The Medical History.

          This is a not a story  to criticize health care providers, but to criticize what has happened to a health care system that was once an example of excellence but despite  many technological advances has deteriorated over recent years.  That is because the medical history and physical examination, once the sine qua non of good medical care has faded in significance when compared to the apparent ease and precision (and to some the glamour) of high tech investigation.  It is often forgotten that those investigations, valuable as they are should be to confirm or correct the impressions the physician has formed from the patient history and physical examination.  It has been well established that indiscriminate investigations can result in much harm and expense.   Usually, the patient will tell you the diagnosis if you listen carefully and discriminatingly.

           After an accident in Hilton Head, S. Carolina, my seventy-seven year old wife tripped over a concrete parking marker and hit the ground with an impact that was potentially disastrous.   After observing her throughout the night and deciding her condition was stable.   I headed back to Canada the following morning.  By then, she had a black eye, the whole side of her face was swollen and her right hand was swollen and bruised.  We arrived home, in London Ontario, two and a half days later, after an ordeal, that I’m sure you can imagine.  She looked as though she had been badly beaten up and the sunglasses she wore to try to disguise her injuries merely emphasized them.  To cut a long story short, first thing in the morning, after arriving home, we took a trip to the emergency room, at University Hospital, and that’s where this story really starts.

            On the morning of Wednesday, twentieth of February, 2013,  I brought my much bruised and battered wife to the Emergency room at University Hospital, in London.    We sat there for five hours.  I am a physician and I was satisfied that my wife was in no immediate danger.  I couldn’t help speculating on what might have happened  if a patient  was bleeding from a subdural hematoma or worse during that period of time, with no one to monitor her.

             Because her hand and arm were grotesquely swollen and bruised, they were the immediate focus of attention.    So, after five hours, arm and hand were x rayed and the splint that I had already applied were considered to be adequate treatment for the moment.  Her head was either not noticed or considered to be important, despite extensive bruising and tenderness over the zygomatic bones of the face and a black eye.   I brought her home from the emergency room at University Hospital where she had been sitting for five hours without having been seen by a physician, when she was so uncomfortable that she insisted on signing herself out.   Being a physician I was satisfied that she was not bleeding into her brain.  However, this was not known by the staff and it concerns me that someone whose cognition may have been impaired was allowed to leave emergency without any attempts to assess cognition or to explain the possible risks involved .  Equally unbelievable, was the fact that despite the fact that as Professor and Head of the Department of Family Medicine at the University of Saskatchewan and as a life long teacher of Family Medicine students and Residents I had tried to make my students aware of the fact that they must screen for family abuse, nobody asked my wife if she had been beaten up by her husband or otherwise abused.. No-one ever took an adequate history.

            Next morning, since my wife (understandably!) refused to go back to emergency at University Hospital, and her head had not yet been looked at, other than by me. We went to St. Joe’s Hospital, where the experience was much more acceptable.  The appropriate investigations were carried out and the damage recognized and treated.  In fact, she sustained a maxillary bone fracture.  I have spent much of my life working (and sometimes living) in hospitals and I understand the difficulties that health care workers have to contend with.  Nevertheless this is not good enough, more focus being directed to the documentation than to the patient.    Suffice it to say, that something is amiss in the state of Health Care, that in my opinion is closely related to the deterioration of the conversation between the physician and the patient that all the technology in  the world can't replace. 

Placebo

Definition of placebo in English:

noun (plural placebos)

1A medicine or procedure prescribed for the psychological benefit to the patient rather than for any physiological effect.

Example sentences

1.1A substance that has no therapeutic effect, used as a control in testing new drugs.

Example sentences

1.2A measure designed merely to humour or placate someone: pacified by the placebos of the previous year, they claimed a moral victory More example sentences 

 placebo effect Line breaks: pla|cebo ef¦fect

Definition of placebo effect in English:

noun

A beneficial effect produced by a placebo drug or treatment, which cannot be attributed to the properties of the placebo itself, and must therefore be due to the patient’s belief in that treatment: orthodox doctors dismiss the positive results as a result of the placebo effect

Origin
 A placebo (/pləˈsiboʊ/ plə-SEE-boh; Latin placēbō, "I shall please"^[2] from placeō, "I please")[

? Retirement?

 


    This is a story that Rory, a psychiatrist friend of mine from the old country, who had just come back from a visit to Dublin  told me.  He was thinking about retirement and this encounter gave him some fuel for thought.  I am telling it to you in the first person as it was told to me and I am lightly fictionalizing the events to protect the guilty but the substance of the story remains absolutely true.

The Retirement Years. 

“It was a very lucky thing”, I said, “that the Medical  Society were having a dinner meeting while I was visiting here from Canada.  It certainly provided an opportunity to see a lot of the old faces, of people that I was never really friendly enough with to have looked up otherwise.” I said to Brendan O’Brien, sitting across from me at the table.

“True enough.  I was glad you were able to come.  And what did you think of the after dinner speaker and of the topic?”

“To tell you the truth I was a little disappointed”. I said.  “I thought he was going to be discussing our retirement in all its splendour, but it really was a pretty thinly disguised pitch to sell Mutual Funds.”

Brendan nodded his head slowly, “Yes, it was a bit,” he agreed.

If we hadn’t had a big dinner and a few drinks, I’d probably have been smart enough to keep my mouth shut because I certainly stuck my neck out with the next comment.

“I could have done a lot better myself,” I said.

“So what would have been your approach, if you had been the quest speaker?” he asked challengingly.

By this time, all I wanted to do was get back to my hotel, put my feet up and read the old battered copy of the Borstal Boy by Brendan Behan. I had picked it up at one of the old second hand book-stores along the Quays a couple of days earlier.  But no such luck. I’d set myself up and now I had to try and think on a full stomach.

“Well!" I said slowly trying to buy myself enough time to think about where I was going to begin. "The single greatest adjustment in any retirement, when the retiree is married, and the spouse is at home too, is the fact that  two people who spent a few hours together each evening and weekends find that they're going to spend morning, noon and night together for evermore.  In addition, in many instances all of the major distractions such as rearing children are no longer present, and the kids don’t even live in the same city, so it's a whole new ball game.  Don’t forget that many of the people who are retiring are coming from traditional marriages where the women ran the home and reared the children and dad ran off to work.  Particularly when the going was getting tough. All of a sudden, this guy is at home all day and begins to tell his wife how she should have been running the house all these years.  Actually, I have an interesting story to tell you about that."  

Now that I was gathering some momentum and had the attention of Brendan and the other two men and two women who were sitting at our table, I paused for a moment.

“A few months ago, I looked up Sammy Weldon and his wife in their little rural paradise just a few miles outside of London, Ontario.  They bought this piece of land with it’s own little lake a few years ago and it had really become their life’s work making it a real paradise.  Anyway, Sammy took an early retirement, all set to look after their paradise and do some fancy landscaping and remodeling.  When I asked him how he was enjoying his retirement, I was surprised to hear that he was now back to work on a part time basis. 

"Gee," I said, "I thought you of all people would be so occupied by your other creative activities that you would have had no time to miss work.  Upon hearing this, his wife said. 'Let me tell you why he has gone back to work, Rory.  He has gone back to work because if he didn’t go back to work, I wasn’t sure how long our marriage was going to last.  First, he started rearranging my cupboards, labeling everything and piling them in little stacks.  Soon he was aware of how many cans of peas, corn, soup, we had.   Next it was all stacked according to specific type, of course.  I ignored that for a while even though in the old system, I could always put my hands on anything I wanted or needed immediately and now it was like being in somebody else’s kitchen.  Then I come home one day, exhausted, my shopping bags full and Sammy empties them over the table, to a running commentary like, 'Why did you buy more peas? We already have 8 cans of peas.  We didn’t need any more Clam Chowder soup right now.  Shouldn’t have bought any tomatoes as yet,either.  We’ve got four going soft already.'  Well, Rory, I had one bag full of fresh vegetables still in my hand.  So I dumped them on the floor and said, ' you can tidy them up too.  I think you need to go back to work.'"

Sammy smiled tolerantly and added.  “And I did, and we have lived happily ever after.”

I paused, awaiting comments.  I could see Brendan‘s brain just ticking over, trying to drum up some sort of difficult question.  The only way to beat this, I thought was to head him off at the pass and shoot a question at him first.  

“Well, tell me Brendan”, I said ponderously, trying to smile pleasantly rather than to smirk. “ As a busy successful GP, who has a substantial portion of the upper classes of Dublin, how do you help your patients to prepare for retirement, particularly with respect to their marital well-being, bearing in mind that for the most part, you have a pretty well-heeled clientele?”

“You make it sound as though I have a practice consisting of millionaires, whereas in fact I have a broad cross section of patients.  And many of the ones who you would consider wealthy judging by the big cars and their fine clothes are actually people who have been living at the edge for years and a couple of failed paychecks would put them in real jeopardy.  It's a standard that they really can't afford in retirement.”

“There you go again,” I said, “As though the only consideration here were money.  I do agree that many couples who are facing retirement in the near future never gave much consideration to providing for that retirement.  You must remember many of them grew up at a different time and the sort of affluence that we enjoy today just didn’t exist.  So I think that the realization that people are living longer and the governments are not going to be able to provide the sorts of pensions and social securities that people expected a few years ago, was a real shock. Now they are coming to the realization that people have to provide for their own futures and for many of them it's too late to provide adequately.  You, however, have cleverly side-stepped my question by swinging back into financial issues, which we've heard enough about tonight.  So, what do you do to help your patient population to deal with aspects of retirement other than financial?"

Brendan looked awkward.  "Not much, I guess.  I don't think that's a doctor’s job, anyway."

The others at the table nodded in agreement.

One of the women, who's name I couldn't remember, at the table gave a little sarcastic laugh.  

“It's obvious that you're not a family doctor," she said in a deprecating voice, that made it clear what she thought of psychiatrists.  "It takes me all my time to look after the sick people who fill my waiting room.  If they need help with their retirement they can go and find a retirement counselor, or buy a book about it or something.  I just don't have time for that sort of stuff."

    I stifled the urge to provide a caustic reply and simply said, "Many of your colleagues do have an awareness of the sorts of issues their retiring patients have to deal with.   All I'm suggesting is that we have enough awareness to recognize when our patients need a little guidance to maintain their mental health.  Most communities do have a wide range of resources to help.  Oh, by the way," I concluded, "I missed you name, must be getting a little deaf!"

    "Evelyn Bell," she said coolly.  "So how do you approach this issue in your practice Dr. O'……"

    "Just call me Rory," I said magnanimously.    “I think the most important thing in any relationship is the respect that the individuals have for each other.   When people are spending just a few hours together each day, a good portion of time is spent in sorting out the day to day problems that arise in any family.  Particularly when there are children, there are a lot of issues and deadlines that preoccupy the couple and keep potential sources of conflict on the back burner.  The picture changes when the couple retire, the kids are gone and two people are spending most of their time together. So, I think it is particularly important at this stage for the couple to sit down and contemplate the future together and to recognize and deal with certain inherent sources of irritation and conflict.”

One of the women at the table looked at me gloomily, “So much for the golden years.” She said, “It’s beginning to look like planning for retirement is planning ways not to get on each others nerves.”

I thought for a moment, “I wouldn’t get quite as negative as that.  Some people have well planned retirements and really do have wonderful years together. I think that these are the couples that have well defined interests as well as some common interests.  It really doesn’t matter what those interests are, could be hobbies, organization involvement, the arts, sports, or gardening.  Enthusiastic healthy involvement in something seems to be one of the major keys to success.”

“Ah, well your wife is lucky having an expert like you around.”  Florence said.

I wasn’t so sure that Anna would see it that way.  It’s much easier to be an expert dealing with other people’s affairs than your own.  During our 27 years together, Ann and I had certainly had our trials and tribulations.  And at least one situation that …………………...

Brendan's incisive voice interrupted my reverie.  “So apart from the financial provision, which was all the speaker tonight discussed, and a healthy respect for the boundaries that recognized that each person has their area of expertise, interests and individuality you must have other contributions to make a happy marriage in retirement.”

     He looked at me expectantly, so I thought I'd better try to say something profound.

“In many areas of life, a lot depends on the amount of thought, planning and preparation that is made in advance.  Many people have things that they want to do in their retirement years but the effort required to advance their careers and to raise their families prevented them from developing those interests.  Although what you want at 60 may vastly differ from what you wanted at 30, those interests can often be focused in a way that provides great satisfaction in retirement.  I’m talking about musical and artistic skills,and other aspects of the arts, that as a spectator or participant many people can derive great satisfaction from."

"George retired two years ago and he has never been busier," Evelyn Bell said, "and I think that’s because he was always thinking ahead and began to plan an interesting and fulfilling retirement.  Old age is like everything else.  To make a success of it, you’ve got to start young.   Long before he retired, he decided that he wanted to divide his days between work and play and he set about trying to make it happen two or three years before he actually retired.  He managed to arrange a part time job for a couple of days a week.  In any event, he has been doing that for over a year now and in the meantime, he has become involved with so many other things that he thinks in another year or so he won't have time for the job anymore!”

“Tell me what sort of things has he got involved with that makes him so busy.”  Asked the other woman at the table who's name was Enid.

“Well,” continued Evelyn Bell, “There was a number of things that he always wanted to do. He was very interested in the family history and always regretted that he hadn't tried to get more information from his grandparents and parents before they died.  He has always firmly believed that someday our kids are going to want to know about their roots at which time there may be no one around to tell them.  Anyway, it certainly has become a major interest that that takes up quite a bit of time with research and reading about genealogy.   He then got into this Internet thing and spends quite a bit of time studying the Genealogy sites.  Friends and acquaintances are forever phoning or dropping in for consultations.

Now that he has more time, he follows the stock market  more closely and spends a couple of hours a day reading the paper or looking at the stock market web sites on the Internet. Sure enough, we have been doing a little better on the market.  Mind you, George is a pretty cautious investor, so I don't worry, because I know you can lose your shirt.

A lesson in child education.

   2 little Girls and a Curmudgeon.
   A lesson in child education.

    For the last few years my niece and nephew come to visit us around the holiday season, with their two little girls.  Three years ago, when they were about seven years old, we were looking for something to do, (when you are 80 you really have to use your wits to keep two little girls entertained) so I decided to show them my fountain pen collection.  It was not without some trepidation, as my collection ranges from the almost priceless to the almost worthless.  Anyway, under careful supervision, I showed them pens, old and new, colourful and variably shaped.  These girls are totally different in every way, so I was pleasantly surprised at the overwhelming enthusiasm both of them exhibited.
   "Can I write with them, can I  write with them, Uncle Stan?"  they both screamed pleadingly.
   Now, these are mostly old or vintage fountain pens with sharp nibs and multi - coloured inks in bottles, that must be sucked up into the pens, unlike the cartridges that are used today.  Still, we were down in our basement, so I decided that with careful supervision I could risk it.  After all, an ink-catastrophe can  usually be fixed if one make sure to use washable ink.
    So I searched about for two of my most valueless pens and a bottle of washable ink, got each girl a notebook and carefully monitoring the filling of the pens with ink, with their participation, sat them down at the desk, 'a l'ecole', and showed them how to write with a real live fountain-pen.  The were thrilled.  Their initial attempts, while not stellar, were surprisingly acceptable.
    Soon after they got home to  Montreal, I had a call from my niece telling me that the girls' enthusiasm for fountain pens was persisting and asking me for recommendations for reasonably priced and designed pens, preferably of the cartridge using type since she didn't think they were ready for bottles of ink just yet.

   The following year's visit was initiated by the girls requesting to see the fountain pens as soon as they burst through the door.  It wasn't long before they were demanding their writing lessons and I felt as though I was running a school in my basement.  I gave the girls a couple of nice colourful pens, with which they were delighted, and told them that they better practice because during the next visit there was going to be a test!

   This year, soon after arriving, they wanted to know when they were going to have to do 'the Test'!
"Well, " said I, " you are going to have to do some little practice exercises first."  I brought them down to the 'school-room' and gave them some of the old headline books aphorisms to transcribe, and found they were both writing block letters.  I was aware and horrified that some schools were no longer teaching cursive writing .I wrote out some cursive headlines for each of them.  One of the girls knew how to write cursively, but because of differences in their education for complex reasons I won't go into, the other didn't.  So I tailored her test accordingly (still cursively inclined).  After a period of practice, the girls wanted to know when their test would be held.  
   "Now,"  said I.  Great excitement ensued.  I administered the tests, collected them and graded them.
   "Did I pass? Did I pass?" both of them screamed.  Of course both of them passed!
   "Yes," I said, "you will both be getting your prizes before you go home!  Your certificates will arrive in the mail, but these things take a couple of weeks!"
    Now I'm trying to design appropriately impressive certificates!
    And that's how you educate children! 
    
  

More for Less!

    Everyone seems to know more about medicine today than the professionals.  Fortunately, I am now a  medical has-been so  can say anything I believe.  After all, my years of education and effort, lack of finance, lack  of security, not to mention lack of sleep,  and most of all, lack of certainty that I may eventually graduate, (not everyone who got in to medicine then came out with an M.D., you had to actually meet the standard) really doesn't matter, because doctors "make so much money".  This is, of course, how it appears in the eyes of the public, who are presented with misrepresented figures which sometimes look huge, since the physicians billings represents total revenue without considering the sometimes huge overhead, that often include several salaries, nurses, receptionists, equipment etc.  Gross incomes, presented deliberately without explanation serves to deflect attention from the greatly inflated salaries of the administrative group.   Most physicians have no pension,no sick benefits, no safety net if  ill-fate or misfortune befalls them and must provide for themselves those benefits that no civil servant would consider working without.  Now physician earnings are being seriously clawed back and there is no doubt that this will have an effect on physician supply and service.  So expect things to  change decidedly for the worst in the health care industry.

Let me point out the state of the Canadian Health Care system, using a report that the Department of Health has quoted itself: 

"With regards to international comparison, the 2014 Commonwealth Fund report on the health system performance of 11 countries ranked Canada 10th overall, indicated particularly low scores in quality, safety, access, timeliness, efficiency and equity.17 "
17
Commonwealth Fund, Mirror, Mirror on the Wall: How the Performance of the US Health Care System Compares
Internationally, 2014 Update.  Note the broad range of care in which we are at the bottom of the heap.
 

   The decline is, of course, a carefully guarded secret, the politicians see to that.   They want Canadians, to continue to think that they are still enjoying a 'world-class' health care industry, while the decline continues.

   Administridiots, with business training, are in charge now.  They really have no idea of what good medicine is, other than from  the economic point of view, and even then, often have little real insight.  They understand little about physician - patient relationships, and care less, unless, of course, they, their families, or their political friends are involved.   Things are different then.  I was the Chairman of a Department of Family Medicine, based out of a University Hospital, and not infrequently, would  get a subtle message that an important political figure or one of their family members was coming in.  Just to let me know, you know.  Not that any special treatment was being solicited, God forbid.  (Nod nod, wink wink!)   And , of course, when any of the  administrators or their families came into the department, they never failed, ever so tactfully, to let us know who they were.  So it's time to discard all that BS about everyone getting the same level of care.  It's just not so, and the people who crow most loudly about it are often the ones who are most demanding. 

   Soon, our already overburdened health care system,is going to be furthered burdened by twenty-five thousand Syrian refugees, at least some of them are refugees.   Physicians, who can't adequately cope with the already heavy patient load, and who are being treated in an unbelievably unacceptable manner, including unilateral claw-backs from government, are being asked by the same politicians to provide the coverage that the  politicians have so generously promised.  If physicians do that, they will deserve the consequences.  The government made a promise so they could look like 'good guys' , let them not fulfill it on the backs of physicians.

   I cannot help asking, where are the CMA and CPSO?

 

The Doctor, the Computer and the Patient.

The Doctor, the COMPUTER and the Patient.

S-Myth Buster.

An excellent summary of the  of the Euthanasia controversy in the U.K.s Daily Mail.

http://www.dailymail.co.uk/news/article-2893778/As-debate-assisted-suicide-dispatch-Holland 

And now for  something entirely different! 

     Once a month or so, I'm going to do a reader-inspired research/investigation piece on any medically related topic or phenomenon you request.   I will take special delight in debunking the myths of the  Dr. Oz type quacks and other snake oil salemen.  I might just call it S-Myth Buster!  So try it out!                         

     Here are some of the things I've been consulted on in the last few weeks, in addition to the ones described in  the last blog.    Retinal hemorrhage, broken  bones, gall stones in  seventeen year old, supraventricular tachycardia, facial papilloma, plantar callous, occipital neuralgia, cervical arthritis, dry eyes,digital  arthritis, bladder tumour.    Not bad for a retired old curmudgeon!!              

      Let me hear from  you.                                                               

Don't ask me, I'm not a Doctor!

   It will soon be two years since I retired and gave up my license to practice medicine.  Despite the fact that I regularly remind people that I'm not a doctor (vide supra), my illegitimate practice is steadily building up.  Although we used to  pride ourselves on our comprehensive health care service, since we changed it into a health care industry it has been steadily deteriorating.  Even as the technology becomes more miraculous, expensive and often  misused, some of the basics of the healing sciences are now relegated to the scrap-heap.  Much of this is because experience is now disregarded in  an era when everyone's opinion has to be equal, no matter how egregious their ignorance.  In the desire to be politically correct, we have tolerated politicians and administridiots with little health care experience or understanding taking the reins and directing the industry to the disgraceful  place it is in today.  With that rant out of the way let me entertain you with tales of my contemporary, unscientific and unlicensed medical practice in  the past week..
   1.Pt.A  had bowel problems resulting in major surgery.  He spent twenty-one days in hospital recovering from the surgery and on-going complications.  He had some job related problems before the surgery.  He was distraught about the possibility of losing his  job and his future.  Despite the massive social services expenditures we incur, no one had attempted to address these problems at all.   It took some time to unravel this complex situation and explain the options available to  the patient.  He certainly felt somewhat better after that had been partially addressed.
    2.Pt.B.  An early middle-aged man on some potent medications who could no longer get the precise medication preparation that had been working well.  This appears to have been a manufacturing glitch.  Generic brands had a component that caused him problems. We discussed some make-shift solution to try. Fortunately, he contacted another physician in his family who managed to pick up a supply that was still available in pharmacies in another city, that will  last him a couple of months.  The long-term solution remains uncertain.
     3.Pt.C.  A close friend I usually swim with who is  having radiotherapy at present and has to stay out of  the water right  now.  I volunteered to take him for his therapy, so that I could railroad him to the pool hall for a few games of pool.  If it wasn't one pool it would have to be another!  Anyway, he beat me consistently and I figure that was at least as therapeutic as his other treatment.
      4.Pt. D.  A young man who barely managed to make it  to my eightieth birthday party in  Toronto a few weeks ago because of a knee injury.  This young man appeared at my party on a pair of crutches because he had injured his knee at work.  He had reported his injury and was given a few days off.  When he got home the knee was very painful and he went to the Emergency Room.   After a seven hour wait he had his knee x-rayed and  saw the doctor.    He was told he had a bruised knee and sent home.  About 36 hours later he was phoned and told he had a fractured patella (knee-bone).  He is now in a dispute with the Workers Compensation Board who think  he is ready to come off benefits and go back to work.  He disagrees.  I didn't know the answer to  the problem, but I have had enough of a working relationship with the Board to know that if you don't think you have been treated fairly there is an appeal process and I so  advised him.
        5. Pt. E.  Last night, after arriving home from a pub dinner at my local, there was a knock at my door.  I recognized the lady standing on one foot. She is my neighbour of many years.  Although she has numerous significant health problems of her own, she spends a considerable amount of time helping elderly neighbours.   She was cleaning windows for an elderly neighbour when she slipped, twisting her ankle.  After a while, it became painful, swollen and bruised.  Since the pain was getting worse, she decided that she had better consult me.  I looked at the ankle, it was swollen and bruised below and anterior to the lateral  malleolus (look it up!).  However, it passed the Ottawa criteria for absence of  an ankle fracture, so I advised the age old remedy of rest, ice, elevation  and compression. 
   Other issues I have had to deal with recently include retinal hemorrhage  and supraventricular tachycardia.
       If I go back a little further, I can regale you with more of the same.  In the meantime, I just might have to go on strike unless the pay improves!  
  

Physician Killings.

   The debate re euthanasia continues to rage and Quebec has put a hold on its imminent introduction.  Indeed it seems the Supreme Court decision may be delayed beyond the original one year mandate.  The  issue of the  influence of euphemism (a mild or indirect word or expression substituted for one considered to be too harsh or blunt when referring to something unpleasant or embarrassing.) is eloquently dealt with by Barbara Kay in a recent article in  the National Post.  We cannot deal with the phenomenon until we have the courage to call it by its true name.  Just as the American administration cannot address terrorism until they recognize it as that, so the medical  administration ( mostly composed of non physicians ), cannot possibly deal with medical killings until they call it by its true name.  For the most part when we use the word euthanasia, we are not talking about suicide, assisted suicide, physician assisted suicide, we are talking about physician killings.  If society cannot even tolerate its name, physicians should be even more aggressive about defining it.  We must define issues related to killing patients clearly, even if just to make sure future generations of young physicians are not socially engineered to accept this non medical function as an  obligation of medical care.
     I  would suggest that what we refer to as euthanasia  and other euphemisms for that act be redefined so as to  describe exactly what it is - Social Killing.   As I have emphasized before, if physicians allow killing to become part of their duties they will have done  the profession irreparable damage.  Physician involvement in end-of -life care is called palliative care.  If society wants social killing others can easily trained to provide the service.  Physicians are not 'service providers', much as the political/administrative ranks would like to  make them so.  The feckless role of the College of Physicians and Surgeons is regrettable. 

" We have now sunk to a depth at which restatement of the obvious is the first duty of intelligent men."
George Orwell.


 Has nobody any views on this issue?

The Secret of Immortality. Pt. 2.

  I have already, albeit somewhat facetiously, shared with you the secret of immortality, at least until the age of 80.  It will require several more blogs to get to what seems to be, by popular consensus, the next step, one hundred and twenty years old.  At least, that is what my local newspaper told me with a headline that read "Anti-aging drug could help you to live to one hundred and twenty.  As I scanned through the article I discovered the miraculous drug that the article informed me would be the world's first anti-aging drug to be tested on humans. It was also hoped it would help to dramatically reduce the incidence of such diseases as Alzheimer's and Parkinson's. 
   This is a drug that physicians have been using for many years for the treatment of  type 2 diabetes.  The researchers at the University of Cardiff, in Wales, wanted to know if the drug METFORMIN helps to lower the risk of early death in diabetes.  The study involved 180,000 people.  Previous studies in mice showed that the drug increased their lifespan.  In this study lifespan was compared in metformin treated patients to patients on another anti-diabetic drug. Patients treated with metformin had a small statistically significant improvement in survival compared with a cohort of age and gender matched non diabetics.  Those treated with another anti diabetic drug, sulphonylurea, had a significantly reduced survival compared with non diabetics.
   The researchers said that metformin not only reduces cancer and heart problem risk but also reduces pre-diabetic risk  of developing diabetes.  Obviously, this is going to require much further investigation.

   Meanwhile Nir Barzilai, of the Albert Einstein School of Medicine in New York and other researchers, plan to test that notion in a clinical trial called Targeting Aging with Metformin, or TAME. They will give the drug metformin to thousands of people who already have one or two of three conditions — cancer, heart disease or cognitive impairment — or are at risk of them. People with type 2 diabetes cannot be enrolled because metformin is already used to treat that disease. The participants will then be monitored to see whether the medication forestalls the illnesses they do not already have, as well as diabetes and death.
On 24 June, researchers will try to convince FDA officials that if the trial succeeds, they will have proved that a drug can delay ageing. That would set a precedent that ageing is a disorder that can be treated with medicines, and perhaps spur progress and funding for ageing research.
Let me know if yua're interested in living forever!

The Good Doctor.

   Many year ago, when I was a department head in Family Medicine, I was asked by the Minister of Health to serve on a committee that was to hear an appeal by a physician against the ruling of the College of Physicians and Surgeons of Saskatchewan to restrict or remove his license.  He was an older man and I have no doubt that he was a victim of ageism, but that term hadn't been invented yet and despite the fact that we boast a citizen is innocent until proven guilty, it often looked the other way around.  It still does, perhaps even more so today, when many a fine physician has had their reputation ruined by accusations that turned out to be false.  In any event, the College, which is the ultimate arbiter of physician fate in that it controls the practitioners license to practice does not always seem to be fair-minded and sometimes seems intoxicated with its own power.
    The story took  place in Yorkton, Saskatchewan, about 300km SE of Saskatoon, with a population of about 13000.  A competency committee of  the College of  Physicians and Surgeons of Saskatchewan consisting of three physicians appointed by the College, had assessed the senior doctor over a three day period and submitted their  report to the  council of  the College.  As a result of their conclusions and  recommendations certain restictions were placed on  the doctor.  He had already informed the College that he had recently voluntarily given up his obstetrical  and  newborn practice.
     The following  restrictions were placed on him"
1. That he sign a written, witnessed statement that he would no longer practice obstetrics  or neonatal care.
2.That he not serve on the emergency room roster until he  achieved  certification in life support and ECG interpretation.
3. Comment was made that his history taking was superficial , his his examination techniques were reasonably adequate and that his investigations did not follow an  orderly approach.
4. That he be required to complete 50 hours of accredited CME annually and to proof of such participation.
   The doctor responded that he received no instruction of what was expected of him during the competency assessment.  He felt the process was unfair and therefore appealed to the Minister of Health, who established an appeal tribunal to investigate the matter.

Advertising drugs directly to the public.

     In recent years American pharmaceutical companies direct-to-consumer advertising has become increasingly intrusive, aggressive and misleading to the extent that it is driving consumer demand for their product and that is their objective.  The success of the strategy is supported by the almost five billion dollars last year spent by the drug companies on dtc advertising.   Unfortunately Canadians are plugged into U.S. TV much of the  time and are bombarded with this material although that sort of advertising is not permitted in Canada.  In the last few years before my retirement the increase in patients coming into the office with requests for specific medications that they had seen advertised on television was remarkable.  The requests or demands were often inappropriate and for off-label conditions (i.e. not approved by the FDA or Health Canada) suggested in carefully couched advertisements.   This unethical practice, which is banned in most countries in the world, makes a physicians life difficult as, in a volume family practice at least, it can consume time and effort in explaining why this is not a suitable treatment for the patient.  One of the easier ways I found in dealing with the situation was to pull  my smart phone out of my shirt pocket and read the list of drug interactions and of side effects, many ending in "sudden death".  This was quite effective most of the time, nevertheless one was just compelled to say no sometimes. This sort of advertising certainly damages big pharma by presenting the picture that their sole objective is to sell drugs and to  put additional  pressure on physicians already bombarded with sales strategies.
       The  American Medical Association has voted in favour of a ban on direct-to-consumer advertising, so perhaps in the  near future I will  no longer have to listen to the tasteless advertisements on diarrhea, hemorrhoids and the like over my dinner.
Let me know if you enjoy ads relating to similar complaints to the above over your meals!










Direct-to-consumer (DTC) advertising should be banned in order to reduce the demand for expensive, unnecessary drug treatments, the American Medical Association’s (AMA) House of Delegates voted on Tuesday.
“Today’s vote in support of an advertising ban reflects concerns among physicians about the negative impact of commercially-driven promotions, and the role that marketing costs play in fueling escalating drug prices,” AMA board chair-elect Patrice A. Harris, MD, MA, said in a statement issued after the vote at the association’s interim meeting here. “Direct-to-consumer advertising also inflates demand for new and more expensive drugs, even when these drugs may not be appropriate.”

Advertisement

The policy also advocates for a campaign to urge prescription drug affordability — including demanding more competition in the drug industry — and for urging more transparency in drug costs; it also calls for convening a physician task force on the issue.
“Physicians strive to provide the best possible care to their patients, but increases in drug prices can impact the ability of physicians to offer their patients the best drug treatments,” said Harris. “Patient care can be compromised and delayed when prescription drugs are unaffordable and subject to coverage limitations by the patient’s health plan. In a worst-case scenario, patients forego necessary treatments when drugs are too expensive.”
Banning DTC advertising would be a really good idea, said Sunny Linnebur, PharmD, associate professor of clinical pharmacy at the University of Colorado Skaggs School of Pharmacy, in Aurora. “I can see the potential risks that occur when patients watch commercials and immediately think they need to be on that medication,” she said in a phone interview.
“Number one, it puts pressure on providers — doctors, nurse practitioners, and physician assistants — to prescribe those medications. Number two, patients are not always in the best place to make decisions about which medications they should and should not take, and commercials are targeting patients and can make them think that medicine is for them, when it’s not safe for them.”
In addition, such ads can increase providers’ workloads because “we [may] have to discuss medications that were never going to be on the table to begin with,” said Linnebur.

Advertisement

David Holdford, PhD, professor of pharmacotherapy and outcomes science at Virginia Commonwealth University, in Richmond, said that although too much money is being spent on marketing and too little on drug research and development, it’s doubtful that banning DTC ads will serve to either increase spending on drug research or bring down the price of drugs.
“DTC spending is approximately $3 billion per year — 11% of all promotional spending,” he said in an email, citing a report by the Pew Charitable Trusts. “Direct-to-provider [advertising] is the other 89%.”
“MDs are still in control of the prescription pad,” Holdford said. “They do not have to prescribe for heavily promoted DTC drugs, but they do. In fact, studies consistently show that physicians are not cost-effective in their prescribing behaviors.”
The AMA has grappled with the DTC issue before. In April, the association wrote to the Centers for Medicare and Medicaid Services complaining about the misuse of Medicare’s annual wellness visit by commercial firms that promote whole-body scans as a means of disease prevention.
“We note that some consumer groups have asked the Federal Trade Commission to investigate the direct-to-consumer marketing of some of these commercial entities on the grounds that their advertisements contain false or misleading representations or material omissions,” wrote the AMA along with several other physician organizations. “This raises serious concerns for us about potential program integrity threats that these entities may pose to Medicare.”
The FDA also has been studying the issue for some time. In 2003, the agency presented results from surveys of patients and physicians, which found that of 500 doctors surveyed, 60% said that when they discussed a medication with a patient who had seen an ad for it, the ad had no beneficial affect on the discussion. And fewer than 20% said their patients understood how to get more information about a drug as a result of seeing an ad for it.
In other meeting news, the House of Delegates also passed resolutions in support of:

• Revising quality standards and Meaningful Use requirements to make the program more streamlined and less burdensome.
• Passing federal, bipartisan legislation to speed up paramedic training for returning veterans who received emergency medical training while in the military.
• Developing model state legislation to increase use of prescription drug monitoring programs (PDMPs). “The AMA strongly supports ensuring patient privacy protections, interstate interoperability of PDMPs as well as improving the functionality and workflow of these tools to help physicians make informed prescribing decisions,” the association said in a statement.
• Lifting a Congressional ban on coverage of in vitro fertilization treatment by the Department of Veterans Affairs. Current law prohibits the department from covering this service, even though it is covered for active-duty military.

In addition, the delegates called on the federal government to analyze the consolidation of the health insurance industry over the last 5 to 10 years before approving any further mergers.

last updated 11.19.2015

7 comments

New Health Hazzards.

The Prime Minister seems more concerned with making a 'warm and fuzzy' gesture than he is about causing potential health and other hazards to Canadians.  Instead of carrying out appropriate health and security investigations of the twenty-five thousand refugees before admitting them to Canada, he is determined to ignore the inherent risks in the situation  and to "meet his deadlines", regardless of the consequences.  Apart from the obvious security issues, which he must be well aware of, there are health issues of which he is apparently ignorant.   Before going into the specific issues, let me point out the state of the Canadian Health Care system, using a report that the Department of Health has quoted itself: 

"With regards to international comparison, the 2014 Commonwealth Fund report on the health system performance of 11 countries ranked Canada 10th overall, indicated particularly low scores in quality, safety, access, timeliness, efficiency and equity.17 "
17
Commonwealth Fund, Mirror, Mirror on the Wall: How the Performance of the US Health Care System Compares
Internationally, 2014 Update.

Note the broad range of care in which we are at the bottom of the heap.  The much vaunted health care system of which we were once so justly proud is now near the bottom of the heap in the most developed countries.  Canadians are frequently awaiting appointments for periods that much exceed the bounds of safety.  We should be ashamed of ourselves and trying to  upgrade.  Instead the Province of Ontario is cutting services and doctors salaries quite shamelessly.   An additional twenty-five thousand refugees may not seem much of an additional burden until one realizes that these folks have not had the prophylactic care and immunizations that Canadians take for granted and there is a very real possibility of introducing  diseases that are entirely foreign to our population.   Apart from measles and polio and other vacccine preventable diseases that have almost been wiped out in our country (though the anti-vaxxers are doing their best to undermine their total eradication), there are diseases which Canadians have never even heard of.  We have no idea of the diseases that may be carried into Canada until the refugees are adequately screened.  Let's look at a few:                1. Middle East respiratory syndrome MERS-coV.  A virus infection with a high mortality rate.  This is a new virus which we still know little about, but it looks dangerous, spreads from person to person and is associated with considerable mortality.

2.Malaria.  Although not as prevalent as at one time malaria is still a risk and is becoming increasingly resistant to the anti-malarial medications.

3. Leishmaniasis.  A parasite that effects animals and humans and is not rare in Syria.

4.Dengue fever.  A mosquito transmitted fever that can deteriorate into the often fatal Dengue Haemorrhagic Fever.

5.Vaccination deficiency.      Diseases almost wiped out in Canada by widespread vaccination will be re-introduced by a population that is frequently unvaccinated.  Further, the irresponsible and ignorant attitude of the growing anti-vaccination population is resulting in a waning of the herd immunity that we enjoy.  Expect to see measles and other childhood diseases popping up, including some like polio and TB. 

   I am concerned that Canadians in need of health care, who often are put at risk by having to wait unacceptably long times to obtain the care that they need, may find that their much loved  health system is growing ever more tardy and  falling below first world standards.

And don't think a few Jihadi sleepers won't be among the immigrants.  

   

Minister for Science?

    Mr Trudeau has appointed a Science Minister with very questionable credentials.  Her name is Dr. Kirsty Duncan and her doctorate is in geography, but this did  not prevent her from presenting herself as an expert in both neurology and virology. It is true that Dr. Duncan contributed to a panel that was awarded a Nobel Prize for its work on climate change.  She played a major part in organizing an expedition in the late 1990s to find frozen samples of the epidemic 1918 flu.  It was a futile event which  eventually led to nothing apart from acrimony and ill will.  Her greatest fiasco was her commitment to a treatment for multiple sclerosis due to a hypothetical condition  known as chronic cerebrospinal venous insufficiency — CCSVI described by Dr. Paolo Zamboni.   This was supposed to be due to narrowing of the veins in the neck restricting drainage.  Dr. Zamboni corrected this surgically.   Duncan continued to support the treatment long after it had been proved useless and deteriorated into a cult philosophy, just as she had disputed the judgement of world class virologists in her previous endevour.

 “This is the most curious appointment since Caligula named his horse as consul,” scoffed McGill University’s Dr. Michael Rasminsky, calling the Zamboni ideas “profoundly non-scientific.”    Her behaviour in a number areas would not seem to have been conducive to nurturing the scientific method.  I will be monitoring her leadership and activities as will many others over the next few years.

Let me know if you have any  views on this appointment.

Medical Murderer ?.

                    
    When people ask me why I am opposed to euthanasia, I explain to them I am not opposed to euthanasia, I am  opposed to killing patients being regarded as a physicians responsibility. That directly contravenes the healing role.  If society decides it wishes death on demand to be available, which it does in Canada, then  it is the democratic right of citizens to take this option.  It becomes the responsibility of the state to make this available, but it does not have the right to force physicians to terminate life.  There are some who will find this perfectly acceptable, but to include this as an expectation of all physicians will damage the medical profession irreparably.
       It would  be relatively easy to train a corps of 'terminators' who would  not need to be physicians at all, in  the technical details of the procedure.  Once the guidelines were laid down the decision could be made by a designated group and the 'terminator' could administer the deadly potion.  There is no reason at all that the protocol would require a physician and in fact I don't think it should.       
     Dr. Marc Van Hoey is President of Belgium's Flemish death with dignity association and one of the country's most active practitioners of euthanasia, performing between fifteen and twenty a year.  He has become the first physician to face possible criminal prosecution, for giving an eighty-five year old fit woman, at her request a glass of lethal syrup to drink.  (Yes, it's that easy, doesn't need a doctor at all.)  Her daughter had died and she no longer wanted to live.  Thus, there was no medical reason for her termination   It is possible  he will face prosecution for violating Belgium's euthanasia laws.
   Carine Brochier, project manager of the Brussels based European Institute for Bioethics said, "It's an illusion to believe  you can control what goes on between a doctor  and a patient in a room."  In Belgium, patients who have been diagnosed with depression have been terminated.  Dr. Van Hoey himself said that it was possible to  skirt the requirements for a written request from  the patient.  It would appear that there is considerable laxity about the required second medical opinion and an additional psychiatric opinion, if death is not imminent. Physicians who allow themselves to become part of the termination team will be on a slippery slope that can only damage the profession.  It is shameful that the College of Physicians and Surgeons are lacking the moral fibre to  apologetically  support those physicians who do have those principles.      
What do you think?