Monday, July 26, 2010

Riding With No Cause

I rode 100 km on my bike yesterday. This is my 4th metric century, the second this year. I am no longer scared but still respectful of the distance.

A few months ago when I did century #3 (actually 120 km which is limit of my envelope) I posted this on Facebook. A number of people replied to ask what cause I was riding for.

As with yesterday's century, I spent 4-5 hours out in the sun and wind for my overall health and for companionship of 1000 or so riders (most of whom passed me).

We have in our province a couple of long bike rides in support of a particular cause. We have the MS Bike Tour which is 160 km over 2 days in support of MS and we have the Ride to Conquer Cancer which is also a two day event. I have thought of going in both of them but have never been able to due to conference, call or family. To ride in the MS Bike Tour you have to raise $250 in donations; the Ride to Conquer Cancer is more ambitious,the ante is $5000 which means you get a lot of emails from friends and acquaintances looking for sponsorship.

Both trips are well supported with lots of good food etc for the riders

Treating and supporting people with MS and Cancer are worthy goals and I would certainly never begrudge them the money. However, I sometimes wonder why in the 21st century in one of the richest countries in the world, in the richest province in that richest country and with "socialized" medicine, why should we be asking people to ride a longish distance other than for their personal edification.

While having my post ride lunch yesterday, I was listening to a lady at our table talking about her recent experience in the RTCC. As I often do I drifted off into a fantasy others and I should have more frequently.

"What" I thought, "if instead of having people fund raising to provide things that society should really be providing anyway, we had fund raisers for things that society really could do without"

"Like, for example, the military. Want to send troops to Afghanistan? Have we got a bike tour for you. 50 Billion for fighter jets we don't need? Some Air Force general is going to have to run across the country. New uniforms? Have a bake sale."

Taking it further.

"Want a seat in the Senate? (for those Americans our senate is appointed much like the British House of Lords except for the lack of funny titles.) Whoever raises the most money for a worthy charity gets the seat. (and no writing a cheque on your personal account, you actually got to lean on people to donate)"

I don't ride very fast but I can dream.

Friday, July 9, 2010

News Flash

Just out.

And in related news, the Pope is Catholic and bears still shit in the woods.

Tuesday, July 6, 2010

Follow up to choice in Health Care

I got this comment from Z-MD on my last blog which due to some glitch I couldn't publish so I am putting it here.

Your brothel story perfectly illustrates the lack of capitalism and competition in American health care. People with means will gravitate toward the more expensive product, even if the outcome is the same. Unfortunately many Americans who can't afford it still demand the expensive treatment. With government funding and insurance companies obscuring the true cost of treatments, people want nothing but the best ie/costliest care since they are not paying the full cost. If Medicare was subsidizing brothel visits (isn't sex one of life's necessities?) every old geezer would be down at the Chicken Ranch to get his $10 worth instead of paying $2 out of pocket. And if somebody's getting their $10 worth of subsidized nookie instead of paying $2, then everybody will want it, quickly bankrupting the system which is where we are today.

The point I think I made was that there is no difference between the $10 fzck and the $2 fzck and maybe the problem is not that we have "poor" people demanding $10 fzcks but rather that we offer them at all. I could give examples and maybe will some other time.

Monday, July 5, 2010

Choice in Healthcare?

Great Z has posted again.

Now I admire his blog although it is quite clear that politically we are a little ways apart. I both agreed and disagreed with aspects of his blog.

His story about the choices in his local car wash reminded me of a movie I saw a long time ago (Lady in Red). In this movie a young woman was starting out in a brothel and was told that there were three prices for her product, $2, $5 and $10. "What is the difference?" she asked the madam. "There is no difference", replied the madam.

Health care is however more of a black and white thing. It is either done right or it is done wrong. Actually it is various shades of gray but what makes it less black or less white is more intangible. Those of us in the know all know who our first choice of surgeon or anaesthesiologist would be for any given procedure. We would never think of paying more for them, we just request them. We don't ask for a $2000, $5000 or $10000 gall bladder because we know there shouldn't be any difference.

I have always maintained that if you had three doctors each charging $20, $40 or $60 for a visit, each doctor would be equally busy and that the social strata in each office would be quite similar.

When ondansatron came out 20 or so years ago, it seemed to be clearly a better anti-nauseant than what was available (I am less sure of that now). Unfortunately because of its $20 per dose cost, our pharmacy restricted it. I remember thinking, "I would happily pay $20 in order not to puking out my guts". This is in fact what we did; if a patient came in really concerned about nausea and we saw him in sufficient time, we wrote him a prescription for oral ondansatron, he picked it up and took it pre-operatively. Likewise propofol; I would have happily paid the extra $7.50 in order to be more awake and less nauseated.

Length of stay is another issue, if a patient wants to stay an extra night in hospital and can afford to, why not charge him the extra $1000. The problem here comes, because rich people are notoriously cheap and because frequently patients do have to stay longer than normal, there would be all kinds of disputes over whether the extra night was necessary or not.

Our province and other provinces allow people to pay for MRI examinations. If you have a sore back and want to know what is wrong when your stupid doctor is just telling you to exercise and lose weight why not? This is fine except that radiologists especially when they know the patient has paid out of pocket will never report an MRI as normal. They will find something to report, and the patient will take the MRI to his doctor, and the subsequent follow-up tests, consultations etc will fall on the public sector.

Our hospitals are funded by the government through byzantine and ever changing funding formulas. To raise extra funds, hospitals in Canada depend on revenue from the cafeteria, parking and private room charges. Even then the government insists upon dipping its beak. One of our obstetric hospitals has had for many years theme rooms for post-partum moms for extra cash. Of course because obstetrics is so unpredictable, these rooms are frequently not available plus we discharge normal deliveries so early anyway. The newest of our hospitals was built with no room more than 2 beds. Therefore by definition if you are admitted to that hospital you will get a semi-private. If you keep your mouth shut you will not be charged extra for this semi-private room. If however you don't realize this and ask for a semi-private room on admission, you or your extended health will be billed for this. When I heard this I could not believe the utter sleaziness of the whole arrangement.

Now columnists in the right wing and sadly in a few of the mainstream newspapers are calling for competition in health care as a means of improving quality while decreasing costs. Even our provincial government is once again in the process of getting hospitals to compete with each other. I attended a day long strategic planning session more or less on that.

It would be nice if hospitals actually competed on things like, our infection rate is better, our preventive programs are better, our rehab is better, our costs are lower etc. We all know that that is not going to happen; where hospitals are going to compete is, our theme rooms are nicer, our foyer has better art work etc. We also no that hospitals are going to compete to see who can do the most simple procedures on the healthiest patients, leaving those sicker more complicated for some other hospital. It is already happening.

I did have my car detailed a few years ago and was offered gold, silver or bronze packages. Being Canadian I chose bronze and asked what was included. After hearing all of what was included just in the bronze package, I wondered what more could be included in the silver or gold packages. I had some ideas that were slightly obscene but we really shouldn't go there.

Friday, July 2, 2010

Cardiac Anaesthesia

I suspect if you get a bunch of non-cardiac anaesthesiologists together in a room after a while the discussion will inevitably get around to cardiac anaesthesia, especially if you include enough people who work or have worked in one of these centres. That includes most of us since we all had to do a rotation during our residencies.

Most of us who worked in a centre with cardiac surgery as I did at the centre of excellence, have realized what cardiac surgery is: a resource sucking monster staffed by the most incredibly arrogant individuals (including some anaesthesiologists unfortunately).

I refer to adult cardiac surgery of course. I have only the most respect for those pediatric cardiac surgeons (even more for the anaesthesiologists) who have to figure out those complex lesions. Even those ones who work when they shouldn't. I also don't doubt the necessity of a significant amount of cardiac surgery; while I don't smoke, drink plenty of dark beer and red wine, try to exercise, chose my parents well etc, I have consumed a lot of bacon and fried bread in my time which could come back to haunt me in the future.

Firstly cardiac surgery is pretty easy. You basically sew a piece of vein onto an artery 4-5 times during a procedure. I probably can't do that but I suspect in the course of a 6 year residency I might be able to. Valvular surgery, true might be a little more difficult. Cardiac anaesthesia is even easier. I trained in a centre which didn't have a separate cardiac surgery call schedule, which meant when you were on call you might have to do an "emergency" by-pass. This kept me awake for my first few nights on call. I should have slept. Back in the 1980s we used to describe a simple standard anaesthetic as "Big Syringe (pentothal)- Little Syringe (sux). When I got to do my first Saturday "emergency" CABG, the staff man gave me a Really Big Syringe (60 cc of fentanyl) which we followed up with a Little Syringe (10 mg of pancuronium) and we proceeded happily along. The art line and Swan Ganz catheter are basic skills for any anaesthesiologist and of course we now know that Swan's were actually not very useful and probably harmful.

I actually found it amusing when I actually rotated thru a 3 month cardiac anaesthesia rotation that I would go up and see the patient, look at the cardiac cath report which I would then have to relay to the next day's staff at home on the phone. I would have to recite the location of all the lesions, the wall motion abnormalities and the EF. I could have saved my breath. Regardless of how bad the anatomy and physiology, the induction the next morning consisted of the Really Big Syringe and the Little Syringe. Maybe things have changed? Naw.

A few years before I joined the centre of excellence, an academically inclined anaesthesiologist joined the department. He was one of those fellows who had done his training in multiple programs in multiple countries. This had however resulted in him never having done a cardiac case at all in his residency (apparently not compulsory then). Because at that time (and now) at the CofE, not belonging to a sub-specialty group meant a career of second classness and because of his impeccable academic credentials, he was allowed to join the cardiac group. On his first day on the job, he induced the patient using the "cardiac anaesthetic", inserted the requisite monitors and kept the patient asleep and stable until it was time to come of bypass.

Hmmmm how do we get somebody off bypass?

He went to one of the perfusionists who told him how to get a patient off bypass and went on to a glorious career as a prominent cardiac anaesthesiologist of excellence. (As a junior resident, I asked one of the senior residents how you got somebody off bypass and he said something about walking counter clockwise around the room shaking a bottle of nitroglycerin in one hand and a bottle of dopamine in the other.) That reminds me of course that where I trained we were not allowed to use inotropes to get the patient of bypass. The cardiac surgeons apparently considered the concept of their patient requiring inotropes to be an insult to their skill. This did introduce some degree of art (and occasionally deception) into getting a patient off bypass. I was amazed when I went to the CofE that the cardiac anaesthesiologists were not only allowed to use inotropes but did so with gusto. Where's the sport in that?

Cardiac anaesthesiology off course means working with cardiac surgeons who are with a few exceptions the most arrogant assholes ever to call themselves doctor. Not very smart either. They are also noted for their bad temper. I am not certain whether I have blogged about a cardiac surgeon known as F-tach for his repetitive use of Anglo-Saxon words. It actually took two anger management courses to fix him although one wonders whether any non cardiac surgeon would have been tolerated so long.

A surgery resident I trained with was home one evening when his phone rang. It was the hospital switchboard who connected him to the ward, where his staff man was apparently sitting. His staffman, ordered him to immediately come in and fill out a disability form for one of the patients. Nothing like, "can you do this tomorrow?" or "Since I'm here why don't I just fill out the stupid form?"

The hospital where I trained was a smaller centre where cardiac surgery was only done 3 days a week. This of course left lots of leeway for the "emergency" CABG. Most of these took place on Saturdays in order to take advantage of the weekend premium. Occasionally they were booked on Tuesdays or Thursdays. I remember one day our senior alpha male cardiac surgeon announced during his booked list of Monday that he really had a patient he had to do on Tuesday. To justify fzcking up the OR schedule, he described how unstable the patient was and how he had been afraid he would have to do him on the weekend (so why didn't he bump his elective case on Monday?). Anyway the plan was that the unfortunate patient would be transferred from the hospital where he was languishing in the CCU to our hospital where he would be directly admitted to the ICU and have a balloon pump inserted to off-load the heart. I happened to be on call that night and as well my wife was working in ICU. The resident on cardiac asked me if I could see the patient pre-op. We were of course expecting an ambulance transfer which was why we were surprised, when around 1900 there was a knock on the door of the ICU and the patient was standing outside, having walked over from the admitting department CARRYING HIS SUITCASE, after coming over by taxi. Nevertheless, the IABP was inserted, that the "emergency" CABG went ahead the next day.

I can't help but mention that this particular surgeon carried on an affair with one of the anaesthesiolgist/intensivists for 3 of 4 years of my residency. When they broke up, it made for some interesting dynamics in the OR and ICU.

I could go on and maybe I should, but the bottom line is that most of us really resent the sucking of OR resources into the cardiac room. This happens both during the day and also during the night. There is also the assumption that the flow in OR can be disrupted to accommodate their "emergencies" or conveniences. Nobody ever calls them on this.

There is also the issue that a considerable amount of resources are going to treat a condition which can largely be prevented or treated by much simpler measures. Back when I worked at the CofE, our department chairman made a rare appearance in the coffee room. He described an interesting dilemma. Under the bizarre funding formula in our province, our cardiac surgery team would have to do 300 heart surgeries in the next few months. In order to do this, the CofE was prepared to authorize overtime, etc anything to get those cases done and avoid whatever penalties the province would be imposing. The problem was that because of things like health lifestyles, angioplasties, statins etc. there were only 200 patients actually waiting for surgery (the CofE is capable of doing 40 cases a week). I never found out whether they met their quota. In the odd glance at the OR slate, I did notice a lot of single vessel bypasses and that the average age of patients seemed to be higher. Just a coincidence though.

At that time the CofE was erecting a temple to cardiac surgery next door. This after several glitches is finally opened. As the opening approached it became apparent that because of things like healthier lifestyles,etc that the whole centre was way too much supply for any demand and there was talk of doing non-cardiac surgery in some of the redundant ORs.

I have gone onto greener pastures at my nice community hospital of course.