Saturday, 12 August 2017

"Don't complete your course of antibiotics!" (BMJ)

    That is the advice of an article recently published in the prestigious British Medical Journal.  In an article entitled "The antibiotic course has had its day." by Dr. Martin LLewelyn et al. it is suggested that continuing the course of antibiotics for the recommended time is not only unnecessary but is actually harmful, in that it promotes the emergence of resistant strains and also that it is more likely to cause side-effects.  Funny, because the rationale used to be if you DIDN'T finish your course of antibiotics that you promoted resistance by allowing resistant mutations to supervene.    Both the CDC and Public Health England in their public health information recommend taking the medicine "exactly as prescribed", whereas previously they had recommended "completing the course".  So they are both sitting on the fence. The article even goes so far as to recommend that the patient be advised to stop the antibiotic when they feel better - a dangerous recommendation, especially if they are not under close medical supervision.
   Fifty five years in the trenches as a general practitioner have convinced me that it is essential to prescribe a course of antibiotic treatment that is clearly defined, based on the best current knowledge and on the experience of the practitioner.  Notwithstanding the fact that experience is much derogated in this age when everyone wants to feel their opinion is equal, it has no substitute.  Years of study, observation and practice in the field does confer on the practitioner a level of expertise that is not generally shared by the public or even by many medical specialists.  I suspect that the sort of specialist practice that Dr. Llewellyn follows does not include seeing large numbers of patients of all ages, body types, gender and ethnicities and their response to antibiotic treatment.  I suspect that he has no experience of the recurrences of symptoms and repeat visits generated by early discontinuation of treatment and I suspect that most of his data has been dragged out of computer databases or dusty charts.  His conclusions are based on dataism and statistics, mine are based on patient observation.  I think there is at least as much objective evidence to support the importance of completing the course even if one totally disregards actual experience in the field.
Please comment if you have any views on this.

Saturday, 5 August 2017

Put the clown in the pot.

   Since the clown has already put the Pot in himself, I think it is time for Canada to put the clown in the pot.  The clown to whom I am referring is, of course, the PM.  He knows, that the best chance of re-election is to keep his supporters as 'happy' as possible and he knows that with a good suck of pot, his followers will be almost as happy as he is.  Most of them won't follow the damage he is doing as long as he keeps entertaining them with with his circus and feeding them marijuana. The Romans called it
'Panem et circenses', which literally translates to 'Bread and circuses', the implication being that if you feed them and entertain them, the masses don't care about much else.  We're different only in that we want more, instead of bread and circuses, we want pot and circuses.  In that way we can delude ourselves into believing that not only do we deserve all we can get, but that we are 'noble' in our objective of supporting everyone to be just as stoned as we are.  Put in charge an elite with a 'name', who inherited his mother's good looks, but unfortunately not his father's brain and you will understand why Canada is on the decline, not a gentle gradual decline, but a disastrous precipitous decline that pains me just to think about.  Like the Spitfires in 'Dunkirk', the Canada we knew and the one I emigrated to will be no more.  Tarek Fatah, explained all this to the Canadian Senate recently and responded to the unmitigated gall and naive effrontery of Senator Grant Mitchell, whose comments made it is difficult to understand how an egotistical ignoramus of this caliber qualifies for my tax dollars.  
  Drug addiction in Canada continues to be a huge and growing problem.  Despite this, Tricky Trudeau still intends to legalize pot.  Premier Brian Pallister of Manitoba said the following, " It's time to take a deep breath and put pot on the back burner for an extra year."  He is trying to persuade the provincial premiers at their annual conference to ask Trudeau to delay the legalization.   He raised question about traffic safety, physical and mental health impacts and concerns re detection levels in stoned drivers.   Most of the Premiers seem to be in agreement.   Although it makes sense, is it likely to happen.  I think not, because the PM and his minions will see it as costing them votes and revenue, the two things they are really committed to.

In a report on persistent pot use, by several American universities, a University of California (Davis) news release showed that Cannabis was not safe for long term users. The study leader stated the following: " Our study showed that regular cannabis users experienced downward social mobility and more financial problems than those who did not puff persistently.   Regular long-term users," she continued,  "also had more anti-social behaviours at work, such as stealing money or lying to get a job and experienced more relationship difficulties such as intimate partner violence and controlling abuse."  
   Difficult to support legalizing such a drug for recreational use, but the Man-child PM likes his pot!

Wednesday, 26 July 2017

" Medical care in Canada.-time to drain the swamp!

   Someone finally had the guts to come out and say it!  Brian Lee Crowley, of the Financial Post, on July 5th had the appalling honesty to say what many Canadians know but don't even like to mention, or hear mentioned by others, that we have one of the worst, if not the worst health care system in the developed world.  The heading of Crowley's article is :
     "This report just shredded every myth claiming Canadian medicare is superior - or fair"
  The report he refers to is the report of the Commonwealth Fund comparing health care systems in the rich industrialized world and it is regarded internationally as being highly reliable.
  The humiliation of having deteriorated so rapidly from  among the best to the present sad state is so damaging to the pride and hubris of those who boasted 'one of the best health care plans in the world' that they can't cope with it.   There are some who still think that, but it only testifies to their lack of knowledge or contact with the system.  I know that occasionally folks have good luck but the majority of people who have to depend on the health care system are poorly served.  I also know that there are those who know how to manipulate the health care system and that there are the 'elites' who push their way to the head of the queue.  No politician or bureaucrat or their army of administridiots stand in the line with the rest of the folks.  Oh yes, they will claim all are equal, but as George Orwell said, "some are more equal that others!"  The fairness that boast of doesn't exist.
   How is it, you may ask, that we declined so rapidly from the best to the worst?  Regardless of the fact that we spend a fair amount of money we get poor value for it.  A very disproportionate amount goes to paying armies of civil-servants, many of whom are neither civil nor serve very well.  Most are not health care professionals of any kind and of those who are, few have real experience serving in the front lines.  They attend meetings where they like to hear the sound of their own voices and are frequently resentful of health care professionals who are wiser and more experienced.  Large amounts of money are sequestered to provide generous pensions and benefits. 
   Many of the administrative services that were intimately related to health care were for years provided by doctors and nurses on a pro bono basis - they did it without any personal reward other than that they cared.    They were committed individuals, usually with extensive experience in many aspects of health care.  Most of them knew what worked and what didn't.   Today many hospital administridiots have come up through the financial ranks and know nothing about health care but consider themselves experts anyway.  
   Because our government is not interested in individual health (unless it's a glamour story) but in votes, they have directed resources away from individuals and towards populations from whom they think they can win the most votes.  They play the 'statistics game' and the 'evidence based medicine game', they reward doctors for doing what they and their 'statistical experts' tell them will be cheap and effective and they penalize physicians for spending time on individual patients.  The fee schedule has been manipulated to make doctors do what the government want them to do and the Canadian Medical Association  and the licensing bodies has kow-towed to them. 
   The privilege that most free and prosperous societies  enjoy of allowing citizens to spend their own money on buying their own health care services is too threatening to the Canadian government, because they don't want the population to realize they are now getting second-rate care.  This would save money because some of those closed down operating rooms and wards would become productive, bring more money into the system and shorten waiting lists.  Think the government wants that?  It is that very lack of competition that allowed the disastrous deterioration to occur virtually without  public notice in the first place.  
   The decline will accelerate as the government brings in more and more unscreened refugees, hands out tax payer dollars by the millions and throws away opportunities that could make life better for all Canadians.
   They just want you to go on thinking we have the best health care system in the world!  


Thursday, 20 July 2017

This is how Canada treats its sick patriots.

   My close friend has been struggling with cancer for many years.  He's no cissie and I've rarely heard him complain.  He has been impressed by the care that all health care professional have given him, doctors, nurses, physio, investigatory facilities.  His attitude is upbeat, he has many interests and enjoys life and is determined to continue doing that for as long as he can.  Just yesterday, he had a scheduled check-up and was informed that he was no longer a candidate for further surgical interventions (he had many in the past) and that the options for further treatment were limited.  The best option, he was told by his cancer specialist would be a new pharmaceutical that would cost thousands of dollars a year and was not covered under any health care plan.
   My friend had volunteered for the Canadian Navy in WW2 and had served under perilous conditions for King and Country.  After the war, he continued to serve this country and after a period as a police officer here in Ontario, he worked in various sales positions.  He married, had five children and brought them up as fine, hardworking Canadians.  But, Ontario Health has decided that they won't underwrite his medication.  Our Federal Government has just rewarded a terrorist and murderer with an absolutely obscene amount from taxpayers money and a Canadian patriot is left to do what he can.
   You may have a word to describe that, I call it dispicable.  We need a government that cares about Canadians.  Trudeau must go.
Comment if you care.

Sunday, 16 July 2017

Decline and Fall of the Health care System/


   Something strange has happened to medicine in the last decade or so.  Most of the physicians I studied medicine with and most of the physicians who preceded me had something in common.  Their focus was on interacting with and caring for an individual patient.   I know how corny it sounds to 'modern' folk, but one of my teachers and mentors used to say "Remember, the patient is king", and he actually meant it!  I can imagine the response I would have got a few years ago if I had said that to my students!  A visit to the doctor was an interaction between two people, the patient and the doctor and the focus of the doctor was what the patient was complaining about that brought him to the doctor.   That was called 'The Presenting Complaint' and it was emphasized that it should reflect the patients own words.  I have discussed the significance of a complete history in a previous blog, my point being that if at the end of the history taking the doctor couldn't locate the system which was primarily effected by the disease, he'd better ask some more questions.  The step-wise progress of the history and examination was to pin point exactly what was going on in that patient and it took time, usually more than the ten minute consultation which seems to be today's average and the 'one-complaint only per visit' that some physicians have the temerity to  impose.  Treatment aimed solely at symptom relief was an interim measure until a precise diagnosis could be made.  Until then you could label the case as being 'open', in much the same was as a murder investigation remains unsolved, until it's solved.  Both the physician and the patient were aware that there was a missing peace in the jigsaw puzzle and decided how much time and/or money should be committed to finding the missing piece. 
many optional procedure were discussed  and evaluated when the patient had to pay some of the costs, but when everything costs 'nothing', well, why not have an MRI for your headache, whether you need it or not.  After all, you pay enough taxes, you should  be able  to have anything you like!
   When Government took over health care, they weren't interested in individual needs when the numbers were small, they were interested in 'big numbers' needs, because that's where the votes are.  Statisticians helped them a lot, because the information they provided enabled government to calculate the 'vote value' of any maneuver they consider.  In effect, they were able to calculate maximum returns to them, for every dollar spent.  After all, why waste money investigating or treating rare conditions that would only benefit individuals.  The 'evidenced base medicine' evangelists came on the scene like prophets in the desert, promising to revolutionize medicine and this they did.  They made it clear that experience and know-how really don't matter, that any new or under-educated physician was just as competent as the expert and experienced, as long as they followed the algorithms of the 'holy ones'.  They could and they would decide what was worth spending the tax dollars extracted from us and what treatments, according to their lights, should be preserved.  Money wasn't to be wasted on anything that was not substantiated with what they considered to be an appropriate clinical trial, even though in the opinion of some experts many of those trials are questionable.    The administridiots and groups of 'useful' physicians (to provide medical legitimacy to their deliberations) established committees to define profession guidelines, standards and rules and what comprised good care and what did not.   Frequently their guideline was cost reduction and certainly public care was emphasized and individual care discouraged using statistical evidence to suggest it was wasteful and not worthwhile.  The bureaucrats don't care about you.
   The government has worked hard to impose on physicians and other heath care personnel that they are no more than technicians and in no way exceptional.   They have impressed on physicians and nurses that there must be no deviation from  mediocrity and that above average care and below average care are equally unacceptable. Services have increasingly been taken for granted and expectations and demands have become unrealistic and inappropriate litigation is
commonplace.   As government increasingly deals with physicians in an unacceptable manner, they undermine professional standards and ethics and they work hard to fool the public that they are getting good medical care, despite the severe demoralization of the profession.  They are not, but they are getting  exactly what they deserve, because just as the population majority gets the government they deserve, so do they get the health care they deserve.  Canada is eleventh out of twelve in the quality of health care in the first world.  Soon we will rank with third world countries, unless doctors stand up and tell the country how poor our health care is and what is necessary to redeem it.  The administridiots aren't going to do it, so if the public doesn't get behind the initiative for major change, they deserve exactly what they are getting - and what they are going to get.  Further, a demoralized profession is  incapable of providing the traditional high standards of care that most physicians were once proud to provide. 
   if you have nothing to say I take it you like it the way it is.

Thursday, 6 July 2017

Once a doctor always a doctor.

    For a long time after I retired I took a certain pleasure in responding to the usual medical questions that physicians grow used to fielding on a daily basis from patients and friends alike, with a dumb smile and a jaunty, "don't ask me, I'm not a doctor!"  Eventually that wore pretty thin when I realized how desperate folks really are to find out what's going on with their health in particular and the health care system in general.   Physicians, often seem to be doing a poor job in communicating with patients regarding the implications of their conditions on their life and on their life-styles.  Yes, they give their patients the raw scientific data, but when an anxious patient is sitting in front of a physician the level of comprehension is often minimal.  The physician is busy, in a hurry with a waiting room that is full of scowling patients who have been waiting too long and the priority is to get the patient our of the office and get on with the next one.  The art of medical conversation is dead and the patient, despite state of the art treatment, often remains apprehensive and generally poorly informed.   Thus the necessity for the emergence of the Honorary Doctor, an unpaid, 24/365 position highly prestigious post.  All it takes is a medical degree and fifty-five years of experience and the gift of the 'conversation', which is almost extinct. 
    My case load this week (all identifying data is omitted) has been as follows:
    One case of chest pain in a friend that occurred while the patient was visiting a different city.  She was rushed to hospital where she was initially informed after a CT scan that she had fluid around her heart. Apparently cardiac studies showed no evidence of heart muscle damage and they booked an MRI.   She didn't know the doctor and decided she had enough and wanted  to sign herself out of hospital and go home to see her regular physician .  Her husband phoned me from her bedside.  I talked to her at some length, explained the reasons for staying and the risks of discharging herself.  It was a three hour drive home and we didn't know what was wrong.  Too risky. She decided to stay and have her workup completed.
    The next case in my honorary casebook dealt with a man with a longstanding neurological disorder who had been waiting for a subspecialty consultation for an unreasonable lengthy time, increasingly typical of our health services, while our government grossly mismanages the tax dollars entrusted to them. We discussed his management and the deplorable waiting lists. Unfortunately there was little I could do, apart from offering a little comfort.  
    Case number three was a family member who presented to the emergency with an acute respiratory problem.  After some emergency treatment he spent seventeen hours on a guerney in the emergency department, coughing his bacteria over a room crowded with sick and debilitated patients.  So whatever their problems when they came in they were likely to be considerably worse by the time they got out.  The reason for the lengthy delay was that there were no available beds, but when he was eventually admitted and I visited him there are empty beds all over the place.  That was because those beds were out of service and that, in turn,was because the the hospital budget couldn't afford the nursing staff.   This in a country where the PM can afford to give a jihadi terrorist killer $10000000 of taxpayer's dollars.  Canada has to get rid of this confused PM!  Incidentally, my parking fees were $14 and I couldn't but feel sorry for folks who have family members in hospital for weeks.  Maybe a little of the terrorist reward fee could go towards helping them out.  I'm sure Canadians would rather see their tax dollars spent that way.
    Other issues were minor, a sprained ankle, a couple of teeth broken in an accident, shingles, a benign cardiac arrythmia.  
    Retirement is a full time occupation.
    I can't wait to see what next week will bring to the Honorary Doctor.

If yoi have any horror stories, or delightful ones you want to share leave a comment.

Thursday, 29 June 2017

The Honorary Doctor.

   It's about three years now since I retired (or is it four?).  I'd been practicing Medicine for about fifty-five years and I was never bored with my job.  Frustrated- yes often.  Exhausted- yes, very often.  In those days if you delivered a baby at three in the morning, you didn't get the next day off.  You were at rounds at eight am or if you were lucky nine.  I can remember an occasion when I  delivered two sisters on the same night, one at two am and the other just was ready soon after I had got back to sleep at five am.  I had normal office hours the next day, though I did ask one of my partners to make hospital  rounds on my patients that day.  Doctors did that for each  other and for their patients in those days.  I was no exception to  the rule, that was the standard.  Many doctors actually cared about their patients as they would about friends and indeed many patients were friends or became friends, though I'm not sure that is such a good idea. 
  I can honestly say, that I never feared a patient would sue me and I  never had a suit against me or even a threat of one.   Being a rather but not completely naive individual, I believed that I could present anything I had done in the area of patient management, as being done in the belief that it was in the best interests of the patient, and I believe my patients thought that too.  We were on the same side, I believed I was acting in their best interests and so did they.  If I was worried about something I had done, or something I had not done, I discussed it with my patient.  I thought they would think I was an idiot when in fact they thought, correctly, that I cared.  Sounds pretty corny, eh?  But in an era where doctors were quitting practice because their insurance overhead was so high, the Canadian Medical Protective insurance informed me that they would continue my coverage without further premiums to me as they had never had to provide service to me.   By the way, not long after that, they discontinued this practice because paying members objected to the practice, not recognizing that we, the lifelong suit free practitioners were subsidizing them, not the other way around.   
   I was a competent though not particularly scientifically smart doctor, but I knew the areas where I was exceptional and those where I needed specialist colleagues to help me out.  Even the relationship between the specialist and the GP was very different then.   I recognized early on, that the technical knowledge of my specialist colleagues far exceeded my own.  Many of them had spent enough time doing general practice to have considerable insight into the myriad problems it presented.  Indeed, it was often the catalyst that encouraged them to specialize.  I developed a network of specially competent specialist colleagues in my early days of practice in Regina to whom I referred patients, but whose brains were mine to pick when I needed to.   So, I would call my colleague about a puzzling case, (No multi-level answering service if he was not there, just leave your number and he will call you back - and by God, he did, even if it was after supper!)   The conversation would go like this"
  Hey, I saw this patient today, she had A + B +C +D.  I was a bit worried that she might have  something more than E going on. Do you need to see her ?  
  He might say did you do E +F +G?  If they are okay just carry on with the treatment you prescribed  otherwise I better see her.
  All this was done without any recompense to the  GP or the Specialist.  
  It was a part of professional etiquette which was done as a favour.  Note both the GP and the patient were the recipients of the favour.  
   Something that might require two or more consultations and taking weeks (or months) of waiting for appointments, were dealt with, without recompense by two committed physicians over the phone.  
   I guess the folks just didn't know when they were well off!!
   No wonder the health care system is going bust!!
   I didn't even get started on the Honorary Doctor, I guess you'll just have to come back - or not!