Tuesday 30 June 2015

Euthanasia and the Death Penalty.

          Now, those States in America that have accepted the death penalty, have been  been struggling with its deliverance  for years.  "it's not reliable",  "it's not sufficiently humane", "some spasms have been noted, the victim is displaying signs of suffering"  they cry, before the convicted has moved on to the 'happier hunting ground'.  Gimme a break!  I have never, ever, heard any of these mostly 'Left Wing Luneys', express the slightest concern regarding the unfortunate, mostly desperate people who have opted for euthanasia, usually, in my opinion, because the system failed them.   I have never heard a single voice raised to ask us in the medical profession,whether the means that may be recommended are kind and humane, and demand that the procedure be delayed until we establish that the unfortunate patients requesting euthanasia are at least getting the most humane dispensation of death that is possible. Why is that, you may ask?  It is because the people making these decisions are bureaucrats, administridiots who are non-physicians, or physicians who have not practiced medicine for so long that they might as well not have bothered.  They are sensitive only to the demands of the system and to make it work as quietly and inexpensively as possible without causing embarrassment to their political masters.  I am embarrassed by the ineptitude of the professional organizations in providing guidance and leadership.
           Let me terminate this brief note by asking you whether you consider it fitting, that your loved one, whether it be a parent, a grandparent or other, deserves to exit this world by a method that most States that believe in the death penalty, consider insufficiently humane for its population of murderers?
Surely you have some opinions on this?

Saturday 27 June 2015

Deja vu, all over again!

Medicine is a science of uncertainty and an art of probability.

Deja vu all over again!
          I struggled through the full McGill accreditation report  and I wasn't surprised to feel I was reading through one of the old accreditation reports of the residency training program from the College of Family Physicians of Canada in the seventies when I was residency training director of the newly formed family medicine residency training program at the University of  Saskatchewan.   The accreditation recommendations of the Family Medicine residency in the1970s by the College of Family Physicians  of Canada sounded eerily similar to the recommendations of the McGill accreditation today.  The 2015 accreditation report for McGill College of Medicine would have humiliated me, as I am sure it did the Dean of that great medical school.   Not much seems to have changed in 45 years, but I was surprised at how little progress seems to have been made in  medical  education.   The deficiencies were many and if you want to review them all, the report is available.  I'm going to look at only a few before I move on to more entertaining topics.  
           Broadly, there are two categories of inadequacy.  First, there is 'compliance, with a need for monitoring '(i.e. trying, but not good enough).  Second there is 'non compliance with standards' (self-explanatory).
           There are many examples in each category so I am just going  to give you one or two examples from each category.
          Item ED-27.  A medical education program must include ongoing assessment activities that ensure that the medical students have acquired and can demonstrate on direct observation the core clinical skills, behaviours and attitudes that have been specified in the program's educational objectives.
           The findings of the credentialing committee are as follows: 
                            Direct observation of history and physical examinations has not been consistent across all core clerkship rotations. ( In other words students have not been consistently observed  doing the most important thing that they should be learning in their undergraduate years.   In  fact I have had a senior Internal  Medicine resident assure me that no one had ever observed him doing a complete history and  physical examination.)  The report particularly identified deficiencies in observation in the areas of  Emergency Medicine and in Obstetrics and Gynecology, areas particularly requiring skills and special examination techniques.
            Now let's move on to areas where there is  NONCOMPLIANCE WITH STANDARDS.
          Item IS-1.  An institution that offers a medical education program must engage in a planning process that sets the direction for its program and results in measurable outcomes.
           The committee findings:  The strategic plan should include a timetable for achieving the various milestones and have clear outcome markers.  This is a recurrent issue.
           Wow!  The senior and most respected medical school in Canada hasn't adequately engaged in a planning process that sets its direction and results in measurable outcomes?   What have they been doing for the last hundred years?
            I was going to give some other blatant examples, but I find it too depressing.  You get my drift and if you are interested the report is available on the internet.
            Meanwhile if McGill would like to give me a call I would be glad to help them out on a pro bono  basis.

Sunday 21 June 2015

McGill Medical School Probation.

          Sir William Osler, one of the  alumni and world famous faculty member of  McGill Medical School, would be turning over in his grave.     Osler, received his medical degree at McGill in 1872 and went on  to change the face of modern medicine.   Osler returned to the McGill University Faculty of Medicine as a professor in 1874 after a period of post graduate study in Europe.  Here he created the first formal journal club. In 1884, he was appointed Chair of Clinical Medicine at the University of Pennsylvania in Philadelphia and in 1885, was one of the seven founding members of the Association of American Physicians, a society dedicated to "the advancement of scientific and practical medicine."  He went on to become one of the four founders of Johns Hopkins Hospital and became one of its first professors.and then went on to be professor of Medicine in Edinborough and ultimately became Chair of Medicine at  Oxford, where he remained until  he died.  He did as much as any man to bring medicine into the modern  age and is credited with establishing internships and residency training programs.   He re-introduced bedside teaching to  modern medicine.  Osler's "The Principles and Practice of Medicine" (1892) was used worldwide.  It is still  worth reading.
          McGill  Medical School, one of the senior and most prestigious medical schools in North America, indeed in the world, just received a probationary approval.   This had never happened before but there is no doubt that the accrediting body must have felt there were very serious deficiencies before taking such  a step.  The accreditation  decision placed the medical school on probation and has scheduled  a follow up visit in two years time to determine that the recommendations are carried out.
           Now, I was more than a little surprised at this, but having had considerable experience of accreditation bodies, I want to study the accreditation report.  It may or may not be justified.  I'll get back to you in a week or so and tell you if Sir William should be spinning in his grave  because the report is appropriate or because it's not!

Thursday 18 June 2015

Marijuana pushers -not the doctors!

                 Medical marijuana can legally be consumed in a range of ways—from cannabis-infused cookies and brownies to cooking oils and tea—the Supreme Court of Canada ruled Thursday.
                The pushers, legal and otherwise, think they have died and gone to heaven!     The Supreme Court have shown they either they don't understand the situation or that they are incompetent to deal with it.
                The Harper government’s tough-on-crime agenda was rejected on appeal by the federal government of a lower court ruling that medical marijuana users have a right to a range of products containing the drug.
                Amazingly, the decision was unanimous, convincing me that when it comes to medical issues, the Supreme Court is as capable of making a rational medical decision as most physicians would be of making a legal one.  Until now, federal regulations stipulated that authorized users of physician-prescribed cannabis could only consume dried marijuana. This ruling will make it much easier for children and teenagers.  The ruling stated the following-
               “The prohibition of non-dried forms of medical marijuana limits liberty and security of the person in a manner that is arbitrary and hence is not in accord with the principles of fundamental justice,” said the written judgement.   That certainly opens the the door to all sorts of things they can't even begin to imagine!
                 I don't know much law, but I  certainly know nonsensical mumbo-jumbo when I hear it! 
                 The initial trial judge gave the federal government a year to change the laws around cannabis extracts, but the high court said Thursday its ruling takes effect immediately.
                 Medical marijuana should be treated like any  other drug of addiction and should be subject to the same constraints.     Issuing licenses to questionable groups is similar to issuing licenses to drug dealers to permit them to manufacture their products as long as they can pressure physicians into prescribing them.
                  The various colleges and the CMA are strangely silent on this crucial issue, as they are on many controversial issues.  I am sure many physicians feel they have been thrown under the bus. 
                  It's a Brave New World!

Sunday 14 June 2015

Where ignorance is bliss.

         The University of Manitoba recently had its commencements lecture to medical graduates presented by a journalist who specializes in health care.  His name is Andre Picard.   Picard is unfortunately a sanctimonious hack with little understanding of the health care system despite the thirty years he proudly informs us of reporting in that area.  He bemoans the poor communication between physicians and patients and presumes in the course of a brief presentation to teach these young graduates the right way to practice the art of medicine.   I have spent forty years teaching family medicine residents the art of medicine as well as the science.  I taught them the 'conversation' between physician and patient is vital, that house calls are an important tool, that there are limitations to investigation and treatment before the patient is harmed rather than helped.   Some learn quickly but time constraints are serious and limiting when it comes to applying what they have learnt.  The fee schedule doesn't help either.  The reward for freezing a plantar was more than for a half hour consultation for depression.  Picard doesn't understand that the unfortunate direction of medical care is the result of political decision making and the administridiots who serve them.  He has bought in to the theory that well paid administrators  perpetuate to protect their jobs, that they are the 'experts' in health care and how it should be delivered.   They only understand the 'Health Care Industry,' which has to do  with votes and finances.  Physicians have been manipulated, directed, bribed, threatened and penalized to make health care into what the politicians and their satraps want it to be and the experience and expertise of lifetime practitioners is cast aside. Unfortunately, it is the public who will pay the price for these ill-conceived notions.
        Many of the finest and most dedicated hardworking physicians I know have become so disillusioned with the direction in which medical practice is moving that they look forward to early retirement.
        Finally, our paymasters decided the value of house-calls, an important aspect of medical care, and a great convenience to the genuinely sick and elderly, when they decided they were worth about half the cost of a plumber's visit.

Wednesday 10 June 2015

In Emerg not all patients are equal.

                 Think of the emergency Department of any busy hospital.  Crowded with people, some seriously ill and some with (medically) no right to be there, at all.  You are patient number ten in order of presentation.You have a history of a previous heart attack ten years ago and just started feeling weak and unwell.  You are seventy, and your neighbour drove you to the hospital and dropped you off because your husband is away for the day associated with a part-time job he has and she doesn't want to leave you in the house as you are feeling weak..  The triage nurse asks you if you have any chest pain and when you say no that you just feel a little woozy, assures you that the doctor will see you eventually, after the nine ahead of you are seen.
                  Of the nine patients ahead of you, there are three coughing adults who are concerned that they have the flu, a man with low back pain that he has had for months but getting worse so he thought he should come in on the way home, a kid with a sore throat and another with an earache, a hockey injury, a nosebleed, a migraine headache and a person who needed a refill for a pain prescription.   An hour and forty minutes later you feel weak, lose your sense of balance and are sliding off your chair when the patient next to you catches you and calls the nurse.  You are placed on a stretcher and wheeled into the examining room where you are seen promptly by the doctor and treatment instituted immediately.   
                  What's wrong with this picture?
                  Patients with most of the above complaints should not be in an emergency department at all.   Most of these problems should be dealt with by the patient's family physician, which is how things were managed in the past.  This allowed the emergency room physician to direct his efforts to emergencies.  Unfortunately, through gross administrative mismanagement and failure to adequately understand the structure of the health care system, the administridiots have once again undermined an adequate if not ideal system.  A shortage of family doctors, restrictions which make it difficult for family physicians to get established where they wish and a shortage of residency training positions in family medicine ensure that there will be no solution to these problems in the foreseeable future.  The situation will to get worse as the population increases and in the meantime anyone unfortunate enough to need the services emergency rooms were created to provide will wait times that are unacceptable and sometimes unsafe.

Since you might end up in an absurdly overcrowded ER some time, perhaps you have some views on this?

Sunday 7 June 2015

Marijuana - Blame it on the Drs.

              These days no opportunity is missed to denigrate, derogate and  otherwise castigate the medical profession as a whole largely for the incompetence of  a generation  of  administrators (or administridiots, to  title them accurately.)  Not that we don't have our share of comparable individuals within the profession.  Indeed, some of the above mentioned administridiots are physicians, albeit mainly ones who don't like to practice medicine.  A Dean of Medicine who I respected once complained to me that there were Department Heads, "whose whole objective seem to be to never see a patient again."  That does seem to accurately describe many physicians who have ended up in administrative jobs.  Having said that, most of the physicians I have known and worked with have been decent hardworking individuals who cared for their patients above and beyond the call of duty.  Although everyone wants to make a decent living, money was not their main motivation to put in more time and effort than should be expected of any individual.  So, when I see a headline in one of our national newspapers that reads, "Doctors paid for marijuana referrals", I get angry.  It reads as though doctors were the main motivators in the ill -conceived alteration in the drug laws that many, including myself, considered foolish.  The article goes on to describe some doctors and clinics as the recipients of kickbacks from various licensed marijuana producers sometimes to the extent of up to $350 per referral.  Various excuses to try to justify the payments are described, but the bottom line is that it is nothing more than bribery.  Most doctors are not amenable to this sort of bribery but a small number are going to test the situation to the limit and to squeeze every dollar out of the situation that they can.  Some will manage to precariously stay within the boundary of the unfortunate laws.  Meanwhile, we can expect the twenty-five or so licensed producers to compete in a manner that is less than honourable, if not criminal.  The whole medical profession will be tainted by the action of the few. and the College of Physicians and Surgeons, which has an obligation to physicians as well as patients,does little to resolve the problem that they helped to generate apart from issuing pompous statements.
               We are well on our way down the slippery slope of developing a sophistry that rationalizes the relaxation of restrictions of drugs of addiction and I have no doubt that soon pot will be as available to anyone who feels they need a little holiday from the strain and stresses of life as Soma was in Huxley's Brave New World.
Comment, if you have any opinions on legislation that is likely to effect your children and grandchildren.

Wednesday 3 June 2015

TB, Bladder cancer and Bacillus Calmette- Guerin.

           When I was a medical student, the era of massive devastation by tuberculosis in Ireland was just coming to an end. The countryside was studded with Sanatoria , then largely sparsely occupied or unoccupied because of the miracle of streptomycin.  Prior to that those who developed the disease were segregated to sanatoria where most of them wasted away and died.  To get some insight into what it was really like, compare it to the early days of AIDS, before there was any active treatment  The  great godsend, in addition to an effective antibiotic was the development of a vaccine, BCG, that neonates in Ireland got with their smallpox vaccination.  There was no consent sought in those days, it was a public health measure just as smallpox vaccination was,.  It was administered for the public good and no one was asked if they wanted or not.  For some reason this practice was not common in North America, although I believe it was practiced in Saskatchewan, particularly among the native population.  The vaccine was an attenuated version of  bovine tuberculosis,called BCG, so treated that in humans it stimulated resistance to the human form of M. Tuberculosis organisms without causing any serious side effects.
           Another surprising use for BCG emerged much later.  When inserted into the bladder of patients with bladder cancer it retarded or stopped the growth of the cancer, presumably by stimulating some sort of resistance on the bladder cells against the cancer.  many bladder cancer patients have avoided having their bladder excised because of this treatment.
             You can imagine then, the horror and fear of these patient to hear that shortage result in their dosage being reduced by two thirds, so there will be enough to go around!  Apparently there are only two firms in N.America that produce BCG, one in Canada and one in the United States.  Both companies say the problem is due to" manufacturing problems at the plants."    Makes one wonder the real reason for a shortage of a drug that can avoid such devastation.   Could it have anything to do with profit margins in drugs that have long since ceased to have a patent, if they ever had.   Here's a situation where there could be a real basis for the administridiots of the Health Care System to do something useful.  Not much danger of that happening!