Thursday, 28 January 2016

Misleading Advrtising.

   Health Canada recently posted a list of 152 advertising infractions it identified in the past year.  Most of these cases are resolved without charges being laid once Health Canada challenges the advertiser.  The most common perpetrators are producers of various 'natural' health food type products that cover a spectrum from ginseng to sharks cartilage accompanied by claims that these products can cure many conditions, some of them serious.  Homeopathic products, substances so diluted that they have only molecular amounts of the active ingredient not capable of having any therapeutic effect have been widely and falsly advertised.  This is sometimes dangerous in that it directs patients away from highly effective and proven treatment.  Some generic drug manufacturers were found to be at fault for advertising that their products were exactly the same as the brand drug.  Although the active ingredient has to be the same, the non medicinal ingredients are often different.  Posting the list is certainly a move in the  right direction though much more rigorous vigilance is necessary.  
    Much more malignant is the advertisements we are subjected to on television where advertisements for very potent drugs are advertised to patients with  the objective of generating pressure on the physician to prescribe.  Although legally obliged to list the side effects and dangers of the drugs, the ad men manage to  put together an attractive montage that misdirects the patient.   When patients used to come into my office to ask why they were not on the latest wonder-drug they recently saw advertised, I used to take my smart phone Pharmacopoeia out of my pocket and read the list of side-effects to the patient.  That usually solved the problem.  This sort of direct to patient advertising is illegal in  most countries including Canada.  Unfortunately, we are in the direct line of fire as inveterate consumes of American television.    Recently medical organizations have raised their voices against this practice. We will have to wait and see if it has any effect.

Saturday, 23 January 2016

The other side of sexism!

A young female medical resident in Miami, Florida, tried to take an uber vehicle that had been requested by another customer.   The driver appropriately pointed out that he was there to pick up another passenger, whereupon she viciously attacked him.  He nobly shrugged her off without striking her, whereupon she attacked him viciously while he refrained from retaliating. Then she got into and damaged his car and threw his papers all over the street.  Eventually she got out of the car, turned around and with a toss of her head, snottily yelled back at him, "good evening!".

  Fortunately, this was all recorded on camera, otherwise the unfortunate driver may well have been accused of all sorts of inappropriate behaviour, apart from chivalry!  

  Apparently, this woman, a medical resident, was not charged criminally which was unfortunate.  I hope she will be fired by her hospital.  I know of no patient who would want to be treated by a miscreant like her.   How did she ever get into medical school.

   Just imagine the consequences if the perpetrator had been male and the driver female.
   It would have been quite a different story and his career would have been ruined forever.
   There just aint no justice no more!!
Why don't you comment on this, unless  you think it's alright for people to  get away with  this sort of behaviour.

Monday, 18 January 2016

Doctors strike.

  Junior doctors in Britain took 'industrial action' - a partial strike for twenty-four hours on Jan 12th, providing only emergency care.  On Jan 26th they will be repeating the action, but this time for forty-eight hours.  If no solution can be found they are planning more extensive action on Feb 10th.  To cut to the chase, the issues were hours of work and pay.
   Unfortunately, the industrialization of health care has left physicians with no option in cases of irresolvable disputes but industrial action.
    Here in Ontario the way the government has been treating its physician citizens is even more distasteful and completely unacceptable.  Unilateral decisions have been imposed on physicians that the government would never dare to impose on any rank of civil servant.  They would not even dare to try because they are aware government would be brought to its knees.  With doctors however, it's different.  They are well aware that physicians have always been loath to withdraw their services and count on that obligation that they have to look out for their patients.  But the administridiots have changed things, they have changed the traditional essential physician-patient relationships to an industrial relationship though they still expect physicians to eschew the basic industrial weapons that are the hallmarks of industrialization.  Physicians have a right to be outraged at the attempts by the power-brokers to render them powerless, to deprive them of binding arbitration and to attempt to  deprive them  of the right to strike, er, I mean take industrial action.
    There are only two choices, some sort of industrial action or to grin and bear what our bureaucratic masters want to dish out.
     Take your choice.

Sunday, 17 January 2016

More Nootropics.

   An article in the journal Biol. Psychiatry 77 (11):940-950 (June 2015) entitled "The Cognition-Enhancing Effects of Psychostimulants involve direct action in the Pre-frontal Cortex." stated the following:The precognitive actions of psychostimulants are only associated with low doses.  Findings from this research unambiguously demonstrate that the cognition- enhancing effects of psychostimulants involve the preferential elevation of catecholamines in the pre-frontal cortex and the subsequent activation of nor-epinephrine a2 (an adrenaline-like substance) and dopamine D1 receptors."  It went on to say that the evidence indicates that at low, clinically relevant doses this class of drugs act largely as cognitive enhancers improving pre-frontal cortical functions. This explains their clinical use in attention deficit disorders.  
   Amphetamine like Stimulants  include the amphetamines and similar drugs such as Ritalin (methylphenidate).  They seem to improve memory and attentional control and improve performance on tedious tasks. They also improve inhibitory control.  (Inhibitory control involves the ability to focus on relevant stimuli in the presence of irrelevant stimuli e.g., to attend to the teacher’s instructions in a noisy classroom and to override strong but inappropriate behavioral tendencies).
   Eugeroics:   are wakefulness promoting agents used for
 treatment of disorders such as narcolepsy, shift work sleep disorder, and excessive daytime sleepiness associated with obstructive sleep apnoea.  They have also been used widely as an off label cognition enhancing agent.  examples are Armodafinil and Modafinil.

   Xanthines the most common of which is coffee.   In addition to the undisputed wakefulness that coffee causes, it increases alertness and improves performance.

   Nicotine:  Sorry folks, but a meta-analysis of the acute effects of nicotine and smoking on human performance concluded that nicotine or smoking had had significant positive effects on aspects of fine motor abilities, alerting and orienting attention and episodic and working memory.   So perhaps the few cigarettes that I had lined up on the table and I used to ration to myself on an hourly basis (when I could afford them) when I settled down for a night of study really did help!   Fortunately, my impecunious situation sharply limited my consumption.

   Miscellaneous:  There is suggestion that Valproate, an anticonvulsant drug used in  epilepsy, bi-polar disorders and migraine may enhance some cognitive ability.

   Racetams:   I must confess that I had never heard of racetams before I started working on this blog.  They are a class of drugs that share a  pyrrolidone nucleus, whatever that is!  My interest is that some of them, paticularly piracetam are considered 'smart pills'.  Even stranger is the fact that they appear to be available 'over the counter', i.e. without a prescription.  (I haven't checked this yet).  In studies with aged rats they apparently result in great improvement in cognition!!  So  if you are a......... !   They appear to be used quite extensively as over the counter 'smart pills'.  Their mode of action is not clearly understood but they appear to work on  the cholinergic system and on AMPA receptors.

Tianeptine  is an antidepressant of the seratonin re-uptake enhancer type.  It is believed to increase synaptic plasticity and to improve learning, brain cognition and memory.  It is still under study, like most of these drugs.   Its side-effect profile seems to be relatively mild.

I believe nootropics have been much more widely used than generally thought and we will look at that in the future.

Let me know if you have had any experience with nootropics or are interested in learning more about them. 


Thursday, 14 January 2016

Get Smart - Nootropics!

    Ever since I was a student I wondered why some of my fellow students seemed to learn and digest knowledge so much more easily than the rest of us.  We certainly envied those few who sailed through their studies so effortlessly.  They seemed about as averagely smart as everyone else, and for the most part did not seem better informed about things in general than the rest of us.  Sometimes we even wondered if they had a special pill.  In those days there were multiple speculations about the almost miraculous benefits of amphetamines as a smart pill, that enabled both memory and alertness and I knew a few students who used dexedrine or benzadrine that they managed to cajole from a sympathetic druggist.  I was always too chicken to try that, particularly after I heard the apocryphal story of a user student who thought he had done brilliantly but had simply written his name over and over again on his exam paper.  That was enough to deter me permanently.
    From time to time one heard of drugs that were reputed to enhance mental abilities and there are a few drugs that are believed to improve some aspect of cognition. These drugs are known as 'nootropics' the title derived from Greek terms meaning 'mind' and 'turn' and coined as long ago as 1972.   This name covers the whole spectrum of drugs considered to have a beneficial effect on mental function.  It also covers food supplements and other neutraceuticals. Other names include, smart pills, memory enhancers, cognitive enhancers, intelligence enhancers.  Effects can include attention and memory improvements.
    So what are these drugs and supplements and do they work?
    The oldest and best known of these 'smart pills' fall into the stimulant group and after all, what is better than a little stimulation?  We are all familiar with caffeine and how endless cups of coffee (and cigarettes) encouraged generations of  students to get through the grueling preparations required to jump through the hoops that the system required of us to graduate.
     Stimulants were recognized by many to be useful in staying awake all night studying to pass your exam, or, if you were a truck driver, to drive your truck all night without falling asleep at the wheel.  Some medical students thought that drugs could help them to become a doctor or at least to pass their exams.  The sports world recognized that drugs could help them to become a 'champion' and despite a lot of blather, that seems to have become acceptable and not interfered with the exorbitant payouts for the 'heros'.   So that might be okay for a doctor, too, because such studies  as have been done seem to indicate that with careful dosage control, performance may be enhanced, not impaired, by a few drugs judicially used and  who does not want their doctors performance to be enhanced?
    There are drugs and neutraceuticals and supplements that look promising but are still lacking adequate evidence before being recommended for widespread use.  The question of whether this sort of human engineering is desirable is a question that has to be addressed.
     I find it fascinating that I may still have a chance to become brilliant and will continue to investigate this area.
     In the next couple of blogs I  will  share my findings with you!

Sunday, 10 January 2016

The Alternative Patient.

                                                        The Alternative Patient.
           He was a freelance science writer, and had interviewed me about a year earlier regarding an article he was writing on the management of hypothermia.  For this article his name was Harley.
          "I think I'd like you to be my doctor," he said, "so I set up an appointment to discuss this with you, as I do have some conditions, before I make up my mind.  There are treatments I don't accept."
          "Tell me what they are, and I'll tell you if they are acceptable to me,“ I said, reflecting on some of the bizarre requests that had been made of me in the past.
          "Well, I refuse to be burnt, cut or poisoned," he said.
          "Exactly what do you mean by that?" I asked.
          " I had cancer of the bowel about five years ago, and had it removed surgically.  When I was attending for a follow-up examination about a year later, my liver was enlarged. An ultra-sound showed spread to my liver. so when they offered me chemotherapy, I decided that I would reject the triad of further surgery, radiotherapy or chemotherapy - cutting, burning or poisoning."  He smiled, "that is why I parted company with my previous doctor, and I am coming to you with these conditions. I thought you might be more flexible."
          "I have no problem in accepting that you have the right to decide what treatment you will consent to, as does every patient.  The converse of this agreement is that you accept that I am going to give you the best medical advice I am capable of, and try to make sure that you understand the benefits and the complications of such therapy, and the consequences of not taking the treatment.  If after that you decide you don't want the treatment, then I will have no difficulty in respecting your decision.  I will contact the Cancer Clinic and obtain a copy of their findings and impressions."
          "That's fine with me, Dr. Smith," he said, extending his hand.
          "Now let me tell you exactly why I am here today," he said.  "I have had diarrhea now for about two weeks and that's how my original cancer manifested itself.  So I really want to know what's going on."
          " And yet you're not going to accept any therapy whatever the results of the testing shows?"
          "Well, I didn't exactly say that. It depends on what you have to recommend, and I also have some views and treatments of my own, that helped me get through the previous bout with cancer."
          My curiosity, was peaked.  I wondered what sort of a challenge I was taking on.
          I said, "what sort of treatments are you talking about?"
        He smiled patiently at me as if to say I know you think I'm crazy, but I've got you interested anyway!
          "I did a number of things when the doctors told me they thought the tumour had spread to the liver and that even with the malignant therapies that they had to offer my survival was strictly limited with no indication that the quality of life would be worthwhile.  I decided that the prognosis I was being offered was so gloomy that I was going to take my care into my own hands." Harley smiled again. "In other words, I decided that my health was too important to be left in the hands of doctors. So I decided to do two things immediately.  I decided to try some alternate therapy.   I am not a naive man, and I do have a considerable background in science, nevertheless, I decided to give Laetrile a try. Not because I thought it was a miracle drug, but because if you have nothing to lose except a little money, even the remote possibility that it will do some good is better than nothing.  You doctors don't seem to understand that.  You are so busy protecting yourselves, and so preoccupied with particular types of studies, that you forget that most of the great scientific and medical discoveries were serendipitous events.  Alexander Fleming didn't need any studies to show that penicillin works.  Anyway, I went down to Mexico and had a course of Laetrile.  How much a part that played in my survival, if any, I really don't know.  But I am still here, so I don't discard the possibility that it helped - and if I had another episode, I would try it again.  The other thing I decided was to remove all the sources of stress from my life that I possibly could, and this was the really difficult part of my regimen. You see to do that, I had to give up my job, and my home, and eventually the woman I lived with.  I had a regular, dull writing job, that didn't interest me very much and I gave that up in favour of freelance writing which was something I wanted to do, despite the uncertainty of making a steady living at it. My mortgage was demanding and I got rid of that too.  Just sold the house, paid off the mortgage and had about enough money left over to go down to Mexico for my laetrile treatment."
          In addition to the above history, Harley had diabetes for years and was on regular doses of insulin.  Recently he had an infected foot, and had been on antibiotics for this for two weeks about a month earlier.  It was following this that the diarrhea had started and persisted.  I told Harley that his diarrhea might well be due to the antibiotics and to eat some yogurt to help replace his gastro-intestinal flora.  In view of his past history we did investigate his gastro-intestinal tract, all of which was normal, apart from evidence of his previous surgery. 
          In due course I obtained Harley's test results from the cancer clinic.  There was no doubt that he had a pathologically proven carcinoma of his large bowel, which was resected, and that subsequently he was found to have an enlarged liver, which when investigated by ultrasound was reported to be suspicious for metastases, but for which he refused a biopsy.  At that point the cancer clinic lost track of him, as he did not go back for further follow up after refusing any of their other treatment options.
          Harley, as I call him, continued to visit me sporadically. He did not take his diabetes very seriously, and although he took some insulin daily, frequently changed the dose 'because he knows how he feels'.  He knew all about the complications of diabetes, but really didn't worry too much about tightness of control, because from his interpretation of the literature he didn't think that it made much difference.  When I told him there is much evidence to the contrary, he stated that he was going to review the literature when he had time and would get back to me, he was now very busy organizing a major youth group who had hired him as a public relations man.
          The last time I saw him was some months before my absence from the department for a year's sabbatical.  He wanted to talk to me about an interview he had with a noted veterinary researcher, who was researching a new substance that helps diabetes. It hadn't been used on humans yet, and he thought he would like to be the first, so he wondered, perhaps if he could get the substance that I might supervise his progress.  Even when I told him I couldn't prescribe such a thing or be a party to using it, he was not deterred. He said he'd take it himself, without my prescribing it.  He'd just come in for his follow-up checkups more regularly.  I had no doubt that when I got back to my practice after my sabbatical, Harley would be waiting for me with some new therapeutic regimen he had researched and would like to implement.  He was, and continued to manage his problems his way, sometimes accepting a little guidance from me, as he was still doing a year later when I departed the province to take another post.

Thursday, 7 January 2016

The Modern Family Physician V The Old GP.

   I was an enthusiastic supporter of the College of Family Physicians from its (and my) early days.  Its greatest contribution was in the early concepts of  appropriate training for general practitioners.   Until then, there was the rotating internship, an entirely inadequate and exclusively hospital experience that provided virtually no training for the care of the ambulatory patients that make up the great majority of a general practice.  So the idea was to devise a training program that would enable a physician to look after the majority of patients that a community based physician would encounter.  The need for the well trained generalist was increasing as specialization grew into sub-specialization and as those sub-specialists got to  know more and more about less and less.   General internists became fewer and many of the issues they looked after became the responsibility of the GP by default.  General Practitioners no longer wanted to be considered 'only  a GP' and felt their field was a specialty  in its own right.  Emphasis was to be placed on  the whole person  and  not just on the disease.  That implied focusing on the whole family and considering the myriad influences that impacted on a patients physical and mental health. Our specialty was going to be broad and recognize where our expertise ended and colleagues needed to be called in to resolve the problem.  We decided that Family Practice was a more appropriate description of our role, because we felt it more clearly described where our focus lay and  our limitations.  Since there was no epistomology in Family Medicine, the four principles were detailed to more clearly define our role.  Clinical competence, continuity of care, comprehensive care, community care were and are the four pillars.  Things have changed since then and the pillars and principles have not.  They need to be carefully reviewed in view of the major changes that have occurred in the health care system and in society in general. On a few occasions I have suggested a study forum or to present a paper at the annual College meeting to review those pillars. I never received a reply.
  In particular, the certificates of added competence that the CFPC adds from time to time would seem to fly in the face of a specialty emphasizing the importance of generalist skills.  We seem to be repeating history in splitting off  of 'mini' or second class specialists, from the main nucleus of Family Physicians.  I do recognize that certain circumstances of practice require additional training, but is this the way to achieve it?  This is what we have so far:

Care of the Elderly CCFP(COE)/MCFP(COE)
Palliative Care CCFP(PC)/MCFP(PC)
Family Practice Anesthesia CCFP(FPA)/MCFP(FPA)
Sport and Exercise Medicine CCFP(SEM)/MCFP(SEM)
Emergency Medicine CCFP(EM) /MCFP(EM
This could go on for ever.
   My question, how far is the College prepared to go in certifying mini-specialists?  Is that activity in line with the avowed aims of Family Medicine or is it just starting the whole fragmentation of medical care all over again.  This homeopathic approach of small doses of specialization seems to fly in the face of comprehensive, continuing care and has nurtured walk-in clinics, hospitalists and a growing variety of mini-specialists, all of whom may be very necessary, but have little to do family medicine and even less to do with continuity and comprehensiveness.  It seems that family physicians are doing less and less of more and more and that many of the tradition skills of general practitioners are atrophying.  This is the result of numerous influences, not least of which is the fee schedule and the philosophical underpinnings of the health care industry.
    Maybe it's time to devise a certificate of special competence in general practice? 

CAC Credential in
Care of the Elderly CCFP(COE)/MCFP(COE)Palliative Care CCFP(PC)/MCFP(PC)Family Practice Anesthesia CCFP(FPA)/MCFP(FPA)Sport and Exercise Medicine CCFP(SEM)/MCFP(SEM)Emergency Medicine CCFP(EM) /MCFP(EM) - See more at:

  • Care of the Elderly
  • Palliative Care
  • Emergency Medicine
  • Family Practice Anesthesia
  • Sport and Exercise Medicine
  • - See more at:

    Sunday, 3 January 2016

    Touch and tactile cues.

       People don't touch each other anymore.  At least not without dire risk.  Especially if you are a physician..  Recently, a prepubescent little boy was suspended from school for trying to kiss a little girl.  What distorted minds those so-called educators have!  In my early days of family practice, when I was family physician to a large number of patients, in a relationship that is almost unimaginable today, people touched each other all the time.  There was no salaciousness, no ulterior motive, nothing more than warmth, friendship.  Patients sometimes patted me on the back, I sometimes laid a hand on a patients shoulder, there was never anything unwholesome about it.  We shook hands, occasionally hugged and never thought twice about it.  For reasons beyond my comprehension it all  became perceived as being improper.   Yes, there were always a few who took advantage of their fellow humans, be it financial, professional or sexual, but that should not throw lifelong patterns of human relations under the bus.  When  I was a schoolboy, boys in school frequently walked along  with their arms around around the shoulders of their friends, without arousing suspicions of homosexuality, girls held hands without being suspected of being lesbians.  When did all this change?  And why?   More importantly, does it matter?  I think it does, because many studies have shown a definite relationship between growth and development and sensory stimulation or touch.  Many animal studies have shown the same relationship. Numerous studies have shown mechanical sensory stimulation to stimulate growth and development in neonates who have been deprived of normal stimulation, such as incubated prematures. Introducing periods of stimulation to such infants and infants brought up in some orphanages where sensory stimulus is minimal results in improved growth and development.
        In modern society most of the innocent touching and physical contact that was a sign of warmth and friendship and nothing else is viewed with suspicion and often with accusation.  People have become cautious about touching other humans, even about intruding into their 'territory'.  Most folks seem more comfortable in distancing their interactions, otherwise why would many people seem more comfortable broadcasting their personal and family affairs on facebook?  
       Touch and tactile cues, essential ingredients in relationships between human beings and many other life forms have become suspect.
       Honi soit qui mal y pense.
       I fear that relationships are going to become more distant, more meaningless and  more narcissistic and privacy, almost non-existent, will soon not exist at all.  
       The decline continues.  Don't forget to take your 'selfie' today!