Iron Deficiency in the Elderly, the Silent Killer

    Once more our laxidasical healthcare system has struck my family. My favorite aunt, well into her 80's but living independently with her husband and enjoying life, suddenly goes into congestive heart failure. With encouragement from me, she agrees to go to the emergency, gets the urgent intervention to reverse the failure, and is referred to a cardiologist. Keep in mind she had just been to a cardiologist six weeks before and was told everything was fine----but that is another story.
     During her stay in the emergency it was found that her blood was down several pints and she was given blood transfusions and arangements made to see both a gastroenterologist and a cardiologist. Six weeks later her cardiologist proclaimed her congestive heart was doing well once again and a colonoscopy by the gastroenterologist showed no cause for blood loss from her colon-----and here is where I get confused!!! -----a gastroscopy was not arranged. Now even fourth year medical students know that when considering iron deficiency anemia in the elderly, malignancy of the gastrointestinal tract should be high on our differencial diagnosis with the colon being the number one culprit and the stomach the number two culprit. So when the number one culprit is ruled out as a cause for this ladies iron defiency anemia, would not the stomach move up from the number two slot to the number one slot as the site for pathology?
      This particular gastroenterol;ogist, instead of proceding with a gastric endoscopy (having a look in the stomach) refers this patient to a hematologist (blood specialist). This specialist confirms that the patient has an iron deficiency anemia and instead of referring her back for the much needed gastroscopy (which I had encouraged the patient to press her doctors to do on several occassions), puts the patient on iron tablets to build up her blood and states that if her blood improves a gastroscopy can be delayed.
      Now consider this: My primary responsibility as a physician when a patient presents to me is to ask myself "Could this patient have something going on, which, if I don't intervene, could cause them their life or serious harm?" If I am sure the answer is NO then my job is simple--- address the symptomatic concerns of the patient in the least invasive and safest way. However, in this case:
1) Onset of heart failure because of new onset iron deficiency anemia
2) Stools for occult blood positive indicates probable Gastrointestinal loss of blood
3) Colon and stomach comprising at least 90% of gastrointestinal cancers in this age group and Gastointestinal cancer high in causes of GI blood loss in this age group.
4) A very positive family history of cancer
5) A negative colonoscopy.
    Now, is there anyone out there, medical or non medical, that thinks this patient is not at risk for a diagnosis of stomach cancer?
     Needless to say, eight months later, this patient sees her family doctor because of abdominal pain and he can feel an abdominal mass. Gastroscopy reveals a large stomach cancer that is partially obstructing the stomach and requires surgery. At this point the surgery is considered to be palliative, not curative. But could it have been curative ten months ago?
     Some of you may say "No one is infallible". But consider how many physicians were involved and had knowlege of this patient and her circumstances; her family doctor, the cardiologist, the gastroenterologist, and the hemotologist. This is not a case of one physician having a temperary lapse of common sense and medical accumen, it would seem to me to be more an endemic attitude of medical indifference to the elderly in our healthcare system. Could this patient and love ones seak retribution though the courts? Probably. Does it do my special aunt any good at this time----absolutely not. Will it change the direction of our monopolistic healthcare system in Canada to take this to our courts? Absolutely not. The unfortune fact is that death is cost effective and there is a pervasive attitude within our society (and yes, within the medical community itself) that rationing of healthcare in Canada is an acceptablr way of dealing with its unsustainability. And the rationing is most logical in the high consumer end----our elderly.
    

Obama-care

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

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

Where have all the family doctors gone

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

Health Minister Ron Liebert Stumbles on Healthcare

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

An Obama They Are Not

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

Quebec, Our Healthcare Saviour

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