Dependancy

A study published in the American Heart Journal suggested that prayer has no benefit to patients who have undergone bypass surgery. Eighteen hundred patients were included in the study and divided into three groups: the control group was not prayed for, another group was prayed for and were not aware of this situation, and the third group was prayed for and was told that they were being prayed for.
The group that were not prayed for and the group that was not aware of being prayed for did the best, with no difference in complication rates in these two groups. The group that knew they were being prayed for did the worst with a complication rate 7% higher than the other two groups. It was reported by the Main Stream News Media that the researchers felt this was possibly from pressure on the group by knowing that they were being prayed for and therefore had more pressure on them.
Now I’m not sure if the researchers ONLY put this forward as a possibility, or if this was an example of the MSNM doing some selective editing. I would suggest that there are several other possible reasons for these results, and good researchers would allude to them if they were in a state of mind to do any alluding at all. The article I read stated clearly that the researchers stated that this in no way inferred there was no god----and by raising the issue immediately put this on everyone’s mind. What seems an obvious alternative answer never arose in the article, perhaps because it doesn’t fit with the modern thinking of journalists and many editors.
What if knowing you are being prayed for triggers of a feeling of dependency of the patient; ( this would apply to the “believers”) a feeling that “god will do it”, I don’t have to do it. I think there is general agreement that determination and will power helps performance in physical situations. What if this applies also in medical scenarios and that dependency on others takes away from the mental striving we may do if we know we are on our own? Many of us in the medical profession have marveled at those patients that simply push forward in their determination to get better, and beat the odds. Perhaps this study shows that if people rely on others (or god), it interferes in their recovery.
Another possibility would be, for many of the “non believers” in the group that did poorly, should they be doubting the existence of god, the knowledge that other people are praying for them may have raised the question as to whether they are secure in their doubting god, and raised their anxiety levels. Since one of the common complications of bypass surgery are arrhythmias, and stress, stimulants, and anxiety could increase this risk, perhaps the increase in complications were predictable in this group.
And finally for that group of believers who believe, but don’t totally trust, the group that needs their belief for security reasons; could their feelings of dependence raise their anxiety levels? Could they be caught in the dilemma of whom do we trust: medicine, ourselves, or god?
In short, there are many “possibilities” as to why the group that was prayed for, and had knowledge of that fact, did poorly. As the researchers stated, this had nothing to do with the existence or non-existence, of god (which makes us wonder why the research was done in the first place). It likely had much to do with the complex issues of dependency and the negative impacts this can have on human survival. In a society that fosters dependency, and a news media that champions it, is it any wonder that it was not mentioned at all in this article?

Footnote:
My wife, on reading this blog, stated: “So what you are saying is that if people know they alone have the responsibility for doing something (in this case getting better), they are more likely to do it”? “Well, yes” I replied. Which made me wonder why I took so long to state that simple fact.

At Least Do SOMETHING

We are faced with incredible problems in the world today. It is truly mind boggling. At times I wonder whether it might be better to stay uninformed, insulated against the world tragedies.
In March 29/06 Calgary Herald, page21, Dr. Bob Dickson, a Calgary physician, painted an excellent picture of the situation in the world today as to the status of Tuberculosis. Although he stresses the prevalence and devastation in the developing world, he doesn’t mention the increase in T.B. and the development of resistant strains in some of the large cities in North America. This was in evidence five to ten years ago and continues.
Dr. Dickson points out the synergy between HIV and Tuberculosis. Basically, if our resistance is impaired as it is in HIV, the TB bacterium runs rampant and is more difficult to control. He points out that proper drug treatment can prolong life by as much as five years. I’m sure this is true but we must keep in mind that although predisposition to TB is multifactorial, in the case of Africa and some of the slum areas of our North American cities like San Francisco and New York, AIDS is the primary driver. The resurgence of TB in the world and in North America parallels and follows the increase in AIDS. Equally frightening is the development of resistant strains of TB as a consequence of treating the many AIDS patients who have Tuberculosis.
Much is written in the lay and scientific literature about the development of resistant strains of bacteria. Recently in Canada concern over the deaths caused by C. deficile and the possibility of the development of resistant stains captured headlines. M.R.S (very resistant staph. bacteria) is on the rise in our hospitals. Family physicians are admonished almost daily to avoid using antibiotics in our offices, and when we do, to use amoxicillin where ever possible (e.g. ear infections). At the same time we have to keep in mind that the largest malpractice settlement made in pediatrics was in the U.S. for millions of dollars, because the child with an ear infection treated with amoxicillin, subsequently developed a brain abscess and was rendered a bed ridden invalid. Thousands of Canadians and Americans cross the border every year for a good supply of any antibiotics they want. In many countries antibiotics are bought over the shelf like candy.
I am reminded of a charitable drive to raise money for the purchase of antibiotics for the people of a small country where the life expectancy was thirty seven years of age and the two main causes of death were infections and starvation in that order. These people lived in a country with mountainous terrain and the people above contaminated the water with typhoid, etc. for the people below. Basically all water used was surface water so the children died of intestinal infections or pneumonia when they were weak and debilitated from starvation. When I asked whether the money raised would be better used for development of water purification and better agricultural practices, the organizers were insulted. Somehow, I didn’t see the rational of saving children from infection so they could die of starvation!
No-one can be expected to have the solutions to these dilemmas, but the point I am trying to raise is that the resurgence of Tuberculosis is primarily due to the increasing prevalence of HIV, and we know that the development of resistant strains of tuberculosis corresponds to the increasing use of antibiotics in this patient population. Lengthening their survival time from TB will invite other invaders. Some of our AIDS patients in Canada are on eight to ten medications, most of these being antibiotics and antiviral drugs. These patients certainly live longer and their quality of life is improved, but with the reasonable expectation of developing resistant stains of bacteria and viruses to their drugs. Modified programs such as the Global Drug Facility Plan could improve life expectancy for millions of T.B. patients world wide, but has any one looked at the probability of drug resistance that is likely to develop? As mentioned, we are already seeing this in our Aids patients in North America. Besides, I do not believe we can win the tuberculosis battle without winning the HIV battle first, so is the money being well placed? I do acknowledge the fact that “ it is hard to remember that you came to drain the swamp when you’re up to your ass in alligators”.
This moral dilemma is only one of the ethical issues facing the world today. Many groups of people feel strongly that we, in the “have” countries of the world today, can not humanely stand by and do nothing while these people in dire need of our help are dying. Still, these are the same people who felt we should have stood idly by, while villages in Iraq were being gassed, women were stoned for being raped, and people were beheaded for their beliefs. These may well be the same people who raise their voices loudly when some Canadians wish to change our health care system so that we have the capability of looking after the poor, the chronically ill, and the frail elderly, and allow those who are capable, a venue where they can provide for themselves. I don’t envy the decision makers that have to deal with the many demands imposed upon them by virtue of their positions. Every situation needs to be looked at long and hard, but decisions need to be made and only history will reveal the appropriateness of those decisions.
Of late, Canadians have been far too eager to throw dirt at the U.S. for moving forward in some areas. We in Canada must remember that not making a decision is in fact a decision; a decision to do nothing. For too many years we have coasted in the areas of health care nationally and world affairs internationally. We have lived off of the victories and accomplishments of years gone by and those before us. Perhaps the time has come for Canadians to garner the courage to move forward. History will judge us as a nation, and the world will judge us as a people, but we will be judged.

Whoops, Sorry!

The human mind is a wonderful entity with an incredible ability to make things clear that are vague, make sense out of nonsense, and create order out of chaos. Unfortunately, it can also be totally unpredictable and come up with some really far out stuff.
Keeping this in mind, I think this preoccupation with making our health care system cost effective and sustainable has brought about such an event. I had the unfortunate experience in my years of practice to have a patient who was denied a liver transplant and died. He was denied the transplant because he didn’t meet the Alberta “criteria”. It took them three weeks to make that decision in Edmonton in spite of my many phone calls and although he was approved by the U. S. “criteria” he died within three days of his arrival in San Diego, not enough time to find a match. The Calgary newspapers had a huge spread on this individual after his death, enumerating all the good things he had done for the community, the organizations he sponsored, and the charities he supported. Being quite miffed at how long the Edmonton transplant team had taken, and the fact that they had rejected my patient for transplant, I sent the newspapers clippings to the head of the transplant team in Edmonton. (Criteria for transplant in Canada are often different than in the U.S. because our transplant teams have an annual budget that needs to be met, and therefore there are only so many transplants they can do in a year. In the U.S. the main determinants are availability of donor organs and the feasibility of good outcomes, and the patient’s ability to pay). The transplant team was polite enough to reply to my newspaper mailings and basically told me they did not make judgments on the “value” of a human life.
It was with this scenario in my mind, and the ever pervasive knowledge of the need for a cost sustainable public health care system that I had what my children would have called “a brain fart”. Maybe if we need to make our public health care system cost effective and sustainable, we do have to put a value on a human life. Since the public system is sustained by tax dollars and the very vocal groups like “Friends of Medicare” are adamant that this be preserved, we should look at every opportunity to increase our tax base for funding Medicare. Making the spending part of the equation cost effective is now past the fat, muscle and into the bone, but no-one has looked at what the public health care system can do to sustain its self in addressing the funding side of the equation.
Are you ready for this? The answer is simple, keep the people alive that generate and pay more taxes! Let’s face it, a fellow who employs 100 people, all of them paying taxes, and he himself paying a million dollars in taxes will contribute to the tax base and sustainability of the health care system more than an unemployed worker. Give the available organ to the biggest tax payer. Have your doctor just send your last tax-return along with your medical referral so that the team can make a “cost effective judgment” on who should be saved. What’s that you say, everyone in the system is to get the same care, and we should not discriminate on the value of a human life? But that’s not cost effective. Oh well, maybe my kids are right, I just had a “brain fart”. Sorry. Just trying to help.

Hippocrates in a Rage

Reference is often made by the public and the Main Stream News Media, to the Hippocratic Oath, and it drives my wife wild. “I doubt they have ever read it” she proclaims, and is probably right in her suspicions. If they have, I suspect that it is the “Modern” sanitized version, and not the true “Classic Version”. And believe me there is a difference!
Of note is: the Classic Version starts by swearing by all the gods known to Hippocrates at his time, and making these same gods his witness, that we physicians will live by this oath. He goes further and ends the oath by saying that if we honor this oath, “may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come, if I transgress it and swear falsely, may the opposite be my lot”. The Modern Version starts by simply saying “I swear”. God or the acknowledgement that there is a higher power only comes up with “I promise not to play at God”. The Modern Version ends with the politically correct “If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act to preserve the finest traditions of my calling and may I long experience the joy of healing those that seek my help”. What? No fame and fortune if I live up to my oath? No hell and damnation if I don’t?
One must remember that the Modern Version was written by Louis Lasagna in 1964, and seems to be a very watered down version of the Classic imposes in strong terms “principles”. Perhaps the “flower generation” was already having its impact and making responsibility a grey area. Take, for example the Classic Versions commitment of doctors to each other. We are to consider other doctors and their families equal to our families, and help them in every way we can “without fee or covenant”. Therefore, the profession is to be considered as a family in its own right. The Modern Version states that we should respect and share scientific knowledge. It does not mention our commitment to each other. Little wonder the pride of the profession is almost non-existent. Before Medicare, I never charged other doctors and their families, nurses, and clergy for the medical care I gave them. Now there is no preferential treatment even though the Classic Hippocratic Oath specifically states there should be. In fact, I believe Alberta has a law that prohibits doctors from offering any preferential care.
Accordingly, Hippocrates would be furious with the treatment given to retired Dr. J. Don Johnston of Calgary by the Peter Lougheed Hospital emergency department March 15/06. Dr. Johnston, a Calgary physician for many years and dying of cancer, lay in an emergency bed for nine hours without medical care, and eventually went home where his wife could care for him. Don’t get me wrong, Hippocrates would be shocked at anyone being treated in this fashion, but specifically, we in the medical profession are to look after members of our profession as though they were members of our personal family. I doubt if the doctors working the emergency department that night would have left their dying father lying in an emergency bed without treatment for nine hours! And I don't care what the penalty is for preferential treatment.
But I digress. Specifically, the Classic Hippocratic Oath states that “according to my ability and judgment, I will keep them (meaning the sick) from HARM and INJUSTICE”. (Capitals are mine). Wow, where were we as a profession as “risk” times grew longer and longer in Canada? Then the classic version goes on to specify that we should have no part of euthanasia or abortion. I wonder how that part of the Hippocratic oath sits with those people who keep harping on us to honor the Hippocratic Oath when we talk about the precipitous fall in our standard of living since Universal Health Care in Canada?
The Classic Version states: “Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice”. What’s this? House calls? Yes, you’re right. The Modern version doesn’t mention house calls. But what is this about intentional injustice? Could this mean that we should not have ulterior motives or be in a conflict of interest? That sounds good! Unfortunately the Modern version omits this area. It does, however, try to micromanage our practice of medicine by saying politically correct things like: we shouldn’t over treat, that prevention is preferable to cure, that we should be humble in the face of our “awesome responsibility”, and specifically to remember “that I remain a member of society, with special obligations to all my fellow human beings”. Now this last part really burns me! Keep in mind that this is a special oath taken by practitioners of medicine, as set out by Hippocrates, the recognized “Father of Medicine” who clearly states that our obligation is to the patient we are attending. All of a sudden, in 1964, one university elite decides that I, as a physician, have “special obligations to my fellow human beings”. “More special than any other member of society”, I ask, “and more than my special obligations to my patient”? Is my responsibility to society more special than to my fellow physicians? More special than to my family and friends? And who made this Louis Lasagna the “new father of medicine”? Over the last thirty years we have lost our allegiance to our patients, our pride in our profession and in ourselves, have become pawns to the whims of government, and have bought into the premise that we should be everything to everybody. Predictably, we are rapidly becoming nothing to anybody.
Hippocrates would be in a rage if he were alive today. Although he advocated that we dedicated our lives to serving those that need our skill and knowledge, he advocated that we do it with pride and independence, for it is only as independent practitioners that we can truly advocate for our patients. And we don’t leave our fellow physician who has given his life to caring for the ill, lying in a bed in the emergency department for nine hours waiting for care he never did receive. Shame on us all!

Family Physicians, Healers or Educators.

One of my pet peeves, as some of you regular readers know, is when the medical profession refers to its-self as “educators”. Yes, yes, I know that we certainly have a responsibility to educate, but the truth is, we are healers and education is just a small part of what healing is about. This should be particularly true of family physicians.
I have often said that I, as a family physician, will be anything my patients need me to be, if it will facilitate their getting well. One dying very elderly lady often confused me with her previously departed husband and hugged me frequently. Although awkward at times, it certainly was an asset in getting her to cooperate with the nursing staff and my suggestions. When I was younger I often had the impression that some of my elderly patients had trouble keeping from pinching my cheek as grandmas often do as a sign of affection. When I retired one of my elderly female patients gave me a huge bear hug with tears in her eyes and said: “you can’t retire, I’ve given you the best years of my life”. For those patients that regarded me as an educator, I spent the time reviewing their situation as an educational event and for those that considered me a friend and asked me what I would do in their circumstance; I would answer their question honestly with the caveat that each circumstance was unique and specifically review their criteria for treatment.
Contrary to the modern concept of “partners” in health (although there certainly is a group of patients who need that relationship), I feel that one of the most important roles a family physician has today is to be the parent that a patient doesn’t have, or feels they don’t have. And there does seem to be a growing need for this. This role requires mutual respect, trust, and the feeling on the patient’s part that you are truly there for them “in the long haul”, but have a responsibility that you will live up to.
The following cases best demonstrate this point:
Some thirty years ago I had hospitalized a 14 year old girl for recurring abdominal pain. Unlike most patients this age, she seemed to welcome being hospitalized. Further, while in hospital, her father phoned me daily to enquire how she was doing. The mother never phoned. I had ruled out as best I could organic causes of pain and had proceeded with considering psychosomatic causes. We had developed a good rapport over the years and because of the peculiar “before mentioned circumstances” I enquired about abuse. Suddenly, the most horrific story of sexual abuse was revealed that quite frankly shocked me. This was long before sexual abuse was on everyone’s radar screen. The end result was that the father went to prison and the young lady suffered years of psychiatric care. She trusted no-one except me. She would come to the office when crises, would sit and wait as long as she needed to, would only be admitted to hospital if I drove her, would only stay in hospital if I took her to her room, introduced her to her nurse, and promised to visit her at a specific time each day. She eventually stabilized from her trauma and became a nurse. She moved away many years ago, but drops by for a short visit when she is in town. Her father had abused her, her mother had abdicated her responsibility, and I had become her sole parent.
2) Again this young fourteen year old female patient had come to the emergency department because of a presumed overdose of her epilepsy medicine. Her previous family doctor had “fired” her because of repeated “faked” overdoses. Unfortunately, on occasion she actually did overdose, so the situation was intense. I was the family physician responsible for admissions that day for the emergency so she was assigned to me. She had been under a child psychiatrist and a pediatric neurologist for years and after obtaining their perspectives I spent time with this new patient. It soon became apparent to me that her home was a pathologic environment. Her father had left and her mother had remarried. Her step father was fanatically religious and her mother worshipped him and ignored her. She denied being sexual molested but I had some concerns. It soon became apparent to me that this young lady was extremely bright. I proposed a plan that she and draw up a list of areas were we would each be responsible. We shook hands. Her number one responsibility was to always be honest with me and tell me the truth; mine was to always act in her best interests. After consulting with her child psychiatrist and her parents, we decided to have my new young patient committed to a psychiatric group home if she wouldn’t go voluntarily. In keeping with our agreement she agreed to go voluntarily provided I would visit her at the home every month. I also insisted she be brought to see me at my office once a month.
The therapists at the psychiatric group home viewed this relationship with some suspicion and insisted on sitting in on the first few visits, but as time went by welcomed my visits. After the first year in the home it was decided she should spend a second year. My visits became optional as she gained confidence and security. She became an honors student at university and last I heard went away to do a PhD in criminology. Her visits to me were always special and started with a big hug (in the waiting room). When she left at age twenty two, the tears on her cheeks were an expression of her gratitude.
A person on the hepatitis enquiry asked the question “when physicians become business men, who do we turn to for a doctor”? I would like to ask the question “ when family physicians become educators (teachers), who does the patient turn to for a family physician”?

More on Trust Worthiness

Since doing the blog the other day on trust I have been troubled. This whole trust thing is actually quite complicated. It occurred to me that the measure of trust seems to be, in some way related to the consequences of being wrong in our judgment to trust. If that be so, the fact that firefighters are number one is quite significant, whereas, farmers being in number three position, is not very significant. After all, if I trust a farmer when he tells me it’s not going to rain tomorrow and it does, I may simply get wet. If I don’t trust a fireman who says my building is on fire and I should jump, I may burn to death. So trust seems to have something to do with “consequences” if you are wrong.
Somewhat related to this is, we will trust something to someone if we have the expectation that the information will be acted on appropriately and action will results in some benefit. In brief, the person you trusted can help you. This will depend on two things: 1) Does the person have the will or motivation to help? 2) Does the person have the power to help?
Perhaps in retrospect I have been too hard on the medical profession in my “Trust” blog. the other day. Although the consequences of medical decisions is right up there with the firemen, there is no question in my mind that we as physicians, are not as empowered to help as we once were. This is particularly true of primary care physicians who basically have to abide by what is available (almost a first-come first-served principle, and our perception of our insignificance in the system). Yes, I know that the political powers say their priority is primary care, and then they say, in the same breath, that they intend to push (and are pushing) Primary Care Networks, nurse practitioners, pharmacists, physiotherapists, and many other healthcare providers as the person of first contact in our Medicare System. Will we as patients give all of them our trust? My experience is normal patients are inclined to develop confidence in primarily one person with regard to their health, and not an establishment. They may develop a “high regard” for the establishment, but it is usually because of one person in the establishment, and secondarily, to other contacts. Without patient’s trust and confidence, I will predict the patients will be high health care consumers in our new “vision” of primary health care.
As a consequence of not having the power to help, many Family Physicians have lost their motivation to help. It is difficult to get over the feeling of ‘What’s the use” and “why do I have to push so hard so often to make the right thing happen”? I recall saying to my patients that it often seemed like pushing a boulder up a hill, and when you stopped pushing, nothing happened or you lost ground. I truly feel that many physicians have taken the “human” path of least resistance in order to just get through the day. And caring can be a serious handicap to survival.
Politician’s decisions can certainly affect our lives, so our trusting them can have serious consequences. They definitely have the power to deal with the issues we bring to them but sadly, I feel they don’t have the motivation. They seem to listen to the loud voices of special interest groups, and do poles on how to get elected. I guess that’s why I and about ninety percent of the population of Quebec don’t trust them.

Gardening

For those of you that have been reading my blogs on a regular basis, thank you. The bottom line, however, is I will be blogging less in the future. One reason is that I have already said most of the things that I feel are important. Sure, things will come up from time to time like Premier Klein curing cancer, but for the most part, things move at a snails pace in the medical political world (as opposed to new technologies which move at the pace of Katrina), and repetition is boring.
The second reason is that I am a gardener, and the gardening season is upon us. At present I have 600 geranium slips flourishing in the basement and about 1000 seedlings that need transplanting. Two days ago I transplanted 200 Alyssum, yesterday 200 Clarkia, and last week 100 dwarf tomato plants. All seem to be doing well, thank you.
To me, gardening has been a natural extension of my years of family medicine. Both need dedication, patience, perseverance, and knowledge. Gardening is far easier because other than weather, gardeners have much more control over their plants than physicians have over their patients. Gardeners, after assessing the needs of their garden and plants, can provide the necessary ingredients for growth and health. Physicians, on the other hand provide the information and the McDonald and 7-11 stores provide the food and nutrition. A conscientious gardener plants a plant in a location that is best suited to its nature, where-as patients have the freedom to wonder wherever they wish, and often at 90 miles an hour. If a plant is ailing, the knowledgeable gardener provides the necessary treatment and the plant gratefully complies. Patients wish to debate and discuss, and even after full disclosure and consent, often do not comply with the recommended treatment. To my knowledge, a gardener has never been sued by a plant or a garden, when through storm, wind, and flood, or other untoward event, the plant has been injured.
Although I miss my patients dearly since my retirement, I will satisfy my compulsion “to care for” by nurturing my many seedlings that will, in two to three months, be beautiful blooming flowers. And I will learn from them. They have already shown me that if I heed to their nature and their needs, they will flourish, and will do so quite independently in the appropriate setting. I have learned that my interference must be balanced with ample restraint, and they seem to thrive and show their true beauty and capabilities when given the opportunity to find their place of comfort. Perhaps if we kept these things in mind in designing our health care system, and dealing with health care providers and patients, we may actually have a model for success.

Trust

Front page in the Calgary Herald today “Who can you Trust”? I noted that firemen were first, followed by nurses, farmers, doctors, and teachers in that order. The report stated that order hadn’t changed in the last four years, but I do remember many years ago the order was more like “doctors, nurses, teachers, firemen, and policemen”. What happened that doctors are now in fourth place?
Well, for one thing maybe they have been hanging out with politicians too much in the past ten to fifteen years. After all, politicians are in last place garnering only a ten percent trust vote in Quebec. What’s the expression? “Judge people by the company they keep”.
And as a group we certainly have been cozying up to the politicians. Our parent body, the CMA even went so far as to fire an excellent editor of their journal because he wished to publish something that may have been politically sensitive.
Then of course we have been paid by the politicians (government) for the last thirty six years, so perhaps an element of distrust may creep in when a group you should trust is being paid by a group you don’t trust. And when did we start referring to our patients as clients? Isn’t this a term used by lawyers to refer to the people they represent and aren’t lawyers WAY down there in the trust category? And when did we become mealy mouthed and not be up front with our patients and the community at large? Weasel words like “wait times” are actually “risk times” and the people should know it for what it is----but then that would put pressure on governments to DO something about it, and that would make things difficult for the least trusted politicians, and maybe they wouldn’t agree to give us a pay increase. Actually, come to think of it, I’m surprised we are still in fourth place.
Oh yes, and we don’t tell people what they should do anymore. We are educators and our job is to just “present the information and let the patient (client) make up their own mind”. Can you imagine a firefighter yelling to the person on the third floor of a burning building: “you could jump and we will do our best to catch you and position our nets accordingly, or , we could attempt to place a ladder and have a “person” carry you down, or, we could try to send someone up the stairs to get you, or you could wrap yourself in wet blankets, or, etc, etc” along with all the pros and cons of each course of action. My guess is the firefighter would determine the safest course of action and state categorically what the person should do. Have we as a profession lost our leadership ability of giving the appropriate advice and accepting the responsibility for doing so? Are we just another politically correct crowd? I guess perhaps we have and are. We are a “member of a team”, not a doctor but a “health care provider” looking after “clients”, not patients.
Patients should rightly be asking themselves how we, as their advocates, have allowed things to get to this state. Why hasn’t there been “fire alarms, carbon monoxide alarms, and smoke alarms” clanging daily in our health care system over the last twenty years? How did we get from Ben Casey, Dr. Kildaire and Dr. Welby, television physicians who were decisive, compassionate advocates for their patients, to the hormone impaired physicians in the television show “Grey’s Anatomy”?
I must admit, if I was in a burning building and the fireman (person) yelled jump, I would probably trust the advice and do it. But how many physicians even give advice nowadays other than the predigested politically correct “lifestyles” and “options” copout. How many are trusted enough to be asked “Doc what would you do?” and I can assure you, rarely would you, the patient, be provided with an answer to that question and the reasons for it, in today’s medicine. We have sterilized our approach to our patients and made it impersonal. People trust those that are open, honest, forthright, and have proven themselves as trustworthy. Can we as physicians claim those characteristics today and over the past twenty years?

Whose Choosing the Team?

There is no doubt in my mind that our childhood experiences determine to a significant degree, life-long attitudes. Take my lack of faith in the much toted “team approach” to medicine. When I was a child and grew up on a mixed farm in Saskatchewan, I and my older brother by three years had a long list of chores. Some of these chores were specific to each of us individually and some were things that simply needed to be done by us jointly. My brother learned early on that if he procrastinated or simply abdicated his responsibilities, I would eventually make sure everything was done by the time our parents returned. It was not lost on me, even at a young age; if everything was done there was joint approval, if things were not done, my parents expected me to have looked after it. This did not raise warm fuzzy feelings in me towards my brother or my parents.
The bottom line is that responsibility will usually end up with those people that “feel” responsible, not necessarily with those that “are: responsible. The corollary to this is the people who assign the tasks and expect the results are always more concerned as to whether the results are achieved, than they are as to how that came about.
Some fifteen to twenty years ago Calgary was already experiencing a shortage of Psychiatrists (this may have something to do with the fact that psychiatrists have traditionally been the lowest paid of all specialists in our health care system). As a response to this, the psychiatric department at the Holy Cross hospital decided they would take a “team” approach” on the inpatient psychiatric unit. There would be an “intake worker”, psychiatric nurses would counsel the patients, the admitting family doctor would write the orders, and the “psychiatrist on call” would be the team and patient consultant. In this scenario, as can be seen, the admitting physician had no say in the personnel on the team that was to attend the patient.
About this time I had a patient who had many anger issues, was somewhat paranoid, and I thought posed a threat to herself and possibly society as a whole. After considerable discussion she agreed to be admitted. Within two days of her admission the “team” felt she should be discharged but I would not comply. Complaints went to the department head and administration and when I demanded reasons for the discharge, I was told “she is disrupting our program”. I told them I would not comply unless the psychiatrist involved agreed to take a more active role in the “out patient” setting. When this agreement was reached and set up the patient was discharged. I was certainly left with the impression the “program” was more important than my patient.
Several days later, at approximately 3:00A.M., her room mate phoned me and said my patient had left the apartment with a gun, and her parting words were:“ I’m going to go out and kill myself some people”. I phoned the psychiatrist involved and was told there was nothing to do unless the patient actually did something. I phoned the police department and got the same answer to my concern. Naïve me, I thought taking a gun and threatening the good citizens with death was “doing something”. I guess you have to name the person you intend to kill and fire off at least one warning shot to reach the “doing something” yardstick.
Anyway, over the next few days my sleepless nights were rewarded with no drastic headlines in the newspapers, and I was able to get my patient to return to my office. With considerable time and effort I convinced her of the wisdom of a voluntary admission to the Ponoka Mental hospital. She finally agreed and spent one month under their care and was discharged. Since the active treatment wards of acute care, and their team concept was to coordinate the institutional care with the patient’s introduction back to the community, an attempt was made to have her discharged from Ponoka to the Holy Cross psychiatry unit, and then facilitate her integration into the community and set up a follow up community program. I was told once again that the unit would not oblige in this plan since their last experience with this patient caused a disruption in their program. The patient subsequently was discharged directly to the community, and was lost to follow up.
I never did see her again. She probably rightly felt that I and the system (team?) had failed her, and rightly so. Patients will lay failure at the feet of those from whom they expected help. In our “new team concept of primary health care” who will the patient expect results from? I think the answer is “whoever shows and feels the most responsibility”. Will there be someone on the “team”?
As I practiced medicine in Calgary I developed over the years a team of “like minded” specialists and care givers to assist me in patient care. This included office staff, specialists and many other health care providers. I did this through choice, observing and working with various people so that as the years went by I can say that my “team” was as thoughtfully and thoroughly chosen as any professional sports team. I was reminded of this by my patients when I retired. Many of them not only thanked me for my years of care, but also thanked me for the wonderful people that I had referred them to in the past.
Do I have confidence in the modern day concept of the team approach? Keep in mind you will see the person in the team that a triage person feels appropriate. Keep in mind you will see the specialist that has the shortest waiting list. I suppose I have as much confidence in this approach as I would of choosing a hockey team to win the Stanley cup comprised of players who weren’t anybodies draft pick.

Give Credit Where It Is Due

Evidence based medicine, education, and preventative medicine are continually being promoted as the salvation of our Universal Health Care System. Interestingly enough, there seems to be very little Level 1 research showing that a “healthy” diet as we know it at present, will contribute to longevity. Ongoing debate on low carbohydrate diets versus low saturated fat diets seems to leave us no-where. When my patients went on very strict low fat diets in the past, I noticed their HDL would drop, and now I believe there is evidence that saturated fats are necessary for the metabolism of HDL (good cholesterol). We seem to be quite sure at this time that trans fats are bad and after many years of suggesting that diabetics don’t need to worry about sugars, we are once again back to limiting “refined” carbohydrates. We believe that exercise is good, but there is very little Level 1 research that I know of that shows exercise will significantly decrease bed utilization in our hospitals. Recent research now suggests that perhaps it is not so much what we are eating, but what we are not eating (like sufficient linoleic acid containing foods), that is doing us harm. I will defer all this to nutritional experts (welcoming comments!). Suffice it to say, all of the above is very confusing and requires effort on the part of the patient both to learn and initiate. Personally, in my practice, I always found it easier to get my patients to take a pill than read a label or work up a sweat!
The point I’m getting at is best made in the March issue of the journal “Atherosclerosis in Primary Care”. The feature article is titled “early benefits of statin therapy in lipid lowering trials” and goes on to show that many lipid lowering trials (Level 1) have shown that aggressive lipid lowering with a statin, reduces the incidence of MI’s in 90 days and strokes in two years. This is done supposedly by lowering LDL, improving the health of the intima, and an anti-inflammatory effect of the statin. Since this is good “evidence based medicine” why is it that our (physician) “educators” are still advocating life modifying approaches as first line therapy for high risk patients? Not long ago one of our leading educators suggested (in a medical journal) a conservative approach like this for a patient with five cardiovascular risk factors (high risk). Why shouldn’t we start with 80 mgs. of atorvastatin and at the same time institute the life style modifications? If the patient is the exception to the rule, and is a huge success with life style modifications, consideration can be given to decreasing or stopping medication. For patients that have an aversion to taking medications, this approach may even be an incentive for them to adopt a healthy life style.
The cost of Pharmaceuticals has increased faster than any other aspect of health care over the past twenty years. There is a definite push on the part of our educators to decrease the use of pharmaceuticals in our patients. We often hear statistics on all the hospital admissions and deaths that occur because of medications but is this because of error and mismanagement or from the medications themselves? To pass judgment, this must be balanced against the lives saved and hospital admissions prevented by these various medications. The statin group of medications, and most of our anti-hypertensive group of medications, have that information available to us. There is very little rational for delaying pharmaceutical interventions.
Statistics show that we as a society are getting more obese and less active in spite of efforts at education. We are reaping the results of fifty years of smoking, years of consuming transfats, and an increased pollution to our environment; and still the life expectancy of men and women in Alberta is ten years longer now than it was when I graduated in 1962. It is not because people eat healthier or exercise more. Perhaps if we, as a profession, didn’t join in the chorus of voices giving pharmaceuticals a “bad rap”, we wouldn’t have so many patients who are non-compliant with their medications.

A Useful Future Program

For those of you readers who may think that I am simply critical and never constructive, today’s blog has to do with a program that I have mentioned previously. This program is directed at the two thirds of hypertensives and the two thirds of hypercholesterolemic patients that are not, or are inadequately treated. It may also help in terms of the epidemic of obesity and diabetes in Canada today.
I have sent this information to theAlberta Health Ministry and have sent it to the Calgary Region Medical Staff Association.
Critics will wail about an infringement on privacy but note that already governments at all levels have infringed on our personal freedoms in a more aggressive way. We have seat belt laws and helmet laws that are restrictive, punitive, and protect only the individual, and are supported by our medical associations and our tax dollars. This program would not be punitive but would be more like our immunization programs, which also are strongly supported by our medical associations and our tax dollars. This program would help identify people at risk for diabetes and cardiovascular disease so that information can be individualized and appropriate interventions suggested.
Our Health Minister, Iris Evans, stated in her letter to the Editor, Calgary Herald, Mar/11/06, “Opening opportunities in the private sector will also help recruit and retain health-care professionals that will result in increased capacity and access”. This is the first time I have seen this type of statement in the Mainstream News Media although I have attempted to put it forward for ten years. Mostly all we hear is the idea that the public system will loose all their professional workers and be left destitute if there is a private parallel system. If the powers that be are as slow to implement this, my latest suggestion, at least my grandchildren may benefit. This is the letter that I have sent to the Provincial Health Ministry and the Calgary Health Region.

In my last letter to Vital Signs I raised the issue of “Fidelity” in health care. As previously mentioned this term relates basically to the “systems” application of our medical knowledge. I mentioned also that when family physicians attend seminars on cardiovascular disease, we are always impressed with information pertaining to the number of untreated and under treated hypertensive and hypercholesterolemic patients.
It is my understanding that at this time considerable money is being offered by various levels of government for innovative approaches to health care in Canada. May I propose the following?
The idea of reviewing a person’s health at a particular age is not a new phenomenon in Alberta. For years physicians have been examining 75 year old citizens to establish their ability to operate a motor vehicle. My suggestion is to set up a similar process to screen for cardiovascular disease that needs a treatment approach. The system need not be nearly as complex as the driver’s scenario. In fact I would suggest starting with the following: 1) Blood pressure reading 2) Weight and waist circumference 3)BMI 4)Smoking history 5)Family history for diabetes, stroke, and MI. This approach would require minimally trained people as “examiners” and could be repeated every five years starting at age forty or fifty. A weighting system would be attached to positive answers and a threshold applied at which point information was forwarded or handed out to the person as to the need for intervention and resources available. Each year a new age group could be added to the screening program e.g. Fifty year olds in 2007, fifty five year olds in 2008, sixty year olds in 2009, etc. Within five years the core group of people at risk would be covered.
A computer generated reminder system would annually remind the “at risk” group that they should be under medical observation and care.
Immunization programs, to date, have been demonstrated to be the most cost effective interventions in medicine. I would suggest that the system that I have outlined above would come in a close second through the resulting early detection of diabetes, people at risk for cardiovascular events, and the appropriate timely interventions. This program could be contracted out to the private sector but funded provincially. Referrals resulting from this “screening” would, of course, be dealt with by the public system.
Would the public oppose this imposition? Possibly. But the expectation of getting something for nothing needs to come to an end. The generic public education attempts to date are falling far short of their intended mark. Perhaps it is time the province and the medical and nursing professions took a combined stand on prevention that has some “bite” to it. The last time we did was many years ago with immunization. Let’s take a similar stand and develop a similar program for the epidemics of diabetes, obesity, and vascular disease.
Respectfully submitted,
Dr. Al Wilke.

Midwives, An Obstetrical Boutique

What would I do for material if the Calgary Herald didn’t expound on health care from time to time. In Monday’s Herald (Mar13/06) the editorial starts with: “If one of the key goals of Alberta’s “third way” in health care is to rein in escalating costs of the public system, then it makes no sense to refuse to fund a service that will save the system money” and ends “With a solid business case like that, there’s no reason to delay this increasing popular low cost to doctor-directed deliveries”.
Their entire position seems to be predicated on statements provided to them by the Alberta Association of Midwives. No outside analysis or independent analysis is quoted. Reference is made to other provinces paying midwives $70,000.oo to $72,000.oo per year or approximately $2,000.oo per delivery but I could not find any cost accounting by these provinces as to whether this was cost effective as compared to family doctors and obstetricians being paid less than $1,000.oo per delivery. Personally, if I was a family doctor or obstetrician practicing in a province that paid midwives twice as much as physicians, I would quit doing obstetrics.
Midwives say that they deliver a different service than a physician, and this is likely true. It is probably the “boutique” of obstetrics with special catering and individual service geared to patient’s likes and dislikes with more “public relations and hand holding” thrown in. But should I, as a tax payer, pay for this special service?
There is no question in my mind that other provinces have brought in coverage of midwives for political, not economic reasons. In the face of an ever decreasing obstetrical care work force it would be and is politically difficult, to turn down potential caregivers at any cost. Kudos to Health Minister Iris Evans and Alberta Health spokesman Howard May for making Alberta’s position clear, and I agree with that position. Adding a new service to the list of covered services at a time when the goal is to bring in more private services and review existing covered services would be unwise. Many points made in the Herald editorial are obviously taken directly from the Alberta Association of Midwives public relations people or persons. From my inquiries the issues of midwives delivering in the hospital setting are many and complex, and certainly do not point to any cost savings. Cost savings can certainly be realized with home deliveries and deliveries outside of a hospital setting. (birthing centers). This raises specific quality of care issues, and the monitoring and provision of safety in the home and birthing centre settings. If the government paid for the service, should there not be quality assurance and safety guarantees? Good medicine for me has been: “Always expect and be prepared for the unexpected”. The following experience in my professional life convinced me that I would never be involved in, or recommend, deliveries at home or in community birthing centers.
In my early years of family medicine I was delivering approximately fifty babies a year. On one occasion I was called to a delivery at the Holy Cross Hospital at approximately four A.M. to deliver the first baby of a twenty year old woman who had a totally normal prenatal period and would be termed “low risk”. As the baby delivered and I leaned forward to place the infant on mother’s chest she exclaimed “I don’t feel so well” and promptly became unconscious. At the same instant I experienced a gush of warm wetness over the entire front of my gown, and on looking down, saw a gush of blood one to two inches in diameter basically shooting out against the front of my gown. One would have to estimate the rate of flow at about one gallon per minute if it were to continue. Fortunately, there were two nurses in the room and within 15 seconds there were two more nurses present. The baby had to be taken to a safe place, the mother had to be tipped head down, intravenous medication had to be given, the blood pressure had to be monitored continuously, a second I.V. line was started, the laboratory had to be called for “stat” cross matching of blood, a specialist had to be called. Meanwhile, I had to do an immediate manual removal of the placenta and then apply immediate and considerable pressure on the uterus from above and from below per vagina until the I.V. medication controlled the bleeding and the uterine tone. My arms ached from the maintained pressure. Once the bleeding was controlled, the cervix and perineum were examined for lacerations. By the time the specialist arrived the mother was stable and awake with two I.V.’s running and blood on the way. The bleeding had stopped, the baby was fine.
Since that time whenever someone advocates home deliveries I think of that experience and on occasion have had nightmares of that scenario in a home environment. Other life threatening events can occur during obstetrical deliveries: prolapsed umbilical cord, uterine rupture, placental separation and precipitous fetal distress to name a few. Although the majority of deliveries need very little intervention from health professionals, our and the systems responsibility is to be prepared for the worst. And as one elderly wise obstetrician reminded me: “If you haven’t experienced this kind of unforeseen obstetrical emergency, you simply haven’t delivered enough babies yet”.

Conscription in Canada

If one is to believe the news media and our public health experts, a pandemic of some sort is not a matter of “if” but rather a matter of “when”. If one is to believe various government sources, Canada is among the nations of the world that are best prepared to deal with a pandemic. We hear about vaccines and biological approaches to such a pandemic, but have heard very little about our human resource and facility capacity to deal with such an event. Perhaps there are reasons for this lack of information; perhaps we don’t have the necessary capacity and any moves so far by governments are non-existent, inadequate or so draconian that the public relations people would rather keep the publics eye diverted elsewhere.
Take Bill 56, for example. This bill was introduced by the Ontario Government on Dec./15/05, the last day before the Ontario Parliament shut down for Christmas break. The bill provides for a $100,000.oo fine and one year in prison if qualified medical and possibly other qualified personnel refuse service in the event of a pandemic. Apparently the bill does not make provisions for, and mandate the government’s responsibilities to, the people who are conscripted.
During the SARS outbreak in Toronto, my understanding is that the majority of the morbidity and mortality occurred in the “caregiver” population---physicians, nurses and their families. In a pandemic, one would assume the same scenario. In effect, caregivers will be the “canaries” in the “mine” of a pandemic. Considering that in Canada we already have a shortage of caregivers (physicians and nurses) is this approach wise? Even worse is the fact that there are no assurances in Bill56 that the necessary supplies and resources to protect caregivers will be in place (such as caregivers and their families given priority to immunization, appropriate masks, gowns supplied, etc.).). Further, no compensation (disability insurance, life insurance, family support provision in the event of sickness or death) is stipulated. My understanding is there are no exemptions specified. Can you imagine how a family physician who is the mother of three small children and whose husband is also a family physician feels about this Bill? Strongly enough to leave Ontario?
The response of the Ontario Government so far is that such things will be negotiated as the need arises. Unbelievable! Who is going to want to discuss these issues when all hell is breaking loose? Were these things determined before health care providers became exposed during the SARS outbreak? For that matter has there been any resolution of these issues for the victims and the families of the victims of the SARS outbreak? Probably not.
So far the Ontario Medical Association and the Canadian Medical Association have “voiced their concerns”. We will see what good it does. The Ontario government intends to have final reading on this Bill by June/06. Does anyone know what other provincial governments are doing in this regard? Although we are repeatedly reassured of our preparedness, I suspect there is very little in terms of a concrete plan. After all, if caregiver and facility shortages have been getting worse over the past fifteen years with no end in sight or solutions on the horizon, what is the likelihood of governments having solutions to the incredible increase in demand and complexities of a pandemic? They certainly haven’t shown brilliance in health care planning to date. Certainly, Ontario’s Bill 56 is a shining example of a very bad start.

Quebec, Canada's Abortion Capital

Happy Birthday to me, happy birthday to me, happy birthday to meeee, happy birthday to me! Since it is my birthday today I thought I would write a blog in support of all those little people who have never had the opportunity to celebrate a birthday. I also realize that by doing this, there may be some bloggers out there who will take this opportunity to point out that my blog is a justification for unlimited access to abortion, but, so be it.
A recent article in Canada’s obstetrics and gynecological journal stated that the abortion rate in Quebec was ten times higher than the rest of Canada for a corresponding “at risk” age group. In addition the article stated that within one year, forty percent of the women under twenty five having their first abortion would have a second abortion! Even more astounding was the premise that they would solve this problem with a new education program. I found the entire article simply incredible! No one seemed to be asking the questions as to WHY Quebec had this incredibly high abortion rate. Was there evidence that the women getting pregnant didn’t know about birth control pills (they’ve been around for forty years), do they not have access to condoms, are they not aware of STD”S, AIDS, etc.? Do condomes and birth control pills cost more in Quebec? Certainly the forty percent that got pregnant within the first year of having their first abortion should have known pregnancy can result as a consequence of sexual activity. Possibly they thought if you did it for pleasure instead of procreation, pregnancy wouldn’t occur!
This clearly is a sociological problem that needs investigation and I would think provides a huge opportunity for sociological research. You can’t address a problem without knowing something about the underlying determinants that contribute to that particular behavior. Quebec at one time was a strongly Catholic province. Has the Church lost its influence? Or is its’ influence now limited to birth control and not sexual activity. It certainly seems to have lost its negative influence on abortion. Is their abortion rate a reflection of general attitudes that prevail in Quebec and not the rest of Canada? Can this be equated to morality in any way? Perhaps Quebec is truly a separate country in many ways in addition to language. They claim their culture is unique---is their abortion rate part of their uniqueness and what else does it say about that uniqueness? This issue should be a sociologist’s paradise. Good scientific research could shed valuable light on an issue that most Canadians are struggling with-----how can we reduce the number of abortions in Canada without taking away the women’s right to choose? How can we as a compassionate society encourage the prevention of unwanted pregnancies and discourage the use of abortion as a contraceptive? These are common goals for which we can all strive, but it will never happen as long as our scientific bodies keep throwing out that wonderful placebo “education” instead of doing good sociological research. And it would seem that good scientific research is always trumped by the taboos of discussing and investigating the “off limits” areas of abortion and Medicare.

Health Care as Entertainment

After ten days nothing has changed. The news media is still skirting around the real issues in our health care system. Tom Olsen, in the March 09/06 issue of the Calgary Herald, writes an article entitled: “Health debate makes for good theatre”. My position is that if the news media didn’t treat our health care crisis as “good theatre” perhaps we could experience some good debate.
In his article he goes over the usual tiresome comments from the provincial NDP, Liberals and lobby group “Friends of Medicare”. He also quotes Elaine (whose qualifications are unknown) as saying: “The people who have money will go to the private system, the people who are disabled, who have chronic conditions, the private system won’t take them” ( she doesn’t say why they would go to the private system). To me, this statement opens up several questions. As a compassionate society, do we have an obligation to look after everyone or just those that for whatever reason are unable to look after themselves? Why do we have laws that prevent people from looking after themselves, thus making them a burden on the tax payer? If more people look after themselves won’t there be more resources in our system for those who are unable to look after themselves?
The “Friends of Medicare” and their supporters say health care providers will leave the public system and go to the private system. Why would they? Are they being treated badly? Would a private system lure caregivers back to Canada who have left over the past twenty years? Has any one actually surveyed doctors and nurses who have left to see if they would come back under a different system? Has anyone surveyed our existing care givers in our public system to see if they would go to a private system and if they would, why? It amazes me that in a country and at a time in history when communication is “king” we don’t have answers to any of these questions, only assumptions.
I think it is safe to say that generally once an ill person accesses our public system, they receive as good care as most private systems in the world. So why would Elaine bemoan the fact that the poor, disabled and chronically ill will be left in our public system as though it were in some way second or third rate? Statistics show it is equal to private systems except in one way----access. The bottom line then: Any way and all ways of improving access to our public system will improve the medical care of the poor, the disabled and the chronically ill. So, news media, use your investigative and communication powers and let’s do some real investigative reporting. Leave the theatre to the entertainment industry, at least on this one important issue.