Treating a patient on a plane

While on a plane from Calgary to Phoenix with my Family yesterday, the stewards asked for medical personnel for help.

A 74 year old female complained of nausea, light-headedness and shortness of breath. The Stewardesses had already appropriately given her oxygen, but she did not improve.

On assessment, I discovered that the patient's pulse was weak and thready and that her heart rate was regular, but zipping along somewhere close to 200! Her pressure was normal and she was otherwise well with no comorbidities or cardiac history.

It was apparent that this lady was in PSVT and getting increasingly anxious and not maintaining pressure. After listening to her neck, I decided to do a rather firm carotid sinus massage while having the poor lady (a retired trauma nurse) valsalva (bear down) at the same time (There didn't appear to be any bruit (turbulence) in her carotids).

Thankfully, she converted right away....and this lasted about 10 minutes until her next episode.....so the valsalva was repeated again with some success (and ice water).....and seemed to stabilize after the 3rd "conversion".

The captain asked me a couple of times whether or not he needed to divert the plane....but she seemed stable and had calmed down. A diversion would only have made about a 15-20 min difference in any case.

A peds ICU nurse that helped along opened the "medical pouch" on the plane, and it appeared that all there was, was ASA, Tylenol and some old Sublingual nitro tabs. I gave the ASA as a precaution (no allergies or asthma), and held back on the nitro (no chest pain or variant angina)

I wanted to keep her calm and relaxed, so we had a nice long chat while doing breathing exercises for an hour or so - and learned that she was the widow of a fighter pilot, she snowbirded in Phoenix, had 2 daughters (one in Philly where she was en route and one that was a Pediatrician in Calgary).....it was very interesting to learn about her life experiences and her travels throughout the world and the wars with her fighter pilot husband....in fact, listening to her about her life was more interesting than any novel or in flight movie I could have busied myself with!

Eventually, the firemen arrived and I filled them I on a synopsis of "successfully converted PSVT in probable need of a long-term beta blocker".....but they didn't seem that interested in the details (the Medics were waiting off the plane).....their job was to assess and manage overall risk.

I then returned to my seat amidst some kind but rather embarrassing applause from the other passengers.

The whole experience - although far from a serene and relaxing flight, was overall a positive experience for me....I'm not sure why there are grumblings in the odd newspaper stories about Dr.'s on flights being "forced to work" when called upon on airline flights.

The fact is, that being a Doctor is a rare and special privilege. Should we be expected to always help out in an urgent situation? Absolutely......but to do so at a personal or professional cost should not be assumed by the airline or cruise industry.

A Physician's urgent actions on an airplane or other similar situation (I once put a chest tube in an old man with a pneumothorax on a cruise ship) is ONLY between the Physician and the person/people that they treat. Cruise ships and Airlines are external to that relationship......although one would think that a note or acknowledgment of appreciation from the airline or cruise ship would just be good form.....

ps.  the stethoscopes, blood pressure cuffs and meds kits they carry on airplanes are woefully outdated, and inadequate of quality or quantity.  They really should address this.  From now on, I'm going to carry my own equipment and emergency meds!

JF

Mental illness can hit anyone

A nice young lady was booked to see me last Friday; for an excision of a large epidermal inclusion cyst on her scalp.

This lady worked as a consultant archaeologist, but seemed to be abnormally bothered by her Epidermal inclusion cysts - a thing I noted on her initial consultation several weeks ago.

On Friday, she called my nurse while she was driving to her surgical appointment at my office - she was about 10 minutes late, and was extremely agitated and crying while driving.  My nurse gently talked her in to the parking lot of my office, and then ushered her into the surgical suite.

I then met her and talked her into a state of calm - all while noticing the fact that the left side of her head seemed to be missing a lot of hair, and that her scalp was terribly excoriated.  One of the cysts that I was supposed to excise was missing and the area over top of it was excoriated.

We chatted for a while during the surgery to remove the larger of the scalp cysts, and what I discovered was that this poor, gainfully employed professional had been suffering from severe Trichotillomania (A compulsion to pick at one's skin or hair) since her University years.  Prior to that, she had been suffering from a lifelong generalized anxiety disorder.  She had a normal, happy childhood with normal relationships and normal parents.

She stated that she had been treated initially by a Physician with Luvox, but that the efficacy of the medication wore off years ago.  When her Physician left, she saw various Docs at walk-in clinics that would variably refer her to a Psychiatrist with a years-long waiting list.

She then lost faith in walk-in clinics, and continued to suffer and just "live with her illness" for a number of years.  The Doc that referred her to me knew nothing about her illness and did not appear to have made any commentary about her trichotillomania on the referral note.

It was interesting that while technically, I was performing a surgical procedure on her (elliptical incision, cystectomy, rotation advancement flap) - what I was really doing was taking a proper psychiatric history....a medical procedure that would make a far larger difference to this lady's life than the surgery I was performing on her.

Ironically, I was being paid much more to do the surgery than I would have been for the Psychiatric history and diagnosis.

But at length, the surgery was complete and I was able to determine that the lady suffered from Trichotillomania as a compensatory response to a severe ongoing somatic generalized anxiety disorder.

I am not a Psychiatrist.  I would have really liked to send this person to a Psychiatrist.  But a referral to a Psychiatrist that will see her for an ongoing therapeutic relationship, takes at least 2-3 years in Calgary - if the referral will be accepted at all.  

So while I lament that I will be unable to see this patient again (my Family Practice is closed) for the ongoing Psychotherapy that I know she will need, I was able to start her on the Effexor that I think will make a significant positive difference to her life.

I have to see her in two weeks to remove her sutures - and at that time, I will hopefully find out whether or not she is covered for a private Psychologist.  If she is covered, I will refer her on to one of the very fine Psychologists that I have been referring to for a number of years.

This case just highlights the suffering of people that fall through the cracks as Family Physicians abandon working in their traditional areas of expertise that depend upon long term Physician Patient relationships.  

While walk-in clinics serve a vital and valuable role, I believe that society is slipping slowly but surely into another kinds of "dark ages" of medical care when we accept the limited services that they  and the Emergency Rooms can provide as our highest standard of ongoing care.

I would like to teach students to do what I do - and to show them how to thrive financially while they do it...but I've learned that each student costs me a fortune/day to keep in my office (we don't get paid to teach students).  The $5000 at least per month a student would cost me would be far better spent on a savings plan for my kids' education as well as my retirement plan.......

So for now...we'll make change one patient at at time.....

Cheers!

Medical office costs spiraling

Yesterday, the autoclave technician came by the office to service and certify the gizmo that we use to sterilize surgical instraments.

He replaced a perfectly good $20 "O" ring and changed the water in the tank (something we do weekly).....and the bill? $550!!!!!!!

Yes, he operates a virtual monopoly in the city...he's pretty much the only guy that does this kind of "certifying" work.

Did he deserve $500? Certainly not! Is charging honestly? Certainly not! Is it a 100% tax write-off? Yes - so that is why I'm tempted to not worry too much about it....but I hate getting ripped off! So I'm going to investigate how buy my own "O" rings and get my friend (a boiler technician) to give this guy some badly needed competition in the city!

When I calculate the cost of each surgery, I now have to factor in the cost of the autoclave technician, and the fact that my bipolar cautery setup costs $250 for only 10 uses!

No wonder our Calgary Health Region is $100M in the hole! People want first world class service for third world class prices!

I think that thoughts about universal health care reality is now slowly starting to "swing" the other way....it's a nice idea, but it is impossible to provide "for free" to constituents that insist on avoiding "socialist policies"........
Sent from my BlackBerry device on the Rogers Wireless Network

Why Family Medicine is such a great Profession.....

In the last few days, I excised skin cancers, reconstructed some ugly facial wounds, solved a little girl's ongoing abdominal pain (turned out to be Celiac Disease), helped a depressed and suicidal teenager, ablated a supraventricular tachycardia, diagnosed a flesh eating disease "in time", made it possible for an end-stage Cardiac Failure Patient to travel with her Family to a Mexican resort and resolved a person's headache that had lasted for months (responded to Doxycycline which inhibits tumour necrosis factor alpha...a new discovery by a Neurologist in Edmonton).

And these are just the cases that I remember from an intense, dizzying pace wrought with emergencies, intense pressure, and unpredictable hours.

My wife and my staff manage the 250+ calls to our clinic daily while conducting a virtual cacophony of verbalized suffering into a virtuoso's daily masterpiece of combatting disease and anguish.  

Thank God for my wife!  Without her, I don't think that I could practice Medicine...she makes it so I can just get on with the business of being a Doctor...without having to attend to the business of being a Doctor....does that make sense?  This woman is PERFECT, and soon I will have been married to her for 16 of the 22 years we've been together!

And the reward for all of this work and exhaustion?  It certainly isn't the huge paycheques, paid vacations or large dividend payouts....

This week's payoff was a hug and "thank-you" from a little girl with celiac disease, proving that she wasn't faking all the abdominal pain to get out of school all these months; FORMERLY earning her parents' ongoing suspicious ire.

While it is fun to bitch about the ongoing and seemingly innumerable injustices that Family Doctors face in daily practice; it is a huge secret of the Profession that this is the ONE Profession that - if done well - will keep you in the highest regard of people, provide the highest personal satisfaction of any occupation and reaffirm the indescribable feeling that for a great many people - you are making their lives a great deal better than almost anyone else can or ever will possibly do for them.....

Sure, my office costs are getting out of control and my paycheque keeps shrinking...but at the end of the day, I and my family still live well, people are working on the "paycheque thing" and I'm really very happy.  What more could a person want?  

It has been said that a single failure in the home is not worth any amount of success in life...wisdom to live by!

It's late on Friday night and I've finished my mound of paperwork that will grow my another 20lb by Monday evening....I suppose that I can get back to more bitching then.....

On Requesting a Colonoscopy

It is interesting how things happen in Family Practice....I spend every day dealing with a plethora of human suffering, anxiety and disease.  

From one moment to the next, I can deal with anything from excising a tumour to counselling a suicidal teenager that wants to die because a girl has failed to notice him.  Each hour, I have to be on my game to deal with any and all aspects of Cardiology, Endocrinology, Orthopedics, Psychiatry, Obstetrics, etc., etc., and the list goes on.....

But the only thing that gives me anxiety, believe it or not, is having to refer a patient to a Gastroenterologist for a Colonoscopy in Calgary.  I have a growing list of patients - all of who need a colonoscopy - and none are going to get the procedure done in a reasonable amount of time.  Current wait lists are in excess of two years - no matter what lies "officials" state to the media and when confronted at an educational seminar.

The procedure for referring a patient to the Calgary Health Region can only be described as insanely stupid.  I write a detailed letter that includes my reasoning for the patient needing a colonoscopy...in several cases, I have included a reports of a Barium Enema SHOWING an obstructing abnormality in the colon....and the Radiologist commented in his report that a Colonoscopy is suggested....but the triage nurse in charge of access to Colonoscopy returns my note - unread - and insists that I check off one of 4 boxes on a stupid referral sheet.

They refuse the referral unless I can tell them what the patient's serum ferritin is.  The problem is that the patient has a chronic inflammatory disease - and his serum ferritin will be falsely elevated - which means that it will be normal even though he is chronically bleeding out of his gut.

But triage nurses in programs like Gastroenterology all too often have too little education to understand nuances like this...the referral is rejected unless I provide them with a serum ferritin and check off some of the boxes on their form.  My letter isn't read and it isn't appreciated.  An M.D. never reviews my letter...an issue which I believe falls far short of a minimal professional standard.

So - on behalf of my increasingly desperate patient -  I am going to lie through my teeth and check off every box there is on the stupid little form.  Some "nurse practitioner" will then see the patient and mindlessly follow a questionnaire algorithm to make the patient an appointment for a Colonoscopy.  

A nameless masked face hiding a Gastroenterologist will then step into a room with my terrified patient, tiredly mutter an incomprehensible string of reassurances while they instruct the nurse to push some Fentanyl and Midazolam...and then the patient will wake up in a cold room under fluorescent lights....be checked by a disinterested nurse and then told that they should "see their Doctor" - which is me.

The patient will then go home and suffer anxiety until they come to see me 2 weeks later - only to discover that the Calgary Health Region didn't bother to send me any kind of report.  My nurses will spend an hour trying to get a report faxed - and then I will receive a report that can say any of a number of things from "Cancer" to "Unremarkable" to "Biopsies are pending".  One time, the report was "lost" by the Region and I had to put the patient through the whole thing all over again!  Could not even find the name of the Gastroenterologist because he/she was a "fill in" that doesn't have a real office!

If  "biopsies are pending" is on the report....my nurses will then spend literally another couple of hours on the phone while juggling desperate patients, making triage decisions and juggling insurmountable paperwork.......to get a copy of the Pathology report.

The report can then say anything from "Celiac Disease" to "Cancer" to "Inflammation"....I will then try to contact the Gastroenterologist...only to discover that they don't actually have an office...or a nurse...or a secretary.....they just do colonoscopies from time to time when needed.

It will then be left to me to decide how to proceed with the patient.

It's a scary process - and it is getting worse for these patients!

It is sad that Gastroenterologists are allowing the esteem of their profession to suffer under the auspices of the Calgary Health Region.  Family Physicians  in the community are losing trust in our Gastroenterologists.  We are also losing trust in our Calgary Health Region.  As my Father-in-law likes to say, "It's so broke, you can't fix it".  But can we fix it?

Our Medical system is as close to "free" as any medical system can really get.  But the "costs" of our "free" system only become realized if you ever really need it!  We need to restructure our Health Care System from the bottom up, not the top down!  We need more "Indians" and less "Chiefs"!

Perhaps a new system being put together by our new Health Minister will be better...perhaps not!  All I know is that the increase in, so-called, "allied health care professionals" like nurse practitioners that replace what M.D.'s are supposed to do....is rotting our medical system from the inside.  For M.D.'s to assign many of their patient interaction responsibilities to Nurse Practitioners is an erosion of M.D. skills, esteem and trust!  

Gastroenterologists that don't actually interact with patients are allowing themselves to become mere technicians!  Medicine is a proud profession with a proud history and a proud foundation...to allow oneself to become relegated to a mere medical technician is something that requires a real wake up call!

I do everything I can to support the Specialists that I refer to...but they are increasingly overwhelmed - so they invent new punitive administrations to "manage the demand"....and in so doing, drastically deteriorate the quality of their work, their reputations and their profession!

We need to do better...but our extremely top heavy medical administration in Alberta has to be fixed first....I remain grudgingly optimistic......

On Chiropractic Neck Manipulation

A great article on Chiropractic Neck Manipulation is in Saturday's Editorial Section of the Herald (a copy of the article is attached at the bottom of this post).

We have all been told that stroke from neck manipulation is rare...if this is so, why do I have three patients that have all had strokes as a result of Chiropractic Neck Manipulation?

One of these patients was a 25 year old pregnant mom (with twins) that suffered a vertebral artery dissection in her neck, immediately following getting her neck cracked for back pain during her final week of pregnancy.  I see her once a month for ongoing complications of this dissection.

I personally congratulate the two Alberta Lawyers that are suing the Government Regulators and Alberta Health for allowing Chiropractic Neck manipulation to thrive despite the ongoing and repeated warnings and pleas of Physicians over the decades to the contrary!  In short - I hope that the Government gets nailed to the wall in this lawsuit - because they more than deserve it!

I know and respect an excellent Chiropractor.  He is basically a highly trained Physiotherapist and Massage Therapist.  And he doesn't "crack necks".  I believe that the College of Chiropractors should be taken to task to protect the public from the quacks that are destroying a potentially respectable profession.  The "legit" Chiropractors should ban together and toss these "quack supporters" out of their own College!

Herald Article Follows:

Cracking necks destroys lives

DR. JOHN WILLIAM
KINSINGER

Sandra Nette of Edmonton suffered a locked in syndrome stroke immediately following a chiropractic highest neck manipulation on Sept. 13, 2007.

Journalist Jean-Dominique Bauby described his own suffering from locked in syndrome stroke in the 2007 AcademyAward-nominated French movie, The Diving Bell and the Butterfly, adapted from his memoir.

Nette remains able to understand, see, think and feel. Yet, she will never again speak, walk, feed herself or take a normal clear breath of air. Who locked a healthy 40-yearold Alberta woman in an under water diving bell?

The first locksmiths were two quacks, David Palmer and his son B.J. Palmer. One hundred years ago, David started manipulating the backs of people and his son B.J. began cracking the highest neck as a cure for most diseases. “I have found the only cause of disease,” he claimed. The omen of chiropractic highest neck manipulation was born.

Nette, now 41, who is suing her chiropractor and Alberta Health, was locked in the diving bell by graduates of schools of chiropractic all over North America who have adopted the Palmer belief as the very essence of chiropractic philosophy. The Canadian Memorial Chiropractic College in Toronto is named after Palmer. Graduates of chiropractic schools are allowed by the politicians to call themselves “doctor.” None have studied a day in a hospital or had their teaching approved by a faculty of medicine. Years of non-scientific study, no matter how long, lead to graduates who claim to be experts of the nervous system. These experts falsely believe that neurological function is centred on the spaces between our backbones, especially in the highest neck. This teaching has no brain.

Sandra was locked in the diving bell by the false notion that quacks could regulate quackery in the public interest. Thus a recent president of the College of Chiropractors of Alberta, the body here to protect the public, swears his allegiance to “the principles taught by the founder D.D. Palmer.” He sets the healthcare standard for chiropractors that they should manipulate the bodies of “those who are only moments old to just before they leave to the next state of existence.”

Log onto the Alberta public information website of the College and Association of Chiropractors (www.albertachiro.com)and you will find a spokesperson, Gregory Stiles pointing to a Chart of Effects of Vertebral Subluxations. At the highest neck area, these subluxations are claimed to cause an endless number of diseases including crossed eyes, deafness, pituitary gland disease and the common cold.

The final lock on the bell was placed on Sandra by those in government. Public officials have totally ignored the evidence and warnings about this. Alberta pediatricians met with government officials to explain to them how useless and potentially dangerous spinal manipulation in infants and children is. Alberta Health paid more than $40 million in the past decade for chiropractors to take the heads of babies and children, turn them suddenly and claim that they have done an adjustment for subluxations. Neither the diagnosis nor the treatments are valid. Taxpayers keep paying.

While this is a scam, the ministry may have become complicit in strokes and deaths when one recent health minister totally ignored the personal pleas of an Alberta physician to do something about the near death of a 21-year-old woman who fell on her tailbone and yet had her neck manipulated by an Alberta chiropractor. Subsequent ministers ignored the clear statement of 62 neurologists all across Canada to do something to stop the strokes and deaths.

The biggest myth is that stroke and death from neck manipulation is rare. Indeed rare is not the issue. The bottom line is that twisting the highest neck to produce a cracking sound — nitrogen gas coming out of solution — is never necessary. It is not a treatment, it is a deadly philosophy, started 100 years ago by quacks, taught in non-scientific schools, supported by regulatory bodies and ignored by governments who had the ultimate responsibility.

To try to downplay the risk, the chiropractors have produced non-scientific “research,” studies done on people already dead, self-serving insurance statistics done by their own company and Medicare billing records, which have nothing to do with the issue. The families of these chiropractic victims have now provided 70 years of scientific data to every member of the legislatures in British Columbia, Alberta, Saskatchewan and Manitoba.

Alberta lawyers Daryl Wilson and Philip Tinkler have taken the risky, yet inspiring and necessary legal action to go after the head of the snake, the regulators and the government. Their motivation is not financial; it is simple humanity and pain at the unnecessary suffering of their client. These lawyers will not go away. Chiropractic subluxations will be on trial. If they are shown not to exist, which they do not, chiropractic will be reduced to simple manipulation therapy for the almost negligible instances where it is helpful. Chiropractic highest neck manipulation in particular will be gone.

The physicians who care for Nette in Alberta as well as those caring for stroke victims in B.C., Manitoba and Saskatchewan have issued a public warning. They never want to see another case of neck manipulation stroke. The victims and doctors have also outlined exactly what the provincial health ministers must do. They have to impose six specific restrictions on chiropractic which would in effect lead to all chiropractic highest neck manipulation being stopped. Only a foolish minister of health would not recognize the opportunity to limit possible liability. The time for political protection of chiropractors is over. One look into the eyes of Sandra Nette and her devoted husband, Dave, tells you why. As in the movie, The Butterfly and the Diving Bell, only the imagination can set Sandra free. That imagination is the end to chiropractic highest neck manipulation strokes and death.

Patients that "No Show" for appointments

Today's Calgary Herald had an nice article in the Editorials section by a staff person that works in a specialist's office (see following).  The article laments that the specialist had 21 patients "no show" for their appointments in one week.  And these were patients that had confirmed their appointments soon before their appointments!

My own experience with "no shows" started approximately 8 years ago when I was just taken over the practice from the Physician who had retired from it.

A "no show" rate of usually 3 to 4 per day was normal.  I almost always see patients on time and I don't double or triple book - so I really noticed a hit in my income when 4 patients per day didn't show up!  In "real dollars" in those days, patient "no shows" cost me approximately $500 per month - which translates roughly to $6000 per year in lost income!

I had no way to make up for that lost income, and this problem became magnified when rent increased by almost 200% over the course of a few years - not to mention the drastically increased costs associated with staff and office supplies, etc.

My answer to this problem ironically was inspired by my wife's hairdresser!

This enterprising and efficient businessman charged $50 for a "no show" for haircuts in his shop.  This practice was tested in court in Calgary within the past 5 years, and the judge found against an Oil Company that booked a whole restaurant for an office party - but did not show up for the party.

So, I started charging patients in my office a $60 no show fee for regular office appointments and a $150 no show fee for consultation or complete medical appointments.

Also, when patients "no show" for Specialist Appointments that my office arranged for them, we charge them a $150 fee for rebooking the appointment and we require that they pay the Specialist's "no show" fee as well.  Patients that don't comply with the above are discharged from the practice.

Our collection rate for no-shows in our office is about 100% for Family Practice patients.  We don't apply the fee for punitive reasons at all - and we respectfully explain to our patients why we need to charge them.  To date, we have had very few, if any problems.

We only collect about 10% of "no shows" that are referred to us from other offices.  It is a rare circumstance that I get to see both sides of the referral process, as I both generate and receive referrals.  

I think that as Family Docs, we really need to support our Specialists in terms of requiring our patients to take ownership of their appointments times.  The result will be a medical system that is improved for everyone!

I now send a little note with my referral letters to Specialists, informing them that if my patient doesn't show up, I will charge them $150 for the inconvenience, plus I will require that the patient pay the Specialist's no show fee.  Patients that refer to me that are no shows end up getting a quick note on the referral letter to inform their referring Doc that they didn't show for the appointment.

Of course, I never charge a no show fee to patients that have legitimate reasons (like an emergency, etc.) for not showing up.  These people are accommodated in a friendly and professional manner - and they seem to really appreciate our efforts to help them out.

Some may argue that wait list times in excess of 2 years just beg for "no show" patients that simply forget about their appointments....this is perfectly reasonable.  But most offices (like mine) call patients before their appointments to confirm them for the patients.  We do this as a courtesy to patients and they really seem to appreciate it.  I believe that most Specialist's offices (except those attached to a Hospital for some reason) usually do this as well......

(Herald Article Following):

Empowering
patients

Dawn Rosine, Calgary

I work in a very busy surgeon/specialist office. Our wait list is well over 50 people. We are booking new patients into February 2009. Some waits to see a specialist are close to a year, considering one must first go to a general practitioner or walk-in clinic for a referral. These specialists change lives and, in many cases, save lives. In our office we work exceptionally hard to accommodate all patients, including phoning to remind them of their appointment if they haven’t confirmed. Last week, we had 21 patients who were confirmed miss their appointments. No phone calls.

They just did not show up. I know we aren’t unique with this frustration. MRIs and CT dates are also missed. I think it’s time for patients to take some ownership in the constant struggle of our health-care system, the system most everyone loves to complain about. If you know you are being referred to a specialist, take ownership and call them and find out the status of your appointment. Make note of your time and date. If you don’t need your appointment, take the time to cancel so someone else may be moved up. Above all, be responsible!

On Gardasil being covered in Alberta

So - Alberta is now going to pay for Gardasil injections to immunize grade 5 girls to the Human Papilloma Virus.  The department of Public Health is going to take this on - with the associated costs (3 injections over 6 months at a cost of approximately $200/dose).

Is this a responsible decision by our public health decision makers, or just the result of good campaigning and the efforts of public relations experts hired by Merck to sell as much as possible of this product in the interest of shareholder dividends?

The injection probably won't cause any harm - and intuitively makes sense - but it must be kept in mind that immunization to Human Papilloma Virus numbers 6, 11, 16 and 18 has never been shown yet to decrease the incidence of cervical cancer.

The fact is that we don't know as much about various infections as we think we know.  For example, bacteria cause a great deal of intestinal infections...but we now know that killing all the bacteria in the intestine is a very bad idea that can lead to horrific diarrhea and a potentially deadly condition called "toxic megacolon".  Another observation has been made in Germany, showing that our lack of intestinal parasites may be a cause of horrific diseases like crohn's disease.  We got rid of almost all known intestinal parasites in the modern world....but - as sufferers of Crohn's disease will tell you - this may have been a bad idea!

So, will immunizing our grade 5 girls now make them actually at risk for the development of even worse gynecological conditions in the future?  We just don't know!  So until this is proven, why the heck are we paying millions to immunize our young girls?  If you are a Merck stock shareholder - the most profitable answer is a resounding "WHO CARES?  JUST SELL IT!!!!!!"

I suppose that on the other hand - it can be weakly argued that doing nothing can result in millions of girls developing cervical cancer that could have been prevented by Gardasil.  

This probably isn't true.  Millions of cases of Cervical Cancer simply don't happen.  In fact; because of screening programs like the annual PAP smear, Cervical Cancer is surprisingly rare in Alberta.  Although my practice population consists of the relatively socioeconomically advantaged, I have not seen a single case of Cervical Cancer in 10 years of practice!  I have seen a lot of cases of "pre-cancer" - but these were all 100% successfully treated with colposcopy.

In my opinion best prevention of cervical cancer is (in addition to PAP testing)......you guessed it:  GOOD PARENTING!!!!! Having said that - while I had good parenting...I was a bit of a handful!  Perhaps I am to experience a bit or irony in my never-ending attempts at parenting!

The risk factors of cervical cancer that have been shown to be effective if managed are the following:

Sex at an early age

Multiple Sexual Partners

High risk Sexual Partners

Kids whose moms took DES (diethylstilbestrol) during pregnancy in the 1970's to prevent miscarriage.

Long term use of Oral contraceptives

Infections with chlamydia or genital herpes

Poor socioeconomic status

Exposure to cigarette smoke.

But people (especially policy makers) are often sheep-like in their decision making...and we are now going to immunize young Alberta girls with Gardasil.....I personally would like to see more data on how well Gardasil prevents Cervical Cancer....which I am sure will be eventually forthcoming.....won't it?  

Will there be any incentive for Merck to do so after the immunization become generic and all invested dollars are considered to be remunerated at the targeted profit margin? I wouldn't blame them for "moving on", as it were, to....say....immunization of teenaged boys against stupid risk-taking behavior....

Any parent that will eventually have a child that gets cervical cancer would certainly be in favor of spending millions to prevent even one case...and I'd be right there behind them.

While their decisions for/against immunization campaigns are necessitated by our limited public health funding, I don't envy the task of public health policy makers!  Obviously - given the recent news in Alberta of the top end Public Health Physicians resigning from Alberta Health - the people that actually know about this stuff should be cultivated as valuable public resources by government - not let go of by some near-sighted administrative dinosaur.....

On firing patients from the practice

I spoke to a colleague's wife the other day.  She told me that her husband is often being "held hostage" by patients who don't want to pay their bills (like no-show fees, etc.) and who bully her husband with a threat to "call the College" if they don't get what they want.

I felt sorry for the fellow, as I know exactly how he feels!  This is a terrible way to experience medical practice!  You have to be able to look at your day sheet in the morning and look forward to seeing each and every one of your patients - or you will eventually get the soul-deteriorating, life force-draining, depressing practice that you deserve.  

I know!  I had some very dark years where I had to drag myself into the office to face people that were often difficult, unappreciative, demanding and bullying when they didn't get what they want!

In 8 years of practice, I have had my fair share of "frivolous" College complaints by "nasty" patients that tried to use the College as a tool to bully me or my staff.  But this is a reality of life, and I have learned over time that the College is actually quite reasonable - if inconvenient to deal with.

So - after hitting my limit with "the nasties" (with the encouragement and support of my wife) - we instituted a new office policy of firing patients within 24 hours if they were in any way mean, derogatory, threatening or pretty much anything less than either pleasant or proper.

The experience was like a breath of fresh air, and absolutely invigorated the practice!  We actually like everyone we have left (well, except for a few that I decided to guide/help through the system for their cancer treatments until they achieve remission - before I fire them).

Any patients that make you or your staff cringe when you see them have to be fired - no exceptions.  You have an obligation, in fact, to get rid of them!  You simply cannot maintain good objectivity to make complex medical decisions in the best interest of someone you can't stand!  And your staff cannot advocate effectively for someone they hate!

Another colleague of mine, who is an excellent Physician, fires 10 patients every year on her birthday!  This has the effect of keeping her practice happy and invigorated.  I'm not sure that that strategy would work for me, as I actually like everybody that is left in my practice - but at least making an "annual list" can serve as a reminder that you can assert a certain standard of conduct in your office.

I am going to chat with my colleague and encourage him to restate himself and what he expects from his patients - he is a really great Doc and he deserves better than he is getting!

An interesting medical conundrum

A long time patient of mine asked me to see his adult son as a new patient.  My practice has been closed to new patients for a long time, but I agreed to see the fellow, who currently lived in L.A.  The story was that the son had been deteriorating to the point of being unable to function gradually for the past couple of years.  A lengthy hospital admission and over $70,000 in addition to the extensive insured investigations revealed nothing.

The long and short of it was that the fellow was eventually convinced by some sort of Naturopath that he was suffering from chronic "black mold exposure" - which led to even more deterioration of the fellow's financial resources.  An interesting point in the history was that this fellow's symptoms of diffuse joint and muscle pain, fatigue, mild depression, insomnia and other constitutional symptoms did were investigated with all kinds of bloodwork and imaging studies.

The "American Team of Physicians" did, however, find that this fellow had antibodies to H. Pylori - the bacteria implicated in stomach ulcers.  Further investigation revealed that the fellow had been suffering from bleeding ulcers.  The Physicians treated the fellow with a proton pump inhibitor (a medication that turns off the stomach's ability to make acid)....but within a few weeks, the fellow's symptoms of joint and muscle pain, fatigue, etc. became a great deal worse!  He stated that while his stomach was sore - he actually felt constitutionally better when he had his ulcer!

He then discontinued the medication and got his ulcer back - but at least the rest of him felt a little better.....he then went bankrupt form the "American Medical Experience" and ended up moving to Calgary where I saw him in consultation.

After really listening to the fellow, it turned out that we could discern several facts:

1) He felt like crap with muscle/joint pain with weakness and fatigue

2) He had a bleeding ulcer/gastritis

3) Treatment of the bleeding ulcer/gastritis made him worse

There was only really one thing that could explain this....and it turned out to be correct!

An investigation revealed that the poor fellow had been suffering from hemochromatosis - a disease that results in iron overload....the excess iron accumulates in various organs and soft tissues of the body, making the person with the disease feel terrible.  The only real treatment for hemochromatosis is getting bled on a regular basis to "remove" excess iron from the body.

The poor fellow's hemochromatosis was being treated by his bleeding stomach!  Which is why the treatment of his bleeding ulcer - although it made his ulcer/stomach bleeding better - made his hemochromatosis worse!

Cost to the patient for his diagnosis in Canada after being undiagnosed in the U.S. for $70,000+?  ------------> $0.00. (other than Alberta Health Care premiums).

The death and rebirth of Family Practice in Alberta

Well, this is my first blog.

I am essentially running two independent medical practices: a full-service Family Medicine Practice, and an Office Surgery Practice.

The Family Medicine Practice is a smoothly running machine.  We take great care of a lot of folks and we're happy to treat these ones.  It's a closed practice - meaning that we pretty much don't take any new patients (unless Paige feels sorry for one).

But I am slowly getting abandoned; not by patients or population - but by colleagues!  There appears to be fewer Family Doctors to go around.  I used to be able to bounce stuff off my partner, or walk around the corner in my Medical Building and talk to a colleague about a case.

But now, there a very few Family Docs around to chat with - and those that are still in practice are literally drowning professionally in responsibilities and demands!  In fact, almost half of the referrals I receive lately for surgical consultations are from Family Physicians that are no longer in practice by the time I get the consultation letter written after the surgical procedure is done!

So, I have decided that enough is enough and that it is time to fix Family Medicine!

Government has been short sighted and should be blamed for poor planning - fair enough.  The fact that they claim that there is not enough money in the budget to pay the Physicians - while voting themselves in excess of 30% pay raises looks pretty bad to the tax-paying public.

But the secret to fixing Family Medicine is to decrease the dependence of Family Medicine on Insured Medical Services that are tied to the impossibly outdated Canada Health Act.

This means charging patients for uninsured services that have been traditionally provided to patients free of charge....what might these sorts of services be, you might ask?  The answer is pretty much anything that my staff does for patients other than booking an appointment to see me.  See My Website and click on "Uninsured Services" for an example of services that are provided but not paid for by the Alberta Health Care Insurance Plan.