Thursday 30 April 2015

Wasted health care resources.

                Having practiced medicine for more than half a century, I have observed some major trends that have made many services less accessible without contributing anything to the quality of care.  Although various rationales are put forward for changes, the truth is that financial motives underlie most.  Some of these problems are due to the reorganization of medicine in  the Health Care Industry model.  Medicine does not lend  itself to the assembly  line approach which is the way that most administrators would like to reconfigure it.  Guidelines, which are merely that, and not rules of treatment, may have their place, but woe betide the physician, whatever his knowledge or experience, who deviates from  them.  The administration strives to control the standard of care and seeks a baseline minimal standard.   They are as critical of physicians who exceeds those standards as they are of those who fail to meet them.  (Except when they themselves are ill!)  They strive to structure the fee schedule to engineer the system the way they think it should be.  They strongly endorse electronic records not because it is in the best interests of patient care, but because it gives them more control. The trouble is, that they themselves don't understand the true nature of quality in health care.
                An example of the detrimental effect that fee scheduling may have is as follows.  For many years I gave intra-articular (into the joint)  injections for patients with  severe arthritis.  I can't remember exactly what I was paid for this, but it was considerably under $20.  It was quick effective easy management for the patient.  It avoided the inconvenience of extra visits.  I never had a single complication.  Now with the various capitation systems of payment (the Dr. is paid on the basis of the number of patients in his practice), there is no fee for the injection.  So, what do you think happens?   Well, this procedure falls into the specialty of  orthopedics.  So, most physicians and particularly younger ones, don't bother to spend the time and effort in  mastering the technique and refer the patient to orthopedics.  Unfortunately, it takes months to get a consultation and of course it costs many times what it did when done in  the GP's office.   Most egregious of all is the inconvenience and suffering and perhaps absence from  work, that the patient is subjected to that no one seems to consider at all.  This is merely one example of a situation which squanders our health care resources.

       Comment if you have any views on this.

Sunday 26 April 2015

Ageism,Sexism and commonsense. Pt 2.

                Follow-up on a topic I  wrote about a week or two ago.
                Mr Henry Rayhons, a 78 year old former stat legislator had been accused of raping his wife in a nursing home to which she had been admitted.  There was no evidence of abuse or coercion.  The unfortunate woman had been diagnosed as having Alzheimer's disease and about a week earlier her physician had written that she no longer had the mental capacity to consent to sex.  Everyone appeared to agree that the couple had a loving relationship.  Initially, Mrs Rayhons had a private room. Her husband visited her twice daily.  He took her out to church  on Sundays.   Then she was moved into a shared room and Mr Rayhons on some later occasion, drew the drapes around the bed and climbed in with his wife.  Apparently, the room mate with whom she was now sharing complained that she heard "sexual noises" , which she later modified to just "whisperings".    Despite the fact that there was no evidence of abuse or coercion this elderly gentleman having what appeared to be consensual sex with his wife in a nursing home was charged with rape without any evidence whatsoever that this is indeed what happened.   A jury of seven women and five men found that Rayhons did not sexually assault his wife and the man embraced his family and broke down in tears of relief, stating "the truth finally came out."
            Unless there were circumstances omitted from the description that appeared in the press this case was horribly mishandled when a modicum of that increasingly rare commodity, commonsense, could have dealt with it effectively, sensitively and without intimidation, while assuring that justice be done.  It strikes me that there was some vindictiveness involved somewhere for such inappropriate and disproportionate action to be taken.   Fortunately, the jury seems to have had more commonsense than any of the professionals involved.

Wednesday 22 April 2015

Wizard of Oz!

                A distinguished group of doctors have written to Columbia University’s  Dean of the Faculties of Health Sciences and Medicine protesting that this preeminent Medical School permits the well known quack and medical entertainer Dr. Mehmet Oz to have a faculty appointment and a senior administrative position in the Department of surgery.   As a retired Family Physician, clinician and academic, I find it hard to  understand how this man has a license to practice, let alone prestigious academic appointments.  He is an embarrassment who would long since have been removed from the medical register in Canada or the United Kingdom.
                 Dr. Mehmet Oz often appears on his popular show to promote new health products and devices.   Anyone with even a rudimentary knowledge of Medicine can see that many of his promotions are completely lacking any scientific basis and are motivated by other considerations than  the welfare of patients.  A series of emails released by Wikileaks between Dr. Oz and his cohorts give some entertaining  insight into what makes Oz tick and it certainly isn't evidence based quality health care.  The fact that this narcissistic product of the "selfi" generation is allowed to propagate  his 'health' allegations, with the imprimatur  of the American medical  establishment and a Columbia staff appointment is disgraceful and doubly damaging.  Indeed, his  recommendations were sufficiently outlandish and commercial to result in a senate hearing.  In a study conducted by the British medical Journal, they found that about half of his recommendations either had no evidence behind them or actually contradicted what the best available science tells us.
                 The situation is particularly egregious in that Dr.Oz  appears to have had a brilliant and successful  career before he decided to abandon any attempt to  help anyone except himself.   Unfortunately, he has vast influence over a large and gullible following, most  of whom have well authenticated evidence based care available to them.  A large section of the public are taken in by the recommendations of celebrities and charlatans.    Dr. Oz has chosen to join their ranks, despite the fact that he knows better.  At least let us remove him from the ranks  of serious, dedicated physicians.

Saturday 18 April 2015

Ageism, sexism, what the............!!

Ageism,sexism or just plain Nuts?

              Sometimes it’s hard to decide whether we are living in Brave New World or 1984.  Either way social engineering is aflame   The Administridiots have seized control and are doing their best to impose on people what they may do and what they may say and even what they may think.  In other words what is politically correct.  They are changing the very language we speak in their attempt to direct thought, with a considerable degree of success. Orwell’s 'thoughtpolice’ are no longer just around the corner,they are here.
              The extent to which the state and it satraps are prepared to go is well illustrated in a case reported in the press recently.  A picture of an Iowa state senator mournfully standing alone over his wife’s grave was accompanied by an incredible story.  Even his accusers did not dispute that he was a loving and caring husband in a good marriage.  This, however did not prevent hm from being charged with third degree felony sexual abuse,(whatever that may be), accused of having sex with his wife.  There was no allegation that there was any abuse involved or that she had been coerced to participate against her will.  The staff corroborated that the husband visited her twice daily, that she seemed to enjoy his visits and that they seemed to have a loving affectionate relationship.  What then was the basis for any sort of charge to be brought against the husband?  Well, this unfortunate woman had developed Alzheimers Disease.  The administridiots involved decided that she was not sufficiently ‘compos mentos’ (with it), to decide she wanted to have sexual intercourse.  When her husband could no longer look after she was admitted into a home.  Initially, she was in a private room and since the husband spent a lot of time with her one could presume that they carried on their relationship as was normal for them.  However, eventually she was moved into a double room and when her husband came to visit he would draw the drape around the bed and climb into bed with her.  The woman in the other bed complained of noise of ‘love-making’ from behind the drape!  Obviously, there was a problem to be redressed, but one would have thought that even the administridiots would have had more sense than to turn it into a legal case. Unfortunately, the legal administridiots seem to have had no more sense than their health care colleagues.
          In an era when society accepts sexual intercourse between almost anything that moves as normal, it is ironic that non coercive sex between an elderly married couple is deemed criminal.   This Kafkaesque story  is a sad reminder that sexual relations are no longer regarded as an act of love between two people, but something else.  I'm not quite sure what.
           Go along with this sort of fiasco and before long, the administridiots will find something for you too.  They may have already done so.
          The decline continues.

Wednesday 15 April 2015

Freedom to choose?

          I believe that every civilized country needs a a health care system that ensures that every citizen have coverage for consultation and treatment of any serious or potentially serious condition.    Medical  care is expensive and there is tremendous waste within the system.   This results in rationing of one sort or another, whether you call it that or something else.  A waiting list for your hip surgery of a year or more is nothing more or less than rationing.  Even potentially serious conditions have unacceptably long waiting periods, sometimes  with disastrous results.  Anything that can decompress the system and make urgent/emergent care more readily available in a timely fashion deserves serious consideration, even if it does not fit in with the politically correct concepts of the day.
          So let's  look at how immigrant working class Poles in Britain deal with the National Health Service shortcomings.  The 'My Medyk' Clinic in West London opened in 2008 and has over 30,000 patients on its list.  It has opened a second branch and is considering opening a third.   These private clinics consist of family Physicians/ General practitioners, pediatricians, gynecologists and dentists.  The physicians are Polish speaking, although many of the patients  speak  fluent English.  They have succeeded in selling their services to working and middle class people who could get it for nothing from  the NHS.  How can one explain this?  The  clinics charge fixed fees and have no  other sources of income for consultations and treatment which are published on their website.  This means that they have to build  up a clientele who feel that what they are paying for is substantially better than they get from  the National Health System.  The clinics invest in diagnostic equipment and can perform investigations such as ultrasound and bloodwork.   The Physicians are not afraid of hard work and sometimes the office stays open until two or three  in the morning and on Sundays.  Although set up originally to meet the  needs of Britain's growing Polish population, the clinics are attracting people of diverse nationalities  and a broad range of backgrounds.  They are providing a service that neither the British NHS nor the Canadian Health Care service seems to be able to match in a number of ways, not least of which is that patients can usually be seen the same day if they feel it is  necessary.   Weekend and night hours are available and that allows people to get medical attention without taking a day off work.
          Until our Canadian Health system can or will match such services, it is hard to understand why Canadians are not allowed to avail of  this  sort of service.  After all, they are paying for it with their own money as well as supporting the national health program with  their tax dollars and thus contributing more than the average end user.  Or is it just a case of 'politically correct' no matter what the cost or inconvenience to citizens?

If you have any views on this freedom to choose, feel free to comment.

Sunday 12 April 2015

Witch Doctor?

After 45 years practicing medicine, it still never bored me.  Frustration and exasperation sometimes, but never boredom.  My last two patients that day, after a busy day of seeing patients were enough to keep me wide awake. 
            Johnny, a fifty-five year old native patient, walked in at five o'clock.
            "What can I do for you ?" I asked him.
            "Something is interfering with my thinking, Doc," he said.
            "What do you mean?" I asked.
            "Someone put a curse on me, Doc," he said.
            "Tell me about it," said I interestedly.
            "I think it was my cousin," Johnny said.
            "Why would your cousin put a spell on you?"
            "I think it was because he thought I was making love to his girlfriend," said Johnny.
            "When was this?"
            "Oh, years ago. I took no notice, I didn't do anything, but he thinks I did, that's why he put the curse on me. Can you get rid of it?"
            I knew that what I said next was going to determine whether Johnny was going to take treatment if necessary, or not.
            "Yep, I've got some medicine here that will help you, if you really need it," I said.
            "Oh, it takes off curses?"Johnny insisted.
            "It'll really clear your mind," I countered.
            "So you can exorcise spells?"
            "We can get rid of your problem for you.  I'm not going to write you a prescription right now.  We'll talk a bit and I'm going to see you again next week and see how you are doing.
            "Okay, thanks.  I'm glad you can help me."
             I breathed a sigh of relief and after a few more questions to satisfy myself  he wasn't going to  hurt himself or anyone else, I scheduled a half hour appointment for the following week.
            Then the last patient of the day walked in to the office.
             He was about sixteen years old and he looked as though he carried the weight of the world on his shoulders. I was alerted when I read the name on the chart, because I had seen the boy's mother not very many days earlier and she had expressed some concerns about her son. 
           I sat him down and attempted to put him at ease.
           "What can I do for you today, Glen?" I asked him.
            "I have a problem," he said, coming straight to the point.  He thrust his right hand into his trousers and pulled out an empty square tinfoil wrapper.
            "I'm hooked on this and I need help to get off it," he said, with obvious agitation.  "I feel so nervous all the time and I can't sleep.  I lie awake most of the night sweating and twitching and I can't get up in the morning.  I've been missing a lot of school."
          I looked down at the discarded  packet. Duragesic Transdermal Patch, it said, 50 micrograms per hour.  This was not good news.
            "Where have you been sticking this?"  I asked.  A transdermal patch is applied on the skin, through which the active ingredient is absorbed.
            "The kids at school cut them into four and we suck them."
            "This is heavy duty stuff," I  said.  I wanted to know where Glen had got hold of this stuff; this stuff came right out of a hospital.  It sure as hell didn't come wrapped like that on the street, but I didn't want to break the spell.  I thought I might be getting through to him.
            "Yeah, I know.  I have to do something about it," 
            "I'm going to tell you what you have to do.  You've got to join Narcotics Anonymous or Alcoholics Anonymous, you can't do this on your own."
            Glen looked doubtful. " I think I can do this on my own, if you can just give me something to help me sleep at night."
            "That's not the way it works," said I.  "Right now, you're at a crossroads in you life.  If you do things the right way now, you have a chance.  If you don't you're on the slippery slope to a life of addiction, detox centres, rehabilitation centres and worse.  If you don't want to waste your life, you have to act now."
            "Okay," Glen said, perhaps a little too readily, I thought, "I'll do it"
          I answered, "I'm going to make time to see you next week and when I do, I want to hear that you're been to an AA or a NA meeting and that you have plans to get set up with a sponsor.  I'm going to give you a few pills to help you to sleep, just a few, enough to last you until I see you next week."
          I knew I'd probably never see him again, and that he was here seeking drugs but at least I had to give him  the benefit of the doubt. 

Thursday 9 April 2015

The Annual Physical Examination

              "I would argue that we should move forward with the elimination of the annual physical," says Dr. Ateev Mehrotra, a primary care physician and a professor of health policy at Harvard Medical School.

                I absolutely disagree with him!   The 'complete history and physical examination' was the foundation of the relationship between patient and physician, when I was a medical student and for hundreds of years before.  One could debate the optimal frequency and whether it needs to be annual and that depends on the patients age and other factors.   The Health Care Industry wants to change all that and is succeeding.   The general objective seems to be to weaken and ultimately undermine the physician patient relationship that results when a patient has built up a lifelong relationship with a doctor.  That relationship plays an important role in the healing process and is unlike any business or industrial relationship.   It is an essential ingredient of medical professionalism.  The last thing the health care administrators want is a relationship between doctors and patients that undermine their ability to engineer the health care system to fit their ideal model.  Bearing in mind that many of these administrators come from a financial background, it is not peculiar that cost is a major preoccupation.  And so  it should be, it is the manner in which they try to manipulate the changes that is destructive.     Ignorant of medicine and anxious to please their political masters, they try to effect savings without costing votes.  That is hard to do unless one can make it appear that a lot of the expenses incurred are wasteful and unnecessary.    They certainly don't want to cut back on any dramatic newsworthy procedures but if they can cut back on demand for perceptually minor, less newsworthy  services perhaps they can eat their cake and have it too.   So, the Choose Wisely Program (and who wouldn't want to choose wisely?) was born.   The doctor and patient would collaborate and decide what tests should be done, by mutual consent and (implicitly) do much less testing.     Nowadays, with universal internet access, patients often come in with reams of printouts that they'd like to discuss.   Doctors, with ten or fifteen minute appointments, struggling to meet the additional time requirements of their relatively recently introduced time consuming electronic medical records, are going to see fewer patients.  

            But let's get back to the annual history and physical examination.   I believe it to be one of the most relevant exchanges in health care, ancient or modern.  The conversation between patient and doctor is the essential exchange that is the initiating point for most medical care.   Conversation, the informal exchange of thoughts and information by spoken words; oral communication between people.   It is at the annual health examination that the doctor and  the patient get to know  each other.  The patient doesn't have to be sick for a valuable and meaningful exchange to take place.   For years we have idealized preventative medicine, the wellness model, total health care etc. etc. and while we sometimes have gone overboard, let's not throw out the baby with the bathwater, largely under the mistaken impression that it will make health care less expensive.   The  history, physical and screening procedures developed over the years have sometimes been excessive, but have played no small part in the improved health status that most Canadians enjoy.  The  educational opportunities that have been a part of that process have paid off big time.  Don't let any administridiot convince you otherwise.   I can assure you they won't be giving up their periodic health assessments.  

              In the course of the annual health examination one comes across a significant number of unsuspected morbidities, physical and psychological, diabetes, cardiac conditions from murmurs to atrial fibrillation, malignant skin lesions, cervical carcinomas. osteoporosis and conditions too numerous to list here.  Mothers ask about their children, middle-agers ask about their parents, and many other issues.  Other important health care topics are often briefly addressed , without any cost to the health care system,  which the administrators cannot even begin to perceive, because it does not fit in to the 'Health Care Industry' model, that they are understand.

               I am  afraid that medicine is going to do as well under the direction of the health care administridiots as finance would do under the direction of physicians!     In any event, let's not eliminate  the foundation block  of communication in  modern medicine, the periodic complete history and physical examination.


Monday 6 April 2015

The right stuff.

Headlines in my National Post last week: "Trainees bow to doctors  - and patients suffer."

       The interviewee was an anesthesiology resident who self-righteously described the treatment by a senior resident and consultant anesthesiologist of a new mother with a serious blood infection, as having been responsible for her death.  He knew better than they, knew the treatment was likely to kill her, but said nothing.  
      The reason?  He lacked the courage to mention this to the attending physicians because he felt intimidated.  He thought he might be making a fool of himself, so he said nothing and made a fool of himself!  He felt so intimidated by the situation that he must have concluded that it would be better to let the woman die than take that risk - even though he was confident that the treatment might kill her.  He blames the whole thing on the pressure to bow to authority.  It was obviously a better choice to say nothing than to possibly alienate himself from instructors who might have an negative  influence on  his future.  In effect, he is accusing them of incompetence without due process.
      The article went on to describe how trainees complained that fear and intimidation prevent them from  questioning their teachers who seemed to enjoy intellectually abusing them and teaching by "shock and trauma".  It complained how even the nurses "lorded" it over them (poor darlings), right until  the last minute when they got their specialty qualification.   In a lifetime of training Family Medicine residents, I can't ever remember encountering such a feckless bunch.    I guess in the interim things may have changed a good deal more than I realized.  The incident, according to the interviewee, 'inspired' him to conduct a study that suggests that the pressure to bow to authority weighs so heavily that it put patients at risk.  I would frame it another way, that it requires residents to be responsible to their trainers and to ask them to explain their actions and to challenge them when necessary.  It is the responsibility of the resident to have the courage to stick his neck out in the interests of his patient if he really believes it to be in the interest of his patient.  In this case, the resident obviously put his own  interests first.  Interpret that as 'bowing to authority', if you like.  Having been a patient on occasions, as well as a physician for more than half a century, I certainly want the residents looking after me to be responsible to 'authority', if that means a responsible experienced physician.   
      I have trained Family Medicine residents for a substantial part of my life, both as a community based physician and as an academic and have rarely found them to be hesitant in voicing their opinions.   If they are baselessly being victimized for that, there are many channels to seek redress.   To assume, without any attempt to provide an evidence base, that one's preceptors are wrong and one knows better, is arrogance, and is one of the most dangerous traits a young physicians can show.   Unfortunately, I  smell it here.
       Perhaps respect and 'bow to' are synonymous in the mind of the writer.
       One thing hasn't changed.  To be a good physician, you have to be made of the right stuff.

Friday 3 April 2015

Happiness Can Kill You

We North Americans are accelerating the seemingly-selfish atheistical obsession with the pursuit of happiness for its own sake, while quietly disengaging from the actual commitments and self-sacrifices in life that might lead to happiness secondarily.

Despite the rampant sales of books which imply the contrary, a remarkable multi-disciplinary study of genomic expression of “well-being” from UF , UNC & UCLA look at inducible gene activity for inflammatory mediators such as IL 6, 8 and TNF in response to the philosophical camps of instant self-gratification behavior (hedonic) vs the “eudaimonic” form that results from striving toward meaning and a noble purpose beyond just “getting one’s rocks off.” The more ethereal aspects of psychological well-being seem somewhat abstruse. However, the clear association of IL 4 and 10 expression inhibition, and C-reactive protein and TNF as inflammatory markers predictive of poor cardiac/CNS outcome in CABG populations and the population overall for MI/stroke risk is well established. The article recognizes its own limitations but concluded that the simple pursuit of a “stress-free life” for its own sake does NOT favor the inhibited expression of disease-promoting genes, in contrast to a eudaimonic approach.

MEANING in life that leads to happiness being more important than happiness itself? I am somewhat relieved by this possible epiphany. Though we all have our off-days, one might hope that a virtuous life leading to a happy life is more important than a simply happy life at any cost. Modern genetics substantiating the few positive aspects of religious doctrine? Perhaps.

This contemporary perspective is in line with Victor Frankl’s observation in 1946 that “Happiness without meaning characterizes a relatively shallow, self-absorbed, or even selfish life, in which things go well, needs and desire are easily satisfied and difficult or taxing entanglements are avoided.” Frankl’s plights and insights were made apparent to me after learning what intact convictions Ilan Ramon died with aboard STS-107 Columbia in 2003. (Ramon and his son both died not of inflammatory-mediated disease, but the actual flames in their respective terminal environments). Frankl himself, a victim of Nazi Germany wrote “Man’s Search for Meaning” post-war faster than I could read it. He consoled and counseled peers in Bergen-Belsen with a conviction despite his woes that would level anyone with heart. A prominent Austrian neurologist & psychologist, he described a tripartite template for meaningful living which rings true to the eudaimonic individual. "A man who becomes conscious of the responsibility he bears toward a human being who affectionately waits for him, or to an unfinished work, will never be able to throw away his life. He knows the 'why' for his existence, and will be able to bear almost any 'how' ". The principles of love (the bridge between others), the meaningfulness derived from one’s contributions (labour for others), and the ability to derive strength from suffering (feeling worthy of its challenges) allude to selflessness being a possible ingredient for the achievement of meaning in life.

Thank goodness that science is starting to substantiate that greater reward might await aspiration greater than the simple vapid pursuit of happiness for its own sake…


Wednesday 1 April 2015

Patient Privacy- not for much longer!

                           Should a pilots medical history be the doctors responsibility to report because of the huge responsibility for so many lives? 
                           Okay, so what about school bus drivers? 
                            So what about a regular bus driver? 
                            And a cab driver? 
                            And a surgeon? 
                            And a family doctor? 
                            And a nurse? 
                            And an old guy who drives a car?
                            See where I'm taking you? 
                             I have had air line pilots, with various illnesses, who I  have told to take some time off while I investigate  their condition and have provided them with a certificate to be off work  for a specified time.
                            Should I have phoned the airline to report their condition even though I did not anticipate any unfortunate outcome and trusted the patient?  Of course not.
                             Soon, it will  all be resolved.  The administridiots in the ministry of health will  have  access to the electronic records, but only in very relevant cases, of course!  And if you believe that, I have a beautiful bridge I can sell you in San Francisco.  Very cheap!