What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Sunday, September 16, 2007

You may pay for our Canadian System With Years of Your Life

Chapter Five: How is Mr. LD doing now?

First the bad news; Mr. LD has spent approximately 300,000 dollars to date for medical treatments south of the Canadian border. He has been inconvenienced considerably by having surgery in a foreign country, staying in hotels, being apart from his family during these stressful times, and of course, enduring the pain and discomforts of his surgeries. He is being maintained on 4 mgms. of Zemeta intravenously once a month and 30mgms. of Depo-Sandostatin intramuscularly once a month administered by myself and a home care nurse. He occasionally takes some ordinary acetaminophen or Advil for a slight ache in his left arm residual from a bone met. that was previously radiated but is not progressing. He has two other small bone mets. that have showed up on scanning in the past six months but also do not seem to be progressing. He continues to visit the MDAnderson Cancer Center every three months for scans and follow ups that likely will set him back some additional dollars.
Now for the good news; He is free of 99% 0f his tumor load and since this has been identified as a slow growing malignancy, likely will still have another four or five years of life expectancy. He is basically pain free and symptom free, walks one to two miles everyday, and continues to run his many businesses, paying in excess of 300,000 dollars in income tax every year. I’ve listed the tax as a good thing since it is better than his demise in which case, tax would not be a problem for him. Basically he continues to enjoy his normal good quality of life. I find it quite ironic that he supports our health care system with his considerable tax dollars, but the system certainly did not support him.
So what went wrong for this man at one of our more “advanced” cancer centers in Canada? Some of you will say it was a failing on the part of the physician surgeon, but it is my understanding that this particular physician is one of the most respected at the Center. Perhaps we do not have the technology to determine that he had 50% more liver than necessary to survive the surgery. If this is the case, why not refer to a center that has more accurate CT scanners and the necessary technologies. For that matter, why was not a second opinion/referral given when the patient specifically asked for that information? The cliché that “we all read the same medical journals” certainly was of no help to my patient. Or are we, in the medical profession so pressed for time that such a time and effort commitment is only made when there is the potential for a cure, not simply for additional years of life. Even more frightening is the question: “Are we as physicians prioritizing what we do to save the system costs”? We do know that our transplant teams are given annual budgets and patients are selected as to “who will benefit the most”? Has this become a “Modus Operendi” for major surgeries in general?
So once again the question needs to be asked “What is a year of good quality life worth to you. If Mr. LD lives another four years he will have gotten at least five additional years that he would not have had by accepting his “fate” in our healthcare system. That will work out to about 60 to 70 thousand dollars per year of life, a figure that he feels is a bargain. But do you and I have those resources, and why is private insurance banned in Canada. The Supreme Court of Canada ruled in the Chaoulli case that the law was unconstitutional. Why haven’t provincial governments in Canada responded, or is the constitution for the protection of Quebecers only? After all, the average Joe doesn’t have the deep pockets of my Mr. LD, and insurance was designed to protect us low income folks from unforeseen major costs. What I would like to know is whether, as a Canadian citizen, I could take out insurance in the U.S.A to cover second opinions and delays in access to our healthcare system. It may be something to consider.

Thursday, September 13, 2007

MDAnderson Medical Center, Houston, Texas

Chapter 4, Some Surprising Information

Technology can be a wonderful thing. Within 36 hours of requesting patient referral information from the MDAnderson Cancer Center, I received the necessary forms via E-Mail. The forms were completed and appropriate information was provided and returned. Surprisingly, an appointment was not obtained for three weeks, and this was with a gastroenterologist specializing in carcinoid malignancies. Of interest was a request for a line of credit to be established for $50, 000.
At first I was taken aback, and then I remembered that 18 years ago when I was having a dispute with our Canadian tax department, the firm I wanted to represent me requested a $50,000 deposit to take the case on. We as Canadian physicians in the Canadian socialized system have totally lost track of the relative value of our services and simply think “small”. The thought also crossed my mind several times since then as to whether Canadians can take out health insurance to cover them for American health care (seems to me there is a business opportunity there!!).
In any event the line of credit was arranged, and Mr. L.D. was seen at the MDAnderson Cancer Center, Houston Texas. In three days he had been seen by the medical oncologist, the chest surgeon oncologist, the abdominal surgeon oncologist, had all the special scans done, blood work done, (that, in Canada, take two weeks to get the needed blood test results, and as indicated previously, months for the opinions and diagnostic imaging) , and was given their considered opinion. That opinion was as follows:
1) Surgery was the best approach to his problems. Since the cancer was relatively slow growing and hormone producing, debulking was the approach of choice. Further it was proposed that the liver tumors (cancer), were to be approached first since they consisted of 90+% of his tumor load and the size of the liver growths interfered with his pulmonary function. Further, they suggested that he would have 50% more liver left after the surgery than he would need to survive the surgery (note that, here in Canada, he was told that he would not have enough liver left to survive the surgery). He was given a mortality rate of 1.5% with this surgery.
2) It was recommended that two to three months after the abdominal (liver) surgery he should have a lobectomy for removal of the lung cancer. Their pulmonary assessments suggested that he would have sufficient respiratory function after the lobectomy to tolerate the procedure and suggested a 1.3% mortality rate with this procedure.
3) If he survived these two procedures he was given a life expectancy of four to five years. Please note; here in Alberta a mortality rate of 5% was given with embolization alone which, at best would shrink one liver tumor. Here in Alberta he was given no chance of surviving the abdominal surgery, approximately six months to live, and offered palliative care only. At the MDAnderson Clinic, a combined mortality rate of 2.8% was given for REMOVAL of all three liver cancers and the primary lung cancer, and a four to five year life expectancy. Which would you choose? (A cure was not possible because Mr. LD had a small metastatic bone lesion in his left humerus).
4) He was told to go home, consider and discuss the options with his family and physicians, and let them know. The first surgery could be booked in a matter of weeks.
The patient, of course, opted for the program proposed. He flew to Houston, had his surgery and was discharged after six days in hospital. He remained in Houston following the surgery for ten more days, was treated as an out patient with I.V. antibiotics for a wound infection, and returned home feeling well except for post operative pain. It should be pointed out that the surgery (my impression from reading the three page operative report), was quite incredible. Using an intra-operative ultrasound, all three liver cancers were removed during a seven and one half hour operation. The approach used in the surgery had to be modified with access posteriorly because the cancer was partially surrounding the inferior vena cava (main vein returning blood to the heart from the lower part of the body), and much time was spent dissecting the tumor away from this major blood vessel. It was apparent to me had this surgery not been done, the cancer would have invaded/choked off this blood vessel eventually with dire results.
Within three weeks of the patient returning home, he developed incapacitating diarrhea with fever and decreased blood pressure. I sent him to Calgary’s “hospital of excellence” emergency department, informed them of my concern for a C. deficile infection since he had I.V. antibiotics three weeks prior, and requested a stool culture be done. I was informed that it was not necessary, Mr. LD was given two liters of intravenous fluids for dehydration, and sent home. I must say, this amazed me; a post operative cancer patient (impaired immunity), had I.V. antibiotics less than a month prior, symptomatically deteriorating from diarrhea, and a stool culture is NOT DONE. Needless to say, when the patient got home six hours later I arranged for a stool culture, the culture came back as food poisoning, and because of the fever and the circumstances (debilitation/cancer) he was treated with the appropriate antibiotic. He breezed through the remainder of his post-operative period.
Three months later he had his lobectomy to remove his primary lung cancer. He was discharged after five days in hospital, and remained in Houston for an additional ten days, and then returned home. His progress postoperatively here was uneventful.
Next, Chapter five, How is Mr. LD doing now?


Sunday, September 09, 2007

Incredible Medical Avances

Chapter Three: Searching For Information.
I find the starting of a project is always by far the most challenging (where to start?). Yes, I know you can go to the internet and find reams of material, but two problems arise; the first is to know the validity of the information obtained, and the second is to obtain the most recent available information. I basically took three approaches:
1) I combed the medical literature, not just for neuroendocrine tumors and their treatments, but the treatment of cancers, in general, spread to the liver, and the liver lesions themselves, since I still felt that reducing “tumor load” in this patients’ case, was key to his longevity.
2) I looked at pharmaceutical sites and reviewed the research that they were doing in various fields,
3) And I contacted a specialist in respiratory diseases that I knew and respected. It certainly was an advantage that he also sat on several international committees that dealt with respiratory disease and therefore knew which centers were highly regarded for treating lung cancer.
Meanwhile another physician friend of my patient did some medical searching as well and forwarded me huge numbers of trials which I reviewed. Unfortunately, most of these trials had been completed in 2002 and 2003, and therefore had been started several years prior, thus making them considerably outdated.
My main concern on the short term was from the effects of the hormones on the heart so an echocardiogram was arranged and reported as normal. The second concern was of a major pulmonary bleed, since my patient was coughing up significant amounts of blood at this time. A referral was made to an excellent interventional respiratory specialist (not the surgeon seen at the cancer clinic previously) and a bronchoscopy was performed and appropriate cauterization done. The patient tolerated the procedure well and was much improved from a coughing blood perspective. I contacted one of the specialists at Calgary’s “specialist” hospital and was quoted a mortality rate of five percent with embolization of this patients’ primary liver tumor. I requested a meeting with the physician in question and was told that the risks would be discussed with the patient prior to doing the procedure and a meeting was not necessary. Mr. L.D. did not accept these risks without a meeting and time to consider, and I concurred. This ended my resources within our public system.
As a physician I am probably more aware of the amazing things happening in medicine than the average person, but I must say, the research going on around the world is phenomenal, even to a physician. Some research and a researcher in Frankfurt Germany were written up in an issue of the Medical post. He was treating liver cancers with a laser probe. I was able to obtain his E-Mail address from the internet and sent him some of the info on my patient. Within 30 minutes I had a response to my enquires along with three research studies that he had done consisting of 700 plus patients. In these studies many patients had 18 months added to their life expectancy. Unfortunately, the largest tumors treated in these studies were eight centimeters in diameter and, as previously mentioned, my patients’ main liver tumor was 18 by 20 centimeters and far too large to treat in this fashion. He did mention that a fellow researcher of his did chemo-embolization and often would shrink the tumors down to a size that could then be laser treated. He forwarded additional research information. Instead of obstruction the arteries to the liver tumors completely, this protocol identified the artery supplying the tumor, injected chemotherapy into the artery (and thus the tumor), and then injected a sludge like substance that would clog the small arteries of the liver tumor and delay the exit of the chemotherapeutic agent. Using this technique a tumor reduction of up to 70% was obtained in some patients. Interestingly, the mortality rate was a fraction of one percent.
At the end of a considerable amount of literature review by myself and Mr. L.D.s’ other physician friend, and upon the advise of my internationally recognized respiratory specialist friend, arrangements were made to consult with the Anderson Cancer Center in Houston Texas. Information between me and a physician at the clinic was exchanged and test results including C.T.s, X-rays, blood work, etc was forwarded on with the consent of my patient and they felt they could offer him some realistic hope. An appointment was arranged.

Next Edition: Some surprising information.

Friday, September 07, 2007

The Obsolete Second Medical Opinion

Chapter 2: This is Our Opinion, and It’s The Only One You Get
Neuroendocrine cancers are uncommon, and primary lung neuroendocrine cancers are actually quite rare. So much so that the neuroendocrine cancer “Team” met only once a month in Calgary. We were assured that we would be meeting with a team of specialists that were prepared to answer all questions. My patient, Mr. LD, asked if I would attend this conference with him since, as a lay person he was quite unfamiliar with the medical jargon and wished my presence to assist him in addressing all the pertinent issues. I consented; as much from curiosity as from allegiance to a former patient, I must confess.
We were first interviewed by a nurse who took some medical history and a blood pressure. Next, a resident in neuroendocrinology came into the room and took another history and did a cursory examination. This was followed by a senior resident in general surgery who again took a history and did quite a complete examination. By this time one and one-half hours had gone by. Finally an endocrinologist that I had known for years (a very nice elderly man) and a surgeon came into the room with the aforementioned residents in tow. A few additional questions were asked for clarification and the patient was told he had very few options. The situation and the disease were explained to him in detail, and he was told that they could offer an injection that would help control his symptoms but would have little if any effect on his cancer (his symptoms were already controlled with codeine over the past three months). The patient enquired about chemotherapy, but was told this would likely not be helpful since the size of the one liver lesion was out of reach of any chemotherapeutic agent, and generally, these tumors were unresponsive. The endocrinologist said he would check with the Edmonton cancer clinic, but was not hopeful. The patient enquired of other centers in the world but was told that medical information was shared world wide, and the information being given to the patient was recent and up to date.
I had done considerable research before this meeting (I had months to do it) and the literature stated that many patients with neuroendocrine cancers died of the effects of the tumors produced by the cancer rather than the cancer itself. I asked the surgeon regarding a “debulking” procedure that may dramatically reduce tumor load and thereby reduce hormone secretion (one measurable hormone was ten times higher than normal and another one was one hundred times higher than normal and ninety percent of his tumor load consisted of the one liver lesion). The surgeon gave me a less than tolerant look and stated there would not be enough liver left for the patient to survive the surgery. Still looking at the idea of reducing tumor load, I asked about embolization of the major tumor. Liver cancerous tumors are usually supplied by branches of the Hepatic Artery; whereas the liver proper is supplied with nourishment and oxygen primarily by the Portal Vein. I was told that it was an interesting idea but there was no initiative taken to arrange an interview with a specialist in embolization. After a total of almost three hours, the endocrinologist wrote the prescription for Sandostatin and we were exited from the room (as mentioned previously, I had been controlling his symptoms of dysentery very well with a small dose of codeine).
The ride home from the meeting was very quiet. After some twenty minutes Mr. LD turned to me and said; “You know, they were very nice, but I think they just sent me home to die and quite frankly, I’m not ready to die! Could you possibly do some digging for me and see what other treatments are available out there and where they are offered? I will pay you for your time, even a retainer if you wish”. By this time I was plenty unhappy with what had transpired and already decided to look further into the matter privately. Indeed they were very nice, but the meeting was lacking good scientific medical data. And what happened to the idea of a second opinion, especially in life and death scenarios? The very least they could have done was give us the names of Cancer Centers that may have more experience in this rare cancer and how to contact them!
Next edition: Searching for information

Wednesday, September 05, 2007

What Is a Year Of Your Life Worth To You

It seems when a medical scenario arises that shows our health care system in a bad light, the avid supporters of maintaining the monopolistic public system cry “that’s just one case. You can’t bring up one case as though it is the norm”. But how do we know that it is not the “norm”. How do we know that we are receiving the best and most appropriate care? How do we know that we are receiving the right treatment at the right time? One very learned orthopedic surgeon once told me that the average Joe Public hasn’t a clue about whether they have received good care. When you, as a surgeon, know you have given your best, you may get sued; when you are sure you could have done better, the patient may sing your praises and send you gifts.
The following is the story of a patient who has not only agreed to my writing his story, but has encouraged me to do so. If, on the other hand, your mind is closed to criticism of our publicly funded system, save yourself the time of reading this, for if you believe it, you may be quite shaken and perturbed; but if you are going to rationalize and justify the situation, you have wasted your time reading of this real-life account.
So think about it. What is a year of your life worth? And what if those years are good quality years in which you can do all the things you are doing today-----earning your usual income, holidaying, making love, watching your children and grandchildren grow up, and being totally pain free. What is each year worth?

Chapter One: The Inertia of the System

I have often remarked that getting appropriate treatment in a timely fashion for a patient in our public system is like pushing a boulder up a hill. If everyone involved pushes hard and together, you make progress. When the pushing stops, progress stops. Unfortunately the disease process you are attempting to treat may not stop, and for the patient the “boulder” comes crashing down on them.
The following is the story of a sixty two year old man (we will call him LD) who was diagnosed with cancer and told he had six months to live; this is a man who on returning from the Cancer Clinic and having a full “team approach and opinion”, turned to me and said “I think they just sent me home to die”!
This saga begins two years after my retirement in the early days of October, 2005, at which time a previous patient of mine presented to his new family doctor with a complaint of change in bowel habit of three months duration. During routine work up he was found to have a liver mass (on abdominal ultrasound). Since the waiting time was considerable and he could afford the cost, he elected to have a private CT of the abdomen instead of waiting in the public queue). The CT confirmed three abdominal masses; one was 18cms by 20cms, one was 3cms by 3cms, and one was 3cms by 2cms. Furthermore, the CT suggested a 3cm by 2cm mass in the base of his left lung. At the end of October upon my return from a holiday a message had been left on my answering service. Apparently his family doctor had told him these masses could be cancer and that biopsies would have to be done. Three weeks had passed and he had no word of any time commitment for the biopsies. Could I please intercede and find out what was causing the time delay?
Placing a call to the appropriate diagnostic imaging department and a radiologist I knew from my years in practice, I found out that the referral had been made but no indication was given as to why the biopsy was needed, and no arrangement was made for a physician to assume responsibility in hospital in the event that complications arose following the biopsy. Upon my providing the appropriate information and arranging for a responsible physician, the required biopsy was done within three working days. O. K., at this point you may say that the family physician was incompetent, and you may be correct.
Within three days I telephoned for the pathology report and was told that this patient does indeed have a malignancy, a rare neuroendocrine malignancy, with various testing indicating similarities to carcinoid. Now carcinoids arise 95% of the time from the gut and less than five percent of the time from elsewhere, including the lung. The question now becomes whether the lung lesion is primary or secondary to a yet unidentified bowel lesion. I arranged for LD to see a specialist (specialist #1) within two days (again by using contacts established over many years of practice) and arrangements were made for a lung biopsy within a week. See, things can happen in a timely fashion in our healthcare system! Unfortunately, the lung biopsy came back negative, which simply means the person doing the biopsy missed the tumor. Forms were sent in to the Provincial Cancer Clinic and on a follow up telephone call some two weeks later I was told that although it was acknowledged that the patient did have cancer, until the origin of the cancer was determined, the cancer clinic could not book the patient into the appropriate department.
So I spoke to the neuroendocrinologist (specialist #2) involved at the cancer clinic, and was told that two special scans would need to be done and that a specialist would have to order the scans (I suppose it wasn’t in the provincial budget to allow a family physician to order the scans, or I suppose in the Cancer Clinics’ budget to order the scans). In any case, I gave the name of the specialist already involved (specialist #1), and was told the scans needed would be requested for him to arrange, and a request for this would be sent to him. Two weeks later I phoned specialist #1 and was told that he had received no correspondence regarding any special scans on my patient. I related to him the scans that were necessary and he arranged for the scans. Unfortunately the scans could not be done for two weeks since some of the material to do the scans had to be ordered and were not kept in stock, and that alone may take ten days or more. At last the two scans were done and the results sent on to the Cancer clinic confirming that the tumor was a neuroendocrine cancer, carcinoid in nature,that the lung lesion was the primary lesion, and an appointment given for mid Jan, 2006. When I phoned to see if things could be moved up I was told that it was the earliest the entire team could review the case and no priorities would be given. So we waited for the famous TEAM to consult.
In spite of my best efforts, three and one half months had elapsed from the time a CT demonstrated a likely cancer, until the patient would be seen in the Provincial Cancer Clinic. This in a patient that had been told his life expectancy was six months.
Tune in for Chapter two: This Is Our Opinion, and It’s The Only One You Will Get.

Saturday, September 01, 2007

Controlling The Prescription Pad

The above was the heading on the Calgary Herald’s editorial page on Mon., Aug. 27/07. It was followed with the statement “Doctors should recognize that pharmacists can share the load.
From my perspective, editorialists of Calgary’s major newspaper should recognize that pharmacists already share the load. Furthermore, editorialists should recognize that they might inform themselves better when writing on a complex subject.
Giving them the benefit of any doubt, perhaps they were simply trying to generate discussion by presenting an absurd and negative perspective on a subject that demands good clear thinking. On the other hand perhaps they really don’t have a clue.
First, the editorial rants on and on about such things as the ever increasing cost of drugs, the fact that many patients are consuming far too many drugs, that medications are the fastest growing cost in our health care system, that many deaths and hospitalizations occur from drug interactions, etc. THEN, they suggest that prescribing be opened up to pharmacists, midwives and nurse practitioners. Will someone please tell me how opening the door to MORE prescribers will decrease the cost of drugs, the number of drugs a patient takes, or the number of drug reactions that occur? In fact, the more people prescribing to one patient the more likely patients will become large volume consumers. At present pharmacists do a great job of monitoring the drugs a patient takes along with the family doctor (if a Canadian patient is fortunate enough to have one). They are very involved with patient education regarding the medications they are taking and they work closely with the family doctors in the communities. It is quite appropriate for them to renew an ongoing medication for hypertension and other chronic illnesses in the family doctor’s absence, but they are not trained to diagnose, and should not be writing new prescriptions.
Many years ago many specialists felt so strongly about the principle of “One patient, One prescriber” that they refused to prescribe for a referred patient and sent the suggestions to the prescribing doctor to initiate. Today the family physician must review with the patient the possibility of specialist prescriptions, dental prescriptions, naturopathic medications, over the counter medications, walk in-clinic medications, and herbal medication intake before writing a prescription (the editorial suggests the addition of midwives, pharmacists, and nurse practitioners to this already inflated list).
They then suggest this has something to do with TURF protection and don’t even mention the fact that it may have something to do with good medicine. Like we need to protect our turf when every area of Canada could use 20% more physician manpower.
From my perspective, perhaps we should open the doors to pharmacies so patients can freely access what they wish (welcome to Mexico) and physicians simply act as consultants who make suggestions. Unfortunately the courts in our country deem the physician who last saw the patient as the one most responsible and mete out punishment accordingly.
So, to the editor of the Calgary Herald I would like to suggest the following “Go to Mexico and get and take whatever medications you wish on the advice of whom-ever you wish. You will find the medications considerably cheaper than in Canada and there are several drugstores on every city block. But don’t suggest we move in that direction in Canada to save a failing healthcare system, and don’t berate a profession for doing what they can to prevent harm coming to their patients. We all must work as a team, but we must bring to the team, the talents and abilities derived through appropriate training.