If We Are All Specialists, Are None of Us Specialists?

I have been thinking about training and licensing and how things have changed during my lifetime.

Gather round children while Grandpa tells about how we became docs in the olden days.

When I was in medical school we did the first three years with increasing clinical exposure. Everybody took the same courses, there were few or no electives. The quality of experience you got in your clinical rotations varied with hospital and clinician but that averaged out.

Fourth year was what was called a clinical clerkship or where I trained, a medical student internship. You were dropped in on the wards with little preparation or supervision to look after whatever disasters were there. True you were "supervised" by interns and residents but they often had disasters of their own to deal with. You did a lot of what we called scut work which was noneducational service oriented work but I, at least, learned a hell of a lot in that year. The clinical clerkship was based around the core rotations of medicine, surgery, paediatrics, obstetrics and psychiatry. There were electives of course. Again, while there were differences from hospital to hospital, everybody more or less got the same experience in fourth year.

When you graduated you were what was called an undifferentiated physician. You needed one more year of training to get a license in most provinces. This was done via a rotating internship which was again based around the 5 core specialties (sometimes less psychiatry). Almost everybody did this, even the future specialists. It was possible to do a straight internship but very few people did this. The rotating internship was a lot like the clerkship except you were more senior and you had the opportunity to work in another centre.

So one year after medical school, basically everybody had the same training, and the same experience. Those of us who chose not to become specialists became general practitioners. General practitioners at that time did a lot things including some surgery, orthopaedics, obstetrics, emergency work, anaesthesia as well as what we now call family medicine. How much they did varied from centre to centre with rural doctors doing more than city doctors, although not necessarily so. Some people had taken extra training, some people just went out and did it.

This idyllic world was already about to end around the time that I finished medical school. Sometime in the past, some general practitioners, resentful of the supposed prestige of specialists, decided that they too could become specialists and the "specialty" of family medicine was born. This was quickly followed by the family medicine "residency" which lasted 2 years as opposed to the one year rotating internship. I worked along side these "residents" in family medicine as an intern. We of course called this the "internship for slow learners".

We shouldn't have laughed at them. Only 8 years after I graduated from medical school the rotating internship was dead. The only way to get a licence to practise in any Canadian province was to do a specialty or to complete the family practice "residency".

Now back when I was coming out of medical school and internship, I really couldn't have told you what specialty if any I wanted to do. I was 24 single, sick of training and not having any money. I was happy to be "just a GP". There were lots like me; we drifted around doing locums for a few years before having a revelation and starting a specialty. I think the specialties preferred it that way, they got older, battle tested residents. I should also mention that it was often people passing time before specialty training who staffed the remote communities which is why there is such a shortage of docs in those areas.

With the general practice route now closed off however now you had to decide on a specialty sometime before early in fourth year. Coincident with this, most medical school went to a two year student internship with core rotations mixed with lots of elective time. The elective time has for the most part, become a time to visit various programs and get some brown-nosing in, in the hope that they will rank you high in the match saving you from a career in radiation oncology.

This has resulted in medical students now spending large chunks of their clinical years doing electives, often in a small number of specialties. I was impressed, not necessarily in a good way, in how much time our prospective residents in anaesthesia spent doing electives in anaesthesia. This often means that students slide through rotations they are not interested in, knowing that they will not be failed and they will not be asking for a letter of reference from that rotation.

The result is after 4 years, instead of undifferentiated physicians we now have "specialists" in plastics, anaesthesia, urology; whatever they decided sometime in third year they were going to be. This means we have internists who know nothing about obstetrics, neurosurgeons who know nothing about psychiatry etc, etc.

The point I am making is that 25 years ago, all doctors graduated equal and then some went on to be a specialist in a certain field. These specialists had at least had a taste of what other doctors have to deal with and the relationships between specialties was better. Specialists were physicians who happened to be specialists. Now however we have all been put into our silos early on in our careers; I can still consider myself a physician who specializes in anaesthesia, but the graduates of the last 10-15 years who are no longer physician specialists but now merely anaesthesiologists.

As a future consumer of healthcare I am not optimistic where this is going.

Treating Family

My father phoned me a few days before Christmas, a little worried. An incidental finding on an abdominal ultrasound showed a 5 cm aneurysm and his FP had referred him to a vascular surgeon who reviewed the aneurysm and decided it was actually 5.5 cm and suggested endovascular repair. My father asked me what I thought. When I told him that it had been 10 (mostly great) years since I had done any vascular surgery, that I was out of touch with that aspect and therefore couldn't really advise him, he sounded a little upset at me. I felt a little guilty, I probably wouldn't have become a doctor without his support.

One of the crosses I have had to bear since becoming a doctor has been having to give advice to relatives.

When I was an intern I worked on the infectious disease ward. One of the children we treated was the son of a doctor who had meningitis. Problem was that for five days his physician-father had treated him for otitis media with Amoxil. While Amoxil was not very effective for killing the meningococci in his brain, it was very effective in prevening anything from growing in culture which meant prolonged treatment with chloramphenicol. This made a powerful impression on me.

This is not to say I haven't glanced at my kids when they were sick and said, "They don't look too bad, and probably don't need to see a doctor". At the same time, I rushed my son into emergency when I thought he had epiglottitis (which of course got better as soon as we hit the cold winter air and turned out to just be croup). I also took the same son's stitches out last night. When my kids obviously broke something, I usually phoned the orthopod rather than deal with the family doc or the ER. I do draw the line at looking in ears, throats and of course other body orifices. My observation is that doctors' children either get very little medical attention (my kids for example) or way too much medical attention.

While I am sure that many doctors are much smarter than me and are able to make an accurate diagnosis and suggest treatment based on the information given over the phone or at the family Christmas party, I usually need to ask some personal, occasionaly intimate questions, lay my hands on and review the medical history. There is also the matter that I am a specialist in anaesthesiology. I was a general practitioner 23 years ago but back then I treated hypertension with Aldomet. Working with surgeons in teaching hospitals has exposed me to much surgical education, how much of it I remember reliably is questionable.

More onerous is the request to phone a relative's doctor. I have been pressured into this a few times and it is usually a tense time for me and for the treating physician. Firstly we are all busy and why should I burden another doctor with a phone call. In addition I have only recently figured out that there are two sides to every story and that usually doctors are not nearly as neglectful as they are made out to be. There is of course the privacy issue; why would a surgeon even discuss my sister-in-law with me. I have in my Pain practice spoken with physician relatives of patients. I usually make sure I have permission from the patient first.

Early on in my career when I was still in general practice, I was visiting my brother. I came home early one day and his wife decided to burden me with her medical history. She laid on a constellation of symptoms to which I replied, "Sounds like you need to see doctor". She said she had and he had found or did nothing. A year or so later she was diagnosed with breast cancer from which she ultimately succumbed. I often wondered whether she knew she had this lump in her breast and was just trying to get somebody to examine her breasts without actually asking.

Shortly after my residency I was visiting my brother in law. His wife asked me if I could see her mother (mother in law of my brother in law) who had swollen legs. I explained that I was no longer a general practitioner, I was a specialist in anaesthesiology, that I was not licensed to practice medicine in that province and that further I felt uncomfortable seeing her. A guilt-trip was laid on me and so I walked over to her house with my wife. It turns out that her family doc had diagnosed venous stasis, suggested bed rest and compression stockings which I would have suggested and which she decided not to comply with. We otherwise had a nice visit and she gave us 2 loaves of bread which she had baked while she was supposed to have been off her feet. I wonder often what would have happened if what was going on was a DVT and she had been found dead the next day.

Can an Atheist Enjoy Christmas?

As I mentioned in my previous post, I really like Christmas. Burntoast (what a great name I wish I had thought of that) commented on how he deplored the secularization of Christmas. While I am not one of those who write letters to the paper about "how it's not Christmas without Christ" I agree with him.

Firstly let's get something straight. Christ was born in March or April. We know that because the Romans kept records and the census the Augustus ordered which is why Joseph and Mary were in Bethleham took place then.

For centuries possibly millenia before Christmas, people had been celebrating the mid-winter. It is a time of hope, the days start to get longer. In addition the feasting gives people an opportunity to slaughter animals and eat them so they don't have to feed them during the winter and to eat all the perishable food before it spoils. Thus fortified they can face the lean months of Jan thru May.

When Christianity spread to Europe, the Christians adopted the pagan festivals. Afterall if you celebrated Christ's birth in April, it would kind of conflict with celebrating his death in March or April (I have never quite figured out the movable feast thing).

Therefore celebrating Christmas is not a celebration of our Christian heritage; it is a celebration of our (most of us anyway) European heritage. While this leaves our people who emigrated from other (usually warmer) continents who didn't need to celebrate the Winter Solstice, it is largely not these people who object to Christmas. I saw an interesting picture in our local paper of a school choir singing. One of the singers was wearing a full Islamic head scarf. It is largely fellow people of European origin (PEOs?) who are trying to suppress most of the symbols of Christmas most of which are pagan in origin (like the Christmas tree).

Christmas carols it is true are mostly about the birth of Jesus. But, they are great music and way better than most of the secular Christmas music. Joy to the World vs. Grandma Got Runover by a Raindeer? I love Baroque music and what better way to get two hours of it live than attending Handel's Messiah. I can never make out the words anyway.

Therefore when I wake up on Christmas, open my stocking and my presents and watch the sun come up around 8 o clock, I am merely celebrating a millennia-old tradition that is part of my culture (3-4 days late).

Humbug

I like almost everything about Christmas. I like the carols, Handel's Messiah, the decorations, giving presents, eggnog lattes, turkey, and of course the time off. I don't like working over the holidays however I have enough colleagues with large mortgages or ex-wives who are "happy" to work over the season that I don't actually work much at Christmas. The great thing about Christmas is how we more or less shut down society for 2 weeks and nothing bad really happens.

There is one aspect of Christmas that I always disliked and fortunately no longer have to deal with.

The school Christmas concert.

I told this to my wife over dinner last week and started an argument. I don't know why, I always went cheerfully; frequently I had to sell my soul in order to get out of call or get someone to take over my long case but I never missed a single Christmas concert.

I should clarify, as a musician, I always appreciated the band concerts at Christmas. They were universally of good quality and I like to think that most of the kids were actually enjoying themselves.

It is the elementary school concerts I dreaded. Those combinations of bad singing, acting and dancing lasting about 2 hours. I now realize that I suffer from Seasonal Affective Disorder. This means that as the days get shorter and I start coming to and going from work in the dark (and usually spending the day in a windowless room), at best I feel tired, at worst I feel depressed and crabby. Therefore at the end of a day, the last thing I really want to do is to get dressed up,rush (these concerts usually start before 1830)and sit on an uncomfortable chair for 2 hours watching for the most part other people's kids. Worse was when we had kids in two different schools; not only did we have two concerts but we had to drag the uninterested sibling along as well.

A couple of years ago, the music teacher at our local elementary school decided for various reasons she did not want to have a Christmas concert that year. Since she was the one who was going to have to arrange it in her own personal time, I could understand her position. At the same time I had the sensation of elation of being released from some weight on my soul. Other parents in our neighbourhood were less impressed although I think a silent (largely male) majority agreed with me.

The major thing is that the kids really don't enjoy them either. After a frosty ride home because of the argument I started, my 20 year old met us at the door. "So", I asked him, "All those Christmas concerts; did you really enjoy them?". "Are you kidding?" replied my son, "I hated every minute of them". My wife was actually surprised.

When I was younger we had what we called Christmas assemblies. These were held during school hours; no self respecting teacher in the 1960s was going to come in for the evening. They were attended mostly by our mothers. Back in the 1960s nobody's mother worked (at least not outside of the home for pay). In case I ever go into politics, I'm not saying that this was a good thing. These "concerts" were for the most part benign and we got out of an hour of classes.

There was one exception. The year I was in Grade 5.

Our large baby boom school was from Grade 1-7 and was divided into Grades 1-3 and 4-7 for purposes of assemblies. That year it was decided by someone, that at the Grade 4-7 assembly the massed "choir" would sing "Go Tell it on the Mountain". This not being a common carol, we had to learn it. In order to do so, for 2 consecutive days all the classes assembled in the gym to be taught the song by Mrs. Leacock.

Mrs. Leacock taught Grade 7. She had bright red hair, was heavily made up and wore an amount of perfume that even in the 1960s was excessive. As I later figured out she was probably boinking the Vice Principal. She had a really bad temper and liked to yell. Her days on playground patrol usually resulted in a steady stream of children being sent to the principal's office. From Grade one onward, I dreaded that I would be in her class in Grade 7, (fortunately she transferred to another school to join her lover, who had been promoted to principal there, after I was in Grade 6).

Just to get us in the Christmas spirit, before the first rehearsal, the principal informed us that anybody who misbehaved would be sent out and that would mean getting the STRAP. With Mrs. Leacock, looking at her the wrong way could be construed as misbehaving.

For the two hours over 2 days we sat terrified on the floor of gym while Mrs. Leacock pranced histrionically in front of us, cajoling us to sing. We survived, only one person got sent to the office and we sang the song for our mothers at the assembly.

And to this day I hate that song.

Why I won't be wearing a poppy again this year

One of the highlights of elementary school was getting the free poppy that was passed out every year. Back then they were made of felt and were a whole lot better than the plastic ones passed out today.

Poppies "celebrate" the deaths of Canadian soldiers in the First World War as celebrated by the poem "In Flander's Fields" by Dr. John McCrae a physician who died shortly after writing this poem. I can still recite most of this poem from memory (but I can't remember where I left my keys). Every year in November poppies are given out for a donation by Royal Canadian Legionaires and Army/Navy/Air Cadets. Not wearing them is, certainly for someone in the public eye such as a politician or other figure, a major faux pas.

I haven't however worn one since university. Not because I forgot to get one, not because I always stab myself with the pin, not because of the cheap plastic or that I always seem to leave them on the coat I am not wearing.

I first got a little disgusted at an event that happened years ago. At the ceremony in Ottawa, a group of women wanted to lay a wreath in memory of women who were raped during war-time. A little strident but we must also remember the number of civilians who suffered during the war as well. These women were physically restrained by a group of veterans from laying the wreath.

Remembrance Day was started as a day to remember how awful war really is in the hope that we would not have another one. Some people say that it was the horror of the first world war that lead politicians in Britain and France to appease Hitler in the years running up to WW2. Those of us who study history would say that WW2 was probably inevitable and whether or not Hitler was appeased only affected how early or late the war would have started. In fact probably not just a few British, French, Canadian and American politicians and businessmen actually liked what Hitler was doing until what he was doing threatened them.

When I was young most of our fathers had actually served in the second world war. My father did although he fixed radios at various airfield in Canada. Quite a few WWI veterans were still alive. These veterans marched silently on Remembrance Day in memory of their colleagues who died and in the hope that more would not have to die. Unfortunately as we get farther and farther away from wars as devastating as the First and Second World Wars, Remembrance Day has moved from a solemn remembrance of the horror of war to a celebration of war.

Over 100 Canadians have died in the war in Afghanistan propping up a government that oppresses women, Christians and ethnic minorities. Any criticism of this war is answered by the usual reply of, " Do you want those brave soldiers to have died for nothing". It is hard to answer this except to reply that yes indeed they have died for nothing and that maybe we should get out before more die for nothing.

I had a lot of hope for the 21st century. I really felt that we would find a way of solving problems in a way that didn't involve killing people.

I think I'll be forgetting to get a poppy next year.

Unnecessary medical testing

White Coat has a post about unnecessary medical testing

He challenges us to find examples of unnecessary medical testing.

Just off the top of my head:

1. Electrolytes unless the patient is in renal failure, on diuretics or steroids, or has been vomiting or has diarrhea.

2. PT/PTT unless the patient is on Coumadin, or you are suspecting liver failure or sepsis.

3. MRI of the back or neck for chronic pain unless there are leg or arm symptoms.

Stupid People

An acquaintance of mine recently started work at the phone advice centre for our health authority. This service allows patients to call 24 hours a day and speak to a nurse who will triage according to protocols and give advice. This hopefully avoids some ER visits while getting some people who need to get into the ER right away into the ER right away.

She has been quite frustrated with just how stupid people appear. She feels that by tolerating their stupidity she is "enabling" them.

This of course reminds me of when I first started out doing locums as a family doctor. I was on call for a large clinic. They had a lobster party that night and even though I was on call for the group, they suggested I come out after the evening clinic as on call meant for the most part answering phone calls. At some point in the evening I had to call a patient who had called the answering service. I had already spoken to her earlier that day. One of the doctors overheard my end of the conversation and remarked when I hung up, "They don't teach you how to talk to stupid people in medical school do they?"

How true.

Both my parents were professionals and highly intelligent. I grew up in a middle class/upper middle class neighbourhood and went to a really good school. From junior high on academic and non academic students were segregated into different classes. I hung out mostly with the academic kids. I then went to university and on to medical school. Now some of the people I knew in University and Medical School weren't the sharpest knives in the drawer but we didn't have to deal with them except maybe to laugh at the stupid questions they asked during lectures.

Maybe I am a little dense but it wasn't until my internship that I noticed that there was this large underclass of people who didn't grow up with well educated parents, go to nice schools let alone university. These people showed up with complex problems that required some work on their part and some insight into their condition. And back then and now I still have a hard time putting a complex problem into simple words that can be understood.

Before the advent of pre-assessment clinics and screening, we saw most patients the night before their surgery and a few days pre-op in a pre-assessment clinic. When I worked at the CofE, just about every patient presenting for inpatient surgery was about to have some type of terrible horrendoplasty. I would sit there, try to make sense of their usual complicated medical history, and then try to explain the anesthetic aspect of their care including the epidurals, art lines, central lines and the possible ICU stay they were about to experience. I tried to go slowly. After all this, I would ask if they had any questions. Inevitably they asked one or more of the following three questions:
1. What time is my surgery?
2. How long will my surgery last?
3. Am I going to see my surgeon today? (I started replying, " I don't know, I'm not his secretary" until a patient complained about this.)

As a resident, when we did elective C-sections we actually used to give patients the choice between regional and general (as opposed to now where the OB tells them they are having a spinal). I actually overheard a person say, "Well if he doesn't know what is best, how am I supposed to decide". So much for informed consent.

Stupidity should not be confused with the absence of education nor does education guarantee the absence of stupidity. Stupidity is not just endemic in patients, it has infiltrated the system. Much of the administrative policy over the last 20 years has either been malicious or stupid. I think stupid. I used to think most internists and pediatricians were intelligent people who just lacked common sense. I know just think most of them are just plain stupid. I have already on this blog said what I think about surgeons. And yes, we have stupid anaesthesiologists too!

Anesthesia Shzt List

I read an interesting post on Great Zs blog.

I have only once said I would refuse to work with a surgeon. It was at the centre of excellence when a thoracic surgeon could not be located after his resident got into some significant bleeding and we had to find another thoracic surgeon. I wrote a letter to my chief. This lead to a staff meeting that turned into a lynch mob, the surgeon was disciplined by adminstration, but continued to work for a couple of years after before going on "leave" from which he has never returned. I did work with him about six months later and he was quite cordial.

There are lots of surgeons who I prefer not to work with; if for example I am asked if I will stay late to do their emergency, I generally decline. For some surgeons late is any time after 1200.

In a community hospital where I used to work we all knew that certain anaesthetists hated certain surgeons and vice versa so whoever was assigning the list didn't assign them in the same room unless he was feeling particularily evil.

We all of course have surgeons we would like never again to have to work with:

Dr. Tardy

He not only is late for his first case but is late for every case of the day. This means you either stay until 1800 to finish his list or his last case (and he always books his longest case last) is cancelled which means you go home at 1300 losing income and quite often witnessing a nasty scene between him and the nurses. Dr Tardy has not figured this out.

The teacher

He loves to teach. This means he lets his residents or even medical students do much of his cases. This "teaching" consists of mostly of him leaving early to presumably do something else while his resident closes. He never compensates for this in his booked times. This means his list usually runs late (see Dr. Tardy). The teacher's enthusiasm for teaching rarely extends to anaesthesia residents. Plus one can only take so much teaching, after a while it becomes repetitive and you realise that The Teacher doesn't really know that much, he just repeats what he does know over and over.

Dr. Pottymouth.

I am not one of those people who is easily put off by swearing. I swear a lot, I actually enjoy swearing. As my scout master told me, it is not the word but how you use it. We had a cardiac surgeon at the CofE who went into what people called F-Tach. It took two anger management courses forced on him to cure him of this affliction.

Dr. Angry

Lets say a surgeon has two OR days a week and is angry for both of them. He works for 30 or years so think of the number of days in his life he is angry. Is there anything that makes him happy? If what I trained 5-6 extra years for made me angry, I might reconsider things or perhaps it just might make me more angry.

Dr. Whiny

A slightly more benign and passive-aggressive version of Dr. Angry. He just whines all day. Nothing is right with him.

Dr. Nightowl

This guy loves to operate after hours. Nuff said. You wonder why you are always up all night with him and not with the other surgeons who presumably see the same emergency patients. It may be something to do with afterhours premiums. In case emergency doesn't supply him with work, Dr. Nightowl usually gets patients on his wait list to show up in emergency so he doesn't have to waste time on activities like spending time with his family while on call.

Dr. Perfect.

Every thing about this guy's professional and personal life is beyond reproach as you will hear for the entire day. Of course you are screwing up his perfect case just by being there. In addition to the platitudes you will hear him reciting to everybody who has no choice but to listen, you will of course hear about his perfect children, his perfect car and his perfect vacation.

Dr. Fingerpointer

A cousin to Dr. Perfect. Every complication is someone else's fault usually yours and he will point that out in ways ranging from conversions in the doctor's lounge that you overhear, and that are told back to you, to sneaky progress notes that of course you never read but are part of the chart forever. He occasionally will confront you personally and quite often will write a letter to your chief. Dr. Fingerpointer is quite often a vascular, thoracic or urologist; all specialties that by the nature of their work or patient population get bad results. They have not accepted that.

Dr. Slowhand

Some surgeons are slow because they are meticulous. Most of us don't mind because we hope we or our family get such good care. For the bulk of slow surgeons the old slogan "First you get good, then you get fast" comes to mind. This of course usually results in the cancellation of Dr. Slowhand's last case (see above). Quite often Dr. Slowhand is not the most punctual person.

Dr. Knowitall

Dr. Knowitall is an expert on everything. This includes anaesthesia, and Dr. K is always ready to give you helpful advice on how you should be conducting your anaesthetic. Dr. K. will also hold forth on just about any non-medical topic, as well as medical topics outside his narrow area of specialty. Woe to you if you actually try to challenge Dr. Knowitall.

Dr. Powderkeg

At least Dr. Angry is angry all the time and Dr. Whiny whines all the time. With Dr. Powderkeg you can see it building up all day and you are just wondering when the shit is going to hit the fan and who is going to be on the opposite site of that fan.

I Knew a Terrorist

Some people I knew as a child, teenager or young adult went on to become famous. Three people I knew a bit played in the NHL, I knew two future cabinet ministers, and one concert pianist. Some other people while less famous have had successful and practical lives.

But I also knew a terrorist.

His name was Brent Taylor and he was a member of the Squamish Five. You can read the links.

I'm not saying Brent and I were good buds. He probably didn't even know I existed. He was a year ahead of me in school. I first learned of him in Grade 8 when I started Junior High. He was in Grade 9. He was a good athlete, was on most of the school's sports teams and was on the students council. I think he held the provincial triple jump record in his age class at one time. I believe I played at least one rugby game with him. Our rugby team was pretty desperate and he was a good athlete.

By the time I got to High School in Grade 11, he was in Grade 12. His hair was now much longer than it had been before and he had grown a beard. I would have said he looked like Jerry Garcia but I didn't know who Jerry Garcia was then.

He went on, I went on and I had completely forgotten him until I heard of the arrest, subsequent trial and conviction.

Why is all this significant.

In Canada because of the "war on terror", a number of innocent (or not yet proved guilty) Canadians have been held without trial, sent to third world countries like Syria to be tortured or have not been allowed to come home. While there are varying levels of suspicion, from the accounts I read in the paper, the compelling reason for treating these poor individuals as they were or are being treated is that, they knew, were seen talking to, or were related to someone who actually had some connection to terrorists.

I have this recurring thought; Brent Taylor is being roughly interrogated and asked about who his accomplices are. He names the biggest nerd he can remember from school, me. And I am off to Syria.

As a postscript there was another student who went to the same school, a little younger also named Brent Taylor. I bet every time he tries to enter the US he curses his namesake.

Fertility Treatments

I was a little late in reading our national medical journal and so came on this editorial.

Essentially the editorial recommends as way to prevent multiple births from fertility treatments (thus shutting down half the reality TV shows) that the procedure should be covered in Canada. Currently prospective parents wanting in vitro fertilization treatments have to pay for the procedure. Because the procedure is expensive, in order to improve the odds multiple embryos are implanted. The hope is that only one will survive to babyhood. Often as we read from the tabloids more than one and in some cases many more than one survive.

Now as the editorial says, there is a significant risk to the mother with multiple gestations. Further as the editorial points out:

Perinatal mortality is 4-fold higher among twins and 6–9-fold higher among triplets. Complications such as cerebral palsy are 3–7 times more common among twins and 10 times more common among triplets. 4 When these complications occur, it is the public health care system that bears the cost while the parents and children bear the grief.

I have two perfect children so I can be smug. I can't really feel the anguish of a couple who is unable to conceive and how empty my life would be without my kids (empty of early morning hockey, school concerts, expensive hobbies?).

The bottom line is however, what are these infertility specialists thinking? Any other specialty who had an elective procedure which could predictably worsen the life of the mother and children would probably be under investigation by licensing bodies, the government and the press. While I hope most infertility specialists entered that subspecialty with a goal of enriching the lives of infertile couples by providing them with children, I suspect a lot of them are Ob-Gyns who at some point in their residency realized that delivery babies in the middle of the night really sucks and they should find a nice well paying subspecialty with good hours. Very few of these infertility specialists actually deliver the babies they implant.

And why is the procedure costly. Part of it is the cost of the infertility drugs. Why are they expensive? Is it the cost of production or is it because some economist with the pharma company calculated that that was the amount that desperate couples were prepared to pay. Another is the private fee that the doctor collects. Again based on what the market will bear rather than any relativity to what other doctors earn for work of similar complexity.

Public health care in Canada was introduced by Tommy Douglas an NDP premier and later national leader of the party. When the NDP government in Ontario decided as a cost cutting measure, that they would no longer cover fertility treatments (one reason was the observation that couples on the wait list conceived as frequently as couples under treatment) there were editorials about how Tommy Douglas was rolling in his grave at the violation of the right to public health care. Tommy Douglas who started out as a Baptist Minister would have no doubt frowned on test tube babies.

Somebody else pointed out years ago that a screening program for clamydia would markedly reduce the rate of infertility and would be a whole lot cheaper.

The whole issue that nobody wants to address is that there are two many damn people on the planet already. If we are going to maintain our standard of living while not exhausting our food and energy we are looking markedly reducing our fertility rate not creating new octomoms.

What I Did Last Night on Call

I spent about 5 hours doing a bowel resection for cancer of the recto-sigmoid.

Why was I doing this "elective" case on call?

The patient has quite severe lung disease (industrial exposure and smoking) with CO2 retention, requires home oxygen and even with the O2 he can basically walk from his bed to the bathroom but not much farther. The cancer was asymptomatic but had been picked up during screening for anemia. He had been canceled once because of no ICU bed and now one had opened up.

Fortunately we weren't very busy so the second call person didn't have to hang around long and there were no cases to follow.

The poor fellow is now residing in ICU on a ventilator and hopefully will be weaned off over the next few days although I have my doubts.

The "bottom" line is that rectal cancer while undoubted not a nice way to die, it is unlikely to kill him before his lung disease so why did we even bother?

But of course I am only an anaesthesiologist.

My Time is More Valuable Than Yours Part Two

A couple of weeks ago I was sitting in the lounge waiting for something and I struck up a conversation with one of the other anaesthetists who was also waiting for his surgeon to arrive. (I have never added it up but I suspect I have now spent months of my life waiting for surgeons to arrive) It was however the excuse for why the surgeon was late that struck me.

The surgeon had phoned ahead and told the OR he would be starting late because he had to take his oldest daughter to her first day of school. How sweet. How nice for the anaesthetist who gets to cool his heels, along with the nurses while the Kodak moment is occurring. How many of the nurses are missing their children's first day of school because if they show up late, they might actually get in trouble? And of course the surgeon will want everybody to be extra efficient the rest of the day so he finishes on time after starting late so that he can get home early to debrief his daughter on her milestone day, maybe even pick her up from school.

I of course missed both my children's first days of school. I'm still not sure what constitutes the first day of school, is it playschool, kindergarten or Grade One. Never mind, I missed all 6 of them.

I have long accepted that part of being an anaesthesiologist means you work when other people want you to work. If I have enough warning about important events, I take the day off if I can. Sometimes I have gotten somebody to take over my room so that I can get to that late afternoon concert, soccer game, hockey practice or "leaving ceremony". I coached hockey for a year. One of the parents commented on why, if I was a doctor, was I able to make almost every game and practice. I didn't bother explaining, the amount of horse trading, begging and soul selling I had to do. On call is different with call schedules usually made three months in advance and the complexity making it difficult to switch. When the "oh by the way" evening school concert happens to fall on my call day, I have in the past found somebody to come in for a few hours in the evening. Often I just missed them. It is the price I have to pay for being able to call myself Dr. and earn 6 figures.

The point is our family oriented surgeon could have switched OR days with one of his partners or he could have given up his time that day. (His wife is an ophthalmologist, why does he have to work at all?) Open OR time is usually snapped up within minutes. But he didn't because his time is way more important than everybody else's.

Why did I think of this just now? I was on call last night and the same surgeon had a presumably strangulated or incarcerated hernia he wanted to do. When we were ready to send for the patient and phoned him, he announced he couldn't come until after 2000 because his wife an ophthalmologist was at journal club and he was baby sitting his children. This fellow has a nanny (I know this because he was talking about how he bought a car for her) and I am sure there are lots of teenagers in the neighbourhood who would love to babysit his perfect children just like we had to do when I was on call and my wife wanted to do something.

Medical Students

A while ago I was walking towards my room first thing in the morning when I saw what could clearly only be a medical student hanging around outside. Immediately one thought came to my mind, " Please let him be for the urologist and not for me". Fortunately he was for the urologist and I had as pleasant a day one can have in a urology room. I did feel bad about how I thought when I saw the student however when I related the story to another staff member, she said feels exactly the same way when she sees a student in her room.

I used to love teaching. I really believed that anaesthesia was the coolest specialty, I wanted every medical student to go into it. I wanted to teach everybody to intubate. Even those people who had a clear career path mapped out already, I thought I could help. The future internists I felt I could teach them not to write those stupid consults; the future surgeons I felt I could teach to, well just not be so stupid. I loved having students in the Pain Clinic; I was evangelical about chronic pain back then.

No more. I decided I wouldn't take students in the Pain Clinic over 10 years ago (I make exceptions for students who contact me personally). Conditions of my hospital appointment require me to take medical students (and RT students and paramedic students) in the OR; that doesn't mean I have to enjoy it.

There is no single reason.

I like to work alone. In the OR I work with the nurses and with (or against) the surgeon. Medical students somehow ruin that dynamic. I have what I call my crease. That is a triangle with the three points being the patient, the machine and the anaesthetic cart. I don't like people in my crease; medical students get in my crease. In the Pain Clinic at least one patient every day is either going to cry or else call me an asshole. Why would I want someone to witness that.

I have gotten older. When I started medical students were often only a few years younger than me, occasionally my age or older. Just about every medical student now was born after I graduated from medical school. Generation gap city. (This also applies to residents but I can actually get some work out of them).

Over two years of interviewing prospective residents, I have learned that most medical students' shit doesn't smell. All that volunteer work, overseas missions etc. Sometimes I just don't feel worthy having them in my crease.

How many times can one explain how an anaesthetic machine works or the difference between a depolarizing and non-depolarizing muscle relaxant. Or explaining why we don't use halothane and enflurane like they learned about in pharmacology (actually I can't explain why we don't use them anymore).

I feel I have to entertain them and I usually run out of material by about 10 am.

Nowadays you have to be so careful about what you say.

As students have to make their life decisions so early in medical school, many students are doing an elective in order to get a letter of reference from you or from the fool who agreed to coordinate students for your department. This means that you have to fill out an evaluation and woe to you if you check anything less than excellents dooming them to a career in radiation oncology. A colleague of mine at another hospital who coordinates students says she spends a great deal of time dealing with complaints about such evaluations. By the way, when I got to interview prospective residents I read some of those reference letters and couldn't believe what was written because I have never seen a student that was as good as some of those letters made them out to be.

Certain cases of course aren't good for teaching. The patient is too complex, the operation too risky, tension in the OR, having to do things quickly no time to explain why. I always feel bad telling them they should go and read for a while but sometimes the best way to help me is not to "help" me. One introduction since I trained is the laryngeal mask. I love this device and use it for about half my cases, many of whom I used to intubate. I just can't see modifying my technique for teaching purposes. Actually a couple of years ago I was assigned a medical student for a week which is normal at our hospital. By Friday he hadn't intubated a single patient. Friday I had a list of arthroscopies, who I usually do with an LMA. I felt sorry for the poor guy (even though he wanted to go into ortho) and so I modified my technique so he could intubate. Anyway, they were all smokers who coughed, bucked, horked and generally desaturated post-op and of course my student missed all five intubations.

I of course did an anaesthesia rotation as a student and again as an intern. Some staff were friendly and pleasant to work with, some were not. It was the ones that weren't friendly (and the prospect of 6 months on internal medicine) that lead me to not apply for anaesthesia right away. I realize the necessity to teach the incoming generation just as I was taught. Next time I see a student in my room however, I will be keeping my head down and avoiding eye contact.

Making the Most of Your Pain Clinic Appointment

In our area and I suspect even in areas with better funded healthcare systems there is a shortage of people willing to deal with chronic pain and consequently a long wait list for new appointments. As one of the docs who does see new patients it appalls me at how patients waste theirs and my time when they finally do actually get an appointment.

Here are some suggestions.

1. Just because I can't charge you for your missed appointment doesn't mean I'm not pissed off. (That doesn't make sense of course I am pissed off.) Not just at the consult fee I am out. Just about every week I deal with a sob story from a family doctor or patient advocate and I have to try to figure out how to fit the latest sad story of the week into an appointment. So when you miss your appointment, someone else didn't get an appointment.

2. If you are late for your appointment, I may not be able to see you. If I do see you don't be surprised if I am in a hurry. Try being late for the bank or the airlines.

3. Your medical records are your property. While it would be nice that your family doctor sent all the relevant records with his referral; this usually doesn't happen. If you bring them in yourself I will actually have them to peruse. If you bring in a huge binder however, I will try to read them but much later.

4. There are about 200 types of yellow pills. I can't guess which one you are on or were on. Your pharmacy can give you a print-out of everything you've been on in the last few years. It would however be nice to know what didn't work, what gave you side effects etc.

5. Please don't call all the doctors, you have seen in the past, idiots. The first thing I think about when I hear this is how you are going to be calling me an idiot in six months.

6. Your WCB or Disability Claim may be really important to you. All I can go is send them a copy of my consultation. The semi-retired antiquarian doctor who is responsible for your disability/WCB file has already made up his mind. The best advice I can give you is to forget about it and get on with your life. If that isn't possible you need to see a lawyer.

7. It's not possible to be allergic to anti-depressants as a class. That is like saying because you are allergic to broccoli, that you can't have tomatoes.

8. Try and figure out what your goals are. Then think how realistic those goals are. Then try and figure out what your goals are again. Your family doctor may have some goals for you as well. They may not be what you have in mind. Try and discuss this before your pain clinic appointment.

9. Just about everything I will prescribe for you and everything everybody else has prescribed for you in the past has side effects. What you need to do is weigh how bad your pain is and whether you are going to put up with the side effects.

10. Even in the unlikely situation where I actually have all your records, I may want to ask you all the questions again. It's called getting a fresh perspective. Don't keep telling me, "its all in the chart".

11. I realize medication is expensive. Don't complain about the cost of the medication I prescribed unless you: Don't smoke; Don't drink bottled water; Don't own a cell phone better than mine.

12. If your last three MRIs were normal, I am not going to order another one. In fact in 16 years treating chronic pain patients I am still waiting for an MRI that actually helped me with my diagnosis and treatment.

13. I am not going to write a letter to authorize out of country treatment by the doctor you found on the internet.

14. Please don't bring in forms to be filled out at your first visit. These forms are legal documents, I need to get to know you before I can fill them out. Please don't expect me to lie on the forms. I could face professional discipline or your insurer could sue me. When you get turned down please don't blame it on me; what you think is disabled and what insurers think is disabled are two entirely different conditions.

Calling vs. Trade?

Great Z's blog has hit the nail on the head.

People basically are not altuistic. Everybody has some motivation for what they do.

A number of years ago a national society on whose executive I sat, had Patch Adams talk at their annual meeting. This was at the instigation of a Big Pharma company who offered to pay for Patch Adams, take him or leave him. Because I was on the executive I happen to know that Patch's fee was greater than $10K. Not in Bill Clinton's or Wayne Gretzky's ($99,000)range but still not bad for one hour's work. Like many people I saw the movie with Robin Williams which by the way, the real Patch didn't like. One of the issues Patch mentioned repeatedly during his talk was that he only earned $400 per month. While it is possible that most of his $10K+ fee went to some worthy cause, I'm sure Patch has somewhere nice to live, eats okay and is generally well taken care of.

Why did I go into medicine? My father was a professional, it was instilled into us early on that we had to be professionals. Other professions didn't appeal to me; it was medicine by default. One of the biggest draws was not the money but rather the fact that even in bad times, I was likely to be employed. I make a nice living, I am more or less happy. A lot of people I work with or know make less and are equally or more happy.

How to save on health care costs

This lady wrote an article on how to save health care costs.

Articles like this always leave me split. The progressive in me says, "right on"; the physician in me says, "bullshit". There is a mixture of both in this article.

Firstly, unless you are a radiologist or a pathologist who owns a lab; you don't make money by ordering tests. If you are a radiologist or a pathologist you aren't allowed to order tests although certainly radiologists often come very close to doing so. I agree there are too many tests ordered and what she has cited certainly sounds eggregious. However as a nurse practitioner, she could simply look at the lab req. and tell her family doc, "no I don't want all these tests".

Likewise when she had the swollen knee, why didn't she just tell her FP, "all I want are some anti-inflammatories or physio". If her doctor is like me, he will find it a hell of lot easier to write an Rx for diclofenac than to fill out an MRI requisition.

There are some reasons why doctors like their patients to come in at regular intervals for prescription refills rather than phoning it in. In her case it sounds unnecessary but her FP probably can't tell the less controlled, less compliant diabetic in his practice, " You have to come in every 3 months but she doesn't" Actually he can. As someone who now takes regular medication, my FP also only gives me 3 months supply and won't refill over the phone. And it pisses me off. So I fax him to get past his secretary and he does a refill. Professional courtesy.

When I was an FP years ago and there was a small glut of FPs. Those of us starting our practices used to call patients in far more than necessary to build up their patient numbers. Now that there is a doctor shortage maybe this needs to be reviewed.

Salary?

25 years ago if you told me I was going to be on fee for service 25 years later, I would have said you are nuts. 25 years later, still on FFS.

No question salary would save $$$ possibly at the expense of patient care and convenience, however I am still waiting for an offer.

Love Boat

I posted a couple of weeks ago about a doctor who went off on holidays leaving her patient high and dry, and in narcotic withdrawal.

I wrote a letter to the doctor as a courtesy explaining what had happened and why I had written a prescription for her patient.

She wrote back explaining that she works a lot as cruise ship doctor and can't get a locum (or persuade the doctors she is in partnership with) to cover her practice. She also said she took this patient on as a "favour".

So.....

Somebody else didn't get into medical school and the taxpayers paid for 80% of the cost of educating you so you can work on the love boat and see patients as a favour into between cruises.

Like the title of this blog says:

I used to be disgusted......

Time to Bite Your Tongue

I saw a patient in consult regarding her back pain a few months ago.

She was accompanied by her husband and actually when I saw the husband, my heart sank at the prospect that he might be my consult. He was morbidly obese with no neck and breathed very loudly. Sleep apnea until proven otherwise, I thought and I suspect his wife has not slept thru the night in the last 10 years.

Her family doc gave me some background. She had previous back surgery and complained mostly of low back pain with no leg pain. This was reasonably well-controlled with a modest dose of morphine and the family doc only wanted to see if I thought some type of block might help her. He also mentioned she looked after 8 children, 7 of hers fathered by her current husband and 1 of her husband's by a previous relationship.

I talked to her and examined her. She really didn't have a lot a findings and talking to her I got the sense that her pain was pretty well-controlled and nothing I could do was going to help her. So I gave her my "you're doing really well, nothing I can add to your treatment is likely to improve where you are' spiel.

At this point the husband awoke from his torpor. "Damn it", he said, "Don't you know she has to look after 8 children?"

Now what I should have said at this point was:

"So Mr. Doesn't-believe-in-birth-control? Why don't you get off your butt and help your wife out around the home?"

But I am such a wimp in matters like this.

Stupid Allergies Part 3

I should mention that a stupid allergy almost killed a patient under my care.

I had only been at the CofE for less than a month then. The CofE was in the process of developing sub-specialization. This included pediatrics. The problem of course was that most surgeons were not sub-specialists but did both adults and kids. The other issue was what type of training was necessary to be a pediatric sub-specialist (and not a single member of the group at the time had any post-fellowship training in pediatrics). I had done pediatrics in my last job, and was interested in joining the group but was sort of on some type of double secret probation.

Anyway, because of a liver transplant, that day's list was thrown into chaos and instead of the nice general surgery list I was supposed to have, I was sent into the pediatric ortho room. I was to do a 14 kg child with Rett's syndrome (which I understand is like cerebral palsy but is not really CP) for spinal instrumentation. (Every orthopod knows that straightening the back will raise your IQ).

I went out to the receiving area and talked to the father who was quite nice and very concerned about his daughter if not terribly realistic about her prognosis. As we were wheeling the patient down to the OR with the surgeon, he mentioned that he thought that his daughter "might" be allergic to cephalosporins.

I had a very junior resident with me that day. We induced the patient, and I placed an art-line and a central line (I was pretty proud of getting these in). I was a little nervous but I had done some pediatric backs as a resident. We turned the patient prone, started the surgery. I sent the resident off for coffee, he came back we talked for while and about 2 hours into the case I decided that things were running smoothly enough that I could go for coffee and a pee.

Seconds after a left the room the orthopod asked the resident if he could give 500 mg of Vancomycin to our 14 kg child with the undocumented cephalosporin allergy. My resident gave this over 10 minutes which he thought was quite safe and so it was 10 minutes later that I was paged stat back to the room.

When I arrived, the blood pressure was 20/-. I interogated the surgeon and resident about what had happened since I left the room and after what seemed a long time, they fessed up to the Vancomycin. 200 mcg of epinephrine solved that problem and we went on our merry way.

The CofE had quite an active Quality Improvement program at the time and this and other aspects of the case came to their attention with the result that a couple of months later, I got a copy of an unsigned letter accusing me of administering an overdose of Vancomycin among other sins. I fired off a reply stating that as per the note on the chart which I had written at the time, the drug and dose were chosen by the surgeon and administered by my resident under his direction.

Anaphylactic reactions to Cephalosporins even in patients who are "allergic" are fairly rare, anaphylactoid reactions to Vancomycin are quite common. The whole issue of allergy should perhaps have been straightened out long before the patient came to the OR; Clindamycin while also a fairly nasty drug should possibly have been the next choice.

I should have learned something about the culture of blame that existed and still exists at the CofE.

Needless to say, I was never invited to be part of the pediatric group.

Paging Etiquette

I have intermittently worn a pager since since 1981 and finally somebody has put down what I have been thinking all these years.

I will print it out.

Rules for Paging Properly:

1) If you are going to be allowed to page me incessantly, then you should be required to wear a pager so I can return the favor.

2) If you page me, please wait 5-10 minutes for a response before paging back. Heaven forbid I be answering another page, seeing to an emergency, walking in a hallway without a phone, or sitting on the john. I am very conscientious about returning pages and really try hard not to make you wait, but sometimes it's unavoidable.

3) Please attempt to coordinate your pages. Having 2 different nurses page me about the same patient within 30 seconds of each other (indeed, I received page #2 while I was on the phone with nurse #1) is a little annoying. Especially when said patient isn't actually dying of a heart attack or writhing in severe pain, but "just wanted to talk to the doctor."

4) I know mistakes happen, but please attempt to look through the medications before paging me to say Ms. so-and-so needs a sleeping pill. If I stop what I'm doing and pull up the chart only to find Ambien in their list of meds, it's a little irritating.

5) Blood pressure of 135/anything does not excite me and I do not need to be paged for this, unless it was 220/190 5 minutes ago (in which case, why are they on a psych floor?).

6) The primary team arrives around 8 am M-F. I do not need to be paged at 7:20 (while I'm trying to check out and leave) for 2-day long sore throats or potassium of 3.2 drawn 4 days ago. I appreciate your incentive and that you are trying to help care for your patient, but it can wait.

7) When possible, please page me to an extension you'll be easily reached at. If you page me and I call you right back, only to reach someone who puts me on hold "while I find out who paged you", I get a little irritated, especially when this happens frequently.

8) Perhaps most importantly, when I call you back, please introduce yourself and state the patient's name clearly (perhaps even spell it) before rushing into the story of how the patient has an urgent foot rash. I have some hearing problems--not your fault--and I will have to interrupt your story to ask you to repeat the name, spell it, and wait while I access that patient's chart in the computer before you get going again. Also, if you have a non-American accent, it is going to be difficult for me to understand you over the phone, especially if you speak rapidly.

9) On my end, I promise to keep trying to answer pages promptly, identifying myself clearly when I call back, being really nice (or at least non-snarky) when I answer, and trying to educate the people paging me about appropriate paging. (Hey, I said "trying", didn't I? Stop looking at me, swan!) I know I fail at this frequently, but I really do try, I swear. I don't like paging people only to get yelled at, so I don't want to be the person yelling.

We are now in what I call the "Cult of Availability". With pagers and cell phones so freely available and widely used, there is now a tendency for people to call somebody instead of trying to solve the problems themselves using the resources available.

My mother was a nurse until she got married in 1951 and had to quit (that was the rule then no married nurses!). Back then doctors had only a single land-line rotary dial phone in their house or office. I highly doubt most doctors sat by their phones waiting to be called. They had a life outside of medicine plus some of them did housecalls. I asked my mother once, what did they do when they couldn't find the doctor. She said she didn't remember. She probably didn't remember because it was never an issue. The nurses back then probably were able to think independently and did what they could to solve the problem with the resources they had.

Like the blogger above, I try to answer my pages quickly and I don't know how many times I have answered the page, to be told, "it's okay we've solved the problem." The question I always want to ask is "why the hell didn't you try to solve the problem before you interrupted my supper/TV viewing/sex?" But of course I have learned from sad experience never to say what I am thinking on the phone.

Intimidation Based Learning

There have only been two occasions when I have wanted to give up medicine for good. The second was when I was in general practice and I went as far as getting a law school application but went into anaesthesia instead.

The first was during my internship.

I don't like internal medicine. I should elaborate. I enjoy the clinical problems, and much of the patient care aspect. I don't like the constantly having to justify why you did even the most minor thing to a staff person who was home asleep when you did it, I don't like the hours, I don't like the scut work and I don't like the placement problems. Therefore I really wasn't looking forward to my 8 week internal medicine rotation during my internship which to make matter worse took place in December- January (i.e. over Christmas).

At least I thought I had the foresight to pick a non-academic hospital to work in. In the internal match, I chose and got Camp Hill Hospital which was an old former veterans hospital in Halifax.

Camp Hill didn't have an emergency room. This should have been a godsend and indeed was during my surgery rotation at the same hospital. In medicine however we accepted emergency admissions from the large teaching hospital about a kilometer away. In theory there were 4 medicine services at the LTH and our hospital was the 5th which meant that we took every 5th emergency admission. It wasn't exactly like that however. The patients had to be stable enough to transfer by ambulance. This meant that we usually got elderly failure to thrive patients who became placement problems, and alcohol related problems. There was a tendency of the ER docs and the internal medicine residents at the LTH to lie bald-facedly about the condition of the patients they sent over.

We had a 4 bed ICU which was covered by the interns. This was a glorified CCU mostly made up of patients on medicine who had deteriorated after their admission, disasters from the surgical service and the odd patient from the LTH who was stable but needed to be monitored. We had three teaching wards which acted as services with two staff physicians on each ward, each of whom had their own house staff. When you were on call as an intern, you covered your own ward, were second call for the wards covered by medical students and you covered the ICU. The rule was, if you were the unfortunate who admitted the patient to ICU, you covered that patient for the duration of his ICU stay or life whichever was shorter. We also had residents. These unfortunately were either junior medical residents with a few months more training than us or second year family practice residents. At that time, you could go into general practice after your internship; we called the two year family practice residency "the internship for slow learners". Therefore having a second year "slow learner" as your back-up was not terribly reassuring.

Our little ICU was covered by two staff physicians. Each covered for a month. On weekends and holidays, a single physician covered all the ICUs in the city and went from hospital to hospital rounding. The first physician was Dr. Kookie . He may or may not have gone to medical school somewhere in the third world but had obtained a fellow-ship in Internal Medicine something I have since learned is not correlated with intelligence or good judgment. He also practised as gastroenterologist at our hospital. The second was Dale the Hut. Later in my internship, "The Return of the Jedi" came out and as I watched the movie, I had the odd feeling of deja vu on seeing Jabba the Hut. I later realized he reminded me of this doctor. Dale the Hut was fat and smoked stinky cigars back when you could smoke in hospitals. He had a really bad comb-over. He practised as a cardiologist although as I later learned, he only had a fellowship in internal medicine. He also had an untreated strabismus so it was difficult to know whether or not he was looking at you. (He may have had a grudge against doctors because his strabismus was missed and not treated which he took out on trainees). He was extremely dogmatic on just about everything.

The fact was as I learned later when as a resident I had to look after ICU patients, neither Dr. Kookie or Dale the Hut knew anything about looking after ICU patients. I suspect they were either covering ICU because they needed the extra money or because Camp Hill couldn't find anybody else. Unfortunately as I have learned, when you are uncomfortable with something, a good strategy is to make everybody feel uncomfortable too.

So if you were unfortunate to end up in our little ICU. You were looked after by an intern, backed up by a junior resident, with Dr. Kookie or Dale the Hut (who were idiots) as your staff physician. After hours the nurses would page you for problems. Occasionally they would go over your head and page the resident instead. If you didn't know what to do, you could phone Dr. Kookie or Dale the Hut and get yelled at on the phone, or you could do what you thought was best and get yelled at at rounds the next day.

The low point of every day was ICU rounds which started at 1100 to allow us to get our ward work done and to ensure that we would have no appetite for lunch. We would all sit at the desk with Drs. K or Hut and the intern responsible for the patient would present the case. This you learned had to be a detailed and organized present no matter how long the patient had been in hospital. If there had been changes over night, the on call intern had to describe what happened. I tend to be a bottom line person: this is what he has; this is why I think he has this; this is what I did and this is why I did it. That didn't cut it.

Dr. Kookie was merely clownishly incompetent and indecisive; once you accepted that you could survive rounds. With Dale the Hut, ICU rounds was a hour long ordeal of squirming in your seat, in pool of sweat under his strabismic gaze. One the big problems was that occasionally changes were made by the medicine resident who usually didn't attend rounds, or on weekends by the covering ICU staff who usually knew what he was doing and Dale the Hut inevitably disagreed with what somebody else had done but you now had to justify as if you have ordered the test or treatment.

This is a long digression to how I almost gave up medicine.

As the 8 week rotation went Christmas, we were given 4 days off out of the 8 days over Christmas and New Years. I worked 1 in 2 over Christmas and then had 4 days off. The last night I worked I was lucky enough to admit a patient to ICU. She was a 90+ year old lady who was still relatively with it. She had presented to the LTH ER with left arm pain and got a cardiogram which showed she was in complete heart block. The rest of her cardiac work-up was normal and she was transferred to our hospital for monitoring. I admitted her and went home the next morning. I thought she would only be in ICU for a few days; I couldn't imagine anybody putting a pacemaker in an otherwise assymptomatic 90 year old.

One of my coping mechanisms is that I usually completely forget about what I have done at work as soon as or before I get home. When I returned on January 2, I had completely forgotten that lady. I got in a little late and spent the morning catching up on what had happened to the ward patients while I was away. At 1055, the ICU nurses phoned me to ask me if I realized that I still had a patient in ICU, that I was going to have to present to Dale the Hut in 5 minutes?

Dropping everything I did, I ran (or walked fast, I never run) over to ICU. During the Christmas break, the ICUs were covered by city wide ICU staffmen, a different one every day. Somewhere along the line someone had decided to put a temporary pacemaker in the my LOL. The temporary pacemaker was giving her PVCs and someone else had started her on lidocaine. There was a paucity of progress notes explaining the rationale for any of this. She was booked for a permanent pacer later that day.

When my turn on the hot seat came up, I presented the case in my disorganized fashion. Dale the Hut was not impressed. When I said she had a temporary pacer, his response was "Why?". I mumbled something about how I didn't personally think she had needed one either but that I was not working that day. He also didn't like the lidocaine. I gave the same response. This precipitated a lecture on just because I had been away for 4 days didn't absolve me of responsibility for the patient's care.

I was on call that night. Our patient went over to another hospital to have the permanent pacer put in. (Even though Dale the Hut hated the pacemaker, he was not about to kibosh it). Someone at the other hospital stopped the lidocaine infusion, a permanent pacer was put in and the temporary pacer was left in to be removed the next day. When she came back to our hospital, she was not on lidocaine, I elected not to re-start it and she had no PVCs during the night.

1100 came and it was my turn on the hot seat. I presented the case in slightly more organized fashion at which point the Hut asked me why the lidocaine was stopped. I said it had been stopped at the other hospital. Why wasn't it restarted, asked the Hut. I said she wasn't having PVCs anymore so I didn't restart it. "Why was she having PVCs in the first place" asked the Hut. Because of the temporary pacer, I replied. "And is the temporary pacer still in?" asked the Hut.

I had been up for most of the preceding 28 hours and I was losing this interrogation badly. I decided to punt and I shrugged in a "yes I should have done that but no harm no foul" manner. This precipitated the worst temper tantrum I have witnessed in 30 years as a student/intern/resident/staff. "Get that smirk off your face", yelled the Hut. Because of his strabismus my first impulse was that he was yelling at one of the other interns who was taking too much pleasure in my discomfort. "And stop shrugging" That was when I realized he was yelling at me. He went on to yell about how we were the worst, stupidest, laziest, most incompetent interns ever, that the standard of care over the past few weeks had been terrible and this had to change.

At that time just to confirm his point, one of the four patients in the ICU arrested. After failing to resuscitate that patient and finishing rounds, he stormed out taking the two residents with him for a little talk.

As I said, I don't like internal medicine, but I am a professional and I do take pride in my work and am my own worst critic and looking back over 25 years to the incident I don't think there was anything wrong with MY management of this patient. Later that afternoon, the two residents called all the interns for a meeting in which they told us that basically Dr. McMahon is very dogmatic (true), he has a bad temper (true) but he is a good clinician (false) and you can learn a lot from him (false). I suggested that maybe if we actually got some formal teaching on looking after ICU patients we might actually be able to look after them in more praise-worthy way but neither resident thought that was practical. I thought but didn't say that maybe the Hut should be told that we are all actually fairly intelligent and hard-working interns who don't deserve to be yelled at.

I got home at 7 o'clock that night (after admitting another ICU patient because it was "my turn"), opened several bottles of beer and ordered pizza. I was so depressed, I had spent my first Xmas away from home, it was a drizzly grey Halifax winter etc etc. I seriously wondered if I really was even a marginally competent doctor, and whether I would be able to survive the remaining 4 weeks of internal medicine not mention my internship. But I got up the next day, went into work, survived internal medicine and sailed thru my intership. I never saw my evaluation for internal medicine; I assume it wasn't too hot.

Nowadays, there wouldn't be any question. I would have headed straight for the Dean's office and Dale the Hut would have been off for anger management courses.

For a few years, every time we got a Dal grad, I asked them about Dale the Hut but nobody seemed to remember him so I assume shortly after I left, his clinical teaching career ended. Pity.

Summertime Blues

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.

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.

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.

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.