Monday, October 25, 2010

I Never Knew I Was A Victim

Our national newspaper has over the last week documented the indignities we males suffered and still suffered in the school system

I hope what I am going to say will be taken in the spirit that I have intended it.

As a male who "survived" quite nicely our educational system and as the father of two male children now attending university, I am glad that after 45 years this scandal has been unearthed (sarcasm).

I remember well elementary school. All the girls who showed up to class immaculately dressed while we boys wore whatever we found on the floor; who brought flowers for the teacher; their neat handwriting; their better artwork; how they could sit through 5 hours of class; they were smarter; often bigger; better coordinated (remember skipping in the playground, no boy could have mastered that). They never got sent to the principal's office, never got THE STRAP. Our teachers were all women until at least Grade 6; usually older unmarried women. It was a dark time to be a man.

All of us boys hated girls then. We knew we would eventually marry one but we really weren't sure why.

At the same time at least in the 1960s our mother was at home; our father worked, he was usually gone before we had breakfast, he showed up around supper. He controlled the household, he was the breadwinner. How were we going to go from our state of oppression in elementary school to our eventual destiny?

Somehow between elementary and high school gradually the tables turned. By Grade 12 boys were clearly in charge. Sure some girls got to be student council president but that was only because we let them.

Really not much had changed a generation later. My son actually had a male teacher for Grade 1 but it was clear that elementary school was not a friendly place for boys. I remember going to a play put on by my son's school and being amazed that even the male roles in the play were played by girls with boys playing only secondary roles. But just like when I went to school by high school the tables had turned and boys were at least equal.

The series of articles bemoans the lack of males in university. Actually females outnumbering males is not a new thing; it was the case prior to the second world war, even when I attended university the number were roughly equal. More interesting was the section on McMaster University where 75% of the class were female with the result that affirmative action for males had to be instituted. McMaster is by the way an interesting case, a medical school which from its inception committed to accepting students from a variety of backgrounds with less emphasis on academics with the result that females have for most of McMaster's time been the majority.

My medical school class was 3/8 female the highest percentage and absolute number in the history of our medical school. Once we got over the whole sexual tension of the whole thing (or realized that most of us had absolutely no chance with these intelligent hardworking women, many of whom had boyfriends) we were able to accept them as colleagues and friends and I think they really gave a positive tone to our medical school class. The class behind us which split evenly 50:50 generated 10 couples (as opposed to one from our class).

With our class and with the one a year later, there was much muttering about affirmative action for females. This was in my opinion rubbish. Most of the women who entered medical school in the that time entered with marks as good and usually better than the men, not to mention other intangibles such as personality, life skills etc. What should have been more of an issue was the affirmative action for children of doctors which was the case for not a few people in my class.

Likewise much has been made of how women doctors work less than do male doctors which may be true although many of the new generation of male doctors who want to work less hard than our generation. On the other hand I have trained with a number of female residents, interns or staff whose work ethic put mine to shame.

The bottom line is that while the education system may be a system that gives females an advantage, that advantage is solely limited to within that system and that both sexes are going to go out into a world that is still tilted towards men. It is probably a good thing that boys have to labour against sexism in the education system. Whatever doesn't kill you makes you stronger, besides how else would boys learn to write neatly, behave in public, read, and learn about music all skills that the female centric system forces on boys.

Saturday, October 23, 2010

Nickel and Diming

I read this on Great Z's post and as almost always I agree with his sentiment if not his solutions.

I have always taken my role as a gate-keeper into health care very seriously and so I try with limitations to give the patient not only the best but the most cost effective care. In the scheme of things anesthesiology are not big contributors to hospital costs but ever since I started practice we have had to look at every little cost.

As I mentioned, one of the advantages of getter older is the perspective one gets over practices over the years.

When I started I did my first rotation in pediatric anaesthesiology (the result of this is that to this day, I know the dose in mg/kg of every drug). One of the anesthetists, an older British fellow used what was called the Liverpool technique. This involved 70% N2O, curare, and morphine. No volatile! It was a marvelous anaesthetic from a practitioner point of view; you reversed the muscle relaxant, turned on 100% O2 and the child woke up (or was never asleep?). They all received 0.2 mg per kg of morphine so they were comfortable as well. There was never any hypotension and as the children woke up promptly, laryngospasm was infrequent. What was more significant was the cost. Each case must have cost less than $1 in drugs. The other anaesthetists at the hospital used a similar technique with small doses of halothane.

When I went to the adult hospital for my first adult rotation, the anaesthetist (after admonishing me for trying to figure out the dose of pentothal in mg/kg) chided me for turning on Isoflurane. "You really like the expensive stuff", he said, turning off the Isoflurane and turning on the Enflurane. We of course used Bain circuits with their 5 L flows then.

So it went during my residency. The first time I used vecuronium on a case, the staffman warned me that the patient would sit up during the case. I told him I planned to also put the patient to sleep.

It was the introduction of propofol when we first became aware of costs. I was on staff then at a larger community hospital. Our first attempt at using it was rebuffed by pharmacy, however by sending our bad cop anaesthetist to the next P&T committee, we were able to obtain a rationed supply. Each anaesthetist was rationed to 6 200 mg vials a week. This resulted in a lot of after hours borrowing from other people's carts (we had our own carts there, something I wish I had where I am now) and of course diluting with pentothal to create what I called "President's Choice" propofol. It also lead to the widespread practice of "saving" propofol in syringes or in the original vial until we found out how easily propofol could be contaminated.

Propofol is of course unquestionably better than pentothal for short cases; less so for long cases. It has of course eclipsed pentothal which is actually temporarily unavailable in Canada. Propofol does allow for earlier discharge from recovery room and day surgery however the clinical significance of this is questionable because discharge times are more affected by factors like hospital policy, availability of porters and whether the patients ride home has showed up. In addition savings from shorter stays are only realized if the shorter stay is accompanied by staff reductions.

When I joined the CofE, they were in the midst of a massive cost cutting exercise. The administrative strategy du jour was to give each department a budget which they had to keep within. Therefore our department was responsible not only for our drug and disposable costs but also for the cost of our techs. This was an interesting exercise where we learned that for years our techs had manipulated their shifts to maximize the amount of overtime they got, something that should have been easy to fix but which we never really got a handle on. Drug costs were another matter. Pharmacy was able to give us a monthly figure of how much we spent on drugs which we divided by the number of cases to come up with a cost per case. This was quite rough as cases at the CofE went anywhere from 30 minutes to 30 hours. Our average cost per case varied from $15 to $20 per case. This was something we all strived to reduce although that is the cost of a single suture or 2-3 doses of Ancef.

We subsequently went through decade and a half of very little control in anaesthetic costs during which Sevoflurane, Desflurane, Rocuronium, and Remifentanyl where introduced. Much of the research on Sevoflurane and Desflurane was done during my residency which is when (unlike today's residents) I actually read journals. It was pretty clear to me and to other residents that Desflurane and Sevoflurane were going to be huge busts. Desflurane for example requires a special heated pressurized vaporizer, which Sevoflurane breaks down to toxic metabolites. All this for a recovery time which is statistically but not clinically significantly better than Isoflurane. Despite this, when I go into my room today, I will have the choice of Sevoflurane or Desflurane because we only have room for two vaporizer on our machine and it was too expensive to keep Isoflurane vaporizers which nobody was using around. Des and Sevo are really triumphs of marketing over science. Remifentanyl on the other hand is a huge advance although I remember poo-pooing it. "What is the use of a short acting narcotic," I used to say.

But getting back to Great Z's discussion about how everybody else gets expensive drugs and we don't. This has also been my observation and of course I remember the fights as I outlined above we had to just be able to try out new drugs. This also applies to some anaesthesia drugs and products which other specialties get before us. I remember, as a resident, when midazolam came out, anaesthesia requested it and were denied; then gastroenterology requested it and got it, therefore we also got. The same thing happened with EMLA cream which pediatrics got after anaesthesia was turned down (we soon found out that EMLA is worse than useless). At the CofE, our emergency physicians got rocuronium before anaesthesia did (aside from the spectre of half trained ER docs burning their airway bridges with a non-depolarizer; what an insult to anaesthesia!).

We haven't (yet) come to point of not having propofol, we have as a mentioned temporarily and I suspect permanently lost pentothal. I could certainly see that anaesthesia could be at risk. Even in a country the size of Canada, a corporate bean counter could look at the potential profits to be made by making propofol versus what can be made using the third generation version of Lipitor and decide that maybe they won't make propofol anymore.

Perhaps however the answer is not to demand our own expensive third generation drugs but to ask why we are using what are for the most part unproven and in many cases harmful drugs in place of the old standbys. Take hypertension for example. The Canadian guidelines from 1999 which they have not seen fit to revise state:

1. Initial therapy should be monotherapy with a thiazide
diuretic, preferably at a low dose, a β-adrenergic antagonist
or an angiotensin-converting-enzyme (ACE) inhibitor
(grade A). If the response is inadequate or there
are adverse effects, substitute another drug from the initial
drug therapy group (grade D).
2. Combination therapy, either with a thiazide diuretic
and a β-adrenergic antagonist or with a thiazide diuretic
and an ACE inhibitor, should be used if there is
only a partial response to monotherapy (grade A).
3. If blood pressure is still not controlled, or there are
adverse effects, try other classes of antihypertensive
drugs (calcium-channel blockers, angiotensin II receptor
antagonists, α-adrenergic antagonists or centrally
acting agents) either as monotherapy or in
combination (grade D). Consider possible reasons
for a poor response to therapy, such as noncompliance,
secondary causes of hypertension or interactions
between prescribed treatment and diet or other
drugs (grade D).

So when was the last time you saw a patient on a hydrochlorthiazide for hypertension? Or a beta blocker except when there is some ischemic heart disease. They are usually on about 3 different drugs that you have never heard of (but will soon learn about when you read in the newspaper how that drug has been pulled from the market because it is killing people). Psychiatry is the same. Everybody is on a cocktail of "atypical antipsychotics" all of which have side effects of weight gain. Like we need more obese patients. This has rubbed on onto family practice where these drugs are being prescribed for things like insomnia and anxiety.

Enough of this rant. Like the title says, I used to be disgusted now I try to be amused. It is getting harder.

Monday, October 18, 2010

The Most Arrogant Thing I Have Ever Heard A Surgeon Say

I should have posted on this a long time ago. This happened in the last millennium at the C of E.

Naturally being a Centre of Excellence, the Centre of Excellence has doctors from all over the world come there to become excellent. In the late 1990s we had a surgeon from a third world middle eastern country spend a year or so to learn to do liver transplants. Now there are a lot of people who would think that most third world countries should maybe focus on things like public health, vaccinations and non-excellent things but they are not thinking excellently. As the fully qualified surgeon working as a fellow, he was given some latitude in working and was mostly working unsupervised on the memorable day.

I came in to find that as usual my list was all messed up and my first scheduled case couldn't start until the early afternoon, however in consolation, I was allowed to pick up an emergency case from our ICU. This was a liver transplant patient who had had his abdomen packed due to oozing at the end of the case. It was now time to remove the packs. I was not a liver transplant anaesthesiologist but now that he had a sort of a functioning liver I was deemed competent to anaesthetize this patient. He was still ventilated, lines in, plug and play.

After removing a number of packs our now more excellent surgeon announced he was closing. "Not so quickly", said the circulating nurse who had the count sheet from the original operation. "There is still one more pack in." "No there isn't" said our surgeon. Fine said the nurse we'll X-ray. Our surgeon left the room leaving his residents to close which they did in time. X-ray was summoned and a flat plate showed surprise, surprise, the missing sponge. Our surgeon was summoned back.

There are a number of appropriate responses to this scenario; most of them involving some expression of regret or remorse. None of these were forthcoming. Was did come was the surgeon angrily accusing the nurse of not being more forceful in insisting that he look for the sponge. I rolled my eyes; I do after all get paid by the hour.

The last time I worked with this surgeon was during the evening and I witnessed him being walked through a laparoscopic cholie by a junior resident. I decided this wasn't really appropriate and complained and he shortly returned home where I suppose he is doing liver transplants and laparoscopic cholies and might even listen to the nurses occasionally.

Saturday, October 9, 2010

Tipping Point

I recently finished a guided bike tour of the Czech republic which was easily the best holiday of my life. At the end of every guided trip however comes what I find to be unpleasant. How much to tip the guides?

There are a variety of formulas, some people do so much a day, some people do a percentage of how much the trip cost (which is what we ultimately did). Many tour companies are happy to help you out by "suggesting" how much you should tip. Then there is the question of currency; local currency (if the guide is not from the country where you are now), Canadian dollars, US dollars, Euros. This followed by the trip to the bank machine to get the requisite money.

This is not to say that our guides were not fantastic. I fortunately have never had a bad guide. They do work hard and long during the trip but hey they are guiding not working in some dead end job. On this trip however one of the other members decided that one guide should get much more than the other which I didn't really think was fair; one guide clearly appeared to do more but she was the lead guide and that was her role and we didn't really know how much the other guide did behind the scenes. I pointed this out to the lady who was collecting the money but she was adamant that the two guides shouldn't get the same so under her watchful eyes we actually took back some of the money for the second guide. I really had a hard time looking our guide in the eyes for the rest of the trip.

Of course while we did all put our tips into a single envelope I have no idea how much everybody put in. Guided bicycle trips like the one I recently went on are quite expensive and while I can afford these trips now, I wonder however about some people who save up and budget for these trips and find out at the end of the week that they are expected to pony up what usually amounts to hundreds of extra dollars for what they thought they had already paid for. (At the end of a kayak trip once not only where we supposed to tip the guides but the tip was to be presented at a dinner where we also picked up the guides' tab; I don't mind doing this on my own but hate being told I have to do it!)

I make a good income and I am very sympathetic to people who make less than me. I tip 20% usually even when the service is bad. Occasionally when the service is bad I have been tempted to withold the tip but in the interval between the bad service and the presentation of the bill I always soften and consider whether the bad service was really the fault of the server or whether it was beyond his control. (My father usually tells the server when the service or food has been bad and has received numerous free meals in his life.)

But here is an interesting concept. Why not end the charade of tipping and actually pay people a decent wage? I am not naive enough to expect that if we had 15-20% added to our restaurant bills that this would necessarily result in a wage increase for servers. In Europe and Australia however where tipping is less common, waiters and bartenders are actually valued employees who are paid a good wage. This is unlike Canada and US and this shows in the service we sometimes get. As an aside, I remember as an intern 6 of us went out to dinner at ski resort. The service was not very good, the waitress was surly and at least two people didn't get the meal they ordered (she argued about that two). Nonetheless we are put in cash which included a 10% tip and handed it to the person who agreed to settle the bill for us. For some reason (he said it was an error) he only left enough to cover the tab. The waitress actually chased us our of the restaurant to ask why we hadn't left a tip. Oh yeah we said, a mistake and handed her the extra money.

There is the question of who gets tipped. My server I suspect gets about the same wage as the guy who washes the floor in the OR. Why does one get tipped and not the other. I could give more examples.

One of our guides (ironically the one I reluctantly stiffed) who guided us on another trip works as a server in the off season and we actually had a long discussion about tipping on this trip and she had some interesting experiences in that field to relate. She told me for example that in some restaurants the servers are expected to pay 6% of the bill as the share to the cooks and dishwashers whether or not they get a tip and that she has often wondered how much of this money actually gets back to the workers.

Now as a physician, I never get tips or expect one. I do get chocolates and liquor at Christmas from patients. There was once a Greek lady who I treated who would bring to every treatment a bottle of Ouzo and $200 in cash. I kept the Ouzo and would walk the $200 over to the hospital foundation office. (They told me that they sent her a charitable receipt and she sent it back). She stopped coming after a while by which time my wife and I had acquired a taste for Ouzo which I now have to buy myself.