I got a phone call the other week that I was expecting having gotten several every summer just about every year.
I practise chronic pain management part-time. In addition to sticking needles into people, I also prescribe medications. These include opioid medications. After a number of years, I realized that a significant number of my appointments were people whose only purpose was to get a refill of their opioid prescription. Don't get me wrong, in carefully selected patients (which of course describes all mine), opioids are the most appropriate way to manage chronic pain and most of those patients were doing well on the opioids. I was concerned that because I was using up valuable clinic time simply to see someone, ask them how they were doing and write them a prescription for what was often the same dose of the same drug they had been on for years, I was unable to see as many new patients and was not able to spend as much time with more complicated patients.
I therefore did the logical thing. I made up a form letter for their family doctor, explaining that their patient was on a stable dose of medication and that in order to free up pain clinic time I was asking that the the FP take over the prescribing. In almost every case the FP did.
Now however between June and September I can expect to get at least one phone call or visit from a patient asking for a prescription because their FP has gone on vacation (often for more than a couple of weeks) and either has no one covering his practice, has a locum who will not prescribe opioids, or has partners who will not prescribe opioids. As I have told some of these patients, these requests put me in a bit of a bind because I have no way of knowing whether the story they are telling me is true although I suspect it is.
The most recent lady is a lady from the north of the province where family docs last about a week. She was already on a fairly hefty dose of opioids when I first saw her in consult and because I accepted that she would probably have trouble getting the doctor of the week to prescribe for her, I wrote prescriptions for her for three years. Despite trials of other drugs she is more or less what I was on when I first saw her. There were problems because of the distance, and she missed some appointments especially in the winter and I had to fax in prescriptions which I find to be a hassle. (Narcotic prescriptions which are triplicate in our province cannot be phoned in).
Earlier this year she triumphantly told her that she had found a doctor in one of the larger towns about an hour away from her small town who had agreed to take over her care including writing the prescriptions. I breathed a sigh of relief.
Prematurely.
About two weeks ago I got about 4 messages on my voice mail followed by 2 or 3 direct calls to my cell phone, the number which she had somehow obtained. Seems her family doc had taken 4 weeks off and neither of her partners who either see the patient or write a prescription for the patient. The patient was now our of medications, going thru withdrawal and was unable to go to work (did I mention she was working full time?). I wasn't too please with the whole affair, I told her that doctors were obliged to cover their practices, and anyway didn't she realize that doctors also took summer vacations and shouldn't she have anticipated this? I did phone the FP's office to verify that she was indeed on vacation and to ask if one of the other docs could write a prescription for her. The receptionist told me that the other docs were only covering "Warfarin and lab results" and that anyway it was well known that this particular patient was double doctoring. I phone our College and got a copy of the narcotic profile which verified that the patient had in the last two years only got prescriptions from her new family doctor and from me. After this I faxed in a new prescription which I suspect I will be doing a few more times until either she dies or I retire.
This isn't the most egregious case. I once co-managed a patient with one of the FPs. The FP prescribed OxyContin and I did trigger point injections. This patient again was doing fine, working full-time etc. Until the FP decided to take the summer off to go to Europe with his wife. He is a good FP and got a locum. Our patient showed up for an appointment to get a refill of his OxyContin. The locum recoiled in horror, called up a psychiatrist who arranged for an emergency psychiatric admission. He was detoxed and discharged on diazepam, in my opinion a far more addictive medication. Nobody bothered calling me although my progress notes were all over his FP chart. I only learned of this when he showed up in August for his trigger point injections. I sent off a hopefully not too-tactfully worded letter to the doctors involved.
I have a methadone licence. When I first got it, I was the only doctor in the clinic who had one. In 1999 I took three weeks off and while my colleagues covered my practice, neither could write a methadone rx. Because of this, I and the unit clerk spent the two months prior my departure, trying to ensure that every patient on methadone would not run out while I was gone. We managed to cover every patient but one. And she complained to the College. And I got a phone call from the deputy registrar and an aural hand-slap. But that of course was 10 years ago.
Friday, August 14, 2009
Humiliation Based Learning
I still remember the day I learned I had been accepted into medical school and intense feeling of euphoria because I knew that I was essentially set for life. Once in medical school it is extremely hard not to graduate, once graduated after going thru some type of post-graduate training (for which you are paid) you are assured of being employed earning a comfortable and possibly lavish income for the rest of your working life. (Actually I was unemployed for weeks at a time as a family doc and in the early 1990s a number of anaesthesiologists I knew didn't have jobs).
For that privilege you have to put up with a few things, including student loans, long hours, hospital food and of course proving that you are actually learning something.
A general surgeon at our hospital preceptors medical students which means he takes them for several weeks, during which time they come to his office, his clinics, round on his patients and come to the OR with him. This is a heck of lot nicer than my surgical clerkship which largely consisted of dealing with problems on the ward and holding retractors. He is to be accurate not the only surgeon in our city who preceptors students.
He recently read the evaluation on his rotation by one of the students he had preceptored for a few weeks. This was a negative evaluation and the student accused him of "humiliation based learning". Seems our surgeon actually expected his students to read up on what they were seeing or going to see, to answer questions and if they didn't know something to read up on it. He would ask them questions during the day including in the operating room and the clinics where there were people like me and the nurses to listen. I heard him many a time and he was never disrespectful although he would remind the student that they had already talked about this.
This was of course how I and most of my generation of doctors learned things. We went around the wards with a clinician who would ask us questions in front of our peers and whoever else happened to be in earshot. If you didn't want to publicly humiliated, you learned to read up on your material. If the clinician knew that you were generally up on your stuff, he or she was a lot easier on you when you didn't know something. As you got higher up the food chain with more responsibility for patient care, the questions could become more pointed and the response to not knowing was often a reflection on your competency. There is no doubt some clinicians were bullies and targeted the weaker students/interns/residents.
Worse were the clinicians who played the "what am I thinking?" game. This involved a vague open ended question to which any answer you could give was not what the clinician was looking for. We had a number of clinicians like this in medical school. Sessions with them could be miserable.
Humiliating anybody is wrong. However we learned that if you knew the answer, if you at least appeared like you had read around the topic, if you had a reputation for usually knowing the answer or sometimes if you just said, "I don't know" instead of bull-shitting your could usually avoid the humiliation. The pendulum seems now to have swung too far.
When I was a resident, there was still the mantra, that a resident must be prepared to present on any topic at any time. We actually believed that and the first year of your residency was a terrifying game of catch up. The upside of this was that the last year of your residency when you had exams was less of a terrifying game of catch up. Due the CofE being on academic probation our little hospital is seeing more residents especially juniors and I am sometimes amazed (although less so now) but how little they have read, how they don't read journals at all and how a simple question like "tell me the anaesthetic implications of diabetes" (this is usually asked while we are doing a diabetic patient) sends them into a panic.
One of our gynaecologists informed me that they were told they shouldn't ask residents questions where the resident doesn't know the answer!
One likes to think that things like OSCEs, written exams and FITERs will weed out the unsuitables,knowledgeables and incompetents , however another doctor told me she is never going to fail a medical student again after having to take an unpaid day off work to attend the (successful) appeal. As a future consumer of the healthcare system, I am more than a little worried.
For that privilege you have to put up with a few things, including student loans, long hours, hospital food and of course proving that you are actually learning something.
A general surgeon at our hospital preceptors medical students which means he takes them for several weeks, during which time they come to his office, his clinics, round on his patients and come to the OR with him. This is a heck of lot nicer than my surgical clerkship which largely consisted of dealing with problems on the ward and holding retractors. He is to be accurate not the only surgeon in our city who preceptors students.
He recently read the evaluation on his rotation by one of the students he had preceptored for a few weeks. This was a negative evaluation and the student accused him of "humiliation based learning". Seems our surgeon actually expected his students to read up on what they were seeing or going to see, to answer questions and if they didn't know something to read up on it. He would ask them questions during the day including in the operating room and the clinics where there were people like me and the nurses to listen. I heard him many a time and he was never disrespectful although he would remind the student that they had already talked about this.
This was of course how I and most of my generation of doctors learned things. We went around the wards with a clinician who would ask us questions in front of our peers and whoever else happened to be in earshot. If you didn't want to publicly humiliated, you learned to read up on your material. If the clinician knew that you were generally up on your stuff, he or she was a lot easier on you when you didn't know something. As you got higher up the food chain with more responsibility for patient care, the questions could become more pointed and the response to not knowing was often a reflection on your competency. There is no doubt some clinicians were bullies and targeted the weaker students/interns/residents.
Worse were the clinicians who played the "what am I thinking?" game. This involved a vague open ended question to which any answer you could give was not what the clinician was looking for. We had a number of clinicians like this in medical school. Sessions with them could be miserable.
Humiliating anybody is wrong. However we learned that if you knew the answer, if you at least appeared like you had read around the topic, if you had a reputation for usually knowing the answer or sometimes if you just said, "I don't know" instead of bull-shitting your could usually avoid the humiliation. The pendulum seems now to have swung too far.
When I was a resident, there was still the mantra, that a resident must be prepared to present on any topic at any time. We actually believed that and the first year of your residency was a terrifying game of catch up. The upside of this was that the last year of your residency when you had exams was less of a terrifying game of catch up. Due the CofE being on academic probation our little hospital is seeing more residents especially juniors and I am sometimes amazed (although less so now) but how little they have read, how they don't read journals at all and how a simple question like "tell me the anaesthetic implications of diabetes" (this is usually asked while we are doing a diabetic patient) sends them into a panic.
One of our gynaecologists informed me that they were told they shouldn't ask residents questions where the resident doesn't know the answer!
One likes to think that things like OSCEs, written exams and FITERs will weed out the unsuitables,knowledgeables and incompetents , however another doctor told me she is never going to fail a medical student again after having to take an unpaid day off work to attend the (successful) appeal. As a future consumer of the healthcare system, I am more than a little worried.
Tuesday, July 7, 2009
Mandatory Volunteering
Several months ago I heard a sad story.
One of the surgeons sits on the medical school admissions committee.
A young applicant to our school had an interesting life. She was raised by a single mother in one of our poorer neighbourhoods. Despite this she was able to get marks good enough to get into university. To be able to afford university however she had to work part-time during the school year and full-time during the summer. Even with this burden she was able to get good enough marks and and MCAT score to be considered for a place in our medical school.
Sounds like a slam dunk. Horatio Alger story, proof our society works, good time management skills, hard worker, blah, blah, blah.
Something was missing though. Because she had spent her undergraduate years either working to support herself or studying she neglected to do the volunteer work now considered mandatory in order to be a good medical student.
She was told not to bother applying.
Now I hope some other medical school in Canada is not stupid enough to turn down what sounds like an excellent candidate (and that she will be able to afford to travel there for the interview). This does bring up the whole concept of mandatory volunteering and volunteering in general.
One of our friends' sons recently was accepted into medical school. He knew from the start that he would have to volunteer. Our friends are quite religious and very active in their church and it was made clear to him that church related activities did not count. He did some type of volunteering somewhere and will be starting medical school in the fall.
All this makes me wonder whether I would have gotten into medical school now. When I was in first year university somebody told me that if I was interested in medical school I should join the pre-med club. (Actually as I soon found out that was about the worst thing you could do). On club day I kind of shyly approached the pre-med club table. There was a young lady (older than me) at the table who asked if I was interested in signing up. "Signing up for the pre-med club?" I said. "No", she said," we are going to play volleyball with prisoners and we are looking for volunteers." I politely declined and retreated from the table and never ever considered the pre-med club. For many years I wondered, "why the hell would the pre-med club be interested in playing volleyball with prisoners". It only recently struck me, to have something good to put on their medical school applications.
I later got railroaded into being my residence floor rep for most of two years, sat on the students council(along with one future federal cabinet minister and one future provincial cabinet minister) and got involved in the Science Undergrad Society. I like to think that I never got involved in any of these activities because I thought it would help my chances of getting into medical school. I like politics, I had an agenda which I hoped would make life better for me (and my peers) and it opened up a whole different social circle to drink beer with. With some prodding I remember mentioning my activities to to Dean of Admissions, some of things I had been involved with, I didn't think the Faculty of Medicine would necessarily approve of.
My youngest son who just graduated from high school took physical education in Grade 12. In order to pass PE 12, it was necessary to do a certain number of hours of volunteering. For him this meant staying after school and working as a linesman at volley ball games. A necessary thing, but not something that should have to be coerced.
In hospitals we of course have a large number of volunteers and I suppose they do an excellent job. My impression is that most of them, especially the younger ones just stand around looking bored. Now when I look at them, particularly when I look at one of university age, I wonder, what are you applying for and do you really want to be here. We had an excellent volunteer, a retired lady who helped out in the pain clinic for a number of years. She functioned like our ward clerk,did a great job and was really a part of team. One day the nurses approached me and said it was time we got a real ward clerk, I wrote a letter and we got one. I could see on the first days of the ward clerk that our volunteer was a little insulted. She hung on for a year but stopped coming when her husband got sick and now we don't have a volunteer.
I entered the universe of volunteerism a couple of years ago. We had the World Master Games in our city. I heard that they were desperately short of medical volunteers and I was in town so I volunteered. This entailed filling out an on-line form that took me at least an hour (I am not exaggerating). After some time my wife and I were notified that we were to help out with the 10K run. I assumed this was in a medical capacity. In order to be volunteers we had to go downtown and stand in line to get our volunteer package which included our identification/lanyard, a polyester shirt that is now probably being worn somewhere in Africa, a baseball cap that is now in the landfill and a fanny pack (also now in the landfill). Then we had to spend another evening on orientation. It was at this point that I realised that I had volunteered to pass out water and Gatorade at the 10K run although I suspected maybe my medical skills might be required. On the day of the race, we got there early set up our water station mixed up Gatorade and filled paper cups full of water or Gatorade. When the runners came by we offered our cups shouting, "water" or "Gatorade". (Oh by the way anybody who reads this who runs in races, if you don't want a drink just run by, don't slap the cup out of the volunteer's hand.) After the last runner limped by we took down the station and left. Meanwhile a friend of mine who volunteered told me they were desperately short of medical volunteers all week but apparently I'm not good for much besides passing our water. I have not volunteered for anything since.
Sunday, June 14, 2009
Airways
I got the idea for this from Notes of an Anesthesoboist who published this on her blog
About a month ago I was on call, minding my own business, watching the Bruins when emergency paged me to come and intubate someone. When I first started in medicine emergencies were staffed by people with very little formal training who largely did a good job and knew their limits. Emergencies are now staffed by ER docs who are highly trained and don't know their limitations. Thus when I got the page, I knew it was going to be something difficult.
Therefore before I left the OR I took our fibreoptic bronchoscope, every other piece of equipment I could think of and more importantly an OR nurse.
Emergency was its normal confused state and it actually took us a few minutes to find the patient. To my relief he was lying flat on his back, breathing easily and was acyanotic even though the ER hadn't got around to giving him oxygen. He had ingested some type of home remedy the night before and was having swelling of his throat. A gastroenterologist had come and gone and left me a nice picture taken thru the gastroscope of his supraglottic region. There was a moderate amount of swelling. ICU had seen him and had a bed for him (I asked right away, I have been burned by ICU too many times).
In retrospect I could probably have intubated him with a big syringe and little syringe. But for some reason I went into oral exam mode and decided to do a fibreoptic intubation. Probably due to my inept topicalization and his bizarre agitated reaction to sedation, it was not that easy but by holding him down and giving lots of propofol we got the tube down and I only missed the second period.
Of course the only thing we anaesthesiologists are acknowledged as being good at is airway management. This and the above post made me think about my experience with airway management.
I spent most of my last year of training preparing for the dreaded oral exam. This meant hours spent imagining every possible scenario and how to deal with it in an organized fashion. At the beginning of my last year, I did a pediatric rotation (not because of a desire to do pediatrics but rather due to willingness of the pediatric staff to give time off to study for the written exam). At that time the ex-chairman of the department had gone back to work after a brief retirement having found that his university pension couldn't support himself in the style he was accustomed to. Of all the people I trained under he still comes across as the person I liked the best. He did know his limits however and I was advised when I came that when he was on call, I had to be on call as well.
One Sunday afternoon I was at home when I got a phone call from the ex-professor. He told me there was a teenager with facial burns in the ICU who needed to be intubated. I met him in the change room and he asked me how I was going to do it. I probably said something about taking a history and applying my usual monitors but the bottom line, I said was we have to do a fibre-optic intubation. He told me there was no way, that the child would tolerate that but after looking at the poor child he agreed and I intubated him fibre-optically thru the nose with a little ketamine at the chairman's insistence. It seemed to take a long time but time always seems to go slower when you are trying to do a fibre-optic intubation. On Monday I triumphantly told all the staff what we had done and the universal answer was, "why didn't you call in one of us?".
About a week later, the chairman went off on sick leave. He had started having chest pain and got an EKG which showed a recent heart attack. I think he probably had it that afternoon. He later had and angioplasty and 20 years later is still alive.
I had a similar episode on my first weekend on call as a staff. I was called to the burn unit to intubate somebody who should have been intubated 12 hours earlier. My oral exam training kicked in and with no hesitation I intubated him fibre-optically.
Since then all kinds of devices for difficult airways have emerged. Most of these are expensive and require some kind of trained help.
About 10 years ago when I was at the centre of excellence, we had a newly minted staff who arrived at our department as a self-proclaimed expert on airways. At the CofE we did a lot of head and neck tumours, burns, broken necks and reconstructive plastics. Apparently we had been doing this wrong. Our airway of excellence fellow would hold forth at rounds and I would sit at the back thinking, "OK wiseguy how many of these have you actually done?"
He had trained with a prominent academic anaesthesiologist who considers himself a guru on airways. I happen to know someone who was a resident at the same time as the airway guru. Seems the airway guru almost snuffed several patients due to his inability to manage an airway. Those who can't teach?
One of the reforms brought in was an airway rotation for residents. Now airways are a central part of being an anaesthesiologist so it is almost like saying surgery residents should have a suturing rotation (now that I think about it not a bad idea as long as they don't practise on humans). This meant that instead of being assigned to a room, a resident would be designed as the "AIRWAY RESIDENT" but only until 1530 on weekdays. Actually if you had time and warning, if the resident was around and if he actually came the extra pair of hands was pretty useful because at the CofE you take any help you can get.
Maybe I have been too tough on my former colleague who is a nice guy if a little full of himself. He only lasted about 5 years at the CofE before going to greener pastures which means he is much smarter than I am.
The other recent event which prompted this post is the announcement that the Trach-Lite light wand will no longer be produced. Good riddance I say. Trach-lites were a neat party trick in patients with easy airways but of course of no use at all in the difficult airways scenario. All things being equal which they usually aren't, I like to see where I am going when dealing with fragile mucuosal surfaces. This is not to say that I haven't passed tubes blindly thru cords, I have and many times I have never been so relieved to see the ETCO2 wave. It's just not something I start out with a mind to.
About a month ago I was on call, minding my own business, watching the Bruins when emergency paged me to come and intubate someone. When I first started in medicine emergencies were staffed by people with very little formal training who largely did a good job and knew their limits. Emergencies are now staffed by ER docs who are highly trained and don't know their limitations. Thus when I got the page, I knew it was going to be something difficult.
Therefore before I left the OR I took our fibreoptic bronchoscope, every other piece of equipment I could think of and more importantly an OR nurse.
Emergency was its normal confused state and it actually took us a few minutes to find the patient. To my relief he was lying flat on his back, breathing easily and was acyanotic even though the ER hadn't got around to giving him oxygen. He had ingested some type of home remedy the night before and was having swelling of his throat. A gastroenterologist had come and gone and left me a nice picture taken thru the gastroscope of his supraglottic region. There was a moderate amount of swelling. ICU had seen him and had a bed for him (I asked right away, I have been burned by ICU too many times).
In retrospect I could probably have intubated him with a big syringe and little syringe. But for some reason I went into oral exam mode and decided to do a fibreoptic intubation. Probably due to my inept topicalization and his bizarre agitated reaction to sedation, it was not that easy but by holding him down and giving lots of propofol we got the tube down and I only missed the second period.
Of course the only thing we anaesthesiologists are acknowledged as being good at is airway management. This and the above post made me think about my experience with airway management.
I spent most of my last year of training preparing for the dreaded oral exam. This meant hours spent imagining every possible scenario and how to deal with it in an organized fashion. At the beginning of my last year, I did a pediatric rotation (not because of a desire to do pediatrics but rather due to willingness of the pediatric staff to give time off to study for the written exam). At that time the ex-chairman of the department had gone back to work after a brief retirement having found that his university pension couldn't support himself in the style he was accustomed to. Of all the people I trained under he still comes across as the person I liked the best. He did know his limits however and I was advised when I came that when he was on call, I had to be on call as well.
One Sunday afternoon I was at home when I got a phone call from the ex-professor. He told me there was a teenager with facial burns in the ICU who needed to be intubated. I met him in the change room and he asked me how I was going to do it. I probably said something about taking a history and applying my usual monitors but the bottom line, I said was we have to do a fibre-optic intubation. He told me there was no way, that the child would tolerate that but after looking at the poor child he agreed and I intubated him fibre-optically thru the nose with a little ketamine at the chairman's insistence. It seemed to take a long time but time always seems to go slower when you are trying to do a fibre-optic intubation. On Monday I triumphantly told all the staff what we had done and the universal answer was, "why didn't you call in one of us?".
About a week later, the chairman went off on sick leave. He had started having chest pain and got an EKG which showed a recent heart attack. I think he probably had it that afternoon. He later had and angioplasty and 20 years later is still alive.
I had a similar episode on my first weekend on call as a staff. I was called to the burn unit to intubate somebody who should have been intubated 12 hours earlier. My oral exam training kicked in and with no hesitation I intubated him fibre-optically.
Since then all kinds of devices for difficult airways have emerged. Most of these are expensive and require some kind of trained help.
About 10 years ago when I was at the centre of excellence, we had a newly minted staff who arrived at our department as a self-proclaimed expert on airways. At the CofE we did a lot of head and neck tumours, burns, broken necks and reconstructive plastics. Apparently we had been doing this wrong. Our airway of excellence fellow would hold forth at rounds and I would sit at the back thinking, "OK wiseguy how many of these have you actually done?"
He had trained with a prominent academic anaesthesiologist who considers himself a guru on airways. I happen to know someone who was a resident at the same time as the airway guru. Seems the airway guru almost snuffed several patients due to his inability to manage an airway. Those who can't teach?
One of the reforms brought in was an airway rotation for residents. Now airways are a central part of being an anaesthesiologist so it is almost like saying surgery residents should have a suturing rotation (now that I think about it not a bad idea as long as they don't practise on humans). This meant that instead of being assigned to a room, a resident would be designed as the "AIRWAY RESIDENT" but only until 1530 on weekdays. Actually if you had time and warning, if the resident was around and if he actually came the extra pair of hands was pretty useful because at the CofE you take any help you can get.
Maybe I have been too tough on my former colleague who is a nice guy if a little full of himself. He only lasted about 5 years at the CofE before going to greener pastures which means he is much smarter than I am.
The other recent event which prompted this post is the announcement that the Trach-Lite light wand will no longer be produced. Good riddance I say. Trach-lites were a neat party trick in patients with easy airways but of course of no use at all in the difficult airways scenario. All things being equal which they usually aren't, I like to see where I am going when dealing with fragile mucuosal surfaces. This is not to say that I haven't passed tubes blindly thru cords, I have and many times I have never been so relieved to see the ETCO2 wave. It's just not something I start out with a mind to.
Sunday, May 24, 2009
Cosmetics
This fellow runs a cosmetic practice.
He has billboards all over the city. He also advertises in the local papers.
This past weekend our local paper ran a "puff-piece" on him. A local columnist went in to get some cosmetic injections and wrote and article on him. As is often the case, the column started on the front page of the section and continued on to another page. Flipping through the pages to get to the rest of the article, it was impossible not to come across an advertisement for his clinic featuring a picture of his naked wife (with the naughty bits covered up of course).
This fellow and his ads have bothered me for some time.
The main reason is that while I don't know the exact stats; more people apply to medical school than are actually accepted. Therefore in order for him to practise exclusively as a cosmetic "specialist" somebody else didn't get to be a doctor. Now I am sure when he was interviewed for medical school he probably told them that his ambition was to practise cosmetic medicine in a large urban centre and not have to take call or look after sick people. NOT!!!
Secondly, while medical students do pay tuition in the 5 figure range, this apparently covers less than 20% of the cost of their training. So the taxpayers of the province, many of whom no longer have a family doctor paid for his training.
But what about plastic surgeons?
I have the utmost respect for plastic surgeons and not just because I wish they would hire me for one of their private suites. While there are some plastic surgeons who practise exclusively cosmetic surgery, most of them don't. They take time out form making women's boobs bigger to look after burn patients, repair tendons and reconstruct faces. They take call and work nights and weekends unlike Dr. Singh.
He has billboards all over the city. He also advertises in the local papers.
This past weekend our local paper ran a "puff-piece" on him. A local columnist went in to get some cosmetic injections and wrote and article on him. As is often the case, the column started on the front page of the section and continued on to another page. Flipping through the pages to get to the rest of the article, it was impossible not to come across an advertisement for his clinic featuring a picture of his naked wife (with the naughty bits covered up of course).
This fellow and his ads have bothered me for some time.
The main reason is that while I don't know the exact stats; more people apply to medical school than are actually accepted. Therefore in order for him to practise exclusively as a cosmetic "specialist" somebody else didn't get to be a doctor. Now I am sure when he was interviewed for medical school he probably told them that his ambition was to practise cosmetic medicine in a large urban centre and not have to take call or look after sick people. NOT!!!
Secondly, while medical students do pay tuition in the 5 figure range, this apparently covers less than 20% of the cost of their training. So the taxpayers of the province, many of whom no longer have a family doctor paid for his training.
But what about plastic surgeons?
I have the utmost respect for plastic surgeons and not just because I wish they would hire me for one of their private suites. While there are some plastic surgeons who practise exclusively cosmetic surgery, most of them don't. They take time out form making women's boobs bigger to look after burn patients, repair tendons and reconstruct faces. They take call and work nights and weekends unlike Dr. Singh.
Thursday, May 21, 2009
Bar Codes
A while ago I posted about the new infusion pumps we have which are supposed to make life safer for the patient and more difficult for the caregivers.
I was in the hospital today and my chief said to me, "Here I've got something in my locker for you". He pulled out a hospital ID with my 10+ year old photo on it. At first I thought it was the ID I lost. It was in fact my "Smart Pump Bar Code ID".
Now in order to prevent well or ill meaning visitors from reprogramming the pump, your ID has to be scanned every time you reprogram the pump. This of course presents a problem when your ID is in your car. Fortunately a resident told me how your bypass this. All you have to do she told me was scan the bar code on the kleenex boxes we have in the OR and the pump will open its heart to you.
Which is what I did the other night with patient from the ICU on the levophed infusion which I felt I had to adjust up and down throughout the case. The kleenex box worked just fine.
Now that I have a proper bar coded ID, I won't need to use the kleenex box. Until I lose the ID.
I was in the hospital today and my chief said to me, "Here I've got something in my locker for you". He pulled out a hospital ID with my 10+ year old photo on it. At first I thought it was the ID I lost. It was in fact my "Smart Pump Bar Code ID".
Now in order to prevent well or ill meaning visitors from reprogramming the pump, your ID has to be scanned every time you reprogram the pump. This of course presents a problem when your ID is in your car. Fortunately a resident told me how your bypass this. All you have to do she told me was scan the bar code on the kleenex boxes we have in the OR and the pump will open its heart to you.
Which is what I did the other night with patient from the ICU on the levophed infusion which I felt I had to adjust up and down throughout the case. The kleenex box worked just fine.
Now that I have a proper bar coded ID, I won't need to use the kleenex box. Until I lose the ID.
I survived the public school system
Or rather I survived my children's time in the public school system.
Yesterday my youngest son graduated. There is still a month and a half left in the school year so technically he hasn't graduated (I looked at the "diploma" he got yesterday and it only acknowledges he was a member of the graduating class of 2009).
I only have two children. At some point we agreed we only would have 2 children (my wife's family fires off twins and 3 could become 4) and I got a vasectomy. My wife said to me last night words to the effect that we should have had another, I'm not ready for this by which she meant I'm not ready to be a mother with two children out of school.
Not me however, this was a moment I have been waiting for for years.
I hated elementary, junior high and high school. I liked university but I think that was because I liked the drinking and partying. Between my two kids I have just finished 15 straight years of school. I have had to go to parent teacher interviews, Christmas and year end concerts, band concerts, open houses and sports events. I have had to "help" my kids do homework, nag them to practise, phone teachers and principals. I am so ready to finally graduate.
High school graduation has become a much bigger event than I remember. My kids have fortunately been fairly low key and aside from buying the graduation suit that they will only wear twice in their life, we haven't had to spring for limos and the accessories people now believe is necessary. The big fuss is despite that fact that high school graduation has become the minimum ante for entry into mainstream society. Most kids, at least in our socio-economic group have not seen their last classroom.
It was a very pleasant if somewhat long graduation ceremony. There were something like 500 graduates. The band cycled thru "Hope and Glory" I don't know how many times as they all filed in. You could see the conductor frequently looking to his side, thinking when is this over. The grads received their diplomas in three batches with entertainment between each group. It was an elaborately choreographed ceremony. Most of the presenters and the valedictorian were extremely poised individuals. The quality of the entertainment all by graduating students was surprisingly good.
All the grads wore gowns. I of course graduated from university and have never completely approved of gowns for high school graduations. I realized that the one of advantage was that it leveled everything off. All the grads walked across the stage wearing the same black baggy gown. (It also allowed some of the girls to wear fairly risque dresses that they might not have wanted to parade across the stage in.)
The most interesting thing in high school graduation ceremonies is seeing how kids and parents you knew years ago have changed. Many of the kids the graduation class, we knew from elementary school or from hockey but haven't seen them or their parents for years. It was a big of a shock seeing the bratty kid you knew from hockey as a grown man. More impressive was how much some of their parents had aged or expanded in girth. That made me feel pretty good about how I look.
I thought back to my own high school graduation. My parents always expected me to go to university so high school graduation was a minor formality for them. Graduation at our high school was unfortunately to most students about the drunken party afterwards rather than any solemn sense of life progression. We sat in bleachers in the gymnasium on a Friday night for a fairly brief ceremony with minimal speeches. We didn't wear gowns so the men wore a medley of suits, sports jackets or rented tuxes. This was of course in the 1970s so you can imagine just how ghastly everybody looked.
Our student council seemed more preoccupied on the drunken party to be held afterwards than having a ceremony that people might remember, something to send everybody off into world. While I went on to university, many of my circle didn't and the end of grade 12 was the last time I saw certain people until the 10th reunion and some I have never seen since.
Anyway after the tame Friday night dance sponsored by the school, there was the after grad held on Saturday night. The student council was even able to get a liquor licence until the principal found out and got it cancelled. My friends and I arrived to find the curling rink where the party was held surrounded by a phalanx of policemen. Somebody decided we should try to hide the beer we naively thought we could smuggle in, outside the rink so we could at least go outside for a beer. A cop saw us headed off and followed us to relieve us of our beer. He didn't dump it out in front of us so I assume he and his buddies drank it later. The whole thing was pretty boring and I walked home at 2 in the morning.
All in all I think I preferred my son's graduation.
Yesterday my youngest son graduated. There is still a month and a half left in the school year so technically he hasn't graduated (I looked at the "diploma" he got yesterday and it only acknowledges he was a member of the graduating class of 2009).
I only have two children. At some point we agreed we only would have 2 children (my wife's family fires off twins and 3 could become 4) and I got a vasectomy. My wife said to me last night words to the effect that we should have had another, I'm not ready for this by which she meant I'm not ready to be a mother with two children out of school.
Not me however, this was a moment I have been waiting for for years.
I hated elementary, junior high and high school. I liked university but I think that was because I liked the drinking and partying. Between my two kids I have just finished 15 straight years of school. I have had to go to parent teacher interviews, Christmas and year end concerts, band concerts, open houses and sports events. I have had to "help" my kids do homework, nag them to practise, phone teachers and principals. I am so ready to finally graduate.
High school graduation has become a much bigger event than I remember. My kids have fortunately been fairly low key and aside from buying the graduation suit that they will only wear twice in their life, we haven't had to spring for limos and the accessories people now believe is necessary. The big fuss is despite that fact that high school graduation has become the minimum ante for entry into mainstream society. Most kids, at least in our socio-economic group have not seen their last classroom.
It was a very pleasant if somewhat long graduation ceremony. There were something like 500 graduates. The band cycled thru "Hope and Glory" I don't know how many times as they all filed in. You could see the conductor frequently looking to his side, thinking when is this over. The grads received their diplomas in three batches with entertainment between each group. It was an elaborately choreographed ceremony. Most of the presenters and the valedictorian were extremely poised individuals. The quality of the entertainment all by graduating students was surprisingly good.
All the grads wore gowns. I of course graduated from university and have never completely approved of gowns for high school graduations. I realized that the one of advantage was that it leveled everything off. All the grads walked across the stage wearing the same black baggy gown. (It also allowed some of the girls to wear fairly risque dresses that they might not have wanted to parade across the stage in.)
The most interesting thing in high school graduation ceremonies is seeing how kids and parents you knew years ago have changed. Many of the kids the graduation class, we knew from elementary school or from hockey but haven't seen them or their parents for years. It was a big of a shock seeing the bratty kid you knew from hockey as a grown man. More impressive was how much some of their parents had aged or expanded in girth. That made me feel pretty good about how I look.
I thought back to my own high school graduation. My parents always expected me to go to university so high school graduation was a minor formality for them. Graduation at our high school was unfortunately to most students about the drunken party afterwards rather than any solemn sense of life progression. We sat in bleachers in the gymnasium on a Friday night for a fairly brief ceremony with minimal speeches. We didn't wear gowns so the men wore a medley of suits, sports jackets or rented tuxes. This was of course in the 1970s so you can imagine just how ghastly everybody looked.
Our student council seemed more preoccupied on the drunken party to be held afterwards than having a ceremony that people might remember, something to send everybody off into world. While I went on to university, many of my circle didn't and the end of grade 12 was the last time I saw certain people until the 10th reunion and some I have never seen since.
Anyway after the tame Friday night dance sponsored by the school, there was the after grad held on Saturday night. The student council was even able to get a liquor licence until the principal found out and got it cancelled. My friends and I arrived to find the curling rink where the party was held surrounded by a phalanx of policemen. Somebody decided we should try to hide the beer we naively thought we could smuggle in, outside the rink so we could at least go outside for a beer. A cop saw us headed off and followed us to relieve us of our beer. He didn't dump it out in front of us so I assume he and his buddies drank it later. The whole thing was pretty boring and I walked home at 2 in the morning.
All in all I think I preferred my son's graduation.
Subscribe to:
Posts (Atom)
Posts
