Tuesday 29 December 2015

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. 

Friday 25 December 2015

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! 

Thursday 17 December 2015

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 "
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?

Saturday 12 December 2015

S-Myth Buster.

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


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.                                                               

Wednesday 9 December 2015

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!  

Sunday 6 December 2015

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?

Wednesday 2 December 2015

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!