What's Wrong with Healthcare?

Obama-care

2010-03-20T14:20:00.000-07:00

I must say, I am amazed. It looks like the U.S.of A. is heading down the road to socialized medicine. Perhaps I shouldn't be amazed since Obama was elected in a frenzie of worship reminiscent of Trudeau's ascent to power. All the idications were that Obama was extremely "left leaning" and quite frankly, I always felt the U.S.A. would be the last bastion of capitalism; but Obama care and other Obama policies would indicate he is taking the country in a totally different direction.
The part that most amazes me is the talking point by the Democrats that Obama care will save the country money. Perhaps it is true that the average American knows squat about Canada, but surely they would be interested enough in the finacial impact of government run healthcare to make some enquiries of their neighbours to the north. Healthcare in Canada has been taking an ever larger slice of our provincial government's budget and there is no reason to believe it will be any diferent in the U.S.A.; and once an entitlement is given it is almost impossible to take it away, as our Canadian governments well know. Most informed politicians in Canada know that our present system is unsustainable, the just hope they are not at the helm when we up here hit the iceberg of baby boomers.
The bottom line is that governments in a democratic society have many responsibilities that we, the taxpayer, expect them to carry out. We, the people, provide them with the financial ability to do this through our taxation systems. Governments do not, as a rule, produce a product that will generate revenue on the open market.
When governments "take over" or "add-on" to their list of social responsibilities the entity becomes a part of many competing priorities. In Canada we are faced daily with what is termed a "scarsity" of healthcare resources. This, however, is not an absolute, but rather in this context (being a government monopoly) is a societal "choice" and must compete with other societal demands such as education, justice, defence, welfare, infrastructure, and so on. So if a government takes on a "new responsibility" what other area of responsibility will be financially usurped? the military perhaps, research? The most common way is to levy increases in taxation; albeit ways that are not evident to the voting public.
I certainly do not know what is in this Obamacare bill (but don't feel bad since most of the U.S. Senators and Congress persons don't either), but from what I have heard, it will be a significant step down the road to socialized medicine. As a Canadian I have mixed feelings; pleasure at the idea of more affordable holidays in the winter with our strong Canadian dollar, and trepidation at the thought of our good and stong neighbour to the south heading into finacial demise and healthcare mediocrity.

A Bird's Eye View of Family Medicine

2008-09-15T15:59:00.000-07:00

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

Where have all the family doctors gone

2008-05-09T08:22:00.000-07:00

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

Health Minister Ron Liebert Stumbles on Healthcare

2008-03-14T15:05:00.000-07:00

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

An Obama They Are Not

2008-02-21T19:41:00.000-08:00

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

Quebec, Our Healthcare Saviour

2008-02-20T15:01:00.000-08:00

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

Healthcare Top Issue, Canada and USA

2008-02-19T15:02:00.000-08:00

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

Universal Healthcare Torturing Canadian Citizens

2008-01-27T16:58:00.000-08:00

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

Obesity Vanquished in Alberta

2008-01-16T21:44:00.000-08:00

Tonight I listened to our health minister, Mr. Dave Hancock, expound on his vision of healthcare in Alberta and some of the solutions. I actually have heard all of this before but was quite surprised that he never once used the word “innovation”. Maybe he feels we have innovated our healthcare system into oblivion already and he should avoid the word. In any case, it would seem the solutions at present are the same as the solutions of the past: 1) Healthcare providers should be used in accordance with their training and 2) A greater emphasis needs to be put on “prevention”. As to the first solution he totally missed the point that one of the family physicians made, and that was in his practice, comprehensive care was already too complex for him in the community setting, and that an assistant would be more appropriate than “dumming down” the care givers. As for the second solution he pointed out that he was doing his part as health minister and had lost 75 pounds on his way to a healthier life style. This of course gave me a great idea as to how to beat obesity in Alberta; simply make every obese Albertan a health minister to give them incentive to lose weight. Sometimes solutions are so simple!

Gore Saves Canada's Healthcare System

2007-12-21T15:48:00.000-08:00

Is it possible that more than 50% of Canadians have some type of a generalized anxiety disorder, or for that matter, a specific anxiety disorder? With healthcare in Canada failing on any scale we wish to implement, and this having a direct impact on their lives NOW, the majority of Canadians would seem to think global warming should be out number one priority. Without getting into the debate about humans’ contribution to global warming and the various discussions that rage in the MSNM (mostly with the theme that we are in crises mode) I am continually reminded of the patients I have cared for over the years that felt they were in crises for one reason or another. One patient, some thirty years ago, who believed in numerology, was certain she was going to die because “sevens” lined up in a particular way. Well, the day came and went and she is alive and well today. Many patients present with the “feeling” something is terribly wrong and they just can’t put their finger on it. Others have phobias and other groundless worries. One patient scrubbed her shower stall eight times a day to rid it of hidden bacteria; another washed her hands fifty times a day for the same reason. It is estimated that roughly 80% of the office time of family doctors is taken up by 20% of the population, many of their complaints having a strong emotional component.
So my question again is “Has the MSNM and some clever/far-sighted/brilliant/opportunistic group basically yelled “fire” in a crowded building and compiled all these generalized, specific, and vague anxiety disorders into one huge mammoth anxiety disorder specifically pertaining to global warming? Is it further possible, then, that visits to physicians, subsequent investigations for non-existing diseases, and therefore costs, could dramatically drop if Prime Minister Harper addressed global warming to everyone’s satisfaction? He could SAVE our Healthcare System and the planet! That’s it! The MSNM, Al Gore, Suzuki and the boys are saving our Universal Healthcare system. Who would have known; brilliant! Give Al another “Nobel Something” prize.

Sicko

2007-12-20T21:32:00.000-08:00

Hey, some people up here in Canada are starting to see the light (dimly). Zoe Geddes-Soltess wrote in the Calgary Herald “Letters” page that turning down coverage of the medications Humira and Enbrel is “eerily similar to U.S. insurance companies refusing to cover so-called experimental treatments as a cost-cutting measure, and sets a frightening precedent for the future of healthcare in Alberta. Here is a news flash Zoe, this type of precedent was set here in Canada many years ago and is in no way a new phenomenon! Where is Michael Moore when we need him.
You see, Zoe, our provincial healthcare acts exactly like a U.S HMO (substitute insurance company if you like) with the exception that it is a monopoly. The insurance companies and HMO’s “cut” for profit; our provincial governments “reject” coverage to “save” tax dollars in a competing priority budget. The argument then basically comes down to the question of: 1) do you want consumer choice in deciding on your coverage? And/or 2) do you think a government monopoly can provide healthcare services more efficiently than competing private companies.
From my perspective, I want choices. I also know I must familiarize myself on the coverage contract and know exactly what I am buying from a coverage perspective. But do you have any idea of what your Alberta government Healthcare System will or will not cover? Probably not.
The problem with many of the new drugs, including new cancer therapies, is that we have very poor ways of knowing who will and who will not respond to a specific drug. This area is making huge advances but is still at infancy, so although a study may show very little benefit as a group in a trial, there are individuals within the treatment group that can show amazing benefit. However, our Canadian government healthcare programs are aimed at the average response and probabilities, and you have little choice as to whether you’re a responder or not without either digging into your own pocket and/or traveling to another country for the service. Perhaps, like the patients in the movie “Sicko”, Michael Moore could gather up a group of Canadians and take us for a little trip to Cuba.

Dying With Dignity

2007-11-28T20:41:00.000-08:00

From where I sit the above expression must be an oxymoron. Who, these days, dies with dignity? No longer do men dual with pistols for the maiden’s virtue or the honor of their family. We seem bent on criticizing the people who defend our country and often loose their lives in doing so. And our sick and dying, in this country of plenty, rely largely on their family and loved ones to care for them in community beds that are conscripted by the system. Don’t misunderstand me; patients should have the option of dying at home, but how about taking the cost of an acute care bed and transferring that cost allowance to the patient and his/her caregivers. Why should the system benefit from conscripting loved ones?
Perhaps we pride ourselves in the fact that we now can keep most patients reasonably comfortable during their terminal illness, but here is a news flash: “There is more to suffering than physical pain, and there is more to maintaining ones dignity during the dying process than crying with pain”.
I suppose at any time in our lives we could take the attitude that we are dying, and in my experience, some people seem to have that attitude (these are the people that most of us would rather not hang out with, no matter the age); but there is something about dying over a short period of time that is demoralizing. How does one maintain their dignity when one month you are an independent, self reliant individual and six months later you are dependant on a caregiver to attend to any and all of your basic needs, even the simplest thing (sitting propped up) without feeling shaky, insecure, and anxious? How can one maintain their dignity when one cannot pull covers up to be warmer in the night without help, not to mention toiletry and other personal hygiene issues?
Yes, we still have a long way to go in medicine before we can make claim to the expression “Dying with dignity”. Oh, I know. We can say that dignity comes from within, but what are the ingredients of that dignity. I would venture to say that each person is unique in what comprises their dignity. Certainly in the old west the cowpokes wanted to “die with their boots on”. To me this meant that they wanted to die doing what they enjoyed doing, certainly not dying in a bed. Some people loose dignity when confronted with pain, some in loosing their independence, and some simply by watching themselves deteriorate in appearance. Others seem to maintain their dignity in spite of all the things mentioned above.
Recently I have been given an example of dying with dignity. In spite of all of the above and more, this person maintained her dignity through the love of her family and friends and her ability to love them in return. She went through the various treatments, suffered their side effects, and tolerated the disappointments, because she still was able to love and be loved; and when this was no longer possible, she took control of her situation, stopped the intake of all fluids and died quietly within five days. She knew that even healthy people die within a week or so without fluids. She made the decision; she took the responsibility. She didn’t want or ask for someone to “assist” her “suicide”. She asked only for comfort measures; and she didn’t whine about the fact there is no “euthanasia” law in Canada. She died in the arms of her loved ones, in her home, in her bed, with dignity. The last thing she would have wanted was for that final control to be given to the state or some other person. And we should all say “Amen” to that.

Right to Die Debate Heating Up

2007-11-11T19:19:00.000-08:00

Nice article in the November 3rd Calgary Herald! It has suddenly occurred to a few University types that, as I have said many times, dying is cost effective; or maybe they have finally gotten brave enough to state the obvious. Or maybe they finally acknowledge that our Universal Healthcare System god is demanding human sacrifices. Several noted “authorities” are quoted as saying it is time to have discussions re “dying with dignity” and I’m all for it, but should we even mention rising healthcare costs as part of the discussion? Apparently Dr. Carruthers, Ottawa hospital Chief of Staff thinks so and is quoted in the article as saying “The cost of healthcare is not sustainable…..and the society is going to have to make some tough decisions”. But Dr. Robert Cushman, CEO of the Chaplain Local Health Integration Network in Eastern Ontario wins the prize for primitive and retrograde thinking when apparently he proclaims that seniors deserve independence and dignity in the twilight of their lives and the debate should take place in the context of ballooning healthcare costs.
Deserve independence and dignity?? Is there a suggestion here that when one looses their independence they have lost their dignity? I recall that ancient tribes would leave their elders, who were frail and dependent, with some food and water and move on with their migration. After all, these frail dependant people endangered the group by slowing them up. By leaving them behind the frail elderly could fight off the wild animals and die with dignity.
I guess what really P-ssed me off about this article and the quotations was that there was the distinct inference that rising costs in our health care system should be laid at the feet of the chronically ill and frail elderly, THE VERY GROUP THAT OUR PUBLICALLY FUNDED HEALTHCARE SYSTEM WAS INTENDED TO PROTECT. The second thing that riled me was the suggestion that the term “dying with dignity” had been used to influence the discussion. In my experience the more assistance the patient and their families receive (all of it costing money) in their final months and days, the more likely the patient will die with dignity. Euthanasia and assisted suicide are usually the result of failed intervention programs, either through ignorance or lack of resources.

Medicare, Phase II

2007-11-04T07:35:00.000-08:00

I keep getting copies of a magazine called “albertaviews” (unrequested). Today I decided to read the article on “Medicare: Phase 2, a conference with the Answers. It was actually quite humorous. In a nutshell they claimed the solutions to our problems could all be solved with telling people to live healthy lifestyles and to have health providers work in groups (obviously a totally new concepts!!). Oh, yes, and the keynote speaker, Greg Marchildon, the former executive director of the Romanow Commission, extolled Tommy Douglass’s vision of “Idealism---dream no little dreams, pragmatism----work with what you have, and Tenacity, act regardless of the means”. Isn’t that how we got to today’s’ deplorable state? But then they went on to say that our healthcare system certainly is sustainable! Yes, health care is taking a greater and greater percentage of the government’s budget but the problem is those dastardly pharmaceutical companies; and the fact that the government doesn’t tax you and I sufficiently. Well, I don’t know about you, but I am taxed sufficiently (I think Canada ranks about third highest taxed of the industrialized countries, depending on what you call a tax).
If this is to be informative journalism, no point in reading the other articles; and I certainly won’t assist disinformation by putting it in my waiting room. Sounds more like “Saskatchewanviews”. Little wonder my wastebasket fills up quickly!!!

A Cure For What Ails Family Practice

2007-10-23T19:33:00.000-07:00

I’m not sure if Dr. Tom Feasby (Dean of the faculty of Medicine at the University of Calgary) is truly unaware of the reasons traditional family practitioners are going the way of the Dodo bird or whether he was simply providing the public with a somewhat palatable, politically correct, placebo, in his Calgary Herald dissertation “A cure for what ails family practice”. Although he did bring forward some crucial issues like family medicine remuneration and disparities in specialist/family doctor incomes, he waters down the problem by mentioning a recent increase in fees, and the government overhead subsidy program, both designed to maintain the status quo and won’t come close to addressing these two critical issues. He then states “This is an issue the Alberta Medical Association is working on and requires an effective solution”. Here is a news flash! The AMA has been “working on” this since the early 1970’s when I was chair of the Incomes Committee and has not, and likely will not, ever address the issue effectively.
It is unlikely that a solution will arise for “what ails family practice” when our Dean of Medicine fails to mention one of the main reasons for the decline in traditional family practitioners, ie., burn out, or the prospect of burnout, of traditional family physicians in the present Canadian system. When we as primary health care providers feel a patient should be seen by a specialist in two weeks and they are seen in two months, when our patients are in pain and require intervention and wait months for relief, while we feed them drugs that impair their mental capabilities or put them at risk for heart attacks and/or falls, we go home each day with the knowledge and the feeling we have failed our patients. As a result, retirements are accelerated and greener pastures are sought. And I’m sorry, Dr Feasby, but exposing bright your minds to this reality, coupled with the income disparity, will not encourage new graduates to become family practioners.
Of more concern to me, not that I blame them in the least, is the trend for young graduates who go into family medicine to “take the path of least resistance”. Dr. Feasby brings this forward as a positive and states “Calgarians also need to be aware that although traditional family practices are not as common today, many family medicine graduates are choosing to practice in high demand areas such as emergency medicine, palliative care, low risk maternity, and care of the elderly”. Excuse me? Why are these high demand areas? Could it be that FIRST there has been a decline in TRADITIONAL family practices that at one time was comprised of all of the aforementioned areas.
This ongoing disintegration of family medicine has continued and now excludes hospital care, nursing home care, and for that matter, people who are genuinely and acutely ill. In some offices, the front desk triages sick people to the emergency departments or walk in clinics, and the physician only sees the regular booked appointments. The system has fostered, almost mandated, this scenario. After doing closed fractures for 35 years, the Rockyview Hospital Cast clinic advised me that any booked fractures for casts in the cast clinic would have to be done through the Emergency department. My obvious response was then to advise my receptionist that any phone calls from patients that may have a fracture should be sent directly to the emergency department. Why should I see the patient, send them for an X-ray, look at the X-ray, know they need a cast, but then send them to an emergency department to incur more cost and wait for hours to be told the same thing by the emergency physician and then booked next day at the cast clinic? But I digress.
The truth is that physicians have responded to their inability to access resources by:
1) Avoiding traditional family practice where they have the responsibility for both short term AND long term outcomes. Following patients who have significant medical needs that are not being met by the system in a timely way, you, as the patient’s advocate and friend, suffer with the patient. I found it amusing that Dr. Feasby felt that the qualities of compassion and caring in a medical student would lend itself to being a good traditional family physician. It also lends itself to early burnout in our present day system.
2) Some physicians have taken on the role of “hospitalist”. Although this area of care is stressful, there is less personal involvement in the care of the patient, with the primary area of responsibility addressing the acute care needs. Specialists and resources are usually readily available as early discharge is seen as being cost effective. The time of responsibility is clearly delineated into shifts, and there is very little if any administration required.
3) Working as a locum (covering for family doctors when they are away) requires responsibility for the time you are covering, and an easy approach for difficult access situations is “see your doctor when he gets back” or more urgent situations can be foisted onto the emergency departments.
4) Contrary to the implication by Dr. Feasby that part of the shortage of traditional family doctors is that they are turning to palliative care duties, there is, in fact, a severe shortage of family doctors willing to be involved in palliative care and the care of the elderly. This again is because of the time issues involved (we get paid per visit with little regard for time spent), complexity issues (requires more time and involvement), and the difficulty accessing resources (these are groups that need timely intervention and resources). Meanwhile, in spite of these factors, Alberta continues to have a small differential in fees for elderly patients and complex problems compared to other Canadian provinces.
5) At present, walk-in clinic work seems to be the most attractive alternative for physicians coming out of family practice training. However, this service is, for the most part, episodic care, and addresses cases on a presentation bases with whichever doctor is available, rather than a health and disease management basis. As such, patients see different doctors at different times, and the turnover per hour is high affording a better income. As a response to this inequity, many traditional family doctors have limited patients to “one complaint”, thereby raising the obvious possibility of missing several complaints that point to one diagnosis.
In summary, I was very disappointed in Dr. Feasby’s “Cure for what ails family practice” article in the Calgary Herald. He seems to have not taken an accurate history or done a thorough examination, and he certainly has prescribed treatments that have been tried and failed, or, at the very least, have “not been proven”. Until we pay family physicians for the time, complexity, and responsibility they take; AND until we provide the resources for them to perform their duties in a manner that enables them to feel, at the end of the day, that they have provided a valuable service to the patient, we will continue to see traditional family medicine disappear over the horizon like Tom Mix in an old western movie. As the Supreme Court has stated “Access to a waiting list is not access to Healthcare”. No one in the medical profession understands and feels this more than the caring, compassionate traditional family physician.

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

2007-09-16T19:45:00.000-07:00

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.

MDAnderson Medical Center, Houston, Texas

2007-09-13T11:07:00.000-07:00

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?

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Incredible Medical Avances

2007-09-09T16:36:00.000-07:00

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.

The Obsolete Second Medical Opinion

2007-09-07T16:16:00.000-07:00

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

What Is a Year Of Your Life Worth To You

2007-09-05T09:45:00.000-07:00

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.

Controlling The Prescription Pad

2007-09-01T12:03:00.000-07:00

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.

Semi-Private Rooms for Sale in Canadian Hospitals

2007-08-20T19:40:00.000-07:00

I thought I had pretty good insight of the workings of our healthcare system having been a family doctor for forty years, and I suppose as a physician I do. As a physician AND caregiver of my wife who has stage four lung cancer, I have now the added perspective of a consumer of the services rendered by our system, and I come back repeatedly to “How in heavens name do lay people deal with the system when I as a physician caregiver am at my wits end regularly?”.
Having asked this question as we were driving into the parking lot at the Tom Baker Cancer Center a while back, we looked over and saw seven ambulances lined up at the Foothills Hospital Emergency Department. That gave us a partial answer.
The people working within the system, for the most part, are super; but the SYSTEM is in desperate need of an overhaul. Making an appointment to see the patient’s oncologist can take over an hour and usually results in speaking to several different people and finally simply leaving messages. If the situation is urgent, one doesn’t know if one should wait for a return call (which may take a day or two), or call an ambulance. I suspect to some degree access is necessarily made difficult to protect the caregivers. Otherwise the flood of patient needs would overwhelm the staff with resultant resignations, stress time off, sick leave, etc; but making the appointment process complex, is simply ridiculous.
As a patient and as part of the care-giving team, it has become apparent to my wife and me that the system is stressed to its maximum. On her recent admission with a pulmonary embolus, my wife was put into a semi-private room with a more than slightly demented patient in a “lock-down” ward. Likely it was the last bed in the hospital (although if it was, she should not have been billed specifically for a semi-private room), and with her blood oxygen and blood pressure cratering, who is going to complain? It did make for noisy nights, frequent incursions into my wife’s space, including her room mate giving her kisses and suggesting it was inappropriate for me to do so, setting off her bed alarm frequently, insisting for hours she needed to go to the bathroom, etc (we won’t mention the other poor demented soul who shouted and swore throughout the night). All in all, not the ideal environment for a palliative care patient.
The nurses did their best, often showing patience above and beyond the call of duty. As a physician that was significantly involved in administration, I fully understand the difficulties in appropriate patient placement, especially with present bed shortages, but will this ever improve, or is the system on a downward skid? Two things made me think we are on a downward skid. Firstly, of course, the inappropriate placement of my palliative wife in with an obviously demented room-mate. Secondly, on two consecutive days a nurse came in to irrigate my wife’s intravenous. The problem was my wife did not have, and never did have, an intravenous line. In addition, for the first two days the nurses were busy doing output measurements. The problem was that there were no input measurements being done and therefore output was of little value. It is said that to fix the errors made in hospitals we need to look at the “near misses” and find out how they happened and then fix the system that allowed them. These two occurrences are obviously not a nurses fault; they were simply following orders recorded somewhere----orders that wasted the nurses time and clearly were of no benefit to the patient. My wife was in the hospital two and one half days. If this is happening to other patients with the same frequency, there is a major problem somewhere, and may be of more dire consequences.
Within a week of discharge I received a bill for $48 (24 dollars a day) for the semiprivate room. Actually, we got quite a chuckle that the accommodation was termed semi-PRIVATE, when a ward of ten non demented patients would have been more private and restful.
When did hospitals start billing patients for hospital beds? Obviously, unless you are in a four bed ward they have taken the position that anything less is preferred accommodation. Can this be termed a user pay approach to raise revenue for the health care system----extra billing anyone??. In fact, if we were to look at the number of patients in wards as compared to two bed rooms (semi-private), the norm is a two bed room. From our perspective, a four bed room in a “non locked ward” would have been preferable.
All in all, my wife got excellent care from the healthcare professionals involved and I sent the region their forty eight dollars. But as a health care professional of many years and now as a personal caregiver, the cracks and strains in our public system are evident. Will we as Albertans and Canadians address them, or must we wait until there is a total collapse similar to the recent Minneapolis Bridge? My understanding is there was considerable evidence of deterioration years before its actual collapse.
In the mean time, I would suggest the Region charge for meals since strictly speaking one could argue that “necessary” hospital treatment need not include meals. The Canada Health act has already been transgressed more than the Ten Commandments.

Building Shrines, Calgary's South Health Campus

2007-07-21T08:49:00.000-07:00

A few weeks ago I attended a presentation pertaining to Calgary’s “South Health Campus”. Now for those of you that are not familiar with Calgary’s hospital history, a hospital was planned for Calgary’s South East Quadrant at least ten years ago. This hospital was to be less than 400 beds and would come in at an estimated cost of less than 400 million dollars. Since that time, there has been much in the news media about the soaring estimated cost of this health facility, some reports estimated as high as 1.2 billion dollars. The blame for this has been attributed to Alberta’s overheated economy and rising construction costs. I was considerably enlightened by the presentation (I suspect much of the increased cost has been from expansion of the “vision”)!
Firstly, as one might surmise from the politically correct title “South Health Campus”, this “hospital” has turned into a shining example of the province’s and the Calgary Region’s vision of healthcare, and of course, a reflection of ego and the need to build edifices unto one’s self. The concept itself is quite acceptable. Calgary is in dire need of both out patient services and more hospital beds. However, this proposal has a very aggressive out-patient intervention facility, educational component, research component, and an in-patient facility that covers a broad range of services in a location that for most aging seniors, the poor, and many of the chronically ill, is not accessible. The concept is commendable; the location of the outpatient services and some of the other services, disastrous. The hospital aspect of the project is great, with a wide range of in-patient services suitable for a growing community. In particular they have provided for in-patient pediatric beds, an active maternity department and in general, everything that was once considered to be a “general hospital”. Kudos to the planners with regards to the acute treatment facilities; strike one on the large out patient aspect for the infirm and chronically ill in a location that is unaccessable.
Let me re-iterate. My problem primarily lies with the huge resources and facilities for out-patient services IN THAT LOCATION.
The presenter listed the “drivers for change”:
1) Growing and aging population
2) Increasing chronic disease
3) Safety issues
4) Workforce shortages
5) Emphasis on wellness
6) Patient and family expectations
7) Public expectations
The goals of this project were then listed:
1) Enhance capacity
2) Develop new models for care:
a) Patient and family centered
b) Quality and safety
c) Efficient and sustainable

3) Integrate care across continuum
4) Promote wellness
5) Attract outstanding professionals
6) Build a versatile/flexible infrastructure
7) Create a culture of innovation
8) Centre for education and research
9) Empower and connect the community.
From my perspective gathered from years of community practice, the aged and the patients with chronic disease have the greatest need for out patient and in patient healthcare services. Unfortunately, they are also among the most IMMOBILE people within our society.
The Deerfoot Trail is the major roadway servicing the proposed “South Health Campus” from the rest of the city. The Deerfoot trail was designed for 100,000 cars a day. My understanding is that, at present, 150,000 cars a day are on the Deerfoot Trail. The facility is projected to be completed in 3 to 4 years. By then the Deerfoot will probably be handling 200,000 cars a day. Any suggestion of help from a leg of the C-Train is at least 20 or more years away. Access to health care in Alberta and Calgary has been the number one problem to date. In order for our aged and chronically ill to access these new innovative resources at the South Health Campus, they will have to traverse the Deerfoot Trail. Is this some kind of “survival of the fittest” scenario? Good Grief!! And how do we envision the poor accessing transportation to this facility? Will the city expand its handibus resources tenfold?
The Region justifies the location of these out-patient services by declaring “availability of land”. News flash!! There is even cheaper land farther out!!!
The bottom line is that, like all successful ventures, it is location, location, location. Without access to these out-patient facilities, the development becomes a government shrine of their “vision” of healthcare, but a “white elephant” to the people that really need the services. Out patient services are essential part of our healthcare system, but they must be located as close as possible to the communities that require them.
Educational services can be very helpful to specific groups within the city of Calgary; however, education needs vary (as other needs do) tremendously from community to community. The ethnic and new immigrant communities of Calgary would benefit from many of the services proposed at the Health Campus Site. Could some of these resources be placed at the Peter Lougheed? It is certainly more accessible than the extreme South East Quadrant of the city.
Many of our nursing homes are located in older communities. How aggressively have we looked at forming public/private partnerships in providing these services from these sites (Lacombe Home also has abundant land)? There has been talk of public/private partnerships in Acute Care, Education, etc. How about out-patient care at nursing home locations, or perhaps some of the old school sites that have been abandoned (they are in aging community locations).
Review again the drivers for change and the identified goals as stated previously; and then apply each to extensive-out patient facilities at this location. Surely we need to rethink that aspect of development before another healthcare blunder is made in the Calgary Region similar to selling or demolishing existing facilities before replacements are built. Strike two on the planners.
I understand research is important. I understand also that Edmonton is building a “Mayo Clinic” type facility at a cost of ONE BILLION dollars (and I’m told this will only add 125 acute treatment beds). How much overlap is occurring between these two facilities? Is Edmonton also putting the needed community services in the wrong location (out of reach) for those that need them? One of the goals listed is “empower and connect the community”. You can only do that within the community.
In a previous blog I stated (with tongue in cheek) that we save enormous healthcare costs by outsourcing all our surgeries and other expensive procedures to India. I apologize to the people of Calgary if, somehow, this idea was taken up by the South Calgary Health Campus planners and the provincial government, who seem to be outsourcing all those services that should occur in communities, to the extreme Southeast corner of the city. Strike three for the new “vision”.

Confused About Global Warming

2007-07-08T10:32:00.000-07:00

I usually don’t write about things other than medicine, but yesterday, while cutting my lawn with a gas driven lawnmower (I gave my push mower to my son), I struggled with both my rising panic attack re global warming, and my guilt re my contribution to it. After all, on the previous two days the mercury here had climbed to 30 degrees Celsius, and it was getting quite uncomfortable. Then a strange thought struck me. Why is Canada so concerned about global warming when we are one of the coldest nations on earth when Saudi Arabia, the United Emeritus Republic, and other Middle East countries don’t seem to be concerned? Good Lord; I heard the temperatures there go to 45 to 50 degrees Celsius. Do the Dubai newspapers have daily reports of the impending devastation of global warming similar to the Calgary Herald’s daily reports?
Perhaps that’s it. Our MSNM are simply not reporting Middle Eastern environmental concerns; too preoccupied with things like car bombs and such. I’m sure the Middle East, with their soaring temperatures, has an equivalent to Al Gore, flying around the country putting on rock concerts to raise money to save the planet. After all, with the heating up of earth, they are going to be the first to get scorched. Failing to report the Arab world’s valiant efforts to save their countries, and the earth, seems to me to be a huge failing on our news media’s part.
On the other hand, if the Middle East truly seems unconcerned about global warming, while at the same time being so vulnerable, perhaps they know something we don’t. I’d like to know who yelled FIRE (the world is going to burn) first, and started the stampede to save the earth? Maybe it was the Middle East extremists who wanted to divert attention away from their crusade. Maybe while we are spending billions of dollars to “save the earth”, they are going about their plan to inherit the earth after we saved it; and by then Canada will have warmed up sufficiently that they will find it comfortable.
Then again, the philosophy of many is that the “here after” is better than the “here now”, so maybe they want to leave the earth burn, thereby making the “hereafter” a greater reward.
Wow, I’m really getting some paranoid thinking going on! It must be the heat. Still, it does seem strange that the hottest countries in the world don’t seem to give a hoot about global warming. Very confusing! Think I’ll find some shade.

Appendicitis, An Old Nemesis

2007-06-14T19:43:00.000-07:00

Calgary seems to be having some incredibly “bad luck” with mortalities related to acute appendicitis. If our mortality rate is elevated (and I say IF), one wonders about our morbidity rate. Is it possible that in today’s’ world of new technologies, incredible surgical skills, and powerful antibiotics, we as physicians, have lost our diagnostic skills and respect for that old, but still quite formidable disease, appendicitis. Before the use of abdominal ultrasound, CT scans of the abdomen and other helpful diagnostic modalities, several golden rules existed (at least as taught to me during my training and subsequently):
1) The surgeon is appropriately cautious if he/she removes an occasional “normal” appendix to prevent the morbidity/mortality that can occur from missing, or delaying intervention, in a patient with the presumptive diagnosis of acute appendicitis.
2) The white blood count can not be used to either include or exclude an acute appendicitis.
3) The physician should, if appendicitis is a possibility, refrain from using antibiotics since they may give both the patient and the physician a false sense of security.
4) As a general rule, a patient is “safe” in the first 24 hours from the onset of symptoms, BUT, thereafter there is an increase in morbidity and mortality as time elapses before surgery.
Four years ago at an educational conference on emergency medicine, statistics revealed that the two conditions most commonly resulting in legal action were appendicitis and ectopic pregnancy. That statistic is likely still true today. It is well recognized that the diagnosis of appendicitis is extremely difficult in the very young (under two years of age) and the very old, but Calgary’s mortalities have occurred in the usual age group for appendicitis. The Calgary Herald reports that the Calgary Health Authority has pledged several changes to its approach to appendicitis, including enhanced communication with patients and families who are involved with “serious adverse events” in Calgary hospitals. I certainly hope the changes are substantive, and constitute more than a public relations exercise.

Peemptive Strikes, Ramblings of a Gardener.

2007-06-09T20:05:00.000-07:00

This world is getting far to complex for me. As an example, there has been much discussion about the legitimacy of the term “preemptive” as in “preemptive war”. Wikipedia defines preemptive war as an attempt to repell or defeat a perceived or imminent offensive or invasion, or to gain a strategic advantage in an impending war.
As a physician I personally have knowledge of many surgeons who preemptively attack cancer with fairly aggressive and even life threatening surgery. Most of their patients have considered them some kind of hero. Wikipedia goes on to state that preemptive war should not be confused with the term “preventive” war since the latter is generally considered to violate international law, whereas preemptive wars are more often argued to be justifiable.
Now I’m really confused! Preventive medicine is deemed to be the salvation of our healthcare system in Canada, and any physician not swearing allegiance to preventive medicine simply is a dinosaur and is costing our system zillions of dollars. Why is it O.K., desirable, and even mandatory, to practice preventive and preemptive medicine, and not preventive and preemptive war? Which brings me to how I began pondering these imponderables.
Yesterday I practiced preventive something or other when I applied a generous portion of “OFF” insect spray to my person before I ventured to do my planting and gardening. For a period of a few hours this seemed effective, but as the day wore on it became obvious that my “preventive” techniques were failing. Being an environmentalist, I hesitated to once more contaminate myself and the environment with this repellent. Instead I attempted to negotiate with the hoards of mosquitoes that seemed determined to invade my space, and I believe, have significant harmful intentions to my person. At first I spoke kindly and reassuringly, on the chance they had an abusive upbringing. Then I became more impassioned since they may simply be misinformed. Finally, I waved my arms in a sinister way, occasionally making impassioned pleas and voicing convincing arguments and warnings. My efforts seemed in vane. It definitely seemed the intent, and indeed, the nature of those creatures, to feast on my body. At last I resorted to a preemptive attack, and although my swatting destroyed many, soon my exposed skin was crimson from self inflicted slapping. It seemed the only solution was to retreat from my yard and garden and become a prisoner in my own home.
Tonight I will contemplate both a preemptive and preventive strike for tomorrow. To recapture the use and freedom that is the right of every earthly creature, I will spray my grass and bushes with a dilute solution of malathion (now I’m going to be in trouble with the environmentalists for sure). The other question is what I could do with my neighbors’ pond that he refuses to drain or treat (my intelligence sources inform me that the pond is the epicenter of the threat). Perhaps a preemptive/preventive strike in the middle of the night? No, no! Not the neighbor; the pond!

Investigate While We Wait

2007-06-04T19:30:00.000-07:00

Today I recalled an episode of a T.V. program called “Yes Minister” (comedy) in which a hospital in Great Britain had won numerous awards for its efficiency, but actually didn’t attend to any patients! The thought occurred to me while waiting for my wife, that it would be interesting to track the number of administrative and other personnel in the regional health authorities employ that are not patient service providers. I know that there was a time in the 1990’s when there was significant downsizing in this area. I also know that there was a rebound rehiring, shortly thereafter, as the Calgary and other Regional Health Authorities realized that they would need help in managing a system where there was increasing demand and decreasing resources (facilities and caregivers), available for direct patient care. But exactly what has been, and what is, happening up there at the top?
As I dropped my wife off at the Okotoks Urgent Care Center Laboratory, I observed a waiting room full of people, and people standing in the hall, all waiting for blood tests of some description. I noted two people in the urgent care area (a truly large waiting area about three times the size of the lab. area). On arriving that morning, there was nowhere to park in the patient designated parking area (with many parked on the street), but quite a few parking spaces in the “staff” designated parking area. Since I had to wait an hour and twenty minutes for my wife, I wiled away my time counting parking spaces; approximately 34 (including handicapped parking) for patients, and 64 designated for staff.
Later in the day as I planted my bedding out plants (a great time to do some idle thinking), the thought occurred to me that there are likely more people available for hire in the areas of “health management”, health education, public relations, and many other areas, than there are people available for direct patient care (doctors, nurses, technicians, etc). I wonder if there is an increasing part of our health care budget going to “manage” the areas of shortcomings. Some of this is, of course, constructive and necessary, but how far can we stretch shortcomings with better management? Has the department of public relations expanded in an effort to convince the public that there is not a problem with our health care system, there is only the PERCEPTION that there is a health care problem? And who the heck was involved in planning the Okotoks Urgent Care Center, and in particular, the parking areas? Was a doctor involved at all? Any community family physician could have told them they would need more space and staff for the laboratory area!
Why all the landscaping and public appeal at the patient’s entrance and none at the staff entrance? Could they not have taken some of the designated esthetics for the patient entrance and provided more patient parking? And where are all the people that belong to all the cars in the “staff” parking area? Behind closed doors, I guess, and certainly not working in the laboratory. And if you are thinking that this blog entry is quite disjointed and rambling, who says that random thoughts while gardening or waiting one hour and twenty minutes for a blood test need to be organized and pithy? Hey, maybe that’s the amswer? If everyone dissected our health care system, or better still, came up with solutions, while they waste a good part of their lives WAITING, maybe we wouldn’t be at this stalemate. Let’s face it; it would represent millions of hours of contributed thought.

Corneal Abrasions and the Herpes Virus

2007-05-19T17:14:00.000-07:00

Being a gardener has a variety of health hazards. About a year ago, while transplanting a dracaena, I scratched my cornea. Over the course of six hours it appeared to slowly have been improving, with less tearing and discomfort. Then, for whatever reason, it began to get worse. At 9:30 P.M. I decided that my eye should get some expert attention and accordingly attended a walk-in government medical clinic. The eye was “stained” and appropriately examined, and indeed, a scratch was demonstrated. I was given an antibiotic to instill in the eye, and a “patch” was prescribed for comfort. I was assured that these corneal scratches invariably heal quickly, often within twenty four hours. This certainly fit in with my teaching and experience, but did not explain why it had suddenly gotten worse after five to six hours.
The next morning (now twenty hours) my eye was no better. Since it was not following the usual pattern of healing, I phoned an ophthalmologist that I knew. After hearing my story he advised that I be seen by him immediately. On attending his busy office I was seen shortly, examined, and advised that the corneal lesion was not healing because it had been secondarily infected by a herpes virus. He explained that people who are inclined to have cold sores may secrete the active virus in their tears, and on occasion, will contaminate a corneal scratch with the virus and proceed on to an infected scratch. This infected scratch does not have the typical appearance of a corneal primary herpes infection (punctuate lesions with fluoracein staining), but rather presents by history, as mine did, and on examination, demonstrates an enlarging lesion with inflamed “loose” epithelial edges. Accordingly, this ophthalmologist froze my eye, scraped away the inflamed loosened edges, and gave me antiviral drops for my eye to be used every two hours, and a prescription for Valtrex to be started immediately. As is the medical axiom, he advised not to cover the eye in the presence of infection, and gave me anti-inflammatory drops to be used to assist with comfort (We were taught that covering the eye was done for reasons of comfort, but should never be covered in the presence of infection). Incredibly, my eye felt much improved by that evening, and the next morning felt normal.
Fast forward to May17/07, when someone near and dear to me, telephones, and relates that she had scratched her eye that morning (she thought, but wasn’t sure how she did it. She acknowledged and recalled rubbing her eye on awakening, but wasn’t certain if it felt abnormal before or after rubbing it). In any case it was becoming more painful as the day went on, so she attended a physician, who appropriately stained her eye, saw a corneal lesion, gave her fucidin antibiotic ointment (for infection, she said) and suggested she wear a patch to cover her eye. I remarked that it was unusual to cover an eye in the presents of infection, and it may be preferable, assuming the presents of infection as related by the patient, comfort permitting, to simply try to not blink by avoiding use of the eye (eg dark room, no T.V., reading, etc) and it should steadily improve. The lesson learned at this point should be: Unless you are prepared to take over complete care and responsibility of/for a situation, as a physician, one should not give even a modicum of advice.
At 9:30 P.M. that same evening things suddenly got much worse. The patient relates much more pain and swelling about the eye, and wishes to know if she should go to the emergency department. Knowing of the long line ups for our emergency departments and the unlikeliness of her being seen by an ophthalmologist, and, having already given advice on the matter (and feeling apprehensive about it since I did not do an examination), I thought I should actually do an assessment myself. Armed with Clavulin, Amoxil, Valrex, Viroptic, and ophthalmic Voltaren drops, I make the dreaded “house call”. To my surprise there is little actual swelling of the lids or orbital area, and the redness of the eye is definitely not in keeping with a bacterial infection. (Put away my samples of Amoxil and Clavulin for possible periorbital cellulites and the like!). On ordinary examination with a bright light it was evident that the cornea itself appeared clear, but it was also evident that there was “loose” appearing corneal epithelium in the infra-pupillary area were the corneal abrasion had been identified by staining earlier that day. I left the Viroptic eye drops and Valtrex (1000mgs to be taken stat and repeated in eight hours), with instructions to use the voltaren eye drops for comfort, not to patch because of the possibility of secondary herpetic infection, and see an ophthalmologist the next day (in case the lesion needed scraping and debridement).
Some twelve hours later I receive a call saying it was like a miracle, the eye felt much improved, but the physician she had seen originally wished to recheck her eye (kudos to him for being responsible and diligent). Then these events unfold:
The original physician stains her eye and is alarmed that the stained area is much larger. He refers her to an ophthalmologist (again kudos for referring when events are not clearly understood), who tells her she does not have a herpes infection of her eye and that she enlarged her original abrasion by blinking and not wearing the patch (although we were taught that the patch was for comfort only and you did not take off normal corneal epithelium with blinking.). She was told to stop the Valtex. Now the patient is in a quandary.
From the patients’ perspective, she is likely to be fine. If she had a secondary herpes infection, the two doses of 1000mgs of Valtrex twice in the first eight hours would likely take care of it since the trend is to treat herpes early, and very aggressively, for one to two days only (although I am puzzled by the ophthalmologist not continuing the Valtrex for another day or two since it has an extremely low side effect profile). From my perspective, the patient likely denuded some corneal epithelium in the morning (this is not uncommon if the patient has had a previous finger nail scratch to the cornea, and of interest is that this patient has had corneal laser corrective surgery. Do these patients experience a higher incidence of A.M. corneal epithelial lesions?) Whether she later denuded the epithelium by blinking (are post laser corrective surgery patients that susceptible and the epithelium that fragile months later, and why isn’t this emphasized more in the literature?), or whether she developed a herpetic secondary infection to explain the enlarged lesion cannot be proven, but wouldn’t it be wise to treat a potentially damaging condition preferentially? And what is to be done in the event of future morning lesions? It is clear to me that what a patient hears from a doctor is not always clear and meaningful to the patient. People who have episodes of A.M denudation (apparently there is some drying and subsequent sticking of the corneal epithelium to the lid during sleep, and on opening the eye in the morning some epithelium is torn off the cornea) need some approach to the problem. I used to suggest some Lacrilube in the eyes at night to prevent sticking and drying in these susceptible individuals. I wonder what advice this lady was given to help her deal with the possible recurrence of this event in the future. In any case, lesson learned. I certainly will have to do a better job of monitoring my involvement in the future. A patients’ perception of a situation is not always as the attending doctor related. In this case the initial attending physician may have said the fucidin ointment was to PREVENT an infection; not FOR an infection, and in that case, the patch was quite appropriate.

Family Doctors, a New Breed of Civil Servant

2007-04-15T20:57:00.000-07:00

If we were to do a survey and ask the family physicians in Alberta about being “salaried”, I think the general response would be “no way”! But let’s take a look at what has happened over the years.
When I started practice in 1963, my income was solely derived from what I charged my patients or their insurance companies. From that revenue stream I paid all my office expenses, business and other taxes, retirement plans, continuing education expenses, malpractice insurance and other insurance, etc. There was a suggested fee schedule, but it was acknowledged that I was running a business, and was empowered to charge my patients as I felt appropriate (within the College of Physicians code of ethics).
With the advent of “Universal Medicare”, Alberta physicians were put in the position of negotiating (through the Alberta Medical Association) a fee schedule that the government agreed to honor. For the most part, these negotiations were a farce, akin to a rank amateur hockey player squaring off against Gretzky in his prime. As a result, the settlements were less than inflation the majority of the time. Fortunately, physicians in the early years had the capability of “balance” billing. Unfortunately, this was soon taken away from them by the federal government and the provinces.
At this point I felt the medical profession was no longer a profession. With no ability to address changing environments in their businesses and the government “paying the piper”, physicians soon began to lose their professionalism, and, as the only means of controlling their incomes, began choosing what they would and would not do, depending on time involved, remuneration per item of service, etc. When the government declared they were taking a more business-like approach to healthcare, the physicians responded by taking a more business-like approach to their practices.
So where are we at now? Most doctors limit a visit to one complaint by the patient. Additional complaints need additional appointments. Many family docs have taken up lucrative sidelines outside of the healthcare system (eg. botox injections, hair transplants, etc). A strong trend towards walk-in clinic work and away from continuing patient care and management exists, and the number of young medical graduates choosing family medicine is continually on the decline.
So where do “fee-for-service” physicians get their income from at the present time? Well, the fee schedule for family doctors has certainly not kept up with inflation. Over the last 15 years or so there has been a steady trend by provincial governments to “throw in” financial perks as negotiated incentives to encourage contract acceptance. Continuing education costs can, to a large extend now be reimbursed. Malpractice costs are largely covered by the government (so don’t worry about being sued), making your office techno friendly is even subsidized. Financial incentives exist for rural practitioners, and the perks negotiated recently in Alberta, to be approved by the “profession”, are subsidies for inflationary office cost over-runs ( eg Fort McMurray), and practitioner retention fees that run into thousands a year. Basically, family physicians have become civil servants. I believe some provinces even have gotten into some kind of pensioning!
Does any of this help patient care? In my opinion the answer is an unequivocal NO. Fee differentials for complex and continuing care basically do not exist. There are no incentives for physicians to take on time consuming and difficult/complex care such as the elderly and chronically ill. It would be far better if physicians really were salaried. At least practicing good medicine then would not be a financial hardship, and seeing 12 patients an hour would not be rewarded. Mind you, we would need twice as many family docs.

Physician Assistants

2007-03-25T10:43:00.000-07:00

At least the health care article written for the Calgary Herald, Mar/25, by James Ferrabee, was informative. He describes how much of the primary care in the U.S. is being slowly taken over be Physician Assistants, a program that I supported back in the early 70’s as the U.S. was coming in with theirs.
It was about that time that the Calgary medical school had, as their Dean of Medicine’ a young, bright acquaintance of mine, Dr. L. McLeod. Another young family physician and I met with him and proposed a two to three year program at the Calgary medical school for physician assistants. I had a nurse working for me at the time (Pat W), that I had taught to put on and remove casts, do minor suturing, do prenatal visits, well baby check-ups and assist my office nurse in arranging consultations, investigations, etc. Pat had a group of people in certain chronic disease areas (obesity, diabetes, etc) that she worked with regularly and councelled, and made house calls on palliative care patients. This expanded the number of patients that I was able to accommodate in my practice by approximately thirty percent and I feel, improved the care that I was able to give overall in my practice. Unfortunately, our universal healthcare system provided no means for charging for her services (I could only charge the system if I, as the attending physician, gave the service personally), so when our great leader, Mr. P. E. Trudeau, brought in wage and price controls and “extra billing” was outlawed, I had to discontinue the program because it represented an overhead that I was unable to recapture.
With this practical experience, I felt strongly that we should move in the direction of physician assistants provincially, with a billing system specifically for their services. Unfortunately, Dr. McLeod felt there would be too much conflict with the department of nursing and other jurisdictional headaches, and did not pursue establishing a school for Physician Assistants.
I found it interesting that Mr. Ferrabee quotes an annual median income of $70,000 for Physician Assistance in the States. This certainly doesn’t correlate with charges that are reported by Canadians when seen in the U.S. by physician assistants. They rarely report being charged under one hundred dollars for their visit. The median income for a Canadian family physician doing ongoing continuing care (excluding walk-in clinic docs), probably runs in the range of $100,000 to $130,000 per annum after expenses, and our office visit charge in Alberta is app. $30 a visit. Either the Physician Assistants in the U.S. are being ripped off by a huge overhead beauracracy, or our Canadian physicians are outworking the U.S. assistants by a mile.
Interesting also was the statement that in the U.S there are 62,000 jobs for PAs and only 55,000 P.A.s, pointing out again the universal shortage of healthcare providers. Insulting was the idea put forward, that the resistance to such a program would come from physician groups. If we are allowed to incorporate these care givers into our practices, walk-in clinics, and emergency departments as I did 35 years ago, and not assume the cost directly from out pockets (as I had to thirty five years ago), I see no problems. If this group is to replace the traditional family doctor, then the public should be opposed. As for the hospitals themselves (other than the emergency triage area), care in today’s hospitals is too acute to have anyone but the most highly trained giving primary care.
Naively, Mr. Ferrabee thinks governments in Canada would and should embrace this idea. He should keep in mind that increased access means increased cost, and the primary goal of our politicians in to control cost. Our waiting lists (risk lists) are our implements of sustainability.

I Want To Donate.

2007-03-22T16:00:00.000-07:00

Bill Murray, the Calgary chartered accountant who presently is launching a constitutional challenge to Alberta’s healthcare laws, is my hero. Is there a web site that one can donate money to his cause? Kudos also to the Calgary herald and John Carpay for the article in the Calgary Herald, March 22.
To know where justice lies on this issue, one only needs to know a few facts:
1) His orthopedic surgeon recommended this was the best procedure for him.
2) He was turned down by the Alberta Healthcare Plan based on his age.
3) The surgeon was certainly aware of his age, and, in part, recommended the procedure because of his relatively young age.
4) To carry private health insurance in Alberta is illegal.
5) The patient had to pay for and got the procedure in Montreal.
6) The Government bases their medical coverage on the availability of “relatively” scarce resources (money, so they claim).
7) All medical decisions on the government’s part are therefore suspect, not just on the basis of the lack of personal and medical knowledge of the patient, but also the fact that the government is in a conflict of interest. (Saving money in healthcare to put into education, infrastructure, etc).
8) The above scenario forces patients into the position of not being able to insure against quality of life hazardous events and life threatening events, but refuses to provid treatments recommended by a specialist physician.
9) The above scenario flies in the face of the intent of the Canada Health Act (The rich buy beneficial and necessary procedures unavailable to the majority of Canadians.
10) Constitutionally, discrimination on the bases of age is wrong. Therefore the decision as to what procedure is best is a medical one.
11) Do we want the government to dictate our medical care or do we wish this to be done by our personal physician/physicians?
What really burns my butt is that the Alberta government has the audacity to use my tax money to hire six lawyers to fight this one Albertan. Mr. Carpay states: The Alberta Government should end its legislative ban on private health insurance, rather than spending tens of thousands of our tax dollars defending against Murray’s assertion of his constitutional rights”. Amen to that; except it won’t be thousands of dollars in legal fees for six government lawyers------try MILLIONS.

Anger Management

2007-03-21T10:24:00.000-07:00

I really enjoyed the movie “Anger Management”; but it was just a movie, meant to entertain and make money at the box office. In the real world, anger is complex and destructive, and from where I sit, is one of the most significant negative players in our chaotic world, both at a personal level, and at the international level.
In my early years of practice I had an eighteen year old patient that had made seven or eight attempts at suicide over the previous four years. Her attempts varied from drug overdoses to slashing her wrists. After much consultation with colleagues, she was sent to The Ponoka Mental Institution for psychiatric intervention. After six weeks of treatment she was discharged back to my care and, much to my amazement, never again attempted suicide. On one occasion approximately a year later I asked her if she ever thought of suicide. Her angry response was “I wouldn’t give him the satisfaction”!!
Now I was curious. I telephoned her psychiatrist and asked what had transpired and how he had managed to get her to discontinue her suicide attempts. He responded “Some people have so much anger and so much pathology generating that anger, that there was little or no hope of sorting it all out, so I gave her something to be angry at------me”. “And how did you do that”, I asked? “Simple”, he replied, “I simply humiliated her each time we met”.
That case has always stuck in my mind over the years. Do we all, perhaps, need someone to be angry at? It is certainly less painful to be mad at someone other than yourself or someone you love. Are we actually increasing violence by being “nice” to everyone and not giving them an opportunity to exhibit anger? An article in today’s Herald by Robbie Babins-Wagner, chief executive of the Calgary Counselling Center, speaks of violence simmering just under the surface. I’m sure she wouldn’t appreciate my spin on this, but is that because with all our political correctness, people are discouraged and prevented from expressing their daily frustrations and displeasures? Until they finally blow?
With these thoughts in mind, I turn to the world stage. Perhaps the United State’s foreign policy is responsible for 9/11. By being successful they continually humiliate the rest of us and that continuous humiliation has directed the world’s anger in their direction. Does that mean that the people in Canada who hate the United States are envious of the U.S. and deep-down, consider themselves losers?
The U.S. certainly has become a “lightning-rod” for hate in the Middle East. Was this a deliberate ploy by the clever Bush administration to prevent the people of the Middle East from killing themselves and their neighbors (as they certainly seem to want to do), by supplying them with someone to hate and direct their anger towards? It certainly would appear that in Iraq, if the various factions aren’t attacking the U.S,, they are killing each other and blowing themselves up. Recently, when Israel and Hamas (Lebanese) stopped killing each other, Hamas and the existing Lebanese government turned against each other. It would seem that we as humans need someone to hate and somewhere to direct our anger, or we become self destructive.
O.K, maybe I’ve gotten a little carried away, but one thing is obvious to me. In today’s world, it is becoming harder and harder to find an acceptable area to express our anger and frustration, and easier and easier to find someone else to blame. The United States seems to have become the world’s “whipping boy” by virtue of their success and that they “humiliate the rest of us”. Perhaps as Canadians we need to take more pride in what we are doing, or do more things of which we can be proud.

Observations as a Physician Patient

2007-03-20T10:38:00.000-07:00

It is interesting what goes on in out healthcare system. My wife, presently undergoing chemotherapy, was the 17th in the lab waiting room this morning for her blood test. Before her turn came to have the blood test, approximately fourteen more patients arrived in the room that was about 12 feet by 18 feet in size. This, I know, is a common scenario in our laboratories in Calgary today.
Of interest from a medical perspective is the fact that many of these people waiting for blood tests are doing so because they are ill, many of them with infectious diseases. Of concern to me, as a medical practitioner, is that people on chemotherapy, and people with malignant disease have impaired immune systems, and are at risk for infections. Of particular concern to me this morning was the fact that my wife required her blood work because one week ago her total white blood count was 1.3 and her neutrafil count was 0.4, thus putting her in a particular high risk category.
When I was practicing family medicine I would do my general check-ups and generally see my non-infectious people in the morning, and left openings in the afternoon for the morning phone in fevers, coughs, etc. They would be shown directly into the examining room and not spend time in the waiting room. A few years ago, cancer patients with extremely low blood counts had their blood picked up at home to avoid un-necessary contact with the contagious public. I wonder if these changes have been determined by “evidence based medicine” or “cost effectiveness”.
Since the lab we attended was part of the “community regional health clinic” I found it interesting that only one person was waiting to be seen by a physician in the urgent care facility. I guess the public still prefers to see private practicing physicians. In the case of the laboratories, we have no choice.
Could it be that as choice decreases, quality of care decreases? Just a thought.

Doctors Deal Offers CPR

2007-03-16T18:24:00.000-07:00

A cowboy friend of mine observed many years ago “opinions are like &ss h%les, every ones got one”. The editorial “Doctor Deal offers CPR” in Thursday’s Calgary Herald (March 15/07) exemplifies his position!
The editorial starts out with the position “The two-year proposed contract between the Alberta Medical Association and the province is good for doctors. It’s even better for Albertans, who have been paying the price with their health for Alberta’s Physician shortage. Well, at least they got that last part right, but it pretty well ends there. The writer goes on to give advice to the doctors “Physicians should listen to the A.M.A.’s recommendation and ratify the deal”, now here is the clincher for the doctors “because all Albertans, especially new ones, need and deserve their own family doctor.
Now, keep in mind that I am retired, so I really have no axe to grind other than as a senior, I will likely have to be more dependent on our health care system as time goes on; but my doctor friends are largely approaching my age and they keep me pretty well informed as to what’s happening---------and it’s not pretty.
Consider the following:
1) Rental rates in Calgary have jumped five to six times the 4.5% increase offered.
2) Every business window has a “Help Wanted” sign in the window. Good luck at finding good office help at a 4.5% increased wage.
3) Other office costs, taxes, etc are increasing at a rate equal to or greater than 4.5%.
4) Office expenses for a family doctor doing fairly comprehensive patient care and management run at least 45% of billings. This means that take home pay for family doctors may actually decrease during this two year period with the proposed agreement.
5) A.M.A. negotiations since 1969 (the introduction of Universal Healthcare) has kept up with inflation approximately one third of the time and is largely responsible for the steady decrease in available family physicians.
6) At present, there are areas that family physicians can work outside of the healthcare system. Botox shots, varicose vein treatments, other cosmetic treatments, specialist extenders,etc, provide better revenue for time spent than running a family practice. Even working within the system, we can do much better working as walk-in clinic docs, hospitalists, and Regional health clinic docs; and have a much better home life.
The bottom line will be that we will see a continuing erosion of the availability of family docs.
The editorial states that Alberta physicians, with this contract will be “among the highest in the country, and tied only with New Brunswick”. Good Grief!!!! What does a house cost in New Brunswick? What does it cost to run an office? Surely this editorial was the work of a high school student given a chance to be “Editor for a day”!!!
The final insult to family docs was the statement “There is no shortage of students who want to be doctors. The Medical faculty had U.of C.’s highest entrance grade last fall, at an average of 89.1%. Everyone else was turned away, even those with slightly lower grades who might make wonderful family doctors”. What the!!!!???? Are they saying that you don’t have to be as intelligent to be a family doctor?? The editorial then goes on to say “As long as admission is restricted to the intellectual elite, provinces such as Alberta will have trouble attracting and retaining family physicians”. I think the writer really does think that family physicians are not the intellectual elite and that specialists are!!!!
Here is a news flash, Mr/Ms editor.The last time I looked at the breakdown of medical students, family doctors came primarily from the middle one third of the class and specialist came primarily from the lower third and upper third of the medical class. Specialists coming from the upper one third were more likely to go into research areas. Focusing on one aspect of medicine is often viewed as being easier than being a generalist, which requires a good knowledge of a wide spectrum of medical fields. Specialists spend four to five years of additional training in their specific area, and they certainly should be the authority in that area; but it does not mean that they are more intelligent. In any case, the statements were dumb and demeaning, and certainly won’t entice talented medical students into choosing family medicine.
For those who may be interested, here are some of the real determinants used by medical students when choosing their area of medicine: (not necessarily in order of priority).
1) Primary area of interest.
2) Years of training required
3) Cost/ability, to continue studies
4) Remuneration in practice
5) Marital status
6) Family status (children)
7) Availability of residency training
8) On call status during training and after graduation.
9) Expectation of home-life and personal time after graduation
10) And finally, in some cases the “milk of human kindness” aspect.
11) If some docs are reading this, you can add more, but ability is NOT the issue!
So there you have it, doctors of Alberta. This brilliant editorial suggests you ratify this proposed agreement. If I were a voting member of the A.M.A., my vote would be an unequivocal NO! ---------for the good of all Albertans, and the right of every Albertan to have a family physician.

Healthcare Savings Accounts

2007-02-25T16:04:00.000-08:00

Last week, Mark Milke provided an opinion in the Calgary Herald entitled “A small reform that would work”. Basically he suggested that Alberta’s health care premiums be put into government “owned” health savings accounts instead of into general revenues, and that patients could access them as a deductible for a range of health services (not just ministry designated services). Am I missing something here? Since this money is now going into the government’s coffers and would be the government’s “owned” health savings account with his proposal, expanding the services covered would only increase the cost of health care to the government (i.e. the taxpayer). Isn’t the present problem one of unsustainability? How does increased spending on “new” services address that issue?
The only way this could work is if the government actually de-insured many of the services that are now provided e.g. visits to the family doctor, chiropractor, ophthalmologist, the first $100.oo of a specialist visit, the first $100.oo of diagnostic imaging, laboratory investigations, etc. Can you imagine the uproar by Joe Public over something like that? The bottom line is that the government “bean counters” would have to de-insure more than 900,000,000 dollars of annual healthcare spending in order to come close to making Mr. Milke’s proposal cost effective, and still not address the unsustainability of our healthcare system.
Now don’t misunderstand me; health savings accounts, as done by some companies can have merit; but it does not do so by increasing the coverage of a variety of health services funded by the Canadian taxpayer.
The area that still needs intensive scrutiny in a health savings account system is the area of preventive medicine. Since most of these systems still carry “insurance” (either private or government) for major health expenditures, the participants may decide to spend their “annual allotted moneys” on eye laser corrective surgery instead of medication for their hypertension and not have to be concerned about the cost of their choice. As a taxpayer and a physician, I believe there needs to be justification for, and a shown benefit to, any tax funded health service. Ideally, the system should have significant “built in” incentives for disease prevention. Mark Milke had best get back to the drawing board on this one.

Good Health, and Good-Bye

2006-12-29T09:51:00.001-08:00

There seems to be a consensus that Friday the thirteenth is a bad day. For our family, Wednesday, December the thirteenth, has been the worst day of our lives. A telephone call that morning told us that the biopsy of a small lump under the skin of my beloved wife and my children’s’ incredible mother, was diagnosed as cancer. Furthermore, it was a cancer that had its origin in some other part of the body. Subsequent diagnostic imaging has revealed that the origin is the lung and that surgery of any kind is not an option. We are all devastated.
It is indeed strange that someone such as I, dealing with death frequently, still finds this reality totally unexpected and totally unacceptable. I guess we look at the life expectancy of a woman at 65 to be another nineteen years and do not expect anything less for the person we love. How do we face the reality of loosing your soul mate of the last forty four years? She is so incredibly brave she breaks my heart. One hour after being told the terrible news, she turned to me with tears streaming down her face and said “You know, I’m really not afraid of dying. It’s just that I’m going to miss you and the kids so terribly”.
I would like to thank my physician friends that helped Lea and I reach the diagnosis and plot a course of action quickly. I can’t imagine people waiting for weeks for necessary imaging and attention when a cancer diagnosis raises the distinct possibility of an early death.
It has been one year since I started this blog, and this will be my last blog entry for a long, long time. My priorities lie elsewhere. I extend a sincere thank you to those that have read my dissertations, rambling as many were; and a particular thank you to those that have commented. Good health in 2007 to all, and may the world marvel at your good fortune.

Wal-Mart One, Stelmach Zero

2006-12-23T10:27:00.000-08:00

I love Wal-Mart. Whoever they have running their ship knows how to keep ahead of the crowd. In the last year, some left leaning groups (various unions and their leaders, the competition, and at least two democratic senators), have been bad-mouthing Wal-Mart for not providing their employees with medical benefits. Recently, a plan has been devised by this terrible capitalist entity that I think has significant merit, and may revolutionize primary health care.
It is common knowledge that 50,000,000 Americans do not have health coverage and many, many Canadians cannot find family doctors. Emergency wait times are many hours long and even walk-in clinics in Canada cannot keep up to the demand, with many of them limiting their hours because of staff shortages. Recently, governments in Canada have been in discussions with pharmaceutical associations in Canada, and physician Colleges, to allow pharmacists to prescribe medications for minor conditions. The medical associations have concerns about pharmacists diagnosing, but, what if the pharmacist could work closely with a doctor------closely, as with “ connected electronically”?
Recently my daughter had a rash. She not only told me about the rash, but also E-Mailed me a colored picture of it. Apparently Wal-Mart is looking at electronically providing some primary medical care to it’s workers and its customers. These customers could talk to the pharmacist, the pharmacist would E-Mail a doctor the complaints, a proforma questionnaire would be E-mailed back to the patient (or the pharmacies could have them on hand), they would be filled out by the patient, with comments/pictures added by the pharmacist (or nurse/pharmacy practitioner, and a collaborative decision as to a course of action would be made. The physician could charge half as much (no overhead to speak of), and the pharmacy would get the business from a pharmaceutical and other business perspective. My understanding is that a few physicians would service all of the Wal-Mart stores in a state or province (or health region). Moneys would be collected by Wal-mart and the physicians would be paid by Walmart. The result would be a significant decrease in the cost of a large portion of primary care, and partly subsidizes by Wal-Mart.
Now, to be fair, I’m not sure if the above is precisely what Wal-Mart is proposing, but from what I have heard, it comes close. Many pharmacies have already expanded their services to include health promotion. To facilitate this, the provinces in Canada should allow and encourage health savings accounts; a tax deductible account similar to an RRSP.
The bottom line is this: I don’t think our governments will ever solve our health care dilemma in Canada. Mr. Stelmach got elected recently in Alberta because, at least in part, he promised nothing. Moving forward generates criticism, doing nothing keeps the politician under the radar screen. So be prepared for “nothing” in terms of health care reform in Alberta in the foreseeable future.
In business, maintaining the status quo is a death knell. As demand increases, solutions must be found, or the competition passes you by. My prediction for 2007 and beyond: “Big business will help us find solutions to healthcare, the demand is there, governments simply have to unlock the door”.

Suffering, a Canadian Value

2006-12-19T22:34:00.000-08:00

“In a society where instant gratification is barely fast enough, Canadian’s fierce defense of their right to queue for medical treatment is anomalous. Yet, for some, publicly funded health care defines who we are”.
The above statements were the lead statements in today’s editorial of the Calgary herald. The part that caught my eye was not the part of how bizarre it was for a society to tolerate waiting for weeks and months, in a system that pertains to life or death, but, then won’t tolerate minutes and hours to purchase junk food. The part that amazes me is the fact that some Canadians would define themselves by identifying with our Canadian Health Care System.
Let’s take a few practical examples:
1) A 20 year old patient sees a doctor because she is having some double vision for the past two weeks. She sees her family doctor and relates that three months ago she had a weird sensation in her left leg that lasted six weeks and seems to be stumbling more. She relates that she had an aunt who had similar symptoms ten years ago, has been diagnosed with Multiple Sclerosis, and is now in a nursing home at the age of thirty five. Her doctor examines her and says that MS is a possibility but she would have to see a neurologist, an ophthalmologist, and have a CAT scan to confirm the diagnosis. The patient now is faced with, weeks at the best, and several months at the worst, to have the following questions answered: a) Do I have multiple sclerosis? b) Will I end up like my aunt? c) Can it be treated better than my aunts was? d) What can I do to help?
2) You have just been diagnosed with heart disease that requires by-pass surgery. You have been put on an urgent waiting list. You have been told that survival is far better if you have the surgery, and that the waiting time for this surgery could be up to one month. You realize that your life is at risk while you wait for the surgery; you have trouble sleeping, eating, concentrating, etc.
3) You have had a cough for about a month, see your doctor, and a chest X-ray is done. Your doctor tells you that you have a suspicious area on your lung and need a CT scan of your chest and a bronchoscopy. You think “cancer”. You wait three weeks for the CAT scan and it confirms a “serious problem”. You wait another two weeks to see a chest specialist and another ten days for the broncoschopy. Your thinking “Its taking too long. I’m going to die”. The bronchoscopy and biopsy are done and it takes ten days to get the results. You are told that you have adenocarcinoma of the lung. You are referred to the cancer clinic and see a “team” of specialists. You are told that you need a head and body scan to insure that the lesion is operable. A bone scan is booked to insure that you are a surgical candidate. All the while you wonder “will I live or will I die? If I am going to die, how long have I got to live? Will I die in pain? You have a million other questions.
So tell me again why we Canadians identify ourselves by our public health system? People on waiting lists experience the same basic fears as hostages captured by terrorist; will I live or die, if I am going to die, how long have I got to live and will I die in pain. Many are in pain while they wait for decisions. In short they are under an incredible degree of suffering, and their loved ones suffer with them. Ordinarily, we would call a situation like this cruel and inhumane. Our government calls it difficult, complex, but still keeps the gates to freedom locked. The aged, the poor and the chronically ill have no alternatives but to stay imprisoned in this, our public health care system. The wealthy can pay and escape. They see the specialist, have the CAT scans, bone scans, the surgeon, the radiation oncologist, and the medical oncologist in a matter of days and a course is plotted. They know what lies ahead and what they must do, and they can get it done.
To a large extent, much of the suffering is in “not knowing” and thus, not being able to intervene. Waiting lists are lists of suffering people. What kind of society would take pride in this abuse of the most vulnerable? What kind of society identifies itself by this kind of torture? Depraved dictatorships?
No, it would seem to be our Canadian society; led by the advocates of our universal, monopolistic, and immoral, healthcare system. Each day I would leave work, feeling I had let my patients down. Each day patients were put on lists that were too long; lists where, I knew, in spite of my best efforts, they would suffer much longer than needed. Human rights advocates, where are you when thousands of Canadians need you? We need to be rescued from this “Canadian value”.

NDP/Friends of Medicare Celebrate Hancock as Health Minister

2006-12-17T09:52:00.000-08:00

So Mr. Dave Hancock is Alberta’s new Healthcare Minister. That figures; he said twice as much about health care on his home page leading up to the leadership elections as all of the other candidates combined, and at the same time, said the least. Have you ever noticed that when people go on and on about a subject that they may be treading water. I wrote pages and pages in an exam in medical school and got a 67%. The professor stated that I either knew the material very well, but was unable to express myself, or, I had a very tenuous grasp of the subject matter. I think Mr. Dave Hancock, as a professional politician and lawyer, likely has no trouble expressing himself. His solution to everything is “healthy life styles” and innovation.
Let’s review the key innovative and preventive movements by the Alberta government, and in particular, the Calgary health Region in the past 17 years, so we can get an idea how things are going.
1) Increasing health care costs brought in the innovative idea of decreasing medical school enrolment (if there are fewer doctors, there will be fewer tests ordered and fewer people will be admitted to hospitals). Sick people don’t generate costs, doctors do. This attitude alienated thousands of Canadian doctors and was responsible for the significant loss of physicians to other countries.
2) Increase the training time for a nurse from three years to four years.
3) Hire an accounting firm to set healthcare on a “business model”. This resulted in two hospitals in Calgary being sold, and one blown up. We went from 3.3 acute treatment beds per thousand population in Calgary, to the present 1.7 beds per thousand population.
4) During this downsizing in the province thousands of nurses were let go. These were the recent graduates because the Nurses Union gave privilege to the oldest nurses. Now we have an acute shortage of nurses and an alarming average age (approaching retirement).
5) Walk in clinics were looked at as a way of relieving pressure on emergency departments, but few, if any, took on preventative ongoing care. Income for walk-in clinic docs is much better than traditional family care, so fewer new docs are doing traditional family practice, and fewer docs, overall, are practicing preventative medicine.
6) Private laboratory services were largely taken over by the Calgary Region and more than 50% of small laboratory outlets were closed. This practice continues and patients often wait an hour or more for a simple blood test.
7) As a result of (6.) many small X-Ray outlets also closed and many small medical clinics in Calgary followed suit. Now the government is trying to re-establish similar clinics (8th and 8th, etc) at twice the cost. Little if any preventative medicine is practiced by the physicians that work in these clinics.
8) The region brought in “hospitalists” (physicians who specifically look after hospital patients), and paid them more than the physicians received for looking after their own patients in hospital. This precipitated a flood of family doctors giving up their hospital privileges.
9) Doctors were left out of the decision making process because they were deemed to be a special interest group (I suppose they thought the doctors would only give advice that was self serving). We are told this attitude no longer exists, however it should be noted that our new premier, Mr. Stelmach did not appoint Dr. Oberg as Health Minister (nor did Ralph Klein). The suggestion was that he did not want someone that was “too close” to the medical profession. Interestingly enough, Mr. Knight was appointed as Energy Minister (his background in energy services is seen as an asset), and the fact that Mr. Groeneveld was a farmer seemed to be a plus for his appointment as Agriculture minister.
So much for trying to solicit the help of the medical profession. Could it possibly be that Mr. Stelmach simply needed the “tried and true” rhetoric of “we will save healthcare with innovation and prevention” (and Mr. Dave Hancock can sure preach that sermon), to get elected in the next provincial election. Every prime minister and premier for the last thirty years has been elected with the same song and dance, so why not Mr. Stelmach? And while they fiddle with their innovations and grandiose plans of addressing the “determinants of health”, people die while they wait in “risk” lines.
I note that the NDP are quite happy with the appointment of Mr. Hancock to the Healthcare portfolio, and why shouldn’t they be; he’s their man.
And lastly, the great innovative idea of a health system that is “cost effective” and “patient focused”. I have in previous entries talked of the many pit falls of our cost effective policies. In my next entry I will discuss the “patient focused” part. And if you wish to read more on our new Health Minister, I refer you to my entry “Dave Hancock, a Lawyer’s perspective on Healthcare.

Calgary City Council Solves Healthcare Crises

2006-12-13T21:49:00.000-08:00

Recently Calgary City Council passed a by-law that pertained to the behavior of its citizens; then, they quickly demonstrated that they meant business by fining a homeless person $100 for spiting in a garbage can. Now, from my perspective, he should have been given a medal. If everyone in Calgary spit and discarded what they didn’t want in a garbage can, Calgary would be an example for the “World Model City ( The Calgary Flames games should rake in tens of thousands of dollars each game!).
Now, I’m not saying I approve of spitting in public, or cursing, or putting your feet on park benches, etc, but how did they come up with fining behavior anyway? Just in the past year the fines for traffic violations increased two or three fold. I thought punishment didn’t work. That’s what we are always told about car theft, vandalizing, assault, and even murder. Perhaps it is only when the behavior punishment has a “cost” component, does punishment work. If that be the case, Calgary city hall has just solved the health care crises in Alberta.
If they were responsible for healthcare, I’m quite sure they would put in the following:
1) Fine each person $500.oo per year per point that their BMI exceeds 30.
2) Fine each person $100.oo per year per point that their blood pressure is over the recommended level.
3) Fine each person $10.oo per 1% that their cholesterol levels are over the optimum level
4) Fine each person $500.oo per year who doesn’t have a membership in an exercise club, with corroborating signature of attendance and “clock punching” evidence of time spent.
5) Fine physicians $100.oo dollars per patient that do not reach the above goals.
6) Increase taxes on cigarettes (or add a fine for smoking).
7) Ration junk food (as butter and some foods were rationed during WWII) and fine anyone going over their ration.
8) Tax all foods that are deemed to be “unhealthy” (in addition to the GST).
Some of you, I’m sure, are being critical of these suggestions; but think about it. The city is fining people for behaviors that they (someone) deems offensive, but is any true harm being done? The traffic “fines” are for the peoples’ and public good, to protect from injury and so on. I assure you, healthy life styles and compliance with recognized treatments would decrease morbidity and mortality from strokes, heart attacks, diabetes, and save the system hundreds of millions of dollars in healthcare costs. Furthermore, if we consider the average life style of Canadians, there would be hundreds of millions of dollars derived from these fines. Not only would there be enough money to fund healthcare, but enough left over for education, infrastructure, welfare, and a host of other worthy causes. Control with fines; yes, even homeless people. After all we don’t uphold the law based on a persons address!
The world has gone mad!

Gay Marriage

2006-12-07T15:16:00.000-08:00

Since today is the day our federal parliamentarians vote on the definition of marriage, I may as well add my two bits to the discussion, and since I am posting after the vote has taken place, the entry is only for purposes of discussion. I, quite frankly, have never understood exactly how a group that supposedly takes “pride” in their sexual orientation, would want to “marry” into an institution that already would appear to be going down hill. With the introduction of gay marriage, the definition of marriage would necessarily have to be changed to the “union of two persons” which gives no specificity or “special ness” to their sexual orientation. What happened to the “pride” part?
As we have progressed over the years, the more advanced societies and science itself, have continued to make an effort to define things precisely so as to better analyze and study for the purposes of advancement. In biology we look at the kingdom, phyla, family, genus, species, and so on so as to identify and learn more. This is done, as I understand it, based on its characteristics and function. In society, we have institutions, organizations and the like, each one bringing something special to the table; each one having certain characteristics. The more precise those characteristics and the definition, the more able a civilization can study societal benefits and contributions.
As an individual, I am not against gay marriage or polygamy (as long as the latter abide by, and protect the rights of the individuals within that union). As a scientific member of our society, I feel that it will make it more difficult to analyze and assess positives and negatives of this initiative, in what is already an emotionally hot issue. As a heterosexual, who is partly defined by my involvement in this institution (I am married to a woman), I feel my identity and the identity of the institution have been somewhat obscured. If the claim of genetic influence is appropriate in determining sexual orientation (and I believe it likely is), then why can this not be reflected in a unique institutional name, one that the participants can be proud of and is defining? If all the rights and privileges of these various groups are equal, how is the charter of rights and freedoms being denied?
Out of interest one day, I telephoned the Canadian Legion to see if I could join. I was told that I could have a social membership but would not be allowed to vote and would not be a “full” member. Quite frankly, this annoyed me. Obviously, since the number of people who have been in the military has been declining, the social aspects of the Legion have been on a downslide. As a remedy for this, they introduced a “social” membership; but in an effort to appease the members that are identified by their service in the military, they have allowed those, that have not defined themselves in a similar way, to join, but not vote. My feeling was that you either meet the criteria or you don’t. Allowing “social” members has, in a very small way, taken away from the identity of the other members; and it was done for financial and political reasons.
I think when an organization loses its defining characteristics, it eventually fades and will cease to exist. This seems to be the case in countries that have had “same sex marriage” for the last number of years. Marriage rates have been going down. In North America divorce rates have been going up. This will have the net effect of fewer people belonging to the institution of marriage. I also think marriage helps to a small degree (but certainly not the only factor) in both having children (necessary to sustain a society), and providing a stable environment for raising children. Do we really want it to slowly fade and die? And this is not to say that gay couples unions are not stable; I simply think they should call the union something else and promote it with pride, rather that attaching to some other union name and broadening the definition.
The next big question and “hot” topic surrounding this issue is “Should the church bless same sex unions”? Recently a minister friend asked me this question. He never asked me if the state should allow civil unions with all the rights and privileges of “marriage” because I think he would know the answer would be “absolutely”. I think he also knew that I felt same sex unions should not be called “Marriage” but likely for different reasons than his. The question was simply a religious one; “Should a Christian religion BLESS a state recognized same sex union”?
The first statement that I wish to make is that there is general consensus and recognition that there should be freedom of religion, and that there should be separation of church and state. Put another way, there is no obligation on the part of any religion to condone, yet alone bless the actions of government, or a government to enforce the beliefs of any one nation.
The second point to be made is that there are many kinds of love. Some people love their work, some people love their pets, and some people love nature and the great outdoors. To my knowledge, the bible recognizes these various loves but also puts a different emphasis and characteristics to these different states of love. It mentions the love of a brother for a brother, a child for a parent, and a parent for a child; it mentions the love we should have for God, and the love that a man should have for his wife, and a woman should have for her husband. My understanding is that he “blesses” all these types of love within their context.
The third point that needs to be made is that Christ loves and blesses the sinner but not the sin.
The fourth and final point is that the love between a man and a woman in the “Marriage” sense, and/or, a “Civil Union” sense between same sex couples, is undeniably meant to be a sexual union. There is consensus that if a sexual event does not take place within a union, the marriage is deemed not to have been “consummated” and therefore can be annulled (regarded as not to have taken place).
With the above points in mind, I find the question of blessing same sex unions a relatively simple one, and the question simply becomes “Does Christ consider sexual activity between people of the same sex a sin, or an activity worthy of being “blessed”, since the activity within the relationship defines both the type of love and the relationship.
And now I await my condemnation as a homophobe.

Weyburn Mental Hospital Project, The Precursor to Universal Public Healthcare

2006-12-06T09:20:00.000-08:00

I’m not sure what the T.V. program “Weyburn Mental Hospital Project” was intended to do, but it brought back some good memories for me.. I watched the entire program, and as someone that worked there in the summer of 1958, I felt the presentation dwelt on the negatives and gave short shift to the positives; most of which, in the program, were attached to the architectural aspect of the physical facility. They mentioned the grounds to some degree, but not truly in the context of the patients. They did show some tomato plants growing, mentioned vegetable gardens, and mentioned the dairy farm, but for the most part dwelt on the supposed “atrocities” that occurred within the walls of the building. Granted, there are many things about institutional living that most of us would find offensive, but I think the Weyburn Mental Hospital was, in fact, a step in the progress of our society (almost like a huge societal experiment), to address the issue of “What do we do, as a humane society, to look after those who are unable, for whatever reason, to look after themselves?” From my perspective, the major problem with the endeavor was that the scope of what they were attempting to do, with the facility and staff they had, was simply “over-reaching”. Apparently at one point, the facility housed and cared for over 2000 patients, when it was originally designed to look after approximately one thousand.
Much of the T.V. program showed the dark underbelly of the facility, the bed on bed overcrowding, and the fact that the facility was greatly understaffed. Some of the primitive treatments were shown (Insulin and electroshock therapy) that, to the average person, would appear to be inhumane. Mention was made of the use of leg and wrist restraints for violent patients, and the use of the drug epecac to induce severe vomiting. (Unfortunately, the person that mentioned it suggested it was a form of punishment when in fact it was used to cause exhaustion through repeated vomiting in an effort to prevent self-mutilation). Mention was made several times of the fact that our modern anti-psychotics and anti-depressants were not available in those days, but not enough was said as to what would happen to the patients if there was no intervention. Suicides were mentioned, but there was almost the inference that these occurred because of the terrible living conditions rather than their mental health condition. In those days, the Weyburn Mental Hospital “housed” all the people that had no where else to go.
I look back to my summer of work at the Weyburn Mental hospital quite fondly. I had visited the grounds many years before, and being a farm kid, thought it was great. The dairy farm was incredible, clean and well kept. The grounds were immaculate. Many of the patients had gardens of their own, in which they grew a variety of fresh vegetables. As a summer student employee in the summer of 1958, (of which there were many), I had only on rare occasions, been on the wards. My job was to be in charge of the grounds crew of some 11 to 13 patients. This included looking after the green house (beautiful), some weeding, picking up papers, watering flower beds, occasionally digging and planting, etc. My patients had “grounds privileges” (as many other patients did), and would be at the garden shed as the sun was rising. I can still see the old timers sitting around the shed, smoking their pipes, savoring the warmth of the morning sun.
I enjoyed my work there; and in particular I enjoyed the patients. Since my job was one of supervision, and their jobs were more for the purpose of giving them purpose, I had plenty of time to visit with them and get to know them. Most of the patients in my crew suffered from some sort of organic brain disease, although there was “King George”, who was quite psychotic and delusional, and “Two Step” (who was mentioned in the program), who had had a severe psychotic breakdown after his family had been destroyed in a house fire. Poor Two Step; He would take three steps forward and two steps back where ever he went. Naturally he was very late for his meals, for getting his gardening tools, for getting to the work site, etc, but it really didn’t matter because he could be relied upon to get there eventually. Whatever had happened to his family (I was not privileged to his record because I was a student), his pacing was continuous and in cadence with “Burn their heads, burn their bones, burn their goddamn heads, burn their goddamn bones, burn their heads, and so on. As the summer progressed, because I continually engaged them in conversation, I became familiar and friends with almost all of them. One day “The Millionaire” approached me and told me he had decided to leave all his money to me in his will. I, of course, thanked him and enquired as to whether I could use the money however I wished, even on wine, women, and song. He drew himself up to his full height and exclaimed “Then you aren’t god anymore”. Later I reassured him that I wouldn’t waste his money on wine, women and song, much to his relief.
One of the female patients that had ground privileges was about forty and her name was Sadie (not sure if that was her real name). I had been forewarned about a few of the other patients (with ground privileges) and Sadie was on that list. In addition she had signs put up in her own print (stuck to trees, etc) that stated plainly “Tail, Ten Cents”. Now Sadie was quite a smoker so on occasion I would chat with her and see if she was “firm” on her price. She would giggle and tell me secretly’ on occasion, a cigarette was sufficient. I would tease her and admonish her about being too “easy” and she would get a big laugh out of it.
One very large lady (about thee hundred pounds) was quite fond of men and would occasionally try to catch one. One day I heard screaming from around the side of the hospital. I rushed around the building to find the screaming coming from a window cleaner twenty feet in the air on a ladder. Our hefty lady was giggling and about half way up the ladder to “capture” him. She was reluctantly “talked down” the ladder; much to the window cleaner’s relief.
The only patient that really caused me and my crew a problem was a twelve year old girl who had been admitted for psychiatric evaluation because she was actively soliciting sex. I really didn’t know much about her situation, but during her “ground privilege” times she would hang around my crew and “display herself”; sort of like the recent “Brittany Spears thing (I guess if you’re older that’s allowed). The agitation level of some of the patients rose considerably and I had to report her to her nurse. I never saw her after that.
The program mentioned that between 1964 and 1966 they threw the doors open to many of the previous “closed” wards of the hospital, and from time to time patients would be scattered all over the city and country side. My parents reported two naked ladies walking down highway thirty nine on a hot July day. The hospital was quickly, over this time, downsized to approximately 300 people from 2000 people. Many were discharged to relatives, foster homes, etc, but many ended up on the street or in other institutions (nursing homes). One has to wonder if these people are better off on the street or in an institution, no matter what the institution is called. Are we more humane leaving them sleep out in minus 20 degree weather and foraging for their food in dumpsters? Or for that matter bussing them to a warm “sleep-over” and then back to the minus 20 temperatures through the day? How will the generations 50 years from now judge us on our treatment of this group of people who seem unable to live with dignity? And I wonder what ever happened to Two Step, the Millionaire, and Sadie.
Isn’t it always just about money. Is it not possible that if the Weyburn Mental Hospital had continued with the 1000 occupants it was designed for, kept the staffing and programs up, and with the advent of mental health treatments we have today, would have been a facility that would be a mental health gem? Someone made the decision that these mentally afflicted people could make decisions for themselves and make out on their own, at about the same time the government was deciding to put in place a monopolistic health care system that basically declared that the people with all their faculties were not able to responsibly arrange their own healthcare coverage. In our present Universal Public monopolistic health care system, have we not abandoned those very people that need societies help while depriving capable people the right to insure and provide for themselves? As time goes on, the present system has become increasingly burdened with those people who could fend for themselves, with too few caregivers and crowding in our facilities. Meanwhile, the people that really should be cared for and protected wait on long “risk lists”, and are not specifically targeted with intervention and preventative programs. Have we really not just expanded the Weyburn Mental Hospital situation into a National Monopolistic Universal “Healthcare” project? Has our Universal Public Healthcare system become the Weyburn Mental Hospital without walls? Think about it; the Weyburn hospital simply and inappropriately tried to do too much for too many people with too few resources and at some point, rather than being more discriminative in their “coverage “ of their dependant patients, simply threw the doors open (more to the point, pulled the rug out from beneath them), and left most of them fend for themselves. As costs rise in our public healthcare system and the needs outstrip the capacity, will the government at some point, suddenly throw their hands up and declare that we can all look after ourselves? Wouldn’t it to be appropriate (and sensible) to encourage those that are able and wish to provide for themselves through insurance programs and a private system, the opportunity to do so?

Lies, Damn Lies, and Politics

2006-12-01T16:03:00.000-08:00

Does anyone actually know how this equalization thing works? I’ve tried to get information on the process, but the general consensus of the powers that be is that if someone told us, we would be too stupid to understand it, so why tell us. This afternoon, while half-heartedly listening to Mr. Dinning on some talk-show, I thought I heard him say something to the effect that Albertans shouldn’t be concerned about equalization payments, and how the formula was calculated because it wasn’t actually Alberta’s money that went into equalization, it was federal money.
Silly me, I’ve always thought that the feds didn’t really have any money except yours and mine, and of course taxes from corporations, which we basically pay anyway because we are the consumers that provide that profit.
So, this is my understanding to date, please enlighten me if I’m wrong:
1) The system was set up to ensure all provinces of certain basic social services that are deemed to be part of the “social fiber” of Canada (Is child care in Quebec included?).
2) At present the formula (???? Which contains some natural resources ???), is based on the “wealth” of the five provinces in the middle (not the wealthiest and not the poorest).
3) The federal government then decides what level of transfer payments (monies), is necessary to level the playing field of societal niceties (they may call it essential services to make it sound better----who knows what it entails?).
4) The supposedly “poor provinces” get the lions share; the “rich provinces” get much less.
5) So the feds take tax money from all taxpayers and redistribute it. In Alberta’s case, much of our tax money going out, and little of it coming back in. But, Mr. Dinning, isn’t my tax money still my money when it ends up in the hands of the federal government? Isn’t it sort of a mandated contribution?
So let us see what happens if a different formula is used, including all provinces and natural resources. I think the intent would be to take some of the burden off of the industrial provinces (Ontario) and bring the total redistribution pot up, thus putting more money “earmarked” for redistribution. It is true, it doesn’t change the amount of taxation money in the federal coffers; it just buys justification for more discriminatory distribution of money for the purpose of gaining votes (Man that sounds paranoid. I must be forgetting to take my haldol again!). So, Mr. Dinning, you have either misrepresented the system to us entirely, don’t understand it yourself, or believe that making large areas of Canada dependent on federal handouts is a noble cause. Which is it? In any case, you sound more and more like a Liberal Lite, as per Ted Morton. Who would think Alberta would have a Paul Martin as their premier. Times are a-changing.

Dinning Will Win, Alberta Will Lose

2006-12-01T15:07:00.000-08:00

It continually amazes me that politicians continue to vault themselves into office by declaring they are a “moderate” by supporting our Universal, publicly funded, monopolistic healthcare system. Is that the proper term for supposedly intelligent people, who have the privilege of tracking and analyzing a healthcare system over a period of thirty nine years, witness an exorbitant increase in cost during that time, witness a corresponding decrease in health outcomes during that same period of time, still claim nothing needs fixing and the status quo “rules”. Einstein had a different word to describe it.
Perhaps I am being too idealistic and severe in my criticism and these fellows are simply being politically astute, and the public misinformed; but whatever the case, once again the strategy will work, even in a more independent Alberta. I will predict Jim Dinning will win the Leadership of the Conservative party of Alberta and be Alberta’s next Premier.
Having reviewed how the voting tabulated last Saturday, and taking region by region candidate placement, it becomes apparent how tomorrows vote will go. By adding the first and second placements of Jim Dinning, we arrive at a figure of 76. If we do the same for Ted Morton we get 48, and with Ed Stelmach we get 13. Now I know that this is a region by region perspective, and that the leadership will be determined by the total number of votes for each candidate, but from what I can see, unless there is some unforeseen occurrence, Jim Dinning will be a shoe-in.
And that is too bad for three reasons:
1) If Mr. Dinning has so little understanding and “vision”, of solutions in healthcare, of which he has had considerable exposure, how can we have confidence in his abilities to deal with infrastructure, incredible growth, environment, Ottawa, etc? On the other hand, if he took his “status quo” position on healthcare just to get elected, what does that say about his honesty, integrity, and character?
2) It will indicate that the people of Alberta are no longer prepared to stand up for Alberta. It will mean we have lost the ability to shrug off criticism and to try new things; in short we, who have been the most independent and innovative in Canada, have bought into the philosophy that we should be followers and not leaders. We have become a province and people that believe conflict should be avoided at all cost, and that principle should give way to the common good.
3) Strong leadership on the right could seriously split the conservative part in Alberta. Like many Albertans during the run up to the last election, I considered voting for the Alliance Party, but did not feel the candidates and their leader were of sufficient experience or strength to be credible. Although I voted conservative, many conservatives simply abstained. In Thursday night’s debate, it became apparent that, as Ted Morton stated, Mr. Dinning seemed to have little tolerance for the views of Ted and his followers. The primary ingredient of a “big tent” organization is that each member has respect for each others views. Referring to those views in negative terms such as regressive or scary is not endearing. If the Alliance party were to find credible candidates and convince a Ted Morton to lead it, the conservative vote in Alberta would be split so significantly, the Liberals would likely win the next provincial election.
So there it is folks. I predict a Dinning win and big trouble ahead for the Conservative Party of Alberta.

Private/Public Healthcare, A Synergistic System

2006-12-01T09:59:00.000-08:00

I think the first thing we should deal with in our discussion as to how a private parallel healthcare system would work in Canada, is to look at the idea of guaranteed wait times, since some politicians are suggesting this, as some sort of solution to our long “risk lists” in our health care system. Let us take a case where I need a hip replacement. I am in pain and am developing a stoop because of contractures developing in my hip. I relate to my family doctor that the pain pills he has prescribed are no longer effective and I wish to have a hip replacement. He agrees and refers me to an orthopedic surgeon. I am informed that the waiting time to see an orthopedic surgeon in Alberta (any surgeon who does hip replacements) is six months. The provincial guaranteed waiting time in the province for a hip replacement has been set at three months. Does the time I am waiting to see the orthopedic surgeon count as time “put in”, waiting for my hip replacement? I have already acknowledged, and my family doctor and physiotherapist agree, that I need a hip replacement. So the “system will probably say “No, we only count the time after you see the orthopedic surgeon”. Fine, I take my morphine and stumble around for the six months, finally see the orthopod months later, and he concurs; I need a hip replacement. I am then put on another waiting list, waiting for a slot in the operating room, that is again estimated at several months. What happens when the three months are up on my new waiting list and I have not had my surgery? Do I get sent to the U.S.? India? another province in Canada? Or will I be booked at night on an emergency basis and “bump” someone else who is waiting? If we have that capacity, why don’t we just extend the operating room hours now? What if nothing is done? Who forces the government to honor their guaranteed wait time? Can you imagine the hassle trying to deal with the government bureaucracy?
At the same time I have my problem, my neighbor sees his doctor with a similar problem, but is not sure he is ready for surgery. An appointment is made with the surgeon, as in my case, six months down the road. Is he put on a wait list? He sees the surgeon and is told the pros and cons of surgery but the decision is his. He wants to think about it. Is he put on the waiting list then or two months later when he decides to go for the surgery and signs the papers?
The point is that guaranteed wait times cannot work without a recognized process for the many people that will not fall within the agreed upon parameters, and without a treatment resource outside of the existing public system. If this were not true, we already would have appropriate wait times. A private system would enable negotiations between the government and the private system, to agree upon a price and the conditions to be met, and the protocol to be followed to access the private system when the public system has not met their guaranteed wait time, in advance of the situation. All parties, including the public, would be aware of those terms and conditions and the protocol to be followed. My suggestion would be that the orthopedic surgeon involved could approve the move to the private system if the wait time guarantee cannot be met.
When a parallel private system is allowed in Alberta, it is imperative that companies providing health insurance, be invited to be active in Alberta. These companies would offer full coverage comparable to the public plan, or they may offer coverage that the patient could pick and choose from similar to a “menu” of services. People could review this menu and the cost of coverage and choose the coverage that suits them personally. What would likely happen is that as people get older they would insure for joint replacements if the public system wait times were long, and tend not to insure if the wait times were reasonable. This would automatically, to some extent, control the wait times and cost to the public system. Some people would choose to wait in the public system so their premiums would not go up, some would change their life styles to bring premiums down and within their reach. Patients, as taxpayers with insurance, would always have the right to the public system, or the private system, at their option. The better the public system works, the fewer people will take out insurance.
Timing is critical with this next issue. Although our present physicians must be allowed to work in both systems, it is extremely important for the government to do their homework in advance. A search should be undertaken for physicians who have left Canada and set up practices elsewhere. They should be invited to return to Canada, practice in the public system, the private system, or both. Obviously, the private system will try to attract good physicians into their programs, but they will be looking at physicians in Canada and abroad. The government should focus on those who have left Canada for reasons related to restrictions in practice. Properly approached, many of our native sons and daughters would return. It has always amazed me that we Canadians are so supportive of diversity in our culture, but stick stubbornly to a monopolistic healthcare system. And why do we press for ways of bringing in foreign doctors, instead of looking at ways to recruit back our own sons and daughters who left Canada because of our narrow minded perspectives on health care?
Which brings us to the next point; by having a private system, the public system, its administrators, and the government, will have their feet held to the fire. People will investigate and educate themselves as to what is covered, and what is not covered in the public system, and whether they have a need for additional insurance. People will realize that there are choices to make, and that they cannot be, and should not be, wholly dependant on a government system that has not defined exactly what it is, what it is not prepared to finance, and how it is going to do it.. The importance of life styles is underscored in a private system, adding to patient awareness.
Our existing government leaders in health care continually mention “preventative” medicine, and that this is the answer to sustainability in our Canadian system. Unfortunately, any benefits derived from altering life styles (quitting smoking, exercising, loosing weight, etc) will be many years down the road, presuming there will be enough patient compliance to make a difference. Presently healthcare costs are sky-rocketing, and waiting lists are getting longer, or have not changed. Programs of long term societal changes, to be effective, will necessarily be costly and long term. How will the transition from ever increasing intervention costs and these significant prevention costs be bridged? As previously stated, cost benefit will not be realized for years.
Once again, interim private insurance can bridge the gap. From my perspective, the government’s primary responsibility should be public health with all of its implication. They should be primarily responsible in the areas of pandemics, epidemics, life style issues and preventative health, immunization, neonatal care issues, poverty, food safety, pharmaceuticals, etc; the list can go on and on. The next priority of government and closely associated with the first should be to address the issues that have to do with chronic disease such as diabetes, hypertension, cancer, etc. The last responsibility in healthcare, of governments, should be, on a province by province basis, to provide a safety net for unforeseen medical events for its citizens who are unable to fend for themselves. The idea that we, who are able to fend for ourselves, should be excluded from doing so, is insulting, offensive, and undemocratic. There is absolutely no reason why the private and public systems cannot work together in the “intervention” area of health care.
Finally the issue of healthcare premiums should be addressed. As long as low income people are exempted it is not really an issue. Basically, it is simply another taxation measure. It would be nice if a little ingenuity were used in the administration of this tax. What if rates varied somewhat with life styles? What if those paying the tax (premiums) actually got to pick and choose some health care benefits specific to them and their needs (travel coverage, ambulance coverage, additional drug coverage etc). With the drive to a computerized health record, it would be a piece of cake to implement. But I’m sure someone would find some inequities in such a system. Lord help us if we show some true innovation that may not be 100% inclusive.
The above is a rough draft of how a private health system could be utilized in our present system. It should NOT be considered, in any way, a replacement for our existing public system, as the doom-sayers screech, but an add-on; a tool to be used by those who choose to use it, and by the system, to shorten wait times and give people more control of their lives. Too bad none of the candidates or for that matter, Iris Evens previously, took the time to introduce the subject rationally and objectively. But then again, who is listening?

Naomi and the Left Versus Ted Morton

2006-11-30T13:59:00.000-08:00

Today I wasn’t going to post, and then I read Naomi Lakritz’s column. I know, haven’t I got anything better to do? I guess my only excuse is that she wrote about healthcare and the leadership candidate’s position on it, and, well, I kind of lost it. I guess she is just one more person criticizing a private care alternative, but not offering ONE suggestion on the present day issues on health care in Alberta, or Canada for that matter. Here are some of her mindless positions taken:
1) Iris Evans dropped the third way because the people didn’t want it. What percentage of Albertans had any idea of how it would work. We should probably pay attention to an informed majority; but the usual clamor from the left drowned out any effort at rational dialog. Personally, I think the people of Louisiana should have listened to the suggestions of evacuation long before they did. It would have saved hundreds of lives. I would preferentially listen to a fireman on how to get out of a burning building than the throng of people below. Sometimes leaders should lead.
2) An AON consultation did not guarantee privatization would save money. Here is a news flash: only an idiot would guarantee savings in health care. I would think any increases in cost would then have to be borne by the consulting company. Besides, there are two significant problems in our health care system at present, increasing costs and long waiting lists. A parallel private system would shorten waiting lists by better utilization of surgeons. Even I don’t think there would necessarily be a cost savings, BUT: a private system with private insurance will provide money from those people wanting to be covered by a private system, and thus take less money out of the governments taxation “pot”.
3) She quotes Ed. Stelmach: “Allowing doctors to practice in both a private and public system will not put more doctors into Alberta communities”. Well Ed. and Naomi, it probably would. WE have lost thousands of doctors and nurses to the U.S. and elsewhere over the last fifteen years. Just maybe, if we offered them more options in their practice, with a recruitment program that showed our appreciation of their contribution to society, we could get many to return to Canada.
4) Apparently she approves of Jim Dinning’s comment: “Albertans have said they don’t want it, so I’m not going there”. Mr. Dinning knows the present system is unsustainable. He also knows that five federal elections and lord knows how many provincial elections, have been won largely with a “status quo” stand on health care, in spite of the fact Canadians want it fixed. I notice, Naomi, that you have not made ONE positive suggestion in your column.
5) She apparently likes Jim’s “allowing doctors to practice in both systems would draw doctors to the city ------“. Now where is the evidence for that? Surgeons, especially orthopedic surgeons, already practice primarily in the large urban centers, and rightly so. This is a blatant scare tactic ploy on Dinning’s part to try to garner some rural votes. Pathetic!
6) She criticizes mandating certain obligations on the part of physicians to spend time to the public system. Congratulations, Naomi, you got one thing right. Forcing people to work where they do not wish to work really is autocratic. Fortunately, only five percent of physician in Canada would prefer to work only in the private system. It does, however, open the door to a viable and active recruiting program that can attract hundreds, and maybe thousands of doctors to Alberta/Canada.
7) She states that there is not a market for private care or more doctors would be in private care already. She states that it’s because the market for people who can afford to pay upward of $30,000.oo out of pocket for a new hip is extremely limited. Duh! Isn’t that precisely why we commoners should have the right to purchase INSURANCE? Even without the insurance, people are dipping into their savings and going to physicians in the U.S., Vancouver, and Montreal. Naomi, the dyke has a huge leak, and will soon burst without some kind of relief.
8) She quotes Dr John Kortbeck, CHR’s regional director of trauma “Countries with a private system have found that the public system still does the bulk of surgery” and he apparently adds “our operating rooms are running at between 90 and 100 percent utilization rates, with some open 24/7 to accommodate a balance of emergency, urgent (cancer surgery), and scheduled (hip replacements, etc). I certainly agree with Dr. Kortbeck’s first statement. My guess would be that only twenty percent of surgeries would occur in an insurance based private system; and this would vary with the type of surgery and the length of waiting lists in the public system. For example, if hip replacement waiting lists are two years or longer, the private system for hip replacements may grow to a 30% market share. If waiting times for hip replacement in the public system shrinks to thee months, the private systems share of hip replacements may shrink to 5%. His second statement underscores the fact that according to him, the system is doing as well as expected. A good question for him, Naomi, would have been: “Why don’t we run more of the surgery theaters 24/7 and shorten some of those waiting lists for cancer and hip surgery?”. Do you suppose his answer may have been “lack of money and staff?”.
So that is the sum of it; an opinion column on health care that had one purpose only, to slam Ted Morton as a leadership candidate. Her opinion is most noteworthy by the lack of knowledge of the subject matter demonstrated by the writer and the obvious bias. But then, it was only an opinion, and like arse holes, everybody’s has one (but only proctologists are happy about that fact).
Tomorrow, I will attempt to explain in detail how a parallel system would work, what it would do and wouldn’t do, and how the two systems could complement each other. Yes, I know, the human brain will reject anything that causes conflict or stress (cognitive dissonance), so I will be wasting my time with Naomi and the like; however, for those simply looking for information, it may well be worth the time.

Motivation, The Primary Determinant of Health

2006-11-29T12:05:00.000-08:00

Although our Alberta Conservative leadership candidates don’t seem to want to talk much about healthcare, and Ed Stelmach didn’t even have it on his top four priorities the other day on “talk radio”, healthcare continues to take front page space on our Alberta newspapers. Today, Nov.29/06 edition of the Calgary Herald informs us of the Calgary Health Region’s intent to “construct” (not really true since someone else will “construct” and the Health Region will rent) a 75,000 square foot Health Centre in the unhealthiest part of Calgary. This clinic will replace two existing clinics that a) “aren’t adequate to meet service needs, b) “are unable to provide the unique services needed in the area” c) really doesn’t meet (our) needs. The Health Region then intends to purchase the building back from the “contractor/financer” of the building. I hope that during these times of escalating construction costs, the region has their contract nailed down, no pun intended.
The major point of my entry today is to ask the question of the Calgary Health Region: “What are these needs that are not being met and what is the plan to meet them, and at what additional cost”? Staff increases are stated to be more than 10%, and the only reasons that I can find to justify this move pertains to “life styles” and as a result, I would surmise, a shorter life expectancy. These areas have “the highest rate of smoking, smoking while pregnant, individuals that don’t meet daily nutritional needs, lowest birth rates, and highest rates of unemployment”.
Dr. Brent Friesen, the regions officer of health, said “One of the things that the Calgary Health region is doing, at the present time, is that we are partnering with other groups because the solution to a number of these problems lies outside the health system as a whole”. After pointing out that this group of people are not meeting their nutritional needs, he goes on to say “If people are on a fixed income, then they have to find the money from other areas, and most often the area they get that money from is the diet”. Well, I say “Amen” to both of those statements; but why do they not take that money from their smoking budget, bingo and entertainment budget, etc? Walking is free and gas is expensive. Now, there is a trade we could all make!
The only reference in the article I could find as to the “unique” services to be offered are “diversity and translation services for immigrants, and wellness programs to reduce smoking and obesity. Twenty new employees are planned for the center; I certainly hope they are sociologists and psychologists because this may come as a surprise to Dr. Ed. Friesen, but I suspect that there will be a low enrollment rate in his programs. Contrary to the prevailing belief in many areas at present, I do not believe that poverty and poor education, per se, are the determinants of health. Rather, they are simply the symptoms of an underlying pathology, poor motivation. I know, I know; variation in motivation is probably a normal genetic variant, similar to many other inherited characteristics, but are we as a society ignoring the important environmental factors that can assist development or potentially retard development of motivation? Some people are truly gifted athletes but never show up on the radar screen of performance; others with a fraction of the genetic ability become Olympic athletes. Some people may misconstrue the word “motivation” and combine it with the words “ambition” and “greed”. I prefer to think of it as a need for self improvement. This may mean different things to different people (the state of one’s spirituality and mind, is more important than the state of one’s body), so perhaps it is unfair to have “health measurements” as a measurement of motivation, or motivation as a determinant of health outcomes, but it is more valid than anything we are using at present.
As a farm kid I was very familiar with the expression “the cream always comes to the top”. There was something magical and intrinsic in cream, so that after a period of time, the cream would separate from the skim milk and rise to the top of the milk bottle. That does not mean that cream is necessarily better (although I think it was implied). Because it has certain characteristics, it simply differentiates itself from the milk. I truly feel that people that are motivated will differentiate themselves along the pathways that they feel are important; that they value. This certainly can be influenced by an environment of hope, the exclusion of mental illness, and a host of other environmental factors. But I have learned over the years that a host of other environmental factors can negate our motivation. Imagine my consternation when, many years ago, I moved to the city and found out that when you homogenize the milk, the cream doesn’t rise to the top anymore. Are we as a society trying too hard to homogenize the people in our society? Are we perhaps putting incentives and disincentives in the wrong place? By guaranteeing the status quo, are we feeding our fear of change and thereby taking away the hope of improvement? Or even worse, by rewarding inertia, and dwelling on the risks of moving forward and the sacrifices that would have to be made for independence and self improvement, are we neutering motivation? And what part do high taxation and inappropriate handouts have in this process? If we did a survey and asked people if they valued their health, likely 100% would say that they did. Yet, we find that only twenty percent of people will invest their time, energy, or money, in their health. Why the disparity? Do they really "value" their health, or do they feel that it is not their responsibility and are simply "entitled" to good health?
Today’s entry is not made as a condemnation of the poor, but rather as a commentary on our society as a whole. Why are our young people spending their money on cars, televisions, toys, etc, when these things depreciate by 30% a year when real estate in Alberta is going up at the rate of 30% a year? Obviously, they have different attitudes, priorities, values, etc. Is this wrong? Not necessarily, but along with it seems to be an increase in an attitude of entitlement. A recent “pink book” by a particular federal women’s group seems to epitomize this. If this is their version of “fulfillment” or “self improvement”, we are in trouble as a society.
So by all means, build and staff a medical clinic in North-East Calgary. But for heavens sake, make it a pilot project and hire sociologists to look at motivation. Throwing more money at these problems, I suspect, is simply part of the homogenization process that actually prevents the cream that is in all of us, from rising to the top.

Canada's Healthcare Tsunami

2006-11-28T11:27:00.000-08:00

Outraged readers of my previous post suggesting outsourcing of Canada’s healthcare needs, as a solution to the rising cost of our Universal Healthcare System, should not read today’s post. After all, if the idea of outsourcing our wealthy people to the U.S.A., as is now occurring, and our poor to India (a future consideration), as a solution to health care costs, is a problem for you, then, today’s post may be totally offensive!
It has been said to solve the problems of today, we must often look to the past. Mark Steyn, in his book “America Alone”, goes to great lengths to show the impact of demographics and an aging population within a given society. It is hard to argue with his observations pertaining to demographics; however, I will confine my comments to the impact on health care. Further, I do not wish to get into the arguments put forth by economists (percentage of GDP, percentage of government budgets, etc). It is not my field, so we will leave that to the bean counters. From a medical perspective, and a common sense, here is how I see it (perhaps a more appropriate title would have been “The perfect Storm”):
1) The edge of the wave of baby boomers is now about 60 years old. The evidence is that these people will slowly and continually become increasing consumers of health care more than contributors to health care, i.e they will be hospitalized more, see the doctor more often, etc. and at the same time, they will be retiring from the medical and other work forces, creating both a shortage in health care providers and a decrease in the tax base supporting the healthcare system.
2) Canada has a reproduction rate of 1.6 children per woman. Therefore each generation continues to shrink compared to the generation before it. The relative size of the baby boomers to the tax-paying base of the population will therefore continue to rise.
3) Life expectancy continues to creep upward while reproduction rates continue to creep downward, with a corresponding increase in the disparity mentioned in #2.
4) Modern technology and pharmacology have dramatically increased our ability to intervene in the usual mortality, but not necessarily in the numbers of people requiring ongoing costly “maintenance” therapy and cost. This not only incurs the cost of the intervention and the maintenance therapy, but increases the effect of #2 and #3.
5) Within western societies, there has been a steady increasing empathy for the weak, unfortunate, elderly, disabled, mentally ill; well just about everybody in need. Whether this is good or bad is irrelevant; the net effect of this has been that, as a society, we have tended to bring about the two-fold effect of decreasing our tax base and increasing our “dependant” base with the corresponding increase in cost.
6) Underscoring all of the above has been our resistance to defining “what is a need as opposed to a want in our just society”.
So where will this all end? We have this tidal wave of elderly, demanding, and high needs people being maintained by a relatively decreasing supportive group in our society. Sounds like a societal “Katrina” to me.
I started this post by suggesting some of the answers may lie in the past. Environmentalists may also be showing the way. Perhaps the old saying “radical situations need radical solutions” is correct after all. With the global warming that has been reported, there have also been reports of increasing ice flows and ice bergs. Northern civilizations in the past (faced with the harsh reality of survival), took the most dependant and aged in their society, put them on an ice flow, and wished them “bon Voyage”. Most health care costs are accumulated in the last two years of our life, so that type of a policy could save over fifty percent of our societal health care costs! What’s that, you say. Some countries have introduced and legalized euthanasia with the same principle in mind? Well, then; it would appear that we have come full circle. Isn’t it amazing how things always work out?

Steyn's America Alone

2006-11-26T12:53:00.000-08:00

Since childhood I have always been an avid reader. One of my regrets throughout my medical career has been the time commitment to reading medical material and the time demanded by the job itself. One of the “perks” of retirement, for me, is the opportunity to continue my medical journal reading, and at the same time, expand my reading outside of the field of medicine. Recently I have started reading Mark Steyn’s “America Alone”. Whether you agree with him or not, I find the book quite intriguing.
In particular, I found his statement that Western civilizations have lost their “stomach” for war, very interesting. The statement conjured up visions of how violent mental patients were controlled in mental hospitals some seventy years ago, before the advent of our psychotropic drugs. These poor patients reacted to their aberrant visual, auditory, and in general, sensory hallucinations by being aggressive to the point of, not only harming others, but being a danger to themselves. Confinement and restraints would only limit their destruction, certainly not prevent it.
The solution was to administer a drug called epecac. This drug could cause continuous vomiting to the point of exhaustion and total submission. Could this be the origin of the expression “I can’t stomach that”? If that is the case, the Main Stream News Media certainly are the “Epecac” of our modern western civilizations. For most of us, ongoing scenes of death and destruction is a “stomach turner”; especially when we are made to feel we are responsible for the death and destruction.
Steyn talks about how important it is for a society to have the “will” to succeed and survive. I guess this struck a positive note with me because I feel the determinants of health are related to the motivation (read “will”) of the person to improve their own health.
So why would some societies have a strong “will” to survive and others not have the “stomach” for it? Besides the epecac theory, my aging agile mind (????) turned to our two barn cats. That’s right, our neutered, but not de-clawed, barn cats.
Since I live on an acreage, about every two months, a stray cat comes along and finds my heated barn/garage more comfortable than the underside of my garden shed. Plentiful food probably increases the attraction. The usual scenario is that the stray cat (usually a Tom) slowly sizes up the situation, moving in closer and closer to the food and comfort over a period of days, and eventually, through body language, hissing, spitting, scratching and biting, takes over the food and comfort of my barn and garage, relegating my cats to the -20 degree temperature and no food under the garden shed. Now, I wouldn’t mind if these stray cats helped themselves to some food, or even some warmth on a cold night, but really, why should my cats be out under the garden shed, cold and hungry? After all, they are the chosen ones!
My solution has been to capture these invaders and take them to the SPCA (I don’t have the heart to shoot them). I know, I know, they are likely euthanized in a less cost effective way; but how else am I to deal with it? You see, my cats primarily are concerned with the entertainment derived of catching and playing with the occasional mouse (food and housing is a given for them), and even more concerned as to where they are going to get their next petting and strokes. Survival for them doesn’t appear to be an issue until they are faced with the stark reality of the underside of the garden shed and it is too late. On the other hand, these visiting cats don’t seem to believe that possession is 9/10ths of the law, or any law, for that matter, except the law of survival. Without my intervention, my dependant cat’s survival would be in serious doubt. If we, as a society, don’t have the “will” to survive, who out there will rescue us or intervene on our behalf? Or for that matter, who and what is the human equivalent to the SPCA. And how, over the past two generations, did the western societies become neutered and dependant? And why does the MSNM keep feeding us epecac? So many questions and so few answers!

Who's Hot, and Who's Not, in Alberta Healthcare

2006-11-24T19:47:00.000-08:00

It’s the eve before our big election in Alberta, so I guess I’ll do a run-down of our “premiers-in-waiting” from a “vision of healthcare” perspective. Keep in mind this is my humble opinion only, and should not in any way be considered a “professional” opinion, since I have only met four of the candidates briefly, and have relied mainly on what I could find of their opinions in print (consider this a disclaimer).
1) Mr. Gary McPherson
This is the candidate that I admire most. In spite of personal hardships, or maybe because of them, my impression is that he has learned in life that your success or failure depends on your own efforts. He also seems to know that asking questions gets you more information that preaching to others. He was the only candidate that asked my opinion on healthcare, although they all said that they, as premier, would be prepared to listen. I do believe, however, unless he put an incredible team together to help him, the job is beyond his capabilities.
2) Dr. Lyle Oberg
In the area of healthcare, Dr. Oberg has a huge advantage. I am aware that during his years of family practice in Brooks, he ran a large practice that covered the full scope of family medicine, including obstetrics. I know he has also been consistent in his attitude that private medicine needed to play a larger role in Canada. I do wonder, however, if he has the leadership skills to rally the support of conservatives in Alberta, since he doesn’t seem to have the support of his fellow cabinet ministers in spite of many years in cabinet. In fairness, his approach to healthcare may be frightening the others off; let’s hope that’s not the case. It bothers me that in the past few months, he has shown a tendency to “cut and run”. Not a characteristic we need to deal with Ottawa (well, maybe?).
3) Ed Stelmach
Unfortunately for Ed, I had an opportunity to speak with him personally on health care issues. He seemed to know little about the Barer/Stoddard report that began the decrease in physician training in Canada and seemed to feel the Alberta College Registrar, Dr. LeRiche was to blame. Although Dr. LeRiche had socialistic approaches to most things, I doubt if his influence was Canada wide. Perhaps I should have introduced myself as a physician before he started lecturing me on healthcare. I could find very little substance on healthcare in his web site, and generally felt I was getting a “pep talk”. His “pep talk” approach seems to have won him support; but not mine.
4) Mr. Doerkson
Victor seems to have bought into the present “politically correct” determinants of health, poor education and poverty, instead of looking at the determinants of poverty, poor education, and poor health. He strikes me as a kind man, who, if given a specific task, would do a reasonably good job of it; however, he strikes me more as a follower than a leader.
5) Mr. Mark Norris
Mark was the only other one to answer my enquiries; unfortunately it appeared to be a computer generated response. My overall impression of Mr. Norris is that he may feel that technology is the answer to most things, although I must admit, he seems quite personable. He seems to be big on the “micromanagement” of healthcare, and I couldn’t find any real new vision in the healthcare field. Mark, we need more people in the healthcare trenches. Bean-counters got us into the mess we are in today.
6) Mr. Dave Hancock
I’m sure Dave can talk for hours on health care and the many solutions to every one of the problems facing the Canadian Healthcare System. After all, he is and has been a politician most of his life. My impression is that Dave talks a good game, and can philosophize at length, but isn’t much of a doer. Perhaps that is a good thing since I get the impression that Dave is more than a little left of centre. I’m sure, from what I have read from his web site on health care, he could easily increase Alberta’s healthcare budget from the present 10 billion dollars, to twenty billion dollars in the next four years. Unfortunately, in spite of these expenditures, I suspect healthcare outcomes in Alberta will not have changed.
7) Ted Morton
I would like to see Ted win, but I fear he won’t. He has said very little about health care other than he feels we need more choice in healthcare providers in a free democratic society. He is aware that you cannot provide infinite services from the finite taxpayers pockets, and by having private services, people can have a choice, albeit by financially taking responsibility for their health. He seems to have more faith in free market systems as one would expect of a conservative; and has had the ability in a short period of time, to mobilize significant grass roots support. The MSNM seem to be giving him a fair amount of press, and I wonder if they feel he would be a more vulnerable target in a provincial election than Jim Dinning, thereby giving the Liberals a better chance (My paranoia acting up). He seems to have no fear in speaking his mind, and I think it would be refreshing to have him as the next Alberta leader of the Conservative party.
8) Mr. Jim Dinning
I have had both the pleasure and the frustration of working with Jim in the healthcare arena. He is bright, personable, and although he can talk an excellent political game, unlike Mr. Hancock, Mr. Dinning is a doer. The question becomes, who will be the major recipient of his interventions. Being a very capable politician, I get the impression that when it comes to the difficult decisions, unlike Mr. Harper, Mr. Dinning will “blink”, generally throwing in with the ”powers that be”. At this point in time, Alberta does not need an appeaser on the national scene. Capitulating on the many national issues facing Canada, and Albertans in particular, is not in the best interests of the average Albertan. Perhaps I am being unfair to Mr. Jim Dinning, but he knows better than anyone that the existing healthcare system is unsustainable. His not speaking out on the side of a parallel private system with doctors practicing in both systems speaks volumes (or is it my paranoia once again raising its ugly head?).
I predict that Jim Dinning will win it on the second or third ballot, largely because the existing caucus will not have the courage to back Ted Morton and will push their respective followers to take the “safe route”. Hopefully, I will be wrong.

Candidates Favorite "Visions" for Healthcare

2006-11-24T14:47:00.000-08:00

Before I give my “two cents worth” regarding the candidates for premier of Alberta, I would like to focus more on some areas of medicine that seemed popular with many of the candidates. These were often offered as solutions to the increasing cost of health care across Canada and in particular, Alberta.
1) The electronic health care record.
The experience of practitioners, who have gone to computerization, is that it has actually increased their costs. In Alberta there have been, and are, specific programs to offset these costs, but these programs will end, at which time ongoing costs will be borne by the practitioner. Savings, such as reducing unnecessary repeat testing, are savings to the system, not savings to the practitioner. Improving the tracking of chronic diseases has positive implications for better quality of care and preventative medicine on a personal and global scale, but will mean significant increases in cost in the short term (ten to twenty years), both to the taxpayer and the practitioner. Implementation of “privacy” safeguards will be a huge problem, and have significant cost and administrative implications.
2) This is especially true when putting this together with the other area of enthusiasm, the Primary Care Network (PCNs). Their vision is that, by definition, primary care is the first point of contact with our health care system. Strictly speaking then, the person who answers the phone on Calgary’s present “Help Line”, is a primary health care worker. They fore-see also, community health clinics, where people will be triaged, not necessarily to family physicians, but possibly to physiotherapist, chiropractors, dieticians, optometrists, nurse practitioners, etc. so many, many people will be primary and secondary health care providers, and part of the health care team. Sounds like a real “team effort” so far, right? The caveat on all of the above is, however:
3) Confidentiality. The “vision” is that information should only go to the health care worker if it is needed to perform their duties to the maximum of their “scope of practice”. Whoops!! Whose job is that? Sounds like it may fall in the lap of the family doctor, if there is one. And for heaven sake, how do you set that up on your computer? If you have a moderate sized practice you may have to hire a programmer to set it up, and even then, spend most of your time trying to decide what information to send along to which member of the health care team. Keep in mind, legally, at present, there is pressure to have written consent on the part of the patient before information can be sent along.
Here is the dilemma. I have a patient that is depressed and attempted suicide two months ago. She has been referred to a psychiatrist, and of course it is important that the psychiatrist knows of the suicide attempt. She has a problem with obesity and self image, so I refer her to a dietitian. Should the dietitian know about her attempted suicide? It certainly may reflect how important losing weight may be to this patient. She also is seeing a physiotherapist for low back pain of two months duration. Should the physiotherapist know about the suicide attempt? What if the back pain began with her crashing her car into a cement structure? What if it predated her “accident”?
The bottom line is that in a truly integrated computerized health care system, with the Primary Health Care Networks presently envisioned by the government, we may as well kiss confidentiality “good-bye”. Every health care person that comes in contact with the patient (and many who will not), will have access to the medical information on file. In order for that not to happen, there would have to be a “medical information watchdog” responsible for providing information to care-givers on a “as needed to know basis”. Whoever takes that job had best have lots of insurance against law suites. All in all, a complex, costly “vision”, and a make work project for lawers.

Dave Hancock, a Lawyer's Perspective on Healthcare

2006-11-23T15:57:00.000-08:00

The first thing we have to understand about Dave Hancock is that he has been in politics since 1974. The second thing we need to understand about Dave is that he is a lawyer. The first thing that crossed my mind when I read his “bio” was “Why doesn’t Dave, who has been in politics since his youth and all of his adult life, held many important portfolios in the Alberta conservative government, have more support from the Conservative caucus and Alberta Conservatives in general? The answer, I believe, can be found on his web site while reading about health care issues.
First you will have to take many hours out of your day (as I have) to read the reams of material. Secondly, when you are finished you will probably not know what he said, but will have a distinctly uncomfortable feeling if you are a conservative. Perhaps it is all the “buzz” words and phrases that he uses (that I have heard over the last fifteen years while I wasted my time on numerous committees). Words like collaborate, focus, comprehensive, innovate, guarantee, ensure, teams, commitment, maximize, effective, coordinating, and on and on and on------. Phrases like cost effective, medically necessary, assessed need, social and mental well being, root causes, province wide strategy, and more recently “Full Capacity Protocol” are driving me crazy! If only “coining a phrase” could solve a problem, Mr. Dave Hancock and our political medical planners over the past 15 years would have solved everything years ago.
I certainly don’t intend to comment on all of his material, but rather, try to determine where he stands on critical issues in health care (You of course, are invited to review all of his material, and point out the errors of my conclusions).
1) On private Health care-----Dave states that it is a difficult question (yes, we know that). He also states it plays a significant role now (We know that too). Should we have a public system?----he says we should; all Albertans must have timely access to quality care regardless of ability to pay. We are all in agreement with that, Dave, but you see, they don’t have that NOW! He states there has been too much discussion on Public verses Private already. Wow, I missed that part. When did it happen? Then he gets on to prevention. Healthy life styles, etc, etc, etc. The same old mantra. Mind you, in another section we will look at his “healthy life styles” solutions.
2) Doctors remuneration-----There is no easy answer to this is Dave’s response. He reports that technologies have benefited some physicians but not others and physicians should be rewarded for their time, expertise, and responsibility. Well you have been in Cabinet for the many years that these disparities have been occurring and family physicians providing comprehensive care have been disappearing. We, the public, and I, the family physician, wanted to know how you were going to address the problem. Stating how things “should” be doesn’t “Git-er-done”.
3) Health funding------Dave’s Response: “New and innovative thinking, spur innovation and competition, standardized performance measures, engage leaders, create a Health Care Policy Coordinating Council, and focus on being well (There you have it folks, that’s how you fund our public health care system. Need I say more?). When asked under this same topic about funding issues such as Fort McMurray, aging populations, etc, he states there needs to be flexibility. Duh! But how do you propose to actually install the flexibility feature? Oh, yes, you again mention healthier life styles.
This review would not be fair without looking at Dave’s 21st Century plan for Health and Healthcare. His commitment is based on the following:
1) No Albertan will be denied access to medically necessary health services because of inability to pay. (The problem, Dave, is that we are being denied access already, and have been for some time. The Supreme Court of Canada says that access to a waiting list is not access to health care. And could you please define “a medically necessary service”. I’ve never seen that done before, so maybe you know something that I, and the rest of Albertans, would like to know).
2) Every Albertan will have access to the resources, education, and support necessary to achieve and maintain his or her best possible physical, social, and mental well being (This will be a true Utopia. I can hardly wait. The only trouble is, Dave, we first have to IDENTIFY the people at risk, and then we have to MOTIVATE them to access the resources, etc, etc. Then you have to PROVIDE the resources, keeping in mind that access to a waiting list is not an access to a resource; have we got the money for that? See funding---dealt with earlier).
3) All Albertans will have access to a high performing health care system that compares with the best health care systems in the world. (Now remember, Dave, access to a waiting list is not access to health care. And although our health care system compares to the best healthcare systems in the world, it does NOT compare favorably, as you well know from other dissertations on your web site. Further this has occurred largely under your watch. I think the question is how you are going to change this situation for the better).
Before winding this up, I should deal with two more innovative ideas that Dave Hancock seems to be fond of, that have not been mentioned in the news media to reduce emergency department waiting times.
1) I believe he supports the idea of a low intensity medical clinic near an emergency department to prevent “inappropriate” attendance to emergency departments by patients. My answer to this is three-fold. a) The number of inappropriate visits to our emergency departments have been steadily going down, and at present take up little time and resources in the emergency departments of Calgary. b) You would have to take resources from the community (doctors, nurses, etc) to staff these units. c) If there were adequate resources in the communities, patients would not go to the emergency departments and face six hour waits.
2) He definitely supports the “Full Capacity Protocol” that requires, within two hours or less, all stable admitted patients waiting in the ER for transfer to an in-hospital bed, should be transferred out of the emergency department to the appropriate ward, after a decision to admit has been made. Perfect; if only we had the “appropriate” beds required on the “appropriate” floor, and the appropriate” staff on the “appropriate” floor, to look after the patient “appropriately”. Come on, Dave. You and I both know that although this relieves congestion in the emergency department, more times than not, the transfers to in-patient beds will be “inappropriate”. This is the old “shell” game that I have referred to in the past that challenges the public and news media to find out (or guess) where our health care needs are being hidden. Already patients are being transferred to inappropriate beds by our “first bed available policy” and even when there is no bed available, end up being cared for in hallways. There is, as well, a small matter of having a physician attached and responsible for each and every patient admitted to an in-patient bed (and bringing in more nurses for the additional patient load). Very often our patients are in an emergency department bed, under the care of an emergency physician, because there are no hospital “staff” doctors to take on the care of the patient. On occasion our intensive care patients already “spill” into our medical ward beds “inappropriately” because we have run out of intensive care and/or cardiac care beds. So, please, Dave, don’t use the term “appropriate” when referring to our present Health Care System.
3) Since Dave Hancock suggests eliminating healthcare premiums (along with several other candidates) and recapturing the nearly one billion dollars derived there-from by increasing taxation in general, I should perhaps comment on this approach. There is no doubt that health care premiums are just another form of taxation, but it does continually inform the public that “health care” is not free. Since Mr. Hancock is in favor of “incentives” for healthy life styles (suggests tax-credits), I’m surprised he didn’t suggest eliminating premiums for those people and families with healthy life styles, and charging premiums for those with unhealthy life styles. Tax credits primarily benefit the wealthy. The bottom line is that Albertans are going to pay for their health services one way or the other, so it is a non issue.
I think, on the other hand, that it is “appropriate” to end here. If you want to delve deeper into Mr. Dave Hancock’s thoughts on Health care, he has much more on his web site. But I do advise you to approach it as you would a contract (If Dave gets to be premier, you’re going to be stuck with him), so read ALL the fine print.

Rutherford with Dinning on Healthcare

2006-11-22T12:38:00.000-08:00

It would have been nice if Mr. Rutherford had done a bit of research on Mr. Dinning’s “track record” before having him on as a guest this morning. Mr. Dinning has been going around Alberta trumpeting his good performance, so one could have expected the same to be true on the Rutherford talk show this morning. Still, very little was said as to his performance as C.E.O. and Chairman of the Calgary Regional Health Authority. In fact, when one caller wished to bring up the subject, he was admonished for bringing up old issues. Come on, you can’t have it both ways, Mr. Rutherford. You can’t look at what you consider his “positives” without allowing for what some of us feel were his negatives.
Yes, Mr. Dinning and Mr. Klein started some welcome frugality in the Alberta Government, but along with the decrease in funding to our health care system must come the responsibility of those actions. Your caller had some good points; he couldn’t express himself well, but raising the question of the dramatic decrease in active treatment beds in Calgary during the 1990s, is a fair question. Edmonton didn’t follow this process and although their old General and Misercordia Hospitals were dinosaurs, they still stand and are being well used for transitional care and other medical needs. In Calgary, we dropped from 3.3 acute care beds per 1000 population to at present 1.7 beds per 1000 population. Look at how this actually changed during Mr. Dinning time as chair of the CHRA. and ask some questions. During his tenure, the population of Calgary was already sky-rocketing.
When the Calgary Region decided to sell the Holy Cross, all proposals were to comply with certain criteria. One of those criteria was that the property was not to be used for medical purposes, and that there would be no relationship between the Region and the prospective buyers. The caller was correct. Inside private interests bought the property and it is now being actively used for many medical purposes.
Mr. Dinning’s management and fiscal skills while he was Chairman of the Calgary region were not researched. If you look at the budgets during this time, he was continually short of money with his hand out to government. It was kind of an inside joke within the medical community “Well, at least we’ve got Jim and he’s got the inside track with Ralphy. If anyone can get money out of the government, he should be able to”. The point is, although he took the job of Chairperson because he had concerns about what was happening, and its impact on his mother (really!), he came up with no solutions and things have continued to go down hill. Now he says he supports the path we are on.
As I’ve said before, Mr. Dinning is very personable and very bright, but he is also the consummate politician. Mr. Rutherford, there is only one way to interview a politician, and that is to have the whole story and all the facts.

Ted Morton, Pluses and Minuses on Healthcare

2006-11-22T12:07:00.000-08:00

Ted Morton has got one thing right for sure: Equal access to a waiting list, is not equal access to health care”. Has anyone seen a study of the death rate per thousand people on a cardiac wait list (risk list), compared to the death rate of a similar age group per thousand who are not on a cardiac “wait list”? If there is such a study, I have not seen it in the MSNM. The point is that waiting lists are, by definition, a group of people who have been identified as a group at risk and/or in need. But the identification of this group is only the preliminary step in a multi-staged system. Addressing the needs and risks of this group is the next essential step without which, the first step simply points at the inadequacies of the system. The Supreme Court of Canada has said as much!
For that matter, we are not even doing the first part right. Seventy five percent of the people at risk for heart disease and stroke in Alberta have either not been identified, or are not being treated adequately. If we truly believe in preventative medicine, doesn’t it make sense to identify this group and intervene before they are on a cardiac “intervention” wait list? Don’t get me started! I’ve ranted on that before, so let’s look further on what Mr. Ted Morton has to say.
It would seem that Mr. Morton recommends that Canada follow the European example of a blend of a private and public system. In his home page he recommends:
1) More opting out of insured services to the private sector.
(It should be pointed out that this has been going on for many years. The basic arrangement between physicians and the government is this type of an arrangement. Most physicians in Alberta are functioning as a private small business. The Alberta Medical Association and the government have negotiated the amount of money that would go to physician’s services on an annual basis-----basically contracting out physician’s services to the public at large. Almost all abortions in the Calgary region have been contracted out to the “abortion clinics” for the past eight years. There is nothing new in this policy; and the only money that is saved is the use of downgraded facilities, which may be appropriate, and an assembly line type of turnover. Don’t misunderstand me; I think this is a useful process, but standards of care must be carefully safeguarded.)
2) Attract more investors to build more medical facilities and purchase more diagnostic equipment. (If the government allows a private parallel system, the government/taxpayer will not have to spend one cent on recruiting investors. The health care pot in Alberta for “covered” services is over 10 billion dollars. If only 10% of the population obtains insurance, the incentive is considerable. In addition, the private sector will be actively doing research to find ways of delivering services more effectively and at a lower cost to invite more “contracting out” by the public sector.)
3) Affirm the freedom of Albertans to choose their health care. (You can pay for your pet’s operation and have it done in 24 hours, but you wait in a queue for weeks to have your child’s surgery. There is a problem with this picture!)
4) Allow doctors to work in both the public and private systems (This is particularly true for those physicians that are doing procedural medicine. Surgeons, cardiac interventionists, imaging and other diagnostics, etc, but it will do nothing for family physicians, internal medicine, neurology, psychiatry, etc. The only way these areas would be helped would be to have aggressive recruiting programs in other countries for both our private and public systems. By recruiting for two systems we would be more competitive on the world stage for the best physicians world wide).
5) Requires doctors to work a minimum number of hours per week in the public system. (Basically, I do not agree with this system. Brazil was doing this thirty-five years ago and the public felt it was a disaster. No-one is happy working where they do not wish to be, and if you’re not happy in your work place, you’ll do a crummy job. Surveys show that only five percent of Canadian physicians would prefer to work only in a private system. The majority prefer to work in both areas. Besides, making the public system compete in their treatment of their health care providers and the work environment, will “hold the governments “feet to the fire”, which is not the case now. As a consequence, there has been a steady drain of health providers to the U.S. and other countries).
Mr. Ted Morton also has included a speech on health care that he gave some months ago. Included are points that we have discussed above, but also included is his position that health care in Canada as it is cannot be sustained, and that Canada has been dropping in measures of health care outcomes. We do not “have the best health care in the world”, and rank in the bottom third of industrial nations when measuring outcomes. He mentions five tiers in our existing health care system, but left out the huge “tier” of patients that pay chiropractors and physiotherapists to treat their back pain, naturopaths to treat systemic symptoms, optometrists to treat their eye problems, etc. Many patients cannot afford these alternate services. So, Ted Morton, there is another tier you can add to your list.
Overall, from my perspective, Lyle Oberg and Ted Morton are the only ones thinking outside of the “Canada Healthcare Box” and consequently the only ones that may bring about change. My biggest criticism of Mr. Morton regarding health care is that he does not address, in any way whatsoever, an approach to preventative health and chronic disease. Perhaps he feels that saying too much opens one up to more criticism, but significant change means a more aggressive approach to getting the right treatment to the right patient at the right time, and from where I stand, this does not just mean the people on waiting lists. It includes the thousands of people who are at risk for diabetes, and those that are at risk for strokes and heart attacks. It includes an approach to the epidemic of obesity in general, childhood obesity in particular, and life styles that invite consumption of health care dollars and decrease quality of life. This is the true responsibility of government and its leaders-------identification, education, and intervention on a population basis. As individuals, once identified and provided with the information and available interventions, it is our responsibility to act appropriately. And we should have a choice in living up to those responsibilities.

Mr. Victor Doerksen Strikes Out on Healthcare

2006-11-21T10:11:00.000-08:00

Mr. Victor Doerksen, the minister of Innovation and Science for the Alberta government in 2004, has very little to say about health care. He, of course, spouts the usual rhetoric about how important an issue it is, how everyone should have access to it regardless of their ability to pay, and his concern about sustainability. He presents his position under the following headings:
Determinants of health.
1).Enhance, by twenty five million dollars the “Alberta Child Health Benefit Program” to enable poor families to better access community child activities.
(Immunization is free and it would seem less that 50% of poor families access this resource).
2). Create a health research and innovation fund to focus on complimentary medicine outcomes. (Give me a break! There are at present about 3000 herbal or complimentary medicines out there at present; only about 300 of them have any hard research attached to them, so there are about 2,700 more to go. So far the 300 haven’t proved to be a savior of the health care system. What makes us think the others will be different. In the mean time people are using the “complimentary medicines AND services, and paying for them out of pocket, so it is actually saving the system money-----if there is more benefit than harm in them).
3) Long term funding through municipalities for better housing, homelessness, etc. (Obviously, Victor has bought into the idea that the determinants of health are poverty and poor education, rather than taking it a step farther and asking “What are the determinants of poverty, poor education, AND poor health. Need I say more?)
B. Sustainability
1) Establish a twenty five billion dollar Health Trust by 2016. (This seems to me to be just another way of pouring more money into the public system, and although that may help Alberta’s situation in the long term, the other provinces in Canada will not tolerate the loss of their health care workers to Alberta. The reality is more money needs to be put into the system in the short term, to shorten waiting lists, AND build up your fund. If you’re going to do it, you had better get with it before the federal government and the other provinces turn green with envy, and shut Alberta down like in the 1980s).
2). Work with health care workers to utilize the full capacity of the existing system------. (Mr. Doerksen, have you even been in a doctor’s office, an emergency ward, or a hospital ward, in the last five years?)
C. Refresh and build on the report of the 2001 “Report of the Premiers Advisory Council on Health”. (If the solutions are there, why hasn’t there been progress to date? That was five years ago and you have been in government and a cabinet minister during that time.)
All in all, Mr. Victor Doerksen has struck out on health care. Hopefully he has better ideas on other aspects of government concern.

Mr. Dinning, A Polished Politician's View on Healthcare

2006-11-20T15:56:00.000-08:00

Knowing Jim Dinning somewhat through his and my committee work in the Calgary Region while he was the C.E.O. of the region, puts me at a bit of an advantage (and disadvantage, because I like the guy), in commenting on him as a prospective Alberta premier. There is no question that Mr. Jim Dinning is personable, charismatic, intelligent, and the consummate politician. In fact he is by far, in my opinion, the best politician of the “premiers to be”. The question is “Do Albertans want a politician as the next premier of Alberta?”.
I know, its a strange question, but I will elaborate. To win friends and influence people, tell them what they want to hear, and tell them what they already know. Don’t presume (in their presence) that you know more than they do. A good example of this is Mr. Dinning’s speech to the Calgary and area physicians. His opening statements to the group included: “Thanks for the opportunity to be here tonight and listen to a group---, and while I have some comments to make I’d prefer to hear some from you about health care----“. Then he carefully shows that he is not a neophyte in Healthcare, by stating that he was the Chair of the Board of the Health Region, and states that since then he has been a keen observer of the changes that have taken place in the health care arena. Brilliantly, he then goes on to tell the doctors what they already know:
1) In spite of numerous reports (Kirby, Mazankowski, Romanow) little has been actually done
2) I have learned that “healthcare reform has been more about talk and much less about action (actually, the efforts at reform that have taken place have devastated our previous well-functioning system)
3) Discussions about reform are almost impossible to have (because politicians need to get elected)
4) We’re quicker to come up with new plans than following through with what we started
5) The best ideas for what needs to be done to improve access come from people who actually work in the system (but have been consistently ignored because they have been viewed as a special interest group)
6) That people actually care deeply about health care
Wow, I want to vote for him right now. He certainly has insight, right? Well, maybe we should wait and see what else he has to say on the subject. You have to be careful with politicians. They have a habit of coming on as your best friend, but are nowhere to be found when you need them (mostly I’ve needed them to leave me alone!).
In his speech to the doctors he outlines five “plot lines”.
a) Get serious about health: Under this heading he raises the issue of preventative health, healthy life styles, etc. Nothing new here! We have been trying to do that for forty years. He does talk about establishing a Heritage Foundation to address issues in the first ten years of children’s lives (who can be against that?), but doesn’t say exactly how it would work. He talks about giving children a healthy start (sure sounds good, but will he be taking kids out of homes where people are poor?). After all, it seems less that 50% of these children are up to date on their immunizations. Will we have mandated nutritional classes for families with obese children, or home care nurses doing the grocery shopping for people on welfare? How much “child control” and “parent supervision” are we looking at here? Frankly I would have preferred a policy of taxing junk food, and taking junk food out of schools.
b) Forget about big plans----pick a few priorities and stick to them. (For sure, that is how to get things done). His choices for these priorities are primary health care delivery, an electronic health record, and new models of care for chronic illness. Now, how can you disagree with those three priorities, they lack the substance and detail as to how these priorities with decrease the cost of our publicly funded health care system, shorten wait times, or improve the quality of care, -----all thing that the average person is deeply concerned, but man they sound good! So far, efforts at primary health care reform have seriously shorted the availability of family doctors and primary care givers. What will you do differently? Although the electronic health record may improve some aspects of care and enable “tracking” of chronic disease, the cost of this system in the short term is increasing, and will continue to rise. Any benefits from tracking diseases will be far down the road and may be worth while, but it certainly is not a “here and now” cost benefit.
c) New models for care for chronic diseases. This, of course, means nothing to any of us. Although it has potential, as I have blogged, pertaining to the detection, registration, and targeting of people at risk, research in this area is in its early stages and is a long way from implementation.
3) Innovation----infusing more of it into our publicly funded health system
I think if I hear the word “innovation” one more time coming out of a politician’s mouth, I will be physically sick! The downturn in our health system in Canada, and the slipping of our world standings in health outcomes, started 15 years ago with the idea “we don’t need more money, we simply need more innovative ideas on how to use the money more wisely”. What in the world makes us think that our “innovative” ideas are any better now than they were 15 years ago? Statistics show that only a small percentage of innovative ideas are practical. On Mr. Dinning web site he mentions the success of the “Bone and Joint” pilot project. Jim, to my knowledge, millions of dollars were put into this project, which only underscores the fact that huge amounts of money are going to be needed to shorten our long waiting lists. How does that address our concerns about the sustainability of our publicly funded healthcare system?
4) Increase our supply of health care providers and get them to where they are needed.
On Mr. Dinning’s web site he addresses this issue by first stating that there is this crises in health care workers(again, a fact that we all appreciate) but then sings the same old tired tune of training more, bringing in more foreign doctors and assisting in student loans. Not a very exciting solution; in fact it is no solution at all. Jim, first you have to recruit students into the health care fields, then after you train them, you have to KEEP them. How do you propose that we prevent them from going to the U.S. after graduation? We have been actively recruiting qualified foreign physicians. In spite of half of Sask. physicians being foreign trained, we are still falling far behind----but you know all this, don’t you! Try to focus, as you suggest we all do, and actually suggest a PLAN as you recommend.
5) Find practical ways of containing cost increases (now we have arrived at the crux of the problem, sustainability). Mr. Dinning’s only suggestions in this area are: a) Micromanagement, and b) Examine the use of an independent, arm’s length body to review and assess new treatments and services as part of the process for adding these to the list of things under public health care. Well, to me micromanagement usually means more money to administration, and less to patient care. The “arms length” review body to assess appropriateness for healthcare coverage is nothing new; but what in heavens name does “arms length” mean? Does this mean lawyers, accountants, and politicians? I made a similar suggestion to Mr. Don Ford, Health Care Policy adviser to the Klein government, in a presentation submitted in Feb/1998, but I suggested a “hands-on” group consisting of doctors, nurses, pharmacists, chiropractors, physiotherapists, and tax payers. The “arms length” group, Price Waterhouse, suggested in the 1990s that all the hospital boards in the Calgary Region be brought under one “Arms Length Board” which agreed to their proposal to sell the Grace and Rockyview Hospitals, and blow up the General Hospital. Can Calgary survive another “arms length” provincial body looking at health care?
I have always said and still maintain that no government can provide infinite services without having infinite resources, and the reality is, that in spite of very ingenious tax methodologies, governments do, in fact, have limited resources.
So, that’s it folks. Mr. Dinning, like Mr. Oberg, has more knowledge of our health care system than the other candidates, but I’m afraid has no new solutions. In fact, by not thinking outside of the “Canada Health Care Box”, Mr. Dinning takes away many potential alternatives. On the other hand, keep in mind I have stated that Mr. Dinning is an extremely “bright” guy, and the most “polished” of the candidates (I apologize for the attempt at humor in such a serious dissertation), and it certainly wouldn’t be the first time that a political candidate vaulted themselves into office by supporting our “Universal Health Care System”. Could this why he is pushing the status quo? Perhaps I’m just being paranoid. Pass me my haldol.

Abuse of Nurses and Staff

2006-11-19T13:35:00.000-08:00

It would seem that our health care system in Canada (if Calgary is any indication) is getting weirder by the day! The Calgary Herald, Sunday, Nov. 19/06 edition headlines read “Abusive Patients Attack Nurses”. Now, as a family physician with more than forty years of practice experience, I can assure you that this is not new and is not a surprise. The article relates that documentation indicates a dramatic rise in both verbal and aggressive behavior toward healthcare providers, in particular, nurses. The article gives the example of a patient suffering from a drug overdose, being admitted to a cardiac unit for monitoring, becoming very aggressive and physically abusive to the nurses after two days. Here is a news flash! This is to be expected. People going into withdrawal frequently become agitated and abusive; that is the medical reality. The real question is “Was there an appropriate place, with the appropriate staff available, for appropriate transfer”? Why was the patient on a cardiac unit after two days? Did he really still need cardiac monitoring, or was there simply not an appropriate bed available? Many times in my practice patients for medical reasons are admitted to a medical bed for observation, and when the appropriate time came for transfer to a mental health bed, no bed was available. Consequently, a mental health patient ends up in a medical bed, being treated by a medical nurse (in this case, a cardiac bed and cardiac nurse), when they should be in a psychiatric facility treated by staff familiar with psychiatric and drug withdrawal problems.
This problem has been ongoing for many years and continues to get worse. Since the dramatic downturn in available hospital beds, patients get admitted (from the emergency departments) to the beds that are available, not necessarily to the department that is most appropriate. If there are beds available and the emergency department is jammed up, what is to be done? The staff use the beds available and the staff available, even though it may mean a medical patient ends up on a surgical unit, or even worse, a psychiatric patient ends up on a medical unit (the overdose scenario is typical).
I am sure, as the article implies, there is an increase in frustration on the part of patients who perceive that their needs are not being met, and this leads to increased acting out and abuse. When patients are suffering and in pain, it is not surprising that these patients become more difficult to manage. Nurses have always been, and are aware of this fact, and have dealt with it appropriately. Aggressive personalities often come to light when people are ill, or coming out of an anesthetic, but this isn’t a new phenomenon. Could our sense of entitlement as a patient be having an effect, or are there genuine deficiencies? Probably both are factors. But I think that the basic problem is not a “patient” behavior problem (not making excuses for abusive behavior!). Let us look at the actual statistics and what can be gleaned by the article.
Reported incidents have doubled at the Peter Lougheed Hospital in the last year. At the Foothills Hospital, complaints went from 25 in 2004, to 79 in 2005, to 112 already this year. Other hospitals have shown similar rises (It should be pointed out that an “incident” includes any situation where the nurse feels unsafe, or when the nurse feels the patient has been put at risk). Wendy Brigham, president of the Alberta Nurses Association local 121 at the Rockyview Hospital says “Nurses are getting really frustrated. They’re finally taking the time to document what’s going on”. This statement says it all, if we look at it closely.
Are they frustrated at the patient’s behavior (which they likely fully understand from a professional and intellectual perspective), or is it that their general stress and frustration level relative from a difficult work environment, has reached a point that their tolerance for bad behavior is now almost non-existent? As innovation and other changes have occurred over the past 15 years, nurses and other health care providers have simply put their heads down and worked harder and harder. Some of you may have read a previous blog where I mentioned that, during my recent visit to the recovery room of a local hospital, I was amazed at the intensity of care level, and the looks of stress on the faces of all the nurses. Perhaps the nurses have simply reached their level of endurance; perhaps more and more have simply reached that point of saying in writing “I can’t cope anymore with these conditions, something has to be done”. And it is about time. So they are now taking the time to report what has been going on. Perhaps the reporting is not so much a reflection of the “bad behavior” increase of patients, as much as the level of exhaustion of our nurses. We all tolerate untoward behavior better when we are rested and feel good in our jobs. Feeling you are doing a good job, getting “kudos” for the job you are doing, and having some control of your responsibilities in your day to day work place environment, goes a long way to putting up with your job “incidents”. But if at the end of every day you go home with the feeling that you didn’t have the time to deal with the responsibilities you’re given, deal with “patient at risk” situations, feel helpless from lack of resources and staff, and have the ongoing feeling that you are unappreciated, at some point, the frustration level must become unbearable.
The most incredible aspect of this situation has been the response of the Region. Their response to long waiting room times in out emergency departments is to hire an emergency room social worker. Their response, apparently, to the shortage of nurses and the increase of (reported) abusive incidence in our hospitals, is to hire 150 more security staff. Can security staff really take on nursing duties? Is this an “expanded role” of health care providers as suggested by the “premiers-to-be” of the Conservative Party of Alberta?
The article in the Herald states that the Calgary Region intends to aggressively hire the new graduates from our nursing schools. Great! But good luck! You not only have to hire them, you have to retain them. High stress levels in nurses work place is not going to help in the face of a world shortage of qualified nurses and aging demographics in the nursing profession and the population at large. Are we as nation going to start addressing the core problems, rather than the symptoms, or are we going to continue to simply insert more fingers in our Universal health care dyke, while the healthcare needs continue to rise?

Healthcare Pep-talk by Mr. Ed Stelmach

2006-11-19T08:33:00.000-08:00

The only thing that I could find on Mr. Ed. Stelmach’s website with regards to health care, was his “pep” talk under the heading “A commitment to a publicly funded health system that works for all Albertans” I guess the mother’s milk statement has worked so well for federal politicians over the last twenty years that there is no reason to believe it won’t work here and now in Alberta. To save you, the political healthcare keeners from having to go to his web site, I will include it, verbatim, below.
“I envision a health care system that is efficient from a patient’s perspective. An efficient healthcare system doesn’t only mean saving money. We must be focused on the patient and put their needs first. Governments must work with health regions and health care professionals to find solutions together and develop incentives that improve the system and improve the health outcomes for Albertans. I believe we have the answers.
Our health care professionals are knowledgeable, dedicated, motivated, and most importantly, care deeply about meeting the health care needs of patients. We have seen successes, with the hip and knee projects, with the primary care centres, and soon, with an expanded scope of practice for more health care professionals. There is still work to be done; however, I believe our public funded system is up to the challenge”.
Well, thank you for the above “pep-talk” and vote of confidence, but I, as a health care professional, do not share your enthusiasm. Many outcome measurements show Canada falling far behind other industrial nations of the world, yet you state that we have the answers. I’m not sure you heard the questions: How do we address the increasing cost in our tax funded monopolistic healthcare system, how do we deal with ever lengthening waiting lists (risk lists), how do we deal with the dramatic lack of human resources in providing the needs of Albertans, and so on? The hip and knee pilot project you mention, required the input of additional tens of millions of dollars to bring about a small dent in the number of people waiting for joint replacement. How does this address sustainability? I suppose, when you speak of primary care centres, you are referring to such clinics as the Calgary 8th and 8th clinic, the South Calgary Clinic, the Okotoks Clinic, and other regionally run and heavily subsidized clinics. Here is a news flash! Before the devastating cut backs of the nineties, Calgary had many community medical clinics that provided equivalent services to the community, and none of them were subsidized. So how do you see these heavily tax-payer funded community funded medical clinics being the answer to sustainability of our health care system? Sorry, Ed. but your position seems to be “cheer everybody on and good things will happen”, and frankly, Ed., I find that bordering on administrative dereliction of duty. To have a “vision” one must take off the blindfold.

Mr. Mark Norris, The Healthcare Micro-manager.

2006-11-18T13:00:00.000-08:00

Mr. Mark Norris likes to preface many subjects with “this is a very complex subject”. It is little surprise then, for him to introduce the issue of “health and wellness” with the statement: “Over the years the system has evolved, become complex, expensive, and difficult to understand. He goes on to admit there has been a significant increase in cost per capita, but from what I can decipher, his answer is primarily an increase in micromanagement. Isn’t this just putting money into administration, and taking it away from the frontline caregivers? But let us see where he is going with this, in more detail.
1) Ensure the partners in the health-care system are accountable for health and financial outcomes. a) Review management systems (does this mean we will have managers of managers? I think we have lots of that already).
2) Ensure health-care delivery standards will be set, measured, and met (sorry, this should have been done many years ago before the standards had slipped to their present level). He recommends more a) discussion (fifteen years of it isn’t enough?) b) review of the electronic system as per patient confidentiality (that will certainly help sustainability). c) Establish a peer review process for new technology and drugs as to what is cost effective (I would suggest that this has been going on continually already, but behind closed doors; now if he had said a professional body should be structured to do this, with public overview and accountability----------). d) Set up a “group purchasing” model to improve the purchasing power of the entire system (this has already been done in a major way by the establishment of large health regions. The most significant area that would benefit would be in the area of pharmaceuticals, and this would be best done on a national basis. Unfortunately, the federal government is not likely to take on the area of medicine with the sharpest rising costs).
3) Ensure access to health care is maintained for all Albertans a) Further extend the diagnostic and treatment centre clinic model that is working effectively in other areas (is this the same model that practitioners had before cut backs in the 1990s that provided comprehensive care without subsidization from the Regional Health Authorities, or the models that are now being run by the same Authorities, providing the same services, but are being heavily subsidized by the Region?). b) Consider locating medi-centers near major emergency wards (and where will the doctors come from to staff the place. I think improving the care in the communities, rather than taking doctors out of the communities, serves the needs of patients better). c) Review the 3.5 billion capital plan for health care to ensure the right facility is being built in the right place (Mark, this should have been done ten to fifteen years ago. The problem now is to provide people/power for the facilities that are being planned, and not one of your proposals addresses this dilemma. Almost any physical structure that will accommodate patients and health care personnel would be welcome at this point in time).
So that’s it folks. Our premier-in-waiting, Mr. Mark Norris, will review, analyze, study, supervise, and in general, manage the managers better, with a view to improving the efficiencies of our system. Nice try, but no cigar.

Dr. Lyle Oberg on Health Care, Some Good Suggestions.

2006-11-17T15:16:00.000-08:00

I suppose the fact that Dr. Lyle Oberg was a busy family doctor in the Brooks area of Alberta, does give him a distinct advantage in discussions on health care. He correctly identifies the problems with regard to the sustainability of health care in Alberta, quoting budget increases from 3.3 billion in 1994 to 10 billion at present. This is reflected also in the proportionate increases in the relative increase that health care takes in the provincial budget expenditures. As the population ages with the relative proportional increase in the geriatric population, we can expect health care spending to continue to grow out of proportion to taxation revenues, inflation, etc.
Dr. Oberg presents his “vision” in a five point frame of reference.
1) Guaranteed access.
Since not having access means not having health care, this is pretty basic. Guaranteed wait times have been discussed for some time now, and the principle has been approved by both the Canadian Medical Association and the Alberta Medical Association. At present I have seen little movement on the part of governments to introduce legislation to this effect. Personally, I think it is one of those “feel good” solutions that are almost impossible to put in place. First, there must be a recognized authority on specific wait times that would be appropriate. I recall seeing a rough draft of such a recommendation that said forty eight hours was an acceptable wait time for patients with a fractured hip. There are excellent studies in the literature that show increased morbidity and mortality after waiting times of twenty four hours, for a fractured hip, are surpassed. The second problem with guaranteed wait times would be the complexity of monitoring and implementing such a system. The third problem is that provincial governments do not have the capacity (either facility wise or personnel wise) to meet even semi-reasonable wait times. Problem four is, since we don’t have the capacity, where do we send the people who require a treatment and have surpassed their guaranteed waiting time? Will the government be penalized in any way for not meeting their “guaranteed” waiting time? How do you punish a provincial government? Do we want Ottawa to do it by with-holding transfer monies? If so, there will have to be Federal and universal Provincial agreement on both, what comprises a guaranteed procedure under the Canada Health Act, and what the time frame should be for any and every procedure that is guaranteed.. Dr. Oberg suggests that the accountability will rest with Albertans in provincial elections. Perhaps that is the simplest solution.
2) Public guarantees.
Dr. Oberg recommends that doctors be allowed to practice in both the public and in a private parallel system. He doesn’t spell it out, but this would infer that he would approve of patients being able to apply for health care insurance, and would allow health care insurance companies to be active in Alberta. This, in itself, is a step forward. This will push the public system to identify the procedures they cover and do not cover, and the time frame that they are prepared to back. The public will demand it in order for them to decide as to whether they spend money on additional health coverage. The longer the waiting lists, the more privately insured people there will be (thus shortening the waiting lists); the shorter the waiting lists, the fewer the people signing up for private insurance. Dr. Oberg’s idea of forcing doctors to work seventy five percent of their time in the public sector before they can work in the public sector is simply not workable. Administration of such a system would be a nightmare. What are we, as practitioners, to do; I will be working in the public sector from January to September inclusive, but won’t be available to the public sector in October and November because I’ll be in the private sector? I don’t think you have thought this one out clearly Lyle. People don’t like being forced into situations that they do not wish to be. Studies show that only five percent of physicians would want to practice in the private sector. Likely this group could be augmented with active recruiting of Canadian physicians who have immigrated to the U.S. over the past fifteen years. The majority of Canadian physicians have indicated a preference for staying in the public system. If our governments treat them right, there should be no problem allowing physicians practice where they enjoy their work. The majority of physicians practice medicine because they enjoy the work!
3) Enhancing patient choice
Choice should be a “given” in a democratic country, but with privilege, there should be responsibilities. Studies have shown that when the patients have to make choices, they tend to inform themselves as to the pros and cons of their potential choices. The possibility of a parallel insurance system will, of itself, be a stimulus for people to look at cost effectiveness. It will bring about more investigative searching on the part of patients, to look at various forms of interventions and preventative therapies and their benefits (the private system usually gives premium breaks to patients with healthy life styles, the public system will have to look at alternate ways to encourage and motivate healthy life styles). It brings alternate care providers into the equation (homeopaths, chiropractors, podiatrists, etc.) without forcing the patient to pay out of pocket, and at the same time, not be a burden on tax dollars. Some European health care systems have included some of these services under the public umbrella, as we in Alberta have done to some degree with chiropractic and podiatry.
Basically, the increase in patient choice must take place in a more free market environment if it is not to be a drain on the provincial government’s tax-payer funded budget.
4) Proactive solutions
Here again, one of our candidates brings up preventative medicine and promoting healthy life styles; however he distinguishes himself from the rest with some important methodology. He correctly points out that managing chronic disease is the key to preventative medicine’s cost effectiveness. In doing this we need to think of chronic disease in a broad sense; not just those people who are symptomatic such as patients with arthritis, diabetes, asthma, etc. The greatest benefit would be to capture those people that are asymptomatic and before they experience the complications of their chronic disease. Hypertensives, the obese, the hypercholesteremics, the smokers, etc, fall into this category. This group of asymptomatic chronic disease patients need to be involved in a very direct way to change their life styles and intervene when appropriate. With the help of electronic technologies, registration and tracking systems for those people at risk could potentially be a real winner, treating the right patient at the right time with the appropriate intervention. (I believe that money spent on generic T.V. commercials directed to the public at large is money poorly spent). To my knowledge, Alberta, at present, is investing millions of dollars in such tracking pilot projects in chronic disease. This is one of the few bright lights in preventative health since immunization programs were introduced. I encourage strong support for these preventative pilot projects and trust this is the area that Dr. Oberg is referring to.
5) Equitably Sharing Costs
Health care premiums are simply another tax, so I agree with those candidates, to some degree, that they should be eliminated. If the premium system were implemented in a different way, there could be some advantages. What if there were variable premiums, dependant on life styles? What if your premiums were determined by B.M.I., blood pressure, smoking, activity levels, etc. (and don’t give me the garbage of taxing the ill; it is RARE that normal blood pressures cannot be achieved with proper intervention). Money seems to be a universal incentive, and cost a universal disincentive. Note the use of fines for speeding, not using seat belts, wearing helmets, and more recently in Calgary, for spitting on the sidewalk. Let’s get consistent.
So, Dr. Lyle Oberg, you have done the best of the bunch in the area of health care. I guess my concern is that you have been in cabinet many years, and there is little evidence of your input. As premier, will you have the courage and determination to move from the present point of stagnation (and back-sliding from world standings perspectives), to a more truly innovative, thinking “outside of the Canada Health Care Box” position?

Mr. Gary McPherson's Vision of Healthcare in Canada

2006-11-16T11:16:00.000-08:00

For completeness and fairness sake, I will continue this dissection of the “vision” of Alberta’s “would be premiers” by critiquing the information obtained from their home web sites. Keep in mind, this information has been compiled by the candidate and, I would presume, their advisers, with ample time to think, ponder, pontificate, obfuscate, and in general confuse the reader. Is anyone out there good at de-coding?
Today we will look at Mr. McPherson’s “vision” and solutions for healthcare in Canada. He states that heath care in Canada needs to be sustainable, and does not believe that this should be done by bringing in “private” medicine, because this would amount to a “two tiered” system. I’m sorry, Gary, but we have many tiers to our health care system at present. One of my patients recently returned from the U. S., where he had life saving surgery done, that was not available in Canada. This “two tiered” boogy-man is getting tiresome. We have multi-tiers, at present, in our health care system. It would also seem that Mr. McPherson believes that “expanding the role of the current department of health to include more opportunities for alternate treatment methods and healthy living initiatives that will help to ensure that the medical care system is only accessed when it is absolutely necessary to do so”. Wow, that sounds good, except it implies certain things. It implies that people are using the system when they don’t need to. The evidence shows that people are actually using the system appropriately. Who would sit in an emergency department for eight hours if they didn’t genuinely feel they needed help. And the statistics back this up. Check it out Gary! Besides, wasn’t the system brought in so patients didn’t need to “worry” and make choices between food and medical care? Now their choices are wait on lists or ignore your problems or concerns. Both amount to “no care”.
The healthy living initiatives sounds good, but this has been pushed for forty years and we are failing miserably. Only 25% of the people with high blood pressure are being treated to target. Similar statistics apply to people with high cholesterol. The Saskatoon Star Phoenix newspaper recently reported a study that showed 95% of children in most average and well to do communities were up to date on their immunizations, but there still were “poor” communities in Saskatoon, where only 46% of the children were up to date on their immunizations. Now, immunization programs are the most cost effective preventative measures in medicine, and have been around for more than fifty years and ARE and HAVE BEEN FREE. Please don’t tell me that these parents don’t KNOW that, or that smoking is BAD, or that they shouldn’t eat junk food, etc. The problem is MOTIVATION. How are you going to get people to be motivated to live healthy life styles, Gary? What is your PLAN?
Mr. McPherson’s final assumption and implication is that other providers offer cheaper services than a family doctor for an equivalent service, and by involving these providers more opportunity, we could reduce costs to the health care system. I suppose that is true if we keep them OUTSIDE of the public health care system; but it seems Gary means to bring them into the public system! Let us look at some of these opportunities:
1) Maternity care and delivery
Midwives $2500.oo to 5,000.oo
Family Physician Approximately $1000.oo
2) Office visits
Family Physician Approximately $30.oo
Podiatrist App. $40.oo to $45.oo
Chiropractor App. $30.oo to $40.oo
Acupuncture App. $40.oo to $50.oo
Physiotherapy App. $40.oo to $50.oo
Holistic physician outside of Alberta Health care---- $300.oo to $325.oo per hour.
The bottom line, Mr. McPherson, is that a good family doctor, doing comprehensive continuing care, is the most cost effective practitioner we have, so we had better come up with ways of restoring that part of our health care system. The Americans recognized this twenty years ago, and aggressively recruited our family doctors. In Canada, we are just beginning to see their value. Other care givers are saving the system money at present because, for the most part, they are outside of the system, and people fork money out of their pocket to obtain these services. Our long waiting times for traditional medical services actually pushes people outside of the system, and saves the system money. Of course, I am referring to those that can afford to pay for these services (it’s another tier of health care).
Tomorrow we will look at Dr. Lyle Oberg’s “vision” and contribution to the health care debate.

Conservative Leadership Hopefulls and Health Care Solutions

2006-11-13T09:43:00.000-08:00

Apparently, health care is no longer the number one concern of Albertans; so for those who have been sitting in traffic for the past hour, are having trouble finding housing and shelter, etc., save yourselves some time and don’t read this entry-----boring! But for those of you who have been waiting in the emergency rooms, hospital hallways, on waiting lists, and, well, even if you are over 65, it may be worth while reading. Still boring, but factual stuff always is. What a pain it was for me to try to glean factual information from all the political double-speak.
It has been two weeks since I sent some questions to the “premiers to be” of Alberta and have two responses to date; Mark Norris sent a computer generated response thanking me for my “comments” and Gary McPherson actually sent me his approach would be to involve more disciplines as providers, and then asked me what I thought of the idea! Good for you, Gary. At least you put some personal effort into a real response and asked a doctor for an opinion; a novel approach for a politician. I guess I shouldn’t feel snubbed, though, since (from what I can determine) the Alberta Medical Association asked the candidates a number of excellent questions, and only Dave Hancock posted the questions and answers on his website. The Calgary and District Medical Association also posed several excellent questions, and from what I can tell, only McPherson, Hancock, Oberg, Dinning and Norris gave “answers” that were subsequently printed in the Associations’ news letter “Vital Signs”. So, having little or no response myself from the candidates (I’m just a Conservative voting member), I searched their Web home pages for answers to my questions (and the questions of others) on their position on Health Care in Canada, and in particular, Alberta. This is what I found and didn’t find. First, from the Calgary Region doctors:
1) “There currently is a physician shortage in Alberta which is expected to get worse over the next five years. As premier, what steps would you take to educate, recruit, and retain the physicians needed to care for Albertans”? This is a very good question and here are some of the answers given. McPherson, Oberg, Hancock, Dinning and Norris all said they would increase, or work at increasing, or fund additional spaces in medical schools. Please note that to train a family doctor takes EIGHT years, so this is unlikely to improve the situation over the next FIVE years. Mr. Dinning and Mr. Norris improved their answers by suggesting some modifications to the residency programs in Canada. Certainly, increasing the available residency programs in Canada may prevent our medical graduates being forced to go to other countries to obtain their residencies (and then not be eligible to return to Canada); however if these additional spaces are filled with “paying” foreign graduates, our boys and girls will be no better off. Still, it will shorten the time line for improving our doctor to patient ratios. My understanding is that there is, apparently, in some areas, a shortage of physicians prepared to teach, which of course makes increasing residency positions quite difficult. McPherson, Hancock, Dinning, and Norris all mentioned the recruitment of foreign doctors. Mr. Dinning attempted to do them one better by mentioning recruitment “nationally”. Well here is a news flash, folks. We have been doing this for many years and it has only gained us the ill will of other provinces and other countries. We continue to fall far behind in spite of a significant effort at recruitment for at least twenty five years. The question was what STEPS you would take to recruit. It is estimated that at present a full 50% of Saskatchewan’s physician force has been imported! The well of reasonably qualified international candidates is drying up.
Startling in its absence is the candidate’s response to the question of the “retention” of physicians. Not one of the candidates made one suggestion to address this problem. It seems to me that if we train physicians, only to have them leave the country after graduation, we have accomplished nothing! Sort of like poring water into a bucket with a large hole in the bottom!
The second part of the first question had to do with the recommendation from Alberta Learning that interest free status should be given to learners completing a residency program, and that repayment requirements for student loans not be initiated until residency requirements have been met. All of the candidates mentioned above thought this was a great idea. This is really a nice thought, and encourages students to undertake residency programs that may be longer and not have to worry about interest on student loans and repayment plans until they actually have a license and get a “real” job. The problem is, in medicine, we don’t need more super specialists; we need more generalists. We already have a shortage of family physicians and enabling students in medicine financial incentives to specialize will aggravate this problem. Certainly I would have thought seriously of continuing on in a specialty if I had not had financial pressures to get on with getting a job. I’m not saying that this idea isn’t great for some areas of learning. I’m just suggesting that in medicine it may be counter-productive and aggravate an existing problem.
2) What steps would you take to ensure the survival of the family practice doctor in Alberta? Wow, another great question; especially since encouraging them to specialize with interest free loans and delayed payment schedules will encourage specialization. Although many other professions and trades have been able to keep up with the inflationary cost of living in Alberta, family doctors are tied to a fee schedule that is rigid, and actually is punitive to those family physicians doing comprehensive continuing care in their practices. Mr. McPherson thought that perhaps interest free loans and tax incentives for new graduates would be helpful. It would seem he didn’t realize that it was the older physicians who were doing the less lucrative work (geriatrics, palliative care, etc) that were giving up their practices. The new graduates were finding niches that were far more lucrative (walk-in clinics, hospitalists, locum tenens, no one in the practice over 60 years of age, etc). He also thought that some of the ancillary medical people (chiropractors, holistic docs, naturopaths, etc) could take over more of the duties of family doctors. He apparently doesn’t realize that on an hourly basis, these practitioners are much more costly than traditional family doctors. Mr. Hancock said much, but primarily seemed to be pushing the concept of primary care networks, which I have commented on in previous blogs. He again thought there should be more use of alternate providers and emphasis on prevention. In short, it would seem (since he had no ideas as to help the family physician situation), he acknowledged, and perhaps even welcomed, the decline in the numbers of family physicians as a “cost savings” measure. Mr. Dinning referred to “primary care networks” and the present “funding” in place to help computerize their offices may be an incentive, but basically his position was that it was too bad family physicians were declining in numbers, and the issue was really between the AMA and the provincial government during negotiations (I guess he is inferring that money may be a root cause). Nothing new there! Mr. Norris enlightened us with the fact that negotiations are presently going on between the AMA and the government and he is sure that an agreement will be reached soon. Wow, that sure inspired me to be a family doctor! He did suggest that there was a NEED to look at ways to encourage medical grads to choose family medicine. Sorry, I thought the question was “how would you do that?”. Mr. Oberg actually came up with a very novel and unique suggestion “Increase the fee schedule for family physicians doing comprehensive care”. With that revelation I will close today’s mind boggling discussions on the future of health care in Alberta as seen by our “Conservative Leader Want-to-be’s” and premier hopefuls. I will continue their responses to more questions over the next few days. And of course, if any of their representatives wish to clarify, agree, disagree, etc. you are invited to comment.

Health Region Needs Help Quickly

2006-11-09T18:54:00.000-08:00

“Negotiation” is an interesting process. If one looks up this process on Wikipedia we can find information on the a) process, b) tactics, c) the win/win approach d) the advocates approach, and e) a whole lot of information. So why haven’t we (meaning the various levels of government) done a better job of managing the growth and corresponding needs of the Fort McMurray area, recognizing they were and are in a negotiating position with the large international oil companies wishing to be involved in the tar sands? If they didn’t know how to do this, they could have always gone to the internet!
The most interesting aspect of the Wikipedia information, from my perspective, is the reference to the 2005 published material called “Beyond Reason: Using Emotions as You Negotiate” and in particular the five “core concerns”, namely: autonomy, affiliation, appreciation, status, and role.
To simplify this where governments and large multinational companies are concerned, we probably have to primarily talk about money; the large corporations because of their year end profit margins and accountability to their shareholders, and governments because of their continual immediate need for money to buy the votes of special interest and special “needs” groups.
At an international level, some people obviously think that, Radical Islam extremists and the Western World can’t negotiate. This is obviously wrong since these negotiations are going on continuously as a world dynamic. Knowing our regard for life, free speech, equal rights, etc, the question is being asked of us “ How many lives are you prepared to sacrifice, how much abuse of equality, and how much abuse of your free speech are you prepared to give up, in return for granting us what we want, namely, autonomy (leave us alone), affiliation (we can buy and sell what ever we want to whoever we want), appreciation (our values are equal or superior to yours), status (we reject and resent the U.S. as being recognized as a world power), and role (we will determine world order------including the annihilation of Israel and infidels)? But let's get back to the problems in Fort McMurray.
At a national and provincial level, negotiations are going on continuously between various levels of government: who has the right to tax what, whose portfolio is in whose jurisdiction, etc. Saskatchewan and Alberta demonstrate the differences in negotiations that have occurred in provincial negotiations with various groups, including the large multinational companies and the various labor unions, and others. Both provinces are rich in resources, but the development of those resources has lagged far behind in Saskatchewan. Time will tell us which approach was most beneficial to its citizens; the freer hand given to companies to develop resources in Alberta, or the more controlling policies of the Saskatchewan governments.
My criticism of all the provincial governments in dealing with development in Canada is primarily in the areas and responsibilities having to do with infrastructure. For these discussions I include the provision of adequate medical care in the category of infrastructure, since we have a monopolistic health care environment in Canada.
Over the last few years, while traveling in the U.S.A. I have been amazed at the infrastructure development that is done in advance of demand. Overpasses and freeways are built long before housing has created the demand. Just west of Phoenix, Arizona, is an area called “Green Valley” with many miles of four lane highway, turning lanes, an overpass, and hundreds of acres of land with no housing activity at present. In one area about twenty miles from Phoenix we found a beautiful golf course and a large school with no houses for miles around. On asking in the club house about the school, we were told that in order to have the golf course and the large corresponding housing development, the developer was required to build the school. In another area west of Phoenix, a very large school was built and has been completed, and the developer is now proceeding with a golf course and 10,000 homes. Apparently some negotiations went on that falls into the win/win category for both the municipalities and the developers.
There has been much talk about “stopping” the oil sands development of late. The reasons given are many; lack of housing, lack of infrastructure, environment, and in today’s’ Calgary Herald article “Strained health region needs help quickly”, lack of medical resources. Is it really possible, that everyone, in the various responsible levels of government, didn’t see this coming? Or are they simply inept or irresponsible in “negotiating”?
It would seem, from the article, that the recent proposal by Imperial (Kearl oilsands project) includes its own “medical centre”, staffed by a nurse practitioner and support staff. Good grief! What kind of “medical center” is that? How about a hospital with the required staff? Sorry, I got carried away. In Canada we don’t allow “private medicine”!
It would also seem to me that negotiating things, such as the above, are hampered by the fact that the large oil companies and developers in Canada know that our governments cherish their monopolies, and their control of both the education system and the health care system. At a time when there are big dollars for the International Oil Companies and their shareholders in our oilsands, one would think that better concessions could be obtained and still end up with a win/win situation for the tax payers in our province. At one time, oil companies had "Company" doctors. Now all their health care needs are carried by the public system.
As for the loss of physicians and other medical personnel from Canada, one has only to look at the negotiations that have occurred over the last twenty five years between governments and their associations. The five principles in negotiating a win/win situation have basically been ignored, and governments have adhered to the win/ loose scenario that existed prior to the 1970’s. Let us consider the core principles as they have been applied to health care:
1) Autonomy.
A one payer system has been imposed and physicians have been forced to practice in the system or out of it.
2) Affiliation.
Hospitals and practitioners have been grouped into regions, and physicians were basically forced to practice in certain hospitals, or give up their hospital work altogether.
3) Appreciation
Family physicians were considered expendable in hospital care, and doctors in general were considered to be the cause of escalating health care costs. As a result, the positions in medical schools were slashed, and very few family physicians are doing hospital care in our major cities.
4) Status
Many years ago doctors, nurses, teachers, etc, were potential role models. The entertainment area has largely taken over this societal position.
5) Role.
In years gone by, the physician was the patients advocate. At present, most physicians have become dependant on, and as a consequence, advocates of the system.
The bottom line is that I am tired of having various governments and their agencies complain about their difficulties, even during prosperity and high taxation, because of their poor negotiating skills with the multinational giants, and their win/loose approach to the medical services professions. They should now accept the heat, or get out of the kitchen!

Childhood Obesity

2006-11-03T10:43:00.000-08:00

Like most family physicians, I am sadly lacking in answers to the rising epidemic of obesity. The term epidemic is used, I am reasonably sure, because of the dramatic rise in obesity over the last two decades, and the corresponding pathologies that are a result, such as heart disease, diabetes, etc. More appropriately, I think, obesity should be categorized as a chronic disease state (if an adaptive state, it is a pathological adaptive state). Like hypertension and elevated lipid levels, these chronic diseases are asymptomatic until the late stages of the disease. More and more diseases are found to follow a similar pattern (including Alzheimer’s disease).
Recently, I contacted the “would be” premiers of Alberta for their suggestions on how to control spiraling health care costs. So far, I have received one automated “thank you” and one response stressing “preventative medicine”. Total silence from the majority; although in all fairness, most of them sing the praises of preventative medicine in their party platforms on health care.
The problem is when I graduated in 1962, we had a full course on Preventative Medicine with a corresponding huge text book, and in spite of everyone’s best efforts since, we are failing the course in the public forum. This is most evident with the problem of obesity.
Let us briefly look at what we think we know about obesity and in particular, childhood obesity.
At a recent conference on migraine headache and pain control, the researchers suggested that some people genetically have a “pain monitoring and modulating” center that can be moved “upwards” with opioids and other pain medications, which results in addictions. In other words, more and more drug is required to produce the same therapeutic pain relieve, because “sensors” simply “adjust”. Research articles suggest that this type of genetic predisposition can exist in at least 60% of obese patients as well, but of course, controlled by a different neural system. It is suggested that we all have a “set point” for metabolism that is largely controlled by metabolic “sensing” neurons in our brains. This is supposed to tell us when to eat, so as to keep our energy level and our total body fat level, at a constant. Confusing stuff ; but basically, there should not be the problem of increasing weight with age----unless of course, something goes wrong----and therein is the “chronic disease” aspect. As mentioned previously, some 60% or more of the population have metabolic “regulators” that have the capacity to change during early life (and to some extent, throughout life), so that with increased food and a sedentary life style, metabolic rates may actually go down, but the regulators tell you that you need more food! What a mess!!! In effect, you become kind of a food addict!
Now, from what I can gather, our regulating system is most vulnerable to this change during pregnancy (inside of our mother’s womb), the post natal, neonatal (the first year of life), and during childhood. Once our system has been upgraded to do the wrong things and lie to us, this basically becomes a permanent thing (for many people, it continues throughout their lifetime). This explains why people “struggle with their weight all their lives”. Obesity, once established in the adult, has basically become a permanent and chronic condition.
One of the articles I read said (because of the above fact), that obesity prevention, therefore, is probably the best treatment. Which gets me to the gist of this entry. Let’s see how we are doing in the prevention of obesity in children, and therefore in the entire population.
Apparently, the city of Toronto, in the summer of 2000, abolished half the playgrounds at city schools, supposedly because they feared injury to the children. Now, I always thought that running and walking was good exercise, and that falling down from ones own height was a fairly benign event. The research suggests exercise helps prevent the “deregulation” pathological process responsible for obesity, so why get rid of playgrounds? Could this have something to do with real estate values and not injuries? I’m sure they put in lots of swings, slides, etc. for the kids (how many calories do you burn doing that)? Or maybe some great “monkey bars” that are ten feet high (it gives me creeps to see kids climbing on the top bars), but take up very little real estate. And of course, computers in our schools are a must (probably replaced Gym class in many schools). I understand that in some U.S schools, the “virtuous” school administrators prohibited playing “tag” and other similar activities on the school grounds. “Hey, you kids, stop running. You’re going to hurt yourselves! Get in here and sit in front of a computer, or get up on those monkey bars”! And what is with all this junk food in our schools? One of the researchers stated that “intake of highly palatable diets override the basic static controls of ingestion because it is regulated by neural systems mediating reward and motivation”. I think he was saying that by allowing junk foods, as parents and as a society, we are CREATING obese kids. I’m not suggesting we prohibit the manufacturing of these products, but perhaps as parents we should exercise some authority. Parents seem to be able to get peanut butter out of the schools, why not junk food? Yes, it too is killing our kids!
So how are our governmental leaders doing? Yes, the ones that say preventative medicine is going to save our health care system. They could penalize the schools that have junk food by decreasing funding to the perpetrators, and increasing funding to those that have healthy alternatives. They could also tax the h-ll out of junk food. Maybe take that tax money and give it to the schools? Apparently one of the main reasons we have junk food in the schools is to increase revenue. Now that’s a good one! We negotiate a financial deal that puts money into the education system, creates food addicts that are going to drain the health care pot in the future, and will usurp money out of the education system! Harper tried to take a baby step in the right direction by giving tax deductions to kids that sweat, but ran into criticism from parents whose kids were taking “archery lessons”. Good grief!
And how is the medical profession doing in addressing this problem. We used to restrict weight gain during pregnancy to 20 pounds. Now we say “eat as much as you want, as long it is healthy food”(good luck!). Some women gain forty or fifty pounds with no information to the contrary. The breast feeding mother is told that she is eating for two, so don’t be concerned. Still, as previously mentioned, this is an extremely important time for programming the infant to be obese. Restraint in any form seems to be a “bad” word these days. The toddler’s mothers are told that they will “wear it off” when they start playing soccer and become more active. But they don’t become more active. They discover T.V.s and computers, and these serve as super “baby sitters”. And if they cry---feed them, and if they don’t like what you feed them, keep offering them “stuff” until you hit upon something they like. As parents, why do we harbor so much guilt that we can’t say “NO”. Or are we so self involved that we can’t be bothered to be a parent to our child/children? Or is it that we don’t want to harm their self image by saying “NO”?
Well, here is a news flash, most obese people struggle with their self image.
We are indeed a weird society. We talk “ad nauseum” about prevention, but think about bumps and bruises. Some efforts of pediatric prevention have been laudable (seat belts, helmets, car chairs, etc), but how can we sit back and do nothing about behavior that will sentence a large number of our children to diabetes, heart attacks, and strokes? Talk about child abuse! I firmly believe that there is therapy in restraint and the word “NO”.

Compexities of Emotions in Palliative Care

2006-10-30T09:03:00.000-08:00

I do not envy the people that make decisions that impact millions of people and have far reaching implications, including the death of people nationally and internationally. The complexity of decision making in palliative care, involving one loved one, is complex enough for me.
In spite of doing palliative care for years in my medical practice, I still find that each situation is unique, and even with careful consideration, the best intentions, significant medical knowledge, and rational thinking, surprises often occur. The problem is that each person is unique, each relationship is unique, and in many of these situations, human emotions (which often don’t lend themselves to logic) may be the main determinant of “suffering”.
On a previous entry I spoke of the development of the systems of palliative care in Calgary and its delivery (fidelity), and although we have made tremendous strides, we are far from the ideal. In this entry, I would like to discuss in some detail the emotional aspects and interactions that affect the quality of care, and may pertain to the patient’s “suffering”. My intention is not to delve into the technical and specifics of symptom management to any great degree, but rather how our personalities and our relationship with the loved one can influence the care the patient receives. Some of you may have additions to this discussion, and they are welcome; but, for the most part, most of you will not have thought of these things, or for that matter, been confronted by the situation. My advice would be to read this entry over carefully, and think on it. When faced with the situation of the impending death of a loved one, we will only get one “go” at our approach to the situation, but we will live with it the rest of our lives. So although the following may be long and somewhat depressing, it certainly has the potential to be enlightening and informative in the future, when you can say “Although I mourn the loss of my loved one, I take solace in the fact that I did what I could, and he/she would be pleased”.
In this post I also do not intend to address, in any detail, the traditional emotional reactions of a patient given the news that they are facing an “end of life” situation. The reactions of denial, anger, negotiations and finally acceptance, are generally known and certainly have been addressed in the medical literature. I would caution, however, the people who feel that these emotions are typical and easily recognized. One of my patients (an ex-military man) in an end of life facility kept talking about “when he gets home”. His family and the nursing staff concluded that I had not informed him of his dire prognosis, and insisted that I explain to the patient the seriousness of his condition (which I already had----in detail). I had the nursing staff accompany me to the patient’s bedside, and asked him if he recalled our discussion regarding his outlook over the next few weeks, and the fact that he would not leave the facility alive. His answer was “Of course, why would you raise that issue again”? Obviously he had chosen this way of dealing with his death. Besides, he felt that he was protecting his family, and he didn’t know how to deal with tears. I had spoken to him previously about sharing emotions and his response was that he didn’t do that throughout his lifetime and he didn’t see any reason to do it now. Did this man need an attitude adjustment or did he need support in his decision. I chose to inform the family as to his feelings and encouraged them to express their feelings to him in a positive way, and to understand that although he loved them, he felt his function, as long as he was alive, was to protect them, including the emotional pain of his impending death. The basic principle, as I see it, is the patient’s needs should come before our own. We have time to deal with ours.
One of the things that I heard frequently as an end of life physician was that the friends of the person dying “disappeared” as the disease progressed. At first I was upset by this fact, but over the years began to understand that this was a multifaceted problem. The simplest answer given was that people “didn’t know what to say”, and so they avoided the visit altogether. Although this probably is the reality, it still constitutes a cop-out As a friend, whatever you say at the time is probably quite alright with your dying friend; your presence speaks louder than words. Frequently, friends are concerned about giving their loved friend a cold or other contagious illness they may be harboring. My advice is to simply wait a few days, or wear a mask and wash your hands during the visit, or ask the nursing staff and the patient for input. Although it is true that people who are dying may be more susceptible to infections, you won’t be contagious forever and your visit may be important to your friend.
Be attentive during your visit. Address the patients concerns and discomforts and forget about your own discomfort. Know when to leave. As a rule, short frequent visits are preferable to long visits, unless you are in the role of an involved care giver. If your usual relationship involved human contact such as hugging, it should continue, with due consideration of the patient’s frailty. In short, it is best to continue your relationship in a normal, supportive manner and focus on the needs of your loved friend, not your insecurities. If some situations bother you, call a nurse or leave the room. I have seen amazing care given by lay people----the kind of care that probably is incredibly important to the dying loved one. I have seen friends put on the make-up of their dying friend, provide the basin and hold hair away from the basin while the sick person vomits, provide foot rubs and neck rubs, assist walks, or take their friend for a stroll in a wheel chair. Human contact can be extremely important during this period of time, so just the simple act of holding their hand can be helpful and reduce the amount of medication needed. One of the most touching scenes I remember was while making a house call on a thirty seven year old woman dying of cervical cancer. As I entered the room, her younger brother was sitting on the couch, cradling her head on his lap and gently stroking her hair.
The above is relatively easy. More difficult situations arise with the immediate next of kin, the immediate care givers, respective husbands/wives, attending physicians, etc. The husband may feel that the dying person does not wish to be seen in their emaciated state; and although, when we are healthy, this seems rational, I have rarely seen a patient that did not appreciate short visits. For the most part, our vanity under these circumstances seems to disappear, and we appreciate our friends.
We should keep in mind that for some people visiting can be stressful. This is particularly true of the person that was always the social “entertainer” and attempts to continue to entertain, and the person who never was by nature a people person. I recall one woman who complained that her husband was rude to his visitors by leaving the room and going to bed after an hour’s visit. Obviously both she and the visitors were not sensitive enough to his needs to know when “leaving” on their part should have occurred.
On the other hand, I have seen situations where the husband/wife has felt the visitor’s presence, for whatever reason, exacerbated physical symptoms. If this was clearly evident, with the patient’s approval, visitations should be restricted. I should point out that this is rarely the case. The usual scenario is that the visit is too long, the disease process is worsening (against the hopes of the “significant” other), or the patient and his/her spouse is embarrassed by the disease symptomatology in the presents of friends. If it is perceived that this latter is the case, continual reassurance is needed that your presence is for the purpose of aiding and providing comfort. I have found that this hurdle is actually harder to overcome in dealing with the spouse than the dying patient.
On many occasions, I have found that the wife has felt that it is her responsibility to look after her dying husband 24/7. It is as though this is her last tribute to her loved one. As caregivers, loved ones, and friends we must recognize this as a strong need on the spouses’ part. At the same time every effort must be made to give her/him time to rest. An exhausted spouse is not going to help her/his mate, and after a while everything becomes a blur to them. If possible, spending the night (a minimum of 8 to 10 hours of rest time and the unloading of responsibility is mandatory) and just sitting at the bedside, is reassuring to both the patient and the spouse. Availability of help with bathroom needs is a small thing that is extremely important when we are in an extremely weakened state. Maintaining bowel and bladder control goes a long way in maintaining one’s dignity. Some option time during the day is also useful for the caregiver. This must be done with the understanding of the spouse’s strong need to be continuously present. Reassurance of notification of any change in condition goes a long way in relieving the spouse of their guilt and the feeling that they are abandoning their loved one. Generally this downloading of the responsibility for care is easier for the spouse if the person assuming care is a family member, but friends, professionals, and even volunteers can often be used.
We all have hopes that our dying loved one is going to be the exception to the rule and make a miraculous recovery. Hope certainly is beneficial and should never be totally abandoned. We must, however, always be cognizant that our hopes for our dying loved one may create problems with the care of the patient and be in conflict with their priorities. One of my patients, who had been on intervention treatment for years and was failing again for the fourth time, was in tears as she told me that she wanted to stop her chemo and aggressive treatment, and only wished to be kept comfortable. She didn’t know how to tell her husband, and felt that she was letting her doctors down who had been so positive and helpful. Isn’t it strange how remarkable and considerate people can be when they are the ones who are in desperate need? Unfortunately, in this case, in was the patient that was showing the most sensitivity. I have seen situations where a patient with a complete bowel obstruction is encouraged to take some “nourishment” by mouth in the hopes they will improve. Unfortunately, this simply increases gastric secretions and causes more nausea and vomiting. Occasionally the patient and their loved ones will grasp at straws, with the attitude that desperate situations require desperate approaches. One of my patients sold their house and went to another country to find solutions against my advice. Unfortunately, he was told by this alternate cancer care provider that he could take ONLY medication prescribed by their facility. Needless to say, in a short time, he returned to Canada in severe pain and in a near death situation.
Occasionally, patients are referred for counseling as an adjunct to end of life care. For the most part, this is a positive experience; however, councilors must be careful not to overemphasize the importance of having a positive attitude. Some patients (including my sister), feel that they are a failure if their disease progresses in spite of positive thinking and see this as a failure on their part..
I suppose much of the above is simply common sense, and being sensitive to the patient’s needs. In this regard, an experienced family physician who knows the patient and the family is invaluable. Ready access to palliative care personnel and expertise also is invaluable; but in all cases, time with the patient and the next of kin is essential. Knowing the patient, knowing their likes and dislikes, their beliefs, their character and nature, can be incredibly useful at times. I recall a cowboy who simply felt better with his boots on (which gives credence to the expression of wanting to die with your boots on). One of my patients in a care facility became restless when he was turned. He settled quickly if the bed was turned in such a way that he could “see” his family was in attendance. Obviously it bothered him to sense that he was all alone when he was facing a blank wall. Another rancher patient was extremely restless until his bed was turned and the head of the bed elevated in such a way that he could see the expanse of the countryside outside of the window. Was he claustrophobic, or did he simply feel peace when he was able to see the great outdoors where he had spent most of his life. The bottom line was he required less medication and he was at peace in this position.
As physicians and care givers, we have become very competent in the technologies of end of life care. Today, palliative care physicians and care givers understand that management of suffering is paramount. Sometimes I think we are almost too enthusiastic about our pain management. I remember one situation where the patient was comfortable except when she was moved. During those times she grimaced with pain and sometimes would cry out. The pain only lasted a few minutes after the positional change and then she was comfortable again. As positional changing is imperative for bed-bound patients to prevent painful bed sores and tissue break down, and because the compassionate nursing staff wanted to keep her comfortable, they pressured her to receive an injectable pain killer to make the positional changes more tolerable. The patient didn’t want any pain killers because they interfered in her “being with-it” and her ability to visit with her family for three to four hours, and besides, she said, her pain on turning lasted only a few minutes. It became necessary for me to intervene on the patient’s behalf. Although the turning and pain response on the part of the patient was disturbing to the nursing staff, the needs of the patient to maintain “control” over their life, in this situation, was paramount. When one is dying, I’m certain that the sense of loss of control can be the most devastating part of the process. Thank goodness we now have pain control measures that have rapid onset and only last 30 minutes, to deal with these scenarios.
I have found that the profound weakness that accompanies end of life time is perhaps even more demoralizing than pain. Can you imagine going from an independent, in control individual, to a helpless person needing help to turn over in bed? In medicine we have made tremendous strides in the treatment of pain, nausea, depression, and exhaustion, but weakness has remained untouchable frontier. Your strength, both physically and mentally, assistance, and willingness to be there and help, are the main resource at the present time for such a patient.
As I have previously mentioned, we teach care givers the emotional process that patients go through when they are given the news that they have a terminal illness (denial, anger, negotiations, acceptance), but I have not read anything on two common emotions that I have encountered in my practice-----shame and guilt. In my experience, this is more common in people with a significant sense of responsibility. In matters of health, no one leads the “perfect” healthy life style. It is a short step, then, for some people to reflect on, and feel guilty about, their past disregard for healthy life styles (eg. smoking) and as a consequence, the pain caused to their loved ones. The surviving spouse may also feel guilt about their contribution to the illness (second hand smoke). It has been my experience to put these matters should be openly discussed and put to rest quickly. Nevertheless, as friends, we should assist in emphasizing the things that really matter. For the most part, unresolved guilt issues simply drive people apart.
The shame aspect certainly is more difficult to cope with. So much attention is paid to image in today’s society that it is difficult to suddenly say “appearance doesn’t matter”. Fortunately, this seems to be primarily a problem during the denial, anger, and negotiating stages of dying and when the patient and family accept the situation for what it is, they seem to amazingly focus on those things in life that truly matter. Is this what is meant by “when we are about to loose our life we actually may gain it”?
In closing, people often ask me how I could cope with the emotional impact of caring for dying people. I believe there are two answers to this. Firstly, always look at the patients needs, not your own. And secondly, and possibly as a corollary to the first reason, I have found the people that I have cared for (and their friends and families), under these circumstances, have always amazed me with there courage, understanding and appreciation. I recall one Dec. 24th, a patient whispering to me: ”You should be home with your family”. He passed away four hours later.
My hope is that by my relaying my thoughts and experiences, you will be able to meet these challenges in the future in a way that is less stressful to you and most helpful to your loved one.

Outsourcing, Our Health Care Solution.

2006-10-06T20:47:00.000-07:00

Man, I hate when I misjudge a situation. For years I have been opposed to our health care system taking on a “business” approach to health care, I have criticized the over emphasis of cost effectiveness, and of late I have even doubted the effectiveness of guaranteed wait times (I’ve never been sure whether a patient would be MADE to wait the guaranteed time or-------). In any case it occurred to me the other day, that, when the governments had decided to morph our health care system into a “Business Model”, they were thinking big and I was thinking small. I admit that I did not see all the possibilities. I couldn’t understand how sending someone somewhere else (of course I was thinking of the U.S.A.) if their wait time was too long, would save the system money (a system that already is thought to be financially unsustainable). But then I thought: But why think U.S. A.?” Let’s look at OUTSOURCING as a solution---PERIOD!!! That’s what big business is doing. I’d venture to say that surgery in Canada that costs $30,000.oo could be done in India for half that amount, and maybe even cheaper in Cuba! (Probably less than a thousand dollars if we were to use the same facilities the locals in Cuba use, and not those for the tourists). And Cuba has a Universal Government System just like ours. I’ve heard tourist comment on what good care they got in Cuba when they were tourists and got ill. People may even be prepared to pay their own airfare and have a bit of a vacation at the same time!
We have a shortage of family doctors----- so what? Most health problems can be diagnosed by the history alone. Medical help lines could be established with Cuban doctors (there are lots of them because education is free) and they would give advice as to how to deal with our problems. The Alberta government could work a deal with the Cuban government and send a few barrels of oil down there in exchange.
Americans have shown us how to deal with the increasing cost of pharmaceuticals. They come up to Canada to buy their medications because they are cheaper here than in the U.S. Here is a news flash. On my last visit to Mexico there were drug stores on every street corner and their prices are about one half of ours here. We could outsource our drug coverage to a large Mexican drug store chain or perhaps to the Cuban government.
It certainly would be cost effective to send all our chronically ill patients to Cuba. They may actually get better. It seemed to have worked for leprosy! Why not give it a try? So what are a few more barrels of oil?
And what about people in their last two years of life? Apparently this takes up a huge slice of our health care pie. Who wouldn’t want to spend their last days on a tropical island? Lets have all our long term care facilities built in Cuba!
I guess I truly have been an idiot and not seen the big picture. Guaranteed wait times and OUTSOURCING; the next big innovative idea that has come of age in our Canadian Health Care System. I can hardly wait.
And now I'm off on a holiday. I think I really need it.

Conservative Leadership Forum in Calgary

2006-10-06T17:00:00.000-07:00

Well that was a waste of time! The other night I attended the Alberta Conservative forum at the Red and White Club in Calgary hoping to hear something about what many Albertans rate as their Number One concern-----health care. NADDA. The only two candidates that dared to go there were Lyle Oberg (who claimed health care was the elephant IN the bed with Albertans, and Ted Morton (who claimed the health care system didn’t need more money, just more choice). Well Ted, if it doesn’t need more money, why is it unsustainable? I think he meant it needs money from sources other than the government’s budget, but he didn’t elaborate. Lyle Oberg’s plan, on the other hand, allows physicians to practice in both the private and the public system; but physicians would have to dedicate at least 75% of their time in the public system. Well, that is better than the existing situation, but someone should tell Dr. Oberg that as a general rule, no-one is happy working where they don’t wish to be working, and the attitude of these physicians (conscripted into doing public work) may be less than compassionate. When I was at a medical conference in Brazil, years ago, Brazil had such a system, and the people felt the attitude of physicians working in the public system was terrible! But I digress.
When the forum began, the audience was encouraged to write down questions and was led to believe these questions would be addressed by the candidates. Naturally, I wrote down questions about health care. Within five minutes of starting, it was apparent that all questions were prepared and circulated to the candidates in advance of the forum. Further the questions were designed so that the candidates and the Conservative party was going to “look good”; in other words, the entire affair was a “public relations” and “news media” event And you know it, no questions were posed on health care, the number one concern of most Albertans (obviously a divisive area).Could well have been the worst five bucks I have ever spent! Other than Dr. Oberg and Ted Morton, the other candidates did not allow “health care” to cross their lips.
Not to be totally sidelined, I cornered Jim Dinning and asked him if he could talk on health care without using the word “innovation”. He felt that he would be compelled to mention the “innovative” bone and joint program that has prospects of shortening hip and knee replacements. When reminded that this pilot project is being subsidized to the tune of twenty million dollars a year (approximately 12 ½% of the total provincial budget for joint replacements), he simply said he wasn’t ready to give up on the existing system (as though having private provider {and insurance} involvement automatically meant the demise of the universal, publicly funded, health care system we have at present).). I had a brief discussion with Ed. Stelmach on health care. He seemed to think Dr. Le Reich (a previous president of the College of Physicians and Surgeons of Alberta) was responsible for the cut backs in graduating doctors in Canada. Now, Dr. LeReich struck me as a genuine socialist, but I doubt if he single handedly convinced Canadian provincial governments that the way to go was to decrease physician manpower in Canada. Further, Ed did not seem aware of the Barer-Stoddard Report (which is usually given “credit” for the cutting back of physician training in Canada), and its impact on our health care system.
All in all, although the candidates presented the idea that they were going to “listen to the congregation” they seemed more intent on preaching; except of course in health care, where the majority were as quiet as the proverbial church mouse!.

Rutherford and Health Care

2006-10-06T12:19:00.000-07:00

As a rule I find Rutherford (QR770) fairly sensible, and makes a good effort to stick to the evidence available; however, after fifteen minutes of listening this morning, I need a valium (no, I won’t go to the emergency department to get one!).
I suppose all talk shows and phone in shows are primarily for entertainment value, and being a full moon, perhaps he should be forgiven; but I do wish there was a “talk show” on health care that had basic knowledge as to how we arrived at today’s emergency department dilemma.
Here is what I heard in the few minutes I listened:
1) Mr. Rutherford states something along the lines of “I’ve heard there are as many as 80% of patients that go to the emergency should be cared for elsewhere”. Mr Rutherford should be told: a) he can get statistics on these things and he will find that the number of “inappropriate visits to the emergency departments in Calgary is steadily decreasing and is presently less than 20%”, and b) if the community cannot attend to the needs of the patients, they will end up in the emergency department. The “elsewhere” may simply not exist!
2) The shortage of nurses, like the shortage of doctors, has been precipitated by policies going back a few years. During cut-back times, thousands of nurses were let go (fired, laid off, etc), and there was a switch to part time employees so the Region could avoid the benefits that are paid to full time employees (this was an innovative idea!). At present there is such a shortage of nurses that the region is indeed looking for, and is prepared to hire, full time nurses. I suspect however, the nurses are now in a position to “pick and choose” their employment, and the conditions attached there-to. Consequently, now, nurses may pick part time and only work the “time and one half pay” shifts, avoid the night work, and choose life style issues over full time employment and benefits. The stupidest thing done in the past 15 years was to bring about a “short supply” of all health care providers. They are now in the driver’s seat and have adopted “The Business Model” that our governments thought was so necessary in our health care system. Lord help us if we keep innovating in the health care system! Perhaps I should have continued to listen, perhaps someone may have phoned in and made a contribution with some understanding of where we are, and how we got here; perhaps I should forgive all the B.S. that is being thrown around today (research shows that you are healthier if you have the capacity to forgive), but if I had, I may have ended up in the emergency department!

Public Opinion, Is It Public Enemy # One?

2006-09-14T08:19:00.000-07:00

You will just have to excuse me. Today I will do the unforgivable. We all have a breaking point and I have reached mine. After all, blogs can be used as therapy, right? And I need therapy. After watching the ABC presentation “The Path to 9/11”, I simply have to say something about how I feel. Yes, I know I’m a man and men aren’t supposed to be capable of expressing their feelings according to Oprah, but perhaps I’m the exception to the rule, because here I go!
I truly believe the biggest threat to law and order and good government is PUBLIC OPINION.
Just think about it. In democratic countries all levels of government get voted “in” through some type of majority and get voted “out” by the same process. The driver behind this process obviously is “public opinion”. This is our Democratic Achilles heel. The only thing that democratically elected officials and governments have to fear is public opinion. Previous prime ministers routinely used poles to decide policy (obviously Prime Minister Harper doesn’t). Jane Taber and Greg Oliver repeatedly raised the issue of decreased support in Quebec regarding the Afghan issue with questions like “But aren’t you concerned about decreased approval in Quebec. How do you expect to get a majority government? The question wasn’t “is it good policy”, or “is it good for Canada”; it was more a “you better watch out” kind of thing. Governments seem to function based on “How do we get public opinion on our side? When Jack Davis was sent to Calgary by the government in Alberta, he was to change the “perception” that we had a health care problem in Calgary, and that perception was causing public opinion to turn against the Klein government. Any type of reform involving private care in our monopolistic health care system has always been put in abeyance by special interest group’s lobbying and influencing public opinion. This one issue has to a large degree determined the governments elected over the past fifteen years.
While watching the events leading up to 9/11, it would appear that many times the Clinton administration failed to take action because they “feared how it would play out to the public and the press”. Which brings me to the second conclusion; and that is the MSNM feel they own the gun (public opinion) and can pull the trigger on public opinion any time they wish. Note the struggle between the Ottawa News Media and Steven Harper. The struggle basically is on control of public opinion. The MSNM recognizes their strength is through their ability to help form public opinion, and by doing so control and determine which party will be in power. Stephen Harper is also very aware of the power of public opinion, but wishes to determine the direction of the government and its policies on the merits of the issues, based on the information provided. Limiting the ability of the MSNM to manipulate public opinion by having orderly question periods and giving everyone a fair chance to ask question (not just the most aggressive) is simply following the first rule of confrontation: “Know your enemy”.
On a global scale, the various terrorist groups of the Middle East learned a long time ago there was only one thing that democratically elected leaders feared, and that was public opinion. And they quickly learned how to use it. Unencumbered by the usual games and frailties of political correctness, truth, negotiating in good faith, fairness, peace on earth, etc. they simply played to our sympathies and portrayed themselves as the victims, continually using our media and freedom of speech, to sway public opinion in their favor. In their country, the media has been strictly controlled, and only the messages they wished the public to hear were ever heard. They have used public opinion throughout their nations and, indeed the world as a whole, for recruitment of suicide bombers, raising money, preventing aggression from other nations, and even managed to paralyze the United Nations and the European Union (and the Canadian NDP party).
So it would seem the MSNM has it right, those who control public opinion control the most powerful weapon in a free society. With the MSNM wanting so desperately to have control of this weapon, it seems to me, crucial to know, “Are our guys with us or against us”?
Even more importantly, we must recognize that our opinion has tremendous impact on the government that we will have, and the policies that the government will bring in. We must always seek the truth, knowing that many would try to influence us to their way of thinking and their values. When the world was larger, and the MSNM did not have the slogan “It’s not the story, it’s how you tell it”, we could reasonably rely on the news media to relate factual material. Today we must always be aware of the potential spin and the desire to help formulate public opinion, and the power of that public opinion in democracies. I have often been asked on telephone surveys about matters that I know nothing about. Most often I still present an opinion on the matter. Wrong!!! I should simply say that I am not informed enough to have an opinion on the matter. Just consider how uninformed most of us are when we get out of our area of daily function, and still governments tend to develop policy based on the accumulation of that ignorance. I certainly do not endorse media or special interest censorship. Free speech is vital to a free society. But I do endorse the utterance of an informed opinion. Remember, your opinion is part of the larger opinion called “public opinion”, and that has the power to cause great nations to wring their collective hands and do nothing in the face of a threat like 9/11, not to intervene in the genocide in Dafur, or for that matter, decide the fate of the failed nation, Afghanistan. So the next time you are asked for your opinion in a pole or survey, remember, your opinion is going to help shape the policies of the free world, or not; so if you don’t know what you are talking about (which of course doesn’t include any of us), keep your opinion to your self, your family and your best friends. But do not, I repeat, DO NOT, make it part of a “PUBLIC OPINION”.
There, I feel better already.

Appeasement, Short Term Gain for Long Term Pain

2006-09-11T12:28:00.000-07:00

Every once in a while I venture out of my comfort zone of experience (medicine) and wonder into adjacent, but at the same time, distant, areas. Over the last few years, and I suppose, because today is Sept/11th and the fifth anniversary of one of mankind’s greatest acts of inhumanity, the word “appeasement” has come up as a strategy for dealing with terrorism, terrorist groups, and rogue nations. So in my usual obsessive-compulsive way, I began ruminating about the situation, and in my overly simplistic way, I applied my experiences in family medicine to the world stage, and the premise that “appeasement” is the solution and approach, that should be taken to the aggressors in this world (My dictionary defines “appease” as “to make calm or quiet, esp. conciliate (potential aggressor) by making concessions). My first reaction to the discussion point was ‘When does living in harmony with conflicting views, deteriorate to negotiating peace, then to appeasement, then to enabling, then to aiding and abetting, and then to abdicating all the things that we believe in? Is the slippery slope the negotiating? Or even before that---simply talking about our different opinions (many friendships have been destroyed by talking politics and/or religion)? After mulling over these imponderables, I got a headache, and decided I would leave those hefty intellectual exercises to men, er----persons, wiser than I.
Now, back to the topic, my medical practice experience with “appeasement”; could I think of instances in medicine and human behavior, where this was a useful and beneficial approach to aggression?
Of course! The well known and respected “baby soother”. Whenever the baby is unhappy and invades our peace and solitude with piercing screams and cries, stop what you are doing immediately, and plunk that wonderful little nipple facsimile into her/his mouth. What’s the worse that can happen? Sucking a soother at school at age ten when unhappy? Big deal, kids have to learn to be tolerant. Come to think of it, there may be a time when the soother doesn’t work and the infant wants the real thing plus warmth, reassurance, company, visiting, singing, entertainment. So what if it is in the middle of the night and the child is two years old, surely a little appeasement, say a cookie, in response to the discontent this once, er—twice, er---five times won’t do harm? Anyway if this starts to fail, you can always appease them by taking them into your bed with you; that usually is very soothing and comforting to children. Besides, it acts as a fairly good method of birth control. Mind you, when they reach puberty (well, actually even maybe before) you had best find some alternative appeasement method. Child services are suspicious of aging children sleeping with their parents. O.K., maybe the soother wasn’t the best example.
How about a cookie to appease children who scream, cry, yell, turn blue, etc when you are trying to visit. That can’t be so bad. Oatmeal cookies are healthy, and you will only do it when you have company, ----- and I guess when you’re shopping, er, and in a restaurant, and, well, I guess in public. Well, maybe at home too, but only if he does it for more than five, or maybe two minutes when we are at home. And of course, if I want to sleep; but that is actually a negotiated compromise, right? But I’ll be tougher on him when he gets older and he understands more and I can reason with him. I won’t try to appease him then-----unless he threatens to burn down the house, of course. Well, what else could I do? O.K., I guess I could have bought him the car he wanted even though he was only fourteen. So, O.K., maybe the appeasement cookie wasn’t that good an idea.
I know. Appeasement works in situations of marital dysfunction. Say the husband likes to have his meals exactly on time and gets yelling and aggressive if they are ten minutes late, just make sure his meals are always on time, and show him his shiny shoes, he always settles down when you show him his shoes that you shined. And when he starts yelling and shouting, just say “yes sir”. That usually appeases him. Except, of course last time, when he hit you because he thought you were being a smart ass (were you?) Maybe the doctor was right when you saw him about that black eye. The aggression and abuse does seem to be getting worse in spite of your best efforts at appeasement. I guess that wasn’t a very good example.
Of course, here is a good one. My daughter had a very aggressive and hyperactive six month old dog that she needed help with. Being a kind soul, she took the dog to an obedience school that believed in the carrot and not the stick. During the first class the dog was uncontrollable in the new exciting environment and barked continuously. At first the instructor reassured my daughter that under the circumstances (new environment, other dogs, etc.), her dogs behavior was normal. After thirty minutes of ongoing chaos (I think the chewing on people and furniture may have had some impact as well), the instructor gave her dog a “doggy” biscuit. The dog lay down quietly and ate the biscuit. Peace at last! Everyone cheered. A great example of appeasement. Unfortunately, bad behavior returned two minuets later and the remainder of the session was spent feeding the dog various treats. The next session was worse, and, after being satiated with treats in the first twenty minutes, the dog proceeded to destroy the environment around him. The instructor deemed the poor dog as incorrigible, and my daughter and her dog were expelled from the class. Perhaps the instructor was right, the dog is incorrigible (although he behaves perfectly with me in all circumstances), but as I write this blog entry I am starting to have some doubts as to the benefits of the “appeasement” process and philosophy. In fact, I have a suspicion that it may be a process where short term gain leads to long term pain. Perhaps I just need more time to think about it.

Canadian Medicare, Another Failed Utopia

2006-09-10T10:40:00.000-07:00

The thought occurred to me the other day that the reason we hang onto Canada’s “Universal” Medicare system is that it represents the “ideal”; the utopia of health care in a society. As normal biological creatures, we have a strong drive to move to comfort (who wouldn’t want total comfort guaranteed?), and therefore any perceived impediment to that movement is resisted and considered to be counterproductive and an enemy to the public’s best interest. It supposedly follows that to achieve the “ideal”, no regard for conditions, prerequisites, or stipulations are required, and everybody should have all their needs and comforts attended to equally in every respect. The other side of this equation is that, unfortunately, there are thirty million Canadians who all have unique needs and wants, and not having a want fulfilled generates frustration and discontent, and therefore stress; a very unpleasant phenomenon.
The truth is that as a society, and as a people, we have many wants, needs, and often different priorities, and most, if not all of them, are dependant in some way on resources (in the broad sense), and therefore, money. Resources and money on the other hand are directly related to productivity in the broad sense, and in particular, effort; again, one of those things that requires us to be somewhat uncomfortable (note that we know many things we do are harmful to us, but effort is needed to change them and their eventual result).
The point is that our original Medicare System was seen (and is still seen by some) as a health care utopia, and as is the case with all utopias, they eventually self destruct because of the complexity of human nature. Communism and other social structures that were purported to be “ideal”, have demonstrated that as time goes on, more and more regulation and micromanagement is needed to address the dissatisfactions of the people within the “utopia” and maintain its “utopian” perception. The more control imposed, the more people will find control measures objectionable (note the objections to airport security that is designed to safeguard the people using the facility and planes). Dr. Rachlis has stated that it is better to build a fence at the edge of a cliff than a hospital at the bottom of it; but the question again arises as to when your “fence building” creates a corral, a containment that is objectionable in a free society. Addressing the problems of one group to try to achieve perfection creates problems for another group. Soon the supposed “utopian” society pleases no one other than those that cling to its ideological intention. Further, any attempt at change is made impossible by both the forced micromanagement and control, and the fear of loss of the “ideal”. Is it any wonder that the Canadian Health Care System continues on a downward spiral? Handicapped by the utopian ideology, that a system of “one size fits all” is ideal, and can be devised, stagnation and decay sets in.
Perhaps the premise to start with should be that we are all unique and have unique needs and wants and “comfort zones”. The ideal system in Canada then, with its thirty million people, would be a system with at least thirty million health care options (thirty million “tiers”, if you like); each one perfectly designed for each person, with each person determining their own “tier”.. True, this “ideal” can never be met to perfection, but wouldn’t we at least be on the right road? And wouldn’t it be better if each one of us were given the opportunity to at least look at options, and decide where our priorities lie, and how we wished to participate in those options? We have gone a long way down the road in our attempts to give life support to our present “utopian” health care system; but from what I can see, there is no question that both the Canada Health Act and our Canadian Health Care System have passed their “Best-Before-Date”.

Nursing Homes, Part of the "Shell Game"

2006-09-07T11:15:00.000-07:00

The discussion of health care needs, and the “shell” game as to where the needs are being “stashed”, would not be complete without talking about our “long term” bed allocation.
In order to have any understanding of this situation, we must understand that there is a language in the health care administration field that is unique and changes frequently. The term “long term care beds” is equivalent to the old term “nursing home beds”. I note in the Calgary Herald, Sept6/06, that the term “hospital beds”, now includes beds used for “rehabilitation” and “recovery”, which now are likely to be located, and have replaced many “nursing home beds” in long term care facilities. As an example, the “once upon a time” Glenmore Auxiliary Hospital” which was a facility for long term patient care (not truly a hospital, and the beds were not included in the calculations for “acute” care), with an expanded capability for complex long term care, is now primarily used for “rehabilitation” and “recovery” care, and included in the “hospital bed” to population ratios given in the Herald’s article. I note with interest also, that the figure given for acute care beds in 1990/91 is 2.67 beds per 1000 population which likely reflects the “beds in use” at that time. The truth is that our capacity was much higher since at any time, the hospitals had wards with beds that were not in use, but could be opened up should the need arise; quite different from the existing situation. Don’t you just love statistics and the administrator’s ability to pick and choose their presentations?
To get back to long term care beds, the province had a moratorium on the building of long term “bed building” back in the 1980’s and early nineties. Although mostly privately built and privately owned, the government picks up most of the cost of long term care and therefore decides when beds are needed and when they are not. Like other government activities, they used “guidelines”, and the guideline they had decided on was, I believe, 50 long term care beds (including “lodges”) per 1000 population over the age of 65 years (At one time we were at 57 beds/1000 seniors in Calgary, thus the moratorium). Don’t ask me how they came up with the “ideal”. In any event, with the moratorium, and the push to decrease cost in our hospitals, it soon became obvious to the administrators in the region that money could be saved by transferring people from hospitals to nursing homes (and as mentioned in previous blogs, to the community as a whole). With this, a new administrative animal was born: “The Placement Assessment and Coordinator”. With this, neither the patient, or the family doctor, had any say in where the patient was “placed” for care. The “placement coordinator” decided the patients “needs” and the most appropriate location of their care. As a result, patients were often placed miles from where their loved ones lived and their family doctor of many years practiced. This resulted in many family doctors discontinuing the care of many of their long term patients, and indeed, many of them giving up nursing home care and hospital care entirely. Of equal concern, as a consequence of this downloading policy, units (consisting of many beds) in the “long term care category facility” became specialized areas of care “used” by the hospitals to “dump” patients. I use the words “used” and “dumped” because although these beds were designated beds for: recovery, transition, rehabilitation, and palliative care, little was done to upgrade the facility and augment the personnel to accommodate that increased patient care NEED. Further, little was done to monitor or measure the changing mandate of care and whether it was being addressed adequately or appropriately. Little wonder advocates for the seniors in these institutions are concerned, and news headlines are beginning to appear pertaining to the care of our elders in long term care facilities.
Where we are today in the old ratio of long term beds per 1000 seniors population, the Lord only knows. The moratorium ended some years ago, and since then some beautiful nursing homes have been built, Sadly, most are grossly understaffed for the care expected, and most are sadly lacking in access to investigative management. Where at one time, lodges provided assistance (at reasonable cost) to elderly patients who required health care assistance, (but did not require nursing home care), expensive assisted living accommodation has come on the scene and is a fast growing industry, the cost of which is fully borne by the patient. Whether the beaurocrats admit it or not, health care has, and is changing rapidly, and the chronically ill, the poor, and the frail elderly are bearing the major burden from a cost and care perspective (the very group our system is to protect). We seem to be shocked almost daily by situations arising in our hospitals and emergency departments, an area of visibility. We certainly can keep score of the casualties in the conflict in Afghanistan. Too bad no one can see what is happening in our own communities and the various “invisible” community facilities, and the casualties that are occurring there!

The "Shell" Game, Dumping Health-care Needs Into The Community

2006-09-05T13:08:00.000-07:00

Recently Dave Rutherford had the CEO of the Capital health Region (Edmonton) explaining what a good job the various Health Regions in Alberta were doing, and I suppose indirectly, justifying the salaries administrative types make. Calgary Health Region’s senior vice president of people and learning (don’t ask me what that means), Margaret Munsch, said in Thursday’s Herald that “The compensation reflects their accomplishments as individuals”. So let us take a look at the accomplishments of administrative types at all levels of health care in this province (especially Calgary).
1) Wait times in our emergency departments have grown drastically. Ten years ago we were upset at waiting times of one and one-half hours. Today wait times exceed four hours.
2) There have been longer waiting times for various surgical procedures such as joint replacements.
3) There has been an increase in waiting times for specialty consultations.
4) There has been an increase in waiting times for diagnostic investigative procedures. There has been an increasing delay in many cancer treatments.
5) There has been a decrease in family doctors (and specialists) doing obstetrics.
6) There is a drastic decrease in family doctors with hospital admitting privileges.
7) There has been an increasing proportion of the government’s budget going to health care during this same time (out of proportion to inflation and population growth).
8) There is a drastic shortage of family community doctors (now in Calgary alone estimated between 200 to 300 doctors).
9) And there has been a very impressive increase in the salaries of administrators!
But our administrative friend from the Capital Health Region states that innovative ways of providing medicine has occurred.
1) Hospital stays per procedure or per disease treated are decreasing.
2) More people can be treated as out patients.
3) The cost of hospital care as related to the total health care cost in the Regions is going down (didn’t mention that the cost of community care is skyrocketing, which is of course the other side of the cost equation).
And the above three statements are absolutely true; but what isn’t being said is:
1) By downloading patient care from hospitals to the community, we have conscripted the loved ones of the ill as care givers, and their beds as treatment beds. This is cost effective because instead of $1000.oo a day for a hospital bed, the family takes on the care of the patient with minimal support from the system, eg. palliative care and home care nurses drop by periodically and the region will kick in up to $3000.oo a month to beef up care for palliative care patients (a savings of 27,000 dollars per month per patient).
2) Home treatment programs aren’t assessed as to patient and family impact (someone taking their holiday time to care for a sick family member, someone quitting their job to care for a dying family member, the stress and exhaustion of family members staying up day and night to care for their dying loved one, etc.). I’m not saying that care in the community is not necessarily appropriate. I’m saying that it is not adequately compensated, and the system is taking advantage of the loved ones and the community care-givers!
3) Early discharge is not being critically assessed as to patient and family impact.
The problem is that by downloading health care NEEDS into the community, no tools are being used to measure the impact of the innovative “cost effective” practices that we herald as advances. In hospitals we are able to look at waiting times in the emergency departments, hospitals putting patients in hallways, surgical wait times, etc. In other words tracking and visibility is easy and unavoidable. Ten years ago I strongly recommended using “known “tools” for tracking health care needs in the community on an annual basis, to see the impact of the changes being brought about in the Calgary Region (this was being done by some of the consumer groups in the U.S. to monitor the activities of HMOs in the U.S) To my knowledge this still is not being done by the Calgary Region (What independent consumer groups in Canada and Alberta are tracking health care provision here?). In effect what we have here is a “shell” game ----- “Bet you can’t find where the sick people are?”
The process is simple and is comprised of a questionnaire sent out to a random, statistically significant number of people in the Region. The questions would be as follows: IN THE LAST YEAR
1) Have you been ill?
2) Did you see a doctor?
3) How long did you have to wait?
4) Were you investigated?
5) How long did you have to wait? a) in the Laboratory b) for a diagnosis, c) X-ray, Ct scan, MRI, specialist.
6) How would you rate your experience?
7) How much time from work did you miss?
8) How much time was needed from other members in your family (or friends) to attend you or assist you?
9) Are you still having problems?
10) Have you had pain?
11) How would you rate your pain (from 1 to 10 with one being little pain and 10 being the worst pain you can imagine).
12) How long did you have pain for?
13) Do you have a family doctor?
14) How far do you have to book ahead for a complete check-up?

You get the idea? There are standardized “tools” (much better than my effort above) that have been used for years and reflect the community “burden” of health care needs similar to emergency wait times, surgical wait times, etc. To my knowledge this is still not being aggressively pursued. Think about it; health care needs are being put into the community where no-one can see the impact------except of course, those poor unfortunates that happen to become ill (and their families), and are deemed to “not need a hospital bed”.
Don’t get me wrong, many cases are more appropriately treated in the community. But in the face of an increasing shortage of family physicians, an increasing population, an increasing percentage of seniors, and increasing health care costs (which, it seems, providers and provinces are all trying to contain), wouldn’t it be nice to know how we are coping in the community with the most vulnerable in out society. In this case, what you don’t know may in fact “hurt” you! Available acute care beds in Calgary have dropped from 3.3/per 10000 people to 1.8/per1000 people. The health care needs of the people of Calgary have actually been increasing per 1000 population with increasing age, obesity, diabetes, etc. The people that once were treated in hospitals are now treated in their community. Do the highly paid administrators know how well the chronically ill, poor, and frail elderly are doing in the community? Does anyone besides the sick patients and their families know how well they are coping? After all, the Health Regions and
their administrators, are responsible for all health care provision in their regions, directly or indirectly, not just the care and budgets and care in the hospitals. And from what we can see from a community health care and access perspective, most of us wouldn’t consider it worthy of the increases given.

Public and Private Medical Systems Can Be Synergistic

2006-08-30T08:07:00.000-07:00

Now we get into the fun part!!! Today we will discuss: B) Areas of health care change and innovation that may well contravene the Canada Health Act. These are the areas that probably never get explored in the MSNM because very vocal lobby groups raise the negative side of the equation to public awareness, but little discussion occurs as to the positives.
1) Doctors being able to work in both the public and private systems. Probably the public doesn’t know that in some provinces there is a “cap” put on doctor’s earnings. This means that effectively some doctors (even family doctors) who work hard are penalized for their productivity; the more patients they see, the less they get paid for their additional work. This is a definite disincentive to work to capacity. If they were allowed to spend additional time in a parallel private system, they would be fairly remunerated for there additional work, and more community needs would be addressed. The more patient needs that are addressed in the community, the fewer patients show up in the emergency departments for treatment.
2) Surgical waiting lists comprise an “at risk” group of patients, and at risk patients are more likely to end up in the emergency department. This is true of cancer patients waiting for investigation and/or treatment, joint replacement patients who are more prone to falls, etc, or patients waiting for coronary by-pass surgery. Many presently practicing surgeons in Calgary have limited operating room time, and many surgeons who possibly would come to the Calgary region do not do so because of lack of operating room time. Allowing surgeons to work in both a private and public system would make full use of the existing highly trained physicians, would entice surgeons to come to this area despite restricted access to public funded operating rooms, would shorten wait times, and by doing so, reduce visits to the emergency departments by these high risk patients.
3) Allow insurance for “covered” investigative procedures and treatments (in a private parallel system).
a) People waiting for investigations such as C.T. scans, MRI’s, and other investigative procedures, are usually getting these procedures done for medical reasons. They comprise a community group of patients at risk, who are more likely to attend the emergency departments of our hospitals than the average patient who does not have medical concerns. The faster these patients are dealt with and their medical issues addressed, the less likely they will frequent the emergency departments.
b) As in “(#2), access of treatment, through insurance, takes patients off treatment lists in the public system, and by shortening the “wait” times, reduces emergency department visits.
4) Allowing a private, parallel, health care system.
a) This could entice thousands of doctors and other health care providers who have left Canada over the years, back to Canada. More care providers in the community will decrease the need to visit the emergency departments.
b) Insurance for various “services” of health care, that are in short supply at present, will be taken up by the people who can afford to do so. This will take these patients off of the wait lists in the public system with benefits to both the private and public patients. Further, the care of the insured patients will not be coming from the tax-payer funded public system. As the waiting lists shorten in the public system in various areas of service, the patients will decide whether they wish to carry insurance for a particular service. As an example, if waiting times for joint replacements are two years, I would probably take out private insurance coverage. If the wait times for joint replacements are six months, I likely would not take out private insurance coverage. At all times this system will give options to the average Canadian (right now only the very wealthy have options), and at the same time have an ongoing effect on shortening the waiting times for many procedures in the public system. Keep in mind, the public system will still be there as it is today, with appropriate emergent and urgent care (and should be more accessible).
c) Privately owned and operated facilities could be established in this environment, but the finances for these operations are completely paid for by the insurance carriers. If, on the other hand, it is expedient (by virtue of cost benefit or demand) for the public system to “farm out” certain procedures, the private system acts as a resource and a possible safety valve at times of critical demand (disasters, epidemics, etc). On the other hand, the public system may be able to compete very effectively in providing certain privately insured patient’s services. This could be a financial benefit to the public (tax payer funded) system. After all, the proponents of the public system continually state that they provide services more cost effectively than private systems.
5) An interesting thought is for the government to actually be one of the insuring companies. They already have a premium system in place. People could either take out separate policies with them that would give them access to private facilities or simply “beef up” the existing universal health care system in such a way that it complements their individual needs. I personally don’t need abortion coverage, but I would like better “portability” coverage.
All in all, significant and major changes are necessary in our health care system (we are running out of band aids). In spite of ever increasing proportional cost to our governments disposable, tax payer funded budgets; huge new money is needed within the system. We need to make a decision; do we increase government’s taxation significantly, or do we devise a system where, in return for slightly better access to elective and non-urgent care, those that can afford it will take some of the pressure off the system. I personally, always opt for systems that provide personal options, consumer input and control. And I see no reason why the public and private systems can’t work synergistically.

A Prescription For Decreasing Emergency Department Demand.

2006-08-29T14:39:00.000-07:00

I think it needs to be stated at the beginning that there will always be some public discontent with health care systems, just as there is always some discontent with life itself. As I’ve stated before, all normal creatures move to and desire survival and comfort, so just determining the parameters of Health care”, yet alone society’s obligations to its citizens (as opposed to personal responsibilities) in this area, presents enormous controversy. The purpose of today’s blog entry is to show that no matter where you stand on most health care issues, improvements can and should be made to the present system. I will discuss solutions that fall within the Canada Health Act and solutions that fall outside of the Canada Health Act.
A) Solutions within the Canada Health Act.
1) Graduating more medical, nursing, and technical practitioners. This is a given; however, unless we retain these practitioners, the money invested in them has been wasted (Retention of practitioners is a topic in itself and will be addressed separately. Basically it involves giving more autonomy, independence and control over a myriad of working conditions, to workers in the health care field). This solution lends itself to “long term” approaches since training time for various professionals in the health care field varies from four to fourteen years.
2) Fast tracking the qualifying foreign graduates is given as a solution but is far more complex than the general public perceives. Matters of language, training, attitudes, beliefs, social customs, and many other factors come into play. Doesn’t it make more sense to try to recruit back the thousand of Canadian graduates that have sought employment in other countries? To do that we have to look at the reasons they left, and address those issues. Providing a more “comfortable” work environment for health care providers in Canada could start a significant and immediate return to Canada of many of them.
3) Put incentives into the system that encourages doctors and other health care providers to look after sick people outside of the hospital and emergency department settings. At present there are only negative incentives in the community for caring for the chronically ill, acutely ill, complexly ill, and frail elderly. At present a community physician, by limiting their practice to trivial episodic care, can generate 200 to 300% more income than a practitioner doing complex ongoing care. My suggestion would be that for the next five years all fee increases be applied to increasing the fees for complex care. If the fee for seeing a diabetic seventy five year old with pneumonia was five times more than seeing a twenty year old with a sore throat, we would see a renewed interest in the care of the sick and elderly. When I retired one of my elderly patients with Parkinson’s disease was interviewed by several family practitioners as a prospective patient and rejected on the basis that” the practitioner was not THAT knowledgeable about Parkinson’s Disease”. I would suggest to you that most “interviewing” done today to see if there is a “patient/physician fit” is primarily done to see how time consuming a patient may be, and whether taking them on as a patient would be cost effective. Perhaps if the complex/ill patient visit paid five times what a “routine” visit paid, there would be competition for the seriously ill patients by the community physicians. As a consequence these patients would show up in the emergency department less frequently because a physician actually seeks, assumes, and takes responsibility for their care in the community! The same principle should apply to the medical care in extended care facilities in the community and to hospital care.
4) Use and payment of “physician extenders”.
At present, if a group of physicians hire a physician extender, nurse practitioner, etc, there is no payment system in place to recapture that provider’s salary. Years ago, dentists found that adding an hygienist to the office practice was both cost effective and a benefit to their patients. A registering system for qualified physician extenders/nurse practitioners should be set up and a payment system for their services undertaken. This payment system could be part of the “Medicare” System, private, or a combination of both. This addition to an office setting would enable physicians to direct their TIME to the more seriously ill, as well as increasing their capabilities in dealing with the more seriously ill. The end result will be better access to care in the community, better use of the physician’s skill and training, and fewer visits to the emergency departments.
5) Fast tracking of community patients who are of considerable concern to their community family physicians. This basically means that community physicians who take on the care of patients who are seriously ill, and/or have special needs, must have better access to resources. For example, as long as the emergency department physician can get an MRI the same day and the community physician can’t get an MRI for the same patient for two months, patients of concern will be downloaded to the emergency departments. As long as emergency physicians can refer directly to cast clinics and community physicians can’t, telephone triaging of traumatic injuries directly to emergency departments will occur, and these people will not be seen or cared for in the community by community doctor’s offices.
6) Having physicians do the triaging in the emergency departments, and fast tracking those patients that have the greatest medical needs.
Physicians are trained to diagnose illnesses and know the consequences of the various diagnoses. Priority must be given in the public system to those individuals in an emergency department that may come to harm. Those that will not come to harm will have to wait or be seen in the community. Some of our emergency departments have accepted and implemented the U.S. Hospital System of fast tracking minor conditions. This is wrong on several fronts. In the American system, hospitals MAKE money from seeing minor conditions in the emergency departments. In our Canadian system, it takes from the hospital budget and takes the time of personnel that should be attending to the more critically ill. Today, only a small percentage of patients use the emergency departments for trivial complaints. If we shorten the waiting times for trivial complaint, more and more people will use the emergency departments inappropriately.
7) We must develop more capacity in community facilities (both physical and care-giver), to deal with patients that do not need the acute multidisciplinary approach of a full general hospital. This entails transitional care facilities (patients simply slow to get well enough to return home), rehabilitation facilities, palliative care facilities, etc. This has been done to some degree, but has been marginalized and not supported sufficiently with appropriate diagnostic and financial care-giver support. This type of a program is both medically sound (if done properly), and cost effective. It is imperative, however, that the care givers in these settings are given the tools, autonomy, and financial rewards for their complete buy-in. The Calgary region has attempted to implement some of these ideas, but since there has not been financial and medical back-up for them, most care givers view these attempts as “dumping” into the community. As such, there is continued resistance on the part of community doctors. If this were to be done properly, with the appropriate incentives, many acute treatment hospital beds could be freed up for emergency department admissions, and patients could be triaged directly to these community physician/facilities, by the emergency physician.
The above suggestions are only a few that I think would improve the provision of health care in Canada within the terms of the Canada Health Act. Most of these suggestions are based on the premise that if we pay people for what they do, we will get a better return for our taxpayer dollar. The present system IS NOT a fee-for-service system; it is a fee for visit system. As such practitioners are rewarded financially for taking the least time and the least responsibility for a “visit”, and penalized financially, time wise, stress wise, and from a medico-legal perspective, for looking after complex and significant health problems in the community. In most areas of our society, people get paid for what they do; whatever and whoever decided medical caregivers can and should be treated differently?
Since this dissertation has gone on long enough, I will make suggestions that may well fall outside of the Canada Health Act on my tomorrow’s blog. Any comments or questions are welcome!

Innovation/Cost Effectiveness Equals Emergency Room Crises.

2006-08-27T12:31:00.000-07:00

I suppose it will be interesting to see where the Health Quality Council of Alberta goes with their assessment of Calgary’s emergency departments; but I’m not optimistic that anything good will come of it. To really look at emergency services in Calgary, one has to understand that emergency services are only one part of a continuum of health services (although one of the more visible parts), that ranges from the care of relatively healthy people in the community, aged and chronically ill, people with assisted living and aids to daily living in their homes, institutionalized people with assisted living, transitional care, rehabilitation care, long term care, and palliative care, in combination with community health care providers (family doctors, home care, E.M.S, palliative care providers, etc), to the care of people in the intensive care units of our Acute treatment hospitals. The demands on the emergency departments of our hospitals, to a great extent, reflect our failures in the community as a whole, and in the care and discharge processes of our hospitals. In short, the innovation and striving for cost effectiveness that has taken place over the last fifteen years. Do we really think that a government appointed body is going to point a finger at “innovation” or cost effectiveness? Now I’m not saying that all that has happened is wrong; I’m just saying it was predictable and could be expected.
Let’s start with the healthy people in our society. They impact our emergency departments because of accidents, acute illnesses, anxieties, etc. The truth is that this group is actually decreasing its demand on emergency services. As we put in helmet laws, seatbelt laws, and safety standards in the work place, as a group, the healthy people in our society are taking a smaller toll of our emergency resources. Contrary to popular opinion, only a small fraction of the visits to emergency departments these day are from people who are there inappropriately. So far, so good!
But lets take a look at where innovation and cost effectiveness has taken us in the care of the aged, chronically ill, and others needing more ongoing interventions.
1) To be more cost effective, smaller community laboratories and x-ray (diagnostic imaging) facilities were shut down and centralized. In itself, no big deal for the healthy and mobile, but a huge factor for both the community physician and the aged/chronically ill patient. Rather than inconvenience a patient with pneumonia by trying to assess their risk in the community, it was expedient for the community physician to simply send them to emergency departments.
2) Stratification of patient care became the champion of cost effectiveness for those that needed on going care. The community physician no longer determined the level of care for the patient. A placement assessor and coordinator determined where a patient would get the most care (often rightfully most appropriately) for the health care buck. Each patient was given the maximum care with the minimum cost (services). This is good and well, but since the aged and chronically ill are a quickly changing group with regards to their needs, and since the facilities where they were placed did not have the capacity to assess their needs, little change was required to warrant a trip to the emergency (this of course was aggravated by lack of diagnostic community resources, see #1).
3) Early discharge from hospitals to communities with decreased resources in the communities precipitated the revolving door syndrome----- the patient was discharged in the A.M. and because of a multitude of factors (communication, follow-up, community resources, lack of community physicians, etc), the patient would be in the emergency department the next day.
4) Stagnant fees for family doctors, lack of visible appreciation for those that put out extra effort (charged parking for seeing their patients in hospital), did continuing care, nursing home care ,etc., forced family doctors to look at their practices in a cost effective way. This resulted in many dropping hospital privileges, nursing home privileges, restricting geriatric care and any other care that was time consuming. Many took on walk-in clinic care that gave more control over their lives, but did less to address ongoing or complex care issues. I tried for years to encourage the family doctor’s fees committee to build in incentives for doctors to take on more complex care, to no avail. At present, seeing a diabetic patient with heart and renal failure and pneumonia pays the same as seeing a healthy twenty year old with a sore throat. In Alberta, we get less that $2.00 more for seeing someone over the age of 75 years. So if we see someone in the office who is aged and ill, and will require time to assess properly, the reasonable thing to do for the physician, from a cost effective perspective and a malpractice perspective, is to send them to the emergency department (and considering all aspect of access to community resources, probably best for the patient as well).
5) Centralizing services for patients such as cast clinics at hospitals. For years many community physicians looked after a wide range of patients with fractures. With limited access to community diagnostic imaging, doing these things in my office became impractical. When I attempted to refer to the cast clinic I was told to send the patient to the emergency department (where the physician simply looked at the X-ray that was done and sent the patient to the cast clinic). With such a system in place, why would I even see injuries in my office, yet alone inconvenience the patient by sending them for an X-ray, having them bring the X-ray to me, and then sending them to the emergency department (where they have X-ray capabilities). If a patient phones the office with what sounds like a significant injury just triage them directly to the emergency department.
6) As emergency departments became busier, they soon realized that many of their visitors fell into the “revolving door category” due to inadequate placement, follow up, community resource access, etc. Soon emergency departments were given priority and resources to deal with home care, palliative care, mental health, placement issues, social service, and numerous resources that as community physicians we had difficulties accessing, but realized would be a benefit to out patients. Subsequently, when these patient needs presented in out offices, the best way to access these resources and benefit our patients was to send them to the emergency departments.
7) Lastly, and very importantly, patients cannot stay in the emergency departments for extended periods of time. This is due to lack of physical capacity and manpower capacity (once you are admitted to the emergency department a physician must be responsible). This means that at some point you must either go back to the community (and/or its institutions) or be admitted to hospital. Admitting to a hospital bed is dependant on two factors: a) availability of a bed, and b) availability of a physician who will agree to take on your care. Since we now have 1.6 acute treatment beds per 1000 population compared to 3.3 acute treatment beds per 1000 population fifteen years ago, and since most family physicians have discontinued hospital practice, the emergency holding beds frequently are taken up by patients requiring admission.
The above are but a few of the factors affecting our emergency departments, but constitute a significant impact. In short, there is a huge increase in acuity of illness and need for intervention in Calgary’s communities as a whole, and an abysmal lack of community resources. I find that, for the most part, community physicians feel they have been abandoned in our health care system, and are in survival mode. Since the emergency departments of our hospitals simply reflect the acute care needs of the community, it will be interesting to see what the Health Quality Council of Alberta will come up with, but as I said earlier, I’m not optimistic.

Emergency Department Services in Calgary.

2006-08-26T15:20:00.000-07:00

So the Board of the Calgary Health Region is bringing in the Health Quality Council of Alberta to examine, assess, consult, mull over, deliberate, and generally pontificate, over Calgary’s Emergency Department problems. Great; a government appointed Board is asking another government group to look at (aka rubber stamp) what is being done at present and make the usual recommendations to solve (see Jim Dinning’s suggestions: innovate, explore, more of the same) our emergency health care crunch. Sounds like a make work project to me!
Keep in mind that it wasn’t that many years ago that a costly and quite extensive consultation process took place to look at the health care provision in the Calgary Region. Come to think of it, this may have occurred shortly after Jim Dinning and Jack Davis were sent from Edmonton to get things in order down here. The word on the street at the time was that Calgary didn’t have a health care provider problem; there was simply an erroneous “perception” that there was a problem. Well, during Mr. Dinning’s two and one-half years as the Calgary Board’s Chairman, costs escalated, as did waiting times in all areas. I suspect even at that time Mr. Dinning realized that the present monopolistic public system was unsustainable. Could this be why he left the post after only two and one-half years (before the present crunch) with nothing gained functionally? On the other hand, as an ambitious politician, he could leave early and still, using the universal health care mantra as the universal “get elected” tool, present himself as the savior of our universal public health care system.
At the same time, as the government (through the Calgary Regional Board), is dishing out more money to get another government body to give an opinion on ongoing and long-time problems, we find out there has been a million dollars spent on ads, booklet design, consultations, etc, on what they had previously termed the “third way”. Now the opposition parties call this propaganda, and squashed that process through the help of the MSNM and Medicare lobby groups. Personally, if some of my tax money went to putting this together, I would like to see it. One of the strident cries of the advocates of Medicare, against the “third way”, was that no one knew what it entailed. So let’s have a look at it. Seems to be a bit of indirect censorship going on; on one hand they are saying no-one knows what the government is talking about regarding the “third way”, and on the other hand they say the public shouldn’t see what was put together and the money was wasted. Maybe, just maybe, there is and was some information in that million dollar expenditure that is credible.
The facts are simple: in spite of annual funding to the Calgary Region from the government (since the beginning of Mr. Dinning tenure as Chairman), surpassing the annual combined inflation rate and population growth, there has been an increase in waiting (risk) in both our emergency departments, access to procedures, hospital beds, and diagnostic tools. In spite of this and an ever increase in government’s budget going to health care, the policy makers, opposition parties, and “would be” premiers, refuse to even discuss alternatives. One of the truly stupid comments that I have heard regarding the non-sustainability issue is “More money isn’t the answer”. Of course it is! If money didn’t provide better access to health care, why all the paranoia about the wealthy getting better access if there were a private system? Why do many high profile people get opinions and service south of the border and from private sources in other provinces?
A common comment made now in Alberta is: “With all our surpluses, why isn’t the Alberta Government putting more money into Health Care? Here are some of the answers:
1) At present there is a shortage of doctors, nurses, technicians, etc. Alberta could probably afford to give them all a fifty percent raise. I guarantee this would do several things. a) Bring in a good supply of these people from other provinces, b) Create a worse shortage of these people in other provinces, c) Create significant hostility in the people and administrations of nine Canadian provinces, and d) bring about federal taxation policies that would take away Alberta’s ability to lure workers from other provinces. This can be already seen to some degree with our “bribing” of construction and oil field related workers from B.C. and Ontario.
2) If workers in the health care field were to get a fifty percent increase in their income, what do you suppose workers in education and other public services would want? Suddenly there would be a huge inflationary effect on salaries throughout Alberta.
3) Keeping in mind the above scenario, what would happen, if, in the aftermath of this, Alberta’s revenues from non renewable resources were to drop or a change in federal taxation evened the playing field between provinces? I doubt very much we would be happy with a deficit budget or a fifty percent decrease in salaries.
Realistically, Alberta has to use its resources revenues in such a way as to not significantly disadvantage Canada’s other nine provinces. We could though, do some health care provision that is costly (may mean we don’t get federal funding), but truly innovative. With careful monitoring of process, outcomes and cost effectiveness, we may be able to show the way to true health care reform that would benefit all Canadians.

AIDS Conference, A Missed Opportunity

2006-08-18T17:05:00.000-07:00

Is there nothing in today’s world that is not a political opportunity? Forty million people in the world today are infected with the AIDS virus and sentenced to declining health, suffering, and eventually, an early death. This is indeed, a humanitarian disaster. One would think that a conference supposedly designed to rally all of mankind to eradicate this disease would bring thoughtfulness, intelligence, compassion, science, innovation, and in general, all those things that pull people together in the face of this ever increasing threat. But no, the major coverage in the MSM pertains to whether Our Prime Minister attended or not.

I suppose it is inevitable. Politics is about power, control, and influence; doing what is right places a distant fourth. Internationally, some highly placed people couldn’t resist a jab at our Prime Minister, and refused to come because he wouldn’t be there to welcome them. Certain movie stars had to have their two-bits worth of say, a past president of the U.S. had to take advantage of the “photo op.”, and Mr. Gates appeared as a major philanthropist. I would have thought the person most deserving to be on the international stage would have been Mr. Gates. If a half billion dollars for the cause doesn’t give you some air time, what does (although I understand the crowd was more appreciative of his money than his advice)? Our Federal Opposition Parties saw Harper’s absence as an opportunity to better their lot, and the MSM, still smoldering over their loss of control over the Prime Ministers Office, joined in frequently with similar criticisms. I heard little during the days of the conference of any worthwhile scientific medical information.

From my perspective, Canada’s Health Minister, Mr. Clements, and Canada’s International Co-operation Minister, Josee Verne, were Canada’s appropriate representative attendees. From a political correctness perspective, Harper could have attended, but haven’t Canadians had enough of politicians doing the “photo-op” thing. Had Harper gone, I imagine the spin from the MSNM and the opposition would have been “usurping minister’s jurisdictions, micromanagement, etc.

The only good medical information that I was able to glean from the News media took place during an interview before the conference began. Two well respected scientists spoke of AIDS, its impact world wide, the various approaches to treatment, and the future hope for a cure. Some of the information that they presented wasn’t new to me as a physician:

A significant rise in AIDS in Canada is being seen in heterosexual women (no mention was made that primarily this is due to bisexual and other unfaithful partners).
Drug usage is the main means of transmission in Canada and the U.S.
Sexual activity is the most common means of transmission in Africa and most other countries.
Aggressive treatment can lower contagiousness and spread.
The resurgence of tuberculosis is largely related to AIDS, and the development of resistant strains of T.B. likely related to the difficulties in treating people who are immuno-compromised with multiple antibiotics.

What I found interesting, from a medical perspective, was that of the 40,000,000 people in the world with HIV infection, only 10,000,000, or ¼ are under treatment. The experts being interviewed felt dramatic progress could be made if all were under treatment, since this would decrease contagiousness. Further, progress in immunization offers hope for the future.

Unfortunately, I am not nearly as optimistic as the specialists being interviewed. HIV infection, like cardiovascular disease, is inherently bound to human nature and human activities. When Mr. Gates tried to address some of these issues at the conference, he apparently was booed. If all the appropriate medications were available to all the people in the world today who have HIV, and there was immunization that was 100% effective to all the others, we would still have an AIDS problem. After all, in Canada today, we have antihypertensive medication that is effective in 99.9% of the hypertensives, but only ¼ of hypertensives are treated to target, with the result that many, many Canadians die an early death from strokes and heart attacks. They may not show the wasting, skin lesions, etc. that AIDS patients do, but dead is dead! We have the best food in the world available to us, but we eat junk food! We know how, and have the means to treat most cardiovascular risk factors, but only 20% of Canadians get adequate exercise, only twenty five percent of those who need their cholesterol problems addressed, do so, and there is actually an increase in teen-age girls smoking. As I’ve stated many times before, the scientific knowledge and capability is extremely important, but cannot achieve the desired benefits unless there is good fidelity (system of application) of that knowledge and a buy-in by the population. But how close are we to addressing this issue when even referring to root causes (the human behavior element) provokes booing?