Saturday, 21 April 2018

Medical musings.

  After finding it impossible to shake the blog addiction, I decided to use this site as a note pad to incubate my new blog which will be commencing in a few months.   Most of the scribbles here will have little to do with Medicalmanes, but feel free to peep in and see what's cooking, if you so desire.  For the present this is just the incubator for whatever will ultimately evolve and to keep me scribbling.

An amusing incident (but not for my sister!).
    A couple of weeks ago, my sister was at a community affair in the province where I spent the large part of my professional life practicing.  She was approached by a neurosurgeon who had been a colleague and something of a friend years ago.
   "Sorry to hear of Stan's passing away," he said .
   My poor sister almost passed away.  As she related the story, after the panic attack subsided and she realized I could hardly have passed on without her having heard about it, she informed him that I was alive and well.  He was somewhat embarrassed to hear this!
   What had transpired was this.  This man had worked with a colleague and me in putting together a neurosciences program for Family Medicine residents and we had worked together as a threesome for a considerable period of time.  Unfortunately, the other Family Doc, Mike Spooner had recently passed away and the neurosurgeon had thought it was me.
    I instructed my sister that the next time she saw this  man she was to inform  him, in the  immortal words of Mark Twain, "rumours of my death have been greatly exaggerated!".

    I recently had an echocardiogram (an ultrasound of the heart).  The echocardiography technician was a middle-aged Chinese gentleman and it was soon  apparent in the course of our conversation that he was very knowledgeable regarding cardiology and medicine in general.   I commented on this and he replied, "I was a specialist in cardiology in China, but couldn't get a license to practice in Canada."
   "Surely," said I,"you could have studied and passed your specialty exams in Canada?"
"I did," he said, "but while I was trying to get a residency position in Cardiology, a research fellowship came up in the States and I made the mistake of taking it.  It turned out to last for a few years and  when I came back to Canada, I was told there was no way I could  get a residency spot although I had passed the Fellowship exams.  I was eligible for  such a spot before I  went to the U.S. but I  was told the situation had changed and I was  no longer eligible.  I was able to get licensed as a electrocardiography technician and have been doing that ever since.   I still think about going back to China and practicing cardiology."
   I have had some experience in organizing health care in rural  Saskatchewan.   There are places in  Canada where they would sell their souls to have the services of a cardiologist, so if this man's qualifications are in order, it is difficult to understand why there isn't a position available for him.
But of course it facilitates the rationing of  health care by just not having the service available.

Thursday, 15 March 2018

Medical School. Who should be in and who should be out? Are we makng the right choices?

      When I decided I wanted to become a doctor, life was a lot simpler.  First one had to pass the entrance examination to University.  If one couldn't manage that, that was the end of the  story.  As far as I can  recall one was permitted three tries and if one failed three times, that was the end.   You weren't getting into University at all, let alone into Medical  School.  No-one thought, in those days that everyone should go to university.   No one considered that it was unfair discrimination or racism that all potential candidates were not accepted.  In fact, it was widely recognized that an applicant required a certain initiative and level of competence to be a suitable candidate for a university education.  In those distant days, applicants or their families had to pay their fees, so even the candidates did not want to waste their time and money entering a program that they were likely to fail.  This tended to weed out those who were not likely to ultimately gain a degree that would be an asset to their success  in later life.
      Getting into medical school in those days did not mean you were going to come out a physician.  If one failed to meet the standard one might easily be thrown out!  There were other standards that had to be met, as well as mastering the core content of knowledge.   There were standards of professionalism demanded of a prospective physician.  If the academic faculty. the professors and the Dean of Medicine felt a candidate did not meet the required standards, unless the situation was remediable that candidate  would not allowed to continue the program.  Although the years have clouded my memory, I believe about twenty per cent of the class I started with in Medical School  fell by the wayside.   Any appeal would be dealt with in-house and if it failed, no lawyer would have been sufficiently presumptive to assume that he knew better than a committee of  professional peers whether a candidate was fit to become a physician or not.
     Things are quite different today, when short of criminal activity, no  matter how inadequately a candidate performs he/she is almost certain come out of the program with an MD degree.  The martinets of Academe dare not face the legal teams that will appear on their door-step to challenge their decisions.   As you may have already read in a previous blog, a failed resident is currently trying to establish a suit against Western University, (until recently the University of Western Ontario) for failing to pass the specialty fellowship examination.  Should he succeed the nature of medical education in Canada, and perhaps elsewhere, will be radically changed.   Since it is almost impossible to fail a candidate, the admission process is critical, because once admitted, short of illegal or immoral behaviour, almost everyone who gets into med school will come out as a qualified physician.  The old joke, Q. "what do  they call the person who graduates at the bottom of his medical school class?" A." Doctor!" isn't so funny anymore.
     The Universities, the licensing bodies, the doctor's union (the Canadian Medical Association) and virtually all of the medical associations are intimidated by the prospects of litigation, or falling foul of government and its legion of administridiots. There remains a method in addition to marks, to attempt to ensure that the quality of prospective physicians and other health care workers meet an acceptable standard.  That is by the selection requirements to get into medical school and even that is a target of the bureaucrats.   So, let us at least make it as relevant as possible.
     Not  all schools require a personal interview and other requirements, such as letters of reference and letters from the candidates vary considerably from school to school.  Aside from marks, some of the qualities are extremely difficult to assess even in a carefully planned interview and almost impossible without one.
    The academic knowledge component is the most easily examined and tends to be the most  emphasized, perhaps because it is so well documented and available.    While undeniably important, it is often over-emphasized. In many areas of medical  practice there are very important skills that are unrelated to high marks.  For many years I have maintained that a B+ student with the right qualities can make an A+ practitioner.
     The value of the interview is that it gives skilled interviewers an opportunity to observe the general  presentation of the candidate and his/her attitudes, aptitudes and aspirations.   Admission interviews are very labour intensive.   They require training of the interviewers and tie up four people per interview, and I suspect for that reason in many institutions much of this sort of information is gathered by references, letters or essays written by the candidate and/or referees.  Unfortunately, these are often more indicative of the candidates ability to hit on the 'right' formula and sometimes templates are easily recognizable in the letters submitted.
     In the interview, the demeanor and general presentation of the candidate tells a lot.  Anxiety is normal and we spent some time in making the applicant as comfortable as possible.  Some candidates were obviously well rounded, had broad interests in what is going on in the world and showed comprehension appropriate to their age and experience.  Some were totally lacking in general knowledge.   Some had never read a book. Some had a realistic idea of what it might be like to be a physician and had talked to a doctor or nurse or someone at their local hospital.  Some had aspirations and ambitions to do something in health care, like be a family  doctor or a pediatrician or a 'research' doctor.   Some had no such aspirations and one fellow answered my question re an important achievement with, "I'd like to get around the golf course in par."        
    There were four interviewers and while that may have been a bit  overwhelming, it made the procedure very fair, as each interviewer graded the candidate separately and only after the interview did we compare scores.   If ALL of the interviewers were not very close in their assessment, the candidate got another interview.   That did not happen very often. 
    I continue to believe that the interview is an important part, perhaps the most important part of selecting prospective physicians, who will deliver the best possible care to the population.   I hope it will not be abandoned in favour of easier but less valuable methods of selecting the future generation of physicians. 
If you have any opinions on this, share them with me!!

Monday, 5 March 2018

Be your own Health Historian.

  Some time ago I blogged about the value of developing a systematic approach to keeping available your own personal health history, which should be in your possession and available at all times.   This applies to everyone but particularly to active senior citizens, who, like vintage automobiles may be functioning admirably most of the time, but on occasion require immediate attention to keep  running.  I addition, the tendency to forget issues you wanted to address or at least mention during the standard ten minute visit to your family physician is often forgotten in hustle and bustle of a busy office and the anxiety of the moment and needs to be to be added .
   Few people read my blog, (my kids assure me of this quite frequently), so it is particularly gratifying to me, when out of the blue, a friend or acquaintance mentions some aspect of my opinions or suggestions that they deem helpful to them in traversing the vicious medical jungle, that all but the political 'elites' encounter whenever health problems arise.
    Most recently, one of my friends casually mentioned a recent encounter with Health Care Ontario, when his health care interrogation was just beginning, he put his hand into his breast pocket and pulled out the carefully written history he had crafted in response to suggestions in a previous blog and said something to the effect,
    "you'll find it all here!"   
    My interpretation of what he told me was that they his interviewer re-acted with something akin to amazement and commented on the clear and concise history he had written.
   "Can I keep this,?" the astonished  doctor asked.
   "Of course," my friend said.
   " Where did this come from?" he asked .
   ( My friend smiled at me, "Of course, I got it from your blog.")
    "Oh, a friend of mine in the business recommended it as a way to ensure accuracy and save everyone's time."  he replied.
      I interrupted my friend to mention, " I always take three copies with me when I have an appointment for hospital consultations or investigations.  Because everyone I encounter on my way to treatment usually has to take the time to take a history.  I used to get tired repeating the story to the student, to the resident, to the staff physician and anyone else involved when I  was referred for investigations or consultation.
   'Can I keep this', is the question they most frequently ask, because it reduces their work load and everyone wants their work load reduced.  Additionally, they know there is no one more concerned than you, the patient regarding the accuracy of the information.  When I get to the resident or doctor who settles down in front of the computer, ready to start pounding out the necessary details before we can proceed, I present him/her with the documented history.   As a result, h/s can take their eyes off the computer and actually look at me.  Instead of interacting with the computer and trying to type everything into the record in the ten or fifteen  minutes available for our appointment the doctor actually has time to to establish eye contact and to talk to me."

   The sad truth is that even dedicated, caring family physicians have been bullied into practicing medicine based on a ten minute consultation fee.  If your physician spends much more time than that with  you he is subsidizing you and the bureaucracy  at his own expense.      Much of health care has gone the way of the house call. When the people decided that the doctor's home visit is worth much less than the plumbers visit, they sealed the fate of now almost defunct house call.  The miracle is that some physicians will still make house calls when they feel it is in the patient's best interest and if you look at the fee schedule you will realize that this is a charitable act by a caring physician.  So, bearing in mind that a ten minute visit is now the norm, anything that will focus that ten minutes into a therapeutic session is valuable.  The last thing a sick  patient requires is the physician wasting both their time filling in the boxes that the administridiots need to run the health care system as the Health Care Industry.  And that is what much of the interview has become, primarily concerned with collecting the business data instead of being solely focused on patient care.  The physician's forced occupation with the data being entered is not primarily concerned with patient care.   It is concerned with the business of the system, not of the patient.
   I was an early and enthusiastic proponent of the computerized medical record and its benefit to patients.  I introduced the computerized medical record to  the Department of Family Medicine at the Mt. Bridges Family Medicine Unit, the first EMR in the Western Family Medicine Clinics. I am disappointed with the current use of the EMR generally, because the administration has diverted the system from its vast potential as a health care tool, to use for their own benefit.   It has become a distraction from the very purpose it was created to address. 

   To get back to the point, you, the patient must do all in your power to re-direct your ten minute visit into a concentrated patient-physician interview.  Neither you, nor the physician, have time to waste. Not only do  you need a focused, concise history to present to the doctor you are seeing today, (who incidentally may not be the one you are familiar with), you also need to have pre-considered questions you may want answered and to write them down.  It's easy to forget things you wanted to address amidst one's anxieties in the hustle and bustle of a busy family physician clinic.
   Because we are so mobile these days I think a simple inexpensive project could improve health care significantly.  It is so simple and inexpensive and involves so little high tech expense that no one wants to be bothered with it, despite the fact that it may save more lives and money than high tech devices.   Everyone could carry their entire medical history on a card not much larger than one of the many credit cards that most of us carry in our wallets.
   So, in addition to  having your medical history available in a concise and easily accessible form on your person at all times, you need to have a list of the questions you need answered the next time you see your doctor.

If you are interested in learning more about this, or have ideas about how to achieve these objectives, let me know.

Sunday, 25 February 2018

How to get into medical school (or not)!

   I spent most of my professional life training Family Doctors.  I have had the privilege of  training residents, male and female in how to be excellent family doctors and I  know the standard of excellence required to achieve that objective is a bell curve that is unrelated to gender, colour or religion.  In the 'olden days', when I  first started interviewing candidates, most of the applicants to medical school were motivated quite differently from many of todays applicants.  There was a naivety (we called it dedication back then)  and we even had some aspiring physicians actually state that they had a 'calling' to become a physician and help suffering people. ( A sure way to get dropped off the  list pronto, these days)   While we very seriously considered the academic history of the applicants and their level of intelligence, we recognized that a committed B+ student often had the right stuff to be a good physician, we also recognized that an  A+ student sometimes didn't.  In fact, high  marks alone were a poor indicator of the quality of medical practice a graduate would offer.
   It didn't take long for the slicker applicants to figure out the answers that the admissions committee would be impressed by.  The admission committee itself was composed of a member of the medical school faculty, a member of the University faculty, a senior medical student and an interested member of the  public.  Saskatchewan, in those days had at least fifty per cent of their medical personnel well-trained British physicians and had difficulty in finding Canadian graduates willing to practice in  rural Saskatchewan.  In fact the situation outside Regina and Saskatoon was critical in many areas without even considering the isolated areas in the far north.  It didn't take long before, outside a small core of dedicated local graduates, applicants learned to answer the question, "What made you decide to  go  into medicine?" as follows:
  1. I want to  help people.
  2. I'm really interested in medical science.
  3. I want to provide medical care to rural and remote areas in the Province.
      A sure recipe for success!
   A slick computer-generated CV and career plan also helped and became easily identifiable to  the seasoned interviewer.

  Meanwhile, most of the rural/ remote care in Saskatchewan was provided by a small group of exceptional Canadian Physicians, British Physicians anxious to escape the Britisn NHS and later white South  African Physicians anxious to escape from South Africa.
   Unfortunately, we have systematically removed most of the dedicated physicians in Canada from positions of influence and power by transferring responsibility and decision making for the future of health care to the political administridiots who claim credit for everything until  everything goes wrong.   Everything will go wrong.  We have one of the worst health care systems in  the developed world, but Canadians are too polite to mention it!


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?"
    "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.