Tuesday 29 March 2016

Fitness to Drive.

   Most Provinces have a requirement for physicians to report any patient who has a medical condition that may make it dangerous for the patient to drive.  Although there are many obvious situations in which one should not drive, the situation is by no means always clear cut.  The loss of a driving license involves a major life change, particularly in a climate like Canada, where one's winter mobility is dependent on one's ability to drive. There is considerable variation in the rules between  provinces varying all the way from the physician's judgement as to fitness to drive to rigid rules directed by the Ministry of Transport as in OntarioIn Quebec it is mandatory to report patients the physician has reason to believe will continue to drive despite being warned not to. There were 95 medico-legal cases between 2009 and 2013, falling into three categories:
     1. Physician failed to report a patient to the Ministry of transport.
     2. The report made was considered inappropriate by the patient.
     3. A physician  refused to support an application to reinstate driving privileges.

     Increasingly physicians are put in a conflicting situation between their civic duty and their requirement to provide privileged information to government agencies.  During most of my career, it would have been considered entirely appropriate for a physician to instruct a patient not to drive, either as a temporary or a permanent measure and to convey that judgement to the family, particularly in  the case of an elderly or non-compliant patient.  Thereafter, it became a family responsibility to see appropriate measures were taken.  In fact, when  the situation was appropriately presented to the patient and family, most people accepted the temporary or permanent restriction on driving.  Some, of course didn't and reacted aggressively to the situation.  I recall a harassed clinic business manager who came back from the bank after being loudly berated by a patient because of the fact that I had reported to the ministry that she should  be temporarily prevented from driving until the cause of a seizure she had suffered be investigated.  She informed him that she had found a much better doctor elsewhere who "really knew what he was talking about".
     Of course, despite what bureaucrats may think, most patients aren't stupid and it didn't take long for  them to learn what not to  tell their doctor in order to keep their driving license, thereby confusing the issue and the physician and perhaps impeding an appropriate diagnosis.
      Much  is made of privacy and confidentiality issues, but for a long time now they have been eroded and apart from occasional 'show trials' to convince patients that the administration cherishes privacy, they are steadily being whittled away.   
      Medicine is unlike any other profession and not amenable to algorithmic solutions of most of the problems that physicians have to address.  Experience is no longer considered as one of  the most important tributes of a good physician and anecdotal evidence is regarded as insignificant. The combination of physical and mental co-morbidities that physicians must address do not lend themselves to solution by a Google search no matter how much administrators  might like to think they are and that is why all the clinical practice guidelines in the world, no matter how cleverly crafted will never be more than that.  Guidelines.  Any attempt to make them rules will be to the detriment of the patient.  That is why physicians are professionals and not technicians.
     Would you support a mandatory information and road test for everyone over a certain age?

Friday 25 March 2016

Overuse and waste in the health care system.

   When I opened the journal 'Canadian Family Physician' this week, I was not surprised to find that the topic of the 'op-ed' was the expense of health care.  I learned some interesting facts.  In Canada, on average, the provincial governments direct about 40% of  their budgets to health care.  Hospitals account for about 30% of that, drugs 16% and physician services 15%.    Based on American studies, there emerges a category of health care consumers labelled 'super-utilizers'.  (Had their English been more correct they would have called them 'super- users', but that's another topic.)  Super-utilizers are the 1% of patients who consume between 30 and 50% of health care resources.  Comparable figures for Canada are not available, however on an anecdotal basis after fifty plus years of medical practice there is no doubt that a comparatively small number of 'frequent-flyers' consume a disproportionately high percentage of the resources. Now, some of the super-utilizers have a completely valid basis for consuming mammoth resources.  There are many life-threatening or severely debilitating conditions that justify such use and other than providing them in the most efficient and cost effective way there is little more we can do.  On the other hand, there are a significant number of patients who are very heavy users of the resources when medically there is no basis for it.  I am  not saying that these people do not require help of various kinds, I am saying they are using very expensive and scarce resources when a lesser level would serve them as well or better.  It compares to having a nuclear scientist fix your toaster.  If you have to pay the bill yourself you'll get an electrician or perhaps a handyman.  These users deprive the really needy from receiving the care they need in a timely fashion.  Devising an efficient way to deal with this will not always be politically expedient even though urgently required.  So the politicians and their janissaries are desperately seeking a way to get this monkey off their back and onto guess who's?
   The second article in this Family Medicine Journal, was titled  'Addressing  overuse starts with physicians'.   While some of the points are valid, their presentation left me with the feeling that even the two physicians in the five- authored paper did not grasp what it is like to run a busy general practice.  'Choosing Wisely', is a program which, in addition to recommending which tests should be done and which should not be done in various scenarios, depends heavily on an exchange between a reasonable physician and a reasonable patient to decide which tests should be done and which omitted.  Even then, in some cases common ground will never be found. Some patients feel their google search is equal to their doctors degree.  In many cases it may require a considerable amount of time to negotiate, in a setting in which the physician is trying to fulfill the requirements of his  EHR (electronic health record) , another time consuming activity and deal with all of  the other concerns of the patient.  This is likely to have an impact on the number of patients the physician can see in a day.  In a province such as Ontario, where disillusioned physicians are already dealing with significant income cuts, it is unrealistic to expect them to increase their losses by reducing patient volume.  It is also likely to increase waiting time to get an appointment. 
    Unfortunately, in this litigious age there is a strong need for physicians to protect themselves.  No physician is going to be exonerated for not performing a test because it appeared it was probably not necessary.  Lawyers are advertising every day that there is money to be made by medical litigation.  This is one of the urgent matters that the department of health will have to deal with, if they don't  want 'Choosing Wisely' to simply peter out after the initial furore.  In addition, there are situations in which the demonstration of a normal test result is therapeutic to both the patient and their family.  I could go on, but just want to demonstrate that sitting in the physician's chair is much different from sitting in the administrators chair.   
   Every patient is an individual, and 'one size fits all' solutions are not available.or desirable, no matter how much money they save. 


Monday 21 March 2016

Canadian Blood and the Iranian Connection..

   Canadians have always donated blood out of the goodness of their hearts in an honest desire to help their fellow Canadians.  Not so everywhere and in the United States it is customary to sell your blood to the blood bank.  Some have regarded this as a regular source of income and as you can imagine they are not always the most healthy and hygienic section of society.  Many have said that collecting blood from paid donors by for profit clinics is dangerous, and often those who sold their blood were drug addicts infected with HIV/Hepatitis C which they passed on through transfusions.  After the Canadian blood scandal of the 1980s when as many as 30,000 Canadians were infected through the blood bank, one of the recommendations was that donors of blood products should not be paid.
   Enter Canadian Plasma Resources, a company that wants to pay donors for their blood, primarily for manufacturing plasma products for the treatment of patients for certain medical conditions.  Canadian Plasma Resources (CPR) planned to invest several million dollars in Ontario to open donor clinics in downtown Toronto.  The government of Ontario, in their wisdom, drove the company out of Ontario by passing legislation to ban paying people for their blood and plasma.
   Quebec also bans paid donor clinics.
   CPR was however, able to find a Province that would give them the go-ahead.  That Province was Saskatchewan and a collection clinic was opened in Saskatoon.
    On March 7th, a group hosted by Blood Watch, a reputable group which includes the WHO, presented their case opposed to paid plasma donation, on Parliament Hill.  Numerous positions were put forward in support of their position, including the fact that the lure of payment could be an incentive to lie about risk factors.  
    The structure and management of Canadian Plasma Resources needs to be carefully examined before its policies and relationships can even be considered as bone fide health product manufacturers.  Owned 100% by Exapharma., Barzin Bahardoust and CPR has faced problems over its ties to Iran.  The Federal Court recently upheld a a Canada Border Services Agency (CBSA) decision to deny a work permit to Ramin Fallah, a shareholder in Exa Pharma Inc., who had been hired as an executive.  His former employer Fanavari Azmayeshgahi, has been identified in open sources as being an entity of weapons of mass destruction concern. 
   Another alleged link to Iran's nuclear program is through Canada Plasma's business partner with the German pharmaceutical company Biotest AG which has processing plants in the U.S. and Germany.  It has ventures with a company which  is on a list of Iranian companies Britain considers at risk of using exports for weapons of mass destruction proliferation.  The founder of Exa Pharma  is also founder of a  company that has a joint venture with Biotest. 
    I don't know about you, but I certainly don't want any control over our Canadian blood supply or plasma products by a questionable group that has some sort of relationship with Iranian groups who might rather kill us than save us.  
   This issue requires careful  investigation, despite Dr. Bahardoust's statement, "While the majority of our shareholders are proud members of the Iranian-Canadian community,including myself, Exa Pharma and Canadian Plasma Resources do not conduct business in the republic of Iran.  Our sole focus is to collect plasma in Canada and manufacture it into products to be sold in the Canadian market to treat Canadian patients."

There will be more.  Meanwhile if you have any opinions at all, what say you?


Friday 18 March 2016

Trudeau's Soma.

     "And if ever, by some unlucky chance, anything unpleasant should somehow happen, why, there's always soma to give you a holiday from the facts. And there's always soma to calm your anger, to reconcile you to your enemies, to make you patient and long-suffering. In the past you could only accomplish these things by making a great effort and after years of hard moral training. now, you swallow two or three half-gramme tablets, and there you are. Anybody can be virtuous now. You can carry at least half your mortality about in a bottle. Christianity without tears - that's what soma is.” 
Aldous Huxley. Brave New World.

       This is Trudeau's Canada.  The Liberal Government is offering us a new Canada.  An end to the 'war on drugs', a world where it is perfectly acceptable to  use illicit drugs, with the establishment of a safe needle site, all under  the supervision of a nurse, should the 'client' (note I did not write patient), desire it.   No mention of the fact that there is a nurse shortage that is already undermining care of seriously ill patients. No understanding at all of the huge resources that will be consumed without any evidence they won't do harm, let alone any good. Drugs that are dangerous, body and soul destroying, are all going to be much more accessible in the new Liberal administration.  The legalization of the gateway drug, marijuana, will make it easier for the young and naive to get started, knowing they are doing nothing wrong.  My goodness, how could it be harmful, when  it has the imprimatur of the all knowing government.  Why, the Prime Minister himself admitted to using marijuana and 'has no regrets about it'.   This man even stood up at a UN Drug conference, where his progressive drug plans earned 'eruptions of applause'.  By the time his drug legislative changes are doing their maximum damage he will no longer be Prime  Minister and in the meanwhile a good regular dose of 'Soma' should make controlling the 'folks' a lot easier.

Make a comment if you have any views on this.


Wednesday 16 March 2016

Medicine and Professionalism. Justice for all.

   I have often wondered why so many physicians who have become 'administridiots' seem to become unreasonably critical of their erstwhile colleagues. Instead of showing more understanding for their fellows in the trenches, they seem to become resentful of them. Perhaps that is to justify their own abandonment of clinical practice. Ontario has treated its physicians in a disgraceful way, one in which most segments of society would not put up with.   The reasons for physicians inability to deal with such political situations is exclusively due to their sense of responsibility and obligation to their patients.  However, no relationship can be entirely one-way and unfortunately, for the most part, that is what it has become.  Administridiots are constantly writing codes in that direction but rarely regarding patient behaviour.and on occasion, abuse.  Physician administrators show no more insight than those with no medical background.
   A Dean of Medicine I once knew and admired said to me: "I'm sure that most of the department heads (a position with a significant administrative role) around here would never see another patient again if they could avoid it." I think he was right. Most of the department heads I have known, and I have known many, have continued seeing patients a half day a week mainly because it was necessary to maintain their credibility. Department heads are the leaders in medical education and attitudes. So medical administrators with an M.D, degree, are less likely to make recommendations that benefit the health care system and both health care professionals and patients.
   Now here is an outrageous Canadian Medical Association post on March 15th 2016 by Dr. Louis Francescutti,a former CMA President:

"Now here is a rather radical idea!
If implemented properly and with conviction, this idea will not only immediately improve physicians’ morale and increase their sense of engagement, it will also measurably reduce patient error, virtually eliminate waits, improve access to specialist care and save governments millions of dollars. This elusive dream is a reality if we want it.
The solution, as unappealing as it sounds, is rather simple.
We, as physicians, need to stand up and accept responsibility for what is going on in our dysfunctional health care systems across Canada. If we won’t fix the problems, who will?
At the individual level, we need to hold each other to account for our actions and inactions. The easiest way for this to happen is for all physicians to be in salaried positions on one-year contracts that can be renewed if they continue to meet performance standards.
The peer-review processes that are used to evaluate an individual’s performance from the time they apply to medical school to the time they finish their residency training unfortunately tend to end once they enter practice. Most of our professional practices are not reviewed by our peers, and this needs to change. Peers should review each other quarterly and the results should be made public. We need to measure the quantity and quality of physicians’ work, the outcomes of their work and their adherence to standards of care. As part of the evaluation process, we need to ask patients whether their physician is available when they need him or her and whether their physician treats them compassionately.
When someone realizes that they are now expected to meet a meaningful accountability standard, they will change how they do things for the better. If they are unable or unwilling to meet the standard, a difficult discussion will need to take place when the one-year contract comes up for renewal.
At a broader level, physicians need to take responsibility for designing a health care system in which patient-centred care is not just a slogan but a reality. Injuries do not happen only between 9 a.m. and 5 p.m. on weekdays, and diseases do not respect the clock. This redesign needs to be supported by a new data analytical infrastructure that rivals that of financial institutions or Federal Express. We need to start measuring and managing change, and we need to impose consequences for wasteful practices.
Increasing the accountability of physicians sounds simple and logical. Now here is why it so difficult to do. For starters, why would any provincial medical association support the notion of greater accountability for their members? They say all the right things (“The patient comes first”; “Our members are accountable”) but a quick reality check tells us otherwise.
In his 1890 painting The Doctor, Sir Luke Fildes portrayed a Victorian GP pensively watching over a dying child on a makeshift bed of two mismatched chairs in the middle of the night while his parents watched from the shadows. The doctor’s compassion for his patient is clear. But is medicine still a compassionate profession today? A 2013 Ipsos Reid survey found that only 35% of Canadians thought their physician was compassionate, a 30% drop from 2003. Really! Where is the profession heading? According to the same survey, the public also thought we were less hardworking, less well-educated, less dedicated, less trustworthy, and less up to date on recent developments in medicine than in the past.
A recent Commonwealth Fund report was equally damning: Canada’s health care system was ranked at the bottom of the countries examined.
So what exactly are we getting in return for the $225 billion we spend annually on health care in Canada? Your guess is as good as mine. Accredited facilities are harming our patients at alarming rates, so much so that we need new patient safety institutes. Everyone is jumping on board the safety train, with good reason. Recent estimates in the United States peg the death toll from medical errors and misdeeds at over 200,000 patients per year. In comparison, 33,000 people die annually on American roadways. What are the numbers for Canada?
The Institute of Medicine reported that almost 35 cents of every dollar spent on health care in the United States is totally wasted as a result of unnecessary services, inefficient delivery of care, excessive administrative costs, inflated prices, prevention failures and fraud, to the tune of $750 billion per year.
We develop cleverly crafted campaigns with slogans like “Choosing Wisely.” What on earth have we been doing up to now?
Our health care system is in urgent need of change. If we continue to leave the responsibility of improving the health care system to others, we will wait a very long time for effective, sustainable change to happen because there are so many vested interests involved. You want to improve the care systems we work in? Start holding the real power brokers, your fellow physicians, accountable and watch things change. As Dr. Aidan Halligan, a brilliant physician and dear friend who passed away too early, said repeatedly, “What you permit you promote!”
Let’s stop being satisfied with the status quo and start promoting a greater sense of calling to do the right thing.
As the Governor General of Canada told the profession at the October 2012 Convocation of the Royal College of Physicians and Surgeons of Canada, society is fed up with our profession looking after our best interests and is about to rewrite their social contract with us. Let’s get to work and restore Canadians’ faith in us."

   I think this clearly puts Dr. Francescutti in the 'administridiot' category.
   The CMA should be ashamed of itself for failing to comment on this disgraceful biased Orwellian op-ed until after the event.  Unfortunately, they do not understand what 'professionalism' is.

Sunday 13 March 2016

Takotsubo Cardiomyopathy, (A Broken Heart?)

 When I was a young lad eavesdropping on my parents and other adults I would sometimes hear them speak of people who  died from a 'broken heart'.  It may have been in reference to someone who lost a child, a spouse, a lover or almost anyone loved deeply.  Talk of a broken heart, in fact, was not that rare to the ears of a child whose comprehension was awakening in the disastrous years of WW2.  As one grew older and matured one came to realize that the term was metaphorical and  there was no such thing as a broken  heart.  Some people certainly die from stress and suffering, pain and depression and loss of  the will to live.  But a broken heart?

   Well, in  the 90's a cardiac condition was recognized in Japan and subsequently in the U.S. and has now wide recognition.  There were 300 journal articles published in 2010.

   Symptoms of heart failure with an ECG that is suggestive of a myocardial  infarction (heart attack) is a common presentation, so this is easily misdiagnosed.  Chest pain and shortness of breath may occur.  Stress, physical or emotional is considered to be the main factor.  Grief, as from the death of a  loved one, fear, anger are frequently included among the triggers.  

   The exact cause of the myopathy is unknown, but is thought to be associated with certain types of coronary artery spasms.  The heart muscle takes on an atypical ballooning effect.

   While unattended the condition can have serious consequences, most patients recover fully with supportive in-hospital care.

    Incidentally, the stressor can be an exceptionally happy event, like winning the lottery, so be careful!

    Shape assumed during contraction is supposed to resemble Japonese Octopus pots (Takotsubo) after which  the disease is named.

    So perhaps people have been dying of a broken heart since the beginning of time?

Friday 4 March 2016

Reflections in the Swimming Pool.

   In addition to maintaining physical fitness, I really do believe that swimming contributes to mental fitness.  A certain equanimity results from swimming back and forth and as this metamorphoses into a not unpleasant boredom certain thoughts drift in and out of consciousness.   I call this the TAO of swimming.
   Many of the thoughts are philosophical on a grand scale e.g. the nature of the universe and just as many are trivial, but not, I believe, insignificant.  Many are related to medicine, an area to which I dedicated much of my life, perhaps too much, leaving other important things undealt with.  Despite the tremendous leaps of modern science, I fear for my profession as I reflect on some of the amazing physicians I was privileged to know and learn from.  For the most part their likes are gone and in this sad age I fear they would be more the objects of ridicule than of admiration.
   Unsummoned, embarrassing moments come back to haunt me.  Ridiculous, trivial incidents of little or no significance, that should have erased themselves from my memory half a century ago, still bring a metaphorical blush to my cheeks.  Some of the difficult decisions of the past raise their heads and either leave me with a feeling of satisfaction about how well I handled them, or a tinge of regret at how much better they could have been dealt with.  I often think of patients whom I was privileged to care for and admire their courage and attitude in dealing with the hands they were dealt.  I also remember some of the ones who had difficulty dealing with anything, who I could sometimes help.  I enjoyed a warm relationship with most of my patients and in fifty five years of practice never had a threat of a legal suit.  In fact, in my youthful naivety, I firmly believed that if one acted in the thoughtful best interests of one's patients, one was immune from legal suit.  No aspect of my practice of medicine was influenced by fear of legal suit until relatively recent years. It took me a long time to realize that was no longer the case, and that one had little option but to practice a self protective style of medicine in this adversarial atmosphere that our legal colleagues have bequeathed to us.  This is responsible for a very significant portion of the cost of modern medicine, without benefit to health care.
   And sometimes I am reminded of some of the things I don't want to be reminded of, and that's a whole other story.  
   It's all part of the Tao of swimming!

Thursday 3 March 2016

It's all in the genes!

   A short time ago I wrote a piece about speculation that genetic engineering of the Aedes Aegypti mosquito may have brought about a change in the Zika virus that is responsible for the virus's ability to cause microcephaly.  Speculation is just that, nevertheless the very fact that such changes are possible, makes consideration of the science fascinating.  CRISP-Cas9.  This allows scientists to snip a piece of DNA and replace it with a different piece.  This type of targeting is in its infancy but the technique is there and will become more precise very quickly. CRISPR stands for "clustered, regularly interspaced short palindromic repeats."  It is the quality of some bacterial DNA that enables them to create RNA, a single strand version of DNA, that seeks out DNA that matches its series of bases   The bacteria then sends a protein called 'Cas9' to attack the marked DNA.  The Cas9 can also be used to destroy and replace the targeted DNA with something better.
   The science is pretty difficult for folks without a science background and for some, like myself, who do.  A nice youtube diagrammatic explanation is worth looking at.    'CRISPR/Cas9 -how it works.'

    At my stage in the game, my interest is more philosophical than scientific.  I have no doubt that the science will be mastered, that's only a matter of time.  The potential for good is as limitless as the potential for disaster.  The very nature of the human race may be radically altered.  Genetic interference may have outcomes that we cannot as yet imagine.   There will be major ethical issues to deal with in the use of these techniques to breed super humans with perceived advantageous traits.  Both physical and mental advantages may be for sale in the future.  In any event and for many reasons, we all need to  be informed about what is going on in the area of genetics.   A new semi-human species may be just around the corner.

Let me know if you think it's time to engineer a new human race!