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?

A couple of weeks ago a group of Anesthesiologists in British Columbia found out.  

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.  

Unmasked

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 .  

However:

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.

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.

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.

2015 in Review

I haven't been posting much in 2015.  There may be a lot of reasons for this.  Blogger fatigue, too much time on Facebook, maybe I finally got a life.  But for those who still read this here is 2015.

I started the year as I had done the previous 8 years on a Medical Mission to Ecuador accompanied by my wife who works as a nurse.  I was fortunate this time to have two colleagues from my department accompany me.  I have always recruited from other cities, other departments; this time it hit me, I work in the best department in the world why not invite some of them.  So I solicited the 4 or so people who I thought might be able to go and who could get along the surgeons and nurses, 2 of them said yes and so off we went.  

Our mission is to do total joints for hip dysplasia as well for Rheumatoid Arthritis and some osteoarthritis.  Before I first went, I had questioned the utility of doing such major and expensive surgery in a developing country as opposed to say spending the money on public health or something.  Thing is, most of these people are hugely disabled in country without much of a social safety net and there really isn't much short of a total joint replacement that is going to help them.  Of course there are more patients needing the surgery than we can do in a week so there is always the prioritizing and rationing aspect.

What I like most is the team aspect.  Many of the team go down every year and it is always great to work with them again.  Somebody asked once why I come back every year and I said because of the team.  Wrong answer?  I guess I was supposed to say because I wanted to help people which is supposed to be why I went into medicine.  

I think that coming on these missions has made me a better anaesthesiologist and physician.  One thing you learn in the developing world is how to do the best you can with what you have.  This is a very transferable skill to the developed world.   The other thing in a mission like this is that you see the planning and teamwork that goes into surgery, something we don't always appreciate in Canada.

Cuenca where we work has become like a second home to me and I told my wife that if the mission ever stopped, I just might keeping on coming.  

We often take a post mission vacation in South American but didn't do it this year and returned with most of the team following the mission.  

I once again rode in the MS Bike Tour with a team of my colleagues including this year a couple of OR nurses.  My wife and I had ridden this on our own and it was gratifying a couple of years ago when people approached me about forming a team which has increased in size.  We all ride a our own pace but we always meet a the rest stops and this year we rode as a team from the last rest stop to the finish on the second day, letting our slowest rider a 60 something lady who rode a mountain bike cross the line first.  I really recommend riding in the MS Bike tour in your area or sponsoring a rider or just donating, it is a first class event and the people who organize it are great, without the attitude we see so often associated with charities and volunteers.

I was also able to go on a group ride from Mt Robson to Clearwater in July.   This is a nice ride with a net elevation drop and only a few large hills.  We had a really nice group which is nice because group dynamics can make or break a ride.  This was organized through Mountain Madness which I cannot say enough good things about.

I have to reflect on how 10 years or so ago I started riding longer distances and how I have become what some people consider a serious cyclist and MAMIL even if my wife usually has to wait for me.  Some of the rides I have been on I could not have ever seen myself doing.  I was talking a year or so ago to one of my now team members who was concerned about the distance at MS Bike Tour.  "90 km," I told him, "is not a long distance."  Okay yes it is.

I had a little mini-sabbatical.  I felt sorry for one of the residents who had finished and didn't have a job so I gave him all my weeks in July and August and just did the pain clinic weeks.  On top of this I had a cycling vacation already planned in Slovakia followed by a 4 week educational mission to Rwanda.  Taking the extra weeks in the summer was just the tonic I needed; I typically take 3 sometimes 4 weeks but in a city with 7 months of winter, you really want to take advantage of our summer such as it is.  This also enabled me to take the above bike trip.  Most of the extra weeks I just spent at the dacha.

Our Slovakian bike ride was everything we had hoped for.  Technically we started in Budapest and finished in Kraków.   Budapest we had visited in 1999, when it was still quite shabby without a lot of restaurants and tourist infra structure.  It now has all of that and is a beautiful city to visit. 

Our in-laws joined us on the trip.  We had some adverse weather, climbed some huge hills, ate some great meals and stayed in some really nice places.  I strongly recommend this guided trip which can be booked through Freewheeling, a Canadian company or Greenways a Czech company.  We had a couple of days in Kraków after the end.  Kraków was a city I have always wanted to visit and it was everything I had hoped for. 

After Kraków my wife and I flew to Amsterdam, a city I now regret waiting 58 years to visit.  We had 2 fantastic days exploring Amsterdam before we went to the airport, I turned left and my wife went straight.

It was my second trip to Rwanda.  This is a teaching mission through the Canadian Anaesthesiologists Society International Education fund and is aimed at teaching Rwandan residents in anaesthesia.  I had  done this in 2011 and had left frankly a little disappointed and frustrated.  This was in a sense unfinished business for me.  

The educational aspect of the trip unfortunately proved to be another disappointment.  Part of the reason was the success of the program, there are more Rwandan staff anaesthesiologists (very gratifying since I trained some of them) than before so there is less for the Canadian doctors to do.  Another factor was that there are now American Volunteers through HRH who tend to be better funded plus HRH has donated equipment which tended to marginalize the Canadian volunteers.  In addition the teaching program had expanded to two other hospitals in Kigali which spread us very thin.  There were of course all the frustrations of trying to practice medicine or rather to teach others to practice medicine in the developing world and while there are issues of equipment and training there is still an issue of attitude which is a barrier.  I do sound negative however I did notice a lot of positive improvements in surgery and anaesthesia since 2011.

There were also distractions of not having water in our apartment most of the time and a major case of traveller's diarrhea which laid me low for a couple of days.  African toilets are pretty disgusting and the most disgusting ones are unfortunately located in hospitals.

I did take advantage of the tourist opportunities and visited Akagera National Park on the Tanzanian border which is Savannah land, the gorillas on the Congo border and Ngungwe National Forest which is the last untouched rain forest in the country and where I finally got to see a chimp up close.

I was quite happy to leave after 4 weeks which I told my wife were the longest 4 weeks in my life.  I did arrive home somewhat rested, refocused and was prepared to get on with things after 3 months mostly away from work.

Then as I already blogged I got fired as department head.  I should get over this but it has overshadowed the fall for me.

Soon after returning it was back to the airport and off to Las Vegas to see Jimmy Buffett in concert.  I had been a big fan in the late 70s early 80s but had sort of lost touch until a few years ago I bought his box set.  I was pleased to see he was still playing concerts, got tickets for this concert and my wife agreed to come.  We went to the pool party in the afternoon.  It was my first experience with his fans the Parrotheads.  The concert of course was fantastic.  

Vegas on the other hand is a bizarre artificial place whose sole purpose seems to be to extract as much money from you as possible.

In November we flew to Winnipeg for the Grey Cup which is Canada's football championship game.  Our home team was playing which was bonus although we had booked the trip and bought the tickets months ago.  Winnipeg is a way better city than its reputation and they put on a pretty good party.  Of course our team winning topped off the whole weekend.  

In December I went to New York ostensibly for the PGA meeting.  This was a popular meeting when I trained and worked in Eastern Canada but I had never gone to it.  I was able to fly on points in business class which is a bonus and my wife and I got to look around, walk the High Line, go to some decent restaurants and saw two musicals (Lion King and The Book of Mormon) before my wife flew home and I stayed for the rest of the meeting.

I got back from NY on December 15 worked a couple of days and then it was Christmas break and done to the dacha.   

The real highlight of 2015 was getting rid of two Conservative governments as in a shocker the NDP dumped the Conservatives in Alberta after 40+ years and then in the fall the Liberals dumped the federal Cons.  Okay I would rather have had the NDP beat the Cons and I hope the Liberals live up to their promises, something they haven't really done in the past but I would have voted for the Montreal Canadians against Harpo and it is great to feel good about being a Canadian again.

Overall a pretty nice year all told.  I think I will take it easier in 2016.  

Deposed

Almost two months ago, I got deposed, fired, terminated however you want to put it from my job as Department Head.  Officially I was told my term had ended (it hadn't actually) and I was not being renewed.  I was told they wanted somebody younger and who worked full time.

Firstly don't feel sorry for me.  I only got paid a very modest stipend that probably compensated me barely for lost clinical earning time and for the after hours work I did.  I am still working in my same clinical capacity only with a lot more freedom now that I have no more administrative duties.  I am sleeping better and drinking less.

Over the year or so prior to my dismissal I had noticed a chill in my relations with the administration.  The hospital had shaken up its administration meaning that some of long term relations I had with various people were no longer there.  In addition the shake up meant that some positions were vacant for up to a year which was a little frustrating.  I noticed that we had fewer meetings ( a good thing) but that the meetings we did have were meetings where things were announced as fait accompli with no opportunity to even discuss them.  I noticed that I seemed to be more out of the loop, I found myself eavesdropping on surgeon's conversations in the OR lounge to find out what was really happening.

When we did actually meet I found that any disagreement was looked on as bordering on treasonous and often taken personally.  After one meeting one person took me aside and asked me why I didn't like her?  I tried as best I could to be pragmatic and modulate decisions made by administration into something that could actually work in the real world.  This of course put me in conflict with my own department who are a lot less pragmatic than I am.

About six months ago I actually drafted a resignation letter but I thought that would just leave an power vacuum which the administration would exploit.  So I did what they said to do in all the administration courses I took (usually paying with my own money), I hired an executive coach (using my own money which I justified by saying it came out of my stipend).  I had four sessions which were interesting as a venting experience but was really not much help.  After 4 sessions that coach said she would follow up in a few months but I think she just gave up on me as lost.

I took some time off during the summer during which I had a long European vacation and did a one month medical mission.  By time off, I mean that I still answered emails and even attended some meetings by teleconference.  This gave me some time to reflect on what was going down and what I had to do.  I came back feeling that I knew what I had to do, that I could patch up things with administration and the directions we had to go in the next year.  I was actually excited about coming back.

There was the ominous request for a meeting with the Medical Director as soon as I got back.  I didn't sweat this; we meet every few months, I air my grievances, he airs his.  Nothing really gets accomplished.  This meeting about a week and a half after I got back, started with the usual pleasantries and I aired my list of problems.  This went on for about 20 minutes after which he told me that the medical administration was being re-jigged, that my term was up and that they wanted somebody younger and who didn't work part-time (I do chronic pain part-time although I am on site at my hospital 7.5 days out of 10.)  I was a little shocked both that it finally happened but more so in the calculated way it had just happened.  From the conversation I had gathered that I would stay on as care-taker chief until somebody was chosen but the next day the hospital announced by memo that although I was "held in esteem", I was no longer department head.  Having been given the uncharacteristic courtesy of reviewing the memo in advance, I was able to pre-empt this with my own memo.

The response of my department was one of outrage which was gratifying although I suspect some of that was that one of them would have to do it or worse, we would get somebody from outside.  An emergency staff meeting which I didn't attend was held and a letter was drafted.

Meanwhile I headed down to my dacha, walked along the river and stared at the mountains and by noon Saturday, it was all clear.  I could fight this, maybe "win" and live in a poisonous relationship with administration or I could just  focus on all the things I had had to let slide over the last five years (like writing this blog).  I composed a group email, stating that I no longer wished to be department head and that I was at peace with administration's decision.  I asked them to unite behind their acting chief and whoever was chosen to succeed me (almost two months later and no movement on that end).

It is unusual after being involved in the running of the department and aspects of the hospital to just be completely out of it.  I occasionally see down the hall somebody I used to meet with a lot who I never see anymore.  Some of the time I think how little I enjoyed the time spent with them.  A few weeks ago I arrived a little early and the OR committee was meeting next to the OR lounge and of course I used to attend those too.  My email inbox is now manageable size.  I occasionally hear of some problem and think how nice it is that I don't have to solve it.  I can exercise before or after work because I don't have any meetings.

I am still not sure what prompted my whatever you call it.  I kind of wish I had gone out with some outrageous, quixotic, act of defiance which people would talk about for years to come.

Last weekend my department had a nice what I called a "welcome back" dinner.  Speeches were made (actually just one speech) and I got some nice gifts.  I wonder, if the hospital changes its mind, do I have to give them back?

My new religion

I was in the pain clinic a couple of days ago hearing a patient tell me how his doctor wouldn't order a certain treatment because it was against the doctor's religion.  Already doctors are refusing to provide such services as birth control or referral for abortion citing religious reasons.  Some refuse to treat unwed mothers, some homosexuals.  

Since my parents let me stop going to church and Sunday school when I was 13, religion has not been a part of my life.  I have attended the odd wedding, funeral baptism or midnight mass but I suspect I have spent more time in churches as a tourist than as a participant.

But now that I realize I can actually refuse to do things I don't enjoy doing based on my beliefs, I think I just got religion.

Henceforth:

I am not going to observe isolation precautions.

God obviously loves antibiotic resistant bacteria because he makes so many of them.  So who am I to stop them from being fruitful and multiplying.  My righteous brothers and sisters on the wards are already helping this by allowing patients on isolation to go outside to smoke and visit the cafeteria.  Plus I think wearing yellow gowns is specifically proscribed in Deuteronomy or maybe Leviticus.

I am not going to do patients with no coverage (yes we have them in Canada),

I think the passage about render unto Caesar covers this.  I mean, how can I tithe if I don't get paid.  And for what you or  your Canadian relatives paid for you to fly to Canada for pro bono surgery, I am sure there is a little left over for my modest fee.  Plus if you came to Canada to ski or ride in the rodeo and didn't buy adequate travel insurance maybe you don't deserve to have your broken leg fixed.  And I really don't care if the surgeon also didn't get paid, because I expect in about half the cases he actually is getting paid.  Therefore if you want my services you better visit the money changers at the ATM in the hospital lobby to get some money to make the  appropriate offering.  Some people might get a warm fuzzy feeling from providing services for free to people but my righteous life gives me all the warm fuzziness I need.

Working on the Sabbath is out.

I haven't got this Sabbath thing down yet.  Is it Saturday or it is Sunday?   Never mind.  I won't work on either.  Nor on Statutory holidays or should I call them feast days.  Hmmm better think this one out....we get paid more to work on those days.  OK I will work those days, except when I am tired, hungover, something good is on TV, I don't like the surgeon or the slowest nurses are working.

No more emergency sections for breeches.

I'm not talking about the breech vaginal delivery gone wrong; I'm talking about the "stat" section for a persistant breech because they have either started labour or their membranes are ruptured.  Funny how these stat sections never happen during office hours.  If God wants you to come out butt first, you should come out butt first.  Besides if untrained birth attendants in the developing world can do a breech delivery, an Obstetrician with five years training should be able to.  

Because I am a righteous family guy, I get to go home when I want to and take vacation when I want to.

My kids are grown up but still it is the principle.

Obese patients violate my beliefs.

I am sure there must be something in the Bible about this.  We are blessed with a nice premium for patients with BMI over 35 so I will keep on doing those but the 45s and higher where you actually earn the premium are out. 

I am not going to fill out narcotic tracking forms.

Narcotics are one of God's gifts to mankind.  Besides as a righteous man of God, I would never misuse narcotics (and if you really to see what I may have given the patient, you can consult the holy anaesthetic record). 

No more futile surgery.

What can I say.  Who am I to try to interfere with God's will.

If you want me to come to a meeting before work you better provide breakfast and that breakfast better include bacon.

In my religion bacon is a sacrament, and if you expect me to get up half an hour early for a meeting to decide something you could have settled by email or phone call you better feed me.

I intend to live my life outside of work righteously as well.  For example some extreme religions do not allow their adherents to sit next to a woman on a plane.  Okay, it is an abomination for my legs to touch the seat in front of me.  Therefore the airline in the interest of religious freedom must allow me to have a bulkhead, exit or business class seat.  For no extra charge of course.  Also my religion prohibits me from sitting next to young children, people with body odour problems, people drunker than me or obnoxious people.  

I am sure in time I will find more ways in which society can ensure my life goes in as righteous a fashion as possible.  Stay tuned and God bless you all, except those of you who piss me off.