Killing patients:Euthanasia, terminators and others. .

   As of midnight next Tuesday, June 6th, Canadian physicians will be legally free to kill patients who chose to die.  The fact that this contravenes the oldest ethic of medicine since the time of Hippocrates, does not seem to interest the imperious legal autocrats one iota.  The urgency in the ranks of the liberal government to pass this legislation (bill C14) is only explicable on political terms and certainly not in terms of patient welfare. 
   The President of the Federation of Medical Regulatory Authorities of Canada, an organization  I hadn't heard of until now, said,
 "Our concern is that if physicians are unclear, the natural default will be to be hesitant to act, hesitant to deliver the service, and suffering patients won't be able to avail themselves of a service that is legally theirs to pursue."
    I found it difficult to understand Dr. Grant's concern about physicians being hesitant to deliver the death blow, from which there is no reversal, until I looked him up, to find he has a law degree, as well as being a physician.    
    The Canadian Medical Protective Association expects to involve its lawyers to help doctors determine a person's eligibility for termination, which it has euphemistically termed 'MAID' (medical aid in dying). Cute,eh?
     As I have stated before, if the public has determined that it wants euthanasia, it should be available.  It would take only a few months to train a corps of 'terminators' and if some physicians see fit to volunteer for the job, that's fine.  However, we will rue the day if killing patients will ever become part of the the job description of a physician.

Gender Identity and child abuse..

   Occasionally sanity peeks out of the trenches sufficiently to be noted by the inmates who have taken over the asylum so long ago that even they are beginning to think they are sane!  Some brave souls have put down their politically correct shields and exposed themselves to the screaming, increasingly dangerous loonies, who in the name of freedom believe that anyone who does not agree with their looney ideas should at least be silenced, but preferably locked up or even executed.  
   The American College of Pediatricians thought the situation sufficiently serious to issue a temporary statement immediately, while they work on the permanent version.  It's introduction reads as follows:

 The American College of Pediatricians urges educators and legislators to reject all policies that condition children to accept as normal a life of chemical and surgical impersonation of the opposite sex. Facts — not ideology — determine reality.

   Gender, is not a state of mind.  It is a hard biological fact determined by an individual's chromosomes, (XXor XY) a scientific fact, that only the scientifically very ignorant can dispute. A life on hormones that supress normal sexual (and in my opinion psychological) development is not a recipe for physical or mental normalcy.  I find it easy to understand how the ignorant idealogues can disregard obvious science in favour of their baseless beliefs, but how did they convince a substantial number of apparently normal people to buy into this?  I can only come to the sad conclusion that there are a lot more stupid people around than I believed.
   It is worth reading the American College of Pediatricians report, which is easily available, to see how these children are being abused - and that is what it is, child abuse. 
   A pity the American Psychiatric Association lacks the balls to come out with a similar sane statement, or would that be too much to ask?
Feel free to express your views, whether politically correct or not!  

Medicalization of Society: is everyone out there sick?

   Sometimes I wonder, is everybody out there sick?  Now, that may seem a strange question coming from someone who has made his living out of treating sick people and teaching others how to look after sick people.  However, I think I can count the number of times my siblings and I saw a doctor in our childhood and adolescence.  I don't believe it was because we were healthier than kids are today, I think it was because most parents could determine when their healthy kid with a cold was becoming a sick kid and needed something more than the home remedies that worked most of the time.  They recognized that a healthy kid with a stuffy nose or a mild sore throat was a healthy kid with a 'normal' affliction and they were usually right.  They were sufficiently confident in dealing with these minor disorders to recognize that their natural history was that they subsided within a few days.  Most of the time they did, but if they didn't then they wanted expert advice, then they called the doctor.  An old fashioned family doctor, which is what I was, knew most of his families and when a mother phoned up to see if she needed to bring the kid in, or if the doctor needed to make a home visit, the answer was usually apparent.  Often all that was needed was a word of advice, but sometimes the kid needed to be seen,  Those were the days when a patient could actually get to talk to the doc on the phone and when the patient needed to be seen the doc saw the patient, he or his staff didn't send the patient to the ER.  That was also in the days before the industrialization of medicine and before walk-in clinics and before it was considered quite normal to bring the child with 104 degrees temp to the emergency room, to crowd in with a couple of dozen patients all sneezing and coughing and dispersing their germs. Pretending that all the danger was neutralized by a little germicidal hand gel and occasionally a paper mask.  Unfortunately, along with the industrialization of medicine came the medicalization of society, that vital piece of social engineering that is necessary to make the industrialization work.  After all, if there are not enough labelled sick people around how are the Health Care Czars and their administridiots going to justify their outrageous salaries and bonuses.  New diagnoses, mental and physical have had to be generated to produce figures to make it look as though all of the population are in constant need of those services that so successfully win votes.  I am not proud of the role my own profession played in this.
   Turn on your television any mealtime and you will see that we are all ill.  Indigestion, stomach discomfort, constipation, diarrhea, low testosterone, lack of libido, incontinence (indeed, you are offered an amazing variety of catheters of all sizes, shapes and colours, more than on the urology wards!) and a myriad of other complaints that were once considered the minor disorders that normal healthy people deal with.  You are offered medications for your heart, lungs, joints, brain and any discomfort they can think of.   You are informed that no discomfort is acceptable and that there is a pill for everything.  You are told about their side effects by smiling actors walking through green meadows, including the occasional sudden death!   Once the entire popularization is diagnosed, labelled and on the appropriate medication, the government will decide what merits treatment and will be able to cherry-pick appropriate measurements  on  the basis of  cost and votes garnered.  Assisted suicide and legalized drugs will  be popular ways to keep some quiet or at least happy.  Most physicians  will be financially bullied into going along, and don't have what it takes to set medicine on the right course again, though I note that these days the women in medicine seem to have more balls.  Our pathetic professional organizations do little to  ameliorate the  situation.
    The decline continues. 

Foreign Medical Graduates.

   Nowadays, folks don't say 'foreign medical graduates', for some reason it is deemed to be politically incorrect.  I don't understand why, but then I don't understand why much of what is politically incorrect today is deemed to be so.  Foreign medical graduates have a new title nowadays, they are called 'international medical graduates' because foreign is somehow deemed to be demeaning.  Well, let me tell you something, being a foreign medical graduate (FMG) myself, I was rather proud of the title.  First of all, my medical school was producing doctors, scientists and educated graduates before Canada was a country.  Secondly, when I started practicing medicine in Canada in the early sixties, a huge proportion of the physicians and most of the medical culture came from Great Britain and Ireland, and to a lesser extent from other European centres of learning.  It was not until Abraham Flexner published his report in 1910 that both American and Canadian Universities developed modern medical curricula.  Before that much of the excellence in medical care flourished under the leadership of the foreign physicians.  
   So why is it that FMG became a less than flattering title that needed to be euphemized to 'international medical graduate'.  There are many excellent foreign medical graduates, there are also many who are mediocre or worse.  What does foreign actually mean?

Foreign:  located outside a particular place or country and especially outside your own country.
   
   In true Orwellian fashion, the social engineers try to conceal the fact that frequently the 'particular places or countries' have cultures and customs so different from our own, that what they have to offer patients is barely acceptable or even unacceptable.  Of course, the social engineers and administridiots are very favourably disposed to such FMG, because they depend on the largesse of the sponsoring bodies to have a licence to work and therefore have to do what they are told and go where they are told.  Their presence also makes it easier for the elected officials and their janissaries to manipulate and control the profession in ways that would be completely unacceptable.
   Meanwhile, there are Canadian graduates of Canadian universities who cannot obtain residency positions.  Let me repeat that.  There are graduates of Canadian medical schools who cannot get residency positions because of our governmental policies.  There are specialists who cannot get permanent positions, despite that fact that patients wait unconscionable times for urgent treatment.
   The decline continues and only the sick and suffering give a damn.

Am I nuts yet? Warfarin and me.

        As I walked past my TV the other day, I heard one of those twenty-something year old science columnists who frequently pose as medical experts, misinterpreting journal articles.  This 'expert' announced that a recent study has shown that being on the anticoagulant Warfarin may cause Alzheimers disease.  Having been on this medication for thirty-five years or so, I  slowed down long enough to ask myself, "am I nuts yet?"  I decided that I passed that test, in my own opinion, at least.  Then I asked myself why  people are being inappropriately exposed to this potentially damaging information?  Some folks are not doing their jobs.         
     Atrial fibrillation is the commonest sustained cardiac arrhythmia in this part of the  world.  The incidence increases greatly after the age of  65 so as the population ages it is becoming much more common.  Untreated, folks with atrial fibrillation (A. Fib) are victims of  stroke  and other thrombo-embolic (clotting) disorders much more frequently than the general population.  Fortunately, treatment with appropriate anticoagulants greatly reduces the incidence of these catastrophes.  Warfarin, is the most time-tested of this category of drugs and no one could dispute its efficiency in dramatically reducing the complications of  A.Fib.   So, when I hear some semi-educated commentator sewing doubts in the minds of hundreds of  thousands of patients benefiting from this  medication on  the basis  of one poorly designed study, I wonder just how much  harm they are doing.   Don't think this won't affect compliance, an aspect of treatment that is delicate at the best of times.   Physicians spend a great deal of valuable time and effort convincing patients of the importance of taking this medication and the necessity of monitoring the coagulability of the blood on a regular basis.  The consequences of not taking it responsibly or discontinuing it can have very grave consequences.   So when I see or hear some pinhead (and sometimes the pinheads are physicians) speak authoritatively about something that they are just opining about, as though it were established fact, I am naturally upset.  How many patients are going to  stop taking their meds on account of the unreliable information they are being fed?  Have producers, broadcasters and publishers no responsibility to at least see that the information they are disseminating is accurate?  Obviously not.
    So I decided to take a look at the source of this information.  To cut to the chase, after reviewing the literature there are so many confounders that the conclusions of the only one journal article that suggests that there may be a relationship between the drug warfarin and Alzheimers, is a very weak one and certainly not one to merit any change in an acknowledged very effective treatment.  Some of the other studies do note some increase in cognitive problems in patients with A.Fib probably due to the cerebrvascular thromboembolic phenomena associated with the disease.  The evidence would seem to suggest the incidence is somewhat higher in patients whose coagulability was outside the therapeutic range that protects from clotting, rather than being related to the Warfarin.
     Bottom line:  I intend to keep taking my Warfarin as prescribed.  If I'm getting a little nutty, (cognitively impaired, in medical lingo)  I don't think it's from Warfarin. 

Wandering in the Negev.Pt 2

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       Once on the road again we started heading towards Dimona, a modern Israeli town with a 'secret' nuclear reactor.  I say secret in parentheses because absolutely everyone, Arab or Jew knew all about it, but when I  raised the issue they 'shushed' me, "It's a secret, we don't talk about it!" 

    Somewhere in this area we pulled off the road again, for one of those pilgrimages to a Bedouin spontaneous settlement that was virtually invisible from the road, and only after a considerable journey over rocky, uneven terrain, becomes identifiable, when you are a few feet from it.    M pointed out to us a stream that carried the raw sewage from Dimona.  He then pointed out the nearby well that was the water supply, mentioning that in the sandy soil seepage was very likely.  I asked him if the well water had ever been studied for bacteriologic content.  He said no.   He then showed us the  Nissan hut that had been the medical clinic when he was on his FM rural rotation, which he said he had built himself.   He described the difficulty in providing appropriate medical care to  women, who were only allowed to come to the clinic if accompanied by their husband, who remained present during the history and the physical examination. The clinic had been discontinued when he left, and apparently was to be permanently closed down.  The message being that the local people should go to Dimona, which is only a few miles away, where there was a modern well equipped clinic.   My conviction was and remains that this was because after he had left it was impossible to find another physician to practice under those restricted circumstances  He also pointed out that the ambulance would not leave the main road to pick someone up regardless of the severity of their condition.  
    We end up at a traditional Bedouin goat skin tent where we are invited in for tea.  We were seated around the in-tent fireplace where we were offered something to eat, which we politely declined, and were given the hot sweet tea that the Bedouin sit and talk and sip all evening, sometimes very strong bitter coffee was the alternative..  We sat talking for some time, the Sheik sitting reclining on comfortable woven mats that covered the concrete  floor of this communal tent, with their thick embroidered cushions.  His traditional keffiyeh framed his dark mustached face, the gray Western style suit he was wearing forming a strange contrast. Shortly thereafter, the Imam or holy man came into the tent to join us, and was greeted with great respect - everyone stood up and shook hands.  About eight or nine others sat around the fire, the older ones in traditional dress, the younger ones in jeans, but most wearing the traditional Arab headdress.   
      
An Amusing Exchange.
     As we had approached this settlement, I noted that the tents we were approaching were all black.  I wondered about this, because, in the desert, where the sun beats down all  day, surely the tents should have been  white, to reflect the heat and the light of the sun.  M. had introduced me as 'Professor Smith from Canada,' and of course all our conversation in both directions went through him.
     As our conversations drew to a conclusion the Sheik inquired as to whether there were any other questions I  would like to ask.   
      "Yes," I said, "I want to know why all the tents are black, when it would be much cooler to have white tents?"
         All of the occupants of the tent, both old and young, broke out into hilarious laughter.  It went on for quite a while.
        "What's so  funny?", I asked M.
        "Well,"  he said, a smile  on  his face, " the Sheik said , tell the Professor , that the tents are black because the goats are black!"
        After a while we took our leave, and after a long cross-country drive, over moon - like rocky terrain, we passed the Dimona power station and headed back to the road.

Water vapor and autocracy.

     It seems that the group of know-it-all autocrats who have been pushing "medical" and  other marijuana are indifferent as to whether folks smoke it, drink it, or suck it into any other orifice.  However, they are unequivocally committed to getting rid of the relatively harmless habit of sucking on a tube and inhaling water vapor called Vaping.  Despite the recent reassurances of relative harmlessness from the British Royal College of Physicians, the loonies are doing everything in their power to make Vaping so difficult that it will be easier to keep on smoking tobacco or marijuana.  These ideologue pinheads are so obsessed with anything that looks like smoking (except for "medical" marijuana, of course) that they insist it must be stamped out, even if it actually helps some people to quit smoking.   The feeble excuses proffered are the usual nanny state attempts to change behaviour.  "It will be an introductory influence to encourage people to start smoking  it will make smoking look acceptable, it will look cool,etc."   Look, if someone wants to smoke or indulge in any other unhealthy behavior despite knowing it's dangers they are going to do so.  When I was a young lad growing up in Dublin, the street urchins used to roll their own cigarettes from the dried out horse dung that littered the streets in those post war days when gasoline was unobtainable.  It smoked pretty well and they thought it looked pretty cool and they didn't need big business to convince them of it. 
     Let the vapers vape, you may just succeed in reducing lung cancer or COPD a little. 
     Social engineering can be dangerous.

Wanderings in the Negev Desert.

    It was in 1997 when I took a year of sabbatical after having been the chair of the Department of Family Medicine at the University  of Saskatchewan for two terms.  I spent half my sabbatical at Duke University in Durham, North Carolina, working with the stroke prevention unit, with Dr. David Macher and his colleagues.   I had been involved with a similar unit at the University of  Saskatchewan and was focused on  stroke prevention as applied to primary care.
     The second half of my sabbatical was spent in Israel at Ben Gurion University in Beer Sheva, the gateway to the Negev.  Historically an intriguing area, (you can read your bible if you want to know why) it was regarded as a bit of a backwoods then, apart from its outstanding university.  Extensive building was going on everywhere even then, and friends who  have visited since then tell me I wouldn't recognize it.  I was working as a visiting professor in the Department of Family Medicine and since the provision of health care in remote northern areas of Saskatchewan was provided under the umbrella of my department, one of my interests was in outreach care in the desert areas.    But more about all that later. 

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     It was after a departmental meeting when we were discussing issues of providing medical care in remote areas, that I was approached by Dr. Mahmoud Maroud , a senior resident in the department of family medicine at  Ben Gurion University.   His resident project was a study of medical care to patients living in remote places in the Negev desert.  He had heard my presentation regarding the role the department of family medicine played in developing medical care to mainly native people in Northern Saskatchewan.   
    Saskatchewan's 651,036 square kilometres of land area, (population less than a million) is smaller than only two states: Alaska, which is almost three times the size, and Texas, with a population of less than 20,000,000 at that time.  The Negev, on the other hand, is an area of 13,000 km squared, with about half a million population, about 25% of which are Bedouin.  Dr. Maroud, a Bedouin, observed that many of the issues in delivering health care to the native population in remote parts of Saskatchewan were similar to the issues of delivering health care to the remote desert Bedouin, despite the great difference in area served.   Half of of the Negev Bedouin lived in unrecognized villages in traditional Bedouin nomadic tent communities and half of them  lived in towns built for them by the Israeli government between 1960 and 1980.  Dr. Maroud, invited me to  accompany him on  his tour to visit and comment on Bedouin communities and their health care issues.   I enthusiastically accepted his offer and he informed me that he would contact me for his next foray into the desert.   I informed him that my wife and companion was interested in coming along and he responded by pointing out that this would be fine in most but not all of the places that we were to visit, emphasizing the dress code and a number of  other issues with which my wife and I are well familiar, that will make an accompanying woman's presence tolerable  in the Arab culture.
   Here my journal notes start:

 3.10pm phone rings at the apt.  It's Dr. Maroud, the Bedouin physician who arranged to pick us up this afternoon and show us the Bedouin way of life.  He is a tall, dark, handsome man who looks about fortyish,  dressed in modern style and spoke accent-less English.  I first met him at a meeting discussing a research project into the health of the Bedouin.  At that meeting it seemed to me that many of the issues facing those tribes were similar to  those faced by our Indian population.  He was impressed by my interest and suggested a visit to some of the surrounding Negev Bedouin communities, which I eagerly accepted.  I introduced him to Irene, and we both climbed into his small car to begin what was to be a most eventful and unusual day.  As we drove out onto the road from Omer towards Shoket Junction, he gave us some background information on the Bedouin.  There are approximately one hundred and ten thousand in the Negev, and another hundred and ten thousand in the north of Israel.  There are approximately  two and a half million in total, mostly in the surrounding arab countries, but extending as far as Cuba.  We could not imagine how they came to migrate there, but as the story unfolded we were later able to advance a theory as to  why that happened. 

  When we reached S.Junction we turned left and head to Leguia, and pulled off the main road onto a dirt road.   We seemed to be driving across oceans of sand across which no identifying landmarks could be seen and the idea did cross my mind that we could perish in the desert if the car broke down or worse. (That was in the days before everyone had mobile phones.)   M. pointed out to us some of the galvanized iron huts and tents on the one side of the road, which we would never have spotted if they were not pointed out to us by someone who knew where to look.  On the other side of the road were some new houses built by the Israeli government.  He commented that though the new houses looked lovely from the outside that the inside was not correspondingly furnished, but usually contained the furnishings typical of interior of the tent.  The new houses, known as planned settlements, had electricity and running water, while the old shanties have no such provisions, although many of them have small generators.  On the top of a hill we were standing near Mahmoud pointed out a fine, affluent home, and  informed us that was being built by one of the wealthy members of the tribe who had three wives. In fact, he said, many of the young men were reverting to having two or three wives if they could afford it. 

       I asked why some of the Bedouin have new homes insettlements (the so-called planned settlements), while others stay on in tents the old settlements?  Apparently, the issue is one of giving up ones land in exchange for resettlement, and according to M. there is pressure on the Bedouin to resettle.  The reason for this is ascribed to be 'security reasons'.  We then headed east toward Ksifr and then turned south across land where no life could be seen, unless trained eyes were there to point them out.  M. pointed out Bedouin tents that were almost invisible against the background of the rolling hills of sand and green.  The green, I was later to find out is wheat, somehow shlept out of this sandy, stony terrain.  We continued up a meandering stony path, which I wondered if the car would ever negotiate, despite M's obvious familiarity with the land.  finally we arrived at the high point, overlooking several Bedouin tents.  Out of nowhere a white car appeared, a menacing Arab behind the wheel.  M indicated to me that I should lower the window, and started talking to the driver in Arabic.  Once he identified himself as a fellow Bedu, the animosity vanished instantly, and the man came around and shook his hand, ignoring me.  M. showed us some olive trees, explaining to us that the Bedouin don't usually grow trees but the land ownership act stipulates that if there are trees growing on the land it can't be appropriated.  He also explained to us the manner in which the B.build permanent structures inside the tents, another safeguard against land appropriation.  We continued driving over this harsh terrain, pitted, rutted, uneven terrain, over mounds of rocky sandy earth that I was sure the car could not negotiate, picturing the undercarriage hung up on some huge knoll.  M. however seemed to have no such worries, seemed to know every inch of the terrain and traversed it with complete confidence, everywhere pointing out with obvious pleasure Bedouin tents invisible to the casual eye.  Back onto a road where we drove to another resettlement road, where beyond the new dwellings, some of which look very attractive was an impressive looking mosque.  We stopped to look at it, and I asked M. if I could take a photograph.  "Of course!" he answered.  I pulled out my camera and took a photograph.  I was just getting back into the car when a rather aggressive young Arab came over to ask what we we wanted.  Again M. responded in the Bedouin dialect, introducing himself.  The man asked in Arabic (I confirmed this with M. later) "Are you Bedouin?"  M answered in the affirmative, entering into a short discussion.  After which much shaking of hands (including mine!) and friendly farewells.  Again, I don't think I would have felt very comfortable stumbling into this by myself. I asked M. what would have happened if he wasn't there, he answered that we would have just been told to move on.

       " Where do you think the money came from for this mosque," he asked me.

       "Where?" I asked.

       "From fundamentalist countries, Iran, Iraq, they are trying to foster fundamentalism among young Bedouin.  The Bedouin are traditionally non political, but there is some fundamentalism arising among the young people, who feel their needs are not being met and they are in danger of losing their land."

       We pulled out towards the road again.

       "See how far the school is from the village?" he asked, "why do you think that is?"

       "I don't know," I answered.

       "It's because the teachers don't feel safe with the school being right in the village," he said, "in the case of any trouble the school could not become a fortress.  "There is the  Kupat Cholim clinic, also quite far from the village for the same reasons." He pointed out the medical clinic to me.   It looked looked nice and modern and clean, but there was nothing going on in it.

Watch here for episode two next week!