Wednesday, September 5, 2018

First days of medical school

With getting older comes all sorts of anniversaries.  I started medical school 40 years ago today.

There were the prelims of course, getting the letter of acceptance sometime in June, writing back to accept their offer and I believe there was a deposit cheque involved.  There was also a trip over to Vancouver to pick up the microscope they said we had to buy.  I quit my summer job a week early much to my father's distress; everybody except him thought I needed a little time before starting medical school.

Starting was simpler than for some.  I had been at UBC for 3 years of undergrad already; I only applied to one school and planned to be either starting medical school or finishing off my degree.  I had a room in the student residences.  My friends had got a house off campus; I preferred to have the familiarity of residence and the ability to roll out of bed and walk to my classes instead of dealing with traffic or buses.

My recollection is I went over by bus and ferry on labour day.  At UBC the week after labour day was registration week, a week of drunken debauchery before classes started the following week.  No registration week for the medical school.  Classes started the day after labour day.

So it was on September 5, 1978 that I found myself in a lecture theatre in the Woodward Building sitting in my usual seat at the back, looking around wondering if I knew anybody in my class.  As people filed in, I recognized a few faces from lectures and labs and even somebody I didn't know all that well but had gotten drunk with a couple of times.  I had a negative opinion of what I thought would be my future classmates.  I expected a serious, hard working, cut-throat group of people.  I expected the next 4 years to be a busy, hard and socially very boring time.  (The summer before I started I was introduced to a visiting fiance of a co-worker as a medical student.  "Oh," she said, "I know a few medical students....I don't like any of them."  Great, I thought I've known you for a minute and you've already insulted me.)

Negative thoughts notwithstanding it was an exciting time, the culmination of three years of undergraduate always with a goal of getting into medical school.  We were welcomed by the Dean who informed us that we were the chosen people and welcomed us to the great fraternity of medicine.  We were then registered, and photographed.  I am not sure whether we had further classes that day.  There was a trip to the bookstore to pick up all the texts they said we needed, including the anatomy trilogy written by our Professor of Anaesthesia.  I also bought an ugly short white lab coat.

I went to the Pit (the student bar at UBC) that night and ran into my old friends and got little drunk which meant starting my first anatomy lab the following day with a bit of a hangover, which I would not recommend but I survived the day.

Thursday afternoon was the useless touchy-feely course we took in first year and we were divided into groups of 8.  The 8 of us sat in the room and some older adult asked us to tell the group something about themselves.  It was a round table and the talk started to my right so I got to talk last.  That was not good.  The first 6 had all had incredible lives, attending schools overseas, volunteer work and they all knew exactly what kind of doctor they wanted to be (and that kind of doctor was not an anaesthesiologist or a general practitioner).  Fortunately the person to my left, turned out to be a down to earth person, with an ordinary life, actually from Victoria although from a different high school.  Then I told my boring life story and we went on to something else.

Later that Thursday we had a tour of VGH lead by 4th year medical students who seemed so incredibly cool, followed by a party in the Medical Student Lounge on 10th avenue.  This party was by tradition put on by the second year class who had survived first year.  They were, as I later learned, by UBC standards an intense group.  Talking to them was somewhat anxiety provoking as they told us about the amount of work we could expect to do in first year (which was mostly true) followed by telling us that second year was worse (which it wasn't).  This was very depressing but  we had Friday morning off and the beer was cheap, so I got to have a few and made some friends in my class and I remember in the early morning a bunch of us heading off to Bino's on Broadway for pancakes before somebody drove me back to the campus.  This was to be the first of many drunken parties in medical school. 

Friday afternoon the first week was our 3 hour Biochemistry lecture and I was most impressed when Dave, my new dissecting partner loudly announced that the lecture would be continued in the Pit.  It just happened to be the night of the second Ali-Spinks fight which was on the big screen and it was great to see Ali regain his title.  Between that and running into my old friends, I think I closed the Pit down.  Medical school was not looking bad.

First year was heavily weighted on Anatomy with 3 or more dissection labs a week, along with a histology lab and 2 hours lectures 3 days a week.  It became apparent that most of us were in grave danger of failing anatomy if (or even if) we didn't work our buns off.  This was memorization of trivial details on a scale none of us had ever encountered.  It was, I am sure, humbling for all us, accustomed to being at or near the tops of our classes to have to shift into survival mode.  The whole stress of the situation seemed to bring everybody together perhaps in the same way basic training brings together soldiers.  We spent so much time together in those days as we all had same lectures and same labs.  We usually ate lunch and had coffee together, and frequently drank together.  People started inviting the whole class to house parties. 

Our class was the largest ever at UBC with 88 students.  There were supposed to be 100 but they weren't able to expand the anatomy lab to fit that number (which may have been galling to the 12 people who found themselves left on the waiting list the day after Labour Day).  Also a first we had 33 women which was most ever at UBC.

I think back now on how little I knew of what was ahead.  I knew nothing of details like specialization, certification exams or what was involved in being on call.  I had no idea what an anaesthesiologist was.  The only one I was aware of was the morose Australian on MASH, who always seemed to say, "Oim losing 'im Hawkeye".  Looking back it is interesting of how little we were prepared for the world we were going to go into  or that in which we live today.

I believe all but two of our class graduated although it took some more than 4 years.  One poor fellow failed anatomy and the summer supplemental anatomy course and was turfed.  The other developed schizophrenia in second year which was fascinating but depressing to watch.  We all went away to internships, did locums, residencies, settled down in various parts of country, a lot of the class eventually washing up in the lower mainland.  We had a 5th, 10th, 15th, 20th and 25th anniversary.  Only about 40 people attended our 25th anniversary in Vancouver, surprisingly given the number who lived in the area.  Nobody bothered organizing a 30th or 35th (maybe they did but didn't invite me).  Two of my classmates work in my city.  I used to see one, a neurosurgeon, a lot when I worked at the Centre of Excellence.  The other a psychiatrist, I last ran into over 10 years ago.   At least 3 of our class have died including my good friend Dave and also Phil who was in my dissecting group.  (The fourth member of our dissecting group, contacted me a few months ago on LinkedIn and introduced herself as the other surviving member of our group.)

40 years on now, I can just look back to the excitement, the fear and the relief of those first days in medical school.

Sunday, March 25, 2018

Leaving Chronic Pain

Sometime last month was my 25th anniversary of my first pain clinic.  I was at the Centre of Excellence, and the person doing the Pain Clinic went on to better things.  The Professor told me I could do the Pain Clinic until they found somebody smarter than me to do it.  Problem was there was nobody smarter or stupider and 25 years later here I am, although not at the CofE.  I should have had a party, moreover somebody should have thrown one for me.

A couple of weeks ago, I gave notice that in March 2019, I will be giving up most of my chronic pain practice and become a more or less full time anaesthesiologist  again.  Like many decisions there was no “last straw” moment, it was a series of small things.

One reason is that despite everything we complain about, being an anaesthesiologist is a pretty good gig, if only for this reason.  When you see the hospital in your rear view mirror at the end of the day, unless you are on call, you know you are finished.  No phone calls from the ward, patients, pharmacies or other doctors.  If for some reason you want to go on a long vacation, you don’t have to arrange coverage and you know that you won’t spend your first two weeks back, putting out all the fires that started while you were away.

I have been pretty good about setting boundaries and have a great colleague who covers me when I am gone.  Patients expectations about availability are less too, I get a lot fewer calls now.  Still I have voicemail and a fax which go to my email which I check even on vacation and the hospital switchboard has my cell number.   I could ignore them because switchboard is supposed to know when I am away and my voicemail greeting usually says I am away and who is covering but I still feel guilty, even when the problem is not one of my creating.  For example I spent a great deal of time on my 60th birthday dealing with a patient who had messed up big time.  I did this after the pharmacist from the PCN pain clinic emailed me to say he needed urgently to speak with me.  Okay why was I checking emails on my birthday?  Because that’s what I do.

I met a pain specialist from another centre about 10 years ago at an anaesthesia meeting.  "I'm thinking of going back into anaesthesia", she said, "I want to retire soon and I can't handle the demands of my patients."  Sounded strange at the time; most people give up anaesthesia and the call involved to do chronic pain, I almost did a few years ago.  This encounter did plant the germ of this idea in my head.

The biggest thing however is that I realized a few months ago that I have lost my compassion.   I no longer have patience for people who won't try do anything to help themselves, I no longer want to hear about problems that I have no way of solving.  90% of my patients are good people who try do everything possible and I have a treatment that might help them or is helping them.  Like most things in life, it is the other 10% that take up most of my time, that leave me feeling drained at the end of the clinic.  I don't want to be seen as blaming patients for their misfortune, its just that quite a bit of the time I have nothing to offer and don't really want to hear about it anymore.  So often I want to say, "YOU have a problem, what are YOU going to do about it?"

Pain medicine and medicine in general have changed over the last 25 years that make it less attractive to practise.  25 years ago most of my patients had a family doctor, moreover they had a family doctor to whom I could make recommendations that they would follow.  Now when I get a referral, I get the sense that the family doctor has washed his hands of this patient.  That is of course if the patient has a family doctor and a significant number don’t.

Paradoxically we have way more physicians doing chronic pain than 25 years ago.  This should make it easy.  It doesn't.  25 years ago, I was almost always the first person to see a patient.  Now quite often they have already seen one or more chronic pain specialist.  Quite often they are still seeing someone else (I saw a patient a few years ago who was seeing 4 other chronic pain doctors; she was quite disappointed when I told her I didn't think there was any point in my following her as well).   This would be nice if I actually had the records from their previous doctor so I could see if I had anything else to offer but that is the exception not the rule.  Moreover some of my colleagues have developed boutique-type silo practices where they offer single modalities, usually interventional treatments.  Quite often the patient is still getting these treatments but the expectation is that I will prescribe medication for them.  Or one of my colleagues has started them on some toxic cocktail of multiple classes of drugs that I am supposed to unravel and continue.   And with all this expertise floating around we should be able to work together in the patients' best interest?  What universe do you live in?

So why don't I, as somebody suggested, just carve off the parts of chronic pain practice I enjoy and forget about the rest?  If only it was so easy to tell in advance who was going to be easy and who wasn't.  And the easy patient of course so easily becomes the hard patient.  I have for the last few years been more selective in screening out referrals and in my new consults so that I am accumulating fewer patients I know I can't help with the resources I have available.  But I have never been comfortable telling a patient that just because I can't do some lucrative procedure doesn't mean I can't try to help you.

It is hard to talk about chronic pain without mentioning the opioid crisis or epidemic whatever you want to call it.  I still prescribe opioids for chronic pain, although not in the industrial doses some of my colleagues prescribe.  So far I have escaped scrutiny from our medical licensing body.  Every quarter I do get a list of patients who are over the recommended dose which I read with some interest.  Talking however to some of colleagues who have undergone scrutiny and have had to pay 10s of thousands of dollars in  "costs" of the investigation or fees to attend remedial courses scares me a little bit.  I am less than 5 years from retirement, slowly building up my nest-egg.  I look at some of my patients and think, "is patient X, the hill I want to die on?"

And of course with increased scrutiny from the licensing body, a significant number of referrals I get are dumps of patients who have gotten onto these industrial doses not to mention a number that are doing well on a reasonable dose and the expectation is that I will take them over in my solo part-time practice.  Which of course I do because I am an old school doctor, who doesn't want to see patients go through narcotic withdrawal.

Narcotics still confuse me and I have no idea what the right answer is.  I have mentioned above, that I have reluctantly acquired a number of patients on whopping doses of opioids.  Most of these people seem to look okay.  Their function like most chronic pain patients is not the best although I periodically find somebody who is actually working.  Most of them are quite happy on the massive doses they are taking; they don't want to see a psychologist or attend a rehab program and they definitely don't want to come off their meds.

On the other hand I read a lot in the medical literature and on Twitter (where I get most of my medical info now) about all the bad effects of narcotics, and there is no doubt that there is some truth in all of this.  The question is where is the balance because as somebody who follows a lot of patients on narcotics, clearly some of them benefit greatly from them with little or no adverse effects.  Further I have seen a number of ugly cases of forced weans that ended up in my clinic.  Our Workers Compensation board has recently become evangelical about weaning off opioids, at least once a month I have to spend 20 or minutes consoling a distraught patient who has been told they have to go to a clinic in a city 3 hours away to be weaned off their meds.  They all think I have some magic clout with WCB.

Just something I don't want to be bothered with anymore.

In fact these patients are the most difficult for me to abandon.  I hope to transfer those with understanding GPs back to their GP.  Some of the complicated ones I am referring to some of my colleagues and my colleague who is taking over my clinic time will take over some.  Our licensing body told me that as long as I gave them 3 months notice, I had no obligation at all to arrange follow up.

Chronic pain still confuses me.  I still don't know what causes back pain or neck pain.  I could be one of those people who says, "yes it's definitely your facet joints and every three months I will inject steroids into those joints or maybe just burn the nerves"  but I know its not that simple.  So I end up offering what I think might work, usually in my case trigger point injections and an antidepressant but feel like an idiot for doing so.  I should be telling them to exercise and lose weight, like that will ever happen.

Patients often ask me about some bizarre symptom they are having.  "Is this normal?"  they say.  "No", I reply, "it is not normal but it is not unusual."   I have learned that patients have these symptoms, they are real; if they're making it up, that too is pathology worthy of treatment; and that in most cases I can only guess at the psycho-physiological mechanism behind it.

The lack of  supportive infrastructure is another factor.  I usually go to a pain meeting once a year where I hear presentations from psychologists and physical therapists and I come home excited and ready to help my  patients.  That is until I try to refer and find that my patients can't afford any of this and the very few practitioners in the public field have exclusion criteria that effectively excludes all my patients.  Long ago at the CofE one of my colleagues came back from his Pain Fellowship (at Boston College, not Harvard as he now tells everybody) to join me in practice.  "Where," he asked me, "do I refer somebody for inpatient rehabilitation?"  I was polite and supportive.  I didn't roll on the floor laughing.  I told him that no such program inpatient or outpatient existed and that he better learn to live with that.

Periodically we get to meet with our regional admin.  They usually tell us how much they support what we are doing and then we don't meet again.  A couple of years ago when I last got invited, I was a little punchy.  "Are you going to be giving us more resources, " I asked, "because if you aren't I really have no interest in attending any more meetings".  And I didn't.  It is not just not having new resources, it is not being able to access existing resources that bugs me.  And it just galls me to see all the new programs that have sprung up for chronic diseases while we have been told there is no more money for chronic pain.

Things are a little better now, we do have self management programs and also some exercise programs.  Thing is, these are all by self-referral and the likelihood of the passive fix-me-now pain clinic patient phoning the number and driving across the city (because they are never central) to attend one of these programs is close to zero.

Anyway, while I sometimes lie awake at night wondering if I am doing the right thing, blowing up 25 years of practice, I told somebody I was retiring (from chronic pain) and it felt pretty good.  Maybe somebody will throw a party for me.

Monday, December 18, 2017

Getting Older

My father once told his grand daughter, my niece that he was not really old, he was just older.

We are all getting older.  I celebrated my 60th birthday this summer.  This was a quiet celebration as have been most of the previous 59.  That is what happens when you have a summer birthday.  I did take a lot of time off this summer and went on two fabulous bike tours, so I guess I did have a nice birthday.

My parents are also getting older.  My father is 93 and my mother 88.   My father retired at 61 although he did some consulting after.  My parents had a very active retirement (although my mother as a housewife may not have noticed any retirement).  They traveled quite a bit; driving all over BC, Alberta and the Western US.  They also visited us quite a few times when we lived on the East Coast.  They toured Europe and Britain.   My father kept on gardening and with the extra time on his hands his garden became more elaborate.

They were however getting older.  One by one their siblings died until I have only one surviving aunt.  My father started to develop all the health problems, prostate cancer, atrial fibrillation (diagnosed by his urologist, most likely a publishable event), cataracts and an abdominal aneurysm repaired electively.  He also developed significant osteoarthritis in his knees which for some reason his family doctor didn't want to refer him to ortho for.  By the time I did the doctor thing and got an orthopod I knew to see him, all the above problems had presented and the orthopod prudently declined to operate.  My mother however remained in fairly good health and was with it.  While her mother died of TB in the 1930s, she had aunts on both sides who lived well into their 90s so I was anticipating a long life for her.  As my father became more and more crippled by his osteoarthritis, she became more and more his legs.

My parents continued to live in the house that they had lived in since 1960,  This was a single story house with a finished basement.  My mother cooked as cleaned as she had all their marriage, my father worked in his garden and did the yard work.  A few years ago, my mother disclosed to me that she wasn't sure that they could handle the house but that my father loved his garden and didn't want to move.  The garden was becoming smaller and less elaborate and shortly after his 90th birthday my father decided that this was his last garden.  They were getting a little help thru homecare and through Veterans Affairs.

Meanwhile my mother who suffered from macular degeneration, developed what might have been retinal detachments (I don't know for sure, the opthamologist wouldn't return my calls).  Last spring she told me, she could no longer read.  My mother loved to read as do I.  I felt very bad for her.

I had started visiting my parents every couple of months a few years ago.  I no longer had all the weekend sports and it didn't seem that expensive to fly to Victoria any more.  It was a nice trip, I would stay in a hotel and visit all my favourite places.  We would go out for dinner and my mother usually cooked lunch and occasionally dinner if I was leaving later on Sunday.

Last June (2016) I visited my parents and had a very nice visit.  My mother made us lunch and on Sunday because I had a later flight, she made a nice Sunday dinner.  She was at that time having the vision problems but the house was clean and they were nicely dressed.

I came back in August.  Again everything seemed okay.  I arrived mid morning, we had tea and then my mother made lunch.  We went out for dinner on Saturday.  Sunday I drove them out in the country and we went to a nice restaurant for lunch.  I was flying home around supper and told them I would eat at the airport on the way home.

So it was that around 1500, having tea my mother said to me, "you know if you had more education, you could get a better job".  Hey I know I'm just an anaesthesiologist.  She then asked me where I lived and who I was married too.  Thinking back over the weekend, I began to suspect she had not known who I was all weekend.  I left feeling somewhat shattered.

Monday I phoned home hoping to talk to my father. My mother answered the phone, recognized my voice and we talked for a few minutes before I was able to talk to my father.  He confirmed that she had been acting like that for some time now.  I contacted my brothers and one of them who had visited earlier in August, confirmed that she had been acting like that when he visited.  He also revealed that she had been falling over as well.

Concerned about (but secretly hoping it was) a subdural, I phoned her family doctor, got a locum told her the story and the locum was able to arrange a CT scan in uncommon speed for a GP.  This was normal except for atrophy.

A family meeting was convened with two of my brothers and me.  My parents or rather my father agreed that it was time to move to some type of facility.  My father has a good pension and they had considerable assets so a private facility was available for them
.
I am not going to go in detail all of what has gone down in the last year except that it was about 10 months that I never again want to experience.   My mother now lives in a "reminiscence unit", which is a locked ward for patients with dementia and a tendency to wander.  Reminiscence is a nice euphemism for a place inhabited by people who can remember events from the 1930s but can't remember the names of their children or what you told them 5 minutes ago.  My father as of a couple of weeks ago lives in the same building on  a different floor.  He is allowed to visit my mom but can't take her off the unit.

As it happened just over 6 months ago, we got a phone call that my mother in law was in the emergency with back and leg pain and not really able to walk.  Again not going into all the nuts and bolts of what went down but she is now in a nice facility in Burnaby having moved out of her condo.

Life as my father or maybe it was somebody else observed doesn't come with a users manual and I have learned more about getting older than I ever wanted to.  In no particular order.:

Seniors care is very expensive and somebody is making a lot of money off it.

My parents are currently spending between $10 and $20K a month for the rather nice place they are currently living.  My mother in law who had much less assets was after some time eligible for subsidized care.  However when we first placed her in her first assisted living facility she had to pay a significant extra amount of money to have someone dispense her medications and bath her.  This is despite the fact that the person providing the service is probably getting paid the minimum wage for the time spent providing the service.  This is also the case for the nice people who look after my parents.  There is a RN in their building but I suspect she is getting less than she would be getting by working in a hospital.a

Not all nursing homes are created equal.

I of course should have known that that.  We found a nice seniors home for my parents in their neighbourhood with a room available within 6 weeks.  My wife, then I suddenly realized that this was totally not the right place for my mom but the wheels were in motion and so that was where my parents went.  We told the administration right up front my mother's mental state realizing we might sabotage the move and to their credit they were very accommodating especially for a for-profit facility. 

There are in fact multiple levels of care, which overlap and some are available in the same building some are not.  Researching this was very complex.  This may mean divorce by nursing home.

There are of course public and private facilities to consider as well.  It is interesting that in Canada, everybody gets treated equally in the healthcare system (not really) but that where and how live as senior is so dependent on your income or what programs you are eligible for.

Staying in your home might be important but a lot of people can't do it.

The mantra since I was in medical school has been to keep seniors in their homes and we go to elaborate lengths to do this, not necessarily sometimes in the best interest of the elder or their support people.  My father really wanted badly to stay in his house which complicated things incredibly and my brothers and I (most me) tried to figure out scenarios where both my parents could stay in their home.  My parents are quite well off, money would not have been an object; however on thinking things over there was no way they could have possibly stayed in their home, even with the best of help.  This did not stop me from feeling like I had let the team down.
My mother in law on the other hand was an inpatient and it became clear that she could not go back to her condo.  She was eligible for subsidized care, however when we approached people about that we were advised that she could not go directly to subsidized care from hospital; she would have to go home first, fail her trial of home care and then go to subsidized care.  We had the means to put her in a non-subsidized care facility from which she was able to apply to the lovely subsidized care facility she currently lives in.  Had she not had the means to go into a private facility, however she might still be involved in a Mexican standoff where they say she has to go to her home but she can't possibly go to her home.  I am pretty sure that scenario is being played out in lots of hospitalized seniors.

Rather than being pro-active the system is set up for seniors to fail.

Even 30+ years ago when I came out in practice, they were talking about the silver tsunami although they may not have had such a catchy name.

In Canada we have socialized medicine, every person has a health care number, almost every person has some contact with the health care system, every person pays income tax or receives some form of government assistance, a great deal of seniors pay property tax.  In other words there is a huge repository of demographic information available.

So why are we  so surprised every time we have a senior with failure to thrive?  Why do we wait for seniors to end up in an acute care bed or the ER.  Why aren't we proactive?  It is quite likely for example that if I hadn't visited my parents that particular month, nobody would have realized just how far my mother had declined.  Sure, you can say the family should have some responsibility.  This ignores the reality that living in the same city you grew up in is the exception not the rule and that the children of seniors are mature adults who have jobs, look after their own kids and not infrequently have health issues of their own.

When I was department head, I had to attend Medical Advisory Committee meetings.  Most of those meetings involved various members of the administration telling us about the crisis of seniors in the ER or on the hospital wards.  Once I piped up, something to the effect that why don't we look upstream and try and prevent these people from ending up in a place they and we don't want them to go to.  Nice idea, said someone in a suit and we went on to the next topic.

What about geriatricians.  Geriatricians exist.  The problem is they largely work in hospitals where they see people who have already failed the system or in hospital clinics where after being on a long wait list you can get assessed.  Not out in the community putting out fires like they should be. 

Family docs?  Both my parents had pretty good family docs.  The problem is that it is very difficult providing the type of care seniors need in a fee for service system, while looking after the rest of your sick and not so sick patients.

Not everybody ages at the same rate.

I sort of knew this but visiting my parents in two different seniors' home brought it home to me.  The seniors' population is a heterogenous group with very different needs.  Closer to home, this means that a couple may not age at the same rate.  My mother for example doesn't recognize  me, my father's mind is still as sharp as every.  This leads to the phenomena of divorce by nursing home where because of different care needs a couple cannot stay in the same facility.  My parents are lucky enough to now live in the same building but in different rooms on different floors.

Even individuals don't age at the same rate.  I was astonished by the precipitous decline in my mother's mentation even though she may have been hiding it well.  The swift decline form a fully functioning individual to something way less than that, constant catches family and the healthcare system off guard.  It shouldn't.

A week or so ago, a pain clinic patient asked me if I was going to retire.  "Not right now", I said, "but I just turned 60 and things can change in a hurry."

Have I  learned anything from this?

My parents' generation largely didn't deal with this because people died at younger ages from infections or from heart disease or cancer for which there were fewer treatment options.  Therefore faced with their own fragile longevity they have no idea what to do because they never had to deal with elders in the same predicament when they were young.

I am starting to learn and hopefully plan my own senescence. 

Firstly, I  assume that at some point I will not be able to drive.  By that time I  will probably lack the insight into this so it is better to quit well before I am forced to.  This also means living in a place where the services are within walking distance (which  also might be a problem) or that there is good public transport. 

I am  going to need medical services.  I have a good family doctor.   For the rest of you, this means if you don't have a family doctor, you better get one who is a lot younger than you.  Preferably one who isn't an idiot and who works more than 3 days a week.  When choosing what town I am  going to live in, I now have to factor in what medical services are available locally.  This is important if I want to retire overseas as I often threaten to do.

There is of course planning my  home and will I be able to live in it in the future.  Better figure out how you are going to climb those stairs when you have generalized osteoarthritis or heart disease.  The necessary renovations are going to cost money and despite what my financial advisor tells me, I know I am going to have less of that in retirement.  I joked when visiting seniors homes about, "see you in 10 years" but maybe it is more realistic to go into a home when you want to, not when you have to.

There is of course the whole advanced directive thing.  I am pretty health right now and barring metastatic cancer or something like ALS I would probably like a little CPR.  Problem is that by the time I shouldn't be getting a little CPR or the related trimmings, I may not have the insight.  Better discuss this with somebody sensible now.  Make sure they are prepared to advocate for you because there are quite a few doctors out there who are prepared aggressively treat you, based on their religious belief, hospital policies or the irrational fear of  being sued.

In closing

As my parents started to push 90, believing that longevity is genetic, I rejoiced in my potential long life. 

Not so sure about that now.




Thursday, May 11, 2017

You break it, you buy it


I saw 4 patients that morning.  2 of the patients were young men who were cancer survivors.  Unfortunately combinations of surgery, radiation and chemotherapy have left them with disabling neuropathic pain, which in both cases prevents them from working.

Naturally if you read the progress notes from the Cancer agency you will read glowing, back patting descriptions of the success of their cancer regimen.  Both men are going to survive.

The problem is that both of them have severe pain, and nobody really wants to address it.  Despite what you may read in the American and sometimes in the Canadian media, cancer patients actually get quite good care in Canada with a huge infrastructure of nurse practitioners, social workers, psychologists and patient navigators.  If you are dying of cancer, you will go into a similarly endowed palliative program.  This is as it should be; when my cells start acting in an antisocial fashion, I want it all there for me.

If you are "cured" of cancer however you enter the dismal world of the Canadian healthcare system with its waiting lists and silos of care.  Unfortunately if you have chronic pain nobody really wants to take ownership of you, least of all the oncologists and surgeons who caused the problem in the first place.  This usually leaves it to chronic pain "specialists" like me who are stupid enough to still want to see these patients.  We are usually not talking about narcotics here although that is what they frequently need; anticonvulsants or antidepressants are often effective but I frequently see a patient who has gone for the 18 months or so my wait list is, without trialing them at all.

When you think about it, it takes a special kind of sociopath to leave a patient in pain as a consequence of their treatment, (even if they did save the patient's life) and not feel responsible to at least do something to try and help the patient or at least direct him to someone who can.  Back surgeons are of course big offenders in this regard.

Working in my other life as an anaesthesiologist I see the other face.  As I work in a big city hospital, in what could sometimes be seen as tertiary care, a lot of the work we do in OR, is as a consequence of surgery done at other sites, usually out in the country, often by somebody who had no business doing that complexity of surgery but also alarmingly from within the city.  I often pity my general surgery colleagues who get stuck with complications of gynae or urological surgery.  Talking about podiatrists to one of our orthopods is a sure fire way to generate a long rant.

We anaesthesiologists of course get to tag along on these little misadventures because they almost always end up in the OR, usually after hours, occasionally bumping the enjoyable list you thought you had, often in ICU with 20 infusion pumps going or with MRSA, VRE, XYZ etc.  I remember early in my career noting that I had worked until 0400 all on complications of surgery done at other sites.

And we all love to hear of the patient with the post-spinal headache in the ER, who had her baby at another hospital or who had a misadventure with a lumbar puncture.

My chronic pain side is not immune.  I get to struggle with the patients put on megadoses of narcotics by other people, those on big doses of benzos and of course the sloughs from my colleagues who have exhausted their repertoire of lucrative blocks and now want me to manage their patient medically.

Complications are a consequence of medicine and modern medicine is really just a bet that the benefits of the procedure or treatment outweigh the adverse effects, transient or permanent.  This is a bet patients frequently lose.   Sometimes the adverse effects are something we can deal with ourselves, sometimes in the best interest of the patient, some else is better able to deal with it.  It would be nice if there was some mutual respect and communication.

Sunday, April 9, 2017

Does one battle define a country?

Today is the 100th anniversary of the Battle of Vimy Ridge which we are told established Canada as a country.

Just to establish my bona fides; my grandfather was in the Battle of Vimy Ridge.  Unfortunately he died in the 1930s and I never knew him; I only have one photo of him.  He was wounded there which eventually along with being gassed earlier in the war lead to his premature death.  He did meet my mother an English nurse who he married and brought back to Canada.  It could be said that without the battle of Vimy Ridge, I wouldn't be here.  In fact if you take into the fact the butterfly effect, the world might be very different without the battle of Vimy Ridge.

Vimy Ridge was the first battle entirely fought by Canadians.  Not entirely, there was a British General Lord Byng.  Lord Byng later became Governor General of Canada.  Notwithstanding the battle of Vimy Ridge, it would be another 20+ years before a Canadian could be trusted to be Governor General.  Lord Byng's wife, Lady Byng is much more famous: she donated the trophy given yearly to the most gentlemanly player in the NHL.  Those of us interested in constitutional law will remember Lord Byng in another context.

I haven't read much about the Battle of Vimy Ridge but the underlying principle of the battle seemed to be that if you bomb the shit out of the other side and aren't terribly worried about casualties (a large reason why Canadian rather than English or French troops were in the battle) you will win more often than you lose.  The battle was of questionable significance in the long run.

The thing is however.....

The First Nations have been in the territory which became Canada for 10,000 plus years.  The first (non-Viking) European contact was in 1497.  The first permanent settlement in the early 1600s.  The boundaries essentially established after the American Revolution.  A lot of history, a lot of people lived and died to create was is now Canada.

So can you really boil all that down to one battle even if my grandfather was there.

Tuesday, March 28, 2017

Drug Costs

We had a little breakfast presentation by the Sugamadex people last Friday.  Not a bad breakfast and an okay talk by one of their scientific people, a little dry.

Unfortunately any discussion of a drug basically comes down to, "can we afford it; will the hospital put it on formulary?"  The answer came about 50 minutes into the talk, after we had finished our breakfast and were on our second cups of coffee.  The answer was $100.  That is for the smallest dose, the dose for mild-moderate block, the dose that some of us depending on circumstances don't even reverse.  If you go for deep block, like when your resident listens to the surgeon's whining and gives rocuronium while they are closing, multiple by two.  If you want to immediately reverse rocuronium like for example when you give 50 mg to the guy with no chin and realize you can't intubate him (and can barely bag him), you are talking serious cash.

Now neostigmine is not the nicest drug in the world.  I consider it the most dangerous drug in my drug cart.  Surprisingly pharmacy who insist on putting high alert stickers on my midazolam compartment haven't figured that out yet.  It is considerably cheaper however although the price is said to be going up due the Merck buying the licences off all the generic companies who used to make it.

Sugamadex is with a few little wrinkles a better drug than Neostigmine, just as a Ferrari is a better care than my VW Jetta.  My VW Jetta gets me to work on time however.

I have no idea how much it costs to make Sugamadex, even taking into account the inflated R+D costs companies claim they have to pay.  I suspect it isn't anywhere near $100.  Currently they are selling almost no drug at all in Canada.  The question comes, is there a price where the company can make a profit which balances with the hospital paying a little bit more for what is a better drug, which might actually save money by shortening recovery room stays and reducing complications.  I should have asked but I bet I wouldn't have got a straight answer.

Incomplete reversal of muscle relaxants seems to be getting a lot more attention in the literature and at meetings, some of which I suspect is being driven by the makers of Sugamadex and their stable of tame physicians who can write articles and speak at meetings.  I trained at the tail end of the pancuronium-curare era, which gave me a healthy respect for muscle relaxants.  The problem is of course, I suspect we see more incomplete reversal now than we did with pancuronium, if only because people have lost their respect for muscle relaxants.  I have learned that adding a muscle relaxant probably increases your complication rate.  I do a lot more cases with a LMA spontaneously breathing now, I still use sux and quite often if I am just intubating to protect the airway, I don't bother with a non-depolarizing agent, unless the patient is bucking or the surgeon is whining.   Even when using a non-depolarizer, I tend to be sparing in how much I use and quite often if I don't need muscle relaxation have the patient spontaneously breathing or on pressure support by the end of an hour.

The Sugamadex people have cottoned on to the fact that hospitals are not about to pay $100 for a drug, at least not for an anaesthetic drug, no matter how good it is.  The spin last Friday, was getting it indicated for high risk populations like the frail elderly, sleep apnea and high BMI patients.  Probably a good idea, however unless the hospital polices it, you are going to get indication creep.  If you need it for the BMI 45, what about the BMI 44 and so on.  Of course regulation could lead to you trying to call the on call pharmacist at 0400 because you want to use Sugamadex.  Neither very good options.

I was talking later that day with the surgeon and was discussing our morning rounds.  He observed that where a drug that cost $100 used to be considered expensive, now $1000 to $10000 is not unusual.

Monday, February 27, 2017

End? of paper

There are two things that,  if in 1983, you had told me I would still be doing in 2017, I would have called you crazy.

The first is billing fee for service.

The second is charting on paper.

The end may be in sight however.  Last Friday's pain clinic at my main hospital site was the last before the electronic medical record rolls out.  Fortunately I only work alternate weeks so my hope is that all the bugs will be sorted out next week.  There is a huge team of people involved in setting this up.  I attended a meeting with about 10 of them in a large war-room with white boards all over the wall.  I wonder if the money spent on this might be better spent elsewhere.

I work at a variety of sites and so have been exposed to 4 different EMRs all of which are entirely different from each other.  Fortunately the EMR I will be using in a week or so is one I already use at another hospital, which means that I already took the mandatory training and did all the privacy and security stuff.  The IT people who are supervising the whole process keep on referring to me as a star.  I also get invited to "physician champion" meetings which I never attend.  Sorry, guys I already know the system and I am the only person in my department.

It is interesting how the logistics of a paperless system affect your practice.  For the first few months we have been advised to book fewer patients as charting can be expected to take longer.  The other issue is that we are nowhere near the end of paper.  At one place I work which has an EMR,  a parallel paper chart is kept, at another they insist on printing out my most recent note for me to read every visit.  I keep on telling them that I can read the electronic chart but they insist on it.  In addition because none of the 4 EMRs can communicate, if you want records from one practice the only recourse is to print out the record and send it where it is scanned into the other record.  All lab and imaging reports are now available on the provincial electronic record but they still insist upon sending me paper copies as well.

Canada has a socialized medical system which means it should have been easy to set up a universal electronic medical record.  For example if I see a patient with headaches, I should be able to pull up the neurologist's consult.  If however I want a copy, it will most likely be a paper copy mailed or faxed to me, often not available when I am seeing the patient.  Larger HMOs in the US have a single medical record, as do  the doctors in one small Canadian province.

As I blogged a few years ago, we had an issue where multiple miscommunications lead to a patient's testicular cancer diagnosis and treatment being delayed and the patient ultimately dying.  This lead to a lot of hand-wringing and promises to fix the system.  Much of this could have been solved by an integrated EMR which nobody including me, seemed to have the balls to suggest.  Our medical society is trying to set up a secure electronic portal where doctors can communicate with each other confidentially (except for the NSA and the Russians of course).  The problem is of course that such a system is of no use unless there is close to 100% buy in and I don't see that happening because for most doctors miscommunications are someone else's problem.  I have never really seen the problem with just using email.  Is it any less secure that faxing.  How often have you found someone else's fax stapled to one of your faxes.  Anyway I have a personal fax which emails me a PDF.  When someone tells me they can't email me something because of confidentiality issues, I tell them "Just fax it to me".  They do and the faxed gets emailed to me.  I don't point out the contradiction.

Our province has a flawed but wonderful system called NetCare where it is possible to access just about all the blood work and X-rays going back 15 years.   In addition you can get every medication dispensed to the patient.  As well anything that is dictated in a hospital system is accessible.  I can't imagine how I lived without it.  However you still cannot access anything done in a private office and in addition there are quite a few physicians who handwrite their consults and admission histories.  Progress notes which are still handwritten are not available either.  Still way better than the old days when the patient would come in saying he was taking a blue and a green pill and wanted to discuss his MRI results which you didn't have.  NetCare is easy to get on in the hospital, less so outside of the hospital where you need a key fob and a lot of good luck to get on.  (I can access my own chart on NetCare, I'm not supposed to but I do, it is after all my medical information.  My family doctor was horrified when I told him this and set me up with a patient portal where I can access my records, legally but why should I have to memorize another set of log-ins).

Mostly where I have been using EMRs have been low volume practices and I am looking with some horror at my hospital clinic tomorrow where I typically see 24 or so patients.  The EMR people assure me that they will be on site and I have done the appropriate training and have set up the appropriate shortcuts that will make charting easier for me.

I have heard that EMRs have lead to dissatisfaction in doctors that have them, although doctors have a lot of reasons to be dissatisfied and in the 30 or so years I have been in practice I have never seen any doctor completely satisfied with all the aspects of his/her practice.  EMRs certainly are cumbersome, usually requiring multiple log-ins, and their tendency to randomly shutdown or kick you out of the system.  The EMR I am using today refused to let me write prescriptions under my  name, I got around this by printing the prescription under someone else's name and then crossing it out on the paper copy.  I have been assured this will be fixed today.  You do have to remember that paper charts were not the greatest either, trying to decipher your handwriting or looking for labwork that may or may not have been filed were definitely hassles not to mention the effect on patient care.

I have recently been doing a lot of medicolegals which mean a lot of chart reviews.  These have given me to opportunity to compare both paper and electronic charts.  Paper copies of electronic charts have of course the advantage of being legible.  The quality of the information is not better and potentially a little worse as I suspect a lot of doctors are typing with two fingers.  Most EMRs have shortcuts or macros available and I notice that these are being used quite a bit.  For example many family doctors have a macro for their yearly physical exam (notwithstanding the fact that nobody advocates a yearly physical, most patients seem to get one done, if only because the doctor can bill for it).  I have for example reviewed cases with severe neck or back pain, well documented in the progress notes who when they present for their yearly physical will have a completely normal exam documented on the obviously computer generated record.  This is I am sure going to cause problems when somebody less understanding than me reviews the chart.  I have also heard of instances in hospitals where people are cutting and pasting other people's consults or progress notes.  This is of course okay (if a little lazy) if the original information that was cut and pasted was valid, however the old saying garbage in/garbage out comes to mind.  False information, (alternate facts) of course persisted under paper charting as well.

The other issue I notice when I review medico-legal charts is the incredible volume of paper they can generate especially if the patient is admitted to hospital.  For example, at the hospitals in another city which has EMRs, each lab test is printed out on a separate piece of paper, likewise nurses notes.  This results in a huge chart, which if I get it in paper, means lots of turning pages and a high risk of paper cuts and repetitive strain injuries.  Lawyers tend to do fishing expeditions resulting in large amounts of irrelevant information.  I get paid by the hour so I shouldn't mind but the hours available to me are finite and I know that somebody is ultimately paying for this.  Logically when they get the request the hospital would give me a time sensitive log-in to their system for that one patient's chart so I can review on a computer.  It is after all the 21st century.

Fortunately or unfortunately an EMR for anaesthesia or AIMS as they like to call it seems to be years away.  We did spend a great deal of time getting ready for one about 5 years ago with multiple meetings however suddenly without even a whimper the whole process just ground to a halt. I don't see any sign of it restarting and I don't expect to be using it before I retire.

When people express fear or dissatisfaction about EMRs, I remember a story a specialist told me when I was a resident in Newfoundland.  He had started his career working in a remote community as a general practitioner in the 1960s.  When he arrived, he found that the clinic there did not keep any patient records.  He was appalled and told the staff that they would have to start keeping charts on patients, with the result that the entire staff resigned in protest.

Like all changes in healthcare, we will survive this and patient care might even be improved.