A Bird's Eye View of Family Medicine

Considerable time has passed since I last made an entry to my blog site. Basically, I’ve decided the healthcare train is going down the tracks in its predetermined direction and nothing I say or do is likely to change the direction or the time interval at which it slows down, stops, and considers a new direction. Meanwhile I have decided to continue in my small way to help those that fall between the “train tracks” by doing a bit of palliative care and giving sought after advice by some of my friends.
I’m writing today to suggest a totally new and novel approach to the shortage of family physicians (I’m being facetious).
Over the past four to five days I have noticed that my budgie bird, Jo-Jo, was becoming a “Star Gazer”. In medical terms, he was developing a torticollis. Now to appreciate the story, you should know that I inherited this bird from an elderly couple in my practice, when during a house-call, they asked if I would take Jo-Jo if anything ever happened to them. They said he liked me, and besides, their daughter had a cat. In a moment of insanity (my wife hated birds), I agreed. Some two years later both of these dear elderly folks passed on and I prayed that they told no-one of my promise. Unfortunately, the daughter showed up in my office a few days later with bird, bird cage, bird food, and various other bird paraphernalia. My wife was not pleased and I barely escaped the couch the first night.
That was eight years ago. Since that time Jo-Jo became a member of the family, especially the grand kids and other visiting children. Last year the daughter of the elderly couple expressed pleasure and surprise that Jo-Jo was still alive and doing well; but why not? He was fed the best food, water was changed every day, he was in our solarium with music being played almost every day for his enjoyment, and we spoke to him every time we passed his cage. Life was grand! We even knew what music he liked.
That ended five days ago. On changing his water I noted his head was twisted off to one side giving him the classic “star gazing” syndrome. I hoped he just had a “crik” in his neck, however, over the past few days his distortion has increased and his feeding and ability to drink water have become significantly impaired. After much chastising by friends I at last sought veterinary advice (by telephone). Now I know of many things from a medical perspective that could cause this problem, many of them very serious. The internet spoke of various viruses and such, but Jo-Jo shows no signs of illness and has a voracious appetite, so I doubt the virus theory. I was advised by the veterinary clinic that the bird would have to be seen to determine a cause for his malady. When I asked what the fee for “being seen was” I was informed that the fee was 67 dollars and some cents for the examination; any investigation would be extra. Several thoughts went through my head at that time: 1) It’s a wee budgie bird, how useful would an examination be? Are we going to look in his ear with an ottoscope? Take an X-ray? Take blood? Do a brain scan? Will it require a general anesthetic to examine him properly? And 2) 67 dollars??!! That is as much as I bill for doing a complete check-up on an old man with multiple organ failure and twice as much as I could bill for seeing a person with the same affliction as Jo-Jo.
So here is my novel solution to the family doctor shortage-------PAY THEM AS MUCH FOR SEEING A HUMAN BEING AS VETERINARIANS GET PAID FOR SEEING A BIRD WITH A CRIK IN IT’S NECK! OH my GOSH! Why didn’t someone think of that? Bet you haven’t heard of a severe shortage of small animal veterinarians.

Where have all the family doctors gone

Has anyone seen a family doctor recently? They seem to have become a vanishing species. Strange how when it is reported that some farmer is plowing up a field that has some species of rare mouse in it, environmentalists will come out in opposition and headlines occur in national newspapers. In the May 09th edition of the Calgary Herald an article appears in section B------Medical grads shun family practice. It goes on to say that of 104 medical school graduates from the Calgary Medical school only 20% are choosing family medicine as their specialty. It doesn’t mention that only a subgroup of these will decide to provide family medicine in the community.
I found it interesting however that faculty dean, Dr. Feasby, and U. of C. president Dr. Harvey Weingarten were able to put a positive spin on this saying that in 1999 there were only 69 graduates from the Calgary medical school and this year there were 104. Unfortunately they didn’t mention that in 1999 more than 40% of graduates were choosing family medicine amounting to 28 practitioners whereas 20% of 104 graduates this year is an abysmal 21 practitioners. They also didn’t mention that fewer are setting up community practices but did mention that the doctors choosing family medicine may not stay in Calgary.
They did tend to be quite positive and bring in that old worn cliché and say that the young doctors were bright and “innovative” and that there were many ways to serve society. I’m sure this is very encouraging to those chronically ill and elderly people in Calgary seeking care.

Health Minister Ron Liebert Stumbles on Healthcare

The following is a letter that I wrote to the Editor of Vital Signs, a publication put out by the Calgary and Area Medical Association.
Dear Editor;
It would seem from the March issue of Vital Signs that our President, Dr. D. Glenn Comm, is becoming disillusioned as to our ability to deal with the present and increasingly inevitable problems in our healthcare system as costs rise, labor shortages abound, and the population ages. Perhaps he will find solace in the pep talk given by Louise Gallagher, manager, Resource Development and Public Relations, Calgary Drop in and Rehab Center, in the "Letters" section of the same March issue. Actually, I'm very pleased that her mother has received excellent care and I couldn't agree more with her praise of the many caring and hard working care-giving professionals that work in our health care system.
Unfortunately, Dr. Comm, I don't believe help is on the way. Ron Liebert, stated on the Rutherford talk radio show, that Albertans had voted for change and that's what they would see in healthcare in this province. Ed Stelmach was quick, however, to contradict this statement and infer that the "Third Way" was DOA and having private care play a greater role in provision was not on the table. By the following day they got their act together and jointly declared that their basic goal was to squeeze more value out of the system while improving access for patients.
The frightening part of that statement is the reality that the largest cost to the health care budget is healthcare workers salaries and physicians fees, and historically the squeeze has not been to the system, but to the incomes of the providers. Dr. David Taras, a political analyst at the University of Calgary states the real issue is the "catastrophic shortage of doctors and nurses". I'm sorry Dr. Taras, but "squeezing" this group for more output (cost control) without putting incentives into the system to attract more workers is a non-starter so the system needs changing. And I for one, haven't seen any Alberta politician with the courage to take on the special interest groups that have consistently supported a system that continues to fall behind other nations in healthcare ranking, and attack any real discussions that could improve our healthcare system. Who would have thought that entrepreneurial Alberta would follow far behind Quebec and B.C?

An Obama They Are Not

Well, that was embarrassing! We in Alberta can only hope not many other Canadians (or people from other countries, for that mater) were watching Alberta’s great leadership/election debate. A Mr. Obama we don’t have, either from the perspective of an orator, or any kind of a message of hope----particularly in Healthcare. Mr. Mason basically is saying they could do better, and suggested salaried doctors, seemingly oblivious of the fact that a salaried family doctor typically sees fewer patients than a fee for service family doctor (how will that get more people a family doctor?), Mr. Stelmach says they have everything under control, and Mr. Taft simply whines that we are where we are because the conservative government got us here, conveniently forgetting that the other provinces in Canada face the same or worse scenarios. Mr. Hyndman raised the issue of “the money following the patient” which is a principle that has been bantered about for the past fifteen years and has never gained traction.
The entire program could have been a five minute program and could have been limited to their 45 second summaries. Mr. Mason will look after you from the sperm to the worm, Mr. Stelmach states that they are doing a great job; Mr. Taft whines that it isn’t fair that the Liberals haven’t had a chance to rule in Alberta, and Mr. Hyndman states that if we want change we should get back to a policy of “survival of the fittest”.
At the same time the Great Alberta Debate was on, I noticed the program “Lost” was on another channel. Dutifully, as a responsible citizen, I watched Alberta’s Great Debate. Unfortunately it turned out to be just another version, and I might add, an inferior version, of “Lost”.

Quebec, Our Healthcare Saviour

Wow, healthcare in Calgary, Alberta, has made the headlines of the Calgary Herald two days in a row. Today it reported that the system was stretched to the limit and that patients were waiting in the emergency department for as long as twenty four hours for an admission bed. I thought there was some kind of rule in place specifying (mandating) a much shorter time, I guess somebody found out that when the beds are full, and the hallways and sunrooms are full, they stack up in the emergency department and the rule can go to -----. Come to think of it, the article does say that 17 patients were in hallways waiting to be seen by physicians while paramedics “medi-sat” them. Keep in mind, the city budget pays for the paramedics.
It would seem that once more the Calgary region is short of money, 115 million dollars, to be exact (er---sort of exact). In the same paper the Region blames the province, the province blames the Region, and they all blame the increasing population (the patients), and nowhere in the newspaper or on the campaign trail are solutions being offered. Some MLAs are lashing out with accusations that the Royalty increases have killed the economy, while also in section “A” of the same addition a headline reads “Alberta’s 4.2 billion dollar budget surplus larger than expected”. The health Minister, the Honorable Mr. Hancock states firmly that he will not recommend covering the shortfall because it may encourage the Health Region to spend more money, but assures those of us that are gullible that patients will be cared for (even if he has to do it himself????).
Finally, national columnist Don Martin offers some hope on page 10. He points out that Quebec is moving towards solutions that are a threat to Medicare by virtue of a report released by Liberal Cabinet Minister Claude Castonguay. He points out that for political reasons the feds will stay quiet on the issue and if enacted, the report will “turn Quebec into an unfettered health delivery revolutionary” (personally I love the “unfettered” part of the statement). He goes on to say that if that happens, no other province will accept federal consequences or penalties for becoming a rogue state of privatized health care. He then sort of summarizes and buys into the stupidity of the last twenty years with the statement “The Canada Health Act will be dead----and two tiered healthcare very much alive.
The Canada Health Act will never be dead, Mr. Don Martin; it needs to change and will change, but die it certainly will not. As for the “Two Tier Boogy Man”, anyone who has the barest knowledge of our present day Healthcare System is fully cognizant of the fact that it already has many tiers. I say Viva La Quebec!!!

Healthcare Top Issue, Canada and USA

“Doctor Shortage Makes Health Top Election Issue”; this is the headline in Today’s Calgary Herald (Feb 19/08).
So I read the article, thinking I would encounter some thought stimulating innovative platforms from Alberta’s political parties on Alberta’s Healthcare system. Unfortunately, the only ideas put forward by all four parties are the same ones that we have heard over the past twenty five years (promises) and that got us to this present day state; or ideas that are totally irrelevant or counterproductive such as eliminating healthcare premiums. Would someone please tell me how decreasing the government’s revenue stream is going to help provide more family physicians to the citizens of Alberta? Now, if they had said they would increase the threshold of annual income before paying premiums and increase premiums for high risk life styles, at least some discussion would be precipitated.
All four parties claim they will increase long term beds, increase the numbers of graduating docs, etc, etc, etc. Haven’t we heard this a thousand times before? If the number of graduating docs that choose family medicine continues to shrink, how in heaven is graduating more plastic surgeons, dermatologists, etc, going to help? And if we can’t retain in Canada the physicians we in Canada graduate in the various specialties including family medicine, are we not simply providing well trained physicians (at the tax-payers expense) for the United States, Australia, New Zealand, etc?
The reason none of the political parties want to get into the healthcare issue is that they all realize that at present in Canada and Alberta, healthcare costs are being controlled through rationalization of services; not through legislated restrictions, which would be politically onerous, not through direct fees that would be politically onerous, not through private insurance options that are PERCEIVED to be politically onerous, but through restricted access to healthcare personnel and technology by virtue of scarcity, the politicians greatest ally in our present system in controlling costs.
The article in today’s Herald states that “the experts” say there is no simple solution for what ails the health care system, and Dr Glenn Comm, President of the Calgary and Area Physicians Association says “there are no quick fixes” and “We got into this mess over a long period of time”, but my question is: How about some quick STARTS to fixes, how about at least looking at some options other than those that “Got us into this mess over a long period of time”, how about some real discussions without special interest groups trying to STOP discussion. Any solution has to address increasing costs and at the same time offer the population better access. It would have been nice to see at least one of the political parties identify itself as real change (an opportunity for the Alliance Party)
in the area of healthcare, a party willing to look at options on both the left and the right of the political spectrum. A simple example would be to bring in a registry system with intensive intervention in the area of chronic disease (an idea that many would think intrusive and too “left-thinking”), coupled with private insurance availability and facilities for those that can shop the market for the best coverage (an idea that is strongly rejected by the “left” and considered to be “right wing”).
Alas, all the parties avoid any open discussion of healthcare like the plague. Perhaps they all agree with one of Canada’s somewhat notorious Prime Ministers when she stated that an election is not the time to discuss substantive issues. Mind you, she was voted out resoundingly in that election.

Universal Healthcare Torturing Canadian Citizens

Interesting! The headline in the Calgary Herald on Jan 27/08 was “Doctors Critical of Drug Reviews. This headline pertained to various drugs that the Alberta government refuses to cover in its Blue Cross public insurance plan for the chronically ill citizens of Alberta. In particular, the drugs Humira and Enbrel are mentioned in the treatment of “Spinal Arthritis”, more accurately called “Ankylosing Spondilytis”. The government’s argument is “there is no evidence the treatments slow progression of the disease”. Now to be forthright, I have never used these drugs, but over my forty years of practice I have been involved in the management of this condition and the pain these people suffer when afflicted by it. I specifically remember one patient in his thirties whose pain was incapacitating. He only obtained relief from the pain by using a combination of opiates and large doses of an anti-inflammatory drug called indomethasone. Other anti-inflammatory drugs were tried but had little pain relief effect. Without the indomethasone he was in constant pain and unable to be productive; on it he was reasonably comfortable. The only problem was that over a two year period on the indomethasone he had two major life threatening gastro-intestinal hemorrhages with subsequent transfusions (which is not uncommon with indomethasone). This mandated the use of a concomitant proton pump inhibitor drug in an attempt to prevent (but did not guarantee) further hemorrhages. So he remained on three different medications in an attempt to control his PAIN and keep him reasonably productive, albeit exposing him to all the side effect of three different medications, including the aforementioned life threatening hemorrhages.
Would Humira or Enbrel been effective in this patient? I really don’t know; but it would have been an option to be considered by a specialist and the patient if he could afford the drug costs. It seems to me that once again, in our government universal healthcare scenario, the poor are adversely affected; yes to the point of pain and debilitation that would warrant the term “torture” in any civilized country, by any definition, were it being inflicted. Is omission justified when commission is not?
The other drug that stands out from the crowd is the drug Remicade for Crohn’s Disease of the bowel. According to specialists working in the area the drug can only be covered for periods of eight weeks, and I gather, if the patient is in remission, cannot be prescribed again until the patient “flares”. In the article in Sunday’s Herald, Alberta Health officials denied that patients must go off their medications, but then go on to say: “The rules are in place because patients can experience long stretches without symptoms of the disease”. So which is it? Is there a rule or not? It would appear from the article and their own statement that indeed the rule is there. So how do we categorize deliberate withholding of appropriate medication based on cost? Does this justify putting people into repeated episodes of severe abdominal pain and vomiting that may go on for weeks before the medication once again “kicks in” to give them relief?
It should be pointed out that the above drugs have been approved by the federal “Common Drug Review committee” based on their evaluation of both effectiveness and cost effectiveness. One may ask “how does this pertain to our Universal Healthcare system in Canada? Quite simply; provincial governments have the responsibility of providing Canadian citizens with comprehensive healthcare coverage as mandated by the Canada Health Act. If they are short changing you and making “cost cutting medical decisions in pharmaceutical areas, what other areas are they making those judgments or cuts?
Do you know? Not likely. Provincial governments are making numerous healthcare decisions that only physicians and their patients should be making; and people should have options for access, based on their judgment as to their needs. Governments have a finite money resource, namely taxes, and are under continual conflict as to how to apply that money resource to a multitude of priorities. But one thing is clear to me; not allowing options to their citizens smacks of a serious sin of commission, and not meeting their mandate to prevent significant suffering in treatable conditions (relief of suffering short of euthanasia) smacks of an unforgivable sin of omission. If this type of suffering were being inflicted in the prisons at Guatonamo or Afghanistan our news media would be up in arms. As it is, they seem more preoccupied on whether it is appropriate to turn prisoners captured in Afghanistan over to the Afghanistan government. Perhaps it is time to stop the torture going on here within our healthcare system (primarily affecting the poor and uninformed) before getting bent out of shape with what is going on abroad.