No More Free Lunch

About a year ago, our administration banned what are known as drug lunches.

Anaesthesia who use a very limited menu of drugs, most of them now generic or with no real competition probably misses out on Big Pharma's largess and hospitality compared with other specialties.  We did however get the odd free lunch.

When BMS (Pentaspan) and Fresenius-Kabi (Voluven) were involved in colloid wars both reps brought very nice lunches to the OR lounge once a month or.  They were very tasty and we only had to listen to one company tell us how bad the other's product was.  Personally I didn't think clinically there was much difference, Voluven was easier to spike plus you could inject stuff in the bag so I used it.  When BMS showed the white flag, the Voluven guy kept on showing up with delicious lunches although he was now only competing with normal saline and Ringer's lactate. We also had Abbott, who market Sevoflurane.   The only competition with Sevoflurane is Desflurane which I also use but because we do a lot of cases with laryngeal masks at our hospital we use a lot of Sevoflurane.  There is a generic Sevo, coming up and while we are eating our lunches, the rep makes sure we are cognizant of the drawbacks of the potential generic competitor.

I appreciate the lunches, although I always eat too much and am sluggish during the afternoon.  From my point of view, they are a waste of time for the rep.  What colloid we get or what type of Sevoflurane we get is decided by someone in a room far away, who has never been near an OR and probably thinks Sevoflurane is a dietary supplement.  If I hang up a bag of Voluven instead of Ringer's Lactate it is because I think it is going to be better in the situation I am in.  The whole crystalloid-colloid thing bores me.  I earn a good living, I can afford to buy lunch.  I usually bring it from home.   I shouldn't be bothered by banning drug lunches.

Except.......

Our hospital does a lot of total joints and orthopedic trauma.  This means that everyday we have reps from the orthopedic hardware companies sitting in our lounge, walking around the OR and directing the nurses and surgeons in installing their expensive products.  The hospital even lets them park in the doctor's parking lot and gives them lockers.  There are at least 5 of them and assuming they all earn $100,000 a year, that's half a million dollars worth of sales force hanging out in our OR.  Do you think the companies that employ them are going to tell them to tell the surgeon to implant the most cost-effective hardware ?  That's why, instead of the old Moore's prosthesis which cost $300, people who haven't walked in years are getting the modular Moore at considerable extra cost.  This isn't enough, we are know doing total hip replacements in 90 year olds with broken hips.  The old DHS is of historical interest, everybody now gets a gamma nail.

And of course every OR committee meeting we hear about how many millions over budget we are, mostly due to the cost of orthopedic hardware.  But the real problem is that once a month or so anaesthesia  (used to) gets a free lunch!

Hi, I'm one of those guys who puts people to sleep

The medical mission I work with, has a dinner and silent auction every year to raise money.  We hire a local celebrity/ radio weatherman /newspaper columnist.  He is pretty funny and has some pretty coarse jokes.  I almost peed myself a couple of times.  And he mentioned us in his newspaper column.  Not at the top mind you but a little ways down.  And of course any publicity is good publicity.

In his column he says (bold type is my emphasis):

"On January 31st, some 50 volunteers from our city, including surgeons, dentists, those guys who put people to sleep (I can't say or spell the word), O.R. and recovery room nurses and other assistants, will once again travel to South America carrying hundreds of pounds of medical supplies in hockey bags."

Part of this is of course our fault.  We had to choose one of the more unpronounceable specialty names in medicine.  Otolaryngology is close but they had the sense to shorten it to ENT.

Anaesthesiology is 7 syllables.  "Those guys who put people to sleep" is only 8 and all in English and pretty easy to spell even for a Sun* Columnist.  TGWPPTS for short?

A few (actually many now) years ago the anaesthesia department at the C of E decided it needed an image change and was looking for a new name.  I suggested the Department of Patient Centred Wellness which for some reason wasn't accepted but they did change their name to the Department of Anaesthesiology and Pain Medicine.

A few years ago (okay many years ago) I did a mischievous thing to a patient.  He asked me how much training I needed to become an anaesthesiologist.  I said, "Grade 11" and put him to sleep seconds later.  He may still believe this.

But we all had a good time and raised lots of money.

* My son's Cub pack toured the Sun newspaper factory and my son asked me why we didn't read the Sun.  I told him only stupid people read the Sun.

Bullying

There has been a lot of attention to the issue of bullying in Canada after this video was posted followed shortly after by the poor teenager taking her life. The video is quite long but you really should watch it to the end.  She obviously made some poor choices but nobody deserves to be put in a place where taking one's life is the only way out.  This has resulted in more action than I can remember ever happening in response to bullying.  The provincial premier has commented and there is talking of new anti-bullying laws.  The police are investigating aspects of the case and the vigilante group Anonymous has posted on line the name and address of the alleged harasser.

As a serial victim of bullying, I am following this with interest.  As a child I was fat, not good at sports, I stuttered and I got good marks, which made me a natural target.  Moreover, my parents instilled in me that fighting was wrong, so I never fought back.  I certainly not the only child bullied at my school; as Ralphie in A Christmas Story observed society was divided into bullies, toadies and the bullied.
This was accepted as part of the natural order of things as a child.  There was always somebody weaker than you to whom you could be a bully or the toady to a bully.  Bullying could be physical or was often psychological, teasing and excluding from activities.

When I took ethology (animal behaviour) in university, it all made sense.  Human as everybody, except Republicans, know are primates.  Most of the higher primates have strong pecking orders with one dominant male and female; the rest of the tribe neatly ordered each one dominant over the one below.  We are possibly more intelligent than our chimpanzee and gorilla cousins and have evolved a more complex society.  The pecking orders still exist in the smaller divisions of our society and especially in our children and adolescents.  Bullying is unfortunately just the manifestation of our baser primate dominant-submissive relationships.  That doesn't necessary condone it, but it does explain it.  Much bullying goes beyond what is necessary for our inner primate and many of our natural alpha males and females live their life without having having to bully at all.

Anyway most of us down the dominance chain, learned our place we stayed out of the way of the bullies, toadied when necessary and that was how we survived childhood and adolescence.  In junior high and high school with more of us, we were able to form cliques where those of us in the lower or less high social stratas grouped in order to mutually shelter us from the alpha males and females.  These cliques often had their own social strata.

Teachers were often bullies themselves and quite often enabled bullies.  I remember in junior high, one of the track stars punched a projector nerd in the face.  Normally that would have resulted in a suspension from school, but that would have hurt our school's chance of winning the city track meet.  Therefore the principal announced that while what the track star had done was wrong, the service to the school he provided by running fast mitigated his crime.  (Our school didn't win the city championship that year....karma?).  There was also in our school a young man who was hated universally by both teachers and students.  I'm not sure why we all hated him; he was short and a little mouthy but that is hardly a reason.  I wonder now if his mouthiness wasn't just his way of dealing with how we dealt with him.  He moved away after a year.

Quite a while ago our high school class had it's 25th year reunion.  I was talking to the guy who organized the reunion and he was telling me about a friend of mine from high school who didn't come to reunion.  My old friend is now a professor at the local university.  When the organizer phoned the professor up to invite him to the reunion, the professor angrily told him never to try contacting him again.  A few years later, I was having beers with another friend I have known since Grade 5 and told him that story.  "Do you not remember," said my friend, "how badly all of us were treated in high school?"  I obviously had never thought this over or was perhaps more accepting of my place in society.

University seemed a reprieve from the whole tribal culture.  UBC where I went was not a big jock school, most of us were pretty ordinary nerds.  (I told my kids that Revenge of the Nerds is loosely based on my career but it really wasn't like that much)  What bullying went on in University was more of the psychological type.  There was of course hazing in the residence where I lived but this was fairly benign and we thought that this was something that brought us together as a tribe. Residence life was in some ways quite tribal but in a nicer way if you were prepared to accept that ways of the tribe. I never thought about how people who didn't want to accept the ways of the tribe lived.   Some professors and lab instructors were bullies but we worked around them.

Eventually I went to medical school.  I remember our first day, the Dean standing in front of us, telling us all how special we all were and how we were finally joining the exclusive brotherhood of medicine.  I had no idea I was about to enter a world of bullying worse than the worst high school, lasting 9 years (with a three year break for general practice).  Bullying and intimidation were the mainstays of teaching and patient care in that time.  This came from the super-competitive other students, professors, residents and nurses.  We sometimes got a sense of joy and relief watching another student being humiliated at rounds or teaching sessions; we all knew it could (and would) easily be us on the hot seat.  5 years ago we had our 25th reunion.  I always thought we had a really close class but even though the reunion was in Vancouver where a lot of the class had ended up, only 50 of 90 graduates attended.  I was astounded that people wouldn't at least come to part of an event that was taking place in their home town but then I realized that medical school may not have been the nicest time for many of them and that it may have been some of their classmates who contributed to that experience.

Internship and residency wasn't much better except that we now had medical students to pick on and as we got higher up the chain more lower level residents to deal with.  In fact the knowledge that we were now doctors and were getting paid to do what we did served to turn up the heat.  Anaesthesia was a little less hierarchical  (an internal medicine residents was amazed that as a senior resident, I took the same amount of call as the junior residents);  we only had to deal with OR nurses, staffmen and surgeons.  And, of course to remind us of what we were missing, 6 months of internal medicine.

I remember telling someone about what medical school and residency was like.  She was incredulous, "Aren't doctors caring, compassionate people?"  she asked.

Great Zs has blogged about bullying in training programs

The culture of bullying and intimidation never really ended with becoming a consultant.  I still think of the culture of blame I lived through at the Centre of Excellence.  If things have improved for me, it is merely that I am so close to being an alpha male, as to be immune to all but the most malignant bullies.  One of the problems with the whole culture of intimidation which still exists in medicine is that sometimes the only way to get anything done in a timely or reliable fashion is to go into bully mode yourself.   A medical school classmate of mine now a urologist observed a few years ago while we were drinking beers, that he likes to have the staff "slightly" afraid of him.  I was a little shocked but could sort of see where he was coming from. So many bullies in medicine bully to their advantage and quite a few of them have moved themselves into a position that no matter how much the hospital talks about respect and anti-intimidation measures, you know they are never going to be called onto the carpet.

I should have a snappy conclusion to this but I don't.   I am not sure what I went through or what others went through is as bad as it is today.  I am not sure how getting a wedgy relates  to having your boobs displayed on Facebook.  Thinking back about the school and playground bullying and the workplace bullying I experienced, it is hard to imagine having been able to tolerate the workplace bullying without having first had to deal with the play ground bullying.  Dare I say, it built character?  Bullying is in our nature, we can pass laws, hold workshops,  education campaigns and all we are going to do is shift the method of bullying.

We are after all just apes.

The Distracted Anaesthesiologist

The program director of our residency program who isn't given to long emails copied all the Site Chiefs on this long edict to the residents.  My comments are in normal text.

To all residents:

I have received numerous complaints from surgeons over the past year about anesthesia residents reading in the OR.  Typically these complaints come after a surgeon has had difficulty attracting a resident’s attention during the case, however, some have also noticed the increased use of iPads and iPhones during cases.  Please remember that the department and program policies are that residents should focus 100% on the patient and procedure.  Obviously if the staff is also in the OR and has requested that the resident read something that is different.  However, when your staff is absent you need to focus 100% on the patient and case! 

You may ask what about the staff?  There are many examples in the city of anesthesiologists doing things such as talking on the phone, wandering outside the OR, reading, working on their computers, reading the newspaper etc.    Three points here.  (1) You are not a staff who has spent years honing the ability to multitask and can respond to the surgeon’s requests even if concentrating on other things this related to the 10000 thing (2) All research done in multitasking demonstrates decreased effectiveness on all tasks.  Sure total productivity increases, but your ability to focus on the patient is decreased.  (3) Numerous adverse events have occurred in this city when the anesthesiologist was tied up away from the anesthesia work area.  Some of these have resulted in patients with permanent brain injury and/or death.  The CMPA considers it indefensible when the anesthesiologist is away from his/her work area. I can’t imagine how the hospital lawyers [who don’t work for you, ask me if you want to know more].   Lawsuits as a resident are bad.  Jail time is worse and can result in inability to obtain full licensure (yes, I have a case report of an anesthesiologist going to jail for being on the phone – 1995, Appeal File 6579, appealing ruling on file number QBCNJ148/93 J.C. Regina )

Note, I am not aware of any such incidents in our city.  The case where the anaesthesiologist went to jail involved him leaving the room to make a phone call, something that is a little worse (or just as bad depending on your outlook) than talking on the phone, texting or reading while in the room.)  Our PD doesn't define the work area.  Is the entire room the work area or is it just the triangle defined by the OR table, the machine and anaesthetic cart.

So, no matter what you see others do, no reading of any kind, even medical literature when you are looking after a patient on your own.  No iPad use, no texting or personal phone calls.  Place your cell phone on vibrate if you receive personal texts, emails or phone calls during the day and if there is an immediate personal concern ask for your staff to return.  You may answer your pager by cell phone if you in the anesthesia work area.   Please ask the nurse to answer your page.  If they give you sour looks just tell that that you have to focus on the patient and procedure.  As always, if you have issues with nursing or other ancillary staff, please inform me or the site chief of the hospital you are at.

Any questions?  I am happy to discuss this further.

Now obviously our program director must have gotten a real blast from some surgeons.  In my experience the only things surgeons really expect from anaesthesiologists or even have an interest in what we do are;

1. Get the patient asleep and awake as soon a possible.
2. Adjust the table and the lights.
3. Select music that they like at a volume that they like.
4. Know their place.
5. Realize that everything bad that happens to the patient is their fault.

I suspect most of the surgeon's angst is related to 1 and 2.  Anaesthesia residents are, as somebody else observed, expected to be able to work as fast and competently as a consultant within the first month of their residency as opposed to surgery residents who have five years (and the first two plus years of their consultant career) to get up to speed.  Unfortunately  they can't complain (actually they can and do)  about the extra 5 minutes the anaesthesia resident took putting in the art line when it takes their residents 20 minutes to close a 6 inch incision; ergo everything that went wrong today is because the resident was texting.   

Staff anaesthesiologists on the other hand at some point in their careers, not sure just when, develop an ability to  read, work on their lap-tops, book vacations,  and do complex negotiations over the phone while still monitoring their patients.  The fact is, there are a lot of things that are part of our job that distract us from vigilance.  These include charting, taking phone calls from recovery or the ward, getting ready for the next case, adjusting the table and the lights and teaching students.  Sometimes surgeons like to engage us in their conversation.  I've never heard a surgeon complain, "he laughed at my jokes."  When we are staring at the ceiling or out the window  because we are so bored, we probably aren't as vigilant.

We didn't have laptops, I phones or texting when I was a resident.  I did read a lot in the OR during long cases.  I usually carried at least one textbook, as well as journals, and some photocopied articles which I read during cases.  One day the staffman was reading Umberto Eco's "The Name of the Rose".  He went out for a break, telling me as he left,  "this is a really good book, you should read it.".  Which I did starting with the book he left in the room and I later bought it and read the whole book and my life is more richer for discovering Umberto Eco, than anything I learned during that craniotomy.  And I don't think the patient or the surgeon suffered.

Closing the book on my favourite bookstore

Appropriately for the times, I learned last week on Facebook that my favourite book store Greenwoods (I would post a link to the site but it will soon also be coming down so what's the point) is closing at the end of this week. According the owner, this is due to the sudden death of her co-owner brother but in some ways is due to the economics of the independent book store.

20 years ago when I moved here, I quickly discovered this bookstore.  At that time it anchored "The Avenue".  It was situated in a early 20th century brick building occupying the main floor and the basement.  It had a huge selection of books.  I like history and I usually headed straight down to the basement where the history section rarely leaving without buying something.  In the 1990s, it was usually packed on the Saturdays or Sundays where we usually visited.  It was at one point voted the best bookstore in Canada.

Time was not kind to Greenwoods.  In the late 1990s multiple Chapters outlets opened in the city including one down the street from them.  In 2001, their lease expired and they moved two blocks off the avenue into a smaller store in a strip mall.  Their old site was unable to find a tenant for at least two years after sitting empty like a missing tooth on The Avenue.  (This demonstrates the stupidity of the commercial real estate industry which would rather allow a building to sit empty than charge tenants a rent they can afford.)  In it's new location we visited much less frequently but still bought most of our books there.  Sometimes when I saw book I wanted based on a book review, I would order it from them.  A few times I even found a book in Chapters that I liked and got them to order it for me.

About a year ago, Greenwoods moved back to The Avenue into an old building albeit one smaller than their original building.  It seemed as if the universe had been restored.  Sadly the last time we were in, we noticed that there were hardly any books on the shelves.  My wife asked why and an employee said that one of the owners had died and everything was in limbo for a while.  And this week the other shoe dropped.

There are of course a number of reasons why the independent book stores are now going out of business.  These include the big box bookstores like Chapters (now Chapters-Indigo having merged with another big box bookstore).  I have never liked Chapters; I feel that they regard books as a commodity rather than as something worthy of reverence.  On-line sellers like Amazon have played a role and I am guilty of ordering books from Amazon or Chapters-Indigo on-line, something I justify because I usually use gift cards I get for completing on-line marketing surveys.  I even buy books from Costco.  E-books have been blamed and there may be some truth to this.  E-books of course can't safely be taken to the beach or read in the bath (something I have never done), plus of course a book doesn't need batteries or adapters when travelling, plus you can sit or step on a book without damaging it much.  It has been suggested on the other hand that things like cheap books from Big Box stores, on-line and e books may actually make books more accessible.  I certainly get the impression that people read less, there are 100 TV channels, movies for rent, video games and the internet  (where I am wasting time right now when I could be reading a book).

I have developed a relationship with books that may border on pathological.  I grew up in the 1960s in a 3 fuzzy black and white channel universe, and where it seemed to rain a lot which meant I remembered reading a lot.  My mother read to us every afternoon before I went to school but on completing Grade I, she told me that I now knew how to read and she would not longer read to me any more.  I embraced books enthusiastically.  A visit to the Public Library was a weekly event in our family.  I read through Enid Blyton and the Hardy Boys plus heavier fare.  My teachers always allowed us to read from the class library when we finished our classwork, this lead me to complete my work quickly so that I could have 10-15 minutes reading a book from the back of the classroom.  A good book has gotten me through many rainy days, waits and long journeys.

Our house was filled with books.  At that time if you joined the Book of the Month club, you got 4-5 free books if you agreed to buy a certain number.  My father had this scam figured out. If you bought the minimum number of books then quit, the average price per book would be quite low.  He would then rejoin either under his own name or under one of our names.  We acquired a considerable home library in that fashion, supplemented by paperbacks my parents bought a church rummage sales.  My father has, of course, never thrown away a book, although I notice every time I visit he is now trying to pawn 2-3 off on me.

I first learned the charm of book stores as a teenager visiting Munro's then located across the street from the Public Library.  I spent many hours browsing and not buying much there.  Munro's now sits in a magnificent restored bank building in the heart of the tourist district and I can never visit Victoria without visiting (and usually buying a book).  There is just the charm of seeing a book that might interest me, picking it up, flipping through the pages, looking at the illustrations, putting it down and moving on to the next book.  Something I can spend hours on.  Every city it seemed had it's own favourite book store like  Duthies in Vancouver (now gone for many years), and Greenwoods in Edmonton, newly deceased.  A visit to a book store is often one of the first things I do on visiting a new city.  Sometimes a book is a souvenir of where I have been like the History of Poland, I bought in the English language book store in Warsaw (and still haven't got around to reading yet).

Used book stores, I have never really gotten an appreciation for.  To me they appear sad places, almost orphanages of unwanted books, the hard covers bravely trying to look new in their wrinkled dust jackets.  I sometimes bring books I no longer want to our local used book store.  When going on a long journey I often buy used paper backs which I shed as I finish them.

So many things I had come to accept as being there have gone, favourite restaurants, stores and coffee shops.  I adapt, I go elsewhere develop new favourites, new interests.   We are fortunate to have another very good independent book store whose life may be prolonged by the death of its independent competitor. I will go there and after a few visits won't feel dirty or unfaithful.