Monday, March 26, 2007

How I Almost Got the Strap

I was a pretty good student. I got good marks, behaved well etc.

In Grade five though I almost got the strap. I have gone over this incident in my head for the succeeding 39 years and now wish to come clean.

When I was in school we had corporal punishment which meant being hit on the hand with a modified leather strap a number of times depending on the severity of your offense or your record. "The Strap" was administered out of sight in the Principal's office or occasionally in the hall or the cloakroom by your teacher. Usually 1-2 children got "The Strap" every year which increased the mystique behind it.

I never got "The Strap" which I will explain later but I suspect it hurt a lot less than the spankings most of us got from our parents. It was the mystique behind "The Strap" which was sufficient to keep most of us in order.

Now I say I was well behaved but this may not have been the case in Grade 5. We had that year, a very old teacher who had always taught Grade 1 and 2 but this year was given a split Grade 5 and 6 class. Not only that, but she was given the worst Grade 6s in the school. So things got a little out of control in our class shall we say, and I probably took advantage of that. Nothing serious, more talking out of turn, that sort of stuff.

On the day in question, two or more of the Grade 6 boys had got a piece of pipe-cleaner from an art project and had rolled it into a small compact stick that they were throwing back and forth around the class. Every once in a while the teacher at the blackboard would catch it out of the corner of her eye and wheel around. It got quite annoying actually.

Just after lunch, the projectile landed on my desk. I had two conflicting emotions. I was fed up at this thing being thrown around the class, but at the same time now that it was on my desk, I was scared that I was going to be blamed. Logically I should have closed my hand around it, stood up walked to the garbage and deposited it. Instead I did something really stupid. I threw the projectile in the general direction of the garbage can which was next to the teacher's desk, which was where she was sitting at that time. Instead of landing in the garbage can, it landed on the teachers desk.

The result that I, along with two Grade 6 boys, was marched to the principal's office. The principal however was sick that day and the secretary who normally would have summoned the vice-principal (who gave the strap much harder than the principal) to the office was not at her desk. Our teacher said, fine we'll come back after school.

I remember coming back to my desk and shaking uncontrollably. I don't think I learned a thing that afternoon.

After school the three of us stayed at our desks, waiting to be taken to the office. A few people in the class hung around to watch us make the walk. The teacher came to us and said, "Are you ready to go?", I said yes. She said "Do you want to go" I said no. She said that if we promised to behave for the rest of the year we would not get "The Strap".

I left the school feeling freer than I have ever felt before or after.

The Ride of Your Night

In several places around the city there is a billboard advertisng a cowboy nightclub. This has a picture of a cowboy-hatted woman wearing a denim miniskirt and halter top and suggests if you visit said club, you will get the ride of your night with this or similar women.

The sad reality:

1. Women like that rarely go to bars that you go to.
2. If they do;
a) they are not interested talking to you or dancing with you. They are most definitely not interested in having sex with you.
b) they most likely are accompanied by a muscle bound boy-friend who, if you are lucky, will only beat you up if you look at her the wrong way.

I just thought I should straighten this out.

Thursday, March 15, 2007

Rate 2

Okay now I'm getting mad.

Two days ago on CBC there was a feature on this site. My wife saw it and went and checked my profile. Since I last looked there was another post which was even worse than the last one. It stated that I was uncommunicative and didn't listen (i.e I didn't talk and didn't listen, I guess we just sat and stared at each other for 30 minutes).

Anyway I was talking with my colleagues today and they asked if I had looked at the site. I told them I was on it and about the negative comments. They were very sympathetic and promised to log-on and write more positive comments.

I looked at the site after lunch to see if they had done so. There was now a third post stating that I had made someone wait for three hours while I talked and joked with a friend after which I cancelled their appointment and my receptionist booked them one a year away.

Now.... I may be moody, I have difficulty forming an empathetic bond with a small minority of patients, I am frequently in a hurry but...

In 13 years I have never made anybody wait 3 hours. On occasion when somebody came on the wrong day, they may have had to wait until I finished what I was up to but I can't remember an instances. Part of the reason I rush is so that I don't make people wait. Secondly I have never sent a patient away who had an appointment. Now on occasion when a patient walked in without an appointment and I was really busy or had to leave right after I may have told them to come back but never one year later. I am usually pretty good about seeing patients who come on the wrong day, come without an appointment or even patients who just walk in off the street. One of the major criticisms of my colleagues where I used to work was that I was too nice to the patients (I tried to help them instead of telling them to get off their asses and go back to work).

I have contacted the site and hopefully this post will be removed.

Why I left the Centre of Excellence

15 months ago I left the large teaching hospital I will call the "Centre of Excellence" to practise at a smaller community hospital. I had worked at the CofE for 14 years. People often ask me why I left. There was no single reason; it was a series of small reasons. Taken individually they seem petty, as a whole they are a powerful reason.

1. I never fit in there.

When I was a resident I worked at a hospital that was similar to the CofE. I vowed I would never ever work in such a hospital. After my residency I worked at a community hospital in New Brunswick. Problem was, my wife and I are both from BC and I began to pine for BC or least Western Canada. In addition the New Brunwick government was in financial straits in the early 90s and was cutting money from health care like crazy. This not only affected my income but actually increased the number of hours I had to work for less pay. Now at that time, they was a glut of my specialty in Canada so when I got an offer to work at the CofE, I forgot about how much I hated that type of hospital and jumped at it. Within a month I knew I had made a major mistake but I had already spent a lot of money and time moving and besides there weren't a lot of jobs in Canada. In addition when I moved, I told my wife this would be our last move ever.

2. Personality Cults

I am an anaesthesiologist. I realize that patients don't come to the hospital for anaesthesia, they come for surgery. However I soon realized that at the CofE there were actually "personality cults" approaching worship of most of the surgeons. The problem was many nurses worked exclusively in one single sub-specialty while you rotated between rooms. This actually hurts rather than improves care as nurse tend to overlook flaws in the surgeons while focusing on your flaws real or imagined. For example a few years ago a surgeon left his resident to do a mediastinoscopy undersupervised. When the resident biopsied the pulmonary artery (actually he didn't but with the amount of bleeding that was what we thought) the surgeon could not be found. After several anxious moments another thoracic surgeon came from his office. It turned out the surgeon had actually left the hospital. I felt this had to be reported and when we discussed it at the next staff meeting several others had had the same thing happen with this surgeon so it was reported to the medical director and the surgeon was hauled on the carpet for a "corrective interview". Naturally I didn't work in that room again for about six months. I was expecting a frosty reception my first time back but to my surprise (maybe not) it was the nurses and not the surgeon who were frosty. I should mention that this surgeon is now on a forced leave of abscence.

There have of course been less egregious episodes. Like the nurse hissing, "I'm helping the surgeon!" when I asked for help with the severely burned patient.

3. Face-offs
This isn't about hockey. Our hospital does a lot of major head and neck surgery. We call those face-off because they take the patient's face off for cancer and reconstruct. These cases last about 16 hours. They don't require a lot of work once the case starts and always go to ICU post-op so they are not terribly intellectually stimulating.

The problem is that during those 16 hours, you have to eat and pee. This requires you to ask for another anaesthetist to come into your room to take over the case briefly. Most anaesthetists will do this for one another as a courtesy. The CofE has residents as well so they can often take over the case. Recently residents no longer regard helping another colleague to be educational so that route has been closed. There also seemed to be a lack of respect within the department so people would not automatically ask if you needed a break. This meant that around 1400 you were basically phoning around begging for a break so you could pee. We discussed this at multiple staff meetings without any resolution.

Long cases like this are not new. In the "old days" you would do about one a month. At the CoE they do 3 a week. This is in addition to the odd long Plastics or Neurosurgery case. The major head and neck cases used to be thought of as a cross you had to bear in order to do the lucrative ENT short cases. In our city however all the lucrative cases are done at another hospital. Go figure.

Usually one of the on call people takes over the case around 1600. There had been a tendency to assign the second call to that room which meant the lucky second call person gets to do the whole sixteen hours. Of course this means one of the on call people is now finishing an elective case from the day during the evening instead of doing emergency cases.

Add to that the personality cult among the nurses in that room.

4. Major cases
When I came to the CofE we actually did minor cases. Then the regional health authority decided that the CofE should be a pure "tertiary referral centre" and all the minor cases were moved to other hospitals. This means most of the cases are 3-5 hours long with the usual problems peeing and eating. It also means that cases often run into the evening without warning and the second call can't take over your case because he is in the face-off (see above). In addition many of the cases are in patients with a bad prognosis which is bad for morale.

Somebody has to do these cases (well actually some of them would be better off not being done). It just shouldn't be the same people all the time.

Also as people started to leave and it became hard to recruit staff, the chairman recruited a number of staff with questionable skills and qualifications. So guess who gets to do the few low intensity cases we have because they can't be trusted with sick patients?

5. Lack of help

I would think I am at the top of the scale of self-sufficiency for doctors. I can do most things without much assistance. There are a number of things that require an extra pair of hands. Also sometimes somebody has to go and fetch equipment or drugs solely because you can't leave the patient. Oftentime equipment is stored in a location where only somebody else knows how to find it (sometimes I think they do this intentionally).

When I interviewed for the job at the CofE they raved about their anaesthetic techs. I was actually looking forward to having somebody to help me. Unfortunately the techs work mostly in the cardiac rooms and are of very little help in other rooms. I found them very unhelpful.

Because we have techs however, most of the nurses were reluctant to help out. Many of them when I asked for help would go to the intercom and page a tech who never came. Sometimes a tech would come, open the door a crack push in the piece of equipment you needed and leave. Sometimes they would actually come in the room, look around and leave.

As low intensity surgery was moved out of our hospital, the need for the techs became greater, however the level of service did not improve, if anything it got worse.

Over the years I learned how to function without much help. When the hospital started renovating the OR, everything was moved and moved again which meant I couldn't find anything.

In contrast when I did locums or when I worked at other hospitals in the city I was amazed at the level of assistance I could get.

For the last couple of years, if I had to do a major case the next day I would lie awake at night worrying about how I would get throught the case with no help. One thing that always bothered me was that there were certain types of cases we did a lot of like for example liver resections but every time I did such a case, I would have to come in first thing in the morning and ask individually for every piece of equipment I would need to safely do the case.

This was brought up multiple times at staff meetings, and the chairman's (he only works in the cardiac room) was "we get excellent service from our techs".

My "Colleagues"
The CofE has a lot of anaesthesiologists whose shit doesn't stink. I noticed this from about the first month. I would sit in the lounge and hear people talking about the horrendoma they had done and how it was only thru their skill that the patient pulled thru.

I felt very inferior until I realized that I was doing the same cases as them and that my patients were pulling thru if only because no matter how incompetent you or surgeon are, it is very hard to kill somebody.

There were and still are a lot of people there I like. Over the years quite a few people came in who I didn't really like, some of the people I liked left and so on. I used to come to department social functions early on. I stopped going after a while, if somebody asked me, I said," its bad enough having to work with you". After a while, I realized that I wasn't joking.

When I started thinking about working at the community hospital, I thought about the anaes. who already worked there and realized how much more I liked them (and till like them after a year).

Lack of Respect
There are two types of respect.

The first type of respect is a type you have to earn. I know that I have to earn that respect and I don't take that as a given.

The second type of respect is the basic respect that everybody is entitled to regardless of their station. I like to think I try to treat everybody with respect. Maybe I haven't always done that but I always try now.

That second type of respect was totally lacking at the CofE. And for that matter forget about trying to earn the first type of respect.

It was only after working at other hospitals that I learned that I was actually an important member of the team whose input was important.

The declining standard of care

"Back when I was a resident" teaching hospitals functioned on the backs of residents, interns and medical students who worked their buns off. Staff physicians and surgeons did very little patient care and the nursing staffs tended to be more helpless than in a community hospital. It was soul-destroying work and I am glad that residents don't work as hard as they used to.

Except.... if they don't do the work, somebody has to do it. That means that the staff surgeons have to start earning their generous fees and that the nurses have to learn that the solution to every problem is not to page someone (because that someone is not going to answer that page anymore).

Unfortunately the slack is not being picked up. Problems are being missed, patients are coming to the OR on an emergent basis for problems that could have been picked up earlier and dealt with electively or not at all, patients are coming to the OR inadequately investigated or inadequately rescusitated. Charting is attrocious especially on the medical side. I find it disgraceful that I have to rely on the nurses' notes to find out what is going on and even then these are frequently less than adequate.

This happens to a lesser extent at our community hospital but in general the surgeons seem more vigilant and insist on a higher quality of care from their residents.

Disorder in the Operating Room

When I first came we had a clinical director who directed the flow of cases in the operating room Things worked out quite well. Then the health authority decided we didn't need one.

Now we have a clerk at the desk who manages the flow of cases. When a surgeon wants to book an emergency that involves disrupting a room, instead of talking to a physician or even a nurse who might be able to tell when he is lying, the clerk simply gets on the phone and disrupts whatever room she feels like. If you are involved in one of these so-called E1 emergencies, you of course have no idea of what you are getting into because of course the surgeon does not talk to you.

Unbelievably this was raised at staff meetings and nobody thought it was important although a few months after I left, they actually did change the system and now you have to talk to an anaesthetist to book your case.

We also have transplants. I have a lot of problems with transplants but then again I am just one needle stick away from needing a liver transplant so I will shut up. The problem is they typically harvest the donor starting in the evening which means that the heart, liver and lung transplants start after midnight so that come 0700 we have 2-4 anaesthetists who are not available to do their scheduled list. Instead of trying to deal with the problem (do the harvests earlier in the day so that the transplants are in the evening or do the harvests at night and the transplants first thing in the day), we came up with a solution where we have to take turns being the person who has to find 2-4 individuals to work the next at 2300 hours. So after working all day, you get to spend about an hour at 11 pm finding somebody to work the next day.

The transplants also screw up the OR slate incredibly the next day plus on weekends trauma cases get backed up.

There are actually some good people there

I don't mean to be entirely negative. There are a lot of really good people there who are disgusted by what has happened to their hospital and continue to labour on because of loyalty.

My Diary

It seems funny that I am exposing my thoughts on the internet. Maybe not my innermost thoughts but still my thoughts albeit under a pseudonym.

It reminds me of the diaries I kept as a child as a teenager.

I got one of those diaries for Christmas when I was ten. I think I may have asked for it. I think I wrote in it for a few weeks. My parents had the views that if you had nothing to hide you didn't need privacy which meant everybody in the family was allowed to read it, which they did. One of my brothers even wrote in corrections if his version of events was different from mine. I think that was why I stopped writing in the diary. We also had to keep a diary as a project in Grade VI and my mother kept it and presented it to me on the occasion of my 25 high school anniversary.

In Grade X, I was thinking that a lot of really interesting if trivial things happened every day and I would forget them if I didn't write them down. I also decided I should write everything down which of course included things I really didn't want me parents or brothers to read.

I kept the diary in an ordinary school notebook and hid it in plain sight in my room figuring no one would look in one of my school notebooks. This actually worked and nobody read it until in Grade XI, my little brother discovered the book and read it.

Now nothing about my high school life was controversial except that I had the hots for a certain girl which I wrote about extensively in the diary. Needless to say my little brother bugged my continuously about this.

Anyway I ended up destroying two notebooks of my diary and never kept a diary again. Until now; sort of.

Monday, March 12, 2007

Is it time to regulate real estate?

One of the more prescient things I have done financially was to buy a house, a vacation property and more recently some rental properties. Consequently much of my net worth is now real estate.

Real estate prices are now thru the roof and expected to rise. It has gotten to the point where even in situations where both of a couple work, they cannot afford a house.

Of course banks are being very understanding, offering low interest rates and low or no down payment.

While my house is now worth the high six figures, this is fine except that I have to find a place to live. If my wife and I wish to downsize to a condo or move somewhere where Real Estate isn't ski high we might realize a modest tax-free profit. On the other hand, I lie awake at night thinking about how much capital gains tax I will have to pay on my vacation house.

What is more concerning is the amount of debt that is tied up in these highly valued homes. These homes are only worth something if you can find somebody who can pay what you want and I can see a time where people are just going to accept the fact that they will be renters for the rest of their lives. This is going to result in a glut of houses with an innevitable crash in prices. Those of us who have fully paid off their mortgages won't suffer too much except the loss of money we never really had. I worry about those with high mortgages who now owe more than their house can be sold for and the ripple effect on the economy. One thing is certain, it won't be the banks that suffer.

It seems that the real estate explosion is certainly being sustained by two factors; people who speculate or flip houses and the real estate industry who benefit from house transactions.

I read somewhere that back in the 70s when house prices rose in Ontario to the unprecedented high of $50K, the "socialist" government of Bill Davis put the brakes on this. It was quite simple, they put a wind-fall profit tax on flipping houses. If you sold your house in the first year, you paid 90% of the profit, 80% in the second year etc. This would put a brake on flipping properties which is a major factor driving price upwards.

Secondly Real Estate commissions have to be capped. The commission is essentially a built-in inflationary factor. Just to break even if you sell your house, you have to charge what you paid plus the commission which is usually now greater than 10K. When you think about it does the realtor really earn 10+K. Not on your life. Selling houses is easy now with listings on the Internet. Our last lot was found on the net, we bought it and the agent collected a commission basically for answering the phone. Our lawyer did more work and only got about $1000. Imagine somebody making more than a lawyer!

Why not cap commissions at $1000 or some sensible figure.

I should also mention, the Realtor does not necessarily have your best interests in mind when you sell your house. According the book Freakonomics, Realtors who sold their own house consistently sold them for more than their clients' equivalent houses.

Tuesday, March 6, 2007

Little Things That Piss Me Off 2

I went skiing last weekend.

Have you ever noticed that people wait for their friends in the line-up. This means you have to either step around them with your skis on or ask them if they actually intend to board the chair.