Thursday 29 June 2017

The Honorary Doctor.

   It's about three years now since I retired (or is it four?).  I'd been practicing Medicine for about fifty-five years and I was never bored with my job.  Frustrated- yes often.  Exhausted- yes, very often.  In those days if you delivered a baby at three in the morning, you didn't get the next day off.  You were at rounds at eight am or if you were lucky nine.  I can remember an occasion when I  delivered two sisters on the same night, one at two am and the other just was ready soon after I had got back to sleep at five am.  I had normal office hours the next day, though I did ask one of my partners to make hospital  rounds on my patients that day.  Doctors did that for each  other and for their patients in those days.  I was no exception to  the rule, that was the standard.  Many doctors actually cared about their patients as they would about friends and indeed many patients were friends or became friends, though I'm not sure that is such a good idea. 
  I can honestly say, that I never feared a patient would sue me and I  never had a suit against me or even a threat of one.   Being a rather but not completely naive individual, I believed that I could present anything I had done in the area of patient management, as being done in the belief that it was in the best interests of the patient, and I believe my patients thought that too.  We were on the same side, I believed I was acting in their best interests and so did they.  If I was worried about something I had done, or something I had not done, I discussed it with my patient.  I thought they would think I was an idiot when in fact they thought, correctly, that I cared.  Sounds pretty corny, eh?  But in an era where doctors were quitting practice because their insurance overhead was so high, the Canadian Medical Protective insurance informed me that they would continue my coverage without further premiums to me as they had never had to provide service to me.   By the way, not long after that, they discontinued this practice because paying members objected to the practice, not recognizing that we, the lifelong suit free practitioners were subsidizing them, not the other way around.   
   I was a competent though not particularly scientifically smart doctor, but I knew the areas where I was exceptional and those where I needed specialist colleagues to help me out.  Even the relationship between the specialist and the GP was very different then.   I recognized early on, that the technical knowledge of my specialist colleagues far exceeded my own.  Many of them had spent enough time doing general practice to have considerable insight into the myriad problems it presented.  Indeed, it was often the catalyst that encouraged them to specialize.  I developed a network of specially competent specialist colleagues in my early days of practice in Regina to whom I referred patients, but whose brains were mine to pick when I needed to.   So, I would call my colleague about a puzzling case, (No multi-level answering service if he was not there, just leave your number and he will call you back - and by God, he did, even if it was after supper!)   The conversation would go like this"
  Hey, I saw this patient today, she had A + B +C +D.  I was a bit worried that she might have  something more than E going on. Do you need to see her ?  
  He might say did you do E +F +G?  If they are okay just carry on with the treatment you prescribed  otherwise I better see her.
  All this was done without any recompense to the  GP or the Specialist.  
  It was a part of professional etiquette which was done as a favour.  Note both the GP and the patient were the recipients of the favour.  
   Something that might require two or more consultations and taking weeks (or months) of waiting for appointments, were dealt with, without recompense by two committed physicians over the phone.  
   I guess the folks just didn't know when they were well off!!
   No wonder the health care system is going bust!!
   I didn't even get started on the Honorary Doctor, I guess you'll just have to come back - or not!

Saturday 24 June 2017

Hormone replacement therapy and breast cancer/heart risk.

   When I started practice, way back in the dark ages, many women were on long term hormone replacement (HRT) therapy for years.  It was regarded as some sort of 'elixir of life' which protected its users from many of the consequences of growing older, including heart disease, vaginal atrophy, vascular instability resulting in hot flashes, palpitation and generally feeling unwell.  I believed then, as I do now, that it is appropriate to use HRT for a time in woman, who are symptomatic, where there is no contraindication.  In 2002, in a study called the Women's Health Initiative (WHI) the estrogen-progestin trial was stopped early as a result of an initial results press release citing an increase in breast cancer and increase of heart attacks in the treated group. Now Dr. Robert Langer, the lead investigator in the study states the report was written in secret by a small group of study executives and resulted in "misinformation and hysteria". Langer further stated that the study results were not statistically significant for breast cancer or cardiac harm, that there was some increase in venous blood clots but there was a reduction in hip fractures.  He states the study results were not adjusted for pre-existing diseases or treatments and that there was an unusually low rate of breast cancer in the placebo group(The controls).  Further, he states that the trial was designed to focus on long term hormone therapy to prevent chronic disease in women over the age of sixty, but the results were generalized to younger women on short-term therapy for menopause.  Later analysis of the study data showed that these younger women had an absolute risk of twelve (12) adverse events per ten thousand women (10,000), less than a third of the risk noted among women of age seventy to seventy-nine, as well as fewer cancers, fractures and deaths from any cause compared to the placebo group.
Langer states the press release favoured "fear and sensationalism over science".  
   Medical consensus has come around to supporting short-term hormone therapy for symptomatic menopausal women, though as a result of the bad press many doctors are apprehensive to prescribe it. Some specialists are more strongly in favour of prescribing HRT and a study published in 2013 estimated as many as 91,610 American women died prematurely between 2002 and 2012 as a result of avoiding estrogen therapy.
   In practice, my policy was to treat symptomatic woman with hormone replacement therapy after sharing as much information as we had at the time, if they wished to proceed despite the possible minimal risks.  Many had such severe symptoms and such severe an effect on  their quality of life that they were in absolutely no doubt in opting for treatment.   When their symptoms resolved we tapered the treatment as tolerated.  Of course continued careful observation is of prime importance but until the answers are all in, informing the patients as accurately as possible of what appears to be the minimal risks of symptomatic short term treatment and allowing the patient to decide whether to proceed or not would seem to be the appropriate approach.   Long term treatment is inappropriate with the current state of knowledge

Thursday 15 June 2017

OMA Advice ?.

  Below is a recent communication I have received from the OMA.   I have nothing against homosexuals, nor against any other self-interest group, but I do have something against so-called professional organizations who put their sanctimonious politically correct causes ahead of their paying members struggle for survival.  That's what is going on in Ontario.
   I believe people have a right to do whatever they like as long as they are not hurting someone, but gimme a break, I don't even go on heterosexual pride marches, though I haven't had any invitations to. 
   Perhaps the new executive will direct their attention to relevant. business.   The inmates have been running the asylum for too long!!  The OMA has been doing a poor job for too long. 
From: Ontario Medical Association
Sent: June 12, 2017 12:47 PM
To: Stanley G Smith
Subject: 2017 Toronto Pride Parade: 6th Annual Ontario Doctors and Allies Pride March

2017 Toronto Pride Parade: 6th Annual Ontario Doctors and Allies Pride March
Dear Ontario Physicians, Resident Doctors and Medical Students:
Please join a group of Lesbian Gay Bisexual Transgendered Queer (LGBTQ) and allied physicians, resident doctors and future doctors to march in solidarity in the 2017 Toronto Pride Parade!        
Goals of the event:
1.    To combat homophobia within the medical community and society at large.
2.    To show the public that there are outspoken LGBTQ physicians and physician allies, and help attract media attention to this important issue.  
3.    To have fun!          
On June 25, 2017, please march with us! We will be meeting on Bloor Street East between Church Street and Ted Rogers Way at approximately 1:00 p.m. (exact time and location to be confirmed, visit our Facebook page or email us in the days prior to the march). We will be dressing in hospital scrubs and stethoscopes. Bring a motivational sign and lots of energy! Interested individuals can RSVP by visiting our Facebook event page or by emailing
Looking forward to seeing you at the parade!
LGBTQ Doctors and Allies
The Ontario Medical Association (OMA) administers the distribution of communications for its various Constituency Groups, and therefore the views and the opinions expressed in this communication may not reflect the views, policies, and opinions of the OMA.  The OMA does not warrant the accuracy, timeliness, or completeness of the information contained in this communication, nor does it accept any responsibility for its contents.

Forget 'Assisted Suicide', Bring on the 'MAID'.

   Life was simple when I was a  young doctor.    I knew exactly what society expected and demanded of me and I knew exactly what my duty was to both society and myself.  It was easy, my responsibility was protect and extend the life of my patients and where I could not cure the disease or maintain life, to relieve pain and suffering to the extent that my skills would allow.  Medicine was about life and how to make it as livable and free from suffering as possible.  Most of the people I knew thought the same way and that is why they chose medicine as a career.  Not Law, not Accountancy, not political science.  Medicine.  I thought it was a noble profession and so did most of my classmates. You may think this presumptuous and perhaps it was, but somehow and for whatever idyllic misconceptions we had, it seemed to work out very well.  Don't get me wrong, there were always rogues and rascals in my profession, as in any walk of life, but they were a small percentage of the whole and after a lifetime of medicine, I still believe, as I always did that 5-10% of the profession caused 95% of the problems.  I continue to believe, that the objective of most physicians is to prolong healthy life, cure illness, where possible and relieve suffering when cure is not possible.  It was impossible to believe that the state had an entirely different expectation of the role of physicians. Those expectations are related to politics and economics.
   The legislators in the land have now decided that part of a physicians duties include terminating patients.  I disagree. Since the dawn of modern medicine and indeed before that, the goals of medicine have been to restore health, prolong life and relieve suffering.  Although there are circumstances when treatment should be limited to the latter and the objective of prolonging life is no longer tenable, throughout the history of medicine terminating life has been the ultimate prohibition.  And, for physicians/nurses there it should remain.
   If society decides it wants to authorize a group to take a citizens life when the citizen requires it or demands it, that's none of my business.  Let them identify a group of technicians to do the deed, it really isn't very difficult.  When the expectation is that this should be a physician's duty and indeed that the physician who refuses should be penalized, I am outraged.   A technician could be trained to do this in a couple of months.  As someone who has spent much of his professional life training physicians, I know a thing or two about young people and young doctors.  Once a physician ceases to hold life as sacrosanct, the slippery slope begins.  We have seen the end of that slope in Auschwitz, in Buchenwald, in Treblinka, where individuals who had been perceived as reputable, brilliant physicians committed atrocious, heinous acts.  Just beneath the veneer of concern for aging sick patients, the politician/bureaucrats are acutely aware that the health care costs of the elderly are astronomical and growing rapidly.  An efficient method of reducing costs would be for assisted suicide (now known as Medical Assistance In Dying) to become the norm and in the not too distant future gently (for the moment) encourage it.  This piece of social engineering would let the politicians off the hook and help them conceal or at least make much less obvious that there is no alternative but to ration health care before it consumes the complete GDP.
   Canada, sanctimoniously proclaims its sympathy for all of mankind and all of life.  Unfortunately, this concern for the protection of life seems rather hypocritical when we look at the way we kill our own unborn.  I am not against abortion for any religious reason and I think there are circumstances when it is entirely justified.  I don't condone it when the fetus is a viable baby killed for convenience, as it often is.   In many instances it is merely a cruel and expensive method of birth control.   In fact, we have one of the highest abortion rates in the western world.  Still, free and unregulated abortion is so popular that governments are reluctant to place even the most logical restrictions on it.  So let us stop playing the pious protectors of life and human rights.  The administridiots have made it difficult to even discuss these issues dispassionately.
The Colleges of Physicians and Surgeons, the licensing bodies, have allowed themselves to be the willing tools of government, as has the Canadian Medical Association in Ontario and elsewhere.  When a group of physicians protested that their ethical  standards prevented them from assisting in patient suicide or even referring a patient to a 'terminator' and that the College was negating their Charter rights, here is what the College arrogantly responded:  "It is the colleges position that not only can it do so, (override the Physicians Charter rights) but that it should  do so"   Thus the College of Physicians and Surgeons of  Ontario is complicit with the government of Ontario in attempting to compel physicians to violate their consciences. 
   Let's pray that they fail!

Monday 5 June 2017

Medschool 2. Reflections of a dumb GP.


 Our preliminary lecture in anatomy was largely consumed by the Professor informing us that Anatomy was the most important subject that we would ever study and that a doctor without extensive knowledge of anatomy would simply be a butcher, or as a respected pathologist said of his specialty, without a deep understanding of pathology (and even more so anatomy) a surgeon is simply "A hewer of flesh and a drawer of blood'.  This was, of course, before I realized that regardless of the topic we were studying, its professor emphasized that his subject was the one essential topic in producing competent physicians.  He went on to explain to us that we would be divided into teams of six students and that each group would have a cadaver assigned to them.  We would spend the next year systemically dissecting the body in synchronization with the series of lectures and demonstrations we would receive in the lecture theatre.  The dissection room, a short walk from the lecture theatre was divided into alcoves, each with a centrally placed gurney on which lay a cadaver, covered with a sheet.  Each member of each team would have designated duties and in the paired appendages or organs there would be three students working on the left or the right side. After we had been instructed in the respect due to the cadavers we were to learn  from  and been given a list of the surgical instruments that we would require and the texts that we would need, we set out for the a quick tour of the dissection room.   

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   We walk out of the lecture theatre, excited and a little apprehensive  at the thought of meeting real dead bodies that shortly thereafter we would be dissecting.  The professor has dumped us and we are now being shepherded by our 'demonstrators', young newly graduated physicians usually specializing in surgery, who are fine tuning their anatomy knowledge and earning a few bucks at the same time.   As we walk out of the lecture theatre and outside of the building every one pulls out their cigarettes and lights up.  That was normal in those days when almost everyone smoked.  
   " Gotta fag?" I ask Maud, an older woman of about twenty eight, who was my new friend since sitting next to me at the lecture a little earlier, by virtue of her name starting with the same initial as mine.  I was to sit next to her at lectures for several years.   I was eighteen at the time.
      With most of us pulling on our cigarettes to allay our excitement and apprehension and to look cool ,we entered the dissecting roomroom.   This was a large room with alcoves each of which had a Gurney, head in towards the wall, so that of each team of six, three could work on each side simultaneously.   (Fortunately most parts of the human body are paired.)   The overwhelming stench of formaldehyde had most of us just a little queasy.  The bodies, tastefully covered by sheets last waiting for us to start dissecting them next week.  We didn't know their individual histories, but we knew where they came from.  Some noble individuals decided in advance that they wanted to donate their body to the medical school in the belief that it would help medical science, which was true.  Others were people who died in hospital or nursing homes or in the street and had no family or funds.  Some ended up in the dissecting room, where they were treated respectfully, made their contribution to science and were given a decent and dignified burial.
      Maud walked over to ' our' cadaver and gently pulled back the sheet. 
      "Not very old," she said, "quite good looking and not very old.  I wonder what he did in life?"
      "Okay," said another S in our group, "why don't we go across the road to Johnson Mooney's for a cup of coffee and a roll?  I'm really hungry.