Thursday 25 January 2018

Blood Tests and Cancer.

   Newly discovered blood tests, some scientists are excitedly telling us, could detect early stage cancer, before it is causing any symptoms or signs.  The testing, of course is in its infancy and its accuracy is not yet validated.  The blood detection tests were carried out on patients already known to have the disease and in the  first run appeared to have about a 70% accuracy rate in those known to have the disease.  There is a great deal to be learned regarding the reliability, the  specificity and sensitivity of these tests, but that is not what this blog is about.   I'll leave such questions to the statisticians and cancer specialists.  Let us assume that the tests will prove to be acceptably reliable,(what is that?) where should we go from there?   Should we be launching an extensive, expensive and possible harmful investigation on test positive patients who are otherwise well?  Or should we be directing those funds towards people who are already diagnosed and are awaiting confirmation of diagnosis and treatment?
   We may have to make some very difficult  decisions.  The question is can we afford to go on such fishing expeditions when people with very treatable conditions are not receiving adequate treatment within an acceptable time frame because of  cost to the system?  What do we do when we catch a small or medium sized fish, when we have people with clearly established disease, on lengthy waiting lists for the consultations and diagnostic tests and treatment that they urgently need.  Even after diagnosis many wait excessive time until treatment.  There are those who can't afford treatment when it is not covered by a private drug plan.   Under the claim that it is better medicine, physicians and patients are being urged to do fewer tests under a program called 'Choosing Wisely'.  Those responsible for the development of the program disclaim being motivated by financial considerations although there could be huge saving if the profession and public is convinced.  We are told that complete physical examinations, the inexpensive sine qua non of  the medical method since the dawn of modern medicine,  is no longer necessary.  It is too expensive. It's not clinically productive, they say.   Those who say that show a lack of understanding of the very nature of the patient physician relationship.  They prefer to do tests, even when  they are not quite sure what they mean and even when those tests may ultimately result in a further cascade of tests which may ultimately harm the patient.  Unfortunately, over diagnosis and over treatment are sometimes the results of screening tests and can result in significant  mental and physical harm occurring. 
  These are difficult questions to answer, but when already diagnosed patients with serious illnesses that have proven management regimens cannot be adequately treated due to lack of resources, is it appropriate, or even moral to go on an expensive fishing expedition, the results of which are presently unknown?
Let me know what you think.

Sunday 14 January 2018

How to fail your exams and sue your University!

       I still have nightmares occasionally when I dream I am setting out for my final medical exams in Trinity College, Dublin. I already had a job lined up in a food canning factory in England so I could support my wife and daughter while studying for the exam re-writes. Then I wake up in a cold sweat for a few moments before I am flooded with the relief of realizing it is just a nightmare. For the record I did pass my qualifying exam on the first writing but I did gain some insight into how a falling candidate would feel, particularly if in the exiguous financial condition I was in. The option of blaming the University program was unimaginable.
Today, almost every student who gets into medical school graduates. In my day it was quite different. As far as I can recall about twenty percent of candidates dropped out and another percentage had to repeat part or all of a year. Nobody sued the medical school, nobody thought of suing the medical school or university.
    Even as undergraduate medical students, we realized that there was great variation between teachers, some were highly entertaining despite the fact they they were not great teachers, others were extremely erudite but so dull that half the class fell asleep and there was everything in between. Most of us realized early on whether our various programs had weaknesses and as responsible doctors to be, many of us learned how to compensate for the deficiencies of the program. Physicians need to be resourceful and even in the era before everyone had a computer in their pocket and access to all the knowledge in the world, we usually knew what we had to do to make up for the deficiencies. I went to a good school but I recognized there were area where I needed some extra help and sought some private tuition.
    The case in the news at the moment is of an Ontario physician suing Western University for $11,000000 because he contends that the medical school didn't give him the education he needed to become certified as a specialist in medical microbiology. This was a five year residency program which the doctor claimed deteriorated rapidly while he was enrolled in it. He failed his specialty exam three times , in 2012, 2013 and 2014. Then instituted legal proceedings and Western is seeking to appeal a judge's ruling that allows the law suit to proceed.
  In this age in which almost everyone considers themselves a victim of one sort or another, it doesn't seem to occur to the doctor that even if most he has to say is accurate, that HE is responsible for his education. This is not a naive young student, but a man who has gone through the rigorous educational system to get an MD degree. There were numerous remedial steps he could have taken including taking some of his studies at another institution (not an unusual solution in numerically small programs), arranging to work under the supervision of a recognized expert in the area, independently planned study perhaps in coordination with a colleague in a similar specialty. The doctor/victim seems to feel that he is just a victim who never had control over his plight.
    If the Doctor succeeds in his efforts the face of medical education and indeed, of University education may be forever changed. All any failure has to do is sue the University and he/she may never have to work again! Throw in a suggestion of racism, gender discrimination or ageism and maybe we can all be victims.

Thursday 11 January 2018

Canadian Health Care Embarassment and administridiot hubris.

  It's a major embarrassment that Canada,a country that once enjoyed international recognition for its health care system was ranked last of eleven developed countries by the Commonwealth Fund. If you still think our service is acceptable read the report for yourself. You will be horrified. Our politicians have done an incredible job of' fooling most of the people most of the time'. Still, they are smart enough to vote themselves a special health care package.
Most criminal of their activities is their acceptance, even encouragement, of the dangerously long waiting lists. The average wait for treatment by a specialist from the date the patient was referred by the Family Doc has hit twenty (20) weeks. In 1993 it was about 9 weeks. The wait-times continue to increase. In some specialties the wait is much longer unless you have a life threatening emergency.
    I can think of no reason why people put up with this appalling situation other that they have been fooled into believing that we still have the excellent exemplary standards we once had. We are now an example of another kind.
    Countries like Australia, Britain, Germany, France and Switzerland have systems far superior to our own.
    One of the main reasons for our dismal failure in improving or even maintaining our system is the Canada Health Act, a brain child of Canadian Politicians , that is so rigid that it leaves no possibility of improvement. The Canada Health Act prevents the private sector from playing a significant role in health care delivery except when the government is totally unable to provide the service. They jealously guard their monopoly despite being well aware that all of the above countries use all the help they can get from the private sector, sometime involving co-payments or deductibles. The Canada Health Act prohibits this although it is successful and provision is made so that the poor receive the same benefits as others. People in  the above mentioned countries willingly buy supplemental insurance or make modest co-payments thereby injecting much needed funds into the health care system to everyone's benefit.

   Unfortunately the hubris of Canadian politicians of all ilk make them regard any help as a loss of face, although they have already sustained that by reducing one of the finest health care systems in the developed world into one of the poorest, but as long as they do not perceive it as costing them votes, who cares?
   Remember Ronald Reagan's quotation of the nine most terrifying words in the language: "I'm from the government and I'm here to help."  
   How right he was! 

Be sure to read next weeks Medicalmanes to learn about suing your University for not passing your exams!!