Wednesday, November 11, 2009

Why I won't be wearing a poppy again this year

One of the highlights of elementary school was getting the free poppy that was passed out every year. Back then they were made of felt and were a whole lot better than the plastic ones passed out today.

Poppies "celebrate" the deaths of Canadian soldiers in the First World War as celebrated by the poem "In Flander's Fields" by Dr. John McCrae a physician who died shortly after writing this poem. I can still recite most of this poem from memory (but I can't remember where I left my keys). Every year in November poppies are given out for a donation by Royal Canadian Legionaires and Army/Navy/Air Cadets. Not wearing them is, certainly for someone in the public eye such as a politician or other figure, a major faux pas.

I haven't however worn one since university. Not because I forgot to get one, not because I always stab myself with the pin, not because of the cheap plastic or that I always seem to leave them on the coat I am not wearing.

I first got a little disgusted at an event that happened years ago. At the ceremony in Ottawa, a group of women wanted to lay a wreath in memory of women who were raped during war-time. A little strident but we must also remember the number of civilians who suffered during the war as well. These women were physically restrained by a group of veterans from laying the wreath.

Remembrance Day was started as a day to remember how awful war really is in the hope that we would not have another one. Some people say that it was the horror of the first world war that lead politicians in Britain and France to appease Hitler in the years running up to WW2. Those of us who study history would say that WW2 was probably inevitable and whether or not Hitler was appeased only affected how early or late the war would have started. In fact probably not just a few British, French, Canadian and American politicians and businessmen actually liked what Hitler was doing until what he was doing threatened them.

When I was young most of our fathers had actually served in the second world war. My father did although he fixed radios at various airfield in Canada. Quite a few WWI veterans were still alive. These veterans marched silently on Remembrance Day in memory of their colleagues who died and in the hope that more would not have to die. Unfortunately as we get farther and farther away from wars as devastating as the First and Second World Wars, Remembrance Day has moved from a solemn remembrance of the horror of war to a celebration of war.

Over 100 Canadians have died in the war in Afghanistan propping up a government that oppresses women, Christians and ethnic minorities. Any criticism of this war is answered by the usual reply of, " Do you want those brave soldiers to have died for nothing". It is hard to answer this except to reply that yes indeed they have died for nothing and that maybe we should get out before more die for nothing.

I had a lot of hope for the 21st century. I really felt that we would find a way of solving problems in a way that didn't involve killing people.

I think I'll be forgetting to get a poppy next year.

Sunday, November 1, 2009

Unnecessary medical testing

White Coat has a post about unnecessary medical testing

He challenges us to find examples of unnecessary medical testing.

Just off the top of my head:

1. Electrolytes unless the patient is in renal failure, on diuretics or steroids, or has been vomiting or has diarrhea.

2. PT/PTT unless the patient is on Coumadin, or you are suspecting liver failure or sepsis.

3. MRI of the back or neck for chronic pain unless there are leg or arm symptoms.

Stupid People

An acquaintance of mine recently started work at the phone advice centre for our health authority. This service allows patients to call 24 hours a day and speak to a nurse who will triage according to protocols and give advice. This hopefully avoids some ER visits while getting some people who need to get into the ER right away into the ER right away.

She has been quite frustrated with just how stupid people appear. She feels that by tolerating their stupidity she is "enabling" them.

This of course reminds me of when I first started out doing locums as a family doctor. I was on call for a large clinic. They had a lobster party that night and even though I was on call for the group, they suggested I come out after the evening clinic as on call meant for the most part answering phone calls. At some point in the evening I had to call a patient who had called the answering service. I had already spoken to her earlier that day. One of the doctors overheard my end of the conversation and remarked when I hung up, "They don't teach you how to talk to stupid people in medical school do they?"

How true.

Both my parents were professionals and highly intelligent. I grew up in a middle class/upper middle class neighbourhood and went to a really good school. From junior high on academic and non academic students were segregated into different classes. I hung out mostly with the academic kids. I then went to university and on to medical school. Now some of the people I knew in University and Medical School weren't the sharpest knives in the drawer but we didn't have to deal with them except maybe to laugh at the stupid questions they asked during lectures.

Maybe I am a little dense but it wasn't until my internship that I noticed that there was this large underclass of people who didn't grow up with well educated parents, go to nice schools let alone university. These people showed up with complex problems that required some work on their part and some insight into their condition. And back then and now I still have a hard time putting a complex problem into simple words that can be understood.

Before the advent of pre-assessment clinics and screening, we saw most patients the night before their surgery and a few days pre-op in a pre-assessment clinic. When I worked at the CofE, just about every patient presenting for inpatient surgery was about to have some type of terrible horrendoplasty. I would sit there, try to make sense of their usual complicated medical history, and then try to explain the anesthetic aspect of their care including the epidurals, art lines, central lines and the possible ICU stay they were about to experience. I tried to go slowly. After all this, I would ask if they had any questions. Inevitably they asked one or more of the following three questions:
1. What time is my surgery?
2. How long will my surgery last?
3. Am I going to see my surgeon today? (I started replying, " I don't know, I'm not his secretary" until a patient complained about this.)

As a resident, when we did elective C-sections we actually used to give patients the choice between regional and general (as opposed to now where the OB tells them they are having a spinal). I actually overheard a person say, "Well if he doesn't know what is best, how am I supposed to decide". So much for informed consent.

Stupidity should not be confused with the absence of education nor does education guarantee the absence of stupidity. Stupidity is not just endemic in patients, it has infiltrated the system. Much of the administrative policy over the last 20 years has either been malicious or stupid. I think stupid. I used to think most internists and pediatricians were intelligent people who just lacked common sense. I know just think most of them are just plain stupid. I have already on this blog said what I think about surgeons. And yes, we have stupid anaesthesiologists too!