Tuesday, December 29, 2009

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.

Monday, December 28, 2009

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.

Thursday, December 17, 2009

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).

Tuesday, December 15, 2009


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.