Tuesday 30 September 2014

The Patient, the doctor, the beaurocrat and the Test!

     The Canadian Medical Association is a lead partner in this campaign with thirty medical specialty societies collaborating to decide what tests and investigations are appropriate to order on patients.  This campaign is called "Choosing Wisely - Canada" and is a copycat response to "Choosing Wisely" - for some reason Americans don't seem to have to add the - America.  The professed primary purpose of this is to 'help doctors and their patients address unecessary and possibly harmful over-testing and over-treating'.  While this is no doubt part of the motivation, one does not need to be very bright to see what a cost control tool this will be in the hands of the bureaucrats in the Department of Health.    Although it is generally recognized that most tests do contribute to providing good medical care to the patient, some do not and in retrospect appear to be excessive or on occasion even harmful and of course expensive. However that conclusion is more easily determined after the event when the end point has been revealed than in the urgency and sometimes confusion of a potentially serious diagnosis.  It is inappropriate to intimidate a physician under those circumstances, into not doing a test that just may be helpful, because it will likely be normal.  

      Of course there are individuals who misuse the resources through greed or through ignorance and both of these issues must be addressed.  But there are many investigations ordered in good faith when a potentially dangerous situation seems to be gathering momentum and the physician casts a wide net in the hope of capturing some piece of information that may throw light on the situation.  Experience and intuition sometimes save the day and the thought that some administrators, uneducated in medicine but cutting edge in business practice, may be able to squelch these finely developed skills is more than depressing and demoralizing.   It is sad to think that there may soon be no room in the system for the physician who through skill or effort wants to give his patient the best he has to offer.  Uniform mediocrity for all seems to be the objective of these times.

      Apart from such ambitions, every physician wants and needs to protect himself from the avaricious attacks spearheaded by the legal profession which strives to find work for itself by encouraging patients to enter the medico-legal sweepstakes in cases that they know well have no merit other than the one third of any settlement that they might acquire.  Every physician knows that he/she is liable if there is no neck x-ray on record in a cervical whiplash (a legal term originally, I believe), whether or not it was necessary, because twenty five years later if the patient develops osteoarthritis of their cervical spine,it may be attributed to the injury, whether related or not.   Many a physician who tried to conserve resources has found himself accused of less than thorough medical care on account of not having ordered a test that, in retrospect, it might have been wise to do at the time - especially if one wasn't under pressure to conserve.That is not to say that there cannot or should not be some monitoring and restrictions on certain tests and investigations but it will require great care and definition of goals that are acceptable to both the doctor and the patient.

      Finally for today, I must say that I have never met a politician or a medical administrator and I have treated a number of both and their families, over the years, who volunteered to be in the forefront of the initiatives to cut back on  use of such resources.  Nor have I met physicians, nurses or health care professionals who opted for other than their physicians to make the recommendations as to the protocol to follow.

I'd like to hear your view on all of this, because you are the folks who are going to be effected.  Comment, if you would like this thread to continue.


Sunday 28 September 2014

More about "The Big Fat Surprise." by Nina Teicholz.

           On reflection,  I feel a few further comments are necessary.  As I  have mentioned before,  I have had considerable experience over  a several years  of  running a weight control group at University  Hospital in  Saskatoon and of  treating overweight  patients in  both  Sask  and Ontario.
The hundreds of books written on this topic and  the thousands of articles in both  the Scientific journals and in the lay press, were and are a sure indicator that we have many more questions than answers.
           Much of this work challenged the efficiency of what has been known as the Heart Healthy Diet, directed primarily at reducing saturated fats and reducing the low density lipoprotein component of total  cholesterol in the blood.  Ms Teicholz preoccupies herself  excessively with the polemics of the  situation.and with her assessment of  the motives of investigators and promoters of the various theories relating to the many diets that have been advocated over the years.  Some of the rationale she uses for supporting the point of view she supports are quite a stretch.  For instance, the diet of the Inuit, a very  high animal fat diet, is extrapolated into being an ideal cardiovascular diet and preventing heart disease.  It may be, if one lives in a arctic zone, with sub freezing temperatures for a good part of the year,where, even if one wished it would be difficult to eat a fresh  vegetarian diet.  Similarly, the high saturated diet of the Masai warriors that she quotes as being responsible for a  low incidence of heart disease may in fact, have little  to do with a low rate of cardiac disease, if indeed, there is a low incidence.  I think much of Ms T's presented data is questionable and she makes some assumptions that are unverifiable.
           Now, while we must  not fall into the 'post hoc ergo propter hoc' fallacy and despite Ms T's assertions to the contrary, it appears we are doing some things correctly.    The bottom line is that the incidence of mortality and morbidity from cardiovascular disease has fallen markedly in recent years.   Since there are multiple factors involved here, such as  smoking cessation, obesity control and exercise  it is difficult to assign specific values for the precise amount of credit each one plays.however it is likely that our dietary modifications are a factor.
              The bottom  line is that based on the evidence that is available at present AND experience in patient care, I don't recommend abandoning our present dietary recommendations in favour of Ms T's recommendation.  

Thursday 25 September 2014

Ripping off the Health Care System!

Headline:  Hospital to pay $1.700,000 over Tuberculosis Class Action.

Here's the story:

              More than four hundred people tested positive  for tuberculosis after a presumptive contact with two patients who  were proven to have tuberculosis a decade ago.  Note that none of these patients had the active disease.  Note that the positive test only means that the patient was in  contact with tuberculosis and developed antibodies against the disease, which  protects them  from developing the active disease.  The case was based on the fact that because these people tested positive for latent tuberculosis (not the active disease), a decade ago, that the hospital  is responsible.  In fact, nobody can  be certain that those people became positive as a result of infection  in  the  hospital.  I cannot imagine any  other arena in which this sort of evidence would be regarded as reliable.  The basis of the legal case is that the hospital and the doctors should have diagnosed the two cases that occurred in the hospital ten years before, earlier.  In  fact, nobody can be sure that those people became positive as a result of infection that occurred in  the hospital at all.   The allegation that the doctors and the hospital were in any way responsible is totally without merit and in  fact is a prejudiced viewpoint.  It is important to emphasize that none of these patients developed active TB, they just developed immunity to it.   

              When I grew up  and  studied medicine in  Ireland, most of the population was Tuberculin positive,  and regarded as being fortunate to  develop resistance to active tuberculosis and be protected against it.

                Unfortunately, the Judge did not seem to be knowledgeable enough to comprehend the claim of what I can only regard as the avaricious lawyers and non diseased patients, who instigated this class action law suit.

                They are creating a situation  in Canada that approximates to the "medical malpractice lottery" that exists in  the United States and does inestimable damage to the Health Care System   It will encourage any patient presenting with any infectious disease who has been  in hospital in the past decade to inappropriately sue the health care system,  in hope of a windfall.  Such  settlements will leach precious health care dollars out of  the health care system into the pockets of these profiteers and their lawyers (approx 1/3 of the settlements!)  They will be paid for by you and me.

                Please comment if you have any view on this.      

Monday 22 September 2014

Sick Society.

       When a sports hero, admired by children and adults alike, strikes his wife, as Ray Rice did, he deserves the most severe punishment   He is a  criminal and deserves to be treated like a criminal.  When the punishment meted out to him is trivial and inconsequential it is  sending a message to  the society in general and to the youth in particular that this sort of behaviour is in some way acceptable.  When a significant segment of the public speak out in acceptance of  this and sometimes even protectively, it leaves no doubt that we have a major  decline in social standards.  Violence in America has become an accepted way of life that will prevail until society takes the responsibility to make the consequences fit the crime.
        Another criminal Adrian Peterson was indicted on September 11, 2014, by a Montgomery County, Texas, grand jury on charges of reckless or negligent injury to a child He is accused of beating his four-year-old son repeatedly with a tree branch, causing severe welts and bleeding on the child's back, legs, buttocks, genitals and ankles. In their initial response, the Vikings deactivated Peterson for a single game.    Until these criminals are addressed by the American  justice system and the punishment is made to fit the crime, violence will continue to thrive and youngsters will regard them as role models, instead of what they really are.
           The decline continues.

Saturday 20 September 2014

Smarter than the Dr?

A little old foreign lady (I can use those words, being both old and foreign myself) came into my office a few months ago.. She was in her eighties and in pretty good shape.
"Why am I on these Pradaxa pills?" she asked
"You have an irregular heartbeat and the pills are to thin your blood to prevent you having a stroke."
"I know all that, but people on these pills bleed to death and I read that their effects can't be reversed like Warfarin can be with vitamin K! Why nobody even checks my blood every month like when I was on Warfarin"
"You don't have to have the blood checks with Pradaxa."
"Why they can't reverse Pradaxa?"
"They don't know how," I answered.
"Then they shouldn't be selling them until they do!"
Smart little old lady!!

Tuesday 16 September 2014

Consideration, courtesy and the College of Family Physicians of Canada.

       I've been a member of the College of Family Physicians since the early sixties, when a few inspired physicians decided that the lowly general practitioner was the foundation of health care system and was not someone who just wasn't smart enough to be a specialist.  They were a dedicated bunch, who felt that the traditional rotating internship was poor training for a community based physician, who would be looking after a broad spectrum of patients ranging from pediatrics to geriatrics, including obstetrics.
       I strongly supported the objectives of the College, became an early member and served on numerous committees over the years, including the executive committee.  I particularly supported the creative and open-minded approach in those days, when we felt that our strength lay in our support and caring for our colleagues as well as our patients.  Unfortunately, as the College grew stronger and more influential it has largely lost that personal touch and seems to have wholeheartedly embraced the philosophy of the health care industry.
       I retired from active General Practice/ Family Medicine a few months ago.  I was one of the early certificants by examination and was honoured with a Fellowship when it was an earned award. A few years ago I was awarded a Life Membership of the College, I was surprised to receive a registered letter from the College a few days ago.  I couldn't think why the College would be sending me a registered letter. The only thing I could think of was that I had overpaid for something years ago and they were now making a refund, with interest!  (Joke!).
      Let me share with you an excerpt from this letter, but first let me inform you that I have maintained study credits with the College for over forty years.  
       "You have not completed requirements for your five-year cycle.  You will not be permitted to renew your CFPC membership or to have your special designations restored until the requirements for reinstatement have been met.  If you are UNABLE (my capitalization) to fulfill your requirements by September 29th unfortunately your membership in the CFPC will be removed for non-compliance of credits".  
        No phone call, no attempt to make personal contact of any kind, no concern whether the member is alive or dead, ill or well, no interest at all in the circumstances of a lifetime member and supporter of the College.
         What a way to communicate with a colleague.  The physicians who allowed a letter like this, probably coined by some administrator, to go out over their names should be ashamed of themselves.
           I'm afraid the College hierarchy has become so overwhelmed by their own sense of importance  that they are losing that common courtesy and consideration  that is such an essential part of the caring of both colleagues and patients. 
             They'll need to do better than this!

Saturday 13 September 2014

A Very Small Stretch.

                         The duties of the post medical officer in the RCMP extended to interviewing and examining prospective candidates.  Many of the young men frankly admitted that their greatest ambition was to become an officer in the Royal Canadian mounted police.  In those days, the majority of Canadians were proud to have a police force of international stature, incorruptible as we believed then, and famous for always “getting their man”. Small wonder then that many a fine young Canadian aspired to a career in the force.  By the time I was working at the Post the requirement was that applicants must be at least 5’8” tall.  Prior to that there had been a requirement of being 5 foot 10.  I don’t know if there is a new height requirement or even the elimination of any height requirement although I find it hard to imagine a fifty-eight inch officer.  In any event, there were a number of candidates who were just under the five foot eight limit who desperately wanted to enlist.  John Campbell was one such potential recruit.  In those days it was possible to apply for admission to the force up to three times.   Johnny had already applied twice and was turned down because he measured 5 foot 7 ¾”. Each time we had measured him he assured us that he was 5 foot eight and had always measured that in the past.  Anxious to help him to get in both Mike and I measured him independently.  We both got the same results, 5 foot 7 3/4 inches.

            “What are you going to do if you don’t get in, John?”  I asked him.

            “I don’t know doc.  All I ever wanted to be since I was a little kid was to be an RCMP officer.”  When he said this his eyes teared up.

            Mike took over.  “Listen John, I might just be able to help you.  Now I can’t promise anything but over the years I’ve had a couple of other applicants of your height and managed to get them into the force by giving them some advice.  This is what I want you to do.  We’ll plan your next examination in a couple of weeks and you know that that’s your last chance.  It will be a third application.  The night before you come in, I want to spend about half an hour hanging out of the doorjamb and we hope that that’s going to stretch you out for long enough to measure that other quarter inch.  Make sure to get up early the next morning and before going out hang out of the doorjamb for another half hour or so.  That should allow the discs between the vertebra to expand and although it doesn’t take them long to compress again we might just get you measured before that happens.  In fact before I measure you I’ll let you hang out of the door here for ten minutes or so and we’ll measure you right away..”

            When he came in for his last try, Mike spirited him away, presumably to hang out of one of the doors for a while.  I had just finished seeing my second or third patient when Mike came in and announced triumphantly, “5’8” exactly, Doc,”

            “Good Mike, but I think I better see for myself.”  After all, it was my signature that was going on the bottom of the application form, and Mike with all due respects was really a soft hearted guy and could possibly have exaggerated just a trifle.

            “Okay John, get over here I’ll measure you.”

            “But doc, Mike just measured me, he said I’m five eight, you heard him.” 

            “Yes, but I have to measure you myself, come over here.”

            John apprehensively edged over to the scales beside my desk.  “Step up onto the scales.”

            John reluctantly stepped onto the scales while I slid the bar for measuring height.  It read exactly 5’8”.  John stood there speechless for a moment before he gasped, “Oh thank God.  I spent most of the night hanging out of the doorjamb hoping to stretch myself out to five of eight and I prayed a lot as well.  I guess it worked.”

The whole scene sticks in my mind to this day.  It was surely the happiest day of John's life!

Tuesday 9 September 2014

ADHD - The new miracle cure!!

             There have been a few studies recently that indicate that exercise has a beneficial effect on ADHD kids.  Now, fancy that!!   It was estimated in 2011 that 11% of American kids have ADHD,  and 6.1% of all children were taking medication such stimulants.  Fifty-five years of  general practice have convinced me that a high proportion of these  kids are normal, very energetic healthy kids.  Of course sitting in  school all day after an evening spent playing computer games and watching TV would  make for restless, fidgety kids who are easily bored by the classroom routine.  They won't or can't sit still and become a distraction  to the rest of the class and a thorn in the side of the  teacher.  Some doctors and others started noticing that if some sort of regular physical activities are introduced a significant improvement occurs in many of them often resulting in a reduction in their medication and sometimes complete withdrawal. In a randomized controlled group, attention and mood were found to be better in exercise groups than in sedentary groups and this applied to groups considered as normal as well to the ADHD group. Some classroom programs have been devised to achieve this goal.  One of the results was that schools that adopted the exercise program had a 33% decline in ADHD medications used by its students.
              The bottom line, lets try giving the kids a little more exercise and less drugs.  I  suspect they'll do better.
               Feel free to comment.

Sunday 7 September 2014

Code 99.

Two doctors at Sunnybrook Health Sciences Centre in Toronto are being charged with violating the law by imposing a "do not resuscitate order on an elderly man against the family's wishes.
   The man, who was eighty-eight years old had congestive heart failure, diabetes,  high blood pressure and chronic obstructive pulmonary disease, had also had severe arterial disease, serious enough to result in a bilateral lower limb amputation.
    Apparently, the patient's family had originally, presumably in consultation with his medical care-givers arrived at a 'do not resuscitate order'.  In other words if the patient died, there would be no attempt to bring him back to life.
     His daughter and family, presumably changed their minds before his double amputation and requested a full 'code', a request that was documented on the patient's chart.  The doctors later changed the order to a 'do not resuscitate' order.  This was done on the basis that bringing an 88 year old man, with this sort of medical history  back to life was not a humane act, but one that would increase pain and suffering, not relieve it.  Unfortunately, no one had discussed this with the the daughter.and this was wrong.
      The issue seems to boil down to who has the final say when the medical staff feel that bringing a patient back to life,(and that is what we are discussing, not treatment) is inhumane and likely to result in a second death, in a short time.  Of course loving families want their loved ones to live forever but they also want to spare them further suffering.  It is not an easy or simple situation but is one that can usually be resolved by physician and family collaboration.  Changing the order without thoroughly exploring and discussing the situation with the family can only lead to anger and frustration.
      Perhaps a well thought out and documented advance directive might avoid this sort of outcome in most cases.
       I love life, but if I'm dead, please don't bring me back.
         If you have any opinions at all on this issue, please make a comment.

Friday 5 September 2014

Joan Rivers.

     I cannot understand how any outpatient facility would consider doing a procedure that required an general anesthetic, on an 81 year old woman.
    Despite the very soft criticisms I heard on the American media, I consider this medical malpractice.  In anyone things can go wrong, but in the elderly, this is much more likely.  It is necessary to have the emergency backup services that may be required and that exist in almost every general hospital.   This was sadly lacking in Joan's case.

Feel free to comment.

Wednesday 3 September 2014

Pelvic Examination in Healthy Women.

The American College of Physicians recommends against performing screening pelvic examinations in asymptomatic, nonpregnant, adult women. This is a strong recommendation based on moderate-quality evidence of harms outweighing benefits. Screening for sexually transmitted infection can be performed by urine testing or vaginal swabs. This recommendation applies only to the pelvic examination; the guideline does not address screening for cervical cancer using the Papanicolaou (Pap) test.
      This, believe it or not, was what arrived in my continuing medical education program recently.
      I trained many generations of medical students and residents to be competent, well trained family physicians.  The basis of that training was to take a detailed complete history, including family history and a history of the patient's current and past life.  This was considered important in those days and I recall telling my students that if one took a good history one usually had the diagnosis, or something close to it at the end of the process.  In other words, the patient told you what was wrong, at least from his point of view.  Then the physician did a complete physical examination to look for clues and search for evidence that would enable him to arrive at a definitive diagnosis.   The physician would then decide what tests or further investigations to order to either confirm or reject the working diagnosis and decide what further evidence was required.  It was not coincidental that Mr Sherlock Holmes was based on a real live physician.
     Part of that complete physical examination was a pelvic examination and a pap smear and although these were usually normal as were most of the findings in a general practice population, there were certainly unsuspected abnormalities discovered frequently enough to be worth the effort  in an era where we are emphasizing preventive medicine and wellness.   Although uncommon I have found ovarian cysts and tumours of various types, cervical erosions and evidence of infection, among other abnormalities in asymptomatic patients.
     Patients endure some discomfort but I have never known a patient to suffer any harm as a result of the procedure.
      So why is this recommendation which has implications far beyond the simple examination being made?  I believe it is part of an initiative to move away from time consuming history and physical examination, to free up physician time to make Obama Care feasible and affordable and to prepare patients for an automated less personal heath care system.   This it is hoped will enable the provision of health care to the increased numbers by the existing numbers of U.S. physicians.      Abandoning a painstaking history and physical examination, the traditional foundation of any medical encounter is surely not going to enhance the standard of medical practice.