Sunday 30 August 2015

Doctors reluctant to Kill Patients.

      Following up on my previous blog,  the second headline reads as follows:
"Doctors divided on assisting dying:Poll.
CMA says willing minority enough to meet the demand "
    According to the poll most Canadian doctors are reluctant to help end a life.    The article alleges that the results of a survey by the CMA suggests that thousands of doctors would be willing to prescribe a fatal drug overdosage for a patient whose suffering was purely psychological.  Phew!  I was afraid the poor patient might get appropriate medical help and get better before the lethal dose was administered.  Dr. Jeff Blackmer, vice-president of professionalism (gimme a break!) at the CMA reassured the CMA gathering that there would be enough terminators to go around, with the statement, "you are talking tens of thousands of Canadian physicians that are now saying,'I will participate'".
     A CMA on-line survey asked, "if a physician refuses to provide medical aid in dying, what should they be required to do?   The most popular response was, "they should not be required to do anything". 
      I find it encouraging to note that the majority of physicians still embrace the traditional principles of the medical profession.  There will always be enough who feel otherwise to ensure that those patients who wish to end their own lives will have adequate help without forcing those who find termination repulsive to perform the deed.

Friday 28 August 2015

Medicine in the Headlines - again.

         Now that I am retired, I have time to peruse what is really happening in Medicine and it isn't a pretty picture.  Over a leisurely breakfast I have time to page through the national paper that I prefer and hardly a day goes by  without some sort of medical  headline.  Often it is trivia, sometimes not.  So  let me tell you about the last two days 'Medlines'.
          August 25th. -  
         "Weak MDs blamed for opioid epidemic", sub heading - 'We kill  more people now than cars do'. 
        At a CMA Meeting in Halifax the CEO of the College of Physicians and Surgeons of Halifax opined that physicians don't understand narcotics and that he frequently sees undisciplined, unstructured and arbitrary use of these medications, by weak-willed, uninformed physicians!   Hello Dr.  Grant, what's your job?   Isn't a main function of the College to protect the public from just such issues as you are criticizing?  What are you getting paid for, because if what you say is true and you haven't addressed it, you are not doing your job.   Grant went on to say "The number of lives ruined by drugs is a problem of enormous magnitude that is killing people".  Well, Dr Grant, if you were not as weak and ineffective as the physicians you are thus labeling, you would have taken this matter in hand, long ago.  You don't know how?  Well let me tell you, but you do have to  be prepared to take responsibility for what you have to do..   When I was a young physician, long long ago and in a place far away, when physicians prescribed inappropriately, they got a warning from the College.  If they did it again, their license to prescribe narcotics was taken away.  If they offended again, their license to practice medicine was taken  away.  Simple.  Effective.  But you have to have guts to implement such a policy.   It is always easy to criticize (particularly one's colleagues), there is a solution, but it takes conviction and effort to remedy the situation. 
         I'll save the next Medline for the next blog. 
 Your comments are welcome.

Wednesday 26 August 2015

The Pink Pill!

          The impotent male has had the Blue Pill for a long time now.  How much joy, delight and satisfaction it has brought to that group is questionable, but erections, like elections, are an essential part of our social culture.  But why should these droopy males, have all the advantages.  Legions of women who have derived little satisfaction from sex (after the wonder months or years) want to pop a pill just the way that those lucky, privileged, males have done for years now and find instant gratification!    And indeed, why shouldn't they?    I think, the very political correctness of the situation will make it an instant winner and barring any unsuspected side effects, above and beyond those already documented, will make a fortune for those bold enough to invest heavily in it.  

         Flibanserin (Addyi) is classified as a 5-HT serotonin receptor agonist and a dopamine D4 receptor partial agonist. It is a Non-Hormonal agent that increases dopamine and noradrenalin while reducing Serotonin in the brain.  It was being developed as a new antidepressant  and  a large number of women noticed an unexpected positive side effect from Flibanserin. Many woman were reporting more sexual interest and overall satisfying sexual experiences than before. One of the  main  side-effects of antidepressants is loss of libido, so  this provoked much interest.  Apparently some woman in the trials didn't want to stop the testing based on this fact alone.    This led the company to clinically testing this new compound for this exact reason. Can it actually increase a woman's desire for sex?
           Side effects that were reported by some of the users where usually low to moderate. These were dizziness, anxiety, fatigue, dry mouth, insomnia, nausea. Not everyone who partook in the study had any of these but there were more occasions of these being reported compared to the placebo group and due to the fact that this compound is fairly new, there have not been nor could there have been any long term studies on side effects
          Flibanserin (Addyi®) 100mg has been approved by the FDA. It is anticipated that it will be available by October 17th 2015.

Friday 21 August 2015

Killing Patients.


         Euthanasia, assisted suicide, mercy killings are all euphemisms for killing patients.   Something that the long and noble history of medicine always eschewed.   Some are trying to change that commitment and that would be the greatest travesty in the history of medicine.
           Many doctors are absolutely opposed to killing patients under any circumstances. They entered medicine to save lives, to cure patients when they can and to ease suffering, but not by killing the patient, regardless of the circumstances and euthanasia is killing patients. I know all physicians do not share this view though according to the CMA  general council about seventy-three percent do, while others believe that they do have the right to end life under certain circumstances.  Nevertheless, when the President of the CMA and that organization, support a proposal that physicians who object to being involved with killing a patient (euphemistically renamed assisted suicide by the administridiots) ' can't just simply disregard the patient's right to access a service they're eligible for.' and must act against their ethics and the traditional principles of the medical profession, they are doing the profession that they claim to represent a great disservice.  In actual fact non-killing physicians are not interfering with the patient's rights if they make it clear that they do not believe that this treatment is in the best interests of the patient and therefore will not administer a harmful treatment; that is what a physician is supposed to do.   If the physician makes it clear from the outset that he does not prescribe this treatment  he has done his duty.   But let us not have administrators try to dictate morality.  It is not a doctor's duty to perform a treatment that  he/she is convinced is not in the patient's best interests.   If every patient is entitled to prescribe for themselves everything they think they're entitled to, we would have even more dying from oxycontin and fentanyl and other lethal drugs.  Being eligible for a service means being eligible for an appropriate service prescribed by a duly qualified physician. The responsibility of the Canadian Medical Association and of the Provincial licensing bodies is not to enforce behaviour that is repugnant and unethical to most physicians, regardless of the opinions of  the lawyers who make up the Supreme Court of Canada.  The administrators, both physicians and non physicians are accelerating the descent down  the slippery slope in this and many other ways.   Technology apart, medical care is becoming less caring and less humane.    The CMA and the Provincial Colleges are on the wrong path if they support coercing physicians to do things against their ethics and trying to mandate an obligation to kill patients or to help patients kill themselves. 
           The last group that attempted that were called Nazis and they succeeded in turning some physicians into monsters.     But they were just following orders.   Let us not make the same mistake.  

Tuesday 18 August 2015

The Rude Receptionist.

      "Frankly,my dear, I don't give a damn."  Rhett Butler to Scarlet O'Hara in Gone with the Wind.   In 1939 those were shocking words!
       Less than a century later, they reflect a prevalent attitude in our Western society.  In fact, we have had to invent 'political correctness', to pretend that we care.  I expect that from politicians and their administrative satraps, I expect that from 'Left Wing Loonies', I expect that from  the avaricious Wall Street or Bay Street Robber Barons, but I certainly never expected to find that becoming a common phenomenon in  my own profession.  Alas, it is.  The Health Care Industry is becoming indistinguishable from every other industry and the public are paying the price.  They shouldn't be surprised, because they played their share in  encouraging the metamorphosis. That's another topic that I  will  pursue elsewhere.
       I heard a story recently of a woman who after a visit to the hospital emergency room with a constellation of  neurological  symptoms sufficient to require a CT scan which appeared normal, was discharged for out- patient follow up.  Her family history included two first degree relatives who died in their fifties from  neurological causes.  When this patient, in her sixties and still symptomatic was seen by her family doctor, he felt she needed to be seen by a neurologist.  The patient got the shock of her life when she was informed that the follow-up neurological assessment was scheduled for a date almost one year away.    This would be funny if it were not alarming.  The patient phoned the specialist's office and spoke to the receptionist in  the hope of obtaining an earlier appointment, or at least of seeking some further advice over the phone.  The patient informed me that the receptionist not only told her that none of the above was possible, but did so in terms that were aggressive, rude and demeaning to the patient.  In fact the behaviour of the receptionist sounded so bizarre that I wondered how she managed to hold  a job that requires some empathy and sensitivity.   I thought this needed a little further investigation and so I went to Rate MD (ain't the Internet wonderful!) and found many accolades for the doctor and unbelievable criticism of the receptionist.  Every comment about this woman was negative.  Having been  in the medical  game for fifty four years, I  know it would be impossible for the physician not to get negative feed-back from even the most docile patient.  I know my patients would have been screaming their heads off and more than one would have been writing to the College about this sort of unacceptable, arrogant behaviour.   The patient, of course, was upset but did want to  contact the doctor to  get some further advice, such a whether he  thought it necessary to travel to another city to be seen  sooner, so she wrote him a letter.  This letter did not mention the appalling behaviour of the receptionist, simply asked the doctor would it be possible to  be seen sooner and if not whether he could recommend her seeing someone else who could see her sooner.   The physician did not have the courtesy to give her a call  but had the abusive, abrasive receptionist call her back who's rudeness even surpassed her earlier communication because she obviously resented the patient writing to  the physician.
       I have a few comments to make because I do not believe the physician could possibly be ignorant of his receptionist's behaviour.  If he does not approve of that behaviour, and if he gives a dam, one can  only speculate as to why he hasn't fired  her.  I am surprised that none of his patients have complained to the College of Physicians and Surgeons, but of course patients are often reluctant to do that because they are afraid to  lose their doctor, especially in a location where there is a shortage in  the specialty.
      Were I  that patient, unless I received an appropriate apology from that rude and offensive woman, I would  be writing a letter to the College.   
        Physicians are responsible for the behaviour of their staff and should bear in mind that their front office staff can give the impression that even the most caring physician doesn't give a damn!
         If you've experienced anything like this let me know,  I collect these stories!

Sunday 16 August 2015

Oxycontin or Fentanyl ? Or would you like a cocktail, Sir?

      The great Canadian Physician, Sir William Osler, said:
 One of the first duties of the physician is to educate the masses not to take medicine.

     The mounting number of deaths of  people from abuse of drugs in Canada is tragic but not surprising.  What is  surprising is the  failure to relate this  to the permissive attitude to taking drugs that is prevalent and is now regarded by many as 'normal' and a right of folks to put anything into their body that they think will give them a little relief or even pleasure, with no evidence of other than short term effectiveness in  the conditions that they are seeking to relieve.  It is a natural consequence of the trivialization of taking both prescribed and unprescribed drugs that has led to the fatal situations that are so much more common than it was just a few years go.
      Television and other advertisements frankly misrepresent the 'miraculous' advantages of various drugs and have found slick ways of fulfilling the obligatory requirements of the supervisory bodies to publish their sometimes very serious side-effects  in a manner that de-emphasizes their seriousness.  Doctors have become used to dealing with unreasonable requests based on such information but are nevertheless sometimes pressured into prescribing things that they would not normally use.   Over the counter preparations continue to proliferate and powerful drugs that only a few years  ago would not have been available without prescription are freely available, mainly because this is perceived as cost saving device that will reduce doctor visits.   Many of these drugs have serious side-effects and interact with  prescribed medications.  For a variety of reasons physicians may sometimes be unaware of some of the medications a patient may be taking.  In addition, there is an increasing movement to have pharmacists to prescribe.  All of this has contributed to the view that more is better and there is little or no downside to the increasing drugs that the population consumes.
       Social permissiveness has made drugs such as marijuana universally available for people with  no medical  indication despite its potential for long-term harm.  The pretense that there is a need for marijuana farms to supply the rare medical need is absurd.  It could be provided by the same means as other drugs with  a potential for addiction and constrained in  the way they once were.   Instead the social trend has been to make those prescription drugs that were once at least partially controlled as available as marijuana is.   The disastrous consequences of this is an alar increase in death and disability from drug use and perhaps even worse, an acceptance of this as a normal risk,
      Doctors, of course, have contributed to this culture in no small way.  Some patients need to be on this sort of medication,  some are difficult to get off when they could be tapered to something milder and some never needed to be on it in the first place and will never quit as long as they can get it in some way.  Unfortunately, physicians have been the means of obtaining it for a significant number.  Often, it is hard to discontinue, because no one can feel another's  pain, so one gives the patient the benefit of the doubt.  Sometimes refilling a prescription seems to be the only way to get the patient out of the backlogged office.
     Sometimes I used to send such complicated patient to the pain specialist, to get help in  tapering them off  narcotics when I thought them ready, only to have them return on an even heavier doses.  The attitude that the resolution of many of these problems is permanent doses of narcotics is patently false.  The increasing flood of prescription narcotics on  the street would certainty confirm that far more narcotics are being prescribed than necessary. 
       So while Oslers's maxim requires the addendum, 'unless it is proven necessary', the concern expressed is valid.  Taking medications that are not necessary, for whatever reason, have the potential to cause serious side-effects, up  to and including death.

Wednesday 12 August 2015

Medicobabble.The New Buzzwords.

Integrative medicine

From Wikipedia, the free encyclopedia
Integrative medicine, which is also called integrated medicine and integrative health in the United Kingdom,[1] combines alternative medicine with evidence-based medicine. Proponents claim that it treats the "whole person," focuses on wellness and health rather than on treating disease, and emphasizes the patient-physician relationship.[1][2][3][4]
Integrative medicine has been criticized for compromising the effectiveness of mainstream medicine through inclusion of ineffective alternative remedies,[5] and for claiming it is distinctive in taking a rounded view of a person's health.[6]


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Pronunciation: /ˈɪntɪɡrətɪv/

Definition of integrative in English:


1Combining two or more things to form an effective unit or system: an integrative approach to learning
1.1 Medicine Combining allopathic and complementary therapies: integrative cancer care

          I've been hearing a lot about Integrative Healthcare recently and even received an invitation to attend a symposium in Toronto in the fall.  If it didn't cost five hundred bucks to attend I might have gone to it, even though I am retired.  You see, I practiced Integrative Medicine for fifty-five years before they had even conceived of  Integrative Healthcare, let alone given it a name.   It used to be called General Practice and included application of state of the art medical knowledge, with help from physicians who had special training in rare and complicated cases.   When Family Medicine and its training programs arose in the sixties, emphasis was placed on 'the whole patient and wellness'. There were many areas where the knowledge was not what we would call today 'evidence based'.    Much of it was empirical, the result of observation and experience.   Unfortunately, nowadays little consideration is given to knowledge gained in that way and it has to pass the evidence-based' test to become accepted practice.  A group of health 'experts', many of them not physicians, now want to integrate 'complementary therapists'  into mainstream medicine.  Sounds like the initiatives of a few years ago, to establish teams without captains and many of us know how that worked out.   (In the old less politically correct but more truthful days we called that 'too many chiefs and not enough Indians' now there are only Chiefs!) Each of these changes have in the long term increased the gap between health provider and patient. The larger the administrative structure, the greater the space between the patient and the physician.(Smith's Law.)  Ever try to phone a physician these days?   
         Some complementary care is valid, much is not.  Let us subject it to the same critical evaluation as approved medical treatments.   Let us not buy the whole deal otherwise Integrative Medicine may become Fragmentive Medicine.
     Make a comment,anonymous if you wish.  I want to know what you think.      

Saturday 8 August 2015

The Doctor-Patient Relationship.

             Having spent the major part of my professional life training medical students and family physicians, I am embarrassed when stories illustrate a deficiency of the principles of basic courteous human communication.  This, of course, is the quintessential ingredient of all doctor patient relationships, that we have emphasized in recent years.  Here is the story of one needless breakdown in such relationships.

            I belong to a club that meets every Saturday morning at a popular London Coffee Pub.   Being a retired physician and educator, I  encourage club members to ventilate their complaints with the Health Care System in general and physicians in particular.   Rob, a well-educated, laid-back guy with a great sense of humor, and a number of health problems including a previous myocardial infarct, was unequivocal in his praise of the cardiac rehab program that he had been involved in and the support he had received from the people he met in the medical community.     What  disturbed him was not the medical care he had received or the subsequent rehabilitation program, it was what happened following a  stress test after the cardio rehab program.   While waiting in the consulting room, a young physician, and he stressed it was a physician not a medical student, came in to discuss his results.  Rob has been a teacher all of his life, and recognizes the difference between students and physicians..  The doctor informed him that he had done well in the stress test but the blood test indicated a liver problem..

            “You have done well on your treadmill and  blood tests … with one exception; you have to cut down on your drinking.  You should quit drinking  because it is causing serious problems, ones that will be more serious if you carry on.  It is affecting your liver and your kidneys, which are being weakened by the daily drinking."

            Rob was taken aback by these comments because he did not drink very much and wanted to know exactly what suggested that he might have a drinking problem.

            He said, “She told me that the blood tests indicated that I had a problem with alcohol, drinking at an alcoholic’s level, and the problem was serious enough that it was causing problems for the heart and liver.  The tests indicated kidney damage as well.  Taken aback I informed  her that I didn't drink daily and often not even weekly.  We, my wife and I, my 32-year-old daughter and her husband, might share a couple of bottles of wine a month and that I purchased maybe three cases of beer a year for the household.  I admitted to having a little more beer during the summer when at the cottage on a hot day, but that was not a monthly occurrence and we spent only about a month at the cottage each year.  Since I didn't think that fit her conclusions, I  suggested to her that perhaps she should know of what she was accusing patients, because she made it clear she didn't believe me.  When no apology  or explanation was offered  I asked for more specific information. At that point she said “thank you” and left the room.  Expecting her to return with some information, I waited.  About five to ten minutes later the nurse came in asking what I was waiting for.  I explained that I was expecting the doctor's return.  The nurse said she was not returning, she was now doing a stress test with another patient.  The nurse apologized for any inconvenience caused and I  went home.

         When visiting my own doctor a day or so later I related the incident to her, as a result of being very concerned about the condition of my liver and  heart problems. She was furious.  She had another set of blood tests done and her report, a few days later, was that they indicated no such thing and showed only a minor abnormality of the liver enzymes and wondered if the doctor had asked if  I was on Dilantin, a medication commonly used for various purposes. She was sure that was what was responsible.  I answered that I had not been asked that question specifically, but that the doctor had a list of all of the medications I was taking.  She mumbled something that sounded to me like, ‘dummy,.” and went on to tell  me the  blood abnormalities were due to the Dilantin I was  on.

         Rob went on to elaborate further..  He told me that following a repeat stress test  three months later he was told that his triglycerides and liver enzymes  were elevated.  It was again suggested to him that he may be drinking excessively.  Bearing in mind the previous episode, and anxious not to repeat the whole incident, he asked the doctor why he thought that he was drinking excessively.  The answer, ‘the tests show that you are.  It has to be alcohol because we know you are involved in a fitness program and you did so well on the stress test, it cannot be because of your physical conditioning, it has to be the result of drinking too much alcohol.’

      Rob went on, “I told him that I had nothing to  drink since the previous tests  three months earlier and explained in detail exactly how much I drink.  Somewhat taken aback this physician then went to the computer looking up the most recent blood test results.  The triglycerides were 0.09. (Well within the normal range).  I suggested to him that he look into this further.  This he did and subsequently came to the conclusion that the abnormalities were due to the Dilantin .

“I have no objection if this doctor or any other tells me that a social habit, whatever it may be, or however much it may be, is a factor that perhaps could be contributing to a medical problem.  If I drank one bottle of beer a week, or a month and that was a contributing factor to a medical condition, then it would be my responsibility to consider  dealing with it by eliminating that problem altogether.  However, virtually  accusing me of being an alcoholic, and that was part of the first doctor's message, is not only unwarranted and incorrect, it is downright unscientific and unprofessional.”

      When Rob told me that his cardiologist, who was the preceptor of the first physician in this narrative, responded by laughing when he heard the story and stating that his resident had at times, an unfortunate bedside manner,  Rob was certainly not amused!

      No wonder  that our sensitivity is questioned on occasion !

Wednesday 5 August 2015

If it ain't broke!

             My Atria started fibrillating when I was about 45 years old.    Everyone in  the medical world knew that atrial fibrillation, erratic contraction of the atrial chambers of the heart  was a very definite marker for stroke.   The cause being that the uneven contractions allow clots to form in the atria, from whence they throw off fragments that block the small blood vessels and cut off the blood supply.  If that happens in  the brain it causes a stroke.  I was started on warfarin, a blood thinner, that was formerly used as a rat poison.  This tended to stop clots from  forming, the disadvantage being that if it is too anti coagulated the blood doesn't clot when  it needs to, putting the  patient at risk for increased bleeding of various intensity, from  mild bleeding to death.  Monthly blood tests ensure that the blood  is not too anti-coagulated and the dosage is regulated accordingly.  If the  patient is bleeding excessively, the effects of the warfarin can be quickly reversed by Vitamin K orally or intravenously.  It's a bit of a nuisance having a monthly blood test, so that despite the fact that warfarin is very effective, the search for a replacement that does not need blood testing has been intense.  Even minor inconveniences are unacceptable these days.
    Along came the new oral anticoagulants (NOACs).  . Things have changed dramatically with the introduction of the new oral anticoagulants (NOACs)—dabigatran, a factor IIa (thrombin) inhibitor, and the factor Xa inhibitors rivaroxaban and apixaban. Clinical trials have shown them  non-inferior, to VKAs (warfarin).  The fact that they don't require the monthly INR or clotting test that warfarin does, makes them very attractive to many patients.  Unfortunately, they do not have any antidote that will rapidly restore the 'clottability' of the blood, which may have dire consequences.   They are, of course much more expensive than warfarin and are being pushed hard and advertised to the public by 'Big Pharma'.    Despite their convenience, when my medical adviser offered me the option, I opted to continue  on warfarin, convinced that  it is the better option.
      I will  sum up with a conversation I  had with a Wise  Little Old Lady just before I retired.
      She said, "Doctor, the specialist wanted to change me to a new blood thinning pill so I wouldn't have to come in for a blood test every few weeks.  I said no."
       Me, "why was  that?"
        Pt., "When I asked him how he would  know how thin my blood was and what dose to  give me  He said it wasn't necessary to know.  Then  he told me if my blood was too thin there was no way to reverse it.   So  I  told him they had no right to sell it before they had a way to reverse it and that I'd stay on my warfarin and have my blood tests."
         I think the Wise Little Old Lady was smarter than the doctor!
         The search for an antidote to the NOACs continues.

Sunday 2 August 2015

Cecil the Lion. (The real truth.)

           I like animals, but not so much that I am a vegetarian. I eat meat, not much, but the bottom line is that defines where I stand, as it does all meat eaters. Although I am disgusted at the "big game hunter Dentist", and I am not sorry that it has coat him his practice, I an not screaming for his blood. It is a sad reflection that so many are. Folks who don't bat an eyelid at baby-butchering, would like to see the Dentist ' hanged, drawn and quartered'. (look it up of you are not quite sure what that means). What self-righteous hypocrites we can be!  If you eat Kentucky Fried Chicken, Swiss Chalet or enjoy other meat preparations, you are only superior to the dentist in that you get someone else to do the kill for you, and after appropriate disguise, you eat it instead of mounting it in your den. Time to recognize ourselves for what we really are and not assuage our guilt by screaming for the blood of the Dentist!   If the animal is 'cute' and cuddly, folks will go to extremes to protect it.  If it is not, we allow unspeakable cruelties to be perpetrated, such as chicken crated in a space where they cannot move and pigs  in cells where there is not enough space for them to turn around.  Time to recognize ourselves for what we really are and not assuage our guilt by screaming for the blood of the Dentist.
           So if we really care, lets start by focusing on the perpetrators who organize these African trips. Those who plan, encourage and facilitate these trips for a vast profit and their governments who profit by allowing such activities.  Without them the pseudo-safaris would be impossible.