Wednesday 29 June 2016

Mind your Meds.

      Now that the provincial governments are legislating away the annual 'complete' history and physical examination under the pretense that it does more harm than good, you have to look after yourself a lot more than you used to.  Although the cleverly crafted 'Choosing Wisely' program has made some valid points about over-investigation and excessive testing, it has been put together with the purpose of saving health care dollars.  I have commented on this in the past and will do so again in the future. In the meantime, you are going to have to take responsibility for your own care in ways that you have not had to do in the past, if you  were using the system well and wisely. 
      For the most part, with healthy patients, the annual examination was not annual, it was biennial, triennial or less frequently that that.  People, with various health problems for which they needed information, re-assurance or treatment, often used the label so they would not feel silly 'for coming to the doctor for nothing'.  Physicians and nurses of my generation, spent a significant amount of time in educating patients about when to have a health consultation even if one wasn't ill at the time.  It was proudly and often pompously labelled and bragged about as the 'wellness model' by the administridiots who laboured mightily to establish themselves as innovators regarding something that had been going on in the medical and nursing professions for eons.  In any event, the annual exam was a time when many vital exchanges took place whether the patient was ill or not.  It was a time when the doctor got to  know the patient and the patient got to know the doctor.  It was a time when patients had an opportunity to ask doctors many questions and not all of them of immediate relevance.  It was a time when the doctor established a knowledge base that took into consideration medical history, family history, environmental and mental history and many other things that have a significant bearing on the patients personal and family issues.  The administrators don't understand all this stuff: they are not physicians or nurses, most of them have a financial background and not a medical one, and even those who do are usually so removed from medical practice and professionalism that they might as well not have.  They don't understand the conversation between physician and patient, that is a vital part of medical care and particularly the history and physical examination that is its foundation.   They don't understand how much effort it can take to sort out, evaluate and adjust a patient's medications.They certainly aren't going to pay for it.  So you better start preparing to do a lot of it yourself.
      I have previously written about the importance and convenience of preparing your own up to date medical history.  If you haven't read that previous blog, I  would recommend that you do it now, because it leads right into what I am going to  write next.  It is vital  to have an accurate and up to date list of your current medication as well the dose you take.  With our aging population, many people are on many medications (polypharmacy) and it becomes impossible for a physician or pharmacist let alone a patient to carry in their head the number and complexity of side effects possible.  Every drug has side-effects, a drug that has no side effects has no effects.
     So what can you do?
     Well, to start with, you need to establish a complete list of all the medications you are on and the dosage.
     When did you start it, when did you last change the dose?                          
     It really is impossible for you to keep a record of possible interactions in your head, so you have got to have access to appropriate software to examine all the possibilities.  You have three choices:
     1. Ask your friendly family physician to run your meds through whatever software s/he uses and to go over the results and give you a printout.
     2. Do above with your friendly pharmacist.
     3. Get yourself a copy of one of the many medication interaction programs that are available free from the internet and do the job yourself.  Anything you have difficulty understanding you can discuss with your doctor.  (He can still get a modest fee for that, for the moment).
     4. Anything significant that you do find, you can communicate to your physician either at  a scheduled appointment or by mail, just in case it happened to  slip between the cracks.
     Bear in mind that certain foodstuffs can also  interact with drugs.and we will deal with that later.

Thursday 23 June 2016

Despots & Dictators in Health Care.

Vanessa Burkoski is a nurse, here in London Ontario, who had the temerity to speak out about changes in the health system that put patients across Ontario in harms way.   She was a chief nurse and an advisor to three provincial ministers of health, and she spoke out against practices that she believed would put patients at risk. The results, she was fired.  But by all reports, not before Murray Glendining, the CEO of London Health Sciences, tried to buy her off.  She refused to be bought off and go quietly, so she was fired.  Let's give you that again.  MURRAY GLENDINING, THE CEO OF LONDON HEALTH SCIENCES CENTRE FIRED A CHIEF NURSE WITH AN OUTSTANDING RECORD BECAUSE SHE REPORTED ON DEFICIENCIES ADMINISTRATORS WERE INTRODUCING INTO THE SYSTEM THAT SHE BELIEVES WILL HURT PATIENTS!!  I thought that was her job! 

   So, who do you think should be fired?

Here is the letter that this administridiot had the unmitigated gall and brazen effrontery to write to try to justify his action:


   LHSC_ExecOffice Broadcast
  (LHSC_ExecOffice Broadcast) 06/20/16 > As many of you will by now have read in the media, Vanessa Burkoski is no longer with LHSC. We are committed to maintaining confidentiality and therefore do not discuss personnel matters relating to current or former employees. As a result, in circumstances such as this, we are unable to provide staff with further context.      
  I do feel compelled to address the comments made in the media questioning LHSC?s commitment to safety. I would like to convey
to you, on behalf of the entire senior leadership team, that staff and patient safety has been - and remains - an overriding priority at LHSC and this commitment is unwavering. Allegations to the contrary are completely inaccurate and disappointing. Much excellent work has been achieved over the past few years by all of you to strengthen quality, safety and the patient experience at LHSC even when facing significant funding challenges. Our continued focus is to build on the strong work of the past several years at LHSC, by achieving the goals of our 2016 - 2018 Transitional Plan, which specifically aims to further enhance quality, safety and the patient experience through implementation of robust and standardized planning and performance tracking processes over the next two years. An additional element of the Transitional Plan is strengthened communications processes. Our goal is to engage each of you more routinely, to recognize the great work you do, to hear and address your ideas and concerns,
and to ensure you understand LHSC?s goals, how they align with
our mission, and how you can contribute to them.  We will soon announce a new organizational leadership structure designed to help achieve the goals of the Transitional Plan and to further build upon the strong standards in place today for our nursing
and allied health professionals.  We thank you in advance for your understanding and patience in this time of transition.  Sincerely,  Murray Glendining

President and Chief Executive Officer
London Health Sciences Centre

  Burkoski spoke to The Free Press about what she says happened — she says she was called into Glendining’s office June 8 to discuss the report produced by RNAO, (Registered Nurses Association of Ontario) called Mind the Safety Gap. Essentially, this dealt with laying off nurses and replacing others with lesser qualified, lesser paid nursing assistants.

   Burkoski said, she refused to resign with a cash settlement.
“After three requests for my gracious exit, they asked me if I understood what a termination meant in terms of (my) reputation,” she said.
Glendining fired her and then circulated the letter quoted above.

The Registered Nurses Association of Ontario says the chief executive of London’s largest hospital sacked its chief nurse because she was the public face of a report critical of hospitals. Here’s a summary of the report:

“In an effort to cut costs, health organizations across the province are replacing registered nurses with less qualified care providers . . . the RN share of the nursing work force has dropped significantly in recent years. This has left Ontario’s health system unprepared to meet rising levels of acuity in hospitals and in the community, and put the safety of Ontarians at risk.”
So much for transparency in health care. It is encouraging that this woman had the fortitude to stick by her principles and not let the administridiots bribe their way out of this.
Unfortunately, I don't know many physicians who would respond as courageously.
Let me know what you think.

Tuesday 21 June 2016

In memoriam.

  Last week one of my oldest friends 'bit the dust'.  I'm eighty myself so I'm getting used to it.  Still, it doesn't get any easier.
    I attended his ninetieth birthday party in Saskatchewan a couple of years ago and when he picked me up at the airport, he seemed to me to have maintained that posture and briskness of manner that matched his precise British accent,
(Ever since she was a little girl my daughter said he reminded her of Roger Moore, of "The Saint" fame".)
   We arrived in Canada with our families within weeks of each other when I was in my mid twenties and he was in his late thirties.  We became more than friends, we became family.  We were Uncle and Auntie to his children and vice versa.  We joined a large clinic and as a new and inexperienced physician I frequently consulted with him and drew on his experience.
   He has been a paratrooper in WW2, and was dropped in Norway, in time to participate in the liberation of that country from the Nazis.  There he met his wife to be. He must have been all of nineteen.  He was a modest man and although I had known him for many years it was only when I visited on this occasion that I extracted some of the stories of his war time activities,
    He dealt with great tragedy in his life when his eldest son was hit by a car and damaged  irretrievably.
     He was an icon of an age when breeding and education mattered.  He knew the classics, he knew music, he knew history.
     We used to speak to each other regularly.  He called me about a month ago, his voice no longer crisp and clear, and informed me that something had happened in the past week or so and he was afraid he would not be able to continue to live independently and look after himself.  His greatest fear.  I promised to keep in touch.   Within a week, I heard from the family to tell me that he had shuffled off this mortal coil. 
     I shall miss him greatly,as will many others.

Thursday 16 June 2016

Junk Science - all around us!

   A great deal of science today is Junk Science.  This is how the U.S. Department of Justice described it in 1985:

"The use of such invalid scientific evidence (commonly referred to as 'junk science') has resulted in findings of causation which simply cannot be justified or understood from the standpoint of the current state of credible scientific or medical knowledge."
   More contemporary definitions exist, but I don't think any describe the phenomenon better than the above.
   Frequently poorly designed research projects, funded by some body that has a vested interest in the results are twisted and thwarted to produce the desired results.  If they don't do that they often don't see the light of day.  Those results are often extrapolated to huge segments of the population to generate vast sums of money as in the 'gluten free' industry.  Only a tiny percentage of the population are gluten sensitive, but a very significant proportion think they are and generate vast sums for the purveyors of gluten free foods.  
   Junk science is pushed by the likes of Dr, Oz, whom the American Medical Association has never had the courage to take to task.  Many of the same ilk with no appropriate training or knowledge,present themselves as experts pushing junk science and spreading misinformation.  Even some highly trained physicians, in their efforts to simplify, oversimplify and do not present a very coherent explanation.
   Then, the Hollywood experts from DiCaprio to Clooney, most of whom do not even understand the basis of the junk science, take authoritarian positions and their word is taken as Gospel.  DiCaprio was in Calgary this past winter when a Chinook brought the temperature from well below 0 degr C upinto the high teens.   I heard DiCaprio in an interview state he has seen global warming in Calgary and everyone said they had never heard of such warming before.  I guess he only spoke to his Hollywood pals.  He couldn't have spoken to an Albertan.
   Politicians and their janissaries, love all this,of course.  They can often manipulate the data to justify their incompetence and to impose new taxes to benefit humanity.   
   There is probably no area in which junk science has had more influence than obesity.  When I walk into my local bookstore, there are shelves of books on the 'only diet' that really works.  Here are a few of the titles: Atkins Diet, Best Life Diet, Blood Type Diet, Glycemic Index Diet, Macrobiotic Diet, Mediterranean Diet, Grape Fruit Diet, Beverley Hills Diet, South Beach Diet, etc.,etc..
   Now, you know that if any one of these diets was really effective it would very quickly replace the others.  They continue to proliferate.
   Having treated overweight and obese patients for many years I have found that success was much more dependent on the motivation and persistence of the patient and their ability to make and maintain life style changes, than on any particular type of diet.  In other words, behaviour modification is an essential ingredient: there is no silver bullet, there is no magic potion.  The immutable equation holds.  More calories consumed than burned results in obesity.

Friday 10 June 2016

More medicine in the Desert Pt 3.

Mon Feb.13

       As treatment of obesity was an interest of mine for several years and I had established an obesity management program at University hospital  in Saskatoon, I was  asked to give a clinical presentation on this topic to the medical school faculty at Ben Gurion   The work was not so arduous that I could not take an afternoon off to get a little exercise and get away from the desk, to go to the Joe Alon Centre for Bedouin culture.   This is truly a remarkable centre founded by the Joe Alon foundation in commemoration of Joe, who was a pilot in the Israeli Air Force.  The term Bedouin is derived from the Arabic word 'Badu', which means desert dweller. They were desert nomads who lived by herding animals and small farming.  They roamed widely over the Arabian Peninsula.  The museum is an educational and interesting display of all aspects of Bedouin life and well worth a visit.  I learned many interesting details about Bedouin life.  Beautiful view with the 'Green Line' (the 1949 armistice borders) only a kilometer or two away.

       In the evening we went with Dr. Maroud on another Bedouin odyssey. First we went to the encampment that we had visited previously, and there after the appropriate introductions of the "professor", (me) we sat on our cotton mats cross-legged and partook of an excellent meal.  One of the bowls was lamb, which being one of the foods I particularly dislike, I discreetly avoided. Everything else was excellent and the whole meal was eaten with the fingers, and some bread rather like very thin pita, which useful in catching anything falling off the fingers and mopping up the juice.  Conversation was lively, with Mahmoud translating for me, and we reviewed the health care questionnaires we had decided on and discussed various aspects of it. Many of the Bedouins have three or four wives and although the 'enlightened' ones frown at this, and it was being discouraged, apparently it is regaining popularity among the younger ones.  They are largely fatalistic in their philosophy toward illness, and regard such things as being in the hands of Allah, and illness as a punishment for some sort of misdeed. However, in answering the questionnaire they also said if they or their children were ill, they would call a doctor.  Some also stated they would use a 'traditional' healer as well as modern medicine.  Following the meal I asked if I could  take some photographs.  The Sheik nodded approval, and I took some pictures and then M. took a few of me. The Sheik called me over, sat me down beside him and poured me some coffee - that strong, strong, very bitter coffee that the Bedouin drink as well as the strong sweet tea, which I like much better.  As we were doing this the Muezzin's call for prayer sounded and the tribe moved off, one by one, and Mahmoud and I went back to the car and took off for the next leg of the trip.  I was not quite sure what we were going to do next, some sort of meeting, and indeed it was.  M drove back to Laqiya, an unrecognized township of 8000 lying N of Beersheva, and we stopped at a little grocery store, where he seemed to  be well known.  The store was really just a large open room in a house, with an adjoining room which served as a store-room.  The two occupants of the room were young men, who sat huddled over a little open coal fire of the sort I saw the Bedouin use in their tents.  M. asked them a few questions about their dwellings - relatively new ones, and they complained profusely, in what I suspect was a well rehearsed way, about their lack of proper sewage, and how easily their home flooded if it rained and a few other things.  Then we went to a meeting in the offices of the Negev Education Association, an organization I was told, that was established to address the numerous social and educational problems facing the Negev Bedouins.  M. introduced me to two young men, one a teacher, the other a Dentist, trained I believe in Roumania.  The teacher was the spokesman, and although he apologized for his English, he did an excellent job of informing me of many of the problems that exist for the Negev Bedouin. This slight, pleasant looking young Arab man, couched his words carefully,and any criticisms of the Israeli government were carefully accompanied with numbers and facts i.e. numbers of drs/ clinics/ schools.  This soft sell continued for sometime and I wondered if I was being recruited for something, or being solicited for a donation.  No such thing took place. nevertheless, I felt I was listening to the new leadership of the Bedouin, young men who will assume increasing political power.  Every effort must be made to prevent them turning to fundamentalist sources for support, and this I have no doubt they will do if they do receive further preemptive support from Israeli sources.  I have no doubt that the extremist regimes are doing all in their power to recruit them.  We parted with traditional handshakes and farewells - I think I will be hearing from them further - at least from Maroud.    

    During the first part of my sabbatical at Duke, Irene and I  took an evening  course in creative writing.  We didn't learn much, but I think we may have taught the teacher a little and we met quite a few interesting people.  It did serve as a preparation for the next phase of things.  Soon after our arrival at Ben Gurion University, a young American Israeli member of the Department of Family Medicine was appointed as our liaison with the department.  His name is Jeff Borkan and he was a delightful host.   More about Jeff later, I mention this here only because on our first (or maybe second) meeting I hapened to mention to Jeff that we had taken a course in creative writing at Duke.  From there,the conversation went something like this:
   "That's very interesting, Stan" (and he actually sounded interested, you'll understand why in a minute).  I'm editing a book for the University of Wisconsin Press about Doctors and Patients, and I'm a bit hung up on getting the last few chapters completed.  Maybe you'd consider writing a chapter?"
     I must have said 'yes' too easily!
   "If you could do two chapters the book would be ready for publication"
     Some of us are naturally born suckers!!
    I have two chapters in that book.

Tuesday 7 June 2016

Penmanship and medicine.

   I've been a fountain pen collector for years now.  I love them and the older they are the more I love them.  I can  use a keyboard pretty well for an old guy and I must admit that I don't know whether my typing speed or my cursive writing speed is better, but  I can  tell you this, when it comes to getting your inner and deeper thoughts onto paper, there is no comparison.  Somehow, I have always felt that my brain connects directly with my fingers, which connect directly with my pen, which connects directly with the paper and leaves a living flowing deliciously colourful moist trail (of almost any colour) of my thoughts to gradually dry into a permanent record of  what transitorily flowed through my brain a short while before and would have been forever forgotten if it hadn't been thus captured.  A keyboard could never have captured that.
   Some time ago, a new member of the pen club that I have belonged to for almost twenty years, ( asked me why I  felt so passionately about writing cursively  and I related tha above opinion to her.  I added that so much was added to any experience by directly touching and feeling  that anything that got in the way diminishes the interpretation of the information.
   When asked to elaborate, I told her the following story from my early days as a young intern working in  the emergency room.  The patient had come in with a history of abdominal pain and I performed an appropriate physical extermination of the patient, including a rectal examination.  I came to  the conclusion that the patient need surgery and I called the surgeon on call.   He performed his physical examination and said to the patient that he had to do a rectal examination.
   "Dr. Smith just did a rectal examination," the poor patient pointed out.
   "The problem is," the surgeon said, "that Dr.Smith's index finger is not connected to my brain!".
    And that, is why the important, probing thoughts, the connections between the brain and the paper require the multidisciplinary skills of cursive writing, to adequately convey those thoughts.   The consequences of abandoning it will be detrimental.

Friday 3 June 2016

Marijuana, madness and medicine.

    Sun Life Insurance Company, a major Canadian life insurance company has just announced that it will treat cannabis users as non-smokers, thus reversing a long standing policy of treating them as smokers.  This will apply to both medical and recreational use.  There will however, be no change in the manner in which they load the premiums of smokers.  The company made an astonishing statement last week.
   "In our industry, we keep up to date with medical studies and our companies update their underwriting guidelines accordingly.  As a result, people who use marijuana are now assessed at non-smoker rates, unless they also use tobacco."
   In fact they do not keep up to date with medical studies, but just interpret them to their own advantage, much as the tobacco companies did before the evidence that they cause cancer was irrefutable.   It takes a long time to prove something even though commonsense points strongly in the direction.  Smoke from marijuana contains many of the same toxins and carcinogens as tobacco.
   Sun Life is obviously pandering to what it sees as a huge market, egged on by the philosophy and actions of our present government.  In addition to irresponsibly  encouraging a practice that both the American and British Lung Association regard as dangerous to lung health, Sun Life is deliberately ignoring the myriad other effects of marijuana, a mind altering drug.  It would seem that they have concluded that the huge increase in volume would more than compensate for the collateral damages resulting from automobile accidents and irresponsible acts while cognitively impaired.
   I hope the Medical and other Health Care Agencies will pursue this form of smoking with the same venom that they pursued cigarette and pipe smoking. Of course they won't, because now that the inmates are running the asylum, as the song says, 'Anything Goes'.
Hey, try speaking up some time and express an opinion, if you have one.