Saturday, 24 June 2017

Hormone replacement therapy and breast cancer/heart risk.

   When I started practice, way back in the dark ages, many women were on long term hormone replacement (HRT) therapy for years.  It was regarded as some sort of 'elixir of life' which protected its users from many of the consequences of growing older, including heart disease, vaginal atrophy, vascular instability resulting in hot flashes, palpitation and generally feeling unwell.  I believed then, as I do now, that it is appropriate to use HRT for a time in woman, who are symptomatic, where there is no contraindication.  In 2002, in a study called the Women's Health Initiative (WHI) the estrogen-progestin trial was stopped early as a result of an initial results press release citing an increase in breast cancer and increase of heart attacks in the treated group. Now Dr. Robert Langer, the lead investigator in the study states the report was written in secret by a small group of study executives and resulted in "misinformation and hysteria". Langer further stated that the study results were not statistically significant for breast cancer or cardiac harm, that there was some increase in venous blood clots but there was a reduction in hip fractures.  He states the study results were not adjusted for pre-existing diseases or treatments and that there was an unusually low rate of breast cancer in the placebo group(The controls).  Further, he states that the trial was designed to focus on long term hormone therapy to prevent chronic disease in women over the age of sixty, but the results were generalized to younger women on short-term therapy for menopause.  Later analysis of the study data showed that these younger women had an absolute risk of twelve (12) adverse events per ten thousand women (10,000), less than a third of the risk noted among women of age seventy to seventy-nine, as well as fewer cancers, fractures and deaths from any cause compared to the placebo group.
Langer states the press release favoured "fear and sensationalism over science".  
   Medical consensus has come around to supporting short-term hormone therapy for symptomatic menopausal women, though as a result of the bad press many doctors are apprehensive to prescribe it. Some specialists are more strongly in favour of prescribing HRT and a study published in 2013 estimated as many as 91,610 American women died prematurely between 2002 and 2012 as a result of avoiding estrogen therapy.
   In practice, my policy was to treat symptomatic woman with hormone replacement therapy after sharing as much information as we had at the time, if they wished to proceed despite the possible minimal risks.  Many had such severe symptoms and such severe an effect on  their quality of life that they were in absolutely no doubt in opting for treatment.   When their symptoms resolved we tapered the treatment as tolerated.  Of course continued careful observation is of prime importance but until the answers are all in, informing the patients as accurately as possible of what appears to be the minimal risks of symptomatic short term treatment and allowing the patient to decide whether to proceed or not would seem to be the appropriate approach.   Long term treatment is inappropriate with the current state of knowledge

Thursday, 15 June 2017

OMA Advice ?.

  Below is a recent communication I have received from the OMA.   I have nothing against homosexuals, nor against any other self-interest group, but I do have something against so-called professional organizations who put their sanctimonious politically correct causes ahead of their paying members struggle for survival.  That's what is going on in Ontario.
   I believe people have a right to do whatever they like as long as they are not hurting someone, but gimme a break, I don't even go on heterosexual pride marches, though I haven't had any invitations to. 
   Perhaps the new executive will direct their attention to relevant. business.   The inmates have been running the asylum for too long!!  The OMA has been doing a poor job for too long. 
            
St.
    
From: Ontario Medical Association
Sent: June 12, 2017 12:47 PM
To: Stanley G Smith
Subject: 2017 Toronto Pride Parade: 6th Annual Ontario Doctors and Allies Pride March

2017 Toronto Pride Parade: 6th Annual Ontario Doctors and Allies Pride March
Dear Ontario Physicians, Resident Doctors and Medical Students:
Please join a group of Lesbian Gay Bisexual Transgendered Queer (LGBTQ) and allied physicians, resident doctors and future doctors to march in solidarity in the 2017 Toronto Pride Parade!        
Goals of the event:
1.    To combat homophobia within the medical community and society at large.
2.    To show the public that there are outspoken LGBTQ physicians and physician allies, and help attract media attention to this important issue.  
3.    To have fun!          
Details:
On June 25, 2017, please march with us! We will be meeting on Bloor Street East between Church Street and Ted Rogers Way at approximately 1:00 p.m. (exact time and location to be confirmed, visit our Facebook page or email us in the days prior to the march). We will be dressing in hospital scrubs and stethoscopes. Bring a motivational sign and lots of energy! Interested individuals can RSVP by visiting our Facebook event page or by emailing lgbtdoctorsandallies@gmail.com.
Looking forward to seeing you at the parade!
LGBTQ Doctors and Allies
The Ontario Medical Association (OMA) administers the distribution of communications for its various Constituency Groups, and therefore the views and the opinions expressed in this communication may not reflect the views, policies, and opinions of the OMA.  The OMA does not warrant the accuracy, timeliness, or completeness of the information contained in this communication, nor does it accept any responsibility for its contents.
O

Forget 'Assisted Suicide', Bring on the 'MAID'.

   Life was simple when I was a  young doctor.    I knew exactly what society expected and demanded of me and I knew exactly what my duty was to both society and myself.  It was easy, my responsibility was protect and extend the life of my patients and where I could not cure the disease or maintain life, to relieve pain and suffering to the extent that my skills would allow.  Medicine was about life and how to make it as livable and free from suffering as possible.  Most of the people I knew thought the same way and that is why they chose medicine as a career.  Not Law, not Accountancy, not political science.  Medicine.  I thought it was a noble profession and so did most of my classmates. You may think this presumptuous and perhaps it was, but somehow and for whatever idyllic misconceptions we had, it seemed to work out very well.  Don't get me wrong, there were always rogues and rascals in my profession, as in any walk of life, but they were a small percentage of the whole and after a lifetime of medicine, I still believe, as I always did that 5-10% of the profession caused 95% of the problems.  I continue to believe, that the objective of most physicians is to prolong healthy life, cure illness, where possible and relieve suffering when cure is not possible.  It was impossible to believe that the state had an entirely different expectation of the role of physicians. Those expectations are related to politics and economics.
   The legislators in the land have now decided that part of a physicians duties include terminating patients.  I disagree. Since the dawn of modern medicine and indeed before that, the goals of medicine have been to restore health, prolong life and relieve suffering.  Although there are circumstances when treatment should be limited to the latter and the objective of prolonging life is no longer tenable, throughout the history of medicine terminating life has been the ultimate prohibition.  And, for physicians/nurses there it should remain.
   If society decides it wants to authorize a group to take a citizens life when the citizen requires it or demands it, that's none of my business.  Let them identify a group of technicians to do the deed, it really isn't very difficult.  When the expectation is that this should be a physician's duty and indeed that the physician who refuses should be penalized, I am outraged.   A technician could be trained to do this in a couple of months.  As someone who has spent much of his professional life training physicians, I know a thing or two about young people and young doctors.  Once a physician ceases to hold life as sacrosanct, the slippery slope begins.  We have seen the end of that slope in Auschwitz, in Buchenwald, in Treblinka, where individuals who had been perceived as reputable, brilliant physicians committed atrocious, heinous acts.  Just beneath the veneer of concern for aging sick patients, the politician/bureaucrats are acutely aware that the health care costs of the elderly are astronomical and growing rapidly.  An efficient method of reducing costs would be for assisted suicide (now known as Medical Assistance In Dying) to become the norm and in the not too distant future gently (for the moment) encourage it.  This piece of social engineering would let the politicians off the hook and help them conceal or at least make much less obvious that there is no alternative but to ration health care before it consumes the complete GDP.
   Canada, sanctimoniously proclaims its sympathy for all of mankind and all of life.  Unfortunately, this concern for the protection of life seems rather hypocritical when we look at the way we kill our own unborn.  I am not against abortion for any religious reason and I think there are circumstances when it is entirely justified.  I don't condone it when the fetus is a viable baby killed for convenience, as it often is.   In many instances it is merely a cruel and expensive method of birth control.   In fact, we have one of the highest abortion rates in the western world.  Still, free and unregulated abortion is so popular that governments are reluctant to place even the most logical restrictions on it.  So let us stop playing the pious protectors of life and human rights.  The administridiots have made it difficult to even discuss these issues dispassionately.
The Colleges of Physicians and Surgeons, the licensing bodies, have allowed themselves to be the willing tools of government, as has the Canadian Medical Association in Ontario and elsewhere.  When a group of physicians protested that their ethical  standards prevented them from assisting in patient suicide or even referring a patient to a 'terminator' and that the College was negating their Charter rights, here is what the College arrogantly responded:  "It is the colleges position that not only can it do so, (override the Physicians Charter rights) but that it should  do so"   Thus the College of Physicians and Surgeons of  Ontario is complicit with the government of Ontario in attempting to compel physicians to violate their consciences. 
   Let's pray that they fail!

Monday, 5 June 2017

Medschool 2. Reflections of a dumb GP.

  

 Our preliminary lecture in anatomy was largely consumed by the Professor informing us that Anatomy was the most important subject that we would ever study and that a doctor without extensive knowledge of anatomy would simply be a butcher, or as a respected pathologist said of his specialty, without a deep understanding of pathology (and even more so anatomy) a surgeon is simply "A hewer of flesh and a drawer of blood'.  This was, of course, before I realized that regardless of the topic we were studying, its professor emphasized that his subject was the one essential topic in producing competent physicians.  He went on to explain to us that we would be divided into teams of six students and that each group would have a cadaver assigned to them.  We would spend the next year systemically dissecting the body in synchronization with the series of lectures and demonstrations we would receive in the lecture theatre.  The dissection room, a short walk from the lecture theatre was divided into alcoves, each with a centrally placed gurney on which lay a cadaver, covered with a sheet.  Each member of each team would have designated duties and in the paired appendages or organs there would be three students working on the left or the right side. After we had been instructed in the respect due to the cadavers we were to learn  from  and been given a list of the surgical instruments that we would require and the texts that we would need, we set out for the a quick tour of the dissection room.   






No automatic alt text available.

   We walk out of the lecture theatre, excited and a little apprehensive  at the thought of meeting real dead bodies that shortly thereafter we would be dissecting.  The professor has dumped us and we are now being shepherded by our 'demonstrators', young newly graduated physicians usually specializing in surgery, who are fine tuning their anatomy knowledge and earning a few bucks at the same time.   As we walk out of the lecture theatre and outside of the building every one pulls out their cigarettes and lights up.  That was normal in those days when almost everyone smoked.  
   " Gotta fag?" I ask Maud, an older woman of about twenty eight, who was my new friend since sitting next to me at the lecture a little earlier, by virtue of her name starting with the same initial as mine.  I was to sit next to her at lectures for several years.   I was eighteen at the time.
      With most of us pulling on our cigarettes to allay our excitement and apprehension and to look cool ,we entered the dissecting roomroom.   This was a large room with alcoves each of which had a Gurney, head in towards the wall, so that of each team of six, three could work on each side simultaneously.   (Fortunately most parts of the human body are paired.)   The overwhelming stench of formaldehyde had most of us just a little queasy.  The bodies, tastefully covered by sheets last waiting for us to start dissecting them next week.  We didn't know their individual histories, but we knew where they came from.  Some noble individuals decided in advance that they wanted to donate their body to the medical school in the belief that it would help medical science, which was true.  Others were people who died in hospital or nursing homes or in the street and had no family or funds.  Some ended up in the dissecting room, where they were treated respectfully, made their contribution to science and were given a decent and dignified burial.
      Maud walked over to ' our' cadaver and gently pulled back the sheet. 
      "Not very old," she said, "quite good looking and not very old.  I wonder what he did in life?"
      "Okay," said another S in our group, "why don't we go across the road to Johnson Mooney's for a cup of coffee and a roll?  I'm really hungry.

 

Monday, 29 May 2017

Canada's Drug Culture.

  It was a nice sunny weekend afternoon and my wife and I were taking a walk past a crowded outdoor cafe where the students and young folk were having fun drinking coffee or beer or other cool drinks.  In a place where a couple of years ago pulling out a cigarette would have caused a riot, we noticed a few tables around the periphery where folks were smoking.  As we passed by one such table, I recognized that this was not any blend that I recognized from my smoking days. It was pot.  Not a single person was jumping up and down with rage, no one burst into a paroxysm of coughing, no one was complaining of the noxious effects of the slip stream exhalations, in fact no one seemed to notice at all.  It was quite like the old days. I almost felt nostalgic.  It was as though inhaling marijuana into one's lungs was harmless, even though there is no evidence that it is less harmful than tobacco.  Despite the millions of dollars and man-hours spent on smoking cessation programs with considerable success, there is a serious risk that now the liberal government is making smoking pot in public an option, that cigarette smoking and even (perish the thought!) the harmless practice of vaping will become fashionable.  Why, even the Prime Minister likes to take a little suck on his dubie once in a while, so it must be alright!
   Despite Canada's dismal record of drug addiction, and it is dismal, particularly among the youth, this government is doing tremendous damage to the population by perpetuating the notion that marijuana is harmless.  This flies in the face of the evidence, but the politicians and their administridiots really don't care about that.
   So, what do they care about?  That's easy.  They care about votes.  They care about taxes.  Make no mistake, there is going to be a fortune in this for the government.  Between taxing the legitimized dealers and the users, many of whom will become addicted, there will be huge sums of money shuffled into the treasury.  But most of all, they believe that a population of drug users will make a population that is traditionally difficult to handle, easier to manipulate and fit into the Great Social Engineering Scheme that the Elites are planning for you.  
   The permissive society will cost our nation dearly.
Comment, if you have anything to say!
    

Friday, 19 May 2017

Black Market Medical Records.

   So, you think when you go to your doctor and pour your heart out, everything is secure, top secret, confidential ?  That's the way it was once, but not any longer.  Your entire medical history may be available for as little as ten dollars!   The erosion started as long ago as the sixties when medicare dictated that for your doctor to get paid, he had to write your diagnosis on the billing slip that he submitted to the government.  Doesn't matter what the nature of your complaint is, your privacy really didn't and doesn't matter to the administridiots who dictated the terms of the heath care game.  Patient's would sometimes plead with the doctor to avoid filing in the true diagnosis. 
   I clearly recall a patient coming to see me to plead with me not to fil in the true diagnosis.  The conversation went like this.
   "Doctor, my sister-in -law works for the health care commission.  If she sees the diagnosis it will ruin my marriage.  Can't you say I just had a cold or something."  So, being young and stupid, out of compassion for the distraught woman, that's exactly what I did.  When I related this to a senior colleague he was aghast.  "Don't ever do that again," said he,"you could really get into terrible trouble.  The folks knew about that when they voted for medicare, now they have to live with the consequences."   He was right, that was part of the deal.  I never did that again.
   Medical confidentiality was never of any importance to the legal profession, especially when it was obstructing them from getting information they wanted.   On a few occasions when I was trying to keep information confidential on behalf of the patient, it was made quite clear to me I would be subpoenaed.  When I consulted a lawyer, it was explained that if I was subpoenaed and refused I would be guilty of contempt of court and could be fined and/or go to jail! (and by the way, if the patient wanted to sue for breach of confidentiality, they couldn't as long as I claimed the protection of the 'Canada evidence act'.)
   The Electronic Health Record only made thing worse.  The early enthusiasm I had for computerized medical record that would make a patient's medical information available across the spectrum of physicians, specialists and health care providers was staunched fairly early on, by the realization the the politicians and their health care administridiots had something quite different in mind.  What they had in mind was a massive data collection that had no relationship to the patients' health but rather to their long term plans for social engineering.  Many of the physicians I speak to nowadays feel the the electronic system undermines rather than facilitates their attempts to provide excellent health care.   But that is not the thrust of this blog, which is that computers will never be safe and that your health records will be available to anyone who is prepared to pay a reasonably competent hacker a relatively cheap price to obtain them.  Not many folks realize that, or if they do, they don't care.  Other and more dangerous consequences of hacking lie in the development of 'ransomware' in which the hackers can disable vital hospital equipment or scramble data and demanding a ransom to unscramble the data. 
   I have no doubt that someday soon, a very smart medical group with a catchy name like 'Healthcare Confidential' will come along with a data disguising program that will enable the patient to be reassured that any part of their history that they deem too personal to be accessible to the administridiots will be suitably encrypted and not obvious to the medically uneducated.  This will be expensive, of course, but I have no doubt there will be many who would wish to avail of it.  
   I wish I had thought of it a few years ago.  In the meantime, good luck!!  
Comment if you care!         

Monday, 15 May 2017

The New World Order.


  I recently  came across this little story that I wrote many years ago for a writing class I was taking while on  sabbatical in North Carolina.

                                                              The New World Order. 
1980
             "I think the North America Free Trade Association really is screwing the U.S." Phil commented, scooping a leaf out of the swimming pool with the long net designed for that purpose.
            "Yes, Canada too." Steve said, squinting into the setting Carolina sun, "In fact, everyone I know seems to think that. I can't understand how we got into it"
            "Ah," said Phil,"It's because that was the decision of the New World Order."  He skillfully trapped another leaf.
            "What new world order?"
            "You mean you've never heard of the New World Order?  You never heard President Bush's New World Order speech?" asked Phil, incredulously. "You guys up in Canada really don't know what's going on."
            "Of course I've heard of Bush's new world order speech.”  Steve responded with a look of feigned disgust, “Guys like you are always reading ominous meanings into situations. Bush was talking metaphorically, all he meant was that someday we are going to have an ideal, peaceful world where everyone is going to live in perfect harmony, and we are all going to love each other and never fight any more wars. Pure political rhetoric,that's all."
            "Oh no, we're talking conspiracy here," Phil said seriously."
            Steve smiled, "You've got to be kidding."
            "No I'm not!"
 Steve's face assumed a more pensive mien.
            "You're not the first person who I've heard say that, though I must admit that I certainly didn't give it any serious consideration. In fact, I considered that individual to be a nut."
            "That’s no way for a psychiatrist to be talking." Phil was interested, “but tell me about it anyway.”
            "Well," began Steve, "it must be about five years ago now, when Anne and I went to Porta Vallarta.  It was one hell of a holiday because we both got really sick, not the usual 'Montazuma's Revenge', but a very high temperature and a violent headache. I started out with it and I must say was so sick that I thought I probably had a viral meningitis. I was just considering calling a doctor when I woke up feeling better.  That very same day Anne started to get ill,and ran the same course. By the time we were both up and around, we decided to take a trip on a ferry across the Bay of Bandera, to some little picturesque village. The ferry ride was pleasant enough, but as we were sitting relaxing on deck, we were approached by a pleasant enough man in his forties, with a slight foreign accent.  We chatted a while,and he told us he was a Mennonite minister living in Western Canada.
            He was a rather extroverted sort of fellow, who talked a mile a minute and after talking a while his manner became increasingly serious.
            'The whole world is in a desperate state,' he said, 'and is being run by  small, clandestine groups of people, who are gathering more and more power.'
            'And who may they be?' I asked, suspiciously.
            'They are the New World Order, didn't you hear President Bush's speech.
Mostly they’re a bunch of Freemasons.'
            'Pretty farfetched, I think it's all a bunch of poppycock.' I was growing wary.
            'I can prove it,' he said,a knowing smile on his face, 'Put your hand in your wallet and pull out an American one dollar bill.’
            I did, and put the bill on the bench between us.  He turned it over,face down and pointed a finger at it.
            ‘See that pyramid, and the human eye on it. That's a well known Masonic sign. And that's the agreement between Masons all over the world that the New World Order is going to take over.'
            Well, Phil,you know me, and by this time I was getting pretty fed up with listening to this guys garbage. Next, thing he is telling us that Hitler was half Jewish, and I come to the conclusion that we have a real loony on our hands. So, not too politely, I tell him to get lost, that I really have no time to listen to any more of this nonsense and with that, Anne and I moved to the most distant point of the ferry we could find.  That's my story of my
previous experience of the New World Order."
            I pulled out a dollar bill and threw it down on the table.
            " What do you make of it." Steve asked provocatively.
            He picked up the dollar bill, turned it over, examined it carefully and shrugged his shoulders.
            "Funny, I’ve been spending them all my life  guess I never looked at one that closely before," he said. "that symbol is certainly there, I don't know what it means."
            "Well I'll tell you what I'll do," Steve said, "I'll phone the treasury department tomorrow, and tell them I'm a numismatist with  special interest in paper money, and that I'm studying the iconography of paper money and want to know what the design on the back of the one dollar bill means."
            "Don't do it from my phone number and don't give them your name or address,either," said Phil seriously.
            "You're joking" Steve said.
            "No,I'm perfectly serious" he said, perfectly seriously.
            "What do you think might happen?" Steve asked derisively.
            "Anything could happen," he said ominously.
            "Here, in the United States ?"
            "Yep," he said.
            "I know you’re kidding me now."
            "No, I'm not. So if you make the phone call don't do it from here."
            Steve was leaving for Durham in a couple of days, so the next day,sure that Phil wouldn't really mind and that their talk of the previous evening was just the usual kidding they often indulged in, he phoned the Treasury Department.
            "Hello," Steve said."I'd like some information,please."
            It took him a couple of minutes to realize he was talking to a machine.
After going through the usual aggravating automated rigmarole, he finally got through to a human, who sounded more like an automaton than the machine had.
            "I'm trying to find out what the symbols on the back of a one dollar bill means. I'm a coin collector and I'm doing some research on paper money."
            "One moment,sir, and I'll connect you to our research department."
Steve waited for what seemed like an eternity, then a business-like male voice,
            "I understand that you were inquiring about the symbols on the back of a one dollar bill," it said. "can I have your name, address and telephone number, please."
            "Er, I just to wanted ask a question about some pictures on the  paper currency," Steve said.
            "We can't give you any information until you answer the questions I just asked you, sir".
            Steve thought he  heard an ominous click on the line and hung up right away.
            A queasy feeling came over him, which lasted a few minutes. When it settled he laughed at his imagination.
            "That Phil really psyched me" he thought. "What an idiot to hang up like that."
            Although he wondered whether he should tell Phil about this incident, the fact that he had been asked not to make the  call from the house, and did anyway, embarrassed him. He soon forgot about the whole episode.
            Over the next few months, He carried on with his work in Durham, and frequently he and Anne spent the weekend with Phil and his wife. He never mentioned the event again, and as Phil didn't either, he knew he really had let his imagination run away with itself.
            Three months later, just before they boarded their flight to continue the sabbatical abroad, they decided to phone Phil and Jane, to say goodbye.
            "Hi Jane," Steve said when she answered the phone. "Let me talk to Phil."
            "He's not here right now," Jane said. "This morning he had a call from the Treasury Department, and had to go right down to see them today.  I sure hope he’s not having trouble with his taxes.  He paid so much this year maybe they want to give him some back." She laughed nervously.  A horrible thought crossed Steve’s mind, “I’ll call back tomorrow,” he said.
            Steve had a restless night as he so often did nowadays, but on this occasion his mind kept racing back to Phil’s trip to the Treasurey Department.
His mind kept playing over that phone call of months ago, that long wait and ominous click.  He hoped he hadn’t got Steve into any trouble.  He resolved to tell Phil about the call he had made from the house and face the music.  He gave up trying to sleep at six o’clock, and started rehearsing what he was going to say to Phil as soon as it was late enough to call.  At nine a.m. he picked up the phone, relieved that he had decided to unburden himself after all these months, and to  tell the truth.  He picked up the phone and dialed the number.
Jane answered the phone.
     “Jane, Steve here, “let me talk to Phil”
     “Oh Steve,” She sobbed, “Phil is in the Intensive Care Unit at City Hospital, He was hit by a hit and run on the way home yesterday."”
      Phil died the next day.  The driver of the car was never identified. 
        (After posting this  I  looked up 'New World Order' in Wikipedia  - yo might be surprised!)