Cosmetics

This fellow runs a cosmetic practice.

He has billboards all over the city. He also advertises in the local papers.

This past weekend our local paper ran a "puff-piece" on him. A local columnist went in to get some cosmetic injections and wrote and article on him. As is often the case, the column started on the front page of the section and continued on to another page. Flipping through the pages to get to the rest of the article, it was impossible not to come across an advertisement for his clinic featuring a picture of his naked wife (with the naughty bits covered up of course).

This fellow and his ads have bothered me for some time.

The main reason is that while I don't know the exact stats; more people apply to medical school than are actually accepted. Therefore in order for him to practise exclusively as a cosmetic "specialist" somebody else didn't get to be a doctor. Now I am sure when he was interviewed for medical school he probably told them that his ambition was to practise cosmetic medicine in a large urban centre and not have to take call or look after sick people. NOT!!!

Secondly, while medical students do pay tuition in the 5 figure range, this apparently covers less than 20% of the cost of their training. So the taxpayers of the province, many of whom no longer have a family doctor paid for his training.

But what about plastic surgeons?

I have the utmost respect for plastic surgeons and not just because I wish they would hire me for one of their private suites. While there are some plastic surgeons who practise exclusively cosmetic surgery, most of them don't. They take time out form making women's boobs bigger to look after burn patients, repair tendons and reconstruct faces. They take call and work nights and weekends unlike Dr. Singh.

Bar Codes

A while ago I posted about the new infusion pumps we have which are supposed to make life safer for the patient and more difficult for the caregivers.

I was in the hospital today and my chief said to me, "Here I've got something in my locker for you". He pulled out a hospital ID with my 10+ year old photo on it. At first I thought it was the ID I lost. It was in fact my "Smart Pump Bar Code ID".

Now in order to prevent well or ill meaning visitors from reprogramming the pump, your ID has to be scanned every time you reprogram the pump. This of course presents a problem when your ID is in your car. Fortunately a resident told me how your bypass this. All you have to do she told me was scan the bar code on the kleenex boxes we have in the OR and the pump will open its heart to you.

Which is what I did the other night with patient from the ICU on the levophed infusion which I felt I had to adjust up and down throughout the case. The kleenex box worked just fine.

Now that I have a proper bar coded ID, I won't need to use the kleenex box. Until I lose the ID.

I survived the public school system

Or rather I survived my children's time in the public school system.

Yesterday my youngest son graduated. There is still a month and a half left in the school year so technically he hasn't graduated (I looked at the "diploma" he got yesterday and it only acknowledges he was a member of the graduating class of 2009).

I only have two children. At some point we agreed we only would have 2 children (my wife's family fires off twins and 3 could become 4) and I got a vasectomy. My wife said to me last night words to the effect that we should have had another, I'm not ready for this by which she meant I'm not ready to be a mother with two children out of school.

Not me however, this was a moment I have been waiting for for years.

I hated elementary, junior high and high school. I liked university but I think that was because I liked the drinking and partying. Between my two kids I have just finished 15 straight years of school. I have had to go to parent teacher interviews, Christmas and year end concerts, band concerts, open houses and sports events. I have had to "help" my kids do homework, nag them to practise, phone teachers and principals. I am so ready to finally graduate.

High school graduation has become a much bigger event than I remember. My kids have fortunately been fairly low key and aside from buying the graduation suit that they will only wear twice in their life, we haven't had to spring for limos and the accessories people now believe is necessary. The big fuss is despite that fact that high school graduation has become the minimum ante for entry into mainstream society. Most kids, at least in our socio-economic group have not seen their last classroom.

It was a very pleasant if somewhat long graduation ceremony. There were something like 500 graduates. The band cycled thru "Hope and Glory" I don't know how many times as they all filed in. You could see the conductor frequently looking to his side, thinking when is this over. The grads received their diplomas in three batches with entertainment between each group. It was an elaborately choreographed ceremony. Most of the presenters and the valedictorian were extremely poised individuals. The quality of the entertainment all by graduating students was surprisingly good.

All the grads wore gowns. I of course graduated from university and have never completely approved of gowns for high school graduations. I realized that the one of advantage was that it leveled everything off. All the grads walked across the stage wearing the same black baggy gown. (It also allowed some of the girls to wear fairly risque dresses that they might not have wanted to parade across the stage in.)

The most interesting thing in high school graduation ceremonies is seeing how kids and parents you knew years ago have changed. Many of the kids the graduation class, we knew from elementary school or from hockey but haven't seen them or their parents for years. It was a big of a shock seeing the bratty kid you knew from hockey as a grown man. More impressive was how much some of their parents had aged or expanded in girth. That made me feel pretty good about how I look.

I thought back to my own high school graduation. My parents always expected me to go to university so high school graduation was a minor formality for them. Graduation at our high school was unfortunately to most students about the drunken party afterwards rather than any solemn sense of life progression. We sat in bleachers in the gymnasium on a Friday night for a fairly brief ceremony with minimal speeches. We didn't wear gowns so the men wore a medley of suits, sports jackets or rented tuxes. This was of course in the 1970s so you can imagine just how ghastly everybody looked.

Our student council seemed more preoccupied on the drunken party to be held afterwards than having a ceremony that people might remember, something to send everybody off into world. While I went on to university, many of my circle didn't and the end of grade 12 was the last time I saw certain people until the 10th reunion and some I have never seen since.

Anyway after the tame Friday night dance sponsored by the school, there was the after grad held on Saturday night. The student council was even able to get a liquor licence until the principal found out and got it cancelled. My friends and I arrived to find the curling rink where the party was held surrounded by a phalanx of policemen. Somebody decided we should try to hide the beer we naively thought we could smuggle in, outside the rink so we could at least go outside for a beer. A cop saw us headed off and followed us to relieve us of our beer. He didn't dump it out in front of us so I assume he and his buddies drank it later. The whole thing was pretty boring and I walked home at 2 in the morning.

All in all I think I preferred my son's graduation.

Observe and Report

I feel sorry for most security guards. They don't get paid well, they have to wear funny uniforms and people shit on them. Plus they are never going to be police officers.

On the other hand, they for the most part work indoors, there is no lifting, they get to make people's lives less pleasant and they get to wear a uniform. The pay is not great but no-one is lining up to employ the typical security guard type.

Which brings me to my latest brush with hospital security.

We have hospital ID cards which we are supposed to wear all the time. These cards also enable us to get into the doctor's parking lot. At night we need them to get into the hospital thru the ER.

I have never gotten into the habit of wearing a hospital ID. I like to leave mine in my car so that I will be able to get into the parking lot when I need to. But then I usually walk or bike to work which means that my hospital ID is sitting in my car at home or wherever my wife has gone with my car. When I have to go to the hospital after hours, it is because I am on call and I always drive. This is how I have lived my life for several years.

For various reasons my hospital ID left its safe home in my car ; my wife using my car to drive to work, having to get into the hospital afterhours etc, etc. The result was that my hospital ID disappeared.

That is why a couple of weeks ago I had to head over to the parking office to pick up a new ID. The parking office is normally run by a nice English lady who is a huge Who fan judging by the photos on her bulletin board. She wasn't there that day but 2 security guards were. Now one of course could have been on his break and just wanted to keep the other one company but I did wonder why there needed to be two there. I explained that I needed a new ID. The alpha guard told me it would be $10.00. Just to jerk his chain, I pointed out that that I had just finished paying $800 to park for the year (remember I walk or ride most of the time but I need to park when I am on call). He said that the ID wasn't for parking (I guess that's why I had to go to the parking office to get it). Needing to establish his alpha male status in the room, he lectured me on why I hadn't reported my hospital ID missing immediately on noticing it was missing so they could deactivate it. Sure like all kinds on wrongdoers are just waiting to use my hospital ID to get into the hospital.

Anyway he made a new ID (using the picture taken over 10 years ago) and asked for $10. I whipped out my Visa and he tried to run it through the machine and of course couldn't get the machine to work. Major loss of face! I had about $100 in cash in my wallet but after the little lecture I wasn't about to let him off the hook and said, "I guess this pass is on the house" and left to room with my new pass.

Now while I do feel sorry for the individual security guard with his low pay and ill-fitting uniform I have a fair bit of contempt for the whole security apparatus in the hospital. The past twenty years have seen major shrinkage in hospital personnel and we are trying to do more with fewer bodies. The one exception is security whose numbers in most hospitals have exploded. But does this make us more safe? Despite all these individuals in uniform hospitals are more and more closed off. Rooms are locked that weren't locked before. To get into the emergency from INSIDE the hospital requires ID. Over a year ago I posted about a stalker that got into the OR . The thing was; the CofE had a lot of security around, sociopaths know how to circumvent security.

I remember years ago when you had a confused patient, a "special" nurse was brought in to keep the patient company. Often the family paid extra for this or it was covered thru their extended medical. Frequently the nurse was provided because that was the right thing to do. This of course was expensive; one on one nursing usually getting paid overtime. Nowadays a security guard sits with the patient. The first time I saw this I was astounded. Now this is cost effective. Someone who is barely getting minimum wage vs nurse getting overtime. Imagine however grandpas first glimpse of lucidity is the sight of someone wearing a uniform. The securitization of medicine has gone further. In Kamloops BC a confused patient was actually tasered.

Are we getting stupider?

Two recent cases have lead me to believe that the medical profession as a whole is getting stupider rather than smarter.

I got a phone call from an acquaintance a few months ago asking if I could intervene with X-ray. I explained to him that I had absolutely no clout with X-ray but asked him what the problem was to see if I could help in some other way.

His father-in-law as part of a check up had a PSA done which was elevated. He was referred to a urologist who sent him for an ultrasound guided biopsy. This unfortunately could not be done for 3 months and his father-in-law was very upset about being eaten away by cancer while he waited.

I told him, don't worry.... PSA is a very non-specific test, prostatic cancer is slow growing and I am sure your urologist did a rectal exam so if there is cancer it is very small if he couldn't feel it.

Turns out his urologist didn't do a rectal exam!!!!. This is not some elderly urologist eking out a living to pay off his first wife or his bad investments. This is the program director of our urology residency program.

One of the few things I remember from medical school is urologists imploring us to stick our fingers up people's bums. "The worlds greatest cancer detector" they would call their index finger. "You don't put your finger in it, you put your foot in it".

Anyway I advised my friend to ask X-ray to phone his father-in-law in the event of a cancellation which they did and the biopsy was negative.

The second case was related to me by two colleagues who were equally disgusted.

These lucky individuals work in a private dental suite. (Taking wisdom teeth out of healthy people pays a whole lot more than doing ?necessary surgery on sick people.) One day the dentist wasn't feeling well; he was nauseated and had pain in the right lower quadrant. One of my colleagues examined him and told him he might have appendicitis and told him to go to the ER.

After waiting in the ER he was seen by an ER doctor who may or may not have examined him before trying to do an ultrasound of the abdomen. Unfortunately the dentist was in two much pain to be able to press down on the ultrasound probe so they weren't able to do the exam. (I believe this is a sign of peritonitis but then again I am only an anaesthesiologist). So the unfortunate dentist was send back to the waiting room to get a CT. Only after the CT was positive was surgery consulted and he was relieved of his appendix. Surgery was not consulted until after the CT.

Now I am not much of a Luddite and I appreciate the use of diagnostic tests but the bottom line is that as physicians we talk to patients and examine them and then order the relevant tests. The means sticking your finger up peoples bums (and that is one major reason I went into anaesthesiology). It also means that when you have a diagnosis like appendicitis which was first described in the nineteenth century, has a classic presentation and has been diagnosed fairly reliably by surgeons using only history, physical exam and a white blood count for years, why would you subject a patient to two unnecessary exams and delay his treatment when the presentation is so obvious that an anaesthesiologist for god's sake was able to make the diagnosis?

We all complain about ER overcrowding, and waits for diagnostic testing but how much of this is now because we as a profession have become so stupid and helpless?

As an aside, I used to belong to a discussion group on pain and chemical dependency. Some of the doctors on the group were being hassled by the DEA or licencing bodies which I think is unfortunate. One doctor actually complained that he had been criminally charged after a DEA agent came to his office "wearing a wire". I had to jump in and I asked why he didn't ask the agent to take off his shirt and examine him. The doctor replied, "why would I examine someone with a perfectly good MRI?" and several other people jumped to his defence.

Bad Work Habits 2

I read during cases

Now last year I interviewed propective anaesthesia residents (I did this year too). We ask them all kinds of stupid questions that have nothing to do with their suitability to safely deliver an anaesthetic in 5 years time but are more geared towards, can we not stand this person at all or do we like him just a little more than the others. Anyway one of the questions somebody else asked dealt with how you deal with long cases. The prospective resident answered something about this is a good time to bring the laptop into the room. When we discussed this poor fellow at lunch, the program director promptly stated, "well he is not getting a residency in our department." I looked at another interviewer who I know also reads during cases and we rolled our eyes. I feel sorry for the program director who has to wittle 50 applicants down to a short list for 5 positions but....

I read during cases, I frequently bring in my laptop, I write letters and I make a powerpoints. I have written several published book reviews and one CME article for an anaesthetic journal and I largely have done these while a patient was under anaesthetic. I don't just restrict my reading to anaesthesia and pain material. I read the newspaper, occasionaly books and magazines.

I am not sure where I fall safety wise in the anaesthesia community. I think I am around the middle. I know that obsessive-compulsive-wise I fall near the bottom (We had a very OC anaes. at the Cof E named Gray, the residents and nurses called me "the Anti-Gray"). I am not ashamed of this, I am rather proud. Over the years I have had the odd patient who didn't do well, I have made mistakes which hurt patients one of which I blogged about on this blog. One thing I can say is that I have never hurt a patient by reading or innattention. In fact some of my near misses have been while teaching residents and medical students. While I would like to, I am not going to (and cannot) stop teaching them.

Anaesthesia is for the most part boring, this used to frustrate me until I realized what the option to boredom was. Reading keeps me alert, the sheer guilt of reading forces me to look at the monitor more regularily, and keep the chart up to date. This is rationalizing I know; I stand guilty.

Reflecting on My Sexual Harrassment Complaint

Since coming clean I have had some time to reflect on the whole mess.

Was I actually in the wrong here?

The answer is of course yes to a certain extent. I really shouldn't have been so sarcastic on the phone. I was a little irked at what I thought was an inappropriate consult at an inappropriate time. I still had a grudge against the burn unit which is where the call came from.

It could be argued that I should have come over and seen the patient. I was after all just across the street. Fact is, I really thought that ordering PCA in a trached and ventilated patient (probably already getting a fentanyl infusion) was safe if not completely necessary. This was what I had been doing for over 10 years. If our group had said, "we think every such consult request should be dealt with in person" and I knew everybody was making these evening trips back to the hospital I would have done the same.

But was this sexual harassment?

I don't think so. It was just the whole concept that because this complaint has been filed as a sexual harassment rather than a clinical concern that there is no possibility of successfully defending myself, bothered me.

Just had to get that off my chest.

Oh and by the way, after I left the CofE, their residency program was placed on the highest level of probation for....ongoing sexual harassment of female residents. Karma?