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.

Tuesday, March 15, 2016

Rascism and the duty to accomodate

A couple of weeks ago a patient refused to let one of my colleagues give her an anaesthetic because of his race.  What race is not important although you can probably guess.  The surgeon was very much less than supportive of his anesthetic colleague and the case went ahead after my colleague switched rooms with somebody of an acceptable race.  One of the OR nurses was disgusted and refused to work on the patient and she swapped out of the room as well.

Of course when pressed, the patient denied being racist; she said she just wanted to know what his qualifications were.

In case she reads this blog, my colleague was born in Canada, attended medical school in Canada, did a Canadian residency and has a Canadian fellowship.

Admin got involved and we got a meeting with the VP of Ethics and Spirituality (yes such a position actually exists).

It was a good meeting.  He started out by bringing in the CMPA's statement on you to deal with requests based on race.  It is the usual bland unhelpful document that the CMPA puts out.  Essentially racism is bad but try to accommodate the patient anyway. He then brought out the hospital's policy which essentially said the same.  Historically this situation raised its ugly head when women from a certain religion refused to have male doctors look after them in Obstetrics (presumably male nurses too although these are rare in OB).  This is of course a problem because while the woman can go to female GP or OB; doctors do share call and take time off plus male residents also rotate through OB and are expected to deliver patient care.  The solution was to meet with the local leaders of said religion and also to consult said religion's holy book, which aside from some vague statements about modesty was fairly tacit about whether women could or could not have physicians of a different gender.

Anyway periodically when up in the labour floor I will see a sign on the door stating no male staff.  I have been involved in 2 incidents personally.  The first was when I was doing a booked C section.  The usual practice at our hospital is that we see the patient for the first time in the OR, usually sitting up waiting for their spinal.  This is not ideal, but it is how we do things and nobody is stopping anybody from finding the patient in their room pre-op.  I walked around to face the patient and was struck by her facial expression.  When seeing patients pre-op you can see a variety of facial expressions, nervousness, fear, hope, happiness.  What I saw on this patient was hatred.  "She doesn't want a male doctor," said one of the nurses, "but we told her she had to have one."  L+D nurses have never heard of patient autonomy.  I mentioned that had they called me earlier, I probably could have swapped with one of the female members of my department.  Not that I should have to of course and the case went uneventfully.  About a month later I was finishing a C section when the nurse stuck her head in the door and told me I had a retained placenta next door for a GA as soon as I was finished.  The patient when I arrived in the room was quite upset at my presence (this doesn't happen normally) but again the nurses told her she was bleeding to death and I was the only available person.

This lead to a discussion.  During the day you can usually find another person if the patient is uncomfortable with you for any reason.  After hours is different.  Somebody raised the issue of what happens when the first and second call are both of the same sex.  Do you phone around and try to find a staff member of the appropriate sex at 0200?  Even if the second call is of the right sex, they are usually home; do you call them in. Would you come if you got called under these circumstances?

What we are discussing above is however selecting doctors by sex even when it is based on cultural practices.  Most of us are willing to condone selecting doctors by sex, lots of people do it based on personal preference or because of bad experiences, not necessarily medical, with the other sex.  But is selecting your doctor on the basis of his sex just the thin edge of a wedge where the thick end is selecting your doctor by his race.

This already happens on an informal basis.  Despite what you may have heard in the health care debates, patients in Canada get to chose both their primary care doctors and subject to availability their specialists.  I suspect a whole lot of choice may be based on the doctor's sex, skin colour or accent.  It is just never out in the open.

Anaesthesia is a little different.  Patients are assigned to an anaesthesiologist based on whatever system the hospital uses to assign them.  We do however allow again subject to availability patients to occasionally request anaesthesiologists.  When I first started out 25 years ago I noticed that most of the patient requests were vascular patients and it was the same 3, more senior, anaesthesiologists and I realized that it probably wasn't the patients who made the request but rather the surgeons who were concerned that a younger anaesthesiologist was going to cancel the patient many of whom had quite severe cardiac or pulmonary disease.  I also realized when I became department head is that a certain number of requests are not because they want a certain anaesthesiologist but rather because they don't want a certain anaesthesiologist and you can't put that on a booking form.  So I wonder how many patients just told their surgeon they wanted or didn't want a white/yellow/brown/black anesthesiologist and the surgeon just requested someone of an acceptable colour.

After our spirituality person gave his spiel my colleague who had been affected put in his two bits.  He has, as he said, been the race he is all his life.  He states he notices about once a week that a patient is very uncomfortable with him and he has learned to deal with it.  We have a lot more visible minorities in medicine now and while we can pat ourselves on back at their success, we have no idea of what they face on a daily basis in their work and I think what it would like for me to face a patient like the lady above who wanted a female anaesthesiologist, once a week. 

Probably if you surveyed our department, most people felt the patient should have been cancelled and told that she was no longer welcome at our hospital.  She had come in for a total joint replacement and as I constantly remind my ortho friends, nobody has ever died from osteoarthritis.  One person pointed out we are not doing her or anybody a favour by not allowing her to see the consequences of her actions and attitudes.

I continue to be disappointed in the 21st century and it is not because we don't have flying cars or colonies on Mars.

Wednesday, March 2, 2016

The Cancer Card

A while ago while still site chief, I got embroiled in a dispute between a department member and a surgeon.  (Wow like that never happens).

This was over a patient presenting for a mastectomy during the summer.  The patient was obese, had COPD and sleep apnea and now had a URTI.  My colleague listened to the lady's chest which apparently sounded gross, asked another colleague for an opinion as to what to do and then cancelled the case.  

"What?", said the surgeon, "you can't cancel the case, she has cancer".  She cancelled the case anyway.  Letters ensued.  

Now the real issue was that it was summer and the surgeon was about to embark on 4 weeks of vacation so it wasn't like he could do her next week but there are solutions, like for example asking one of his colleagues to do her next week.  I wasn't there and never got to listen to her chest which may have actually been the best it had ever been for years on that particular day.  Maybe I or another of my colleagues might have just bitten the bullet and gone ahead.  

One thing I do know it this.  When you do a case against your better judgement and things don't go like you prayed they would, nobody thanks you.  Or as my former professor told me, "the object of anaesthesia is not to see what you can get away with."

Later that year while still chief I was involved in mediating a problem between the administration and my department for which nobody has thanked me  (and which probably got me fired).

In Canada we have waiting lists for surgery which can be anywhere from days to months.  This causes a lot of angst.  Surgeons generally prioritize cancer cases although not always.  So it came that there was a report in the local press about lung cancer patients dying while waiting for surgery.  Thoracic surgery is of course a little more complicated than other cancer surgery, especially as they insist on doing everything through a scope now, so OR times are long, they usually require ICU or some type of high intensity unit post-operatively etc, all of which limits the number of cases that can get done.  Typically I have found that when waiting lists are long, it is more than a question of available resources, it is also a question of failure to prioritize and quite often lack of organization often by the surgeon's office.  The other issue is that despite advances in surgery and oncology the outcome for lung cancer no matter how quickly and expertly it is excised is pretty grim anyway.  That is why I am glad I don't do thoracics anymore.  You would bust you ass for 2-3 hours trying to oxygenate the patient, not to mention the occasional massive bleeding and then read the obituary a few months later.

Our health authority's response to this bad publicity was to announce extra money to do extra cancer cases.  Any type of cancer case, not just lung cancers.  This was not a problem for the other hospitals in the city which have unused ORs.  They did off course have to find anaesthesiologists which was a bit of a problem that nobody thought of but these were recruited.   Our hospital which runs at 100% capacity was a problem. 

Our hospital's solution was one that is becoming more frequent.  Extend the OR day by two hours to accommodate the additional cancer cases.  This sounds like an easy solution except for a few problems.  Firstly many cancer cases don't easily fit into a 2 hour slot and so predictably rooms that were supposed to finish at 1700 were now running until 1900.  The other issue is that our hospital is staffed to run 2 rooms in the evening.  We use these rooms to do "emergencies" and we frequently run 2 rooms all evening.  Except if you have a late running room, you can't start emergencies until that room finishes and as some emergencies are actually emergencies this meant we were now finishing our emergencies well into the early morning.  All of this I predicted when they first proposed it and like Cassandra was ignored. 

The worst issue for my was that our department has become a sheltered workshop for burnt out baby boomers and entitled generation Yers.  We like finishing at 1530 so we can exercise, run errands and eat dinner with our families.  When I announced the plan to run one room until 1700 2-3 times a week, the pitchforks came out.  I pointed out that if we were seen as obstructing timely care for cancer patients we were going to look like huge assholes but this didn't sway them.  I went back to admin and got "promises" of staffing and ground rules for booking extra cases all of which they reneged on.  (One surgeon booked a hydrocoele as an extra cancer case, "none of my bladder tumours could come in on short notice", was his excuse). 

This is still as far as I know, going on.  As I mentioned I eventually got fired as department head so I don't have to deal with it and I don't really mind working late occasionally.  It is a little tiring but the extra money brings me one step closer to retirement. 

Now before people start calling me a hard-hearted asshole for wanting to deny patients with cancer timely treatment let me state this.  I realize that many people die horrible deaths from cancer.   I realize that cancer cuts short many lives, depriving people of fathers, mothers, siblings, children and friends.  I also know that the odds are pretty good that I will ultimately die of cancer.  Hopefully it will be in a morphine induced haze at home, not puking my guts out in the oncology Ward or bleeding from every orifice on the hematology Ward.  

I also have to accept the progress made in diagnosing and treating cancer in my lifetime.  When I was in medical school, childhood leukaemias, testicular cancer and most lymphomas were death sentences whereas they are now mostly curable.

The bottom line is however what was true 30 years ago when I was in medical school and is still true today.

  • Most cancers are slow growing (except for those which are fast growing and if you get one of those, you are fzcked).  This means that within limits how soon your cancer is diagnosed or treated makes little or no difference to your survival.
  • Early and aggressive treatment is no guarantee of no metastatic disease.  It only takes one little cell to escape.  That's why we see people who had cancers treated 20 or more years presenting with metastatic disease.
  • Many cancers like prostate cancer and some breast cancers are extremely slow growing and the patient will die of what we used to call old age before they die of cancer.  In fact treating them possibly hastens death rather than prolonging life.
  • We are all eventually going to die of something.
So I am not saying we shouldn't screen for cancer or treat it expeditiously; I just resent the way self-interested physicians and surgeons use the cancer card to advance their own agenda.  A lot of physicians and surgeons out there are exploiting cancer patients for their own gain in a way that is just as bad as the Laetrile and coffee enema people.  There are lots of other conditions out there that affect longevity or quality of life that don't seem to get the attention or their share of the finite resources.  We don't even treat all cancers equally.  Breast and prostate cancer to mention two seem to have a lot of political clout.  Every November all our urologists grow moustaches for Movember.  Most of them look stupid (er), the few that don't shave them off December 1 anyway. If for example you have pancreatic cancer which is one of the more common cancers nowadays, nobody is wearing ribbons, or not shaving for you.

You could make the argument that having diagnosed a patient with cancer, just for their piece of mind you should treat it as soon as possible and there may be some merit in that.  If or when I get diagnosed with cancer the patient in me would probably like it whacked out ASAP.  This is despite that the physician in me knows that within a range of months, it doesn't make much difference and I should probably go on that bucket list vacation first.  As a matter of fact I know there is a good possibility as I type this that some cell in my colon, pancreas or bone marrow is starting to behave in a distinctly anti-social fashion.  This should keep me up at night but I have enough keeping me up at night like work, the price of oil, the stock market and of course Donald Trump.