Geriatric Drivers.

     When you are young, energetic, strong, mentally astute and think you are just approaching your prime, it is a little traumatic to get your license renewal form together with a form letter informing you that since you are approaching your eightieth birthday you are required to contact the Ministry of Transport to ascertain that you are in sufficiently robust mental and physical condition to be allowed to renew your driver's license.  I do  a lot of driving, have a good driving record and think I'm in  as good mental condition  (apart from  misplacing a few things now and then) as I have ever been.  It does come as a bit of a shock that anyone could consider it necessary, but one has to go ahead and and pass the required test if one wants to keep driving.  A very important item in maintaining one's independence in  a country with a climate like Canada's.
     So  I set up my appointment for the 'educational and assessment' session as required and was provided with the information that there would not be an actual road driving test, but there would be a vision test that includes assessment of peripheral vision, as well as a screening test for cognitive function.  The remainder of the hour and a half session was an educational presentation to better prepare the elderly for the vicissitudes of driving a vehicle in Canadian conditions.
       I arrived at the appropriate building at eight forty-five am, all ready for the ordeal.   There were about twenty or so folks, some looking their age and some not, split about fifty-fifty between men and women.   We were brought down to the basement cafeteria after being informed that the usual area where the program takes place was being refurbished and there might be some slight delay.  Meanwhile we could sit down in the cafeteria and have a cup of coffee (at our own expense, of course!) and someone would come and get us shortly.  We sat down around a table, while an elderly English gentleman with a broad Yorkshire accent complained about how we seniors in Ontario are discriminated against as the only province in Canada that had a driver evaluation at the age of eighty and every two years thereafter. He informed us this was his third test and he was driving as well as ever.  A delightful elderly lady, accompanied by her younger sister, who was embroidering industriously, informed us that she 'mustn't' lose her drivers license because she has a part-time job and wouldn't be able to get to work.  The conversation was getting really interesting as the folks 'one-upped' each other with stories of their eldest acquaintance driver.  We were up to one whose ninety-seven year old friend had just got a two year renewal, when we were interrupted and brought down to a large board room where we all sat around a table and received our initial briefing.  
     The presentation was well planned and treated the attendees as thought we were mature adults, not presupposing that most folks of our age are in some stage of cognitive decline.   They went to some pains to explain why this program was necessary emphasizing that it was not a witch-hunt to stop older folks driving but a program to enhance road safety and to educate regarding flags to watch for.   Prior to the testing the individual's driving record is scrutinized and taken into consideration.
     The program started with an eye test for each individual and was followed by a presentation sharing current relevant road statistics.  Of interest to all of us oldies was the fact that the oldest driver in Ontario is one hundred and eight and that there are seven drivers of over one hundred!   Then a video clip of common driving errors and some discussion.  Finally, there were two five minute tests of cognitive function, that would be hard to fail if your cognition approaches normal.  The first was to draw the face of a clock, put in the numbers and make the time ten minutes past eleven.  The second is to cross out a given letter of the alphabet in a paragraph of letters.  The letters are all large and clear so anyone functioning normally should have no trouble with this one either.   If there is any problem with any of the above then a road test is scheduled. 
     All things considered I think this is a worthwhile test in that it would likely pick up significant vision deficiencies and gross cognitive disorders.  It also provided some educational content about driving and aging that some folks may not know. 
     I also noted an elderly lady and gentleman getting on extraordinarily well together.  Wouldn't it be exciting to mention at  your wedding, "I met my sweetheart at an over-eighties driving test!"
 No comments required, thank you very much!
 

Every patient needs an advocate in the Health Care Industry.

              When we walked into North York General Hospital our initial  impression was it looked bright and cheerful. The lobby was dressed up really nicely and it had a really impressive gift shop.  My daughter's partner had been admitted two days earlier and had emergency surgery for a bowel obstruction.    I spoke to my daughter (a nurse) the night before and she informed me he was doing well and was already being walked around.  (Seemed a bit early to me, but what would an antiquated old gp know? )
              By the time we got up to the surgical ward the surroundings looked a little less luxurious, in fact one might say a little on the seedy side and the patient was sitting up in bed, cold and clammy,looking rather 'shocky'.  (as though he was about to faint.)  We laid him down flat and called the harassed nurse who was busy trying to get another patient en route to the operating room.    Meanwhile my daughter put a hand on his abdomen and called me over to do the same.  His bowel was grossly distended and he had been given some sort of suppository to accomplish God knows what.   The gastric suction did not appear to be functioning adequately.  Following all of this and I must emphasize that we were pleasant, polite and understanding, we were starting to attract just a little bit of notice.  Unfortunately, that sometimes seems to be necessary to make things happen. My daughter wanted to talk to the doctor or resident and shortly thereafter a bowel x-ray was being arranged.  She cancelled other plans she had and decided that she better stick around and look  after him.
              Now,I am not blaming any of the care givers, but there is something seriously wrong with a system that could allow a post surgery patient to slip into shock in an acute care hospital.
               Not every patient has an advocate in the health care professions, but every seriously ill patient needs an advocate with the patient's welfare at heart,especially when the patient is too ill do so so for himself.    Not to tell the health professionals what to do, but to show  there is someone who cares for the patient as a human being and to provide the care that the often overworked and harassed members of that profession can no longer look after in the Health Care Industry.
              Tell me if you think your family member would need a medical advocate. 
              
                 
                

The letter I almost (but didn't) send to the Minister of Health.

Dear Minister,

                    I don’t usually write letters to newspapers, politicians or lawyers, mainly because I like the Canadian system and have worked hard to see it work.  I was born in Ireland, studied medicine there, and when I graduated I had to decide what I wanted to do with my life.   I did not choose Canada serendipitously, indeed I had family in the US and classmates from the ‘Colonies’ and was offered employment opportunities that would have enabled me to pay off my considerable student debts as well as make a comfortable living for myself, my wife and baby daughter.  I thought carefully about all of these things and finally decided that I wanted to be a Canadian.  Not an American, not an important Physician in some British Colony and not even a partner in a practice in London, England, where I was an assistant family doctor when I applied to come to Canada.  (Just after I arrived I had a communication from that practice offering me a partnership, as one of the partners in the practice developed angina pectoris.).    Minister, as I was applying for a position in Regina, Saskatchewan, I received a communication from the British Medical Association, warning me of the Socialist system being instituted by Tommy Douglas.   They pointed out it was not supported by the BMA.    That did not deter me and I came to Regina nevertheless, and met many fine people, medical and non-medical, political and non-political and spent thirty five years in medical practice in the province, the last ten years as Professor and Chair of the Department of Family Medicine.   Through all those years, Minister, I believed we had an exemplary health care system that, while far from perfect was striving to offer the best possible use of the available resources.  As the Chair and Professor of the Department of Family Medicine at the University of Saskatchewan I had knowledge of medical care across the country, so I believe my comments to be applicable on a National basis and not to be confined to Saskatchewan, or Ontario, where I have been in practice for the past fifteen years or so, initially as a Faculty Member at UWO and more recently as a physician doing some locum work a day or so a week. 

            The story I am about to tell you Minister, is of a recent incident that shook my confidence in certain aspects of the Canadian Health Care system, of which I have been a proponent, participant and patient for the past fifty years.  It is a story I feel compelled to write, because I am in a position to critically evaluate what is going on and feel these comments should be shared.  It is a story not to criticize the health care providers, but to criticize what has happened to a health care system that was once an example of excellence but has steadily deteriorated over recent years. 

            After an accident in Hilton Head, S. Carolina, in which my seventy-seven year old wife tripped over a concrete parking marker and hit the ground with an impact that I was afraid she had suffered a serious and potentially disastrous head injury, I headed back to Canada the following morning, after observing her throughout the night and deciding her condition was stable and it was safe to travel.  We arrived home, in London Ontario, two and a half days later, after an ordeal, that I’m sure you can imagine.  Indeed, in retrospect, I question the wisdom of my decision, to drive that distance, on minimal sleep.  To cut a long story short, first thing in the morning, after arriving home, we took a trip to the emergency room, at University Hospital, and that’s where this story really starts.

            On the morning of Wednesday, twentieth of February, 2012, I brought my bruised and battered wife to the Emergency room at University Hospital, in London.    Minister, we sat there for five hours.  I am a physician and I was satisfied that my wife was in no immediate danger. I couldn’t help speculating on what might have happened if a patient was bleeding from a subdural hematoma or worse.  Because her hand and arm were grotesquely swollen and bruised, they were the immediate focus of attention.    So, after five hours, limbs were x rayed and the splint that I had already applied was considered to be adequate treatment for the moment.  Her head was either not noticed or considered to be unimportant, despite extensive bruising and tenderness over the zygomatic bones of the face and a black eye.   I brought her home from the emergency room at University Hospital where she had been sitting for five hours without having been assessed for a head injury by a physician, when she was so uncomfortable that she insisted on signing herself out.   Being a physician I was satisfied that she was not bleeding into her brain.  However, this was not known by the staff and it concerns me that someone whose cognition may have been impaired was allowed to leave emergency without any real attempts to explain the possible risks involved..  Equally unbelievable, Minister, was the fact that despite the fact that  Family Medicine programs  try to make our students aware of women’s health issues and of the fact that they must screen for family abuse, nobody asked my wife if she had been beaten up by her husband or otherwise abused..  By the way, there were notices around the emergency room advising this would be screened for, except that it never happened.  I found this almost unbelievable and and think that this aspect of emergency room care needs careful review.

            Next morning, since my wife (understandably!) refused to go back to emergency at University Hospital, and her head had not yet been looked at, we went to St. Joe’s where the experience was much more acceptable.  The CT scan showed some bone damage, fortunately not severe.   Minister,  I have spent much of my life working (and sometimes living) in hospitals and I understand the difficulties that health care workers have to contend with .   (Indeed, I hardly dare to as both my offspring work in, what has regrettably become  “The Health Care Industry”.    Suffice it to say, that something is amiss in the state of Health Care, that in my opinion is more related to its administration, than to the delivery of health care personnel.. 

       Those inadequacies must be addressed by the administration, as well as by those who deliver the care.   The Health Care System in Canada is deteriorating.  I do not believe you would have settled for that level of care for a member of your own family and neither would most Canadians.

                              Sincerely,

                                                 

 Stanley G.Smith,  MA, MB, B.Ch, BAO, CCFP, FCFP.

                   Professor Emeritus, Dept of Family Medicine, University of Western Ontario.

Poor pieces of Flesh!

             Foreign buyers are flocking to Canada to find surrogate mothers now that Asian countries have cracked down on this practice.  These narcissistic folks are using Canadian Health Care resources to satisfy their desires and their longing for immortality and for the most part are not interested in offering a good life to some baby waiting to be evacuated out of  the womb.  I see their mission as a purely selfish  one, which I resent subsidizing with my health care dollars.   I  would be surprised if most Canadians didn't share my views.   Canadian surrogates should not be covered by medicare and if the practice is allowed at all, should be paid for  by the people buying  the babies.  Many developed countries ban surrogacy outright.  Surrogacy, catering as it does to the whims of the purchaser may take an ugly and immoral  turn.   Recently a Nova Scotia woman who was 'commissioned' to have a child for an  overseas couple found herself carrying triplets.  Although she wanted to carry all three, the 'would-be' parents insisted one of  the fetuses be killed off.  The woman was told that the couple could cut off expense payments if she insisted on keeping all the babies.  The surrogate agreed to  one of the fetuses being killed off.  One of the two remaining fetuses died too.   Apparently, the remaining baby is surviving its hazardous intrauterine journey for the moment.  If it does one has to wonder about the environment into which the poor thing will be born.    If Canada's medical ethicists and other self professed protectors of patient health don't have something to say about this, they certainly are not doing their jobs.                                                        

                                      Perhaps  they just don't understand it. 

 

The Elecronic Medical Record.

Physicians Use of EHR Systems 2014

The survey on Physician Use of EHR Systems 2014 found that close to, or more than half of all respondents, reported a negative impact in response to questions about how their EHR system improved costs, efficiency or productivity.

Physicians have become increasingly unhappy with EHRs. We really did not need a survey to document this.
The real question is why? I think logical thinking can reveal the answer.
Why do we use information technology in general? We use smartphones, pads and computers when they improve our lives. No one makes me buy a computer. I buy the computer because of the value it gives me. I buy software (or apps) because I find them helpful.
Throughout our economy, information technology must provide value. Developers have to demonstrate value to those who spend money on systems.
Electronic health records are being imposed on health care systems. They are not being sold as helping physicians do their work. In addition to this problem, the government has mandated meaningful use (a term that physicians often ridicule). When you impose technology on users, then an important development piece is missed – user friendliness. Every system that my friends describe has made the user’s (physicians, nurses and other health care workers) charting more difficult. No one asked the physicians how they work. No one has designed a system to be health care worker friendly. We are expected to figure out the system, rather than the way most computer programs are developed.
Bob Wachter, in his important book Digital Doctor, explains the care that goes into developing airplane computer systems. No one thinks the same processes occur in health care.
How does this matter? EHRs add time to the physician’s day. EHRs contribute to physician burnout – a major problem that negatively impacts patients. We should all speak out about this problem.

Medicine gone crazy!

             A Canadian forensic psychiatrist says he regularly treats sex offenders for impotence with Viagra like drugs and advocates the practice as a way to actually keep them out of trouble.
             Dr. Paul Fedoroff’s comments come as a new American study raises legal and ethical questions about helping convicted sex criminals overcome erectile dysfunction (ED).
              Authors of the paper worry that doing so might help some perpetrators re-offend, while American law bars government health-insurance from covering the treatment’s cost.
But in a response to their article, Fedoroff says prescribing Viagra-type drugs or delivering other ED treatment can be part of a strategy to shift offenders away from criminal behaviour — such as assaulting children — and toward more normal sex.
            I have to wonder if Dr. Fedoroff would like his daughter to be exposed to such an offender fortified with Viagra as part of his treatment to steer him in  the direction  of 'normal sex'.   Come off it, Doc.  Further, our contention that pedophiles often target children only because they’re afraid they will not be able to perform if they try to have sex with an adult partner is nothing short of absurd.  He further asks, “Which sounds like the more dangerous person a person who is engaged in fulfilling, healthy sexual relations with a consenting partner, or someone who has no legal sexual outlets?”  He does not seem to grasp, that if the person  was capable of having the sort of relationship that the learned doctor describes it is unlikely that he would be in jail serving a sentence for pedophilia in the first place.                                                                   
            The issue was raised recently, though, in a study by three Boston-based urologists, who noted in the Journal of Sexual Medicine that coverage for anti-impotence drugs by the United States’ Medicaid program was banned in 2005 in the wake of public “outrage” that tax dollars were used that way..                               
            The doctors say they are not in favour of denying care to all sex offenders, but suggest it is possible in some cases that “treating their sexual dysfunction may increase the risk of sexual recidivism.”
          Still, they say the science is unclear, and complain that urologists lack the training to know whether treating the offender’s impotence is appropriate or not.
“Virtually everyone has some improvement,” the psychiatrist said. “Most find a girlfriend, boyfriend or appropriate partner.”
             Most pedophiles engage in inappropriate touching, kissing or genital contact, and an erection is irrelevant.  Castration would probably be a more appropriate treatment than viagra.
             Just another 'politically correct' misconception by the LWLs, until one of their kids are molested.
             Go figure!!

Social Sickness

                         "Pigs in a blanket- fry 'em like bacon!'
            If that's not hate speech, what is?  Hate speech is not free speech, it's anarchy! 
           America is a dangerous place and rapidly becoming more dangerous.  Violent crimes are escalating and a sizable segment of the population, instead of walking softly and carrying a big stick, are walking as loudly as possible and carrying a Smith & Wesson.  When the police are a major target of the violent crimes, anarchy is not far away.  I'm prepared to bet a hefty sum that a police call these days has a longer response time than has been normal  in recent years and if things continue in the present manner, there may well be cases when there is no response at all.  Not good for the nation.  Until someone takes charge, conditions will deteriorate and the mental and physical health of the nation can only decline.  As long as every malcontent can walk around with a gun in his pocket, the health resources required to deal with gun violence will continue to soak up an extravagant part of the health care and the legal systems budget. 
       When I was growing up, long, long ago in a land far, far away, my mother told me while quite a little  lad, "son, if you are worried or afraid of someone or something, just go up to a policeman and tell him what you're worried about and he will see that you are safe".  And that's the way it was.  There was something pretty healthy about that.  Both mentally and physically.  The police were perceived as friend and protector and they usually were.  They didn't need a gun and the truncheon they wore on their belt rarely came out of its sheath.   My parents didn't have to worry when we kids went out for the day and the greatest danger we could imagine was being home late for supper.   
       We are all proud of the fantastic advances that have been made in individual and public health in conquering and preventing disease in recent years.  Unfortunately, during the same time anarchy has been gaining momentum in our society and resulting in more mortality and morbidity than ever.  If we don't elect leaders who have the courage and integrity to deal with this, we will deserve what we are going to get..  Social sickness may now be a greater threat than physical disease.