Thursday, 15 February 2018

Mike and Family Medicine in Saskatchewan. Pt 2.

See previous posting for part 1.

   A week later I met Mike at the construction  site of the new hospital.  He was waiting for me, replete in his yellow hard hat with the rolled-up blueprints in one hand and a spare hard hat for me, dangling in the other.
   "Put this on," he said, passing me the hat.   "I'll take you on a quick trip around the hospital and we'll end up in the Department of Family Medicine.
   I looked around the huge empty spaces, naked apart from girders and dry wall and found it difficult to imagine it ever becoming anything, while Mike did his best to describe what a magnificent cathedral to health the structure would be.  Finally, we ended up at what was to become the Family  Medicine Department.  We stood in the corner of the unit with large windows on  both sides, looking out over the bald prairie.
   "This is going to be my office," Mike said proudly.
   "Not going to be ready for a long time," I answered.
   " That's okay, We are going to have to develop a two year family medicine training program and we are going to have to negotiate with the essential specialty departments and the community family physicians to put together a successful training program orientated to Family Medicine.  We can't do it by ourselves.  So we need to have it lined up to take in our first batch of residents a year from September.  It'll take a lot of work to have the program ready to go by that time."
   We went for lunch.

   Family medicine, or General Practice as we called it back then had fallen upon hard times.  The General Practitioner, was on the bottom rung on the ladder and by many regarded as the basic graduate in medicine who was unable to aspire and ascend to the heights of medical specialization.  The jack of all trades, master of none concept.  Many GPs accepted that role, either because they did not have the resources to continue their studies or because they lacked the confidence to feel they could fulfill the requirements for specialization.  Indeed, in those days, it was common to ask, 'Are you a specialist or just a GP?'.   But there was another group who regarded themselves in another light.  They regarded themselves not just as scientists in the health sciences, but as problem solvers in the broad spectrum of  health disorders, be they pure physical problems, mental ones, including relevant social issues.  Problem solving could mean anything from the practitioner dealing with the entire problem, to dealing with part of it and enlisting the help of those with more specialized knowledge and if necessary to transferring the patient to a specialist or group of specialists, while continuing to follow the patient and be aware of needs that fell outside specialty concerns.  In other words, being concerned with the greater picture of the patient as a functioning human being.  The problem was that the practitioners holding up the base of the pyramid did not receive training either in medical school or in in-hospital internship in how to do this.   Nobody even considered what sort of training would be necessary to achieve these goals, until a group of  generalists got together to form the College of General Practitioners in 1954, which became the Canadian College of Family Physicians in 1968.
   Patients were getting tired of being regarded as 'interesting cases', removed from  the realities of their existence.  They just wanted someone they could talk to and explain their problems to and get some sort of a reasonable answers. While some GPs were doing an admirable job, some weren't and since nobody knew exactly what it was that a family doctor was supposed to do, it was difficult to establish a standard curriculum.  The College of General Practitioners, later to become the College of Family Physicians of Canada, was there to establish that standard and to ensure that it was being met.  The University of British Columbia and the University of Western Ontario were the first centres to  wholeheartedly commit themselves to establishing a Department of Family Medicine and designing a program to meet the needs of future Family Doctors.  The University of Saskatchewan was not far behind and Doctor Mike Spooner was an undisputed leader in the development of the discipline of Family Medicine in Saskatchewan and in Canada.

   Despite the fact that I assured Mike that I was not considering moving out of the partnership that I enjoyed, Mike and I continued to meet for lunch on a weekly basis.
   "You are already involved with teaching and even if you are not considering an academic career, I need all the help I can get from community physicians, because as we both know much of family practice can't be learned in a hospital.  I did learn something about education in general and medical education in particular when I did my Master's Degree at Michigan State and I've visited the few established programs in Canada and the U.S. to see what they are doing.  In fact I think you would find it very interesting to have a look at a few of the programs.  Rochester, New York has a good program and so has Dalhousie in Halifax.  If you'd be interested in having a look at a few programs I think I could get the University to fund it," Mike said.  "Then when you get back we could discuss the best way to put together a really good two year residency training program in Family Medicine.  I have an embryonic plan but I need a good community based general practitioner who's had experience in the real world to help bring it to fruition.  It's a huge job, Stan and it has got to be ready to go by September, a year from now, because I am already recruiting a fantastic group of final year medical students who have expressed interest.  Think about it."
   How could I help thinking about it, a thirty-nine year old GP being offered a whole new career just in time for his fortieth birthday?

See the next posting in a week or two to see how family medicine developed in Saskatchewan and Canada.
   
 

Friday, 9 February 2018

Private Health Care in Canada.

Private Health Care in Canada. 
 
   It's been coming and coming ...and coming and in reality it's here!  Of course it has been here in various shapes and forms for a long time, but it keeps its head down and is careful to keep  low  profile.  If you think politicians and the growing armies of administridiots subservient to them deal with the same obstacles that you and I do, you are just a plain old-fashioned fool.  When the CEO of a  hospital intervenes on behalf of one his political masters, do you think he waits six weeks for an appointment?  But when people want to make health care more available by being prepared to invest their money in the health care system, either by co-insurance or direct payment  (which ultimately would benefit everyone) and which most developed countries do, it is strictly prohibited.   Why?   There are a number of reasons but prime among them is the realization that the public will come to realize a little more rapidly than otherwise the disaster that our health care system has become.  The Canada Health Act, is responsible for our decline from being the finest example of heath care among the developed nations to the very bottom of that list.  We have been in decline for a long time and all the political planners have done is to generate myriads of committees, each generation try to undo some of the damage that their predecessors have done, while holding onto their jobs, benefits and pensions.  At the moment the only threat to their self-replicating dynasties are the real health care workers, the ones who provide the service and thus know about health care.  They must be dis-empowered and subjugated at all costs.  Governments have been quite successful in achieving this goal, but some of the folks are waking up!
   So, when I opened my junk mail this morning I was not surprized to see a very pretty pamphlet entitled:
           
               
                                      Love Yourself


                      Advanced Medical Group
          
               Nourishing Body, Mind & Spirit. 
                 
                              One of the subheadings reads:  
                         
                          Timely access
           
                      Day surgery and outpatient procedures:
    Ophthalmology, Vascular Surgery, Otolaryngology,       Oral Surgery and General Surgery.
                Available for early scheduling.


   It goes on to deal with various health related issues including dental, dietary, diabetic, dermatology, nutrition, physical fitness and obesity.  Seniors care including short and long term suites are available.
   This is the first time I have seen these sort of services openly advertised in our city, though I have seen the 'Pot Pusher Docs' advertise.  The government doesn't mind that, though I'll be watching carefully to see how aggressively they will react to the challenge to their health care dictatorship.   After all, they wouldn't want the folks to wonder why all these readily available services are illegitimate under the Canada Health Act!!  
(I haven't checked this service so this is just the information, not a recommendation.)

I'd welcome your comments.
 

Thursday, 1 February 2018

Dr. Mike Spooner and Family Medicine in Saskatchewan.

   Mike Spooner, an old colleague and friend, died last week.  When Mike came back to Regina circa 1965 with his recently gained master's degree in education, it was with the intent of developing a postgraduate program in Family Medicine in the province of Saskatchewan.  A new family medicine department already existed in Saskatoon, the site of the medical school.      Until then, the one year rotating internship was all that was required for licensure and this was very much 'in-hospital' care. There was a growing recognition that this did not adequately prepare students for general practice, where most of the patients were ambulatory and often carrying on with life as best they could.  many mothers knew a good deal more about common pediatric conditions than their newly qualified doctor.  Developing a family medicine residency training program was essential. City Hospital in Saskatoon traded most of their rotating internship positions for Family Medicine training positions in the early seventies. 
   Mike was determined to develop a residency training program in Family Medicine in Saskatchewan when he started back into family practice in the Medical Arts Clinic and that was when I met him and we became friends.  He quickly developed a general practice within the clinic where his enthusiasm and restlessness to  improve the training of Family Physicians was apparent.
   I left the Medical Arts Clinic after about two years to join a smaller group in Regina and was settling well into that group where I thought I was going to live out my professional career, but as Rabbi Burns said," The best laid schemes o' mice an' men//gang aft a-gley".
    I got a call from Mike, one day.
   "Hi Stan, I've got a proposition  for you," he said.  
   "What sort of proposition, Mike?" I asked.
   " You know the new hospital that is being built on  the North side of the city, by the  by-pass?"
    "Yes,"
    "Well, there is going  to  be a department of  Family Medicine, with the mission of training family doctors for the  province," he said, "I'd like to take you out to lunch and tell you about it and show you the plans of the new Family Medicine Teaching Unit."
     "Sounds very interesting Mike, but I'm quite happy where I am now and not considering any sort of a move in the near future."
     " Just come and have a look at the plans of the new unit," he said, "you've been teaching students in your office practice for a few years, I'd just like to share our plans with you and see if you are interested in being involved."
      "Okay, Mike, as long as you realize I'm not contemplating any moves.  I don't want to waste your time."
      "Lunch at Gulf's, Wednesday at one, if that suits you."
      "That will be fine." I answered.

   So, on the following Wednesday I skipped out of the office a little early to meet Mike for lunch.  I am always early for my  appointments, a habit I have  never been able to  get out of, so I was nicely settled at my table when Mike breezed in, looking very business-like with a roll of blue-prints under his arm.
   After the usual niceties were exchanged, I asked Mike what the rolls of blue-prints he had placed to the side of the table were.
   "They are the plans of the new Family Medicine Unit that is going to be in a new hospital that is under construction,"  he said enthusiastically. "This hospital is cutting edge, it's going to  be the 'jewel in the crown' of the health care system.  It's to be called 'The Plains Health Centre' and we are just in the process of  planning the layout of the Family Medicine Unit which will be the training unit for future generations of  Family Physicians.  It's not good enough to  throw new graduates into a rotating internship when all they have been trained in is hospital medicine. 
   It wasn't long before Mike had the blueprints spread all over the table and was enthusiastically pointing out all the nooks and crannies of the new department.
"Here there's  going to be a well equipped in- department operating room for the sort of minor surgery that family doctors traditionally did in their offices, here," he added, "there will a lab, and around the periphery are the consulting rooms and examining rooms." He went on animated.

    "Really interesting, Mike.but why are you going into all this detail with me?" I asked, knowing full well why.
   " Stan, I've developed a plan for a Residency Training Program for family doctors, I have a group of exceptional new graduates interested in practicing in the province and I can't think of a better role model than you to be the residency training director.  You've been taking interested students into your office to "puppy dog" around after you and see what medicine is like outside of the Teaching Hospital environment.  I'd really like to get you involved.  We need someone to be the Residency Training Director and I thought you might be interested."  
   I knew I was a competent general practitioner but I  certainly wasn't an educator.   I had accepted medical students into my practice to expose them to medical care outside the hospital environment.  Anything I had to teach was not academic, it was 'real world' stuff that a student could get a glimpse of by watching what I was doing and asking relevant questions as to how and why.
   "Mike, this sounds like good stuff.  I spent a couple of years around hospitals after I got my degree that certainly didn't prepare me for general practice.  In fact, as you pointed out, that only prepared me for more hospital care practice.  I support the concept of a training program that emphasizes looking after what you call the 'walking wounded'.  I'm not an educator, I'm a grunt, a GP looking after patients.  You need to find a someone with an academic teaching  background."
    " I'm not asking you for a decision right now.  Just don't say no.  Think about it for a while and maybe we can get together  in a couple of weeks and I can show you the building in general and the Family Medicine Unit in detail.  And I'd like to talk to you about involving community physicians because I know we'll have to involve them in a major way."
   " Okay, Mike, but I don't want to leave you with the impression that I'm thinking of moving.  I'm in a good group, with good partners and I think this is where I'm going to stay until I retire!"
   "I'm not asking you for any decisions just don't say no for now and let me discuss some of the plans I'm developing with you."
   "Okay, but I'm not making any commitment."
   "Fine," he said, "why don't we meet for lunch next week and then I'll take you over and show you the building."
Watch this space for episode 2. 
  

Thursday, 25 January 2018

Blood Tests and Cancer.

   Newly discovered blood tests, some scientists are excitedly telling us, could detect early stage cancer, before it is causing any symptoms or signs.  The testing, of course is in its infancy and its accuracy is not yet validated.  The blood detection tests were carried out on patients already known to have the disease and in the  first run appeared to have about a 70% accuracy rate in those known to have the disease.  There is a great deal to be learned regarding the reliability, the  specificity and sensitivity of these tests, but that is not what this blog is about.   I'll leave such questions to the statisticians and cancer specialists.  Let us assume that the tests will prove to be acceptably reliable,(what is that?) where should we go from there?   Should we be launching an extensive, expensive and possible harmful investigation on test positive patients who are otherwise well?  Or should we be directing those funds towards people who are already diagnosed and are awaiting confirmation of diagnosis and treatment?
   We may have to make some very difficult  decisions.  The question is can we afford to go on such fishing expeditions when people with very treatable conditions are not receiving adequate treatment within an acceptable time frame because of  cost to the system?  What do we do when we catch a small or medium sized fish, when we have people with clearly established disease, on lengthy waiting lists for the consultations and diagnostic tests and treatment that they urgently need.  Even after diagnosis many wait excessive time until treatment.  There are those who can't afford treatment when it is not covered by a private drug plan.   Under the claim that it is better medicine, physicians and patients are being urged to do fewer tests under a program called 'Choosing Wisely'.  Those responsible for the development of the program disclaim being motivated by financial considerations although there could be huge saving if the profession and public is convinced.  We are told that complete physical examinations, the inexpensive sine qua non of  the medical method since the dawn of modern medicine,  is no longer necessary.  It is too expensive. It's not clinically productive, they say.   Those who say that show a lack of understanding of the very nature of the patient physician relationship.  They prefer to do tests, even when  they are not quite sure what they mean and even when those tests may ultimately result in a further cascade of tests which may ultimately harm the patient.  Unfortunately, over diagnosis and over treatment are sometimes the results of screening tests and can result in significant  mental and physical harm occurring. 
  These are difficult questions to answer, but when already diagnosed patients with serious illnesses that have proven management regimens cannot be adequately treated due to lack of resources, is it appropriate, or even moral to go on an expensive fishing expedition, the results of which are presently unknown?
Let me know what you think.

Sunday, 14 January 2018

How to fail your exams and sue your University!

       I still have nightmares occasionally when I dream I am setting out for my final medical exams in Trinity College, Dublin. I already had a job lined up in a food canning factory in England so I could support my wife and daughter while studying for the exam re-writes. Then I wake up in a cold sweat for a few moments before I am flooded with the relief of realizing it is just a nightmare. For the record I did pass my qualifying exam on the first writing but I did gain some insight into how a falling candidate would feel, particularly if in the exiguous financial condition I was in. The option of blaming the University program was unimaginable.
Today, almost every student who gets into medical school graduates. In my day it was quite different. As far as I can recall about twenty percent of candidates dropped out and another percentage had to repeat part or all of a year. Nobody sued the medical school, nobody thought of suing the medical school or university.
    Even as undergraduate medical students, we realized that there was great variation between teachers, some were highly entertaining despite the fact they they were not great teachers, others were extremely erudite but so dull that half the class fell asleep and there was everything in between. Most of us realized early on whether our various programs had weaknesses and as responsible doctors to be, many of us learned how to compensate for the deficiencies of the program. Physicians need to be resourceful and even in the era before everyone had a computer in their pocket and access to all the knowledge in the world, we usually knew what we had to do to make up for the deficiencies. I went to a good school but I recognized there were area where I needed some extra help and sought some private tuition.
    The case in the news at the moment is of an Ontario physician suing Western University for $11,000000 because he contends that the medical school didn't give him the education he needed to become certified as a specialist in medical microbiology. This was a five year residency program which the doctor claimed deteriorated rapidly while he was enrolled in it. He failed his specialty exam three times , in 2012, 2013 and 2014. Then instituted legal proceedings and Western is seeking to appeal a judge's ruling that allows the law suit to proceed.
  In this age in which almost everyone considers themselves a victim of one sort or another, it doesn't seem to occur to the doctor that even if most he has to say is accurate, that HE is responsible for his education. This is not a naive young student, but a man who has gone through the rigorous educational system to get an MD degree. There were numerous remedial steps he could have taken including taking some of his studies at another institution (not an unusual solution in numerically small programs), arranging to work under the supervision of a recognized expert in the area, independently planned study perhaps in coordination with a colleague in a similar specialty. The doctor/victim seems to feel that he is just a victim who never had control over his plight.
    If the Doctor succeeds in his efforts the face of medical education and indeed, of University education may be forever changed. All any failure has to do is sue the University and he/she may never have to work again! Throw in a suggestion of racism, gender discrimination or ageism and maybe we can all be victims.

Thursday, 11 January 2018

Canadian Health Care Embarassment and administridiot hubris.


  It's a major embarrassment that Canada,a country that once enjoyed international recognition for its health care system was ranked last of eleven developed countries by the Commonwealth Fund. If you still think our service is acceptable read the report for yourself. You will be horrified. Our politicians have done an incredible job of' fooling most of the people most of the time'. Still, they are smart enough to vote themselves a special health care package.
Most criminal of their activities is their acceptance, even encouragement, of the dangerously long waiting lists. The average wait for treatment by a specialist from the date the patient was referred by the Family Doc has hit twenty (20) weeks. In 1993 it was about 9 weeks. The wait-times continue to increase. In some specialties the wait is much longer unless you have a life threatening emergency.
    I can think of no reason why people put up with this appalling situation other that they have been fooled into believing that we still have the excellent exemplary standards we once had. We are now an example of another kind.
    Countries like Australia, Britain, Germany, France and Switzerland have systems far superior to our own.
    One of the main reasons for our dismal failure in improving or even maintaining our system is the Canada Health Act, a brain child of Canadian Politicians , that is so rigid that it leaves no possibility of improvement. The Canada Health Act prevents the private sector from playing a significant role in health care delivery except when the government is totally unable to provide the service. They jealously guard their monopoly despite being well aware that all of the above countries use all the help they can get from the private sector, sometime involving co-payments or deductibles. The Canada Health Act prohibits this although it is successful and provision is made so that the poor receive the same benefits as others. People in  the above mentioned countries willingly buy supplemental insurance or make modest co-payments thereby injecting much needed funds into the health care system to everyone's benefit.

   Unfortunately the hubris of Canadian politicians of all ilk make them regard any help as a loss of face, although they have already sustained that by reducing one of the finest health care systems in the developed world into one of the poorest, but as long as they do not perceive it as costing them votes, who cares?
   Remember Ronald Reagan's quotation of the nine most terrifying words in the language: "I'm from the government and I'm here to help."  
   How right he was! 

Be sure to read next weeks Medicalmanes to learn about suing your University for not passing your exams!! 


Sunday, 24 December 2017

Drug Pushers - of a different kind!

Drug pushers of a different kind!  (But not all that different.)

   The amazing irresponsibility of our government and its administridiots is not difficult to explain.  They are well aware that the consequences of legalized recreational marijuana are just beginning to be scientifically examined and that they look significant.   On the other hand, they are drooling at the huge pot of money they are sitting on.  Particularly in Ontario, where the Liberal government has turned what used to be the economic engine of Canada into a 'have-not' province, is the enthusiasm great.  Not only may they realize a significant financial treasure, but they may be able to keep the Mal-contents a little happier and win their  vote.  (In fact, an accountant I respect assures me there is a good chance that the governmental drug pushers of Ontario may be the first drug pushers in history to lose money!) 
   A Canada Health survey,the Canadian Cannabis Survey, 2017, reveals some interesting facts.  The survey included 9215 respondents recruited from randomly selected telephone numbers (landline and mobile).   Of particular interest and relevance was the attitudes of responses to driving among the marijuana users.  Only half of the respondents who had used marijuana in  the past year felt that marijuana use affects driving.  Twenty-four per cent said 'it depends' and nineteen per cent said it doesn't affect driving at all.  Of those who had used marijuana in the last twelve months, thirty-nine percent said they had driven within two hours of its consumption.  Forty per cent said they had done so in the previous thirty days and fifteen per cent said they had driven after using cannabis in association with alcohol.  Concerns about how to detect and deal with this are high, particularly as blood tests are necessary to make the diagnosis and the levels defining intoxication are arbitrary.  The Public Safety Minister says," The message is simple - don't drive high!"  I'm sure the pot users are listening!   Fortunately pot breathalyzers are in development and being assessed for reliability, as well as ignition control devices that will disable cars if the driver does not pass the test. (Cannabix Technologies Inc)  This will enable police to be able to test at the roadside and employers to check in hazardous workplaces.
   So, what's the hurry?  The urgency is that both the provincial and federal Liberals want the votes.  If another few die on the highway - too bad.
  Those pushing for the legalization of medical marijuana in 2018 should carefully study the document "the Legalization of Marijuana in Colorado: The Impact"  published in October 2017 by the Rocky Mountain High Intensity Drug Trafficking Area (www.rmhidta.org).  They might learn something.