Work-life balance

This is an interesting perspective.  Just for your reading pleasure.  Maybe I will comment on it sometime later.

Opioids, a personal journey

I found this article on Kevin MD

20 or so years ago I started treating chronic pain in a University Pain Clinic.  Actually it was just me and the Day Ward nurse who drew the short straw in a corner of the Day Ward that nobody else wanted to use but we called it a pain clinic.  I like to bore people by telling them how we used to treat patients with chronic pain in those days.  I basically had 3 tools:  needles, amitryptiline and carbamazepine.

Needles actually worked in more patients than should have been scientifically possible but didn't work in everybody.  Amitryptiline and carbamazepine work well in randomized double blind trials and in meta-analyses but work poorly in the real world  I started exploring other anti-depressants and anti-convulsants.  A patient brought me the article on the first case series of 9 patients treated with gabapentin and I still look on that moment as  a milestone in chronic pain management.  Gabapentin also only worked in a small fraction of patients.

I started sending patients to the hospital psychologist who, when she realized what was going on, rationed me to one patient a month; the physiotherapy department refused to see chronic pain patients.  Don't worry, I was told any time now we are going to get a big multidisciplinary pain clinic.  Fortunately I didn't hold my breath on that one.

Quite a few of the patients that came to the pain clinic were taking fairly substantial doses of narcotics.  In fact that was the primary reason for referral for most of them.  This was usually tylenol with 30 or 60 mg of codeine or tylenol with oxycodone.  There were the other standbys, talwin, darvin and fiorinal and quite a few patients were on injectable meperidine either thru their doctors office, the emergency department or some actually self-injected.

At this point I should back-track to what I knew about narcotics in chronic pain which was not very much.  I believe we had one lecture in medical school in first year.  This lecture was by someone  from the College of Pharmacists talking about prescription drug abuse.  I don't remember many lectures in medical school; I remember this one vividly if only because it was the first and last time I heard patients referred publicly as assholes.  Other than pharmacology we didn't get much teaching on how to order narcotics either in acute or chronic pain.  The use of narcotics in palliative care was only just starting.  During my first surgical rotation, the surgery resident told me how to write the post-op orders which consisted mostly of:  "Demerol 75-100 mg IM q3h PRN."  (I would like to think this has improved except I don't think is has, except that Demerol is hard to come by.)

When I started in general practice and covering the emergency it became apparent that a lot of patients had chronic pain.  Except we didn't call them chronic pain patients then, we called them addicts and drug seekers.  In the emergency quite a few docs didn't even bother seeing them.  "Oh so and so is here again," they would say as they wrote an order for the nurse to give 100 mg of Demerol.  Some GPs just phoned it in or left a standing order so they wouldn't have to come in from home in smaller hospitals where there wasn't on site coverage.  I remember in my first locums being alarmed at just how much narcotics and sedatives people were being prescribed.  Nobody told me about that in medical school.  To be sure, a lot of them were abusing their drugs.  There were stories about doctors being threatened by patients for not prescribing what they wanted.  I was never threatened but a friend of mine was by somebody just passing through town when my friend wouldn't prescribe the patient's choice of oral narcotic.  A lot of them however especially when you got to know them had legitimate pain problems, they had had multiple back surgeries or suffered from intractable migraines and while there was a lot of tut-tutting about their narcotic use, there wasn't a lot of effort being made to see if they could be helped in another way.

There were a lot of valid reasons why I fled general practice (like not being very good at it) but I have to think that seeing those patients day after day and night after night and knowing I really had nothing to offer them that pushed me just a little bit.

So it was that 7 or so years removed from general practice my opinion of narcotics in chronic pain both from   training and experience was pretty dim.  They were never appropriate and patients who used them inevitably became addicted which was a bad thing even if they did seem to help some people's pain.

The tide was changing.  Use of narcotics in palliative care had become accepted, it was noted that patients could tolerate high doses with reasonable function and long acting oral forms were  available freeing patients from injections.  Because nobody wanted to see chronic pain patients, a lot of palliative care physicians reluctantly saw these patients and used what they were familiar with which was long acting oral narcotics  And some patients actually got helped.  Around 1993 our provincial college (Medical Board) actually published guidelines on the use of narcotics in chronic pain.

In 1995 at the Canadian Pain Society Meeting, I first saw OxyContin advertised.  My experience with patients who were taking oxycodone/acetaminophen preparations in Canada, lead me to believe that the oxycodone molecule had some special properties that other opioids didn't have.  I remember telling the rep manning the booth that OxyContin was going to be huge drug.  Occasionally I am right about things.

I don't remember when I wrote my first long acting narcotic script.  It should have been a memorable experience but it wasn't.  I do know that it took two years for my to write my first 50 triplicate prescriptions and I was seeing a lot of patients in that era.  What I do remember is that when I wrote these prescriptions for people who had failed needles, amitryptiline, carbamazepine and even gabapentin, a significant number of patients actually seemed to improve.  It was actually fun seeing them for their follow-up visits because they were actually happy.  This wasn't everybody of course and many people who aren't satisfied with their treatment just don't show up for follow up visits.  (I always assumed they didn't show up because they were better but of course I know that usually isn't true.)  I got a methadone licence and started prescribing methadone with great gusto as well.

I started even feeling dirty when I did a block on somebody instead of whipping out my triplicate pad.

I started seeing people at meetings talking about their experiences treating chronic pain with opioids.  What I noticed was that they presented the same small group of cases again and again as if this was maybe their only success.  It didn't matter, I drank their Kool-aide; after all we had very little left to treat the majority of our chronic pain patients.  Pretty soon I got approached to start doing those talks locally.  I was still evangelical about pain and to Big Pharma's credit, I was never told what to say and while they provided slide kits, they never minded.when I modified their slides when I didn't agree with what the content.

The gospel my fellow travelers and I preached was:

1. You cannot be addicted to your pain meds if they are prescribed for legitimate pain.
2. There is no maximum dose of opioids.
3. Opioids are safe and there is no end-organ damage.
4. Opioids are efficacious in chronic pain.
5. Controlled release opioids are preferable to short-acting opioids.

You cannot be addicted to your pain meds if they are prescribed for legitimate pain.

This was a reaction against the conventional wisdom of the day which was you would always become addicted to your opioids.  The answer was somewhere in between that.  Addiction unfortunately is not a black and white condition.  It is difficult to find any definition that doesn't have a lot of "yes buts".  The most extreme people defined anybody who took opioids for more than a day as addicted.  We took the opposite.  Many of the signs traditional attributed to  opioid mis-use like dose escalation, double doctoring, buying meds, visiting the emergency room we excused as pseudo-addiction or a cry for help by the patient. 

 After a few years of wild prescribing some of us realized that yes, people could become addicted to their meds and the practice of universal precautions came into being whereby using various questionnaires and tools and urine drug screening we could pick out the high risk patients and deal with them.  Never mind that all these tools had huge false negative and false positive rates.  Therefore the little old lady with pain from compression fractures got the same UDT as the biker with back pain.  The biker of course knew how to beat urine drug screens.

Clearly people can have pain and still be addicted.  Some were already addicted when we saw them, some we introduced a drug they could be addicted to into their lives.

There is no maximum dose of opioids

This was preached by many of the pain specialists who started out in palliative care.  This was expanded by the concept of a therapeutic window for narcotics, whereby patients would get relief but only at the right dose.  If the patient came back and said he was getting no relief, the answer was more higher doses.  There is no denying that patients do develop a tolerance to their medications although this clearly does not seem to be a universal phenomenon.  

I remember watching two of the uber-disciples presenting a case (actually I saw this case presented 3 times) of a lady whose pain was only a control at doses of hydromorphone to the point where every second molecule in her blood must have been hydromorphone.

Of course because we all believed that patients couldn't get addicted when the patient phoned you up saying he had taken a month's worth of drugs in a week, you response was to up his dose.

Part of this came from chasing the patient's pain scores.  Unfortunately most chronic pain patients routinely report scores of 8 or 9/10.  This depressed me until instead of asking them what their score was, I started asking them whether they really felt that the drug was helping.  In a lot of cases it was and I stopped chasing the pain score.

Opioid hyperalgesia was something our palliative care colleagues had observed for some time and I still see this in many patients I see, usually other people's patients but sadly a few of my own. It is hard to tell them that the answer to their pain is less rather than more opioid.  Strangely many of my colleagues continue to disbelieve that this exists; some of them get out right hostile if you discuss it.

Opioids are safe and there is no end-organ damage.

Clearly while in the acute phase opioids can depress respiration causing death which doesn't really happen in tolerant patients (unless they take an accidental or intentional overdose combined with other CNS depressants) this seemed a fairly safe thing to say.  Certainly they weren't nephro and cardiotoxic like the NSAIDs or hepato-toxic like acetaminophen.   

But:

Narcotics do depress endocrine function.  This was actually known in the 1960s with heroin addicts but we rediscovered it when patients showed up asking for Viagra prescriptions and we measure their testosterone levels.  Low testosterone is fairly easy to treat, although treating it never seemed to help them much; women whose endocrine systems are way more complicated were very difficult to assess or treat and I never succeeded in getting an endocrinologist to take an interest in this.  

Methadone can prolong the QT interval leading to Toursades de Pointes.  I have seen about 5 cases of this. This is usually associated with anti-depressants most of which also prolong the QT and motility agents which likewise prolong the QT.  Cocaine use was a factor in at least one case.

Some studies are now showing grey matter changes in patients started on opioids.  Nobody knows what the significance of this is.

We tend to minimize constipation as a symptom but the odd patient develops an obstruction leading in some cases to a perforation.

Opioids can cause or exacerbate sleep apnea which a lot of chronic pain patients already have.

Nausea, constipation and sedation were minimized as side effects but usually require the prescription of medication to counteract the side effect, each with its own set of side effects and drug interactions.

Opioids are efficacious in chronic pain

There are lots of studies and meta-analyses which "prove" this to be true.  The only problem is that almost all of these studies were short-term studies and most of them had high drop-out rates because of side effects or lack of efficacy.  Almost all were Pharma sponsored but that of course is a problem not limited to opioid trials.  Clearly if we looked at the patients who told us that the drug wasn't working as we pushed the dose higher and higher or that simply just didn't come back for follow-up we knew that this wasn't universally the case.

Controlled release opioids are preferable to short-acting opioids.

Controlled release opioids were originally intended for palliative care patients as a convenience so that they wouldn't be taking meds every 3 hours.  They were introduced into chronic pain practice by palliative care physicians but took off like gang-busters in the chronic pain world.  This is despite lack of much evidence that they are really any better than short acting opioids which are cheaper and in many cases preferred by the patient either because they don't mind taking their meds every 3 hours or because they prefer to take them only when their pain is severe.  This is not to say that somebody taking 20-30 doses of acetaminophen/codeine or oxycodone per day is a good thing but there are pure short acting opioids available. 

We originally believed the the CR opioids were less prone to abuse.  OxyContin showed us this wasn't the case although we knew even before OxyContin that MS Contin could also be abused, it's street name was  "red peelers".  We also believed there was less tolerance if a CR opioid was used, without any evidence.

Patients told us otherwise, they frequently used CR Opioids as PRN meds or took them 3-6 times a day because that was what they said worked.  We didn't even trust the CR opioid that much ourselves, we always prescribed a short acting medication as breakthrough medication.  This was supposed to be for exacerbations but our patients more or less took as much as they were allowed (and when they wanted more, we gave them more because there was after all no maximum dose of opioid.)

Published guidelines supported (mandated) the use of controlled release opioids so if you prescribed short acting opioids because that was what seemed to work, you could face discipline.

Controlled release opioids were, of course, more expensive and less likely to be generic.

And so a new era in pain management began

With all this in mind my fellow pain specialists and I began prescribing with great gusto.  Many family docs who attended our talks also took this up.  Many of course steadfastly refused to have anything to do with what was supposed to be the future of pain management.  We knew they would eventually come around.  I acquired more colleagues who had done pain fellowships in the US and were versed in the gospel of oral narcotics.  They were for the most part against interventions so I began to feel guilty when I did a procedure.  Besides it was so much easier to whip out the old triplicate pad.

Even the local entrepreneurial physiatrist  with the "multi-disciplinary" pain clinicwho had previously preached against opioids got in on the act.  He realized that it was much more cost-effective to prescribe methadone than to have to pay for physiotherapists and  psychologists.

It became common to see patients on very large doses of OxyContin or another narcotic, usually with another short-acting agent for breakthrough, sometime two long acting opioids.

And then of course the shit hit the fan

I am of course referring to OxyContin.  As I mentioned above, when I first saw OxyContin at a meeting, I predicted it would be a huge drug.  As soon as it became available, it became my first-line opioid (it still is).  It seemed to have a lower side effect profile and better efficacy than the other opioids.  If I prescribed it, I knew I was less likely to get phone calls or unhappy patients.

Now it is not like there was no prescription drug abuse before OxyContin.  During my time in general practice we knew patients abused codeine products, dihyrocodone(DH) cough syrups, and Talwin among others. Even during the worst of the OxyContin "epidemic" of drug abuse, Tylenol with Codeine was as popular on the street as was OxyContin.  OxyContin was different from other pills in that much higher doses of narcotic were packed into each pill, as much as 80 mg.  And then there was the supply.

Being a sub-specialist I never was exposed to how OxyContin was marketed at the primary care level.  I did however give a lot of talks to primary care, where without mentioning OxyContin specifically, I outlined the five points above on how appropriate, safe and efficacious it was to prescribe long acting opioids for chronic pain. And OxyContin was a very effective well tolerated narcotic which meant that it became the go to drug for family docs which meant that there was a lot of OxyContin around to leak onto the streets.

Pretty soon we heard about "hillbilly heroin", lives ruined through OxyContin and people dying of overdoses.  I have always wondered who is at fault when somebody lies to their doctor, buys or steals a drug to get high.  Is it the drug or it is the person?  I am sort of leaning towards the person.  I would see parents on TV talking about how their son's or daughter's life was ruined through OxyContin as if maybe the way they were raised didn't maybe have a little to do with it?

Nonetheless licencing bodies and governments clamped down.  Family docs read the stories and didn't want to prescribe OxyContin or for that matter any narcotic.  Pharmacies wouldn't carry them.  Patients refused to take them.

In Canada a mulidisciplinary group on opioid use published a document stating that 100 mg of oral Morphine was the "watchful" dose which means that that was the dose at which you were supposed to re-evaluate things but of course licensing bodies and insurance companies interpreted this as the maximum dose.

Companies responded by trying to make their drugs more tamper-proof or by adding naloxone to foil IV drug use.  This is partially helping.  I am told that since CR Oxycodone is now tamper-resistant, illicit oxycodone use has gone down, replaced (surprise, surprise) by heroin use.

So did we (I) learn anything from this?

I like to think so.  I screen for addiction a lot more now and I like to believe I am more cautious.  I don't  push the dose, I figure if they aren't getting relief at lower doses, it may be time to look at another medication or another therapy.  I'm not ashamed to do blocks if I figure they might work.  The bottom line is, I still prescribe oral opioids including controlled release Oxycodone.

A lot of doctors have however been scared off from prescribing narcotics in any form.  On top of this, because there is now a shortage of family docs, many family docs will not see any patient taking opioids, quite a few won't see any chronic pain patient just in case.  This of course puts more pressure on those of us doing chronic pain management and we all know that if we, after exhausting all options, trial the patient on oral opioids, we have more or less married them.

A few "experts" are also piling on stating that narcotics will inevitably lead to addiction (which given the rigid definition they use is an almost certainty).  I actually read somebody who wrote that palliative patients shouldn't be prescribed opioids.

Some of my fellow co-disciples from the old days don't seem to have learned.  I get some hostility at meetings when I suggest that the ways we practised and encouraged others to practise may not be appropriate anymore and we should maybe be a little judicious about prescribing opioids.

One of the advantages of getting old is of course seeing how heresy becomes dogma and dogma becomes heresy.  And of course oral opioids are just another medication fad that didn't work out as well as it should have.  For example:

Hormonal therapy for menopause

Vioxx

Flecainide and Tocainide

Aprotonin

The real issue here is that we don't really have very effective treatments for chronic pain and that many treatments that we do have aren't universally available.  A lot of people's lives may have been ruined by misusing prescription drugs; quite a few people I see in the Pain Clinic already have a life that has already been ruined.

NPO

One of our staff emailed the whole group about a problem he encountered recently.  Our hospital does a lot of ureteroscopies for stones.  This is because we have the only lithotripter so we get the failures from there.  Despite having one room a week free during the day for urgent stones, we do a fair number after hours.  This is highly urologist dependent; 3 individuals account for about 90% of our after hours work.

Anyway one of these urgent stones presented to the OR in the evening having just eaten a full meal.  I didn't find out why this happened but I suspect the patient thought he was coming to the hospital to consult with the surgeon about his stone, NOT to have surgery.  It could have been that he got faulty instructions from the surgeon's office or that he is just stupid but he admitted to having eaten supper.  "That is too bad," said my colleague, "I guess you will have to have your surgery tomorrow."  "But" replied the surgeon, "he needs to have the stone done or else he might get septic!"  "Fine," says my colleague, "After a solid meal he will need to fast for 6 hours."  "That is way too late," said the surgeon, "he is going to get septic, can we do him under local with IV sedation."  "You can do what you want," replied my colleague, "But you are on your own" and went off to cool his heels.  The surgeon according to seemed shocked.

Kidney stones do get septic, I have seen one case in my medical career but as even the urologist who is chief of surgery at our hospital acknowledged, this is rare.  I suspect the urologist in this case was more concerned about getting home to tuck in his kids and have sex with his wife than any impending sepsis.

It does bring up the interesting topic of NPO.

When I started my residency a 6-8 hour fast usually written as NPO after midnight was the rule which meant patients frequently fasted for 16 hours or more.   The 6-8 hour fast was not based on any real evidence.  Up until the late 1950s fasting guidelines were much more liberal including things like tea and beef broth right up until surgery.  The introduction of longer fasting intervals coincided with other things like better anaesthetics (like halothane instead of ether), more use of endotracheal intubation, better trained anaesthesiologists and intensive care units, so any attribution of decreased morbidity with aspiration is more multifactorial rather than just due to longer fasts.  There also emerged a dogma of a gold standard of a gastric volume of less than 0.4 cc per kg and a pH of greater than 4 based on research on Rhesus monkeys extrapolated to humans.

Further we were told that narcotics delayed gastric emptying as did a myriad of other medical conditions including pregnancy so that those patients all had to have their airways protected with a rapid sequence induction and an endotracheal tube.  We asked every patient about reflux.

Many patients of course needed their surgery immediately and we managed them with rapid sequence inductions.  It was also apparent that one could use the NPO interval to manipulate emergency cases.  If you thought you could get the case put off to the next day, you quoted a longer fasting time, if you knew you were going to have the do the case anyway, you accepted  a shorter fasting time.  I played that game fairly recently.  Surgeons also clued in. When I was a resident, I was on call and one of the older surgeons booked an appendectomy.  "He ate lunch," said the surgeon smirking, "So how about we do him at 7 pm?".  What this really meant was he wanted to go home and have supper and then come back to do his case.  I on the other hand was more interested in following the list with the case. As I told the staff anaes firstly the patient had to be treated as a full stomach anyway and secondly if he was actually able to eat lunch, they didn't have appendicitis.  It didn't work, staff surgeon and anesthesiologist ate supper at home, I ate supper in the hospital cafeteria after which the patient was relieved of his appendix.

Already as I started my residency, brave anaesthesiologists were actually doing research to challenge the dogma of NPO after midnight.  One of them who gave a talk at rounds described how some of his fellow anaesthesiologists were horrified and refused to even be in the room while he did the studies.  It became clear however that patients could actually have clear fluids right up to the time of surgery and now the Canadian Anesthesiologists Society recommends allowing clear fluids up to 2 hours pre-op.  Administration asked about 3 years ago if we would relax our NPO standards at our hospital, I looked at the guidelines, asked my colleagues and we agreed that people could have water up until 4 hours pre-op just in case the case before them was cancelled.  We chose water because of the confusion over what exactly is a clear fluid.  The hospital ignored us and rolled out a 4 hour clear fluids policy with huge fanfare this January, however most patients seem to be fasting after midnight.

Exactly what a clear fluid is, has never been clarified.  If you look at the variety of fluids that are considered to be clear fluids, you see a variety of fluids with different pH and often pharmacological properties on their own (tea or coffee).  Many patients think that a large milkshake is a clear fluid.  I suggested just telling patients to drink Gatorade (any colour except red)  which is what my surgeon told me I could drink before my colonoscopy.  I am not endorsing Gatorade, it could be Poweraid, Kool Aid or Tang.  Coffee was verboten until they found it actually raised gastric pH and lowered gastric volume so black coffee is now back in.  I still am not sure what adding a few mls of milk or cream does to make coffee any less safe.

A few years ago, one of colleagues at the C of E announced that she had just cancelled a patient for chewing gum.  "Whats wrong with gum?'"  I asked (as long as they spit it out).  She looked at me like I was an idiot.  "Gum increases gastric volume," she said the voice one uses when trying to explain something to a child.  A few months later a study showed this wasn't the case.  I should have copied it and put it in her box but I didn't.

To sleep perchance to dream

The accusations against Dr. George Doodnaught are as disturbing as they are bizarre. The Toronto anesthesiologist has pleaded not guilty to molesting 21 female patients, who range in age from 25 to 75. While the women lay consciously sedated on the operating table, the 64-year-old allegedly kissed them, groped their breasts and even forced them to perform oral sex, all while hidden behind the sterility drape that divides the anesthesia station from the surgery.

Anyone who has spent time in an operating theatre knows there are nurses, cleaners and doctors buzzing in and out of multiple exits and entrances. So far, with few exceptions, witnesses who worked with Dr. Doodnaught testified he was a sought-after specialist with a good reputation. The prosecution is charging the hospital was engaged in a coverup.

Dr. Doodnaught’s defence: that the medications used to anesthetize his patients caused “sexual fantasies.” The drugs—including midazolam, ketamine, propofol and sufentanil—were given to patients in different doses to allay their anxiety and produce amnesia. The side-effects: the erotic and violent hallucinations these patients are confusing with reality.

It turns out there is an entire literature dedicated to the study of hallucinations and dreams during surgery—particularly sexual ones. “Sexual hallucinations have been reported since the advent of anesthesia,” begins a 2003 review article in the journal Anesthesia. In the late 1800s, the authors write, the use of chloroform in anesthesia was prohibited because of cases where women used “obscene language” while on the drug.

For decades, the medical community agreed that witnesses should be present when doctors give patients mind-altering drugs to avoid false harassment allegations. A 1992 review article in the dentistry journal Anesthesia Progress looked at the effects of benzodiazepines (such as midazolam) for sedation during surgery. The author, a Northern Irish doctor named John Dundee, discussed case studies in which female patients vividly recalled being sexually harassed by their dentists. “In 13 of 16 of the reported events, where patients and attendants were questioned closely, nothing improper could have occurred. In 11 of these, others were present throughout, while two events were physically impossible.” Some of the dentists who were working alone—that is, without witnesses—lost their licences.

The 2003 review article outlined a series of allegations and convictions involving “wandering hands,” “fondling” and forced oral sex. In Ottawa, in 1986, an emergency doctor was acquitted of a charge that he asked a patient to squeeze his penis while she was coming to after a surgery. A Norwegian plastic surgeon was tried in the Oslo High Court for masturbating nine patients who were on midazolam and fentanyl while he performed breast surgeries. A nurse who witnessed the surgeon at work helped to get him acquitted.

While the medical community doesn’t know exactly how anesthesia works, or why it causes hallucinations,, the authors point out that patients may be confused by routine touching during an operation. “Stimuli to the chest such as the removal of ECG electrodes, elbows rubbing the chest while the operator is working in the mouth or on the face have resulted in accusations of breast fondling.” Most cases on record involved female patients and male practitioners, though there are reports of the inverse. Most articles conclude that sexual hallucinations or fantasies are an infrequent, though noteworthy, side-effect of a range of drugs in anesthesia and sedation.

Erotic dreams under the effect of many anaesthetic drugs including Propofol have been known anecdotally if not formally studied in anaesthesia.  This is more likely if drugs are used in sedative rather than anaesthetic doses; patients do not usually  (should not) dream under anaesthesia.  It is possible that patients may dream while coming out of anaesthetic given that most of us lighten up patient while the residents are watching the wound heal, in the hope that the patient will wake up quickly  and we can empty our bladders and have a coffee.  Given low level of most of conversation which occurs in the OR which patients can sometimes hear, it is not surprising that they may have sexual fantasies.

The case against the unfortunately named Dr. Doodnaught raises some questions.

1. If the patients are just dreaming about sexual assaults, why was he the only person in the hospital accused.  Is there something innocently different about his technique?
2. There is a mention of him attempting oral sex with a patient during an abdominal hysterectomy.  Given that most people intubate their hysterectomies which involves muscle relaxation that is relaxation of ALL the muscles it is how to see how this happened?  It is possible that this could have been a spinal with IV sedation but this is stretching things.  Maybe I am not enough of a pervert but I am stumped as to how one would accomplish this.
3. Is he such a nice guy that everybody in the OR is willing to cover up pretty disgusting behaviour by him or did he just piss off the wrong OR nurse?

Don't know all the facts and like most cases involving the legal system and the press, I suppose I never will.

Bullying, disruptive physicians and thoughts on administration

One of my fellow physician administrators forwarded this post from Kevin MD.  I have pasted it at the bottom. 

I was talking with the same physician a few months ago and we were discussing how bullying was going to be next club with which physicians were beaten.  In addition the disruptive physician label has become the latest Scarlett A.  Both are perfectly valid concepts, many physicians were or still are bullies.  It is unfortunately the culture in which we were raised if you want to commit sociology.  Likewise there are many disruptive physicians and many of them have continued to be so in part because the system nurtures them.  It is the extension of the terms to legitimate disagreement or dissent that is the problem.

I have to attend a lot of meetings, which we all know are way to deal with any problem.  These include meetings specifically to deal with problems and regular meetings such as what used to called the OR committee and Medical Advisory Committee among others.

The MAC which is supposed to be a meeting of the department heads with senior management is no longer a forum where policy can be discussed or modified, assuming that was ever the case.  About two days before every meeting, I receive by email a massive document dump which I am supposed to read before the meeting.  There is of course no way I can ever read the whole package let alone figure out what parts of the package I should read.  Assuming I did read the whole package, I would find it full of incomprehensible flow charts and neologisms. This is what is called consultation.

Occasionally you may be asked to give feedback into a particular policy during the planning stage.  The meetings will be scheduled in the middle of the day when you can't get to them because you are working.  If you think it is important enough to take an (unpaid) day off, the meeting will be cancelled at the last minute because one of the "stakeholders" can't make it.  They of course never cancel the meeting because you can't make it.  Or they will invite you by the hospital email address you never use because it is too cumbersome to access.  When the policy comes into force, they will say that they consulted you.

Most policies are then presented to the MAC as a fait accompli.  The medical director, now called the Vice President - Medicine may actually have had some input or not.  It was at meeting about a year ago that I realized that there must be a secret administration running the hospital.  We were presented a policy on standing orders made by our quality department that was completely illogical and was going to hamstring care as we knew it.  Despite the fact that our administrator, both medical directors and all the department heads were present, the policy was presented as something we would have to live with and could not be modified.  Discussion did become a little heated and both sides made some edgy comments.  The policy went ahead however and we are gradually learning to live with it.

My father served in the provincial government for over 30 years rising to fairly high levels and attended multiple meetings.  He told me that every committee should have somebody on it whose job is just to say, "BULLSHIT".  He told me that people get irrationally attached to ideas and need somebody to bring them down.  Keep in mind it now almost 30 years since he (or people who think like him apparently) was involved in decision making.  This is not a new concept.  The Vatican when considering somebody for sainthood actually has an individual known as the Devil's Advocate whose job is to argue why the individual should not be a saint.

Nowadays if anybody is brave enough to object to or suggest modifications to some policy or plan they are told one or all of:

1. It is an accreditation standard.
2. It is a Zone/Regional/Provincial/National standard.
3. Administration is committed to the project.
4. People have already been hired and it is too late to stop.
5. You have no right to comment on this issue.
6. You are an asshole. (While it would be nice if they actually called you an asshole, they never phrase it like that, they just make you look like an asshole).

Pointing out how impractical implementing the policy with the resources that you have or that it won't work in the real world is useless.
In three years I have learned a few things about administrators.  I refer to nursing because I deal with them the most but this applies to most of the heirarchies in the hospital.

1. Administrators are usually hamstrung by how much money they have to work with and the political agenda of the people who decide how they spend the money (this includes the secret administration).  This is true by the way in both the public and private sectors (the private sector just has more money but also has to make a profit).
2. Administrators have the best job they have ever had in their life.  Why would they want to risk it by standing up to the people above them.  This is as opposed to physician administrators who are often doing this out of a sense of duty or because it is their turn and either already have a good job outside of administration or could go back to clinical practice and be a lot happier and quite often better paid. Non-physician administrators know this and resent this.
3. In the health care sector many administrators actually rose up from the trenches.  In a lot of cases this is on merit.  In quite a few cases it is just a case of having been in the right place at the right time.  There is also nepotism.  In one hospital I worked at, most of the nursing supervisors were relatives of a former administrator (she was fired, they stayed around).  The organizational chart resembled the genealogy of the Habsbergs.  Those who rose up on merit usually rose up by virtue of a non-administrative job for example a nurse may become what we used to call a head nurse by virtue of her good work on the floor or by seniority.  Her skills as a nurse however have very little to do with what is required of her (or him) as an administrator.  Frequently nurses who were quite good (or remember themselves as being quite good) have unrealistic expectations of their now subordinates.  Nurses also frequently become administrators for the "wrong reasons", better hours and more pay and who can blame them.  It is of course reasonable to expect anybody to be good as an administrator based on their skills as a clinician.  How many hockey stars became good coaches.  This was called the Peter Principle where people rise to their level of incompetence.  
4. Lower levels of management have shifted.  When I was in medical wards were run by head nurses who wore uniforms just like the floor nurses and some of them actually helped out when things were busy.  Over them were nursing supervisors who also wore uniforms and helped out on nights and weekends.  In essence head nurses were, to use a military analogy, sergeants   Head nurses are no more, they are now called supervisors and wear plain clothes.  Supervisors now have a different title and are not seen in the hospital after hours.  Essentially it is like the sergeants have been replaced with second lieutenants and anybody who has been in the army (I haven't) knows what that is like. 
5. Unlike most industries many of the top administrators and almost all the lower administrators are women.  This of course shows that women can be just a arrogant and out of touch as men can.  They also do stupid things, just like men.  It also creates an interesting dynamic for a male physician who has to deal with a female administrator (not that female physicians have any more luck).    It just seems easier to stand up and get into a battle with another man.  

Anyway here is the post from Kevin MD's blog.  I may just try some of his strategies although I know they won't work.

Become a disruptive physician: How to do it right

DIKE DRUMMOND, MD | PHYSICIAN | MARCH 21, 2013

“Disruptive physician” is one of the most misused terms in healthcare these days. In many organizations, those two words have become the c-suite’s trump card to quash any physician resistance to new administrative programs. These programs are often have purely financial motives or are a brazen attempt to dump additional tasks on the physicians with no regard for their workload or stress levels.

The doctor’s legitimate concerns about quality of care don’t matter. They are lost in the politics of the silos of the administrative and clinical sides of the organization. They are quickly seen as not being a team player. The disruptive physician label comes flying out and the doctor is deftly tossed under the bus so the meeting can move on to the next topic.

Often, this is bullying, plain and simple. It can create permanent consequences for the physician, including diversion into any number of treatment programs and not uncommonly losing their job.

However, sometimes the disruptive name calling is just a consequence of a fundamental clash of communication styles between physicians and administrators. In this situation, the skills inside the disruptive physician’s toolkit will allow you to do the following:

• Air your legitimate concern
• Be heard by the administration
• Avoid being labeled disruptive in the process

Physician vs administrator communication clash

Physicians are highly trained experts at finding a unifying diagnosis, the crux of the problem, the thing that is likely to go wrong. We see clinical issues administrators are completely unaware of.  We do all of this at lightening speed, because in our diagnoses often must be made quickly.

When we see a problem, we point it out without hesitation and we are not used to having to explain ourselves. And we shoot from the hip, without regard to the social setting or the politically correct thing to say in the given situation. One word for this is “blurting.”

This is not how you make your point in the midst of a meeting to a group of administrators. They do not think or communicate in this fashion. It is not what you say, but how you are saying it. Disruptive physician labeling can be the result of this clash of communication styles.

The disruptive physician’s toolkit

If you have a concern, talk to as many people as possible before the meeting where this program will be discussed

To raise a concern for the first time in the midst of a meeting is the definition of rude to an administrator. Discovery and building of consensus is best done before the meeting occurs – much like the work in politics is done in conversations before they vote on the bill on the floor. You want your concern to be discussed, shared, understood and at least a partial consensus on what to do about it. All done before any committee meeting.

Always ask questions, rather than making statements

Ask questions of everyone involved in the proposal and everyone who will be part of the decision on whether or not it goes forward.  Always start your questions with the word “what” or “how.“ This guarantees an open ended question that will draw the maximum of information from the person to whom you are speaking.

Here are some very simple and powerful examples:

• “What are your thoughts on program “X”?”
• “How do you see program “X” affecting the quality of care?”
• “I have some concerns about “X”. How do you see we might be able to address them?”

Channel Columbo

Do your best to imitate the character of “Columbo” in the old TV series. Hand to the forehead, self deprecating, “Maybe this is a silly question, but I was wondrin’ … ”

Columbo’s style goes against our doctor programming to be “seldom wrong and never in doubt” and I encourage you to let that go. Columbo was never called disruptive and was always very effective.

• Try asking questions instead of telling people what to do (giving orders)
• Try channeling Columbo when you speak
• You have no idea how massively effective this is with administrators (and everywhere else in your life)

Find solutions and build consensus

In your pre-meeting discussions, if you find your concern is shared by your colleagues, build consensus (before the meeting) on several solutions or ideas to address your concerns. You will have consensus on the concern and the possible solutions in your back pocket before the meeting begins.

Appeal to the highest value possible at all times

Always keep the team focused on the highest possible corporate value – one that everyone can agree to. Usually this will be quality of care or patient satisfaction. This is your trump card. When you are bringing up any clinical concern about an administration proposal, relate it to one of these  higher values whenever you can. It can sound like this.

“I know we all agree that none of us wants the quality of care to suffer as a result of this initiative.”

This phrase used early and often keeps everyone focused on the big picture, and not your objection. It states something no one can disagree with and keeps them from immediately disagreeing with you.

What not to do

• Don’t communicate like a doctor
• Do not raise your concern the way you would normally do on automatic pilot, as a declarative statement of fact. Example: “I think this is a bad idea and here’s why.“
• Always ask a question. Remember to channel Columbo. Be either curious or confused.
  • “I am confused here.” (Columbo)
  • This patient flow initiative is supposed to make it easier to see 35 patients a day, but a number of us here are concerned it will only increase the EMR documentation backlog and that will affect the quality of care. I am curious what your thoughts are about our concerns here Mr. CEO?” (open ended question)
• Do not show any emotion that could be perceived as negative
• Do not:
  • Stand up
  • Raise your voice
  • Furrow your brow
  • Slam your fist on the table, point fingers, slam doors, swear, throw things
  • Or send any body language signals of anger, frustration or hostility.
• Focus on your breathing and ask question
• If you do feel any of these emotions, name them out loud
• Let people know what you are feeling with a civil tongue. Just make sure you have done the work before the meeting so that everyone is aware of your concerns and feelings.
  • “I must admit when I hear your answer, what comes up for me is frustration.  I am curious (Columbo) what we can come up with for a proposal here that could address both of our concerns. “ (open ended question)
• Do not leave a paper trail or voice mail trail
  • It is completely appropriate to be seriously paranoid about documentation of any of your concerns in a format that could be shared. Do not send emails, text messages, messages through your EMR or leave voice mails especially if you are upset and venting to someone you feel is a trusted colleague. If you must vent in an email, write it and then delete it. Do not create a paper or voice mail trail.
  • If you do leave recorded or written evidence of your concerns, you are running an almost 100% risk of those documents or voice mails falling into the hands of someone who will label you as the next disruptive physician on staff. Here’s why.
  • It is impossible for them NOT to take your concerns and tone out of context.
  • Make sure you raise your concerns only in conversations, where the other person can understand your energy, tone, body language and caring for everyone involved – especially the patients. There is no way any of that can be understood through a text, email or voice message, especially by an administrator who does not agree with or understand your position.

Ultimately, if you work in an organization with a pattern of hostility towards the physicians and clinical staff and a habit of bullying with the disruptive label, you will decide whether that is something you will tolerate  or not. You always have the option to vote with your feet.

If you do decide to leave, it is my intention that this disruptive physician toolkit ensures the following:

• Your concerns have been heard
• You gave it your best shot at ensuring the program made clinical sense
• You don’t have the disruptive physician label hanging round your neck to get in the way of you finding a better position

Have you ever been labeled as disruptive?

If you are in a leadership position, what communication tools do you use to avoid the disruptive physician label?

If you have tried channeling Columbo, how did that go for you?

Dike Drummond is a family physician and provides burnout prevention and treatment services for healthcare professionals at his site, The Happy MD.

More than just being tired?

I picked up the following off the Medical Post otherwise known as the Medical Enquirer who email me a digest of news unsolicited everyday (I could block them, I guess)

There was a sigh of relief across the country in 2011 when a Quebec arbitrator ruled that the 24-hour shifts required of medical residents violated the Charter of Rights and Freedoms. Finally, there was recognition that this treatment of neophyte doctors not only violated their health, but the safety of patients. Doctors shared stories of car accidents after long shifts and of mistakes made in the daze of exhaustion.Key thinkers on health care called it a common-sense ruling. A few months later, Quebec capped on-call duty for residents at 16 hours, down from 24. With mounting evidence about the adverse effects of long-call shifts, it seemed like a move the rest of Canada should follow.Or maybe not, new research suggests.Two studies in the Journal of the American Medical Association argue that the 16-hour limit might not actually improve the lives of residents or the safety of patients. In fact, it may make matters worse.A longitudinal cohort study, published in JAMA, used a first-year resident health survey to track the effects of 2011 duty-hour reforms in the U.S. (which, like Quebec, limited call to 16 hours but only for first-year trainees). Dr. Srijan Sen, a psychiatry professor at the University of Michigan who led the study, told Science-ish that his data busts assumptions. Shorter shifts did not lead to more sleep—nor did it improve the well-being of residents. In fact, they made more medical errors. “There are unintended consequences—negative consequences—associated with capping hours,” he said.For example, most hospital residency programs didn’t have the resources to hire new physicians or physicians’ assistants, so residents were expected to do about the same amount of work in less time. Dr. Sen linked the resulting “work compression” to medical error. “There’s clear evidence that working so long isn’t good for cognitive functioning. But it looks like we’re creating new problems by cutting down those shifts.”The second JAMA study looked at medical house staff at Johns Hopkins Hospital, randomly assigning them to a 30-hour cap, or to one of two groups with a 16-hour cap. The investigators used wrist watches that measure movements to find out if the groups working fewer hours managed to catch more sleep. The lead author, Dr. Sanjay Desai of Johns Hopkins, told Science-ish that the interns who worked less slept an average of three hours more around the period during which they took call, but otherwise got no more sleep than the control group.“Is three hours enough sleep to change levels of fatigue and response times?” he asked. “For us, this introduced potential flaws in the logic that if you cap hours, people will sleep more, and meaningfully more. That doesn’t seem to hold true based on the data we have.”There were other alarm bells. Dr. Desai says residents who worked night shifts felt their education was compromised, since learning and educational activities generally slow down at night. Hand-offs in the 16-hour groups increased between 130 to 200 per cent compared to the previous 30-hour model. As a result, patients were juggled between more doctors than before. (It’s well known that transitions of care can be akin to a game of broken telephone, a major source of medical error.)So what now?Dr. Chris Landrigan, a professor at Harvard Medical School, who did asystematic review on the effects of the 16-hour call, said most literature points to reducing shifts, and notes serious limitations in the designs of the new studies. The first by Dr. Sen relied on self-reporting of medical errors, well-being and sleep patterns. Dr. Desai’s study also made no direct measure of patient safety. Instead, investigators looked at sleep and hand-offs, which weakens the argument that caps lead to more errors.Still, some of the findings in the JAMA studies have been illustrated by the Quebec experience.Dr. Charles Dussault is president of the Fédération des médecins résidents du Québec, which represents the province’s medical residents. The FMRQ is trying to find ways to supplement education in the OR after surgical residents complained they weren’t learning enough. ”OR time is precious,” he explained. “Some of the models we proposed limited the number of hours residents can spend in the OR.”Quebec doctors have also reported concerns about the increase in hand-offs. “People are feeling the fact that there is more patient transfers than there were before could increase the risk of mistakes.” Dr. Dussault said hospitals are looking for ways to improve hand-offs. “We are still in transition,” he added. “People had the same debate when they went from a 72-hour cap to 36, from 36 to 24, and now from 24 to 16.”And that’s exactly it: shift length is a systems challenge that requires a systems solution. Resident duty hours need to be more humane, but cutting hours without redesigning the hospital infrastructure—standardizing hand-offs, addressing work compression or paying attention to resident education—won’t get doctors very far.Both Drs. Sen and Desai pointed out that it wasn’t just the shrinking of shifts that may have increased errors; it was the lack of planning and organization around the changes. Importantly, they cautioned against the 16-hour limit, noting it was too prescriptive — that a one-size-fits-approach is not suitable for every hospital.In Canada there is currently no consensus on the regulation of duty hours. We can do better. Somewhere between the U.S. and Quebec is a model for the way forward. 

There may be a few explanations.

They mention the issue of hand-overs and unfortunately the quality of communication between doctors is not that great; something medical schools need to work on.

Maybe 16 hours is too long a shift, maybe we should look at 8 or 12.

Our department has for years covered night call on a 1600 - 0700 basis.  Let me tell you, a lot of nights when I have to do something at 0400, I am pretty shaky (some nights not so much).  Not that I have knowingly done anything bad; I tend to just simplify things and go a little slower.  Maybe we need to teach doctors shift work management or how to work when tired.  Unlike a lot of shift workers, most of us sleep poorly if we have to sleep during the day; I can rarely manage more than a two hour nap without the aid of pharmaceuticals.  That is assuming you have the opportunity to nap at at.  There are a lot of other factors; how busy were you in the first 8 hours, were you woken from a deep sleep etc, how boring what you are doing is.

Are we talking big or little mistakes.  If you are doing a study on errors, you obviously want to have as many errors as possible.  So if for example I give the little old lady 200 mg of propofol when I only should have  to given her 150 mg and have to give her phenylephrine for her BP of 60, is this a significant error.  Are we just measuring a lot of trivial errors with no global effect, just because we can?  Further because medicine is an art not a science, many errors are just judgments which could have gone either way.

Patients are sicker after hours, procedures are more complex there is most opportunity for error no matter how well rested you are.  Because of the hierarchical system that still exists in medicine, more junior staff will be working after hours with less supervision.

And anyway do we have to make patient safely a justification for not making somebody work 24-36 hours or can we just say in civilized society, that is not how we should train people?

Just a few thoughts.

In the trenches.

As I previously blogged we are in a fee dispute with our government who want to cut remuneration to specialists in particular anaesthesiologists in order to redistribute the money to physicians who are "working in the trenches", meaning family docs, geriatricians and psychiatrists.  One of my colleagues copied me on a letter he sent to the president of our union and I really could not have said it better.

So to hear that I'm now being told to take a 25% pay cut and be insulted every second day by this minister really rubs me the wrong way. He has said that he needs to support the "workers in the trenches" (family practice, gerontology, psychiatry) and this causes me to scratch my head. If looking after a young pregnant woman with PIH at three am is not "In the trenches" what am I doing then? Missing my kids soccer games, dance recitals or just bedtime because I am on call? 

There are few lucky anaesthesiologists who work in cosmetic suites, dental offices or just do arthroscopies and ACL repairs on health ASA 1 and 2 patients.  These are a very small minority.  For most of us we take whatever comes in through the door and try to get as good a result as we can.  Not to sound bitter but our job is made one hell of a lot more difficult by those front line "in the trenches" family docs, geriatricians, emergency docs, (don't get me started on internists) etc who haven't worked up their patients properly, haven't treated their medical concerns and often sat on their obvious problems, turning what should have been an urgent procedure done during the day into an emergency in the middle of the night.  And unlike most specialists in our city, when an anaesthesiologist is on call, he is in the hospital caring for a patient or else he is at home, on a 30 minute leash, NOT sitting around having residents and hospitalists look after his patients for him.

Not to mention that when you phone most GPs offices now, after hours or even during the day, you get a message telling you to go to the nearest emergency room or call 911.  (Of course they can't take your phone call, they're busy out in the trenches!)  At least in the city now and in a significant amount of the country, GPs no longer do house calls, work in the emergency, deliver babies, work in hospitals or do nursing home visits.  So who the hell is in the trenches?  Not the person doing well-baby care from 9-5 and weekdays.  Geriatricians, who are for the most part GPs who took a weekend course, are insulated from any patient care by layers of nurse practitioners.  I don't see a lot of them at night in the hospital.

In defense of GPs or as they like to be called, Family Doctors, they were largely forced out of hospitals, emergency rooms and obstetrical units over the past 30 years that I have been in practice.  I don't remember a lot of kicking and screaming but it did happen.  They certainly have never gotten much respect for anybody, have been blamed for much of the increase in healthcare costs in past and had to put up with practice restrictions.  And quite a few of them do provide reasonably good care for their patients.  And unlike my generation who got a one year hospital based rotating internship where they saw lots of sick patients, FPs now go thru a two year family practice "residency' where they predominantly work with academic family docs and learn how to deal with healthy people and wash their hands of everything else.

Working in a quasi community/teaching hospital one realizes how much infrastructure is necessary for doctors to do their jobs and it is these people who are actually in the trenches.  This includes residents, hospitalists, nurse practitioners, physios, lab etc all of whom insulate doctors from their patients.  These people are the real people who are in the trenches and I don't think any of them are going to see the money that is about to be stripped off me.

Every doctor of course thinks what he does is the most important thing in the world and the best strategy from a government point of view is to get us fighting over who gets paid how much for what.