Wednesday, January 13, 2010

A new indication for induction of labour

It was always my dream to be a rural family doctor. That was until I came up against the reality of rural family practice. My epiphany came during a six month trial period joining a practice in rural BC. For various reasons it didn't work out, I decided to go into anaesthesiology and moved away to do locums.

The last night I was in town around 6 in the evening, I got a call from the hospital saying there was going to be an emergency Caesarian Section and could I come in an assist. When you have a C/S in a small town you need 4 doctors: the surgeon, the surgical assist, the anaesthesiologist and the baby doctor. This places a strain on a community with only 8 doctors.

The C/S was due to a prolapsed cord. I arrived to find my soon to be former partner, with his hand up the vagina. We crashed into an emergency C/S on the hospital bed, the baby came out in reasonably good shape and closed up. The baby was transferred to the regional referral centre as a precaution. Oh yes, the baby had a transverse lie, head obviously not engaged.

Coming out of the room, I decided to read the chart to find out exactly what had gone wrong. As it turns out, the mother who had had no prenatal care presented to my partner at around 40 weeks. He decided to induce labout. No ultrasound to check dates (at that time not available in that town). Of course when he ruptured the membranes after his office, the head was not engaged and the cord prolapsed.

I left town the next morning. I did keep in touch with one of the docs in town who told me a couple of weeks later that when asked why he had tried to induce labour and rupture the membranes, my now former partner explained that the lady's husband was going to be going to jail the following Monday so he indued labour so he would be able to see his baby in his last days of freedom!

Monday, January 11, 2010

Something I wish I had said but am glad I didn't

Part of being department chief is dealing with complaints about your colleagues and "disciplining them". I seemed to spend a lot of time in the principal's office at the CofE but in my new job have avoided that. (Different principal, different school)

Our chief recently had to deal with the following complaint:

One of our anaes. was assessing a patient pre-operatively. As are many of our patients nowadays, this patient was morbidly obese. On top of this he had a small mouth. My colleague thought out loud, a little bit too loudly, "With a mouth that small, how did you manage to get so many cheeseburgers in?"

I might have accepted a trip to the principal's office just to have said that.

The Myths of Private Medicine

Like most Canadian physicians, I have been watching the debate on healthcare in the US. In Canada, we have had public healthcare since the 1960s and earlier in some provinces. No system, no matter how well funded is perfect; if you get a group of docs in a room, it will soon turn into a support group on how badly their system treats them.

I treat chronic pain which is of course terribly underfunded across our country. I am also an anaesthesiologist and as such am entirely dependent on hospitals for that part of my income. If they close a room or if my cases are cancelled due to budget cuts or overruns, I earn no money.

There was been a lot of discussion in Canada on how a supplemental private system would help the crisis in public healthcare. This seems to based on a number of myths.

1. Doctors will earn a lot more in a private system.

That will be true for the doctors who own private clinics or who invest in private hospitals. It will also be true for a small number of procedurally based physicians who have procedures for whom patients or insurers will pay a lot more than is currently paid under Medicare (these people are largely already well paid under Medicare). For the rest of us, expect to get paid exactly how much or less than you would get under Medicare. Having established a benchmark for what we will work for, why would anybody pay more.

2. Unused public hospital space can be used in a private system on evenings and weekends to expedite surgery and tests like MRIs.

I wonder where they plan to find this unused hospital space? Our hospital is staffed to run two rooms all evening on week nights and all day on weekends. Everyday they scramble to find enough nurses to run the rooms. Likewise public MRI suites operate evenings and weekends to cover the demand.

And of course where are they going to get anaesthesiologists. There is still a shortage in Canada. Now if it was financially worthwhile, I might come in on Saturday to do some private cases, I actually did that once. Our workers comp board will pay an extra $200 per case for expedited surgery, so someone asked me if I wanted to do that and I did. I came in worked half a day and with the extra $800 for 4 cases it was like I worked a full day. If this became a regular gig however, I just might want Mondays off, so we would be short somebody on that day. In fact, in our city we have so many anaesthesiologists now anaesthetising boob jobs and wisdom teeth for big bucks that we have a shortage.

3. Rich people will pay more for the expedited service.

Rich people did not get rich by spending their own money; they got rich by spending other people's money. Every rich person I have ever treated without exception haS been the biggest cheapskate since the last rich person. I remember filling out forms so the wife of a local billionaire (with a hospital named after him), could have the medication I prescribed covered under the provincial seniors program.

Rich people don't wait anyway. They make a few phone calls and go to the head of the queue.

4. Healthcare costs are spiraling out of control.

I might believe this if I hadn't been hearing this for the past 25 years. If healthcare costs really had been spiraling out of control, they would now be consuming the entire provincial budget. They aren't. The problem for a politician if that the public now expects health care. I have always said that if a politician had a ribbon-cutting photo op every time somebody got a hip replacement, we would not have any wait lists.

In Canada we are offering services never dreamed of in the 1960s to a larger and older population for the same amount of money adjusted of course for inflation. And in fact most jurisdictions in Canada have been able to cut taxes!

5. A private option will inject more money into the system.

So you don't have enough money to fund a public system and your solution is to add a system that is way more expensive. If the orthopod is doing private arthroscopies on Monday, do you think he going to stop doing his public arthroscopy list on Tuesday? Also in Canada, medical expenses over a certain level are tax deductible. That means that depending on the tax bracket, patients who get private surgery or MRIs will be getting a certain percentage back in the form of lower taxes. As private medicine will be more expensive, once the tax deduction is taken into account, the private procedure may well cost as much or even more than the public procedure. We also have to take into account the fact that many people who get private procedures are people who would possibly not get the procedure in the public system; one of my ortho colleagues saw a patient with knee pain, decided he didn't need an arthroscopy (which means he REALLY didn't need one). The patient when to private clinic in Vancouver and paid $10K for an arthroscopy.

The other question is who is going to deal with the complications from private procedures? Most of these now end up being treated in the public system.

Whether it is collected by taxes, paid to an insurance company or paid directly to a doctor, money is money.

6. Private systems are more efficient.

This may be true. It is however hard to compare the minor procedures done on ASA 1 and 2 patients in a private suite with even the same procedures done on ASA 3 and 4 patients in a public hospital. It is even harder to compare the efficiencies with more complex cases. In Calgary a private hospital, currently does total joints under contract with the health authority. They are only able to do this because the health authority pays them a 10% premium. The same has been shown for cataract surgery. There are a lot of inefficiencies in the public system; I would rather they be dealt with. Certainly as a private system gets bigger and with the ability to pass costs on, you can expect them to become more inefficient.

I in fact work partially in a private pain clinic. This clinic subsists mostly thru having obtained a contract to treat patients from the local health authority. It is incredibly inefficient.

The other issue is of course billing. Currently I submit my claims via the internet for $25 a month although if I acted as my own submitter I could do it for free. My claims are paid within two weeks. Compare this with having to deal with multiple insurance companies, plus charging patients directly. A former colleague moved to Australia and works now in their private system. He told me that while he makes more, 22% of his billings go to overhead, largely to collect money.

7. Wait lists are inherently bad.

Actually wait lists within reason are not a bad idea. Some patients actually get better. Much of my time in the Pain Clinic is dealing with complications of surgery.

The fact that the surgeon has a wait list also ensures that his list is fully booked which helps my income.

8. Only Canada, Cuba and North Korea prohibit private healthcare.

Right wing newspaper columnists love this one.

So..... I see a patient in my pain clinic which is in a hospital owned by a Catholic order, I submit a bill to the public insurer which pays my professional corporation, I write a prescription which the patient takes a private pharmacy and either pays for it himself or has his insurance pay for it.

So where is the public monopoly?

There is in fact nothing to stop any doctor from charging patients directly for his services (with of course ethical and professional exceptions set by licensing bodies). What most provinces have said is:

a. You can't accept a fee from medicare and bill the patient as well;
b. You can't bill the patient directly for some procedures and medicare for other procedures
c. You can't bill some patients directly and some under medicare.

There are in fact so many exceptions allowed to those rules which are rarely enforced. If you visit any doctor's office now, you will see a menu of fees charged for prescription refills, phone calls, forms and even missed appointments.

In closing.

Working in any large system is frustrating. Despite this we seem to make a good living doing what we do. Part of the problem is the unwillingness of doctors to prioritize patients, triage and ration scarce resources. I have learned that no matter how well funded a system is, the funding is not infinite. Healthcare becomes a zero sum game, treatment given to one patient is treatment denied or postponed for another. We also have to accept that a lot of the inefficiencies in the public system are generated by doctors; not using OR time efficiently, keeping patients in hospital too long, doing futile procedures, doing procedures they know don't work and of course ordering too many tests.

Friday, January 8, 2010

Playground justice

I have been spending way too much time reminiscing about my childhood with various acquaintances from childhood who I met via Facebook.

We were "talking" about a mutual acquaintance Michael, the older brother of one of my friends. He told me that he had "punched out" Michael at the park near our school.

Fighting at school was strongly proscribed. Every month or so, a fight would break out on the playground and it would be broken up by the teacher on playground duty and the combatants would be taken to the Principal's office where they got THE STRAP. As my Grade 7 teacher, the vice principal told us, "When two kids fight, I win". I have to wonder about an adult who considers hitting kids half his size on the hands with a strap to be a victory, but he was a good teacher otherwise. Because of this when the demands of honour could only be settled by a fight, the fight was arranged for after school at a park 2 blocks from the school. I believe the proper etiquette was that one said, "I'm calling you out" and the fight was on. I can't remember if it was possible to turn down the invitation. I do know that the psychological damage of not showing up was way worse than any physical damage you could get in the fight. Word usually spread about the fight especially if two "heavyweights" were involved.

Anyway Michael apparently "called out" my Facebook friend Dave and the fight took place after school. As Dave tells me the fight ended badly for Michael with Dave on top of him punching and bloodying his undefended face. Dave tells me he actually felt sick and went to Michael's house afterwards to apologize. The apology could have been more a question of Michael's mom calling Dave's mom but I will give him the benefit of the doubt for a conscience.

I am trying to think how this would have gone down nowadays. No doubt psychologists and social workers would have been involved. Dave would probably have been forced to change schools.

When my kids were much younger, another child at my son's school who we knew was being bullied by a group of 4-5 students in his class. They were on his hockey team and it was actually the hockey team where the bullying originated. His parents went to the Principal who suggested, that they pull their son our of hockey or that they transfer him to a different school. Nothing about calling the kids on the carpet to account for their behaviour.

My wife asked me what I would have done. I told her how it would have been handled in the 1960s. The boy's older brothers (he had two) would have found the bullies after school somewhere and roughed them up. The bullying would have stopped. (Not sure what happened if you didn't have two older brothers; I had two)

The 1960s; such a simple if brutish time.

Saturday, January 2, 2010

A Story I Just Thought About

I was a general practitioner for 3 years before I went into anaesthesiology. I suppose I might have been ahead if I had just gone right into anaesthesia but I at least paid off my loans, was able to make a down payment on a house and of course saw some pretty interesting stuff.

I mostly did locums although I did spend 6 months in one place on two occasions. The second time was in a small town in BC. I actually intended to stay there and become a small town country doctor but that didn't work out.

There were 7 other docs in the town; 5 in one clinic and 2 others in the clinic where I was hired. There was an older ex-missionary doctor and a younger doctor who was 3 years ahead of me in medical school. The younger doctor was at that time the second highest billing doctor in BC.

One evening I was on call and had just seen someone in the ER when the nurses asked if I would pronounce death on a patient. She was a patient of the younger of my two partners. She was well into her 80s and had been bothered by stasis ulcers and other things that just fall apart when you are that old. I had seen her a few times on call, I remember her as a very pleasant lady, with it and with a good sense of humour. I went into see her and sure enough she was dead. After spending the requisite time time feeling for a pulse, listening for a heart beat and looking at the pupils, I walked back to the nursing station to write a note in the chart.

At that point one of nurses asked me to talk to my partner, the patient's family doctor. "Hi BH", said my partner, "I heard Mrs. X just died. Do you mind going in and working on her for while?". "That is a really sick joke", I thought and just sort of chuckled into the phone something like, "Yeah right". "No", said my partner, "Can you go back and run an arrest on her?". "Sure", I muttered and hung up. Of course I never went back to her room.

Friday, January 1, 2010

Passed Over Again

Once again New Years brings the announcements of the latest Order of Canada recipients, Canada's answer to knighthoods. And once again I was passed over. I really don't expect it, but hey Conrad Black, Alan Eagleson and Celine Dion have been selected so hey maybe I deserve a chance.

Celine Dion reminds me of why I really writing this post. As I mentioned last year, Celine Dion was honoured for the second time last year.

This year Neil Young and Burton Cummings were named. Given their contributions not only to Canadian music but also to Rock and Roll in general, it is surprising that neither individual has been honoured until now.

Our National newspaper was not impressed. In an editorial, they bemoaned the fact that James Cameron, who directed Titanic and more recently Avatar was not named. It suggested that Neil Young and Burton Cummings' accomplishments were far in the past and not really worthy of nomination.

Sorry guys. Burton Cummings still lives in Canada. Neil Young while living in the States still considers himself a Canadian. Maybe Cameron is a decent director. I can think of at least 3 Canadian directors who are better (Norman Jewison, Atom Egoyan and Denis Arcand) not to mention all the American directors who put out way better movies with much smaller budgets. Maybe Cameron deserved the OC. I don't know. The issue is that Celine Dion was honoured twice before Neil Young arguably the greatest and most influential rocker was named. One could argue Celine Dion got her OC on Mr. Cameron's coat-tails. Her song "My Heart Will Go On" from Titanic is thankfully the only song of hers I can think of.

That is a travesty that has now been partially addressed.