Thursday, August 26, 2010

SI you- nit

This is a sick joke my physics profs made when they wanted to introduce us to System Internationale Units. These professors were extremely entertaining and funny individuals which is really the only way to teach a pretty boring subject.

I have a pet peeve. It is the way people write dates, more the various ways people write dates.

Today for example is August 26, 2010. This can be written as 26.08.2010; 08/26/2010;26/aug/2010. I could go on, the permutations are endless. This is a concern for me because I write dates several times a day, and occasionally have to fill in patient birth dates on forms.

That is why 20 years ago, I decided that I would follow the SI convention of writing dates as YYYY.MM.DD or YY.MM.DD (we are far enough into the century now). This may not be best or most logical solution but they did make a decision and I have chosen to follow it.

While I realize that the US decided not to use the metric system, Canada and most of the world did and I can't understand why we are unable to figure out a consistent way of writing dates. Every time I fill out a form now, I have to look at how they want the date configured. Worse is when you are copying from one form with the date in one format to a form with the date in another format.

Come on people even in the US we are not dosing in grains and minims anymore.

SI You Nits!

Sunday, August 22, 2010


Emergency docs probably next to proctologists, have the best stories to tell which is why some many of them seem to have blogs.

I blogged some time ago against the routine use of antibiotics in surgery.

Here is an interesting article from White Coat's Call Room.

One of the 200 or so things that I hated about general practice that drove me into specialty training was the constant demand for antibiotics from patients (and the knowledge of that if you didn't prescribe them, one of your colleagues was going to and make you look stupid).

A long time ago, I was at a meeting at our licensing body regarding our triplicate narcotic program. This program is, as I found out, actually quite expensive and probably does very little to prevent drug diversion. The question was, what drugs should be on it? I suggested antibiotics. I was surprised how many people agreed with me.

Thursday, August 19, 2010

Euphemisms, Politics and the English Language

This is a good article,

A while ago I blogged about the tendency to substitute customer or client for patient and how it is subtly affecting medical practice. This article comments on our tendency to substitute less loaded words for loaded words such as substituting "unhealthy weight" for obese. Substituting "hearing impaired" for deaf and "visually impaired" for blind are other examples. It also points out that there is a drift with euphemisms gradually acquiring a loaded meaning. I am just waiting for the guy in front of me at the football game to call the ref visually impaired.

A few years ago I saw a patient with low back pain and dictated a consult in which I referred to her as mildly obese. Her family doctor showed her my consult and she arrived in ill humour at the next visit. "What do you mean I'm obese," she asked,"and how do you define obesity" I told her the I defined obesity as anyone fatter than me. This defused things, she is still seeing me and has lost a significant amount of weight (unlike me).

I still remember 1st year university English. This was a disaster for me. Although I was trying to get into medical school, my chosen career was to be a writer and medicine was just how I was going to support myself until I got published. I loved reading and thought I was going to do well in English. Unfortunately while I love reading, I really can't give a shzt about whether Robert Frost was contemplating suicide in "Stopping in woods...", whether Ophelia and Hamlet were lovers or what was "the theme of language" in Camus' "The Plague". I struggled through with a 66% which was my lowest mark until medical school.

One important thing I did learn in English 100 was the lessons in George Orwell's "Politics and the English Language" which was in our essay book. It still should be mandatory reading for anybody in any position of power or authority.

Orwell of course wrote 1984 and Animal Farm which some commentators have taken as his dismissal of socialism and communism, something the life long member of the British Socialist Party and anybody who has read any of his other books would disagree with.

Orwell's thesis if I remember it, was that people hide their unclear thinking behind overblown language. He also mentioned how politicians misuse the English language for their own malicious ends. "Shot while escaping" was a post WW2 example he gave. We have in the succeeding 50+ years come up with many by own our political and business elite. Laid off becomes downsizing which becomes right-sizing; torturing becomes extraordinary rendition. I could go on.

Healthcare has become a living example of Orwell's thesis. Patients have become clients who have become customers. Doctors, nurses, physios all noble professions with much to offer are lumped in as Healthcare professionals. We all talk about stakeholders, I don't even know what stakeholders used to be. Now that I attend more and more meetings, I find myself slipping into this bizarre newspeak. I have to sometimes step outside and slap myself in the head.

Orwell had a number of rules.

(i) Never use a metaphor, simile, or other figure of speech which you are used to seeing in print.

(ii) Never us a long word where a short one will do.

(iii) If it is possible to cut a word out, always cut it out.

(iv) Never use the passive where you can use the active.

(v) Never use a foreign phrase, a scientific word, or a jargon word if you can think of an everyday English equivalent.

(vi) Break any of these rules sooner than say anything outright barbarous.

The interesting thing is that reading Orwell's essay written over 60 years ago, one gets the sense that it could have been written last week. We have learned nothing. It is interesting that many of todays leaders in politics, business and administration are contemporaries of mine who probably studied "Politics and the English language" in 1st year English. It was in the Norton Anthology afterall.

Thursday, August 5, 2010

Dang Kids Get Off My Lawn

Maybe I am getting old.

Firstly I should say, I support the legalization of most drugs and certainly that legalization would probably stop what I am about to complain about.

3 years ago we moved to a quiet street closer to where I work. The most attractive feature of our new house is the green space across the street from us. From our front window we look onto a grass field, trees in the background and behind that a drop down to the river. We are a touch possessive of our green space even though it belongs to the city.

A snake seems to have invaded our paradise.

For the last couple of months, a couple of times a week around midnight we are awakened by voices in the park across the street. Frequently there is a car parked in front of our house with the motor running most of the time. We hear loud conversations, young men shouting "yeehaw", girls giggling.

It took me a while to figure this out, but it became quite clear. Someone is selling drugs in the park across from our house. Either they hang out there possibly in the woods above the river or our street has been chosen for the transaction being out of the way with little traffic.

After the most recent disturbance, I decided that maybe the police should know about this. Not that I oppose young adults buying drugs. Just not in front of my house.

Police as we know love to enforce drug laws. They are quite happy to attribute just about every crime to drugs. I figured they would jump at the opportunity to bust someone. Actually I just hoped that they would drive a police car down our street around midnight for a couple of nights in a row and get the people to move their business somewhere else.

So the next morning after my most recent interrupted sleep, I phoned the cops. It took me a while. I tried to phone my "community" police station which seems to be nowhere near our community and was directed to the Crime Stoppers snitch line. Obviously I had no one to snitch on so I tried a different number and actually got to talk to a cop. I gave him my address, explained the situation and asked if he could help.

What I got was a bunch of excuses about how busy they are most nights and how it would be totally impractical to patrol our neighbourhood. He did say that if I went to my local police station and filed a complaint in person, I might be able to talk to a sergeant. I said,"How about I contact my city councilor", which is what I did.

Of course like most things, there have been no more late night interruptions since I complained. I suspect that the local drug dealer has figured out that eventually someone would complain to the police who would actually patrol the area.

What has he been smoking?

Tuesday, August 3, 2010

The Cross and the Border

Entering the United States is a huge hassle. This is even worse when one is simply in transit through the US. This makes going to and coming back from my yearly mission to Ecuador more of an ordeal than it should.

I have never quite understood the antipathy US Border guards have towards Canadians. OK we are one of two countries to win a war against the US (North Vietnam is the other) and we did burn Washington to the ground in that war but hey we are reaching the 200th anniversary of that. Further why are customs agents in such a bad mood. They get to wear uniforms, work indoors, do no lifting, have a pension plan and occasionally get to arrest bad guys.

Coming back to Canada via the US means either going thru Miami or through the ominously named George Bush International Airport in Houston. This last trip we arrived in Houston to the large Customs room to find a huge line-up for those non US Citizens of us. No problem, this time I had convinced our travel agent that we would need a long connecting time in Houston and we had 6 hours to get through this hurdle. After about an hour or so we were directed into a short line of about 10 people. We had obviously gotten into the wrong line. The lines around us were moving relatively quickly. I looked up at the counter and saw the crabiest most prototypical US Customs agent waiting for us.

Our mission is a Christian mission. A few years ago a minister who comes with us suggested we wear crosses and so we bought a large number of small wooden crosses with us which we wore and gave to patients, relatives etc. I roomed with this minister the first year so got into the habit of wearing the cross. I figure if it makes people feel good why fight it. This is why I was wearing a wooden cross under my shirt on this day in George Bush International Airport.

As I approached Mr Hardass I flipped the wooden cross out from under my shirt. Mr. Hardass grabbed my wife's and my passports. After a while he looked up, and saw the cross. "What were you doing in Ecuador," he asked. "A medical mission", I replied, fingering my cross. Mr. Hardass smiled, "Have a nice trip home sir".

Monday, August 2, 2010

Patients, Clients and Customers

I have been having a lot of problems with the private pain clinic I work with.

These have been going on since I joined them, but have come to a head recently. Part of this has been to do with one of the "Customer Service Representatives" who worked mostly for me, quitting. I am assured that her departure was purely personal and not related to work but I suspect the fact that it was clear that increasing she was doing everybody else's work as well as her own had something to do with it.

Problems have included frequent no-shows, huge gaps in my schedule with no effort to fill them, coming work to find out that they have forgotten to book patients, finding out that they have booked patients when you clearly told them months ago you weren't going to be there, not cleaning the rooms in between patients and the most recent egregious folly where a patient I had been lead to believe had no showed had been sitting out in the waiting room for over 2 hours, necessitating a return to the clinic over lunch to apologize profusely to him, and try to assess him in the remaining 45 minutes before my next scheduled patient. Wbat was more amazing was the first thing I was asked was whether I just wanted to reschedule the "client"?

There are a number of reasons why the front desk at our little clinic are so bad including the fact that our clinic pays them less than any other doctors office pays and substantially less than an equivalent unionized position in the hospital. (Keep in mind when I say unionized, that our province is not the Socialist Worker's Paradise.) The main reason I have come to a conclusion is that:

1. Instead of being called receptionists they are called "Customer Service Representatives".
2. Instead of patients our clinic has customers or clients. Increasingly we talk about customers.

The first I can deal with simply. A receptionist is someone who receives. This implies the establishment of a relationship with some responsibility on the behalf of the receptionist. Customer Service Representative brings to mind what you get nowadays when you deal with the phone company. Yeah not a pretty picture is it?

Client/customer vs. patient is an interesting lesson in semantics. To break it down, a client is someone who seeks a service from a provider. Providers of course want to provide the easiest and less expensive service for the greatest price. This is human nature and capitalism. Partially (very partially) is the right of the customer to take his services elsewhere. Even this is limited. 25 years ago, you dealt with a single phone company, single cable company etc. Even with the somewhat artificial competition in those areas, there are still de facto monopolies with very little competition.

A patient on the other hand is someone who seeks help from a provider. This is usually a service that the patient believes will have a positive aspect on his health. While the provider naturally like the provider in the provider-client picture wants to provide as little service for as much money, there is an ethical framework applied here. For example if we believe a service is not in a patient's best interest, we don't offer it often to the displeasure of the patient. Imagine on the other hand, the cable company telling somebody he doesn't really need HD. Further while we would all like to get paid as much as possible for as little work as possible, in the doctor patient relationship, we actually try to help the patient regardless of ability to pay and given the choice of therapies, we actually chose what we think is best for the patient not what will pay us the most money.

When I started in Medicine, there was a move afoot to change patients to clients. This fortunately never took root in the medical community although it did to an extent in the paramedical community. Client is an interesting word because while it implies a slightly more equal interraction than does patient, it still implies some degree of responsibility and professionalism by the provider.

Consequently what used to be called patients or clients are now referred to as customers or consumers. The semantics of this are clear. While as with patients and clients, a business relationship is established, customers lose most of the rights that patients or clients have. Sort of like the cable company example above. This is why the people involved in the planning and delivery of health care services increasingly talk about customers and consumers rather than patient or clients.

Now I know I am being naive and the ideal doctor patient relationship doesn't always happen in medicine, but it is still the ideal. We do these things partially out of a sense of ethics drummed into us by role models during our training but also due to outside pressures like licensing bodies, hospital QA committees and of course our friends the personal injury lawyers. This is opposed to the provider customer relationship which is reduced to a business transaction.

But you can see that when we go from receptionists dealing with patients to "Customer Service Reps" dealing with customers and you can see that it is inevitable that this old school physician is going to get a little pissed off.