The Worst Obit Ever Written

Here is the most tortured obituary ever written. It is a great reminder to think before you speak when you decide to critique a friend, family member or co-worker.

What do you want your obit to say?

Thanks to FatDoctor for pointing this one out.

Honour

As a child I was told that honour was made of the virtues prudence, temperance, justice and fortitude. But when I heard the news that 3 Canadian soldiers died in a major road side IED attack in Afghanistan this week I could only question my own honour. How can I sit in the comforts of my home and clinic, while countrymen die abroad and still believe that I hold those same virtues close to my heart.

The soldiers that serve our country leave home, comforts and family for a life of low pay and high risk. In the context of our societal values they live a life of integrity and trustworthiness that is the very essence of honour. But can I say the same?

Honour is contextual. What one society considers honourable another will consider disreputable. The same holds true of values in health care. A surgeon of 1950 would have questioned the moral fortitude of any practitioner that did not work 72 hours straight or come to work with the flu. Modern concepts of patient safety have changed that view. In the same way, we need to challenge our sense of honour in the clinic.

At the end of the day, has every clinician and staff member conducted themselves with integrity, fairness and honesty? If every patient could hear every conversation, would they still respect you?

To compare the daily trails of hospital and clinic life to military service is a non-starter. Honour is contextual and there is no greater sacrifice than to risk your life for your country. That does not mean we shouldn't strive to live an honourable life.

Pro Utilitate Hominum

Domestic Violence

I'm going to take a bit of a tangent from my usual posts to comment on a post at Random Acts of Reality (a blog from paramedics of the London Ambulance Service). In their post on what appears to be an abused women;

"As it is there is little that we can do - we handed the patient over to the triage nurse and made our concerns known to her, then delegated any decision upwards by noting our concerns on one of our 'vulnerable adult' forms. I'm not sure these forms are designed for this purpose, but we do what we do and if someone in the upper rungs of management wants to throw it in the bin it's up to them.

He [sic] is the thing, we have no idea what happened - no-one was volunteering information and we are only with the patient for a few minutes so it's not really appropriate to start investigating. Did the husband do this to his wife? Was it an assault in the street that they are ashamed about? Was she trying to hit the husband and she got the bruising while he was restraining her?

Who knows, I can't judge. I'm not the police so the best we can do is draw it to someone else's [sic] attention within the confines of patient confidentiality. All I am, as one politician said, is a taxi driver with bandages. "

Unfortunately, that same sentiment of helplessness carries through to many levels of treatment. When should someone offer help? Simple domestic violence screening is often enough to get the ball rolling. Have some excuse to separate the husband and wife* and tell the patient that these injuries are often associated with domestic violence, ask her if she is safe and if she needs help. It is a non-judgemental way to open the door. With something like 1 in 4 women being abused in our society routine screening is the minimum that all health care workers should be doing.

*I realize there are always mitigating circumstances such as the language barrier in this particular situation. It was the line "as it is there is little we can do" that set me off.

The Ethics of Block Booking by Insurance Status

Recent cuts to Medicare bring up an interesting practice management problem. If a practice chooses to accept patients on social assistance medical insurance (such as Medicare) is it ethical to leave those patients waiting longer?

Reality

It would be easy enough to offer 1 or 2 appointments a day to publicly funded insurance plan patients and leave the rest for private pay (block booking based on insurance). The result would be longer health care wait times for public pay patients. The dilemma to providers, of course, is that publicly funded plans usually pay less. The alternative is either a cut in revenue for the clinic or complete denial of access to these patients.

Ethics

The ethical dilemma stems from the fact that those with less access generally have poorer health. When a practitioner denies access completely the ethical dilemma is transferred to another because the patient seeks care elsewhere. Where a practitioner chooses to govern access through block booking they retain the moral quandary of different levels of care for patients under the same care provider. Once one chooses to accept a patient, is it ethical to allow two patients with the same disease to have different outcomes based on access to the clinic?

A Moral Choice

My opinion is that a clinic could morally limit appointments as long as the process was transparent to patients, made accommodations’ for emergency/urgent cases and did not violate any legal statutes that preclude differentiation based on insurance status. Ideally, wait times for publicly funded patients would still fall within regionally acceptable limits for wait times based on disease. I do not believe the latter is moral requirement so long as the prerequisite of transparency is met.

Practical Concerns

Another problem is that staff controlling schedules have not undergone the same ethical indoctrination as providers. That is not to say that they are any less moral, only that they may not share the same values with respect to patients’ needs which could lead to behavior and booking patterns contrary to the providers’ value system. To align provider choices with booking practices administrative staff require healthy clinic socialization in addition to formal professional education.

Public Policy Concerns

As countries the world over convert to a mix of private and public funding the issue of primary care access based on coverage are going to become more pronounced. If it is to be public policy that income should not correlate with access public policy will need to be set to bring public funds in the range of private expectations and legislation created to equal the playing field. Assuming that coverage remains an acceptable reason to deny access, practitioners who continue to run dual coverage practices will need to consider the ethical implications of offering the service and professional colleges the standards by which dual coverage access will be provided.

Finding Time

Right now I have a young man (40ish) with end stage metastatic prostate cancer who had a tooth out while undergoing chemotherapy including bisphosphonate drugs (an anti-osteoporosis medication also used to minimize bone pain and the spread of metastatic disease).

One of the side effects is that if you take a tooth out while someone is on a bisphosphonate they can develop persistent dead bone where the tooth came out (osteonecrosis of the jaw). If you do it while they're on intravenous doses during chemo it can be especially bad.

He has a bad case but has decided to forgo any more treatment (of any kind). I see him about once a month, talk for 1/2 hour and see him again a month later*. We talk about the tooth, how he's doing and what's planned for the coming month. The one thing we've agreed not to discuss is the prognosis. There's not a lot of purpose to our talks other than to make sure he's doing OK. I don't think we have many appointments left. Unfortunately, this is not the first time this sad scenario has played out in our clinic.

Because our wait times are under control being able to spend extra time with patients like this is guilt free. It does not increase another persons wait.

I often write about the amount of time that can be saved but a major benefit I don't mention is the amount of time that can be spent. The ability to spend our time as caregivers with someone that can really use it is an often overlooked benefit of efficiency and something that is lost in translation to the charts and graphs of the non-clinical administrative world. How do you measure compassion?

*so that no-one thinks that I'm bilking this man or his insurance plan his appointments are always done on my dime. One of the quirks about our system is that unless an Oral Surgeon sees a patient in hospital medicare will not cover it.

Moved to Tears

Dr. Rob has an extremely raw post that is something between a rant and an ultimatum to all of the insensitive twits out there who sit in judgement of their friends then pass it off as advice.

The post is moving as hell. It's also cause for introspection and a wake up call about what it really means to be a friend. Absolutely beautiful post Rob.

Prime Minister of Canada apologizes to First Nations for Residential School System

Yesterday Stephen Harper, the Prime Minister of Canada publicly apologized to the First Nations (Native) Peoples of Canada for the residential school system.

Between the 1600's and 1996 residential school were in place to enforce a policy of 'aggressive naturalization' of Aboriginal Canadians based on the 'inherently superior British system'. The schools were first set up by the French colonials to convert Native Canadians to Christianity then formalized in the 1857 Gradual Civilization Act*. Eventually, the schools were administered by the Catholic and United Churches of Canada and funded by the people of Canada.

Aside, from the moral issues with publicly funding and systematically trying to erase an entire culture the schools where poorly funded, dirty and overcrowded. They were awash in abuse (both physical and sexual), had poor sanitation and high rates of diseases like tuberculosis. Death rates were as high as 69%.

Originally the schools existed to encourage Aboriginals to become English speaking, Christians and farmers. But by 1920 the system had been perverted so badly that children were being forcibly removed from their families (in the above picture parents camp outside the gates of a school in 1885 to visit their children). In the early 20th century Canadian doctors described the horrific rates of death and disease and by the 1950's compulsory attendance was ended. Aboriginal protests in the 1970's resulted in self-governance and eventual closure of the schools. The last one was shut down in 1998.

The wiki site has a good deal of information on these schools so I'd encourage you to read the full story. All I can say is it's about time that someone from our government publicly apologized.

*The Gradual Civilization Act is another piece of Victorian legislation that deserves mention. It sought to convert Aboriginals into Canadians by having them sign away any rights as a Native in exchange for 50 acres of land. The requirements were; over the age of 21, "able to speak, read and write either English or the French language readily and well, and is sufficiently advanced in the elementary branches of education and is of good moral character and free from debt" and "of sober and industrious habits, free from debt and sufficiently intelligent to be capable of managing his own affairs." Once enfranchised the person and all of their descendants gave up tribal affiliations and any claim to lands.

Strawberry Risotto

Summer time brings friends and time to cook something special. So today is a break from the numbers. When our family went on a Disney Cruise last year we had some weird but delicious strawberry risotto (if anyone at Disney sees this blog please send me the recipe; I still haven't got it right).

The Blog that Ate Manhattan and her readers helped me find a couple of recipes to replicate it so I've tried them out. The final recipe is based on one at theepicentre.com which used a vegetable broth (rather than chicken) and a port wine.

I tried the recipe as written and found it lacked flavour and looked darker than what I remembered from the cruise. So I modified things a little and tried it again. The second time it was still a little more brown than I remember but otherwise pretty close. There is just a hint of sweetness to the mixture. Butter, onion, strawberry and champagne is more aromatic than one would think. Please give it a try and post more suggestions to the comments section.

Ian's Strawberry Risotto

Makes 2-3 servings depending on how much you want to exercise the next day

Total time: 30min

2 1/2 cups vegetable broth (low sodium)

2 tablespoons unsalted butter

1/4 onion finally chopped

1/4 cup chopped strawberries (2 large strawberries) hulled & washed

3/4 cup Fine Arborio rice

1/2 cup Rose Champagne

2 tablespoons Parmesan

A good bottle of red wine (go slow; risotto is a labour of love)

Bring vegetable broth to simmer - the amount used will depend on how you like the risotto cooked. I like mine al dente so it was closer to 2 cups of broth.

Stir Continuously; your arm should hurt at the end of this

• Over medium heat;
• Have a sip of red wine
• Add butter to large saucepan and melt;
• Add onion and saute until glassy (1-2 min) careful not to brown
• Have a sip of red wine
• Add strawberries and cook until they loose their colour and give up their juices (1 min)
• Add rice and coat with mixture (2-4 min - don't rush this step it 'seals' the rice)
• Have a sip of red wine
• Add champagne 1/4 cup at a time until liquid is soaked up by rice
• Add simmering vegetable broth 1/2 cup at a time. When you add the broth allow it absorb into the rice completely. As the mixture become sticky add another 1/2 cup at a time.
• Have many sips of red wine
• As you get to the end of the broth taste the rice. It should be al dente (firm, chewy but not crunchy). It's amazing how much broth Arborio will absorb so don't be shy.
• Add Parmesan a pinch at a time, fold in and taste - the Parmesan cuts the sweetness so use it sparingly.

Serve with Parmesan on the side with whatever remains of your red wine. It still looked more brown (due to vegetable broth) than I remember but it tasted great. I hope everyone enjoys it.

Stories and Statistics

Maggie Mahar has a good post over at the Health Beat on why we need both Stories and Statistics.

""Of course, like any physician trained in the past several decades, I too had learned to view the anecdote with the greatest amount of skepticism, if not outright disdain,” Camp acknowledges. “The anecdote, though beguiling in its familiar engagement of our human sensibilities, is, we are all taught, the enemy of objective, dispassionate observation....."

It's a good post and very relavent to the world of blogging where we tend to verbally "shoot from the hip".

Two Canadian Heroes Die

Two Canadian heroes from my area died this week and deserve mention.

Dr. Sheela Basrur was the "guiding light" during the SARS crisis that rocked Canada in 2003. She lost her battle with hemangiopericytoma (a rare type of cancer) on June 2, 2008. Dr. Basrur's diligence and intervention were pivotal in keeping SARS from spreading even further.

The body of Capt. Richard (Steve) Leary of Brantford returns home. He was killed in an ambush while on patrol in Afghanistan. My thoughts are with both of the families.

Home Run

My son hit his first home run this week (age 8) and gave me a quote of the day.

The kids got a way with words :-)

"Today is going to the top of my best days list and the bottom of my worst days list"

Some Things are Worth Waiting For

Back as resident we had a 30 year old man come in for a bunch of extractions (I'll call him John). John was born with trisomy 21 (Down's syndrome) and all of the associated complications associate with the genetic abnormality, not the least of which was a severe cardiac defect, a bleeding disorder (von Willebrand's disease) and development delay. Where a normal oxygen level is 97-99% John's was 50-60%. Even this minor surgery was not taken lightly (he had multiple abscesses and the concern was that it would affect his heart) so cardiology, anaesthesia, hematology and several other specialties became involved.



Despite John's health concerns, however, he was the sweetest, nicest person I'd had the pleasure of meeting with a heart of gold. His mother stayed with him continuously. John showed up for the OR with an E.T. doll for security and kept it with him his entire hospital stay. He thanked us everyday, would not let us leave his room after morning rounds without a hug and was an all around pleasure to care for. Anyway, after the extractions and anaesthetic he stayed on the ward for close to a week as we tried to get his oxygen levels back to normal. Everything was going OK until post-op day six when I was called to the ward and found my friend in dire straights and his mother screaming "he's dieing". John had developed a pulmonary embolism which lowered his oxygen levels even further, decompensating his fragile heart and within 10 minutes it had killed him.

Jump forward 15 years and I'm running around trying to keep up one day when I walked into a room to be faced by a 30 year old female with Down's (I'll call her Deborah - not her real name). The first words out of her mouth where "sorry I'm late Dr. Furst but I had to have my lunch and brush my teeth before I came". It's easy to look at the day and worry about running 15 or 20 minutes behind but it is memories and people like John & Deborah that remind me why we work so hard to make health care accessible to people. Some things are definitely worth waiting for.

Do Not Evacuate

This is a post by two doctors working in the arctic. It has nothing to do with wait times or delayed care just compassion. It is the most compelling post I've read in weeks and I thought it should be shared with everyone.

http://northmed.blogspot.com/2008/03/dne-do-not-evacuate.html

Ian.