Choosing Wisely - How the patients see it!

          Flipping over the pages of my  my newspaper recently (I still like the feel of a real paper Paper - put it down to my age!) I chanced upon this heading in the letters section, "Playing Russian Roulette with cancer" .     There were two letters from folks who felt that their lives had been saved by early disgnosis, in the one case from breast cancer and in the other from prostate cancer. criticizing the "Choosing Wisely" program and clearly labeling it a  retrogressive, money saving scheme being presented as progressive health care.  I don't know the medical details of the cases they were referring to and anyway what we are reviewing here is the public perceptions of this program not the actual merits of it.  That is another issue.  I do understand the feelings of the patients and their families, however, because I am like thousands of other physicians, educated and indoctrinated for decades to actively pursue a policy of aggressive preventive health care.   Physicians who were remiss in carrying out some of the procedures that are actively being discouraged today would have been considered derelict in their duties.  After spending years indoctrinating patients to have their annual pap smears and mammograms and various other investigations, it is suggested by the various task forces that these measures were not actually necessary at all and in fact may actually be harmful!  What is the poor patient to think?  Have I been the victim of some vast medical scam?  Or is this just some money saving scheme conceived in the US to facilitate obamacare and  opportunistically seized by Canada to bolster up our own struggling health care system?  It's all very well for the various professional groups to discuss the pros and cons of reducing tests and investigations, and suggesting conferences between doctors and patients to decide what is necessary and what isn't, but I know what most patients think.  In real life this is going to be a nightmare for physicians and a potential gold mine for lawyers.

Comment if you care, otherwise we can let this issue die a quiet death!

The Electronic Medical Record.

          Now that I'm retired I have time to reflect on many medical issues that  practicing medicine left me limited time to consider.  The results we see today of allowing many of the crucial decisions of medical care, other than the actual practice of medicine to fall into the hands of ill equipped and often ill-informed politicians and administrators is beneficial to neither patients nor practitioners.  The electronic medical record can be a great asset to medical practice or a net liability.
          Very early in my career I recognized the gross inadequacy of medical records in general practice and elsewhere and soon after entering academe in the 70s, I made a study of Lawrence Weeds Problem Oriented Medical Record.  Weed, a Systems Analyst, before he became a physician, pointed out that the disorganized, incomplete, disjointed and often illegible records which physicians kept were unsuitable for adequately defining the problems of the patient and did not lend itself to logically progressing from the problems enumerated by the patient to a diagnostic plan to a diagnosis to a treatment plan.
          Recently, I have been considering the contemporary electronic medical record of which I was an enthusiastic innovator in the Department of Family Medicine at the University of Saskatchewan and the Department at the University of Western Ontario, where I introduced the first functional system in family medicine at the teaching clinic at the South West Middlesex Clinic where I was Director for a number of years.
          There is no doubt that computerized medical records have much to offer both patients and physicians when properly directed towards health care.   There is also no doubt that administrators want a lot more than that.  They want to control finances, they want to control how health care dollars are allocated and want them distributed according to their priorities.  They want to control medical priorities.  
          The prime purpose of the EMR must be to facilitate patient care and to assist physicians in collecting, collating and distributing medical data and scheduling patient care.  Everything else is secondary.  
          I want to know what my fellow physicians think of this, and how patients and physicians feel that it effects the doctor patient relationship, so I'm going to investigate the current state of the art.  I  want to explore the advantages and disadvantages of using an electronic record.

           Let me know if you care!

Ebola - They don't get it -yet!

     The Washington Times tells me that:
                    U.S. general, troops quarantined in Italy after W.Africa deployment.  The general and his ten troops will  be quarantined for twenty-one days at a separate location after being met in the airport by Italian authorities in full CDC gear.  The Pentagon isn't calling it quarantine, they are just being kept in a "controlled setting".  I guess the Italians are getting it right.
                    Sadly, the people in charge in the U.S. really don't seem to know what their doing.  Just continues to emphasize that you can't put a Community Organizer in charge of something that could grow into a medical crisis.  But, where are the voices of the medically qualified specialists?  If they were my students, they would have failed!

Ebola. Don't they get it yet?

                How is it that all the infectious disease super-specialists in the U.S. don't seem to know (or pretend not to know) as much as this geriatric old GP.    What I had to say a couple of weeks ago still holds.  It is probably not too late - yet.

                        1. Embargo on all flights from infected areas.
                        2.  In-service training so all staff will know what to do and who to contact when a possible case is being considered.
                        3. Intensive training and dress rehearsals for all staff in close contact.
                        4. Sufficient easily available hazmat equipment for all who might need it
                        5. A clearly designated chain of command, military style, that makes it clear.
Why aren't they taking these simple precautions?  

                        It is hard to understand how these measures haven't been instituted.when the consequences, though unlikely, could be disastrous.

The Strange case of Mr. Ahmed.

            Mishbahuddin Ahmed a 31 year old diagnostic imaging technician at the Ottawa General Hospital was convicted by jury of two terrorist related offences.  They were of participating in the activities of a terrorist related group and conspiracy to commit a terrorist offence.He was acquitted of possessing an explosive device.  One of his associates Alizadah was sentenced to 24 years in prison.. Another,  a pathologist, Dr. Khurram Sher was found not guilty of conspiring to commit terrorism. Dr. Loza, an Egyptian psychologist described as criminal assessment expert' , whatever that means, described Ahmed as a 'humble, timid man who didn't realize his activities could result in a long term in the slammer.  No kidding!
          This is what the Globe and Mail had to say:

Joe Lofaro/Metro Misbahuddin Ahmed, 30, walks to the Ottawa courthouse Wednesday, May 14, 2014, to face trial on terrorism-related charges.

"Whatever Misbahuddin Ahmed’s intentions were for the bomb-making materials in the President’s Choice grocery bag found in his apartment, he still knew they would be turned into explosives, a Crown lawyer argued on Monday.
That grocery bag was part of the debate at the sentencing hearing for the 30-year-old former Ottawa Hospital technician. It was his first day back in court since a jury found him guilty of conspiring to knowingly facilitate a terrorist activity and participate in the activities of a terrorist group."
            His mentor, Mohammad Alizadeh  was recorded sayin this: 
           “If Allah wills, we will break their backs in their own country,” he was caught saying in Ottawa, on a wiretap, before his 2010 arrest.
               My major concern about this is that our hospitals/ health care system seem incompetent to adequately screen the individuals they employ.  'Political correctness' should not be the only factor considered.  I think  we need to be more careful  in  investigating who we hire to look after the sick  in Canada.

Euthanasia - a doctors job?

             I've been  reading quite a bit about euthanasia recently.   If folks want that option and convince their legislators to make it legal, that's none of my business as a physician.  If the expectation is that it should be part of the responsibility of physicians to provide this service, I am absolutely opposed to it.  Having practiced and taught medicine all my life there is no doubt in my mind that persuading or coercing physicians to end life would set a precedent that would change the very nature of our medical profession.    If a patient wishes to terminate his life he don't need a physician - that is not our job.  It would not be difficult for the legislators and administrators to incorporate help  in devising suicide packs that the patient could self administer or that the patient's family could administer in the case of the  patient being unable to manage.  There are organizations such as the spinoffs of the Hemlock Society/Final Exit groups that can  make the expertise available.
             I would caution my profession to avoid any involvement in such activity.  The concept of the physician as a healer  built over aeons would be irremediably damaged.
             The oft quoted;  "To cure sometimes, to relieve often, to comfort always." is still the foundation of medical care.  Assisted suicide does not fit into this model.

Ebola - The Bleeding Edge - part 4.

                While your chances of dying from Ebola in this part of the world are far less than  from being hit by a texting driver, the panic factor would suggest otherwise.
                 Ebola, or Ebola hemorrhagic fever is caused by a type of virus called an ebolavirus, of which there are five species belonging to the filovirus family.  The initial symptoms are typical influenza like symptoms which commence a couple of days to three weeks after contacting the virus.   After several  days of fever, sore throat, myalgia (muscle pains), malaise and headaches, vomiting and diarrhea and signs of liver and kidney failure develop.  This is followed by bleeding both internally and externally.
                  Now, unless there is a history of the patient having been to parts of Africa where the disease is endemic or having been in  contact with  someone from those areas, there would be no reason in the  early phases to suspect this to be other than influenza.
                   Until now, the experts have suggested safety measures that appear to be more for optics than serve any useful purpose.  The 'Experts' tell  us that there is no danger of contagion from anyone who  is not running a fever at the time, when the most they can say is that it  is much less likely.   The categorical statement that since it is transmissible only in body fluids belies the fact that if you are close to an infected person who coughs on you that saliva, a body fluid my be sprayed on your skin and penetrate it.  The temperature measurement technique they are recommending for airport screening may be better than nothing, but not much.  The myth that unless the patient is running a temperature that he cannot shed the virus is not supported by any evidence.  Ask yourself how they would  handle the numbers even during even mild influenza or other seasonal respiratory  outbreak, unless they are prepared to commandeer all of the hotels in the region, after staffing them with especially trained personnel!   One U.S. report stated 85 %  of nurses have not received any sort of in-service (in-hospital training) in managing this sort of patient and talking  to a nurse from one of the major Canadian hospitals, I was informed that there was no training and apparently no appropriate hazmat equipment.available.   Despite this lack of protocol there was an implication from the CDC Director that the infected nurse was guilty of  some sort of breach  of protocol.  There was no evidence offered to support that allegation.   The outcry from Nursing Associations is justified.  They received no training in coping with situations that most nurses have never had to deal with.
                     There are two vaccines under development that may be promising.  One is being developed in Winnipeg.
                    While the risk of a general  outbreak of  Ebola is unlikely, its consequence would be so severe that it is essential to establish a plan.  Here's mine:
                      1.  In-service training so all staff will know what to do and who to contact when a possible case is being considered.
                       2. Intensive training and dress rehearsals for all staff in close contact.
                       3. Sufficient easily available hazmat equipment for all who might need it.
                       4. Embargo on all flights from infected areas.
                       5. A clearly designated chain of command, military style, that makes it clear who is responsible for what.
                     Comments?

Choosing Wisely and Prostate cancer screening.

                   
Choosing Wisely^® aims to promote conversations between providers and patients by helping patients choose care that is:

• Supported by evidence
• Not duplicative of other tests or procedures already received
• Free from harm
• Truly necessary
  
  I thought I would try to give this a trial run by comparing the recommendations of 'Choose Wisely' and 'Choose Wisely Canada' for Prostate Cancer.

 The American College of  Family Physicians site gave this advice:
                   " Don’t routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam."

                    There is convincing evidence that PSA-based screening leads to substantial over-diagnosis of prostate tumors. Many tumors will not harm patients, while the risks of treatment are significant. Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by patients."
                    
How This List Was Created : The American Academy of Family Physicians (AAFP) has identified this list of clinical recommendations for the second phase of the Choosing Wisely campaign. The goal was to identify items common in the practice of family medicine supported by a review of the evidence that would lead to significant health benefits, reduce risks, harms and costs. For each item, evidence was reviewed from appropriate sources such as evidence reviews from the Cochrane Collaboration, and the Agency for Healthcare Research and Quality. The AAFP’s Commission on Health of the Public and Science and Chair of the Board of Directors reviewed and approved the recommendations.
                    When I tried to see if the Canadian site made the same recommendation extensive searching showed no mention of prostate disease of any sort.  Further searching indicated that the Canadian Urological Society report is pending.
                      Incidentally, I did not see any mention of the time involvement of the 'conversations' and of it's impact on the patient load of the physician and how this can best be accomplished.

Ebola - The Bleeding Edge. Part 3.

             The Dallas Hospital Staff that discharged a patient who had recently been in West Africa, with a fever, headache  and abdominal  pain was guilty of an egregious mistake.  The initial excuse was that the electronic entry into the medical record made by the nurse did not appear on the doctor's screen and was therefore missed and the patient inappropriately discharged.  This, in fact, was no excuse at all and was later retracted.  The doctor patient relationship depends on the doctor talking to the patient and taking a medical history, the first and vital stage in any medical  encounter. If that was done he could hardly avoid arriving at a conclusion that would be apparent to any first year resident.   Of course I don't know  the  details of this particular case, but I  would strongly suspect that this patient was not seen by a physician at all. 
              I  am surprised at how quickly  this issue seems to have dropped from the radar, because a mistake such as this could result in wide dissemination of the  infection.  That makes me wonder about the lack of any effective travel controls from  the danger areas into the United States and the rather glib assurances given by some physicians that it is impossible to get the disease from from a person who is not febrile.  While this  is  unlikely, anyone who has practiced medicine for a number of years knows full well that no such absolute assurances can be given. 
              So, while there is no need for panic, there is need careful surveillance and appropriate precautions and care.  One of those precautions should certainty be travel restrictions from infected areas.

Sexting - again!

     

              Just in case you were starting to think that maybe, after all, a bit of sexting, although indiscreet is no great harm, especially if it's just some kids having a naughty bit of fun, let me bring you up to  date.

Reading my daily newspaper, which  is a luxury I allow myself now that I am retired, I came across this macabre tale.    It started at a house party in  Halifax in 2011.  A young girl was photographed leaning out of a window vomiting, while a boy was having sex with her from behind.  A friend of the boy took a picture of the act.  The picture was widely circulated among the students of the high school that the girl  and both  the boys attended.  In  the picture, in which both the girl and boy are naked from the waist down, the fornicator is smiling at the  camera and giving the thumbs-up sign.  A year and a half later the girl, aged seventeen, killed herself by hanging.   The photographer, now aged twenty was found guilty of making child pornography and will be sentenced In November.  The boy in the picture will be going on trial in November.

             One life lost and two changed forever.

             So much for the fun of sexting.

            Even more bizarre, in Grandville Michigan a picture showing a high school student, described as being too graphic to show on the Fox News has been widely  distributed on the internet.The posts prompted an investigation by the Wyoming Police.  Apparently, this female student was giving a guy a blow job outside his car while  several students watched on and took photos to sext to everyone they knew!

             School Officials assured the Press that it didn't happen on school property!!

             Time to get the legislation into order to try to curtail this malignant sexting practice.