town with a 'secret' nuclear reactor. I say secret in parentheses because absolutely everyone, Arab or Jew knew all about it, I knew all about it too but when I raised the issue they 'shushed' me.

"It's a secret, we don't talk about it!"
Somewhere in this area we pulled off the road again, for one of those pilgrimages to a Bedouin spontaneous settlement that was virtually invisible from the road, and only after a considerable journey over rocky, uneven terrain, they becomes identifiable when you are a few feet away.

Maraud showed us the Nissan hut that had been the medical clinic when he was on his remote rural rotation, which he said he had physically built himself. He described the difficulty in providing appropriate medical care to women, who were only allowed to come to the clinic if accompanied by the husband, who remained present during the history and the physical examination. The clinic had been discontinued when he left, and apparently was to be permanently closed down. The message being that the local people should go to Dimona, which is only a few miles away, where there was a modern well equipped well staffed clinic. My conviction was that after he had left it was impossible to find another physician to practice under those restricted circumstances when there was a modern clinic nearby. He agreed with this theory and he also pointed out that due to the terrain, which was subject to flash flooding, the ambulance would not leave the main road to pick someone up regardless of the severity of their condition.
We ended up at a traditional Bedouin goat skin tent where we were invited in for tea. We were seated around the in-tent fireplace where we were offered something to eat, which we politely declined, and were given the hot sweet tea that the Bedouin sit and talk and sip all evening, sometimes very strong bitter coffee was the alternative.. We sat talking for some time, the Sheik sitting reclining on comfortable woven mats that covered the floor of this communal tent, with their thick embroidered cushions. His traditional keffiyeh framed his dark mustached face, the gray Western style suit he was wearing forming a strange contrast. Shortly thereafter, the Imam or holy man came into the tent to join us, and was greeted with great respect - everyone stood up and shook hands. About eight or nine others sat around the fire, the older ones in traditional dress, the younger ones in jeans, but most wearing the traditional Arab headdress.

An Amusing Exchange.
As we had approached this settlement, I noted that the tents we were approaching were all black. I wondered about this, because, in the desert, where the sun beats down all day, surely the tents should have been white, to reflect the heat and the light of the sun. M. had introduced me as 'Professor Smith from Canada,' and of course all our conversation in both directions went through him.
As our conversations drew to a conclusion the Sheik inquired as to whether there were any other questions I would like to ask.
"Yes," I said, "I want to know why all the tents are black, when it would be much cooler to have white tents?"
All of the occupants of the tent, both old and young, broke out into hilarious laughter. It went on for quite a while.
"What's so funny?", I asked M.
"Well," he said, a smile on his face, " the Sheik said , tell the Professor , that the tents are black because the goats are black!"
After a while we took our leave, and after a long cross-country drive, over moon - like rocky terrain, we passed the Dimona power station and headed back to the road.

Sunday Jan 28th.
Meeting with the Dean scheduled for 11am. First I met witn Pesach, and when I noticed the time was a little past eleven and pointed this out, Pesach said, "oh, he'll wait for us" and carried right on chatting. A few minutes later the Dean's secretary came into his office looking for us. The dean was a very nice fellow, who chatted about the various problems that exist in primary care in Israel, particularly in the area of geriatrics, as this population has a high percentage of elderly people. They are talking about increasing the geriatrics in the program - at te moment there is one month of geriatrics in the FM program, and also of having some sort of a certificate of special competence ingeriatrics.
the dean then said, ( obviously he had read my CV carefully!)
"I hear you have a special interest in stroke prevention."
I agreed.
"I think I see a great need for that in Israel. Perhaps you could put forward some sort of a proposal in that regard while you are here. In fact," he continued casually, "I'd like to see something in place before you go."
"Certainly," I replied confidently. And so I've been commisioned!
After the meeting with the Dean, I came home, picked up Irene and went to Tel Beer Sheva. This is the archeological site of the ancient city of Beer Sheva, and is really very interesting. Particularly fascinating is the well, just outside the town site, which is the well of the biblical stiry of Abraham. The well is excavated to an amazing depth, and with the aid of some recently installed flood-lights one can see right down to the water - a long, long way below. Gives one quite queazy feeling in the stomach to look down there. Even though there is a robust grid over the top of the well to prevent one from falling down. We picked up a pamphlet which incudes a map of the general layout, and which will be a appendix to this journal, so I will not describe what others have done better. I took quite a few photos of the site and of the surrounding hills. The site closes at four , and we were a little late getting down to the exit area. A young bedouoin man told us it was timefor himto have a sleep and so it was time for us to go. (very politely). When we got to the exit the woman on the door said he had wanted to lock up the park, but she had seen our car on the parking lot and told him he was to find us first. Otherwise we would have been spending the night in the biblicalcity of Beeer Sheva. There is a view tower in the centre of the archeological site from which the 360 degree view is impressive.
Afterwards we drove around Beer Sheva a little and ended up in the old parrt of the city. Parked the car and found a seventy shekel parking ticket on it, when we got back. Lots of new Russians around town, and many of the stores had signs in Hebrew and Russian.
Monday 29th Jan.
Met with Dr. Ben-basud, head of the clinical decision making group . A very interesting man who moved here from Jerusalem to head up the decision making group. We talked about changes in medical education, (he is about my age) and the change from histo - pathologic based treament, which despite its rationality often just does't work, to evidence based medicine, which is so much in vogue and spearheaded by MacMaster.
Later I went to oneof the other Family Medicine Clinics in Beer Sheva, and after a drug company sponsored lunch, the topic was vertigo, the drug serc, spent some time talkig to some of the recent Russian emigrants who had been accepted into the FMR program. The Residency here is a four year program, the last of which is, more or less a social service year in which the resident practices independantly for the most part, with some general supervision. This usually occurs in the various outlying clinics in the Negev, as far as I can understand. These imigrant physicians are faced with the task of trying to learn Hebrew and English at the same time- no easy job. Incidentally, they are among the best dressed people I have seen in Israel, where most of the physician are in jeans or cords and shirts. Afterwards I was driven back to the hospital by one of these residents, who was driving one of the nicest cars I've seen in Israel.
Irene has a bad cold so we didn't go out once I came home. I tried plugging in the modem, and though I didn't manage to make the connections I wanted, it didn't fry the modem. So I'l have to experiment a bit. Meanwhile, I will continue to use computers around the hospital.

Tue 30th January.
This morning I went up the the shopping centre to have a haircut, while waiting for Irene to wake and see how the cold is and whether we would be able to make the trip to Jerusalem or not. Went into an Israeli salon where they didn't speak much
english and I said I wanted it short. And boy, did I get it short, in a very military sort of style! At least I won't need another haircut for a long time! I still haven't become used to the manner in which Israelis invade your space, quite unlike Canada and the US. As I sat in the chair, one of the female stylists came over to talk o the young man who was cutting my hair. She leans over to talk to him, her bare midriff right in my face, totally oblivious to my presence.
We left for Jerusalem at about two p.m. and made our way across the countryside enjoying the rolling hills, the very green fields, this must be the greenist time of the year, the trees and the sights. Just coming out of Beer sheva, the Bedouin Shanty towns, followed by nice new permanent Bedouin housing developments. Took some photos of both of these to illustrate the contrasts. Once onto the main Tel Aviv Jerusalem stretch, the traffic was horrendous, and the Israeli phenomenon of turning a normal human into a lethal driving machine. As we get into Jerusalem and the traffic slows down before the ultimate gridlock, the other Israeli compulsion of honking the horn incessently becomes evident. Israelis sound their horns insistantly and incessently, for reasons that are often not clear. Sometimes I think its just to let yo know that they are there. They also pass on single lane highways in situations that most sane N.Americans wouldn't think of.
Jerusalem was far busier than when we were last here in 1989. As we were driving in we recognized the area where we were
living then, and drove and walked around a little 'til we found 18 Mitudela where we had stayed in then. We then drove downtown and after much hunting around managed to find a parking place. Ambled around King George street and Ben Yehuda St. and finally found a nice outside restaurant and had fish and chips. Thought it time to start heading back to Beer Sheva as I had no idea how to start back. Stopped at a gas station for some directions and they advised me to head the most direct way which was through Jericho. Now even we are not so poorly informed that we don't know that this is a dangerous place, and since the attendents at the gas station seemed to me to be Arab, perhaps they were underestimating the dangers. Since we remembered that we came in on the Tel Aviv road we headed back out that way to look for the turn off to Beer Sheva, which we somehow seemed to miss. We soon found ourselves almost at Ben Gurion Airport, and I decided to turn into the airport for further direction. As we turned into the airport there ws a sort of obstacle course, which quite obviously, in retrospect, is to stop any would- be car bomber from geting in to the airport. As I came through the path, three heavily armed soldiers, came out and waved me down. I stopped the car immediately and jumped out. They had me pull the car out of the traffic lane, but quickly seemed to rule me out as a serious terrorist threat, despite my military haircut. They could speak hardly any English, and I just kept saying in my very few words of Hebrew "Where is Beer Sheva?" They told me in very simple Hebrew how to get back on the road, and sent us on our way. Later discussed our avoidance of the Jericho route with some of our local acquaintances. They assured me it was the right decision.

Wed 31 Jan 1996.
Went to Research meeting on Bedouin Health and their perceptions of their health care. Main coordinator of the research program is Maroud, a Bedouin resident, who speaks Hebrew, Arabic, Czech, English and Russian. A tall, handsome, dark-skinned man in his early thirties, he is carrying this project almost single-handedly, because acceptance of researchers of other ethnic origins would not be acceptable to the Bedouins. The research project calls for many meetings involving all the different communities and requires separate meetings for men and women, and Maroud attends almost all of the meetings. In addition he attends to his duties as a family medicine resident on his one year rotation of Internal Medicine. Many of the issues are identical to those of our Canadian Indians, and to providing continuity and comprehensiveness of care in the rural areas. One of the differences is that the distances are so small in Israel, that even from the most remote areas its at the most a couple of hours drive to a major centre. Anyway, after the meeting I had an interesting chat with Maroud, and he suggested I might like to go and visit some Bedouins and drink some coffee in the tent. I said I'd love to and he is going to give me a call sometime.
Later I went to a meeting of the Family Medicine Dept, during which time all the peripheral teachers come in to have a dept. meeting and a cme presentation.

When I, the great Canadian Professor, came into the meeting the Chair asked me if I could follow the meeting in Hebrew.  When I answered in the negative he said, "Professor Smith cannot follow the meeting in Hebrew, is there anyone who would object if we change the language to English?"  Not a person objected!