Sunday, May 22, 2016

Oh by the way it's called Medically Assistance in Dying Now.

Afterall why use one good word (euthanasia) when you can use 4 words especially when you get a pretty good acronym out of it (MAID).

Friday, April 29, 2016

End of Life

A year or so ago courts in Canada ruled that people have a legal right to what was then called assisted suicide and is now called physician assisted death but what is what used to be called euthanasia.  They gave the government a year to come up with a law.  Our former Tea Party government diddled around with this and it fell on our new government to come up  with a law.  The law they have come up with is predictably unpopular with both sides of the argument which some people would interpret as that it must be a pretty good law.

I generally disapprove of whatever you call it but as soon as you make arbitrary statements, all the what ifs come into play and these issues are rarely black and white but are rather shades of grey. I could expound further on the ethical issues but all kinds of other people who are able to use terms like beneficence and non-malfeasance and actually understand what they mean are already expounding in the medical and lay press. 

I work in a Catholic hospital.  While the Catholic church has historically had no qualms about killing heretics, Muslims, Jews, or Protestants; the idea of ending the suffering of somebody with a terminal condition seems to stick in their craw.  This is problematic because our sister hospital has 95% of the palliative care beds in the region.  We are assured by our medical director not to worry because most of the PAD will be delivered in the patients' homes because apparently  in the universe he lives in, patients still die at home.

This does give me an opportunity to muse about my experience with end of care.

The concept of euthanasia is not by the way a new one.  I remember having a discussion of it in Grade 10 English class of all places

Anyway as an intern I was towards the end of 8 unhappy weeks on Internal Medicine when we had an unfortunate patient admitted to our service in the evening.  This poor man had been otherwise well until a few days ago when he developed back pain and as we like to say, his bone scan lit up like a Christmas tree.  He had some type of untreatable cancer in his bones and he was deteriorating rapidly.   Now no death is really a good death but we could say that he had had an active life almost up to the end, unaware of what was going on in his bone marrow and that by presenting late in his disease, he was spared weeks of chemotherapy hell.  I doubt he or his family saw it that way.

The medical resident (actually a second year family practice resident) told the patient and his family that there was nothing that could be done and that we would keep him comfortable with morphine until the cancer took it's course.

That was when one of his daughters yelled, "what you are talking about is euthanasia!" and ran out of the room.

Nowadays that would generate an ethics consult, a palliative care consult, a week of chemo and possibly an ICU stay but in 1983 we didn't do that so he got IV morphine which was a relatively new concept then.  Instead of just running an infusion or having the nurse give the med IV (the patient might die?) the intern had to inject 10 mg of morphine every 4 hours.  That meant every 3rd night that was me.  On a q4h schedule, that meant a midnight and 0400 injection.  Generally you were up and around at midnight but at 0400 you were generally trying to catch a few minutes of sleep.  After almost 2 months on 1 in 3 call you would sell your mother for a few extra minutes of sleep.  As it happened I was on call on the above patient's last night on earth and after the midnight injection, I asked the nurse if she might consider a sc injection.  (From a pharmacokinetic point of view, sc injections would give a more steady state morphine level, which I should have thought of).  She of course laughed in my face and at 0400 the page came, I went to the bedside, she handed me a syringe which I injected slowly and went back to bed.  At 0500, I got the page to pronounce death.  "Aren't you glad you got up to give him that injection IV instead of sc", the nurse said.  "What the hell was in that syringe you gave me,"  I replied.

The second episode was early or late in my career as a rural GP.  It was my first weekend in a small BC interior town and I was on call.  Friday night I got a call about a patient with ALS who was at home.  I made a house call and listened to his chest and he had pneumonia.  The one thing I remember was that he was watching the playoff hockey game and I remember thinking, "too bad he's not going to find out who wins the Stanley Cup this year."  Funny the things you think.  I prescribed some oral antibiotic and went home to watch the rest of the game.  Sunday evening I got another call and made another house call and he was really in a bad way.  I called the ambulance which took him to the hospital ER and I could see that he was not going to survive the next few hours.  At the same time his wife seemed quite adamant that everything be done which left me in a dilemma because everything that I had been taught told me that you don't ventilate ALS patients ever.  I called his family doctor who worked in the same clinic at home because I figured he knew the family well and could come in an talk with them.  "Oh" he said, "Do you need help intubating him?".  I muttered something like I didn't really think intubation was appropriate and besides we didn't have a ventilator at our hospital.  Anyway it looked like his wife wanted everything done so we called in a nurse, loaded him up in the ambulance and sent him to the referral hospital an hour away by road.

I talked to the nurse, who went with him, later and she said that they almost intubated him at the referral hospital before they realized that he had ALS and he died shortly after.

I think about how better the whole case could have played out, how he could have died at home surrounded by his family or at worst in the local hospital surrounded by his family instead of spending the last hour of his life in an ambulance.   He might have even been able to watch a little

His wife came in the next week to see me and I told her how sad I was that her husband died and she shot me a look that said, "Fzck you" and asked for prescription for Valium which I gave her.

Shortly after that I decided rural (or for that matter any) general practice wasn't for me so I went in the anaesthesia where we don't have to deal with end of life issues except of course for the six months of IM I had to do which had some really interesting end of life issues, one of which I blogged on years ago.

Somewhere along the line the whole euthanasia debate got hijacked by the concept of "passive euthanasia" which was if you didn't try every single futile treatment, that was the same as giving someone a massive overdose of barbiturates or whatever.  So over the past 25 years we now have end of life patients in ICU, or getting futile surgical procedures.  One third of the beds in our ICU are dedicated to ALS patients now.  

Anaesthesia is in fact quite often involved in end of life care as I will outline below.  This scenario or something similar is not uncommon.

Granny is dying of colon cancer at home.  She has been seen by the palliative care team and is doing great until she develops a bowel obstruction.  Instead of taking her to the hospital with the palliative care unit, where they know her, she gets taken to another hospital.  There the ER doc or the internist calls the surgeon who without seeing the patient agrees to do a laparotomy/enterostomy.  The patient is told she is having a quick general anesthetic where she will have the obstruction relieved by a small incision.  She is seen in the receiving area by the surgeon and you for the first time.  In the OR, of course the tumour is stuck to the abdominal wall and bleeds, or the surgical resident perforates the bowel and all of a sudden cachectic Granny has an incision from her pubis to her xyphoid and the you know she is not going to breath post-op.  You could call ICU but you can already hear the peals of laughter from them when you ask for a bed.  So you take her out to recovery on a ventilator and the recovery room nurses are really pissed off at you. (The surgeon is meanwhile telling the family that she is being ventilated because of the anaesthetic.)

The bottom line here is that other people on your behalf made promises they didn't have to keep, she was just having a quick case, she wasn't going to die today.  Had you seen her, you may have said otherwise but you weren't invited to the discussion.

The other issue is that Granny is a DNR or whatever you want to call it (we have a very complicated Goals of Care document in our region).  Technically you can just turn off the ventilator and watch her struggle for minutes to hours until the hypoxia/hypercarbia trigger the final lethal arrhythmia.  You could even sedate her a bit.  Nobody really wants to see that though. I've turned off the ventilator on organ donors enough but somebody that you talked to an hour so ago?  Not sure about that one.

The other scenario is the pathologic fracture and the ensuing tumour embolus.

This is not to say that either patient shouldn't get surgery.  A bowel obstruction or a pathological fracture can be pretty incapacitating.  The issue is that in that population there is a high risk of death or requiring ventilation post-op and this is something that needs to be discussed with the patient and their family and never is.  Granny for example might elect for an NG tube and a lot of morphine or a radiologist might be able to do something percutaneously.  

When I was on the admin dark side, some people came to our Medical Advisory Committee to discuss the above Goals of Care document.  I took the opportunity to express my concern about these scenarios and the fact that we are never invited to these discussions.  "Yes, that is a problem," said the nice lady and went on to the next question.

The final issue is that having decided it is okay for doctors to kill people under circumstances how do we actually go about it.  Because as I blogged in respect to Capital Punishment it is really hard killing somebody when you really want to.   I mean those of us who do "monitored sedation" know how easy it is to make somebody apneic and occasionally cause a cardiac arrest but when you really want to kill somebody it may not be as easy as you might want.

As I understand currently the practice would be to administer large doses of oral barbiturates.  20-30 years ago getting barbiturates was easy.  About half the population were on them as sleeping pills.  We even gave them to pregnant women.  If you gave somebody a months supply of Seconal you usually gave them enough to kill themselves.  Now if I order a lethal dose of a barbiturate, the pharmacist is probably going to ask some questions.  He may even refuse to fill your prescription. (A significant number of pharmacists refuse to dispense the morning after pill, presumably these people may have some opinion on euthanasia)     That plus in some provinces barbiturates are on the triplicate prescription program.  Assuming that you have gone thru the proper procedures for physician assisted death, you won't necessarily get in trouble but you may get hassled. 

Of course getting somebody who has a swallowing problem or who is drifting in and out of consciousness to swallow all those pills is going to be a little difficult.  That is why probably a lot of euthanasia is going to be intravenous which has its own issues because IV access is not that easy as I find out once a week or so. 
The other issue is that a lot of the euthanasia candidates are going to be narcotic tolerant which means you are looking at bigger doses.  Dose is a problem because you can give a huge dose and still not kill somebody.  (I remember a story in medical school which I hope is an urban legend about somebody who took a huge dose of horse tranquillizers and woke up days later on the stretcher on the way to have his kidneys harvested.)   I have a friend who is now a retired anesthesiologist in Holland who tells me of GPs coming to the OR to "borrow" some pancuronium and everybody knows what they intend to do with it.

Looking forward into our brave new world of legalized euthanasia or physician assisted death (because why use one word when you can use three) who is going to be doing the killing?

I think a lot of doctors are already thinking, I'm just going to call anaesthesia, they have all kinds of cool drugs and besides we already blame them when somebody dies.  I think most of the leaders in anaesthesia are trying to keep a low profile lest more people think that way which is too bad because we as a specialty should be part of this debate.

There are the evangelical physician advocates of PAD who are already active and will probably do a good job of it  although there are not very many of them.  Knowing doctors as I do too well, I predict the following scenario.

We have socialized medicine in Canada which means that doctors who euthanize patients will expect to be paid.  This means that a generous fee will be negotiated, because this has been mandated by a court decision provincial governments will pay whatever is demanded.  This means a certain class of doctors, who we all know, are going to realize that they can make a killing out of killing people and it is they who are going to be doing most of the PAD.  

Wednesday, April 13, 2016

I Call Bullshit

I don't often call out patients.  Something about bedside manner that we sort of learned in medical school.  But a recent encounter with a patient makes me think maybe we should all do it more often.

I was sitting in a multidisciplinary assessment of a patient in a clinic where I work sometimes.  Now I believe many of this patient's concerns about her condition are quite valid and I have a lot of sympathy for her plight. 
She was going on about how for health reasons she only buys food directly from farmers she knows or eats game that her husband and she hunt or is hunted by people they know.  I have no problem with this.  I like to buy some but not all of my food at farmers markets often paying 50% more and while I don't hunt, I am not against hunting and if somebody offers me game I always take it.  I should support somebody who is trying to be pro-active about their health.  Except.....

She smokes 2 packs of cigarettes a day despite now having COPD.  

I had been letting my colleagues run the interview until the alarm from my BD became too loud in my head.  5 years of administration has increased my BT but this was too much.

"If you are concerned so much about what you eat," I said, "why do you continue to smoke, given all the harmful chemicals in cigarette smoke."  She replied that she had smoked for 30 years and was unable to stop.  The visit went on and I don't believe she came back for a follow-up.  OK, I am busy enough and maybe I couldn't have helped her anyway.  I also appreciate how difficult giving up smoking is, because really with all the evidence about how dangerous it is to your health, everybody who is capable of stopping has.  

A few years earlier, I had another almost identical  patient and never challenged her on this but maybe I should have.  

This encounter made me think however.  Are we hurting patients by not challenging them on their beliefs or behaviours.

A good example is the resurgence of vaccine-preventable diseases.  Now many of the patients/parents are not going to listen to reason, however how many family docs or paediatricians knew of patients in their practice, who had not been vaccinated and never challenged this because calling bullshit goes against our concepts of bedside manner plus you depend on the income from their office visits (and if you are in a small town, the visits of their friends and relatives).   Sure, most of them wouldn't have listened but maybe a couple would have.   Call bullshit. 

Obesity.   Look I weighed myself yesterday and I am pretty upset with what I found, not that I am going to forgo the Chinese buffet for lunch today.  But when your BMI 60 patient tells you, they do know why they can't lose weight because they don't eat anything, why not tell them that just to maintain that weight they need to consume 6000 calories a day and unless they have evolved to develop the capacity to photosynthesize, something is obviously going into their mouths.  And when they say they can't exercise because of their knee or back pain, tell them that exercise doesn't work without caloric restriction.  I have a lot of sympathy for fat people because I am one of them and I know how easy it is to gain weight and how difficult it is to keep it off but the odd person does this successfully and if you don't challenge them they might not get started.  So call bullshit.

Drug allergies.  A few years ago while still department head, I got a letter from our Patient concerns office.  Apparently a patient had presented for surgery with multiple anaesthetic "allergies".  Instead of trying to give an anaesthetic with the 3-4 remaining drugs she was not allergic to yet, my colleague called bullshit resulting in a complaint.  (In my response I called bullshit on the surgeon, who should have had this taken care of before the patient reached pre-op holding.  Sure as a urologist, he probably didn't talk to her but with these patients the "allergies" are usually the first thing they tell you about.)  Likewise my colleague who argued with a patient about her morphine allergy.  He got written up despite giving the patient dilaudid intra-operatively.  Then there is the adrenaline allergy which I saw a couple of weeks ago.  The patient said it makes his heart beat fast.  What happened of course was during an adventure in the dentists' chair a little or a lot of local with epi went intravascular, as happens even with good dentists, and instead of manning up and telling the patient this, the dentist took the cowardly route and told the patient he had an allergic reaction.  So if this patient actually has a real anaphylactic reaction under my care, am I going to go searching around for vasopressin or whatever else might work?   No of course, I am going to call bullshit and use adrenaline.  Likewise the local anaesthetic  "allergies" after a misadventure in the dentists' chair.  Penicillin allergies?  Years ago I almost killed a child with vancomycin because of a "penicillin allergy"  ( it was my resident but I am old school and take responsibility for what trainees under my supervision do).

And of course when the patient mentions how great his chiropracter/naturopath/homeopath is, call bullshit and remind them that when they have a medical problem at 3 am it won't be any of those 3 seeing them.  This also applies to conventional practitioners.  When you patient refuses to take your medication because of something the pharmacist told him, remind him that you went to university the same number of years as the pharmacist BEFORE you went to Medical School.  (I call bullshit on myself here; I only did 3 years of undergrad before going to Medical School).  Having said this, I do work closely with pharmacists and have gotten a lot of good ideas from them.

Surgeons who want to do cases after hours because patient has cancer.  Sorry unless it's an obstruction or a pathological fracture.  I already blogged on this.  Doing the surgery tonight or on the weekend makes no difference to your patient's survival and I am sorry that your patient got cancelled earlier because they misunderstood the NPO instructions or they had medical issues or as is usually the case, your list ran over because you still haven't figured out how slow you really are but after hours is for broken bones, appendicitis etc.  Likewise the guy who presented with renal colic 2 weeks ago but is now pain-free and afebrile; not an emergency.  I call bullshit.

Surgeons who game what after hours prioritization system you have decided to use so that they can do their cases when it is convenient for them.   Surgeons who bring in cases off their wait list to make their on call financially worthwhile.  I call bullshit.

And of course admin.

I now wish that during all the meetings I attended, instead of staring at the ceiling and feeling the spirit ebb from my body, I had just kept on chanting bullshit, bullshit, bullshit.

I call massive C Diff, enterococcus filled bullshit on just about everything Infection Control does.

No money for anaesthetic machines but you want to put a Pyxis in every OR.  I call bullshit.

Calling bullshit on admin, as I found out doesn't work which is why I have all this free time to write a blog.  Not that I discourage it. 

Saturday, April 9, 2016

Reefer Madness Part 4 and Another 15 Minutes of Fame.

I just attended the annual meeting/course put on by the Canadian Consortium for the Investigation of Cannabiniods which I joined a couple of years ago.  I have prescribed/authorized medical marijuana for patients since 2001.  I do so in the context of my chronic pain practice and with some hesitation. 

A week or so on what must have been a slow news day our local paper announced in a front page headline story that a medical marijuana clinic was opening in our city.  Having commented on medical marijuana in the past, I had a feeling that I was going to be hearing from the Fourth Estate pretty soon.  

While I do provide authorization for medical marijuana in appropriate patients,  I have a jaundiced view of medical marijuana clinics.  Over the past few years patients have informed me that for $400 a clinic somewhere else in Canada will give them a "Skype interview" after which they will get an authorization for medical marijuana (under the old regulations) and usually are able to buy product from the affiliated grower.  

I am not sure what the Skype interview consists of; holding their wallet up to the camera on their computer maybe.  This is sleazy practice, and I usually offered to complete the paperwork for "free" if I think they are appropriate candidates.  

There have been incidents like this:

I also increasingly believe that chronic pain should be managed in a multidisciplinary fashion not in silos of care such as medical marijuana clinics or for that matter the block shops we have in our city.  Unfortunately opportunities for multidisciplinary management are difficult because while health care in Canada is "free", physiotherapy and psychology are not.  Further for lack of resources, I and the loosely affiliated group of physicians I practise with  have an 18 month wait list for consults which even by Canadian standards is excessive. 

Our thankfully former Tea Party government who were of course anti-drug were most distressed by the concept of anybody using marijuana but were bound by a court decision, so came up with a solution that is probably the one thing in their 10 years in office that actually worked.  Instead of patients trying to grow their own marijuana (which most of them were not very good at) buying it on the street or from the lone government approved supplier, growers would be able apply for licences to supply patients who would get "prescriptions" from doctors.  I had previously discussed this in another blog.  The advantage of this system is that patients can now buy cannabis from facilities that are inspected by the government and that the THC and CBD content of the product is known which allows doctors and patients to select products of known potency.  This has resulted in about 30 companies, some large and some small being able to provide medical marijuana and according to the man from Health Canada there are 2000 applications to become licenced producers.  

Anyway, it wasn't long before I was contacted for an interview.  This came from a reporter from one of the free newspapers people read on the bus or in coffee shops.  A little down market from my usual encounters with the press but there is no bad publicity.   I basically told him what I had said above.  I said for reasons above that the medical marijuana clinic would have very little impact on the treatment of chronic pain.  I also said that what should have been the headline was the distressing lack of resources for treating chronic pain.  Further I said that while I hoped the physician starting the clinic had the noblest of motives, many people in the past had exploited the vulnerable chronic pain population.

The interview lasted about 10 minutes of which a few sentences made the article.  You can probably find it on Google but I am not going to help you.  It did state that I said there was no need for new physicians to prescribe medical marijuana because there were already enough in our city which I don't think I said. 

The entrepreneur/physician got to comment the the next edition of said free newspaper in which he claimed in messianic fashion that our city had been selected of all the cities in Canada because there was a need for doctors to prescribe medical marijuana.  I don't really think we are better or worse than anywhere else in Canada and he may have other motives for adding to his chain of clinics such as availability of office space or maybe he has a girlfriend in our city.  

I must say I only read these articles fully on line just now while writing this blog.

My next interview request came from CTV and they wanted to interview me on TV.  I took a media relations course a long time ago and the one thing that stood out was using the interview to advance your agenda.  Unfortunately when they contacted me I was on my way to Toronto to attend the above meeting but we agreed that maybe I could be interviewed by Skype in Toronto which I agreed to and I spoke with the reporter on phone and basically told her what I had told the free newspaper reporter only having had time to reflect in more polished form.

I was subsequently contacted by CBC French who wanted an interview which I did on the phone in English from Chilie's in the Calgary airport where I was having a beer and a burger before flying to Toronto.  I was on a roll by then and gave what was probably the best interview of my life.  Too bad I don't listen to CBC French.

Just before my plane took off, I got an email from CTV stating that they were going to cancel the interview because of lack of time.  I suspect the real reason was they realized that I wasn't going to talk about medical marijuana (which is sexy) but was going to talk about chronic pain (which is not sexy except when people smoke dope).

As I have said during this time I was getting ready to go the CCIC meeting in Toronto and just happened to look at the program and discovered that my entrepreneur friend was one of the speakers. Interesting, I thought I will at least get to put a face to name.  I was a little worried because as above I maybe hadn't been that positive about his little business and he had probably read my comments.  I went to two talks by him and he is pretty smooth and I am not sure what to make of him.  I probably should have taken him out for a beer (or smoked a doobie with him) to welcome him to our medical community.

The only blowback I got during the meeting was at lunch on the second day when someone sat down at my table looking at my nametag and said, "Oh you're the guy who thinks your city doesn't need a medical marijuana clinic."  I said something about how it was a 10 minute interview and they had taken out a few sentences and the moment passed.

Otherwise it was a great meeting with some really good talks and I learned a few pearls.  Unfortunately the meeting was essentially preaching to the choir although there were some people who were really pro cannabis.   It would certainly be nice if the people who oppose medical marijuana attended meetings like this and maybe we could have a dialogue.  

The other interesting thing was that the meeting was heavily sponsored by medical marijuana companies and there was a pharmaceutical trade show.  No free samples though.

Wednesday, March 30, 2016


I recently realized that the season is almost over and I haven't watched a hockey game from start to finish.  Last Saturday I watched the beginning and end of the Toronto Boston game but turned the TV off for a leisurely supper before turning back on to watch Boston hang on for the win.  I didn't bother watching the second game of the Saturday night double-header.

I used to love hockey.  As a child, teenage and young adult, I never missed a chance to watch a game on TV.  I had season tickets to our local NHL team for 4 seasons.  Now if I tune into a game, I quickly find myself looking to see what else is on either on other stations or Netflix.  If I watch a game, I am usually reading a book, the newspaper or on Facebook.  On the other hand, I still read the sports section, and check scores in the evening on my computer.   It is not a distaste for sports in general either.  I still watch the CFL and NFL.  I love watching the Olympics when they are on.  

This comes at a time which should be the golden age of hockey watching with a game on TV just about every night of the week, and a minimum of 2 on Saturday night. If you look at the quality of play, the skaters are better, more mobile, faster.  I just can't seem to get excited.  I was trying to figure out where my passion had gone.  There are reasons; some of them are things that have bothered me for years, some are new.

I know the NHL brass read my blog so.......

The season is too long.

Not a new problem but the season has in my lifetime gone from 70 to 84 games.  Way too many.  I remember in the 1970s the players union offering to take a 1/8 paycut to shorten the season to 70 games which the owners turned down. This doesn't explain why I don't seem intererested in October either.  

The playoffs are way too long.

The first year I watched hockey (1964) the playoffs ended on April 29.  I remember this date because instead of watching game 7 of Detroit-Toronto we had to go to dinner for my mother's birthday.  I also remember in 1968, my brother telling me that because of expansion, there would actually be hockey played in May.  Crazy I thought.

Okay there were only 4 teams in the playoffs not 16, I understand.  But hockey in June.  Most of Canada and a significant amount of the US have 5-7 months of winter and the last thing we really want to do is to spend time indoors watching playoff games.  Its not just that there are twice as many rounds, it is the leisurely pace they seem to schedule games mostly to accomodate TV.  I remember in the 1970s they actually started the playoffs with 4 games in 5 nights (quite often with games 3 and 4 played Saturday night and Sunday afternoon).   That's right teams were often eliminated within a week of the playoffs starting.  Now there are frequently 2 or 3 nights in between games and frequently up to a week between series.  This is at a time when players are actually a lot fitter than they were in the 1970s.

And, when the NHL added the fourth series in the mid 1970s it was initially a best of 3 series which was extended to a best of 5 series when they went to 16 teams in the playoffs.  And yes, there were upsets where an inferior team eliminated a better team just like there are with best of 7 series.  That's why we have playoffs otherwise we could just give the Stanley Cup to the regular season winner and we could all enjoy our springs.  Major League Baseball still has their first round as a best of 5 even with all the variation pitching brings in.  

So why not make the first two rounds best of 5 again?  Not likely as home teams make $1,000,000 plus for each playoff game and with no revenue sharing no team is going to give up that type of potential payday.

The problem is of course is that by the time the finals roll around, everybody has lost interest outside of the fans of the two teams in the finals and most likely even them.  Take 2012 when the NHL finally had the match-up they had dreamed off when they expanded, a team from New York (New Jersey actually) against a team for LA.  I remember turning on the TV one night.  "Oh are they playing hockey still?" I thought.  So why would you want to take your showcase, the two best teams in the league and put it on at a time when you have the best outdoor weather plus you are going against baseball?  I really can't wait to not watch what will probably be this year's Stanley Cup final LA or Anaheim vs. Florida.

The games are too long.

Common thread here.

The one thing I remember from my years as a season ticket holder is being bleary eyed the next morning after a game that went on for 3 hours.

Now to its credit the NHL has done something to reduced the length of the games.  Not enough though.

I remember again in the 1960s,  games ran 2 hours and 15 minutes or less.  In fact the CBC had a 15 minute program which followed Hockey Night in Canada.

There are lots of possible solutions.  Only allowing line changes on the fly, maybe even getting rid of faceoffs in certain situations.  Reducing commercials.  Yeah right.

 Gary Bettman

A face more punchable than Ted Cruz?  (Not that I advocate violence, a good wedgy would suffice.)

Interesting how you can pin the state of the game on one person.  It is hard to believe (actually not) that he has been commissioner for over 20 years.  Now his two predescessors John Ziegler and Gil Stein were not the greatest hockey guys and maybe some of us thought Bettman might be good for a few years before they got a real hockey guy to run things.

But here he is, still running things.  All he has accomplished is 3 work-stoppages including a whole season lost and the movement of two Canadian teams to the US.  

It just irks me to see him on TV at a game (an infrequent event because he rarely goes to games and I rarely watch now) sitting in the expensive seats or the owner's box looking at his Blackberry, not watching the game.  That and his periodically lecturing city councils about how they need to have a publicly funded arena to replace the perfectly good one already there.

And there is of course the ritual booing when he presents the Stanley Cup.  The most sacred moment in hockey spoiled.  I don't blame the fans, I would boo too.  Since you are not going to step down Gary, why not give us a break, let some hall of famer present the Cup.  Imagine Gordie Howe, Bobby Orr or Wayne Gretzky presenting the Cup.  

It makes one long for the days of Clarence Campbell.  True he did some stupid things, like not letting Vancouver in the initial expansion and not letting the expansion teams draft any players of consequence condemning fans to years of lousy hockey.  But... he was Canadian, he had been a referee, and he went to games including going to the forum in Montreal after suspending Rocket Richard.   Plus when he presented the Stanley Cup,  he then went to the dressing room and talked with the players in their underwear.  Can't imagine Bettman doing that.  

The current divisional line-up

Okay what type of league divides themselves 16/14 rather than 15/15.   This means the Western teams have an 8/14 chance of making the playoffs vs 8/16 in the East.  True the Western teams have a tougher travel schedule.  What it really is, is a giant fuck-you to the concept of expanding to Quebec, Hamilton or a second team in Toronto  when they go to 32 teams because there are clearly too many Eastern teams now.  Which means we will be getting a team in Las Vegas and some other Western city that the league will have to prop up just like they prop up Phoenix now.  Like was there no team in the Eastern Conference that could be moved over to the West?  Why not on rotation make one of the three New York City teams play in the West on a rotation basis so they can see what it is like to travel?   And, what is the point of having a wild card when the teams in each division have a different schedule.  

I have personally thought why not split the thirty teams into 3 conferences, either Western, Central and Eastern or Western, Northeast and Southeast.  Time zone and travel wise, makes more sense.  Playoffs may be a little tricky but it would work.

Some people have suggested a premier league like in soccer and while second division teams might be less of a draw, the knowledge that your team is actually competitive might bring out fans.  Having the top teams play more often would be great for TV.  And like the FA cup everybody could play for the Stanley cup at the end of the season (all the premier league and the top second division teams).

The shoot-out / overtime

Back when I watched hockey in the 1970s, games actually ended in ties.  (Montreal who won  the Stanley Cup in 72-73 had 16 tie games.)  I remember a lot of the time, you turned off the TV or left the arena and thought you had seen a pretty good game.  It is true that occasionally in the last 10 minutes of a tie game, teams just passed the puck back and forth between the blue lines but quite often the tying goal was also scored in the last 10 minutes.  

For no apparent reason however the NHL went first to a winner take all overtime.  That still left ties so they brought in the shoot-out after a 4 on 4 overtime.  I have said this before, the shootout is not hockey.  Now they have gone to 3 on 3 overtime again followed by a shoot-out.  A little better but still some games get decided in the travesty of the shootout.  Another factor is that the winner of the OT/ shootout gets two points, same as the team which wins in regulation time.  The loser gets a point which is fair because if you survive 60 minutes tied, you should be entitled to a point.  This of course means some games are worth 2 points and some worth 3.   At a time when teams make or miss the playoffs by one point this is pretty significant.  

So why not give 3 points to the winner, 2 for an overtime winner and 1 for an overtime loser like they do in international tournaments including the Olympics.  The NHL justifies this by saying that this keeps the playoff races closer.  Artificially closer.

So if you don't want ties, why not just play until somebody wins like they do in Baseball and Basketball (and hockey during the playoffs).  And if the shootout and 3 on 3 are so exciting, why not have a shootout competition or a 3 on 3 tournament?  Just don't destroy the sanctity of the game with a gimmick.

The rules / inconsistency of the refereeing.

As others have pointed out this season, the quality of refereeing in the NHL has been inconsistent.  Not at all what you should expect in the what is supposed to be the best league in the world.

And part of the problem is that the rules are so vague.  For example does anybody understand what the current rules are about the crease and contacting the goalie inside or outside the crease?  Why not makes rules which actually clarify what is and isn't allowed.  Again going back to the 1960s, the rules were pretty clear, all of both feet in the crease and the goal didn't count.  I certainly don't want to go back to the toe in the crease rule of the 1990s.  So why not have a smaller primary crease where you can't go at all and a larger secondary crease where you can't contact the goalie.  And not all goalie contact should be penalized.  Blowing the play dead is enough.

Further while goalies are important, expensive and only 2 are dressed for a game, why should they be immune from contact if they decide to play defence?  

Another thing that bugs me is when a player gets pushed into the goalie and that player gets a goalie interference penalty.  The play by play announcers always, say that the player should have made more of an effort to avoid the goalie.  Sure try doing that when you are off balance being pushed by a defenceman who weighs 50 lbs more than you.   The whole goalie interference thing is so subjective, one guy farts near the goalie and gets a penalty, somebody else skates thru the crease and takes out the goalie and a goal gets scored.

The other thing is whether the puck actually crosses the line.  You would think by now the NHL would have some type of sensor to determine  whether the puck is over the line.  Or else simplify it so that instead of the entire puck crossing the line, the puck just has to break a plane on a line which could be just behind the goalposts for example.  The NFL does this already.  

But there is just the inconsistency in how the game is called.  A penalty at one point in the game is not a penalty at another time in the game.  Even up calls.  No other major professional league does it.  

Other sports (except maybe soccer) bring in rule changes to make their game more exciting and more fair.  Hockey not so much.

Too many teams

From 6 to 30 in my lifetime.  Maybe there are 5X as many elite players as there were in 1967.  The main problem is that it is just too hard to keep track of them all, too hard to get excited about Columbus.  Sometimes I read about some player I have never heard off and they are talking about him being in the running for a trophy.  Baseball which also has a lot of teams at least divides them into two leagues with differerent rules and until recently no interlocking play.  Football has two conferences although they play interconference games.  Because the NHL decided that every team should play every team home and home, this means less games against rivals or other teams in your division.  So every season ticket holder gets to see Montreal and Toronto once a season; they also get to see Columbus once a season.  

Free agency/salary cap/ trade deadline

I am conflicted about this.  Maybe players are overpaid but they have to right to what the market will bear and the owners who all claim to be astute businessmen don't have to pay them.  On the whole I would rather watch an elite hockey player than an investment banker or a corporate lawyer.  It has however gotten to the point where the turnover of players every season robs many teams of their character.  This is opposed to the situation before the advent of free agency where the best teams at least made very few roster changes every season and the move of a star player from one team to another was a major story.  

And why do  GMs feel that they have to rebuild or gut their team the week before the trade deadline.  I suspect if you added the pluses and minuses of trades at the deadline, the ledger would be solidly on the negative side.  And if it is your team that is being gutted imagine how as a season ticket holder being told that your GM has given up on the team you shelled out thousands of dollars for tickets, even while they still haven't been mathematically eliminated yet.

Not sure how you deal with this.  Revenue sharing might be a good start.  

Canadian Teams

OK.  I do cheer for an American team which I have always justified by telling myselve and everyone else that their players are mostly Canadians.  

The lack of success of Canadian teams recently is somewhat upsetting, especially as Canada got skunked in the playoff department this time around.  In fact Canada hasn't won a Stanley Cup since 1993 although 4 teams have made the final since then.  Not much of a statistician but with 7 out of 30 teams we should be looking at a champion every 4-5 years.  

I'm not much of a Habs fan but given that they won about every other year in my youth,maybe the universe would be back on keel if there could be a Stanley Cup parade in Montreal along "the usual route".
I can and do embellish my old-fartedness by telling younger people that I actually remember the Leafs winning the Stanley Cup.  I in fact remember them winning two Stanley Cups and they won four in my lifetime.  

At the same time I wish the national media would remember that there are 7 teams in Canada not just the Leafs and the Habs.  


This has been a topic of conversation a lot but the goalies even the not very good ones have become so big now that it is impossible to score on them.  It is interesting to think of putting someone like Ken Dryden who was pretty big for his time into modern equipment and trying to score on him.  He probably wouldn't have lost a game in his career.  (He only lost 50).  

The league has been talking about this for at least 10 years but haven't really done anything.  Here's a suggestion.  Why not replace the first baseman size glove they currently get with a catcher's mitt.  Lots of padding but smaller and harder to make difficult catches with.  And make the blocker smaller.  Just big enough to protect the goalie.  And their stick doesn't need to be as wide.  And again I remember in the 1970s goalies used to get delay of game penalties if they froze the puck unnecessarily.  The rule is still in place why not enforce it.
The rink is too small

Imagine if Major League Baseball played on the same size field as little league.  The NHL plays on a rink the same size as my kids played on at age 8.  Now watching international hockey with their bigger rink doesn't make for a more exciting game however players are bigger and faster now.  In my lifetime every NHL team has built a new arena including a new one in my home town, and they are still building them to the same size as when players were smaller and skated a lot slower.  (I could be wrong but I think the Saddledome in Calgary built for the Olympics was built to Olympic size and then reduced to NHL size).  Sure in the transition, we would have arenas of different size, but that would  just like when Chicago and Boston had smaller rinks and just like Major League Baseball parks now. 

Saturday, March 26, 2016

You're Fired

Most of us told the Medical School admission committee that we wanted to become doctors so we could help people.  This is of course true only in the sense that outside of the most evil, selfish person everybody wants to help somebody.  This is hard-wired in our biology and soft-wired in our upbringing.  There are much more easier and cost-effective ways of helping people than 4 years of medical school and 2-5 years of residency.

People assume that we went into medicine to make a lot of money.  Again if we had wanted to make a lot of money, a much surer route would have been a Commerce/Business degree, Law or Dentistry.  Or I could have not taken my brothers' advice and gone into Computer Science (I would have graduated in 1979).

The main reason most of us go into medicine is for the job security.  On that day in June in 1978 when I got my letter from medical school, I knew that unless I messed up badly, I was set for life.  

Having said that, I have been out of work at times in my career usually only for a few weeks at a time when I was a family doctor.  When I finished my residency jobs for anaesthesiologists were thin.  I got one, but when I was sitting my oral exams I was the only person of the 8 who sat the exam on my day who had a job after residency.   Into the 90s residents who finished in our city endured months of locums, or picking up a day here and there before gradually sliding into a stable position.  

Currently there are a number of specialists in Canada looking for work.  I met a former neurosurgery resident who switched to family medicine (where there are lots of jobs for now). who told me, all the surgery residents are told up front that only 50% of them can expect to get jobs when they finish.  The fact that so many of them soldier on in the face of such odds is a testament to their tenacity and love of surgery or perhaps just confirms what I have always felt about the intellect and insight of most surgeons.  

However surely once you get a job, you can't be dislodged from it unless you really mess up?

I do not know all the details and if someone will enlighten me I would love to publish it.  They had apparently a long and possibly acrimonious battle with their hospital over Obstetric coverage on call.  (They are not the only such hospital in BC, at one hospital the anaesthesiologists threatened job action, which didn't go so well for them.). This resulted in the hospital mailing to each anaesthesiologist a letter informing them that in one year's time their hospital privileges would be revoked.  The exact significance of this is unclear.  Someone I communicated with told me that probably the people who administration saw as trouble-makers would not be brought back (and that those who came back would come back on the hospital's terms which would I presume include agreeing to covering Obstetrics in the way the hospital wanted). .  There is still a bit of a shortage of anaesthesiologists in Canada.  The area is question is a nice enough if quite expensive place to live and from comments in the media, administration and the government do not expect to have any trouble finding scabs to work there should they fire a whole bunch of people.  (And if you think on principle, doctors, if the position is attractive enough, won't replace doctors who have been unjustly terminated, what colour is the sun on the planet you live on?).  There is also a large pool of people with dubious qualifications in anaesthesia lurking around working in small hospitals or even delivering pizza that I am sure admin would hire in a pinch because after all anesthesia is really pretty easy as you will read below.

Relations between doctors and the government/administration have always been bad in British Columbia going back to the 1960s.  I have worked in BC on and off as a general practitioner and as a locum anaesthesiologist and this relationship and the general unhappiness of the doctors there, despite living in what the rest of the country thinks is paradise, has always struck me.  I am not sure whether firing or threatening to fire 20+ people  is  a conflict resolution strategy taught in administrator school and it is certainly not the way of building a productive relationship with your current and future staff.  

I am reminded of a story I was told about a hospital in BC.  The anaesthesiologists were unhappy and so had a meeting with the administrator.  He started the meeting by saying, "You guys just sit around in your pyjamas and read all day".

Most doctors in Canada have a relationship with the hospital called hospital privileges.  This means that while they are not paid by the hospital, they are allowed to practise their craft there.  In return the doctor has responsibilities including, taking call, practising to a certain (undefined) standard and sitting on committees (although doctors nowadays are rarely invited to do so).  Hospital privileges are just that, a hospital does not have to accept you on staff for any reason, even if affects your ability to practise in the community.  For example many hospitals up until the 1960s in Canada did not allow Jews to be on staff or had quotas.  On the other hand, courts have found that removal of privileges is a disciplinary matter and there has to be some type of natural justice involved in the process.  Many hospitals get around this by having medical staff sign a contract giving them a fixed term as short as one year.  I for example after joining the Centre of Excellence was a little alarmed to find that I was on a one year contract which the hospital did not have to renew.  When the CofE became part of the health region this stopped.  Currently we have to be reviewed every 3 years and during my tenure as chief I conducted a number of these reviews but as far as I know, I never had the option of terminating anyone not that I would have done so.  Our hospital does have, outlined in great detail in its By-laws and Medical Staff rules a process by which a physician could be removed but I suspect nothing is going to happen without lawyers getting involved.

The process of removing an incompetent or dysfunctional staff member is in fact quite a long and unpleasant process.  If incompetence is suspected, there is usually a process of collecting data on the physicians which is difficult because many of the failings of the physician are small but cumulative matters which are individually not worth documenting.  Many incompetent doctors are well-liked (and many not well-liked are extremely competent).  In the case of anaesthesiologists surgeons love incompetent anaesthesiologists because they often work fast, never cancel cases and don't waste time with things like lines and epidurals.  And of course the one skill which never seems to be diminished by age and infirmity is the ability to cover ones tracks.  Medicine is still mostly an art.  What appears to be poor practice may just be the way one was taught 30 years ago or the knowledge through experience that certain corners can always be cut with impunity.  I do many of my cases with an infusion of lidocaine, ketamine and remifentanyl (plus a sniff of the volatile du jour mostly for my piece of mind).  I devised this cocktail during the boredom of 6 hour cases at the centre of excellence.  It works and others have imitated it. I shudder to think of a my-shit-doesn't-smell academic anaesthesiologist / reviewer looking at my charts or spending a day in the OR with me. 

It is somewhat ironic that it is difficult to be terminated for incompetence but apparently easy if you or your group piss off admin.

The ability of a hospital to terminate en mass a group of physicians, especially a group of anaesthesiologists is a bit chilling however.  We are hospital based specialty, opportunities outside the hospital are thin and positions at other hospitals are finite.  It is particularly chilling to my colleagues and I because we have been involved in a dispute with our hospital for years over obstetrical coverage.  Our hospital has a low caseload which means that the demand for anaesthetic services has always been low and it is not unusual to go for hours with no need of anaethesia.  Our operating room on the other hand is staffed after hours for two rooms and so we have two people on call.  One of these nominally covers the case room but there is usually pressure to staff the second room which is fine when OB is not busy but can be a problem with OB is busy.  Even when OB is not busy the nature of OB is such that you have to be available in 30 minutes, which means if you are sitting at home on second call, you have that 30 minute leash, meaning you are for all intents and purposes working even if you aren't getting paid.  This is also a problem when you agree to do the " quick 30 minute case" in OR while covering OB which inevitably (besides finding the case isn't just a 30 minute case), results in the labour floor calling you seconds after intubating the patient about the horrendoplasty which needs your attention right now.  Compound this with OB's traditional reluctance to share any information about what is going on up there and what is coming in by ambulance.  Because of this my successor, the acting chief (now into her 6th month as acting chief) has been summoned to the Administrator's office to discuss how we can provide dedicated OB coverage while also staffing 2 rooms in the OR after hours (which means 3 people on call for a hospital with 10 ORs).  I am interestingly waiting to see what type of "solution" we will accept or have imposed on us.

This leads to the question of whether a department has an obligation to provide a service which is not financially viable (or which adversely affects ones lifestyle) which also applies to other specialties.  OB for example at our hospital has resisted on site coverage and do their offices and elective cases while also covering the labour floor.  None of the surgical sub-specialties at our hospital have a second call, they would argue there isn't enough work to justify it.  (When I was chief and a surgeon phoned me to angrily demand I call in a third anaesthesiologist to supplement the two already working, I would ask them, "Oh, and who is on third call for you?")

I am 58, now.  Although I still love my work, I don't have that many years in practice left anyway, and I only work half time in anaesthesia.  I will be looking more closely at my mail for the next while.  

Friday, March 18, 2016


Image result for famous masked wrestlers

When I was a teenager, I liked to watch professional wrestling.  I knew it was fake but as somebody told me, you will rarely see such good acting.  I used to watch every Saturday morning on CBC.  This was not the steroid fuelled, crotch grabbing, fancy hairstyle wrestling that became popular in the 1980s.  These were men with pot bellies usually wearing briefs and calf high boots.  There were the local wrestlers who were there all the time and a rotating cast of villains and heroes who came for a few weeks.  This included by the way a younger Jesse Ventura.

One of the villains was a masked fighter named appropriately Mr X.  He teamed up with the other villains such as "The Brute".  He was also claimed to be an American and loved to insult Canada, not popular in the 1970s very nationalistic Canada.  

It came that Mr. X was to fight "Gentleman Gene" Kiniski "Monday night at the Gardens". The Saturday morning broadcast (actually taped the previous Tuesday) served to promote the weekly card at "The Gardens" an arena somewhere in Vancouver.  There was a twist to the fight.  If Gene Kiniski who sported a crew cut and wrestled in briefs, lost, Gentleman Gene who was well into his fifties, would have to "hang up his tights".   If Mr. X lost he would have to remove his mask and reveal his indentity.  

Now usually fights like that were set up to end in a draw so that nobody would have fulfill their end of the bargain but the people who scripted All Star Wrestling decided it was time to unmask Mr. X, who duly lost to Gene Kiniski, who wrestled for many years after.  As I read in the sports section of the Vancouver Sun, which actually covered pro wrestling, the following Tuesday afternoon, Mr. X was actually Guy Mitchell, a Canadian.  This probably wasn't his real name either but Guy Mitchell formerly Mr. X wrestled on All Star Wrestling for the next year or so as a hero.  As an aside Gene Kiniski owned a bar in Point Roberts which I visited years later.  

This is a long winded introduction to announce that after 8 or so years of blogging anonymously I have decided to unmask, sort of.

I started this blog about 8 years ago, sitting home on New Year's Eve on call but with no work to do, the family down in the dacha.  I originally intended to write about politics and life.  I had been a very active member of the left wing discussion forum "Babble".  A few months later, I started reading medical blogs and this interested me so I started writing about what I know.  

I kept things anonymous, largely so that I would have freedom to write exactly how I felt without having to be confronted the next day at work by somebody I had inadvertently or intentionally insulted.  In addition, unlike most anaesthesiologists, I do some direct patient care and really wasn't interested in my patients Googling me and reading my blog.  I chose Bleeding Heart which was the name I used on Babble.  Bleeding Heart Liberal was a term I believe was used by Spiro Agnew or Richard Nixon although according to Google it originated in the 1930s.

I could have done a better job covering my tracks.  I have lived and worked in enough Canadian cities that I could have convincingly pretended to work in one of them.  I really didn't think anybody was going to read my blog.  Very early on, somebody contacted me stating that she had been able, using hints I had dropped, to identify me.  

A couple of years ago I blogged about an episode at work which I wasn't involved in.  It involved mis-use of the electronic medical record.  It was considered such a breach that we had hospital wide rounds on it.  Because the physician implicated, denied any involvement she wasn't named nor was she charged or disciplined by the hospital.  It was common knowledge apparently who it was; I have no contact with the area where she works so I didn't know her.  Our licensing body however, has a different standard of proof, and about a year later her licence was suspended and her name was published in the local paper.

This was a fascinating story, involving mis-use of medical records and also some real dirt which I won't elaborate on for reasons you will find out below.  I thereby published it with the details which had been discussed at hospital wide rounds, the details in the licensing body's report and of course the physician's name (I will call her Dr. X).  All the preceding was in the public record.   I had a fair sense of schadenfrude but did not want to slander the doctor.   I included a link to the newspaper article.

Checking my email the next morning, I found that somebody had already commented on my blog.  Opening the comment I found it was from Dr. X and it said words to the effect of why didn't you contact me to get the facts straight before you published your blog.  I got a little chill over that because clearly the blog had been written by somebody (me) working in the same hospital, so I immediately went to the computer, a checked the blog for accuracy, made a few changes for clarity but left it up.  After all everything was in the public record.  I also Googled Dr. X and found to my mixed pride and horror that my blog was the second link after the local newspaper article.

Later that morning in the middle of the pain clinic, I could feel a dark energy and the sensation of something boring in the back of head.  I turned and looked at the door and standing there was Dr. X looking daggers at me.  I had of course never met her, but I asked the nurse who was standing in the door.  It is Dr. X, she said, and she wants to talk to you.  Tell her to wait and I will talk to her I said, and I finished up with the patient I was with.  Meanwhile I was playing out the scenario in my head.  I felt I had three options:  I could lie and say it wasn't my blog, I could say yes it is my blog and I stand by it,  or I could apologize.

I didn't have to do any of this.  When I finished with the patient, Dr, X had left,  I suspect she didn't want to talk to me, she just wanted to know what I looked like, possibly so she could bludgeon me in the parking lot later.  (This hasn't happened yet  but I do remember that revenge is a dish best served cold.)

I thought hard about this.  Besides bludgeoning me, I figured Dr. X was going to go to admin and say, look your chief of anaesthesia writes a blog in which he makes fun of administration, surgeons, intensivists, his colleagues and me.  I would be hauled to the Star Chamber, have my chief badge ripped off and possibly worse things might happen.
Now I should mention that if Dr. X had in a comment outlined her side of the story, I would probably have published it.  In fact if she had contacted me with her side of the story I might have copied it into my blog.  If she was getting railroaded that would have been a  pretty juicy story that I would have liked a piece of.

Anyway after I thought about it I took down the post.  I also took down some posts where I had been really critical of administration.  I wish now I had saved them because they were pretty good.  I sent her a letter through hospital mail, telling her that I had removed the post and asked her not to attempt to contact me for any non clinical matter.  

Now while protecting myself was onr motive I should mention that having placed a face onto a name, I did have a little sympathy for Dr. X who had (or maybe had not) done an egregiously stupid thing but had been publicly humiliated for over a year both by people talking behind her back and later by having her name published and maybe I shouldn't pile on.  

I continued to blog although you may notice I haven't been that prolific due to factors like writer's block, spending too much time on Facebook and other factors.

So last week out of the blue, a colleague emailed me to tell me how much she enjoyed reading my blog.  I have know her for a long time, we started at the Centre of Excellence together.  She was much more prescient than me and decamped to another hospital after a couple of years, while I soldiered on, convinced that things were going to get better.  Is it that obvious that it is my blog, I emailed her back.  Well I am pretty naive,but I could tell it was you, was her reply.  I now wonder how many people read my anonymous blog knowing that I am writing it?

No more.  I am unmasking myself sort of.  I am not going to publish my name because I don't want people easily finding this blog by googling me .  


I am an anaesthesiologist in Edmonton Alberta.  I was department head at a hospital there for 5 years until I was fired.  I also do chronic pain management in multiple locations with moderate success and if you read RateMDs apparently a lot of failures.

Most of what I have published on this blog is true, based on the highest quality sources, namely coffee room gossip and innuendo.  Where I have presented patient cases, they are either composites of patients or I have changed enough details to make identification of the patient impossible.

I have strong opinions.  I have insulted a lot of people and groups of people in this blog.  If you are offended sorry (or not).  In the 360 degree evaluation the hospital paid an American company to do on the administation shortly before I was fired, someone commented that I should stop insulting groups of physicians.  My response to that is when they stop acting like bozos, I will stop insulting them.  (My evaluation was otherwise outstanding as the nice man from Boston who phoned me told me,)

I will continue on with this blog and once I shake my Facebook and Netflix addictions I may actually publish more frequently.