Saturday 30 April 2016

Be your own Medical Historian. Pt.3.

   On re-reading my last blog, I found one omission that I would like to correct.  I would like to add a paragraph titled:        Tests and investigations.
   I think that is particularly relevant these days when lack of continuity of care is so common and when patients  are seeing either a primary care physician or a specialist who doesn't know them.  Adequate evaluation sometimes depends on knowing the results of recent tests and if the physician needs them and they are not at hand or easily obtainable, the most expedient way of dealing with the matter is to reorder them, thereby discomforting the patient and wasting money.   So if you have had abnormal (or normal) tests or investigations you should include them in your document.
   By the way, in my last few years of practice, a number of patients brought me a 'selfie' photograph of their rash or lump or whatever.  As a confirmed 'anti-selfie', anti narcissist individual, had to admit this was an entirely justifiable use of the 'selfie' technique.
   Of course, if there are other individual issues you want to remember to bring to the physicians attention, you can just develop an appropriate line.  That's the beauty of  the system, you can tailor it for you.  
   Now for something entirely different:  Vaping.
   I have been a strong supporter of those who have decided to quit smoking in favour of vaping.  I always believed that the harm, if any, from vaping, was infinitesimal compared with smoking, and that the damage inflicted on others was non-existent.   Now the British Royal College of Physicians has made a public statement to that effect.  I suspect my colleagues in Canada will soon follow suit.

Let me know if the last two or three blogs were of any help and if you have any suggestions to improve the system.

Wednesday 27 April 2016

Be your own medical historian. Pt.2.

   If you haven't read part 1 of this topic, go back and do that now.  Life is much easier and safer, if you have an up to date medical history in your wallet or the glove compartment of your car.  Visits to the doctor or dentist or other healthcare professional can be much less of a hassle for you and for them if you can pull a sheet of paper out of your pocket, which has all the necessary information, including your medications in one place.  During a visit for a medical complaint, many patients are anxious as well as feeling unwell and cannot recall things they would normally be able to. As mentioned previously, I usually have the information in triplicate , because in a teaching clinic or hospital it is often necessary to provide the information two or even three times.  When I was a teacher of Family Medicine one of the most frequent complaints I heard from my patients in the teaching setting was, "Do I have to go over all that again?"  
   If the information is stored on your computer, it is easy to keep up to date and to print off your copies before your appointment.  Unless your history is very long, you will be able to keep all the information on a single page.  So, let's get started:
   First, at the top if the page you need your name and address, phone numbers , email address and next  of kin.
   Under that, make a heading titled : Why am I here today?  You just need enough space to briefly summarize your complaint.  A couple of lines will be sufficient, because that is what you are here to talk to the doctor or about.  You will, of course, be leaving this section blank, unless you happen to develop an acute bellyache while you are preparing the form!
   Paragraph 3, will be your past illnesses and the treatment as far as you can recall.  If you have difficulty you can phone your doctors office, explain what you want and in many instances the nurse will be able to give you the information. Again, be brief.  If the doctor needs further information and you don't have it, he can get it elsewhere.
   Paragraph 4, will be titled: Allergies and Immunizations.
If you're not aware of any allergies, a simple 'none known' is appropriate.  Many older persons don't know what their childhood immunization status is, but will know what they have had in their adult life,
   Paragraph 5 will be titled: "Current Medications and dosage." with a subheading "Previous Medications,(don't worry about the dosage which you prbably won't remember anyway).
  Finally, 'Other physicians I have seen and hospital admissions'  and voila!
   By the way, there are loads of medical records applications on the internet.  Many connect to a web site and I certainly wouldn't want my history floating around in cyberspace.  There are a few that state your data just stays on your device, but for the most part I did not think they were as good as the above and a lot more fussy to maintain, so at present I don't recommend any and i will continue keeping my data on my desktop, and print off copies as I need them.  Keep a copy in your glove compartment or in your wallet and let your family know they are there.

I'd welcome any comments if you have any ideas about this.

Sunday 24 April 2016

O Cannabis,eh?

   Plans to legalize marijuana in the spring of 2017 were announced by Canada's health minister at the UN recently. "We will introduce legislation that ensures we will keep marijuana out of the hands of children and profits out of the hands of criminals" said Jane Philpott in a speech that was certainly prepared by the administridiots who think they know more about health care and drug abuse than the professionals.  I feel tempted to send them a copy of a mug my niece gave me that says "Please don't confuse your google search with my medical degree."  Unfortunately it's too late, they already do that.  I previously shared a blog with you informing you that 'medical' pot use has already increased ten-fold among Canadian veterans, at a cost to the government (us) of over twelve million dollars.  When the new laws come into effect that will be just a drop in the ocean.  However, I am sure the government will manage to keep the results of their legislation quiet until after the next election in the hope that their changes will win votes.
   Canada has a major problem with drug abuse that we keep as low key as possible, while we point our finger south.  We have a major lack of resources in treating those patients who do seek health care and are not just drug seeking.  Some of those patients can be helped.  Enablement is likely to win more votes.
   Since legalizing pot Colorado has had a forty-four percent increase in traffic accidents and hospital visits re cannabis are up a significant thirty percent.  Twelve percent of Coloradans recently admitted to using marijuana in the previous thirty days.
   Meanwhile, Obama is drastically reducing sentences of major narcotics dealers and releasing them onto the street.  It is not unlikely Trudeau will follow suit. 
   The decline continues.
Do you have any opinions on this?

Wednesday 20 April 2016

Be your own Medical Historian.

Be your own Medical Historian.
      As I get older and my medical history gets longer I am pleased that I designed a way to avoid repeating my entire medical history every time I have to visit a doctor or dentist, or for that matter any other type of health care professional.   For years now I have kept an up  to date medical history on my desk top computer and available on any other electronic device I chose.  So when I shuffle up to the desk at reception and they thrust a pencil and clipboard at me to summarize my past medical history and medications in addition to the days complaints, I pull out the copies I have in triplicate in my pocket, clip it onto the clipboard and hand it to the receptionist, thereby saving the time and effort it would take to write them out and then line up at the reception desk again. I then settle in to the waiting room with my phone, pad  or notebook and look around for material for the next day's blog.
      Being a patient of a university teaching unit I usually agree to seeing a resident and/or my own physician.  Here I tear off the second copy to avoid going over the lengthy history and hand it over to the appreciative resident after a polite but short chat, confident that I still have a third copy, just in case.   An astute friend of mine remarked that if everyone did that how would doctors in training ever learn the art (and it is an art) of skilful history taking.  I had to point out that for many that skill has been thwarted by the focus that is  so frequently directed to communicating with the computer rather than with the patient, but that's another topic.
   I have been reflecting on how much easier physician encounters would be for most folks, if they had an accurate portable summary of their medical history that they could keep updated and stored to be printed out as required.  Since continuity of care is often lacking and many see a physician on an episodic basis, that physician is not familiar with their history.  Many patients, particularly those with complicated histories and several medications are not very precise in communicating their medical history and medications.  Indeed, after a lifetime in medical practice, I sometimes have difficulty in recalling details of my own medical history when confronted by a very busy (and businesslike) young man or woman, old enough to be my grandchild (? greatgrandchild).   

   As the population ages and a larger and larger proportion of the population is over the half century mark I think we have to take our health care into our own hands, unless we want to be quietly euthanized, obviously a satisfactory solution for that portion of the population who think it a burdon to keep us alive.
   So, I may decide to direct my efforts towards helping you to take care of your present and future health care needs, or I may just wind up this blog and start a new one on how to find first class food and world class theatre in or near London, Ontario.  It might be more fun!

Saturday 16 April 2016

A 'mess of pottage', or for those who don't understand, is the whole country going to pot?

  Esau sold his birthright to Jacob for a 'mess of pottage'.  Most folks understand that, but for those of you who don't  get it, the biblical  phrase has come to mean trading the valuable things in life for something that brings only temporary gratification.  
   Canada is in the process of doing exactly that in a number of ways, but the phrase is particularly fitting now that we are trading our birthright for a 'mess of pot'.  
   The headline in the Financial Post today, was as follows;
    "Medical Pot facing distributor turf war,"  
   That sounds to me much more like a Chicago daily's description of what's going on in Mobland than a respected newspaper's report on what is happening regarding 'medical' marijuana.  The term 'medical' in front of the marijuana, explains the mindset of those hoping to make their fortune in the legitimized 'drug business', by making a highly questionable enterprise respectable. Politicians, administridiots and others are licking their lips at the profits from a legalized, well taxed drug dealership.  Make it respectable and civil servants, administrators and politicians can make a fortune out of it - and come out smelling like a rose.  Heros like Bill Clinton, Obama and Trudeau can make their drug escapades look innocent and harmless and endear themselves to hundreds of thousands of druggy voters, who are simply following in the footsteps of their leaders.  
   Increasing pressure on physicians to prescribe 'medical marijuana' for a variety of real and phony complaints will ultimately result in a process of attrition where many overworked and over-stressed physicians will succumb to the patients' demands.  Somehow, everyone will manage to overlook the dangers of dope for a generation or two  The era of the demanding, google informed patient who thinks his google search is equivalent to his physician's MD degree is just beginning. 
   Aldous Huxley knew exactly what he was doing in 'Brave New World', when he dosed the whole population with Soma and Sex and kept the population appropriately docile and subservient.
   I wonder if Justin Trudeau ever read the book?  Any book?

If you are interested in pursuing such ideas further, let me know. Otherwise I'll move on to something more comfortable!

Tuesday 12 April 2016

The old GP ain't what s/he used to be.

   I went to see my family doctor today.  It was primarily because of a tiny sore on my earlobe about the size of a grain of rice, and because it was not healing, itching and had bled just a little, I thought it was time to have it biopsied.  The doctor had a look at it and because it had persisted agreed that it ought to be biopsied.  Now, when I was a general practitioner, I'd have injected a little local anesthetic and as soon as it was appropriately numb taken a punch biopsy.  A punch biopsy is a instrument that is like a ball point pen with the ballpoint retracted and a sharp edge.  A little twisting movement takes a core out of the lesion,  The core is sent to the pathologist for identification and to determine that there are no malignant cells.   The patient would have been out of the office in a quarter of an hour and would have had the pathology results in a couple of weeks.  The whole procedure would have cost the health care industry about $30 in the fee for service days, but because most group practices nowadays are paid on a capitation basis per year, any procedures such as the above are unpaid.  So there is no incentive for the GP to do many procedures, that are time consuming and involve possible liability risk and are unpaid, despite being within their sphere of competence.  Instead,such patients are referred on to already overbooked specialists to further lengthen their long waiting list.  Of course, this procedure that would have cost thirty dollars in the gp office ends up by costing much more in the specialist's.  Injections into the knee and other joints in the fee for service system used to cost about twenty dollars and not only gave immediate treatment and saved the patients many months wait but saved the system much money.
   The capitation system pays physicians an annual fee for each patient they have  on their register.  The physician gets paid the same whether he sees  that patient once a year or once a week, whether he does a dozen procedures a year on a patient or none.  The only way to increase income is to have as many patients as allowable on the list, spend as little time as possible with each patient and to refer any procedure that takes time no  matter how competent you may be to do it yourself.   It must be obvious that the temptation to 'cherry-pick' one's practice as much as possible to healthy young families is great, since patients with multiple complaints require so much more time.  The administridiots have engineered a system that they thought would be cheaper than fee for service and provide as good care, thereby displaying their lack  of understanding and insight.  
   In case you are thinking the fee for service the decreasing number of family doc on that system gets I'll give you a few examples from the fee schedule.
   Minor assessment- $21.70
   Intermediate assmt-  $33.70
   Complete Physical Examination- $77.20  
   Proctoscopy - $8.70
   Housecall - $64
 I won't go on, but if you think the health care system hasn't been getting very good value from its family docs you should compare the above with a plumber's fees!

I'd like to hear your comments, if you have any.

Friday 8 April 2016

Cutting costs?

   One of the sub headlines in my national newspaper yelled out at me and the rest of the public, "Surgery longer at teaching hospitals".  It went on to quote a study that claimed on average patients undergoing surgery in a teaching hospital took 22% more time to complete their procedure.  The research doc and his team reviewed 700,000 surgeries over a ten year period from 2002 to 2012, 21% of them in  teaching hospitals and the rest in other hospitals.  He stated that  all 14 types of surgery took longer in the teaching hospitals and the more complex the operation the bigger the gap.  Dr. Vinden, the research leader said the following:  "It will be vitally important to identify at what point this longer duration due to teaching introduces excess patient risk, and to find ways to minimize this risk".   He apparently does not consider that the the patients may be at reduced risk.  Patients in teaching hospitals and teaching facilities frequently benefit from the level of supervision and the generous time allocation in a health care industry where they are frequently rushed through the system.  I do not accept Dr. Vinden's unsupported suggestion of poorer outcome in this circumstance, indeed, I think the opposite may be true.
     Outcome was not discussed, other than to suggest that previous research demonstrated duration of surgery with adverse outcome.  
     I have trained medical students and residents both as a practicing physician and as a full-time academic and I know how much time it takes to teach well.   This particularly applies to complicated procedural items.  Ultimately, poor teaching is much more expensive than good teaching, not to mention the distress and possible danger it causes patients, in the long run. .  Dr. Vinden looked at a tiny part of the picture, implies surgical teaching makes procedures riskier but goes on  to say outcome was outside the purview of his study.   During my early years of recruiting part-time and full time teachers,  I have found them usually to be generous of their time, conscientious in their efforts and in the case of the part-timers often dedicating their time for little or no re-imbursement.   Doctors  have to be trained, there is no way around this, and there is no way around the time it takes to do the job properly.   Poorly trained surgeons and physicians is not a solution. care industry, suck it up and provide adequate training resources, operating room time and faculty time.  And patients, because a huge component of your health care is provided by residents and other trainees, your welfare ultimately will depend on immaculate training.

If you care about how your health care providers are trained, and/or if you avoid seeing a trainee if you possibly can, tell me about it. 

Monday 4 April 2016

The Neonates won't Complain!


     Let me start by pointing 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.

 St. Joseph's Health Care in Hamilton is one of the premier health care centres in Canada, and is associated with McMaster Medical School.   Recently, a nurse I know told me that the institution had decided to replace some of the  highly specialized registered nurses (RN) of the level 2 pediatric intensive care unit (NICU) with far lesser trained registered practical nurses (RPN).  At first I  thought she must be mistaken because, if cuts have to be made, it is obvious to me that this is the last place the government should be cutting back.  She was completely correct.  Unfortunately, today many of the most important medical and nursing decisions are made by administrators who are neither physicians nor nurses, or if they are they are so out of touch with practice, that they are the least competent people to make such decisions.  

   While we spend without complaint,whatever is deemed necessary to scrape late term viable babies out of the womb       ( not dissimilar to dumping a new-born into a bucket of water),  and many other politically correct adventures, it seems we resent spending what it costs to preserve the most frail specimens of our species.   We have no trouble diverting funds to the care of inadequately screened foreign refugees, but cannot afford to care for the products of our own reproductive activities. The politicians and administridiots we have allowed to take over the Health Care Industry are reluctant to provide adequate care for those human beings who survive the perilous journey from womb to our indifferent world.   Shame on them and shame on us for our silence in the name of political correctness.  The decline continues.   After all, the politicians recognize that the neonates don't have a vote, so who can blame them!

Unfortunately, most Canadians don't seem to care either.

    We will end up with the Health Care System we deserve, but don't worry, the neonates won't complain.  

Any views on this topic?





Friday 1 April 2016

Social engineering a la 'Brave New World'.

     Since the myth was perpetuated that patients perceived need need for 'medical' marijuana actually equates with the need for medical marijuana things have been really going to pot!  Veterans' marijuana prescriptions have risen tenfold up to December 31, 2015.  Read that again, yes tenfold.   In addition, the government is actually paying for their pot .    From April Fools day 2015 to December 31 2015 the government has actually paid out $12.1 MILLION dollars on this.  Apart from the fact that this is bad medicine which encourages and perpetuates addiction, it is the height of irresponsibility.The fact that there are obviously many physicians buying into this requires extensive investigation of both the prescribers and the prescribees.  The current shocked reaction is certainly not the results of administrative concern about good medical practice, but about the bottom line.  $12.1 MILLION!   Soon every pot addict in  the country will find a good reason to have their 'soma' dose paid for by the State and if it were not for the economics of the situation the State would be glad to perpetuate a mental fog that would keep the folks  off their backs.
     I believe the  Department of Health needs to initiate an immediate investigation by an appropriately qualified team who understand the issues.
     I believe the College of Physicians of Ontario is obliged to look into this anomaly in prescribing to ascertain that the medical conditions being treated are real  and there is real  evidence that marijuana is an appropriate treatment. 
     There is a real problem with drug addiction in Canada.  The last thing we need is a government or profession that through a desire to be politically correct or for other reasons is handing out drugs.  
      If you or your children have not read 'Brave New World' by Aldous Huxley, I would urge you to do so.  Between that and '1984', one gets considerable insight into the sort of social engineering that is rampant today.

Comment if you have anything to say about this important topic.