The Family Medicine Files

There are the Victims of Bullies....and there are the Nightmares of Bullies......

2011-05-03T21:49:00.000-07:00

Well, I lamented earlier on Bullying, which was heartfelt because my eldest daughter spent a big portion of this past year being victimized by it. Things have gotten a lot better with my daughter's self esteem finally being nurtured by her Mother and I to a robust and decreasingly delicate pillar in her life......

.....And then I have my littlest daughter....my delicate little flower.......who MAY or MAY not have been involved as the victim of a bad bullying incident during recess recently (in case the Principal is reading this).

Allegedly, a much larger boy than her wanted her recess snack - so he grabbed her leg and wrenched it up painfully, causing her to allegedly fall violently and painfully onto her back on the pavement of the playground.

She had the breath knocked out of her and laid there in shock for a second before getting up to challenge the offender. When she reached for her snack, he pushed her back again.

Then, she may or may not have wound up and socked him hard in the mouth - possibly splitting his lip (or it could have happened when he walked into a door) and shocking him into running away, crying out of shock and embarrassment.

My "delicate little flower" then noticed that she might or might not have split her knuckle open on what could have been his teeth - or possibly a "graze from the swing set on the playground"....and she marched into the school and inquired as to where she could obtain a rabies shot.

I only discovered the above that might or might not have happened upon my inquiries that I made of her when I came home from work and noticed her carefully washing her knuckles in the sink and then applying antibiotic ointment (she is quite familiar with wound care after having been patched up no few times from various accidents on mountain hikes, etc.)

So I suppose that there are some people that can be the natural victims of bullies....and there are those that can be the natural nightmares of bullies.......

I'm still laughing.....

Bullying in Teenage Girls is aweful

2011-02-17T21:02:00.000-08:00

I have had patients in my office over the years - teenaged girls and their parents - complaining of their horrific experiences with bullying by other teenaged girls. The problem appears to be getting worse over the years. I suspect that the worsening of bullying in teenaged girls might be a result of the fact of several things:

1) The ubiquity of access to texting, facebook and twitter.

2) No direct consequences for bullying through texting, facebook or twitter.

3) An increased divorce rate, resulting in single parent families that leave teenaged girls relatively unsupervised.

4) The decline of the "stay at home Mom (or Dad)", with both parents' attention engaged at work and not in their daughters.

5) The fact that girls are physically, but not mentally, maturing younger and looking much older than they are between their ears. This is a virtual recipe for poor self esteem.

6) The decline of the community: people no longer know their neighbours. Community support with "friends" in the community is increasingly a thing of the past. People are, now more than ever, living like islands unto themselves. Group support and self policing of kids.

7) Teachers that have been increasingly marginalized by a growing culture of entitlement that does not let teachers discipline kids when it is necessary.

8) A second generation of people that have no idea about how to impart a culture of discipline, honour and respect to their kids - because their parents never taught them these lessons either.

9) An increasingly common belief by uninformed parents that their teenagers are entitled to privacy in their lives and correspondences via twitter, facebook and texting.

10) Parents find it difficult to view their teenage daughters objectively.

It is easy for these teenage girl bullies to do their damage through texting, facebook and twitter.

Bullying from afar through a digital medium is easy, because consequences are rare.

When I grew up, if you said something rude to a person - or within earshot of a person - you risked being rightfully punched in the nose. This doesn't happen any more. There are no consequences for an evil Facebook post, twitter post or text. Broken noses are getting more rare as bullying is getting more common!

It is now safer than ever to be a bully. Consequences are rare, and you can do it safely at home from the couch.

An unbelievable number of teenaged girls are living with one parent after their parents divorce. Inevitably, one or more of these parents ends up in a new relationship - and tends to focus on that relationship rather than their teenager, in the false belief (or hope) that "the kids are older now, and don't need my attention so much any more".

Even when their parents are "still married", an amazing number of teenaged girls are completely unsupervised. Their parents are both working in demanding jobs, and one of them may have returned to work after years of being home for the kids. The parents believe - erroneously - that their teenaged girls no longer need so much time and attention.

Nothing could be further from the truth. Teenaged girls are more insecure than ever in history. Their parents may not know that their teenaged girl is a bully.....or being bullied.

The fact is that - the cause of being a bully is insecurity. And the cause of being bullied is insecurity.

So where does this insecurity come from?

In short - insecurity comes from everywhere. It is inevitable - and each girl will respond to it differently. Their only hope is their parents and guardians (because friends at this age tend to come and go) - who they NEED to provide guidance. When girls don't have parents or guardians that can defend them from insecurity.....these girls need more resources. A friend, a friend's parent(s), a teacher, a counsellor, a clergy person, etc.

If your teenaged girls are getting bullied, try these books & sources:

How to Win Friends and Influence People for Teenage Girls by Donna Carnegie

Odd girl out: The hidden culture of aggression in girls by Rachel Simmons

A post on Bullying in Girls

A review on Bullying in Teenaged Girls

An E-Book Titles "Why Me" on Bullying in Teenaged Girls.

Alberta Health Care at an all time low

2011-01-18T22:41:00.000-08:00

Well, I take care of my fair share of Health Care workers - ranging from cleaners to executives....and they all report the same thing. They are all highly demoralized. They perceive no leadership, vision, responsibility, support or competence from their leaders.

There appears to be no hope that things are getting better - at all. The state of Health Care appears to continue to decline, despite various occasional puff pieces handed to the popular media by one politician, adminsitrator or another. These politicians are not bad people - I actually admire them. Who on Earth would paint such tempting targets on their backs for paltry sums of money and the collective derision of society? They HAVE to be doing this because they believe that they are good people that are trying to do a good thing.

They just aren't doing a good thing.....

At the very least, these people are brave souls that are being tasked with a delicate operation with no training, tools or support. Albertans generally seem to want Health Care - but they don't want to pay for it (ie. they don't want to pay 50% taxes). Health Care is a bottomless pit of costs that will never end. The culture of "free health care" is admirable - but wrought with a risk of development of a sense of collective entitlement.

Ever been to Detroit? How about Greece this past summer? This is what a culture of entitlement gets you. Our politicians - at the very least - should be brave enough to acknowledge this and to make policies that provide care while fighting a culture of entitlement. It can be done - just ask the folks at the Mayo clinic in Rochester. This is a non-profit medical wonder that still makes billions in revenue every year. I'm proud to have met and worked with these Mayo folks. They really do "get it".

We can fix Health Care in Alberta by looking at successes like the Mayo model and building upon them.

This past week, I sent a patient of mine to the hospital with horrible abdominal pain. The initial hospital that I sent him to via EMR, said "no more people!". So he was diverted to another Hospital. He then spent more than a day in the E.R. waiting for a bed in a hallway. He made it into an E.R. bed after more than a day....then he made it on day 3 into a hospital bed in a shared room after a 24 hour hallway wait. During all this time, he was unable to eat due to his pancreatitis. He had to pee in a bottle under a sheet in the hallway whenever he sensed that nobody was really looking.....then he made it to his room once his spot was made available.

He stayed in that room for 5 days until they could take out his gallbladder. He did fine in surgery and his surgeons and nurses were excellent. But his room was filthy. His bathroom was filthy. The tap in the bathroom ran full time from a severe leak. Nursing staff stated that the leak probably leaked over 100 gallons per day and that this had been happening for at least the past 6 months....along with over a dozen other taps in the same hospital ward. This was just the tip of the iceberg on a list of maintenance items that were very necessary in this very busy hospital.

This lack of upkeep has drastically affected staff morale as well as patient well being - and I hate to think of how many hospital infections are caused by the increasingly filthy and improperly cleaned and maintained hospital wards.

Mr. S. went home early with the promise that he would follow up with me asap. I visited him several times in the hospital....and no, I don't think that my payment from Alberta Health for the hospital visits, will even cover the costs I paid for my parking.

So what do we do?

This is, in my opinion, the cure to the Health Care System in Alberta:

1) Attach all health care funding to individual patients and make hospitals and clinic compete for this funding.

2) Allow patients to top up this funding to be able to attend private medical services and clinics if they choose to.

3) Make sure that public hospitals and clinics meet and even exceed the capabilities and service options of the private clinics.....by funding these public hospitals and clinics appropriately.

4) Legislate long term health care plans for the people of the province - and keep this long term plan protected from political meddling. Keep this long term plan administered mostly by Physicians and Nurses. And a few "smart" members of the public.

5) Put the Physicians and Nurses back in charge. Of EVERYTHING IN HEALTH CARE. They are all amazing efficiency experts as part of their work and training, and they know VASTLY more about health care delivery than any politician or administrator. Put a few smart citizens on these boards to work with them.

Hope that helps.

Rural Roots:

2010-08-04T19:52:00.000-07:00

Rural Roots:

Nice composition. Bleakness with lack of contrast and cool dryness of the prairie - with the little, insignificant splash of colour on the flowers remind us of the inevitability and cold finality of often unpredictable death - and our futile attempts to defeat it through beautification.

The status of Health Care in Canada - Obama take note

2010-05-22T00:12:00.000-07:00

Today, I was too busy to see a patient who came to the office in desperation and pain.

That was because I was seeing other patients in more desperation with more pain. In fact, I was doing a little operation on a 17 year old blind boy who had been hobbling around with a piece of glass embedded in his right foot for the past 2 years.

He had seen at least 4 Physicians for his probem and had undergone at least two exploratory procedures. His Physicians had no luck sending him to a plastic surgeon because of an over 2 year wait in Calgary to be assessed - and the difficulty in accessing a Specialist that "does feet".

So - the poor fellow hobbled in pain through most of his highschool years. He was sent to me by his Physician after his Physician learned that I do "things like this" (I don't really - but I suppose that I do now because it seems that I get a lot of referrals like this).

I had just removed a large tennis-ball sized benign vascular tumor from the left buttock of another fellow who had been unable to sit for the past two years. His tumor had recently become necrotic and intensely painful, and he had been advised by the E.R. that they would arrange for him to be seen by a surgeon - the arrangement never happened....twice.

The poor lady in the waiting room went home.....scared at having lost 20lb in the past 3 months and at the intense pain with any bowel movement or passing of gas.....and even more scared that she could feel a mass protruding through her rectal area.

My next two weeks were booked solid with increasingly desperate people. Some of them were returning to ask why their colonoscopy screening tests were taking over 18 months to get booked.....others wanted to know why they had to wait 12-18 months to see a neurosurgeon for their incredible back pain that required surgery.

After a dizzying day of little, but significant surgical procedures; I recalled that I forgot to eat again.....it had been 20 hours since my last meal. When I woke up this morning, I got up from the bed to walk to the bathroom - and distantly heard a loud thump that scared my wife to death and had the kids running into the room......I stared up at them in confusion - not remembering losing consciousness.

I seemed fine (except for a sore left wrist), but for the first time in my life - felt the cumulative effects of rountinely 3 hours a night of sleep, chronic dehydration, stress and probably malnutrition ganging up on me.

The strain of a College Complaint from a patient being charged for surgical supplies that I had to pay for, but Alberta Health wouldn't pay for - and to which the patient felt entitled, combined with the mounds of paperwork for everything from Blue Cross drug authorizations to Handicap parking forms and demanding letters from various insurance companies, employers and various patients that wanted notes for "time off from work".......had finally started to affect me in a way that I have never felt before.

I thought that I was handling this all pretty well; with a generally good mood and an increasingly strained cheerful outlook......however, I'd never fainted before.

The rest of the day had me quite thoughtful about my predicament. I need to see my 40 patients per day - they are desperate to get in for their appointments with my current 3 week wait....but I am also handling about 10-12 emergencies per day that keep me at the office at least 2-3 more hours than I am scheduled for....this adds at least another 2 hours of paperwork to my day and keeps me up later and later at night.

And I am working harder than I ever have in my life while making less than I ever have. Alberta Health, for example, has refused to pay for various surgical procedures that I have done since last May. They grudgingly agreed to pay about 30% of my actual costs of doing the procedure (never mind my income) - and didn't care a rat's ass that I was going to be personally in the hole about it. They simply disagreed that the procedures had been performed. The surgical pathology reports, the patient testimony and my surgical notes complete with digital photos did not appear to matter to them in the least. They simply refused to pay. It's not a battle that I will win with them - and is reminiscent of the deservedly and ubiquitously despised HMO's in the USA.

One of the best, brightest and smartest Physicians I have ever known told me last week that he has had enough of the same sort of strain. The constant pressure to attend to impossible demands from an ever increasingly desperate patient population and decreasing payments from the Government, were just too much to handle for him any longer. He's pulling the plug on his 5000 patients. This is, in part, because Alberta Health fixes our rates to something below our operational costs - and they state that they will charge us as criminals if we charge any rates in addition to what they are willing to pay - even if we just want to make our costs and earn nothing. It is an untenable situation that our increasingly disconnected Government is unwilling to address.

So, for this reason; out of about 36 Docs that have worked in my Medical building about three years ago - there will be only about 4 left starting this July.

Many of them have left to go to private medicine or the USA - shunning Alberta Health....and they're all ecstatic with their decisions. But I am not prepared to abandon my patient population yet.......yet......

And so, after a day of doing these surgical procedures....I got home and listened in awe as my wife skillfully helped my eldest teenaged daughter successfully manage an episode of serious "Facebook bullying" by another grade 8 girl. I may have done some pretty neato surgeries today (the blind boy is walking fine now....I found the damned glass) - but what my wife did today to help our daughter REALLY blew me away. After 20 years, she is still teaching me a hell of a lot. I am soooo lucky to be married to this hottie!

And so, as I FINALLY sat down at the table to FINALLY eat something....my thoughts drifted to that poor elderly lady that I was too busy to see today. I put down my fork, looked up her number in my compter (at the table) and called her. And listened. And sympathized. And became embarrassed at how dreadfully our Health Care System has failed her.

So I watched my meal get cold as I called the Gastroenterologist on call at the hospital.

He listened for a few minutes in sympathy. I had referred this lady "urgently" about 4 months ago, but my referral - like every other referral I have made to G.I. in the past year - went essentially ignored, even after I called twice.

He then told me that he could not really see her soon, as that he was busy scrambling with more urgent cases and that she really had no hope to be seen as an outpatient. He told me that I should just send her to the E.R. as "an emergency" and to tell her to expect to wait at least 15-25 hours to be seen.

I have taken this approach before - and they often just tell these patients to see their Family Physicians because the issue "is not really an emergency" (very true). So I opened my laptop again and wrote an "urgent consult note" to the E.R. Doc and then called the E.R. triage nurse to inform her that the patient was going to arrive soon in the E.R. and that I wanted a call from the E.R. Doc to explain the situation.

As my meal went from cold to arctic - I called the patient back at home to advise her to go to the E.R. She told me that she could not afford a taxi, couldn't drive and didn't know if the bus was operating this time of night. She lived only a few blocks away from my house and I briefly entertained thoughts of driving her to the hospital.....but by this point, I didn't know if I could make it upstairs safely to bed - never mind driving anybody to the hospital. We talked some more, and she agreed to phone a friend for a ride.

Pushed my plate away.....It's time to get some sleep. I hope that she gets to the hospital and gets seen......

Hope the pager doesn't wake me up.....last night I got a call from the ICU about another patient (85 years old) of mine that was frustrated with his cough - so he took a whole bottle of tylenol and ativan in the hope of dying. ICU wanted him sent to Psych after "forming" the patient (taking his rights away). He is very clear about his intention to go home and kill himself. He isn't crazy - he just doesn't want to live anymore with his COPD and mild cognitive impairment.

So - do I let him go home to kill himself, or do I continue to take away his human rights at a cost of $3000 per day to the tax payer because "I know what's better for him".

They didn't teach the wrangling of this stuff in Med School.........

Thank God for my family!

It's the long weekend.........time to recharge (it's going to snow).....

Ok - I'm up to date: the H1N1 flu shot is worth it!

2009-10-24T21:44:00.000-07:00

A little more research (between my daughter’s volleyball tournament games) has revealed some reassuring referenced statements about Thimerosal.

The official CDC statement is here:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4843a4.htm

And the official Canadian Statement is here:
http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/07pdf/acs33-06.pdf

WHO’s official statement on Squalene is here:
http://www.who.int/vaccine_safety/topics/adjuvants/squalene/Jun_2006/en/index.html

A REALLY good and well referenced review of Squalene appears to be this one:
http://www.mdpi.com/1420-3049/14/9/3286/pdf

Bottom line is that it was a good exercise to go through: being asked by a patient to do a mini-lit review on this subject – with additional online discussion through a Physician's newsgroup list. Accepting the popular opinion just isn’t enough....going through the exercise of finding/evaluating/reading well referenced material has been invaluable.

The components of the H1N1 vaccine that are causing concern are the Thimerosal (Mercury) and the Squalene (the stuff blamed on "Gulf War Syndrome". The articles detailed above are very well written, researched and referenced. The bottom line is that - while it is probably preferable to not have these things in the vaccine, having them present in the H1N1 vaccine is not sufficient to exclude the vaccine from your "to do" list.

This is really a question about "RELATIVE RISK". After everything is said - your risk of morbidity or death is higher WITHOUT the H1N1 vaccine than it is WITH it!

I am now a lot more confident in recommending the H1N1 flu shot. At least now, I’ll be able to have a lot more familiarity with the increasing onslaught of questions I’ve been getting about the safety of these components of this vaccine.

This has been a great exercise!

JF

Ps. The Tom Baines Boas got Silver!

The safety of the H1N1 Swine Flu Vaccine - We can always trust the Government, right?

2009-10-23T22:40:00.001-07:00

Patients have been emailing me about the safety of the H1N1 vaccine. The concern is that it is the first vaccine made for the civilian population to contain an adjuvant called "Squaline".

There is not a lot of information on the effect of Squaline on OVID - but the "independent" research appears to be quite chilling.

As a result - I am not comfortable recommending the H1N1 vaccine until this issue is more fully answered.

Does anybody out there have any additional wisdom to add? Read on:

Because there is no listing on the safety or efficacy of squaline on OVID, I have conducted an online literature review on the subject - which is surprisingly interesting. The bottom line is that the Swine Flu vaccine is the first to have Squaline included as an ingredient. Only three other vaccines for civilian use have been developed that contain this molecule - and two of them did not earn FDA approval in the U.S.

If you need to get immunized against the Swine Flu, it is possible that a better alternative will be the vaccination with the AstraZeneca nasal vaccine "MedImmune" - which more closely mimics a natural "real life" inoculation that does not use squaline.

Bottom line is that this is, I believe, the first time a vaccine has been allowed to escape proper FDA approval processes. It is interesting to note that "official published studies in prestigious medical journals have revealed that Squaline is safe in humans". The "studies", however, were published by the "makers" of the vaccine - a new conglomerate of Novartis and Chiron. This is in DIRECT contrast to "profound and lasting autoimmune effects" of Squaline found by independent researchers.

Experience has revealed in abundance that Drug Companies do not necessarily provide unbiased data to the public and to Doctors (remember Viox, Baycol, Naprosyn, Tequin, etc., etc.).

That being the case - I don't believe that I can recommend the H1N1 vaccine to anybody until a repository of reliable information has become available. The Cochrane review people are great resource that does exactly that - and they haven't entirely caught up to the safety of H1N1 vaccine yet. Their official statement about H1N1 flu vaccination is in the following:

Some public-health officials have described flu vaccines as “highly effective,” but the internationally recognized Cochrane Collaboration (which accepts no money from the pharmaceutical industry) did a systematic review of all high-quality randomized trials (25 in all) studying influenza vaccination. They concluded that “the evidence does not support universal immunization of healthy adults.” Period.

An interesting and reasonably referenced article without special interest ties is listed here:

http://www.foodconsumer.org/newsite/Opinion/Comments/180720090846_squalene_the_swine_flu_vaccine_s_dirty_little_secre.html

and here:

http://www.newsmax.com/health/vaccine_swine_flu/2009/07/07/232717.html

Hope this helps somebody.....

I'm between a rock and a hard place. If I recommend the H1N1 vaccine - I could be sentencing patients to significant morbidity as a result of potential dangers from Squaline. If I don't recommend the vaccine, I could be sentencing people to morbidity or mortality from H1N1 infection. This is a tough position to be in - and the old Hippocratic oath of "Doing no Harm" is a seemingly impossible challenge in the absence of good and reliable information.

Do I believe, so called, "Officials"? I know that my Professional knowledge of the issues with this vaccine vastly surpasses that of most "Officials". Also - as a Professional, I've learned to trust my caution when it comes to advice from "Officials". I still remember Tequin, Vioxx and Baycol being bandied about in my office by a small army of Drug Reps that assured me (with less than half of my education and knowledge on the subjects) that all of these drugs were effective, safe and "properly studied".

None of that turned out to be the case.....but then if we had applied the same amount of rigorous concern to ASA - it never would have won FDA approval! The wisdom of the ages has taught us how to handle and recommend the use of ASA. It certainly has its risks and benefits.....but the information gleaned from dozens of years of experience with the H1N1 vaccine is simply not available to us.

So - we are left with inadequate and suspect data.....and patients literally entrust their lives and well beings to my advice!

So - for now, I'm saying "no" to H1N1 vaccinations until I can get better and better referenced, unbiased and properly questioned information.

ps: another good synopsis is at: http://www.digitaljournal.com/article/280927

Bottom line: Wait for unadjuvinated H1N1 vaccine that is devoid of Thioresal (Mercury).

The challenges of practicing Family Medicine

2009-10-09T11:01:00.000-07:00

I am certainly maturing in my ability to treat patients - and I'm probably more up-to-date, skilled, energetic and enthusiastic than I have ever been in my life. I'm pleased to say that I've been able to help patients through some of the toughest times of their lives, discover deadly diseases early while they are curable and provide support for devastating physical, social and interpersonal traumas.

I go to work smiling every day....but this is only because I know that I will eventually prevail in my ongoing struggles with Alberta Health.

It appears that for a Family Doc, there is always an assault upon you. Whether it is patients with boundary issues, Insurance Companies not paying you, staffing and business challenges, government and regulatory College intrusion into your daily operations - it seems as if some person or entity is always trying to stab you in the back.

Add all of this on top of operations costs that exceed your capability to earn money, and a culture engineered by Alberta Health to make Physicians feel like criminals if they earn more than a 7-11 employee.....and it is no wonder that out of over 36 Physicians in my "Medical Building" just 3 years ago - there are now only 6 left. Once the leases mature in 2 years, there will be only 4 Physicians left in my building.

90% of all my stress and concerns of operating as a Family Physician would disappear if I simply chose to stop participating in government insured medicine. But then I would only really be able to treat rich people that don't mind paying personally to see me, and I don't want to abandon my patients.

For example - somewhere in Northern Alberta a couple of years ago, it was found that a few nurses were using the same needle to mix up medications. No patients were contaminated and it should not have been a great big deal. But the government went nuts due to misperceived public pressure - and threatened the College into an unreasonable action.

Physicians in Alberta now have to follow this new "Infection Prevention Standards Protocol". To implement to new protocols, each Physician's clinic will need to invest at least $10,000 in capital costs, never mind staffing costs - which would easily double that figure.

For example - to simply remove sutures, a Physician has to use sterile tweezers. No problem, right? Seems simple. The problem is that the tweezers now have to be sterilized using both biological and chemical indicators ($10 each for a test and control), quarantined for 24hr before use (means you need at least 3 sets of tweezers) and you have to go through a very meticulous audit system to sterilize a simple set of tweezers.

According to the law in Alberta - you cannot charge the patients the cost of the tray....you are supposed to personally take the loss as the Physician.

Physicians have been taking out sutures in Alberta for over a century without any problems - but the now the College (ie. "Government") is telling us how to do it better.

Only the cost was never considered.

How foolish!

To sterilize a simple set of tweezers now costs the Physician about $60 (probably more). An office visit earns a Physician about $30. Therefore, the Physician has to pay about $30 out of their pocket to take a patient's sutures out.

Can you guess what is happening?

That's right - Physicians are sending patients to the E.R. to wait 20 hours to get their sutures taken out. Others are saying "screw the College - they've totally lost their minds and I no longer respect their decrees" and are doing what they've always done.

More disturbing, however, is that lots of Docs are going back to the 1700's and are resorting to trying to pick up the ends of sutures with their fingernails and using a handheld disposable scalpel to take out sutures.

Patients are returning to my office weeks after sutures were supposed to be taken out - with retained sutures that have to be surgically debrided. And no, as a Physician you will not be paid to do the surgical debridement (which needs another tray).

So what is a Physician to do?

Moronically implemented governmental and collegiate policy appears to have cast one aspect of medicine in Alberta backwards in time by over 300 years.

Many Family Physicians in Alberta are doing the only thing they CAN do - they are closing shop and leaving. It is increasingly hard to find a Family Doc in Alberta that will take you on and will be there for you for the next few decades.

But I still go to work smiling because of something that should be obvious to Alberta Physicians........

Each one of us has thousands of people supporting us that would much rather get rid of a bad Government than a Good Doctor!

Leadership review of the current Government happens in November....will be interesting!

;-)

A reminder about Humility.....

2009-09-04T23:23:00.000-07:00

It has been a long time since I blogged! In truth, I had forgotten about it. I have been very busy!

We have totally renovated our office! It is now a place of modern, tranquil beauty - with Italian Slate flooring, Brazilian Granite Countertops, a merrily gurgling slate wall fountain and an updated Electronic Medical Record System.

A few days ago, I - for various reasons - careened off a 6 ft high retaining wall while chasing a helicopter when the lights went out momentarily due to a power failure. I managed to somersault at the last second to save my head...but I based it anyways on the concrete. My left shoulder took most of the energy of the fall, however, as was evidenced by a complete dislocation. I probably had a mild concussion as well - but I seem to remember things just fine.

The pain was indescribable.....after what seemed to be a long while, I ended up in the E.R. and was assessed very quickly, thanks to a very kind and understanding E.R. Doc that I called while en route to the hospital.

While I was completely opiate naive - I have never even taken a tylenol #3 - I had 10 mg of i.v. morphine - and that didn't even touch the pain. What it DID do, however, is make me goofy enough that I called everybody I knew on my cell phone - even the Orthopedic Surgeon on call!

I should not have been surprised, therefore, to note that pretty much everybody I knew ended up coming to the E.R. to see me! I was touched - and I understand that I was very much a source of entertainment for these fine people with my morphine-induced goofyness.

The E.R. Doc was very good and appropriately gave me crap when I called the Orthopedic Surgeon (for some reason, I believed that I had a bad fracture - which I didn't). He was a good Doc and put my shoulder back together very competently. The dislocation was inferior/anterior...and I could feel the head of my humerus grinding into the underside of the glenoid of my scapula. It was absolutely horrible!

I have reduced many shoulders over the years and now I have a much better understanding of the subjective experience of the process!

Today, I did an operation on a very pleasant mentally retarded 30 year old man. His intellect was about the same as a 6 year old, a fact of which he was very much aware. He had a job mowing lawns for Seniors and was flabbergasted that so many seniors treated him so poorly. Last week, he asked his aid worker to attend his job with him - just to see how badly he was treated, and she was able to verify that several of his clients were abusive towards him. She struck them from the register of Seniors that were getting subsidized lawn serviced - leaving him feeling slightly vindicated.

He and I chatted while I removed the mass from his left posterior hemithorax that had been growing against a pain sensory nerve that had kept him up at night for the past few months in unrelenting pain.

His perspectives of the world were very honest, simple and uncomplicated. He still looked at the world through rose colored glasses, and was full of wonder and awe at the beauty and mystery of everything he experienced on a daily basis. I had to explain to him what I was doing literally every minute during the operation - and I was pleased to do so.

Though he was retarded - he was uniquely able to enjoy the wonderful gift of the ongoing appreciation of beauty, wonder and mystery that we as adults and busy "important" professionals seem to have lost some time over the course of our becoming "important adult professionals".

In many ways, over the hour-long procedure, this delightful retarded man was able to remind me of lessons of long ago that I had forgotten - but now have more need than ever to remember!

It was a great privilege to be able to end this fellow's chronic pain, and an even great privilege to learn something from him.

My new motto: There is NO EXCUSE for not enjoying yourself!

Adding an Electronic Medical Record (EMR)

2009-01-12T21:28:00.000-08:00

I've decided to computerize my office and to get rid of all the paper that is now threatening to consume all of my time, energy and resources.

I've searched high and low and have decided that I don't want to go with a private vendor. They just go out of business and then hold your data hostage. They also charge you and arm and a leg and provide poor customer service for their software that doesn't really work all that well anyways.

And on top of all that, their software usually has to run on (gasp!) WINDOWS! Everybody KNOWS that you just can't use Windows for mission critical work. It is too unreliable and crashes to frequently, and the viruses attacking it are too numerous - to the point that over half of your computer's power has to be devoted to virus defense!

So I've decided to go with a LINUX system that is open source, free and developed and maintained by a wonderful group of Physicians and computer professionals that are devoted to only one thing: the perpetuation of top notch free software for the betterment of people.

So, I'm reading my first 1000 page book of a set of three books to learn about Linux, and I am configuring and building a server to run this thing. Some very nice people in the Linux community have decided to help me out for free, and I'm taking them up on it.

This system will also allow my patients to log in to view summaries of their medical charts for travel/emergency reasons. I'll be able to better interface with Pharmacies and other diagnostic testing and imaging facilities.

The future is really exciting beyond this new frontier - and it is especially exciting with respect to this new free EMR from McMaster University (OSCAR).

All I have to do now is to build an economic support structure for this new EMR idea and I think that it'll start to grow exponentially to take over EMR's in Alberta!

Just have to climb this very steep learning curve......

Treating a patient on a plane

2008-10-13T12:03:00.001-07:00

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!

Mental illness can hit anyone

2008-09-07T21:46:00.000-07:00

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

2008-07-19T10:10:00.001-07:00

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.....

2008-07-04T23:23:00.000-07:00

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

2008-07-01T22:51:00.000-07:00

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

2008-06-22T10:26:00.000-07:00

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

2008-06-20T15:35:00.000-07:00

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

2008-06-13T16:13:00.001-07:00

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

2008-06-12T22:05:00.001-07:00

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

2008-06-12T21:41:00.000-07:00

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

2008-06-08T23:43:00.000-07:00

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.