When no doctor is better.

This story popped up recently. A similar story pops up a couple of times a year in Canada. Sometimes it is a radiologist, it could be a surgeon, even an anaesthesiologist. CT scans came into being while I was in medical school which is a really long time ago so if a radiologist hasn't been trained in reading what has become a pretty basic test, one has to wonder when did he train and the real question which the story doesn't answer is where did he train?

On the other hand except when a CT scan is done for trauma or a suspected intracranial bleed, interpretation is pretty much something that needs to done in days not in minutes. Urgent CTs are usually read by surgeons or ER docs anyway. Remember, a CT scan is a computer generated interpretation of multiple X-ray beams which means the image we seen on the screen or in the old days printed on a film, is really a series of 1 s and 0 s which means that it can nowadays easily be sent electronically in real time to be read by somebody who knows what he is doing. This is already being done and we of course hear of X-rays being outsourced to other countries.

Surgery and anaesthesiology of course can't yet be reduced to 1 s and 0 s which means that both of us have to be on site to do our jobs. This is causing problems in rural Canada and I suspect in the rural US.

Canada and the US are gradually becoming exclusively urbanized countries. In our province which is felt to the redneck heartland of Canada, 2/3 of the population actually live in the two largest cities. Rural populations are shrinking or not expanding; our neighbouring mostly rural province has the same population as it had in 1920. No one is denying the importance of the rural areas in producing our food, our lumber,drilling for oil and mining our minerals; clearly people need to live in there and clearly people want to live there. Increasing the rural population is devoted only to those activities with the rural population seeking services in the cites. Many people in fact involved in activities like mining and oil live temporarily in those communities while their families now live in the cities. Whereas people in rural areas used to buy their clothes at the local Saan, their hardware at the local hardware store and their groceries at the local grocery store, they now drive 1-2 hours to shop at Winners, Home Depot and Costco.

When I was in medical school, smaller hospitals still did a lot of surgery. The surgeons were usually individuals who had done a lot of surgery either in a formal residency training program or as medical missionaries. They did general practice as well and could do hernias, gall bladders, Caesarian sections and some orthopedics. A few of the these surgeons were Brits who had gotten sick of waiting for a consultant to die so they could have his position and they were very well trained. More recently we have South African surgeons fleeing their country for greener pastures who are largely good surgeons as well. (There was the embarrassment of the South African orthopedic surgeon practising in rural Saskatchewan who was wanted by the Truth and Reconciliation Commission to explain his actions while working with the army; something about death squads.)

Times are changing. Surgical training is increasing becoming pyramidal with senior residents doing a lot of surgery and junior residents doing almost none. The days when a doctor who was interested in doing a little surgery could sign up for one or two years and expect to get experience are over. I suspect the situation in other countries in the British Commonwealth where a lot of Canadians went to get surgical training is the same. At the same time job prospects for Brits are better with the government having created more consultancies. Further, graduates of Canadian training programs are reluctant to move to rural communities where they can be guaranteed to be on call all the time and may have to supplement their income by being family docs (something which under our licensing policies isn't even possible anymore).

Anaesthesia in rural areas is provided by what is a uniquely Canadian job, the GP-Anesthetist (GPA). These are family docs who have done an extra year of anaesthesia training. Our program trains these individuals, they are for the most part excellent well motivated docs. (Many of them in fact chose to do the entire residency). In the community these docs typically will do one or more morning lists with their offices in the afternoon. They also take call for anesthesia in their hospitals.

Back in the 1990s when jobs for specialists were lacking we noticed that quite a few suburban hospitals around our city were being staffed by these GPA s, some in fact were working full-time in anaesthesia. Many of us felt that these ORs should be staffed by specialists and the result was that another of the hospitals in our city refused to train GPA s. This precipitated the usual shzt storm and we were able to reinstate the program with the stipulation that the trainees had to be sponsored by a community suitably distant from our city with a "commitment" to work there. These commitments and $1.65 will get you a coffee and there still are a number of GPA s encroaching on our city (largely because specialists don't want to work and take call in those suburban hospitals).

When working with a GPA trainee I try to emphasize what should be the key point in their training. Not what they can do but rather what they can't do and more importantly what they can do but shouldn't do. For example a certain surgical procedure may be well within the skill set of both a surgeon and an anaesthesiologist but the hospital may not be able to care for the patient post-operatively. Worse the anaesthetist may be able to give a good anaesthetic but the surgeon may not be able to do the surgery competently or worst still the surgeon can do the surgery but the anaesthesiologist cannot do the patient. An interesting case took place many years ago in a rural hospital with an itinerant surgeon from the city. The surgeon wanted to do a hernia repair in a neonate. The GPA quite correctly said that he could not do the case. The surgeon who is a bit of a bully offered him a compromise. "I will start the IV and intubate the patient for you," said the gracious surgeon. You know where this is going. The surgeon could start the IV but couldn't intubate or bag the patient. There was a lot of fuss and apparently the child did okay and had an uneventful surgery weeks later in the city hospital to which he should have been referred in the first place.

The justification for keeping operating rooms open in these small centres is often so that locals can get their surgery close to home. Frequently now much of their surgical volume comes from itinerant surgeons from the city who are looking for OR time and compliant anaesthesiologists who won't trouble them with concerns about the patient's medical problems, ICU beds or regional blocks. The patients are as likely to have come from the city as they are to be locals. Full-time surgeons have as I mentioned above largely fled these smaller hospitals. A few specialists have actually been allowed by smaller hospitals to develop boutique practices where they practice their specialty in the hospital but do not do trauma or take call.

The problem is as has become very clear is that as surgical volume drops complications go up. In fact the administrator of our hospital at a meeting was quite clear about this when she said at a meeting I was at that if you have surgery at a hospital with fewer than 50 beds, you are putting yourself in harm's way. She said this in a closed meeting. No public official would ever say that in public.

People in small towns while happy to drive to the city to do their shopping are attached to their little hospitals. Reducing any service, let alone close them is political suicide. In many small communities the hospital is the town's largest employer. Closing these hospitals is not the answer, they need their emergency rooms, they need to be able to stabilize patients for transport,they need to be able to take patients for short admission and be able to act as convalescent care areas where people can recover from surgery or serious medical problems close to home. It is hard to think of an surgical problem that is not amenable to stabilization and transfer to a more advanced surgery centre.

Obstetrics is of course the justification for most small hospitals keeping their surgery units. This would be a good justification except that currently many of them are transferring in their patients to deliver in the city as family docs flee obstetrics or refuse to be on call 24/7 meaning that our hospital gets a significant number of transfers because nobody in town is doing obstetrics that (usually) weekend. Further it is getting harder to find someone trained in general surgery who is capable of doing a caesarian section. The days of surgery (or obstetrics) residents doing off-service rotations are over.

But getting back to the problem of the less than competent radiologist; we also have the problem of the less than competent surgeon who is hired to staff a rural hospital. I have actually spent whole evenings on call where every case we did was a complication of surgery done at rural hospitals by surgeons with questionable training.

We also have the problem of the less than competent anaesthesiologist. A few years ago we had an apparently specialty trained anaesthesiologist from another country who married a Canadian teacher who lived in our city. She asked to do a self-funded (meaning unpaid) residency which our chairman approved. I soon noticed she was showing up in my room to work with me quite a bit. She was very pleasant to talk with but in my mind was functioning at a very junior resident level and had some very bad habits. After a while she asked me if I would do a letter of reference for her. I assumed that she was applying for a Canadian residency which we had discussed. It was with some shock that about a month later I received a letter from a hospital an hour away asking for a letter of reference for a staff position. As I said, I like her but I felt I could not recommend her; I talked with the residency program director, who disavowed any responsibility for her saying it was the chairman who had arranged her "residency". I therefore wrote a letter stating that I felt that she was not capable of independent practice to Canadian community standards. She still got the job.

The point of all of this is that sometimes it is better not to have a doctor at all and deal with that problem than to have a doctor who is incompetent. This is not limited to specialists, an incompetent family doctor can hurt rather than help a community. The resources needed to keep these small operating rooms operating could be more efficiently used opening more rooms in larger centres. Residents of rural areas want access to health care which is understandable; what they fail to realize is that by keeping access to less than competent care they are preventing themselves and unfortunately others from accessing competent care.

Into the Maw of the Insurance Industry

I have been fortunate not to have been involved in any motor vehicle accidents of significance. I have had lots of car stereos stolen back when car stereos were stolen but have for the past 10 or so years, just paid my premiums.

Unfortunately this summer while at work and fortunately not doing anything, I got a call from my wife who had been T-boned at a stop light. I dropped everything and raced over there forgetting of course my wallet which had the automobile association card to find our beloved Volvo station wagon severely dented on the driver's side, airbags deployed. A few feet away was the Porsche Cayenne which had T-boned her.

The first thing the driver of the Porsche had said to my wife was," You ran the red light." (not something , like are you okay?) He was quickly corrected by the lady who had been in the next lane to him who informed him that the light had still been red in his direction when he decided to accelerate into the side of our car. On my arrival to the accident scene, I knocked on his window and asked for his insurance info and he told me to go away. All in all not a pleasant encounter.

But nobody was hurt, it was not our fault and we have insurance. Everything should be okay?

We got the address of a body shop recommended by the Volvo dealer and had the car towed there. I drove back to work, my wife got a ride home with the police (after they charged the other driver).

I am less patient and perhaps have unrealistic ideas of how long it should take to fix things but as a month passed I began to wonder why our car wasn't ready. Don't worry said my wife, these things take time. Six weeks passed and our car wasn't ready. We had rented a Kia Rio to get around town plus we had our third car so we weren't greatly inconvenienced? September came and we went off on a vacation to Europe fully expecting to have our car back when we returned. It was now getting close to 3 months.

A couple of days into our European vacation, we came back to our hotel to find a text message from our son. Our other Volvo (S-40) which was parked on the street due to work on our sidewalks which had made our driveway inaccessible had been spray painted and the window had been smashed along with every other car on our street. We sighed, told him to secure it as best he could, remove all the valuables and we would take care of it when we got back. No worry, we have insurance.

Arriving back a week or so later, my wife drove our spray painted car to the body shop where our other car was hopefully fixed and ready to come home. It was then that the body shop told us that it would be two weeks before our first car would be ready and that the reason for this was that the insurance company was questioning every single repair. Because Volvo parts are expensive and have to come from Sweden, body shops don't like ordering them if they aren't going to get paid for them. That meant that after the insurance company approved the repair, there was a one week wait for the part and this happened more than once. The adjudicator on our case was apparently a notorious hardass hated throughout the body shop community.

I decided that it was time to have a little talk with our insurance company. This required multiple minutes on hold, redials after being disconnected, explaining my case over and over again etc. Finally I left a message with our adjuster, saying if I didn't get a reply within an hour, I would be changing insurance companies. 55 minutes later I got a call back, "You seem to be upset about something", she said. Meanwhile I learned that our second car was being adjudicated by the some adjudicator. I asked the company if they minded assigning someone else which they eventually did.

We still had one car in the body shop. This car only had some spray paint on it, smashed windows and a dent in the door. After about two weeks I phoned the body shop to ask why it wasn't ready. "We are still waiting for the insurance company to approve the repairs", was the answer. Adjudicator #2 on his initial assessment missed a whole bunch of stuff that also had to be fixed. Back on the phone to our adjuster whose phone number I had now memorized. "I don't know what you are so upset about, " she said, "90% of the time we miss something the first time we check out a car."

We now have both cars back. I looked at changing insurance companies but decided that it was too much of a hassle plus as our insurance is a group rate through the medical association, we would probably pay more although, I wonder whether paying more might have been worth it.

Eventually we got back both our cars.

As an aside the kids who vandalized our car got caught. It turned out they were 15 year olds from the adjacent (richer than our) neighbourhood. About a month after the vandalization, I got a knock on my door one Saturday evening. There was a plain clothes policeman on our porch. "I have a letter of apology from one of the kids," he said, and produced a type-written unsigned letter. I read it briefly. We apologize a lot in Canada so I have heard or read a lot of apologies and this one covered all the bases. I asked my friendly policeman if the apology came with the $500 deductable I was going to have to pay, and if maybe I could also get an apology from the parents who didn't know what their kids were doing a 3 in the morning and also how could kids vandalize 100 cars without the police being aware of it? He didn't really have a good answer for any of that. I didn't ask him, but wondered whether if it had been a 15 year old from a worse neighbourhood, a plainclothes officer would have hand-delivered an apology?