Thursday 20 February 2020

Reflections of a Dumb GP. Pt.2

There was more to being a medical student than just study. But fun, when you had no money and neither did your family, could sometimes be too expensive! Even more so when you had a girl friend and were planning to get married while still a student. Tuition fees were a constant concern but life wasn't all work and one needed a little money to function even very modestly.
My fiancee , was a self taught, talented pianist and I was a self taught untalented drummer. She was in great demand at parties and family gatherings in our courting days, so I had to do something. I started off by tapping on the piano, in the hope that it would drive everyone away, so that we could have what was called some "quality time" together. ('Quality time" to me meant getting rid of the rest of the family long enough to burn off some of the normal testosterone that every young man had coursing through his veins in those days when we thought there were only two sexes -little did we know!!). I continued drumming on every drummable surface, never expecting that it would later pay off and provide a means to help finance my way through medical school and to getting married.
A classmate of mine since high school days was a talented musician. He went on to become a very successful professional musician after having graduated from medical school. His mother had been a piano teacher, so he played piano almost from birth. Sometimes, when we were in high school, I went to his home to listen to him practicing a la Oscar Peterson. He had a drum kit in his music room and on occasion I would try to accompany him on the drums. He put up with my performance and even tried to improve it. He was well known in the Dublin music world, where he was professionally sought after and he knew Irene and I were hoping to make some money doing a gig or two around town. He recommended us to apply for a gig at the "Paradiso Restaurant and Night Club - where the stars dine!" He had played there in the past and they had approached him to return but he was busy with bigger,better engagements. He had recommended us.
"There's no way I am good enough for that," I said.
He laughed. "They won't know the difference!"
I applied and the manager interviewed. "Experience?"
"Lots," I lied. "I thought Ian (my friend) would have told you."
"And the pianist?"
"Oh, she and her family have just returned from living in Miami (true). She did many gigs there (untrue). She's good!"(true)
"OK, Monday night is quiet. I'll hire you for a one night audition and if it goes well I'll give you a three month contract."
It went well. We got the job at the Paradiso and played from eight pm to midnight five nights a week. After our nightly performance we would walk home, a forty-five minute walk as the public transport ceased at 11.30pm, so we could save the taxi fare. I had to be at medical rounds at nine am, mandatory for all second year medical students.
Guests often bought us a drink and as I had to work in the morning we declined after the first drink. The tuxedo clad manager drew us aside. He was Swiss, he was dignified looking and he was mean.
"You can't decline when guests want to buy you a drink," he barked indignantly.
"Well, I have to go to work in the morning, you know I'm a medical student, and I can't turn up with a hang-over."
"You have to accept when a customer offers you a drink." he replied.
"Okay, you can just give us some ginger ale or soda in an appropriate glass and we can sip on that."
"Yes, I can do that."
"You'll have to give us the cost the customer pays for the drink, of course."
He looked aghast. "I'm not going to do that!" he said.
"Then we won't accept." A thought occurred to me. "If you won't give us the cash, then you can give it to us in cigarettes," I said.
He agreed. For the next months, for the first time in my life I always had enough cigarettes.
The Paradiso was situated in the core of downtown 

Dublin and their sobriquet "Where the Stars Dine" turned out to have more than a grain of truth. Dublin was a great theatre city, so we did play for some of the performers and theatre crowd who drifted in after the show.
We carried on playing the Paradiso until the summer break, when we got an engagement at a very fancy hotel on the west coast of Ireland, in Waterville, Co Kerry, the site of the first transatlantic cable station from St. John, New Brunswick. It operated from 1884 until 1962 making real-time transatlantic communication possible.
A drummer friend who had his own small group was offered a summer season engagement at the Butler Arms Hotel, which he couldn't accept because of his job.
" They asked me if I could suggest anyone, so I gave them your name." he informed me.
I was more than grateful. If we got this job it might just cover my university fees and have a little left to go into the wedding fund.

Tuesday 11 February 2020

Family Medicine - RIP.

The fate of Family Medicine.

They say that Old Soldiers never die, they only fade away.
It's different with Family Doctors,
Old Family Docs never stop, they only lose their pay.
I can honestly say, that since my retirement at the age of 78, not a single week goes by without one, or often many more medical consultations. I carefully explain that I am no longer state of the art, that I no longer try to be state of the art and only follow medical progress in areas that particularly interest me. This deters no one from seeking my opinion, because when they consult me they are looking for advice other than mere medical expertise. Usually they are looking for something that before the 'Ten Minute (or less) Consult' most patients got from their family doc, a conversation with their doctor, an explanation of what they didn't understand or know, from someone who knew something about them and their background and consequently knew how to communicate with them.
The conversation often didn't take much time at all, because most patients used to have an annual history and physical examination during which the physician became familiar with the patient's medical history and background. The physician got to know a little about the patient's life style and preferences and often gave some advice that the patient found useful.  This created a bond that encouraged continuity of care and that benefited both the patient and the physician and was one of the foundation blocks of Family Medicine. Itwas also comprehensive, in that it covered almost everything.
The annual history review and physical examination has become a thing of the past, although it was inexpensive and productive. The government saw fit to rationalize it away and remove it from the fee schedule, to save money and not very much at that. Continuity of care took dedication and effort on behalf of both the physician and the patient and has lost gound to the convenience of episodic care and the ubiquitous 'walk-in' clinics where the Ten-Minute Consult (or shorter) prevails and continuity of care no longer exists. Medicine has become depersonalized and physicians have become technicians. From the physician's viewpoint it is much easier to do away with the 24/7 responsibility philosophy that many of my generation of physicians espoused, often to the detriment of themselves and their families. As one of my finest family physician mentors explained to me many many years ago when as a newly qualified physician I asked him why he had decided to be 'just' a general practitioner instead of specializing in a more esoteric area of medicine: " In another era, I think I would have become a clergyman, but that's a bit difficult when you are an atheist. I was interested in people, in families and in how to help them to deal with their health problems, diseases both physical and mental and that's why I chose general practice." I saw myself as a 'Problem Solver'.  
Sounds corny now, eh? But I believed him and still do. And when it was put to the test in regards to personal issues sometime later, he more than rose to the occasion. But that's another story. Suffice it to say he didn't sign out at 5pm ANY night.
Since I have become an unlicensed pro-bono physician, I do have a steady stream of patients. My latest consultation came this past week-end, when I received an email from an acquaintance who was worried about his ten year old child. It was about ten pm when I read it and this is what it said:
"This is Joe from the pen club. I was wondering if you could help me answer a quick question. My son who is 12y old and about 100 lbs has an ear infection and got a prescription yesterday for amoxicillin trihadrate in a dose of 2000 mg twice a day. Does that sound like a right dosage? It seems very high.
I was trying to contact the doctor who prescribed it, but no luck. I would really appreciate your advice."
I answered that I agreed with him and suggested what I considered the appropriate dosage.
This is his grateful reply:
" Thanks so much Stan! I really appreciate your advice! Have a great weekend."
I was glad to be able to help him out, but sad that our second rate health care system had left him in the lurch. I know many of our health care administridiots would cut in here and say that there are existing ways in which he could have checked this out - and there are. But when a well educated person has a sick child and they are not familiar with the arcane rituals of the Canadian Health Care system and they don't know what to do - something is wrong.  
In health care availability reigns supreme. Ability is not helpful if one cannot access it when one needs it. When a person needs health care expertise now, it is no use informing a patient they can have a consultation in three months time. Or in six months or in a year, if you live that long. One of the rolls of the family doctor was to assess the situation, determine how serious it was and to ascertain appropriate care was available to the patient in an acceptable time frame. Once upon a time, when that sort of situation developed, I (the family doc) could phone the specialist and say, "I have a patient here in a dire situation, could you see him urgently today or circumstances permitting tomorrow? Usually, the specialist would work him in. In latter years, I couldn't even get the specialist on the phone. Thanks to modern technology, I often couldn't even get his nurse or receptionist on the phone.  
" I am at work today and am away from my desk,. Please leave a message and I will get back to you as soon as possible!"  was the automated response.
Sometimes they did and sometimes they didn't.  
In more recent times before I retired, I had difficulty getting hold of my own nurse. Truly, the telephone has become an instrument for the avoidance of communication!
When General Practice started dying in the fifties and the sixties, a group of visionary physicians recognized the values of well informed generalists as becoming a vital component in the face of the development of esoteric and complicated specialties. The importance of interpreting and evaluating and explaining and advising patients regarding increasingly complicated procedures and treatments was recognized as being an important role of the family doc. This was, of course in addition to the daily management of the commonplace illness that beset families. Often minor, but sometimes heralding a more serious disorder or requiring immediate response. Mr Google was not yet upon the scene and patients valued a relationship with a doctor who could explain and interpret and advise them what to do.
Unfortunately, instead of following the original intent of establishing family doctors as 'specialist generalists' and interpreters and appliers of cutting edge medicine, the College of Family Physicians became pre-occupied with remodeling itself as a 'specialty' in the petrified image of the Royal College. This undermined the concept of the competent generalist whose specialty was to problem - solve and that often involved getting the patient to the right specialist at the right time. A knowledge of the patient's history, background and life circumstances had a considerable influence on management.
So where did the College of Family Physicians go wrong?  Indeed, are they responsible for the death knoll of 'Family Medicine'?