Monday, November 12, 2012

Majority Envy

My faith in the US was restored with the re-election of Obama last Tuesday.  Granted he has been a disappointment but one has to look at the alternatives.   I know a lot of the doctors who read this blog are disappointed but get over it. 

There are a lot of things about the US that I admire including, rock and roll, blues, bluegrass, NFL football,  and of course the Boston Bruins; however watching the recent election there I couldn't help noticing that with the exception of a few cases, the president actually gets a majority of the popular vote.  Granted there is the ridiculous electoral college but in most cases the president gets over half the vote and all the electoral college does is turn a narrow popular vote win into an electoral college landslide.

I have always admired the US political system with its checks and balances even if this has been perverted in the last decade or so.   There is a lot of the US system that is bad but as a Canadian, the saying people who live in glass houses shouldn't throw stones comes to mind.

Canada unlike the US has 3 and sometimes 4 political parties and our increasingly presidential-like Prime Minister is elected by our own version of the electoral college, the first past the post election of the House of Commons which allows people to win their seat with less than 50% of the vote (27% in one case).  This has assured that in my life-time only two Prime Ministers Diefenbaker in 1958 and Mulroney in 1984 have gotten over 50% of the popular vote.  In both cases these two got huge majorities in the House of Commons.  Pierre Trudeau, considered by some to be Canada's greatest Prime Minister won majorities with 45.5%, 43.2% and 44.3%.  He also got a minority win with 38.5 % and lost an election with 40.1%.  Jean Cretien managed to win 3 comfortable majorities with around 40% of the popular vote.  In other words Sarah Palin got a higher percentage of the popular vote than most Canadian Prime Ministers. 

I am painfully aware that not everybody shares my political views and I accept the fact that if more people vote for the other guy, he deserves to win and govern.  It does bother me that somebody who got less than half the votes gets to "win" the election.

As somebody else pointed out, a Prime Minister with a parliamentary majority is the closest thing to a dictatorship and our current Prime Minister has a very comfortable majority in the House of Commons with only 39.62% of the popular vote.  The opposition representing over 60% of the popular vote can do all they can but if our PM deviates from his legislative agenda, it is because his advisers have advised him that what he is proposing is not politically sound.  Oh yeah and I did I tell you he gets to appoint all the Senators as well?

Of course this all dependent on his Parliamentary caucus voting along with him.  Our Prime Minister is able to keep his troops in line by controlling things like cabinet appointments and other jobs that increase the income and prestige of the individual member.  He also is able to eject unruly members from his caucus effectively ending their chance of re-election and is able to block their nominations by refusing to sign their nomination papers.

The result of this system is that political parties know that the magic number for a majority is about 40% of the popular vote and they can tailor their platform to this minority of the population.  There has been a distaste among Canadian voters for proportional representation (which seems to work just fine in many of the world's democracies).  Most political parties realizing that they are unlikely to ever get more than 50% of the popular vote are not that enthusiastic about it either.

In effect a Canadian Prime Minister finds himself in the situation Obama found himself in after the 2008 election, controlling both the House and the Senate.  Looking at his first two years in office with his inability to get his legislative agenda through, I wonder how many current and former Canadian Prime Ministers were thinking, "what a wimp".

Sunday, November 11, 2012

The most important article in the history of the NEJM

Thanks to Great Z s for posting this.

This is an interesting article although it would probably not get published nowadays due to not being randomized double blind and of course not getting consent from the ethics committee to do the experiments or from the patients involved to publish.

I was interested in the author's comparison of the effects of ether to the effects of Egyptian hashish.  Medical marijuana anyone?

Not wearing a poppy again this year.

As usual somebody has published my sentiments much more eloquently than I could.

I posted this in 2009.

I posted the Huff Post article on Facebook and one of my "friends" a physician I went to high school with who served in the military and is I believe still in the reserve commented, "Its for remembrance of sacrifice not glorification of war."  If only that was true.

Politicians like to trot out our gallant soldiers for political gain and probably have for centuries.  This is notwithstanding how badly they treat them when they aren't doing photo-ops with them.  Veterans benefits have been cut and the government actually spent a fairly large amount of money defending unsuccessfully a lawsuit from veterans who were only trying to get what they believed they had been promised.  Veterans affairs offices are being closed, however WWII veterans (average age 88) have been advised, "don't worry, here's an app you can download for your smartphone."

Our government is currently spending a great deal of money celebrating the 200th anniversary of the War of 1812 (hey Americans, did you know you lost?).   I enjoy history but wonder whether the money couldn't have been spent better or even just spent on a celebration of history that doesn't just justify the governments current policies.  Plus while we "won" the war, most of the fighting was done by British regulars and our Indian "allies" who the British on our behalf abandoned after the war.  But Washington was sacked and burned by British regulars on our behalf so we can still boast about that.  And the battle of New Orleans (which happened after the peace treaty was signed) produced a pretty good Rock song.

I am still hoping that in my lifetime we can find a way of settling disputes that doesn't involve killing people.

Sunday, November 4, 2012

Celebrating Our Mistakes

This video is 19 minutes long but you should really take the time to watch it all.

Bill Chadwick who was a NHL referee before I was born, is alleged to have made an exchange with a doctor who sat close to the ice and like to heckle him.  Chadwick said something to the effect, "Yes doctor, I make a lot of mistakes; the difference is I don't bury mine".

I went to a Departmental retreat last Saturday.  The first one third of the retreat was on quality improvement.  Somebody said "we should celebrate our mistakes".   What a great concept, I would never have thought of that but I am still going to use it on my blog.

Years ago as a resident we had M+M rounds once a week.  Each staff at our local Centre of Excellence took the day in rotation and was supposed to present his cases.  If you were the resident who was involved in the event, you usually had to present the case.  You never liked to be the person who was presenting a mistake or a case that had not gone well but at the same time, it was a supportive environment.  Somebody usually said the same thing had happened to them.  And of all the teaching I got in residency, the M+M rounds were where I learned the most.

The CofE when I arrived there had a very active QI process.  Two nurses reviewed every single anaesthetic chart and reported variances to our four person QI committee.  This included trivial things like the blood pressure dropping on induction even if no harm came to the patient.  Typically one of the QI committee members would visit you in your room with a copy of the anaesthetic record and point out your errors.  If anything this exercise only taught me to fill in the valleys in my blood pressure.   We had another province-wide initiative.  If your patient died within 7 days of an anaesthetic you would get a summons to the Medical Records department to review the chart and fill out a form which was reviewed by a committee.  This was an interesting exercise because while sometimes you knew or suspected your patient was going to die, quite often patients died for no apparent reason.  At the same time the system was reactive not proactive.  It was punitive and not educational.

With the first reorganization of healthcare in the mid 1990s most of the QI activities ceased to exist.  The cost was cited but there was the suspicion that administration didn't want to know about what was going on because it might reflect on problems brought on by their policies and/or they might actually have to spend money fixing the problem.

The second blow to reporting and discussion of adverse events, was paranoia in the medical profession regarding the medico-legal implications of public confessions.  QI activities are supposed to be privileged which means that anybody who attends the meeting cannot be forced to testify on the case.  Changes to our provincial Evidence Act muddied the waters somewhat.  While we are reassured that QI discussions are privileged and cannot be subpoenaed, nobody wants to be the test case; our medical protective association has for years advised against participating in QI activities, if you think a legal action is imminent.  At the same time, administration while talking a great deal about quality and risk management, is in no hurry to support activities that might expose flaws in their agenda or force them to spend money to correct the flaws.

Our health region has a system called the Reporting and Learning System RLS, a computer based system whereby individuals can report adverse events and near misses.  I actually used it when this happened.   The problem with this system if that reports go into a black hole.  I am still awaiting a response to my report.

Making mistakes is of course the essence of how we learn in medicine and in life.  When I was a junior resident one of the staffmen liked to warn me over and over that one day I was going to make a serious mistake that would hurt somebody (I assumed he told every resident this and didn't think I was especially klutzy).  I got sick of hearing this and so one day I said to him, "How about I do it today so I can get it over with."  He didn't think this was funny.

When I was thinking about writing this blog, I was thinking about how I learned to ride a bicycle.  I didn't learn until I was 8 although I started trying much earlier.  I went through a lot abrasions both to my skin and my pride but one day I got on the bike and just start riding.  Maybe something clicked but more likely it was the sum of all the mistakes I had made trying to learn to ride a bike.  Parents in the 1960s were of course a lot more accepting of skinned knees and elbows.

Learning in medicine is the sum of experience, much of which is mistakes.  Some are obvious like blowing an IV or not being able to intubate; some have to be pointed out to you.  When you fail, you think of how you did it wrong and how you will try to do it right the next time.  When somebody criticizes you, you ask yourself, was that justified?  That is how we learn.  And it involves doing this on real live human beings.  Has anybody been to a simulation session that was even close to being realistic?

Of course many mistakes are only apparent to us and it is pretty easy to cover up or defend something especially if the atmosphere punitive not nurturing and supportive.  The problem is that when you don't confess your mistakes or when the system makes you defensive, you lose the learning opportunity the mistake gave you, as you replay the event over and over in your head what you did becomes more and more right.  Conversely by not being able to discuss freely your mistake, you may actually lose confidence in your abilities without the reassurance that your colleagues have had similar happening to them.  You also miss the opportunity of letting other people know of the pitfalls of doing what you did.

So if you are a non-physician reading this, you are thinking, all these mistakes in the name of training and experience;  is the system safe?  Well firstly, most mistakes are small mistakes.  There are of course single mistakes that can be catastrophic but the most serious adverse events are usually a cascade of small mistakes compounded by the failure to notice the small mistakes.  Small mistakes can be trivialized as is often the case when it is a system problem or minimized when it is an individual problem.  Failure to learn from mistakes, to take action so that the mistake doesn't happen again leads to serious adverse events.  So often the principle, no harm no foul exists in Medicine.

We are all human, we work on humans.  We are not perfect, our patients don't all present the same way.  That is the art of Medicine.  The doctor who realizes he is human, makes mistakes and learns from them is probably a pretty good doctor.  The most dangerous doctor is the one who thinks his shzt doesn't smell.

Sometimes however I just wish I could just say, "Doh".