Saturday 27 August 2016

Negev ramblings. Pt 4.


Physicians and Patients,
Life changing stories of Primary care.
University of Wisconsin Press.
Is the name of the book, and to my surprise is still available.  (a niece who saw a copy in my house wrote to the Press and was able to get a copy!)
Jeff Borkan, a member of the Department of Family Medicine, was an editor of this book in the making and asked me would I recount one or two stories for the book.  It so happened, that during the first part of my sabbatical at Duke University I had taken a writing class, so I was quite enthusiastic to test out my newly enhanced writing skills.  I wrote two patient stories that in due course I sent off to Jeff entitled - The Alternative Patient, and The Next Generation, both of which were published in the book.

Thur 16th Feb.1996
       I took the day off and Irene and I drove to Tel Aviv, only about an hour away to drive from B.Sheva.  Unbelievable how small this country is in the huge Middle East, and how the Arabs resent its creativity, prosperity and industry and would, for the most part like nothing better than to wipe it off the face of the earth. Walked around down town looking at the buildings, the people and the shops.  Some turkey backed into my car downtown, trying to turn in a street about 3 feet wide with cars parked on each side. Since there was no damage done to either car we parted amicably after a polite exchange.  We drove down to the seashore along the coast road and then parked and walked up to Ben Yahuda St. where we found some very nice restaurants and settled on one called Bebeles, and enjoyed a very good 'typical Askenazi Jewish' meal including chopped liver, fried kreplach, cabbage rolls, tzimas and salad. We were getting a little tired of hummus, tahini and falafel etc.

February 16, 1996
       Today we went to Ashkelon, this is where Delila cut off poor Samson's hair and drained his strength, where Herod was born, and where there was much evidence of places where crusaders and Romans had dwelt. Ashkelon has beautiful beaches, and a National Antiquities park, in which are some fascinating archeological finds including some remarkable sculptures. By this time it was getting dark, so I hoped my photos by flashlight would do them justice.  We will certainly have to go back by daylight and take another look at this area.  Earlier we walked along the beach coming to a little cluster of restaurants and shops, including a scuba rental store.  Went in and got some information re rentals etc. in case David comes.  Apparently they have weekend diving locally, as well as excursions elsewhere.  Drive to Beer Sheva took under an hour.   

Feb 17th
       Went to visit Nimrod Shosun and family at his Moshav (village) in the western Negev. The Moshav is called Dekal. Nimrod is a Family Physician who is a part-timer in the Dept of F.M.,and invited us to visit him as soon as I arrived in the Dept.  He lives in a moshav in the W Negev, about 50 km SW of Beer Sheva.  His wife is a nurse who works with him in the Kupat Cholim Clinic. He also looks after a couple of kibbutzim in the area.  In addition to their medical duties, both of them operate a mango and lemon farm.  The fields are behind their home, and the sandy soil in which they grow, requires irrigation and fertilization. Soon after we arrived Nimrod took us on a tour of the orchards and showed us with pride the lemon trees which bear fruit in all seasons, and the mango trees which give fruit in the fall.
       After a pleasant and prolonged lunch,Nimrod took us on a tour of the surrounding district, showing us a monument to the dead of the six day war.  Here, in the centre of the monument is a very tall observation tower.  A staircase winds upwards in tight recurrent spirals to an observation deck from which can be seen the meeting of three borders, Israel, Egypt and the Gaza Strip.   From here we headed out along the road to Gaza.  We soon arrived at the check-point and stood taking  photos of the crossing until the soldiers on guard came up to us and told us politely that we weren't allowed to take photos at this point and that there was a notice saying this.  For a while I wondered whether they were going to take the film away, but they didn't,  finishing up with 'have a nice day',in English.   Went back to the Shosun's and chatted for a while before taking off for home.
       An enjoyable and interesting day.

Sunday Feb 18th
       Work for a change.  Worked on the low back pain project.

Monday Feb 19th
       Left for Kibbutz Katura to visit Jeff  Borkan and wife  Suzanne. Drove by the Mizpa Ramon route, past the great Ramon Crater.  the crater is 40km long and 2-10km wide. The story of its formation is fascinating. Truly astounding scenery most of the way.  On the way down we passed Sde Boker, David Ben Gurion's Kibbutz in the Negev, to which Ben Gurion would retire for renewal for time to time, and to which he ultimately retired.  What a visionary he must have been!  At a time when Jerusalem and Tel Aviv were regarded by most as the most vital areas of the country, Ben Gurion already realized the vital importance of this part of the country and stated that Israel's future lay in the Negev. The scenery was spectacular and diverse.  The mountains of Jordan to our left as we drove south presented an ever changing kaleidoscope of colours, oranges, rust-browns, copper-greens, grays, pinks and reds.  To the right were the smaller ranges of the Judean Hills.  We stopped to admire the scenery, take some photographs, and have some lunch.  After lunch we continued on through the forest of spontaneous growing foccacia trees to Kibutz Ketura, opposite a date-palm oasis.  We drove in through the kibbutz gates, and I used one of my few Ivrit phrases, "speak English?"  Everyone did. So I asked, "where's Jeff's?"  We were pointed in the right direction anad made our way to Jeff"s .  The kibbutz surroundings were attractive and Jeff and Susanne, the couple we were visiting live in a small bungalow, together with their three children.  The living quarters are very small, and we were accommodated in a separate apt., which was probably one of the original kibbutz homes.  We had supper in the dining-room, a sparse meal, mainly of salads, cream cheese and herring, adequate but not appetizing, and short on the protein. We took a walk around the kibbutz, where one family had a pet camel tied up outside their house, which the children came out to feed.  The camel makes a strange roaring sound like a lion, and contrary to usual camel behaviour seemed very good-natured.

Tue 20
       We woke up at the crack of dawn to the sounds of the birds - and the trucks.  we grabbed a quick bite of breakfast, suspiciously reminiscent of the previous nights dinner, and headed out to a nearby kibbutz, where Jeff carries on a clinic. Irene went for a walk while Jeff and I saw patients at the clinic. The chair of the department had asked me to make observations and recommendations regarding the many rural clinics I visited and comment aout how they compared with Canadian rural practices. There was a considerable cross-section of clinical disorders, ranging from the minor to the major.  It was of interest to me that the Kibbutz employs a number Thai workers, mainly as fruit-pickers.  Jeff thought the official figures were 30,000 Thai workers.  Probably there were more, he thought. We saw a couple of them at the clinic.  It was very difficult as they spoke  only Thai.  The technique was to phone an interpreter, and once on the line the patient would relate the problems to the interpreter, who would then relay it to the doctor.  Then the phone would be passed back and forth, and the story relayed.  Time consuming and sometimes the translators skills aren't the  best, but it's the best that is available.
       After the clinic was over we drove to Eilat.  Following along the awesome Jordanian Mountains, the border a mere few hundred metres to our left, we arrived at the Red Sea and Eilat in a short while. We spent a while on the beach, then walked along the promenade, looking into various shops, then around back to our car.  We drove back up the Eilat Road back to Beer Sheva by the Dead Sea route.  Took us about two and a half hours to get home.

Wed 21 Feb.
       Went to work this am and picked up a bunch of mail that was dispatched express from home. It took 11 days to get here. In the mail was a sad note informing me of the death of my old school friend, Bernard Green.  The note was from his wife, with no return address.  I must try to get her address so I can send a note. Bernie and I were the closest of friends during our formative years, and were in and out of many scrapes.

Monday 22 August 2016

The Limousine Liberals and the walking wounded.

   Health Minister Jane Philpott should be ashamed of herself.  At a time when the health care services are crumbling, when patients are on waiting lists for obscenely lengthy periods, when doctors,and nurses are stretched to a greater length than Ms. Philpott's limo, she spent thousands of taxpayer dollars in totally thoughtless extravagance.  A first class taxi would have cost a fraction of the amount she spent.  The fact that the owner of the limo service was an active supporter of Ms. Philpott and a long term Liberal supporter surely played a part.    On one day, (July 12th), she spent almost $2000 on relatively local travel and repeated the performance on a number of occasions, presumably until she was caught with her hand in the 'Carpott!). After failing to lie her way out of the situation,only then did Philpott acknowledge that the expenses were 'inappropriate' and mirabile dictu, offered to reimburse the unfortunate tax-payer for part (not all) of the expense.  Most troublesome is the fact that the recipient of these excessive fees was to someone who had actively supported her election and is a long time liberal supporter.   It is unfortunate that someone who is in charge of health care in this country sets an example to all of her janissaries, in irresponsibility.  A very significant part of our health care budget goes not to health care, but to the politicians and their underlings who administrate it so poorly.  
   Let's stop wasting health care dollars and direct them from the limousine liberals to the walking wounded!

Thursday 18 August 2016

The annual checkup and the self altering Electronic Medical Record.

   A few folks who read my blog (and only a few folks read my blog!) mentioned to me that they found my articles of a couple of months ago on being responsible for having one's own up to date medical and medication history documented and how to produce and productively use that documentation, very helpful.  If you haven't read those blogs, read them before reading on.  The digitization of medical history- taking has moved the art of collecting as much relevant  information about the patient and his/her complaints in order to understand and diagnose the illness to something quite different.  
   Designed by a systems engineer turned physician, the Problem Oriented Medical Record was originally conceived of as a means to logically define and number the patient's problems in a systematic organized manner, so that each numbered problem had a narrative that could be easily followed, together with its management and outcome.  Instead, instead, the EMR has increasingly become a tool for administrators and politicians to gather information for their use, that allows them to control the health care industry in a manner that they feel will  win them the most votes.  In fact, they attribute the vital interaction between the patient and physician as being so unimportant that they are actively striving to eliminate the inexpensive complete history and physical examination from which that problem list is developed from the fee schedule altogether, in the interest of saving a few bucks.  That is unfortunate, because it is during these consultations that the patient's medical and life circumstances are best discussed and the Problem List discussed.  The careful examination of that list is what indicates to the physician what further investigations are required and indeed, allowed the physician and patient to go on to that process the administridiots have given the buzz-words of "Choosing Wisely" as though that were something new.  Most of the "Choosing unwisely" is the result of excessive tests, generated from the necessity of physicians to defend themselves from the medico-legal lottery and the lawyers who profit from it. The information gathered in the course of the 'annual checkup' that was considered so valuable by both the patient and the physician, has become devalued by the expensive high tech commodities that so dazzle the folks today.  Now patient's most frequent complaint is they don't have enough time to tell the doctor about their complaints.  Some folks tell me, "I'm only allowed to tell the doctor about one complaint! Make another appointment if you have a second one!"  The annual physical was the time to tell the doctor about ALL the complaints.  that was what it was all about!   
   Tests are not any replacement for adequate history taking and examination. I used to tell my students and medical residents that by the time you have finished talking to the patient and taking the history and before even starting the physical examination, if you don't have a pretty good idea of what you are dealing with, go back and get more information. The tests and other investigations were to confirm or refute the hypothetical diagnosis, not a fishing expedition to see what one could find.
   Recently, a friend of mine who had a significant past medical history, presented at the emergency room with a significant but non life-threatening condition. She commented on the benefit of having her self prepared documentation as per my recent blog, in the following manner:
   "They really don't have time to take a proper history,they are so busy,"she said, excusing them.  " I'm not quite sure whether they were students or interns or what. They did take a cursory history,.  One seemed quite interested and the other was yawning away, while the first one was typing away and focused on the screen.  When I presented my written history, they both seemed impressed and the one a the keyboard asked, how did you learn to do this?  Can I keep it?"  She specifically mentioned that there was almost no eye contact during the whole interview.
    As the electronic medical record moves away from its specific focus on collecting information for improving medical care and sharing medical data among health care professionals and becomes increasingly a tool for measuring other things that administrators want to collect, it actually becomes an increasing barrier between the patient and physician. There is no doubt that physicians who use this technology spend more time typing and gazing at the computer screen and dealing with included data mining often not directly related to patient care and most agree that it  is more time consuming than the written record.
    A recent complaint from 100 doctors in  Nanaimo, BC who refused to use the exorbitantly expensive system that the hospital had introduced, was that the computer was changing their orders, drug doses and notes without even letting them know.  Not an acceptable situation.
    The design of electronic medical records need drastic overhauling with most of the input coming from those who use it daily for patient care and not from those who wish to use it as a business tool.  That requires a different system altogether.
 Let me know if you care about any of this stuff, otherwise I'll move on to something else!

Monday 15 August 2016

AED Plus Automated External Defibrillator for First Responders

    My son bought my wife and me a gift this week.  It is called an 'AED Plus Automated External Defibrillator' and is  for first responders.  It is designed for use by people with no medical or nursing experience and is simple to learn to  use.  The attached video illustrates just how easy this is.  So, if  I or my wife keel over, the survivor just has to  hook up the machine and miraculously, it talks you through the procedure, step by step.  It make all the decisions for you after it makes a cardiac analysis, which  takes just a few seconds.  Of course it helps to have the machine in a place where you can put your hands on it easily (not good to have to spend three minutes looking for the thing!) and it also helps if you have looked at the attached video a few times to immediately identify what's what, in the heat of the moment.  
   Nice to think one's kids have the old folks welfare at heart, (forgive the pun!) even if you are 80!
   Maybe everyone should have one.  What do you think?

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Saturday 6 August 2016

The Helpful Patient and the medical student.

   Apart from all the philosophical rhetoric, a good patient doctor relationship can have quite an unimaginable payoff.  I am going to  tell you a story to illustrate exactly what I  mean.
   One day, many many years ago, when  I was facing my final examinations to  become a physician,  I had to demonstrate my clinical prowess by actually taking a history and examining a patient and reporting on any physical examination abnormalities I discovered.  In those days, we actually talked to and examined a patient volunteer, not a simulated patient, not a model, not an interpretation of some photo or videotape.  In other words a real live  patient. Time was limited, so one had to establish some sort of rapport with the patient quite quickly, get an adequate history and proceed  with the physical examination, then write up one's findings.  You were not required to make a diagnosis in this particular test, its purpose was to evaluate history and physical examination skills.
   My patient was Mr. Murphy, a working class Irishman with some chronic disorders, who had been volunteering himself as a test patient for a few years, convinced that he was helping medical science, which indeed he was.  I introduced myself to him and we shook hands.
    " I'm a medical student so  thanks for seeing me.  I have to  take a history and then examine you, if that's alright".
   " Oh yes, doctor, that's fine, I've been doing that for a couple of years now".
   I started asking the appropriate questions, which he answered in a pleasant, rather roundabout way as the Irish are wont to do.  Between my questions, Mr Murphy would interject with some  questions about me which really had nothing to do with the case.  I answered him, and over the next  little while we developed a nice rapport, which nowadays folks like to call the "doctor - patient relationship".
   Then I commenced the physical examination.  His ears, nose and throat were normal.  His chest was a bit wheezy, but no  more than one would expect of a lifelong smoker.  Then I came to the abdominal examination. 
   "That's the part they have a little difficulty with, doctor," he smiled at me.
    He was a little on the fat side, but not really obese.  I poked around and poked around trying to get the landmarks I needed and started to get worried that I wouldn't distinguish anything.
    "They always say they have a little difficulty finding the lower margin of the liver,"  he said  encouragingly.
    "So am I, Mr. Murphy," I said apprehensively
    "Well, it's just a couple of inches below where your fingers are now," he said and added, "you'll have to dig in there quite a bit deeper than that, you're being too gentle".
    I moved my fingers down an inch or so and then dug deep into  his abdomen.  
   "I feel it now," I answered relieved.  "Am  I hurting you?"
   "Don't worry about that" he said, "you should measure how far it is below the rib with  your tape measure, that's how they like you to describe it."
    "Thank you so much," I said.
    "Think nothing of it," he  replied, then added with a grin, "they think  my spleen might be a bit enlarged too, but they're not so sure about that."
     We shook hands.  "Good luck  in  the exams, doctor," were his final words.
   How is that for an example of the benefits of a good doctor-patient relationship?

Thursday 4 August 2016

Doctors as terminators - death for convenience.,

 Doctors as terminators - death for convenience.,

   The public voice is demanding the right to medically  terminate life in a manner not encountered since the Third Reich.  In a similar manner we have started with those who have no voice.  The unborn baby and the fragile elderly.  The right to abortion in early pregnancy may be justifiable on numerous grounds, for health reasons or dire social reasons at a stage when the rapidly replicating embryonic cells bears little resemblance to a living child.  It was in an era in which birth control was unavailable, as in the Ireland I grew up in, or of imperfect reliability.  It is never justifiable as a matter of mere convenience.  As a result of increasing medical sophistication and decreasing concern regarding killing whatever was growing in the uterus, abortion was performed later and later in the pregnancy until it became acceptable to kill healthy viable babies in the womb.   Ultimately, society has come to accept abortion as a procedure of convenience and regard the life snuffed out as insignificant. This preamble leads into a recent headline in the National Post.
   "Refusal to reduce twin pregnancy sparks battle!"
    Reduce twin pregnancy in this case means to kill one of the twins in the womb. (Note the avoidance of the word 'kill' in Newspeak.) The doctor and the hospital involved (Mount Sinai, in Toronto) felt this was wrong and refused to terminate (kill) a healthy baby.  The mother stated she was disgusted and felt 'judged' (as indeed she should have been, but this is politically incorrect nowadays).  She found a lawyer, of course, and sued the hospital.  Outrageously, Mount Sinai hospital offered a settlement of $55,000 which the woman thought insufficient and refused.  
   I believe she should  have been offered nothing and strongly resent that health care dollars should be wasted this preposterous way.  I don't have religious convictions in  this area, but I do know the difference between right and wrong and killing a healthy baby 'in utero' is unquestionably wrong.  Rewarding this sort of behaviour sends a savage message that will undoubtedly continue to undermine our concept of what a health care system exists for.  The moral physician who refused to be a part of this deserves a commendation for refusing to let himself be turned into a terminator.  Instead he will be subject to criticism and conceivably other consequences. 
Let me hear your comments on this.