A reminder about Humility.....

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)

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

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......