Alternative

This article “What Do Doctors Say To ‘Alternative Therapists’ When a Patient Dies?” by Ranjana Srivastava appeared on my Facebook newsfeed yesterday.  I couldn’t resist reading it.  I think you should read it too.

First of all, it is clear I am a big nerd when this is the most eye catching thing I saw on Facebook.

But, the big reason it is eye catching is because I was curious what it would say.  And it said what I thought it would.  We say nothing.  We don’t talk about it with others.  We talk about it amongst ourselves.

It also echoed a lot of feelings I would describe having around alternative therapies.

I am probably one of the more “loosey-goosey” of the people in my department when it comes to alternative therapies.  I am touchy feely, I inherently trust people and I do believe that there is value in a lot of things we can’t or haven’t necessarily studied.  I’m that kid who did a presentation on medical marijuana in research rounds and concluded that it isn’t all bad and we really need to look into the stuff more because people are using it whether or not we think they are or should.

I ask people what they take over the counter or with supplements.  I explain why I ask.  You see, some products, although “natural” act in ways that counteract the actions of chemotherapies or radiation or other drugs.  Sometimes in terribly harmful ways.  Ways that make cancers not respond to treatments.  Or ways that make side effects worse.  I ask because I care.  Not because I want to judge you or make you feel foolish.

Actually, some of the drugs that we give people are “natural.”  Some chemotherapies are plant derived.  They are natural and very toxic, but when used appropriately can treat cancers.

I see nothing wrong with trying something different when nothing is working.  I see nothing wrong with adding things that have low risks of harms that may help.  I see nothing wrong with doing things that are healthy for you.

I do see something wrong with people who are encouraged to spend their life savings on a “miracle drug.”  When people risk their lives to procure enough cannabis to make the oil they were told online was a “cure.”  When people entrust their health to internet “doctors” and people who make a profit from preying on the sick and the scared.

Many of the “miracle” agents on the internet are anecdotes.  Sure, everything starts as an anecdote.  But, that is why things are tested, because we are often wrong and they are one-off events.

There is some laboratory in anecdotal data about cannabinoids.  I’m not refuting it.  I’ve read it.  But, there is no cold hard evidence for it as a cure for cancer in humans beyond the odd case.  Could it be coming?  Maybe… But that day isn’t today.  And there is cold hard evidence for other treatments in some cancers.

It scares me that some people believe the person that will make a fortune off of them buying their concoctions is more trustworthy than the person who makes the same amount of money whether or not they take the treatment.   It upsets me that people think I am the one brainwashed because I am offering medicine with evidence behind it, with the experience of time, the monitoring of governing bodies and the backup of provincial funding.

It terrifies me to know that supplements and some complementary therapies (not all) are not regulated at all.  In fact, often they aren’t even containing what they claim or have contaminants that can be harmful.    And people die from complications from these therapies.  Just like conventional medicine.  But in a lot of cases we don’t even know some of the risks.

When something claims to work almost all of the time or have no side effects… It probably isn’t for real.  Too good to be true is something I see a lot.  But people want it to be true.  And why not?  Some people have nothing left to lose.  But really, everyone has something to lose.

It also makes me sad that some of my colleagues think all complementary or alternative therapies are bad or dangerous.  It is scary to see people doing things we don’t understand, so I get it.  And it is hard to trust when people you cared for and gave your all for die, sometimes because they gave it all up for the wrong choice.

Miracles happen.  There are things we don’t understand how they work, but they do.  There are things we know do work and they scare some people because of misinformation or lies spread through all kinds of media.

When people forgo conventional treatments or risk counteracting treatments for something advertised on the internet or sold by an alternative provider, it makes me uncomfortable.  I’ll be honest.  When people die doing this, it makes me sad.

Complimentary and alternative therapies can be many things… I send people for massages, acupuncture, reiki and I think chiropractors do good work. I encourage spirituality and  and exercise.  I preach good diets and appropriate vitamin supplementation depending on need.   I think cannabis can be an option for some people for symptom control.  I am okay with you doing something else so long as it isn’t putting you or your treatment at risk.  I can’t stop you from doing something I don’t agree with or trust because you are your own person.  But, I can be honest and tell you why it is concerning.  I can review the evidence.  I can help you interpret it because I have a background in reading that kind of stuff when many people don’t.   I’d rather know than not know in any case because your health is important to me.  And I make no gains or losses by having someone take “my treatments.”

I just want people to be healthy and safe.

Conventional medicine can’t save everyone.  Neither can alternative medicine.

It is scary, but things go wrong.  Alternative therapies (namely the various supplements and drugs and cleanses) can cause a lot of problems.  But, we don’t talk about it when things go right.  We also don’t talk about it when things go wrong.

Talking would be a good start. Regulations would be wonderful.

There will always be people out there trying to make money and preying on the sick and vulnerable. Sadly, these people give everyone a bad reputation and are the source of my distrust and skepticism.  I know there are practitioners out there who think they are doing good and maybe are not.  That is where better regulations and research could make a change.  And I know there are practitioners out there doing amazing work with the best interest of the patient at heart.

An open mind is good.  Educated professionals are better.  But, I think that opening up the lines of communication between professionals but also with patients could make a movement towards making a difference.  At least in some cases.

ID compared to House, MD

It is Medical Monday, yet again.  Actually, I feel like it has been a long time since the last Medical Monday.  Either way, it is time to hook up with some other medical related blogs for some medical and Monday-ish goodness.

As some of you who read this blog regularly know, I am currently on an Infectious Diseases rotation and I have likened it a bit to the TV show House, MD.

I have been giving it some thought (and noticing the continued strange popularity of my post General Surgery Is NOT Grey’s Anatomy) and decided that it is time I both prove and dispel some more TV related medical show perceptions, this time referring to House, MD.

First of all, why House?

For starters, it is one of the other medical shows I watch(ed).  Also, when I think of real medical specialties that are kind of like “diagnostician” I think Internal Medicine and, more specifically, ID or Rheumatology because they get to see some of the weird and wonderful.  And I am sure in some big places, someone really is a diagnostician specializing in the really complex cases.  That being said, it isn’t a residency or a common position.  At least, I don’t know any, so this is my reasonable facsimile.

The similarities:

  • There really is a gaggle of people who deal with the complicated cases.
  • People do sit in a group and bounce ideas off of one another complete with internet and journal searches and a white board, or more commonly, a sheet of paper.

    Image from teichdoesmedicine.blogspot.com.

  • Someone who is generally much smarter than everyone else does lead the pack (and sometimes bosses people around).
  • Often times, much of the staff are not fans of the person in charge of the hospital.
  • Patients do lie.  For reals.

    Okay, not everybody. Image from Iamilliontrees.net.

  • The days can be crazy long and chaotic, but also interspersed with mind numbing waiting and boredom (or time for other antics).
  • When you just think you have someone or something figured out, there is a twist (sometimes).

    Image from eatliver.com.

  • Sarcoidosis, lupus and obscure infections are often somewhere on the differential.

    Or is it? Image from http://www.quickmeme.com.

  • You do have to work in places you don’t always like to or want to in order to keep the hospital running and such.

The differences:

  • Patients do tell the truth.
  • One does not generally have a team of fellows who were staff in every other area of the hospital.  Those people often just stick to their own jobs.
  • You can’t just go around running your own lab tests, diagnostic scans and procedures all willy nilly.  There are people specially trained to do all of those things better than the doctors on the show.
  • You would lose your job for screwing around with a clinical trial, stealing drugs, blatantly endangering patients, etcetera.
  • A good start to making a correct diagnosis is a good history and physicial.  They tend to skip that step.
  • A next important step to a correct diagnosis is doing the correct diagnostic test.  Most of the scans they do aren’t appropriate and then the images are not actually of the scan they claimed to order.  In fact, they often put the patient in the incorrect machine.
  • You can’t order everything STAT.  That would make “STAT” routine.
  • There are more staff in the hospital than the “Diagnostician” and a lone oncologist who happens to treat EVERYONE (including children) with cancer.

    I do quite like their bromance, though. Image from tinyobsessions.wordpress.com.

  • As a consultant, you consult, not make all the decisions.
  • People don’t code that often.  At least they don’t code that often and survive.
  • Patients die.
  • Sometimes you just don’t figure out the answer and the person either dies or gets better and you don’t know why.  That isn’t a failure.  Just life.
  • Breaking into someone’s home, car, workplace and so forth is a felony, not medicine.
  • It takes much more time to figure out complicated and novel cases.
  • You can’t just throw drugs at people (or take them away) and expect them to get better.
  • If it walks like a duck and quacks like a duck, it is probably a duck, not a zebra.  House almost always gets the zebra.
  • Sometimes, it really is lupus or sarcoidosis.

    Image from housemdconfessions.tumblr.com.

  • Nobody would let you practice medicine on that many drugs.  No matter how good you are.
  • You can’t just go taking over in the OR, bursting into the OR or really, doing anything in the OR if you are not currently practicing as a surgeon.

    No. Just, no. Image from housemd-guide.com.

  • There is a financial and ethical limit to how much you can and should do.
  • Doctors aren’t immune to whatever the guy in the bed has.

Painful procedure

I think we are mean sometimes in adult medicine.

Okay… Not this mean… Image from quickmeme.com.

I don’t mean the heartless jerky kind.  Well, at least I am not, although buddy who I refused to give a narcotic script for a knee sprain may argue that I am.

Today, I did a lumbar puncture.  A difficult lumbar puncture.  On someone who may have had a subarachnoid hemorrhage.  Meaning, they had the worst headache of life.  And then I came at them to stick a needle in their spine.

This is something you have to do from time to time.

I have done many lumbar punctures.  All of them to this point were in kids.  Sedated kids.

Now, I am doing one in a large, not sedated, uncomfortable adult.

Big difference here, boys and girls.

Sure, we use freezing.

That alone hurts like stink.

But we do all this.  And it took a few adjustments before we got fluid.  All without sedation.  Fully awake with just the pain meds for the head.

Image from diagnosisms.org.

It seems mean.

Then, I saw someone with a huge laceration.

You know the bigger they are, the harder they fall?  Well, it is true.

I couldn’t find any topical anesthetic, so I had to inject lidocaine into the area.

Have you ever injected something that stings into the appendage of someone three times your size who is terrified of needles?

I can now say I have.

I actually had to get sedation.  And even that didn’t really help.

It took me and two people holding, as well as enough sedatives to make me comatose to get the freezing in, let alone suture the wound.

And then someone found something topical.

Just in time to make me feel like a big jerk.

We do that to kids.  But, they have topical cream and if they are really stressed we give them drugs to make them loopy.  And generally they aren’t big enough to kill me.

I also want to argue that adults should know how to suck it up.  But, that isn’t always the case.  But, sometimes I feel like we don’t do great when that is the case.  When someone has a legitimate phobia and can’t cope.

Why do we routinely sedate kids for lumbar punctures and make sure their procedures are as pain free as possible, but for adults, we often make them suck it up?  It isn’t that much more complicated to do it.  Sure, sometimes there are observation and airway concerns.  It is more time consuming.  But, sometimes, as someone who isn’t big on procedures, I think it would make the procedure easier on everyone.

Ah, sedation. Image from animal-space.net.

Do I think everyone should get emla cream before needlesticks?

Heck no.

But, I do think we should offer options for more painful procedures more readily than we sometimes do.  Especially people with irrational fears.

And that is what I think makes us mean.  In, reality we are just doing what we can with the time, resources and training we have.  The culture is not always one such that change happens quickly, especially if it isn’t a huge safety concern.

I won’t be doing tons of procedures in my future career (thank goodness), but I hope that the combo of the peds experience with seeing people go through icky stuff with some procedures in the real world will make me remember to try to offer good pain/sedation options when doing procedures, especially those that are extremely anxiety provoking.  I know I won’t be perfect and sometimes things can’t be helped because it just isn’t practical or reasonable, but at least it will be worth a try.

And just so you know, sometimes painful procedures are painful for the person doing them.  Maybe not as much for the person on the receiving end, but nonetheless, it can still be unpleasant.

Doctors Are People Too

It is Medical Monday!  Whoo!!  That lovely day of the month where I write about something medical (okay, that generally happens more than once a month) and link up with other medically related blogs for all sorts of medical awesomeness (that was a lot of medical in on sentence).  Check it out at the link-picture thing below.

My topic today is a rant of sorts.  Sorry in advance.

In case you didn’t know, your doctor (or other friendly health care professional) has a life and time matters to them.  They have good days and bad days.  They get sick and their family gets sick.  They get paid by a publically funded system (in Canada), but so do people who work or don’t work, for that matter, in many other places.

Most people know this.  I think it is something that is obvious to the human condition.  But, there are some people who think this is not the case.  They might think this is not the case for most other human beings who “serve” them in some way.

I complain sometimes that I don’t like going to the doctor because it is a time sink.  I don’t like waiting.  But, really, does anyone?  And I acknowledge it is a fact of life.  We all need to wait for stuff.  I also wait to get my car registered.  Or to buy clothes at Old Navy.

Image from bigthink.com

Here is the catch… If the doctor is running behind or if the cashier is swamped, they are having a busy day too.  And although they are not inconvenienced by waiting, they are trying to move as fast as they can (okay, not all people try, but lets give people the benefit of the doubt).  Sometimes someone needs extra help, or something urgent came up.  Things happen.  Stuff gets behind.

I hate being behind in clinic.  I tear around like a madwoman to try to stop it from happening.  But, sometimes you get phone calls, or someone else is late that throws you off or sometimes, you just get behind.  I feel terrible when I am behind.  I apologize when I am behind.  I know it doesn’t make your day better.  But, please don’t yell or complain as if I did it on purpose.  When I am late for your appointment, you lose out on some personal time.  But, when I am late for your appointment, someone else might be having a worse day than you and I was helping them.  And as a result, not only am I behind for you, but probably for the rest of the day, which means, I get out of work later.  So, I don’t like it any more than you.

I acknowledge that sometimes people are late.  But on that same token, don’t show up late to an appointment and get mad at me if I took someone in ahead of you.  And really, call if possible.  Or at least apologise.  My time matters.  It not only affects me, but the other people booked in.

Image from americanbedu.com.

Sometimes, people who work in health care get sick.  Or they have a bad day.  So do you. Personally, I try to do my best during those days.  And sometimes it is hard, really hard.  But, I grin and bear it because that is life.

We all make mistakes. Even people in health care.  We try to prevent them the best we can.  There are all kinds of rules and plans in place.  But, especially as a student it happens.  I feel terrible when it does.  I never want to see someone have to repeat a test or come back unnecessarily.  Sometimes it happens, though.  I get annoyed when it happens to me.  It happens to everyone sometimes.

Yes, health care providers are funded by government money (at least they are here).  So are your welfare cheques, your car registration clerks, the military and countless others.

Physicians are there to help, but in order to help, they need to use the money provided for health care appropriately.  Sometimes that means saying no to unnecessary tests or medications.  It isn’t just because we are lazy.  We are protecting your health and the health of others.  Going to your doctor’s office is not going to Harvey’s.  You can’t have it your way all the time.  You make your own decisions, it is your body.  But, at the same time, there need to be limits in this system.

And yes, we get paid for doing our jobs.  So do you.  Stop telling me you pay my salary.  There is a good chance I pay yours too in some way if you are going to look at it in that fashion.  My purpose is to provide good care to people.  At my current position, I can’t double book or intentionally cut corners to save.  And I wouldn’t do that even if I could.  As a resident, I am salaried.  I get paid the same working 1 or 20 hours.  I work until my work is done.  That is what is needed.  So, please stop accusing me of being one of those doctors who work the system and get paid a fortune.  Most don’t.

In summary, health care providers are people too.  We are doing our jobs and happen to love people, but sometimes it doesn’t all go according to plan.

This kind of looks like our cat… Image from cheezburger.com.

Why getting stabbed might save a life (and why you should too).

Image from actionalexandria.org.

I got my flu shot today.

It was my first day back after vacation and I was wandering around the surgery ward trying to stay awake (the first 5am of the week hurts, especially after a week of 7 and 8ams) when the lovely charge nurse grabbed me.  I instantly presumed I was in some sort of demand.  Probably someone needs home care forms filled out before discharge or something.  But no, she just wanted to make sure I knew they were giving out flu shots in the unit’s conference room.  And that if I haven’t had one already, I should get one.

This made my day.

No, I am not the sort of person who gets cheap thrills from pain.

I am, however the sort of person who loves some good convenience.  And a flu shot in the very area I am working is just that.

Plus a free pen and an awesome sticker never hurt anyone either.

So, I rolled up my sleeve and got the job done.

Total time out of my day 15 minutes (including the waiting period so they can ensure you don’t pass out, nor go into anaphylaxis).  During said time I managed to drink my coffee, check my blog, check Facebook and my email, plus finish organizing my to-do list.

When you really get down to it, I did something super productive and really did not lose any time in doing it.

Win!

Odds are at least half of you reading this will now roll your eyes and say something like, “The flu shot? Seriously Trisha, I got one once and I got sick anyway.  What a waste!”

I will now respond in kind.

That is a stupid argument.

Blunt? Yes.  Honest? Yes.

Just about every time I get the flu shot, I develop a low grade fever, aches and feel crappy for a day or two.  It is how I roll with just about every vaccine.  My body really likes to take things on full force.

Does this suck?  Heck yes!

But, it is not as bad as the real flu.

Oh, and the flu shot is an attenuated virus.  It can’t give you the flu.

Herein lies the issue.  Most people assume every cold they get is the flu.  No sir.  And other people assume that when they start barfing their brains out that is the flu.  Wrong.

The flu is actually a cold on steroids (though steroids would potentially relieve some cold symptoms, so scratch that).  If you have had a real flu, you know.  You can’t work with a flu.  You have a fever and pain and all kinds of delightful snotty/coughy symptoms.  And maybe some vomiting or nausea.

The flu kills people.

Probably not you.  You are probably healthy and young (unless of course it is H1N1 or the Spanish flu).  It kills babies.  And old people.  And sickly people.  The people who you should be trying to protect.

People who die of the flu often die of things like pneumonia and thus things like insurmountable infection and respiratory distress.  Not good ways to go.  Not on my top ten, that is for sure.

And yes, I am sure most of those people who can get the flu shot do (unless of course one has egg allergies).  But not all of them do.  Yet, they still get out.   They go to malls and touch the same things our grubby hands touch.  Or they are taken care of by people like me who work in the hospital and come into contact with all kinds of lucky stuff.

So, let us think for a second… People who are susceptible to this illness are all around us.  And they could die.  But, we won’t get a two second needle to help protect them?  I am pretty sure most of you were against small pox.  Bet you are glad people back in the day sucked it up and got vaccinated!  That helped to protect you.

It is a concept called herd immunity.  Kind of like how kids these days aren’t getting measles or whooping cough and such.  Well, they weren’t… Until people started to refuse to immunize their kids.  Now kids get those things again.  And die.  Not as many as before, but more than when I was a kid.  Because the majority of the herd is no longer immune.  For a variety of both good and bad reasons… More on that some other time.

I am not talking a vaccine with significant moral sequelae here (unless you are allergic to eggs).  And maybe you are opposed to stem cell research or something.  They grow the stuff in chicken eggs.  Not human fetuses.  And they test it on animals.  Not baby cells.  And it doesn’t go to the animal tests until it is otherwise safe.  So, unless you are a protector of chicken egg rights (which some people are and I respect that decision), you really don’t have to freak out about current vaccine techniques… Unless you go waaaayyy back.  Or talk about some other vaccines, which I am not addressing here.

Even then, sure some people feel very strongly about animal rights or stem cell use and what have you.  I do know that this is a very small portion of people.

And NO I haven’t heard anything official about flu vaccines causing autism.  I know people worry a ton about thimerosal, a preservative used to prevent bacterial growth in vaccines (their purpose is to keep us safer).  If you are concerned, there are thimerosal free flu vaccines available.

There are potential side effects with the vaccine.  There are potential side effects to taking a Tylenol or a vitamin supplement too.  Bad stuff happens sometimes.  Most of the time you get a sore arm.  Maybe a low grade temperature.  I won’t lie, there are scary side effects like Guillian-Barre syndrome.  You can also develop liver failure from Tylenol.  Or anaphylaxis from an antibiotic.  Probably won’t stop you from taking those.

So, why is it that the uptake for flu vaccines is so low?

Hmmm…

This is some serious needle fear. Image from cbc.ca.

People are scared of needles.

Indeed they are.  People are generally more scared of death.

The vaccine doesn’t always work.

This is true.  The method in which viruses are identified for use in the next year’s vaccine is based on flu patterns in the opposite side of the world.  Scientists use all kinds of cool techniques to predict what will be prevalent in our area.

Sometimes scientists are wrong.  And sometimes the viruses just change really fast.  Thus, sometimes, the vaccine may not protect you from one of the strains of flu that is going around that year.  Or it may only offer partial immunity.  This is the same reason why you can’t have one vaccine and be set for life.  Viruses change too fast for that stuff.

But, like other things in like, the overarching notion is that sometimes you just have to hedge your bets.

I know a few people who feel that hedging their bets is equivalent to not bothering with the vaccine.  In fact, in health care workers… People who are told they should get the vaccine, uptake is disturbingly low.  And they work with the people most at risk.

I am not sure if that says they really like their jobs or that they really hate their patients.

Yes, it is your body and your decision.

Again, I reiterate that you can get the flu too.  And it will suck.

But not only that… To me (and public health theory), it is basically putting your coworkers and patients at undue risk for the flu.  You might bring it in to them.  You could be the tipping point, the index case.  I know I wouldn’t want to have the flu outbreak of unit x on my head.  It sounds extreme, but it can happen.

I work in oncology.  So, many of my patients are immunocompromised.  They got their flu shot.  But, they might not be as good at fighting the flu despite that.  If I go to work sick… I am exposing them to that risk.  People feel safe in the hospital and here I am hacking virus all over them.  Seems cruel to me.  Sure, I have my right to security of person, but don’t they have the same right?  And as health care consumers, shouldn’t they be protected.  That is the whole reason we dress like fools to see people with contagious diseases… Not just for ourselves, but for others too.

I work in a hospital.  Someone always has to be there.  That is how it works.  When you get sick at 3 am, there is someone there.  If everyone gets the flu, then who will be there?  Yet another good reason to try to prevent illness, both in you and in co-workers who may not be able to get the shot for medical reasons.

I got my flu shot today.  Yes, my arm is a bit sore.  But, I am riding on my flu shot high horse.  I did my part to protect myself and my patients, as well as my family and friends.  I have asthma… The tables could turn at any minute.  I am one of those people who can die from the flu.  But, so can my friend’s baby girl and by grandfather.  I quite like them.  Please don’t give them the flu.

*This is a link up with Medical Mondays – a once a month blog hop for blogs about all things medical.  Check out some of their posts of medical awesomeness from medical professionals/students/spouses and the like!


Mind the Gap: Resident Work Hour Restrictions

This week’sDailyPost writing challenge is entitled “Mind the Gap” in which they prompt bloggers to write about what we think about divisive topics, complete with a poll of our readers.

**I misread the actual challenge and wrote about a completely different issue because I thought it was open to any issue.  This is clearly what happens when one writes a post in the midst of eating supper and answering pages.  Life lesson learned.  Apparently the post should have been in response to the issue they presented (kids in adult oriented places) not just any divisive issue.  Fail.  At least it got me writing, even if it was about the wrong thing. But seriously, check their stuff out on the subject, it is an interesting debate.  I am on the fence on that one.**

An issue that has been on my mind lately (especially tonight while I plug away at yet another call shift while working on this) is resident work hour restrictions.

There are few professions where people work more than 8-12 hours at a time.  Medicine is one of them.  Those people you see working in the hospital at night are sometimes the same people who were there at 8 in the morning when you first came in.  They need to be available 24/7.  That is safe, that is good car.  What you may not know is that most medical residents cover the hospital in shifts that are at least 24 hours in length.    Some people do longer.

Studies have shown that residents who work prolonged shifts have higher incidences of motor vehicle accidents the day following the shift and make more errors in judgment.

There is a movement right now to change shift lengths.  In some regions, there are new restrictions to keep shifts to no more than 18 hours or 24 hours or 30 hours.  But, there is an increasing push to keep people from working more than 16 or so hours.  This is done by having a night shift of “call” residents to cover the times the day people often sleep.

This, however produces a logistical nightmare for programs needing to accommodate new shifts not otherwise needed and also increased numbers of handovers, which can also hinder patient care.  And the stats on outcomes aren’t as overwhelming as once thought.  Yes, there are improvements in safety, but there are also then issues with the amount of training time residents are getting and the quality of said time.

In fact, many argue that by taking away overnight call, doctors are losing out on valuable training opportunities both at night and day.  Many feel that as a result, training may need to be extended, thus delaying the entry of physicians into the full fledged work force.

So, the question…

Now that I know your feelings, here are mine…

I have mixed feelings about the whole thing.

As a resident, I do know that valuable learning happens on call.  I.e. during the hours that the entire team is not around.  It is when you learn to manage the tough stuff and the finer aspects of medicine that make you a good doctor.  For some specialties, this is a key time.  For instance, surgery residents get lots of valuable operating room time, obstetrics residents deliver lots of babies and radiology residents get to see lots of acute stuff in imaging and manage resources.  For my specialty and some others, this does not change significantly, but it is still an important time of virtual independence.

Sure you get to do all of that stuff during the day.  But, it is more concentrated at night.

The nights on call also add hours to your week, again increasing learning prospects.  Not a bad thing.  Also, you get paid a bit extra for doing call.  Bonus!

All of this added learning is key when you are a resident because you want to become a great attending.

And attendings in most areas don’t have work hour restrictions, which is both scary and not surprising.  Thus, they expect residents to hold similar hours, as residency is training for their job in the future.  There are many pressures to work beyond your time.  Often such behavior is rewarded as “dedication.”  But, one can argue that not having significant work hour restrictions beyond the standard 24-30 hours is being realistic about future expectations.

Then, there is the flip side…

When you do call, there comes a point, particularly around 3am where you want to die.  Literally, death seems possible.  And you get another wind, but you are still kind of cloudy.  Not terribly cloudy, you function on adrenaline, baseline knowledge and help from apps.  I don’t think it is so impairing it is really dangerous all of the time, but it can become dangerous if you aren’t held accountable and the fatigue is prolonged (for instance when people stay after handover).  I know myself, I wouldn’t want to be making big decisions after 24 hours of work.  But, I have to sometimes.

Image via quarksdaily.blogs.

Then, the whole sleep deprivation thing messes up your day the next day.  You aren’t around with the team for the rest of the day, so sometimes you miss out on important details and you play catch up some of the next day.  And when you have to go home post-call, you miss teaching sessions and such. Plus, even if you post-call nap, you (at least I) still feel horrendous the rest of the day and night.  And that next night of sleep really doesn’t fix very much.  It takes at least two good normal nights before I feel back to myself.  So, per call shift, I am screwed up for two days… Not cool.

On the other hand, work hour restriction complicates things too.  It means you need extra people scheduled.  It would change the whole dynamic of the medical team with fewer people.  It also means more handovers (passing of information from provider to provider) and thus more room for error (also more room to catch missed things and such, which can be good).  And some people will get relinquished to nights for blocks of time… Better for sleep habits, poorer again for things like teaching that happen during the day.

There is an argument that if hours get restricted much more; residents will need to add time on to training.  I am already in a 5 year program.  Do we really want to make it 6?

The good thing about work hour restriction is there are fewer sleep deprived people wandering around.  As someone who needs a lot of sleep, this sounds wonderful.  I like the protection and the accountability it would provide, as well as the safety for everyone involved.

Also, the costs of medical error and call stipend saved with further hour reduction may cancel out the costs of additional training time and staffing.  The long term analysis on this is still lacking, although I suspect it may not be sufficiently significant to warrant complete change.

For me, the extra sleep and safety are worth the loss of call stipend and potential addition of a bit of time to my program.  I also have home call for most of my training after my second year, so I may be biased because I am not really affected by it like some of my colleagues.  But, as I sit here at 11pm waiting for test results on a few sick patients and wondering what the rest of the night holds, I do think it would be good to have designated night shifts or at least safer hours… I am currently 17 hours in… And still at least another 10 to go.

On the side of not being just a resident, but also someone who needs heath care from time to time, I have to say that I would much prefer a physician who is awake and alert and had their wits about them.  I think most people who do call do still have their wits, but everyone has bad nights.  The thing is, I would rather see someone than be told there is nobody available at all.  So, I guess I fall somewhere in between on that standpoint.  If there has to be someone there, then be there, even if you are tired.

So shoot me if you will… I would rather an awake doctor needing some extra training and extra staffing (despite costs) than a sleepy doctor.   I know some people won’t agree.  And I go back and forth.  It is an issue that has been ruffling feathers in the medical field and has been coming to the forefront.

Enough about me…  I would love to hear more about what you think on the subject!

Should residents have work hour restrictions?  If so, how much should they be allowed to work (currently, were I work, we are expected to leave at 8am, but generally, I can’t go until at least 9 or 9:30.  Some places are limiting shifts to 16 hours and others still max out at 30)?  What about attending physicians?  Should they also be restricted in hours?  What do you think of physician work hours as a consumer of health care?

For more information check out: Residents Duty Hours BlogResidents Call For Duty Hour Reform (CMAJ), Resident Work Hours: The Evolution of a Revolution (Archives of Surgery), The Effects of Work-Hour Limitations on Resident Well-being, Patient Care, and Education in an Internal Medicine Residency Program (Archives of Internal Medicine),

Choices

Today, I saw a patient who has a potentially curable cancer.  They live far away and would have to travel a great distance for treatment, so we offered admission to our hostel.  We explained everything.  I spent about 20 minutes explaining that it was a big tumor with positive surgical margins, but that radiation would decrease the local recurrence riskto less than 10%.  And chemo would decrease recurrence systemically.  Good odds.

He was well.  Elderly, but well.

Yes, the treatment has side effects.  Significant ones that are still easily managed.

And he took in what we said.  His wife listened.  And at the end of our conversation, I asked him what he thought and he said, “no.”

I am a big proponent of people having autonomy, but I had to ask why.  He said he didn’t want to travel and stay here.  He wanted to be home with his wife.

We reiterated that after the 7 weeks of treatment, he can be home all the time.  He may have years.

He responded that he may not.

He is a competent person who can make his own decisions.  His wife agreed.  They had talked about it before.  No treatment after surgery.

They asked about time.  We don’t know.  The tumor was slow growing, but there was some left behind.

I agree with his decision.  I would take treatment if it were me, but it wasn’t me.  And people have choices.  And he made his choice.  I am glad he had the gumption and courage to actually say what he wanted instead of just going along with the doctors and being miserable.

It is funny, some people beg for treatment.  Treatments that will almost inevitably offer minimal benefit.  Treatments that cause pain and suffering and even hasten the death they are trying to avoid.  They clamour for any experimental drug.  And I get that.  We all have a drive to live.

But, then you contrast it with this couple.  A theoretical potential cure.  A definite, statistically significant increase in disease free survival and overall survival.  Turned down because the travel is unacceptable.  And it wouldn’t be quality of life.  This while so many trade their quality of life for brief periods of extra time.

Some might argue turning this type of treatment down is putting themselves at risk.  Suicide even.  But, really, it is the same as choosing to take antibiotics for an infection.  The infection might kill you, or it could just get better.

Socially, this guy is braver than the people who fight for the cure.  Societally we put a lot of emphasis on cure and avoiding death (not that his death is impending by any means).  People, however, see this as a loss.  He failed to take treatment.  The thing is, he made a choice because there are things in his life other than health.  He understands that.

People are fascinating.  I can’t say for sure what I would do in these situations.  But, sometimes I wonder why people choose the way they do.  And why some people expect so much and others so little.

I hope he enjoys his time with his wife, whether it is months or years.  I hope he never comes to regret his decision.

I respect autonomy.  Sometimes things like this make me sit back and think.  Especially when outcomes could be so very different with a different decision.

Rude interruption… Good reasoning…

A Canadian medical student and physician interrupted a press conference with the minister of health to announce their dislike for the new cuts and policy changes that will change funding and provision of health care to refugees in Canada.

Here is the video.

I don’t necessarily agree with their tactics.  As Patrick said, it was like they were bullying the minister.  And it was rude to interrupt the press conference.

I like to think there are other ways to approach these issues.  But, I know it is a struggle to get meetings with such officials.  And that the current government has been making questionable decisions that sometimes have not reflected perspectives of the majority.

This is something that needs to be said.  It seems that the current government has been making cuts in areas that matter to us and areas that are a point of pride for our country, like universal health care, education and the general welcoming attitude.

I don’t profess to understand politics.  But, I do understand people.  And I know that the changes that are proposed and happening affect people.

My medical school had a fabulous program where the first and second year medical students do full histories and physicials on new refugees to aid their family physician.  They, in partnership with a supervising physician, do urgent consults for any particular needs and do groundwork to get people cared for in an efficient manner.  Often, this is done through a translator.

In doing this program, I met people from around the world who had seen terrifying things.  I referred a young man with kidney stones who had never seen a physician to a urologist.  I helped another young family get in contact with a dentist to help remove and repair the rotting teeth of two of their children.  I met a woman who delivered all three of her children at home on the floor who had never seen a physician and had never had a pap smear… And encouraged her to get preventative care.

This program made me aware of the fears and struggles of refugees.  That these people have nothing.  They come with the clothes on their back.   They don’t have money for medications or dental care or, well, anything in some cases.  So, the fact that our refugees get medications covered temporarily always seemed obvious to me.  Otherwise, they will just get really sick and need even more care.  It seems like the right thing to do.  Protect those you took in to protect.

The people trying to voice their opinions in this video have seen this too.  They understand the value in refugee care.  That it is more than dollar signs.  And that because we provide the extra care temporarily means that they are saving money overall.

The thing is, when we care well for immigrants, they stay in the country.  They become more healthy and can bring skills to the table.  They become contributing members of society.  They aren’t freeloading.   They are simply getting on their feet to take part in our society.

As physicians, we took an oath to “do no harm.”  Doing nothing can be passively doing harm when something can be done.  Refugee and immigrant health care are places where something can be done.

This physician and medical student are taking a stand for what should be valued and maintained.  Where cuts should be avoided.  When you can’t get meetings, when your viewpoints are avoided, sometimes extreme measures need to be taken.  Especially when speaking for people who don’t have a voice for themselves. 

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Random in Radiology

Image via Parmahospital.org.

This is it… I am ¼ of the way through my final clerkship rotation.  And this rotation is… Radiology.  Yes!!

I chose this on purpose.   It is ridiculously relevant to my future career in Radiation Oncology.   And, to be honest, I heard that radiology selective is fairly laid back and provides ample time to study.

So far, it has been eventful in ways I could not have anticipated…

I somehow scammed a day off for the St. Patrick’s Day holiday (only here would people actually take the Monday after St. Patrick’s Day weekend as a holiday… Well, maybe Ireland too… But it is not really a legitimate holiday for 95% of the population here, just high up government people and apparently university administration).  I did not just not show up or something… I literally went in, ready to go.  And the residents told me it was a university holiday.  I told them it wasn’t for clerks.  They told me to go home anyway, nobody would care.  I considered arguing, but then my laziness smarter side got ahold of me and I agreed and went back home.

I had a post-Match career crisis.  But, it was not an “oh my goodness should I pursue radiology” crisis (because I really don’t love radiology).  It was a “oh my gosh, I love peds, what am I going to do without it” kind of crisis.  Weird.  I loved my Pediatrics rotation.  Loved.  I still knew it wasn’t my career goal… Palliative Medicine, Oncology… Those were mine.  But, I was doing pediatric radiology yesterday and I loved hearing the little voices and helping pin down little once for certain tests (nicely, but pin nonetheless).  I think that my love of peds is more my want for children of my own and less my actual love of pediatrics as a specialty.  The most satisfying option still seems to be adult rad onc, probably palliative, but who knows… Maybe I will throw a few kids in the mix.  But wow, not the brief and short-lived second thoughts I would not normally anticipate.

Despite people all saying that you can generally leave at lunch to do independent study and work on our required case presentations, I have somehow managed to get trapped until 4 every day.  Why am I so keen?  And nice?  WHY?

Today, the power went out.  In the ENTIRE hospital.  And back-up emergency power did not kick in right away.  In fact, it took a whole 30-ish seconds.  Which doesn’t sound so bad, except I was in the basement with no windows.  Freaky.  It took about 20 minutes before real power was restored to the building.  The sad part is that this isn’t the first time that has happened here.  I just sat in my corner and did practice LMCC questions on my phone.  Mainly because I couldn’t leave the office… Because it was too dark.

Radiology

Image via Wikipedia

Radiology is a ridiculously busy department.  I always felt guilty when I needed to go down to beg ask for a scan from one of the staff radiologists because I always seemed to be annoying inconveniencing them.  Turns out, I was kind of right.  The sheer volume of people coming in and asking for scans to be done on inpatients or urgent outpatients is ridiculous (one might argue that this could be solved by changing the way in which scans are prioritized and ordered, but apparently that isn’t an option).  It is so tough to get work done with all of those ins and outs and people calling looking for results.

The thing is that we depend so much on radiology.  When we don’t know what is happening.  When we do know what is happening.  Patients ask for scans because they want to know what is happening.  Honestly, we are keeping the radiologists busy with a lot of normal scans.  And we are exposing people to unnecessary radiation and stress and spending government money.  I am not saying that we stop all of our scans.  But, I think, as physicians, we need to think more about what and why we are ordering things.  We did learn how to do histories and physicals for four years for a reason.  And it wasn’t to order a CT of everything and hope for the best.  We need to ask ourselves what the scan will change or prove or disprove that we can’t determine in another way?  We need to ask if it is standard of care or something ridiculous?

Trust me, when the power goes out… Radiology is not really there for you.  They just sit and drink coffee and wait for the lights to come back on.  But, you can still do histories and physicals.  You still have some clinical judgment.

Mind you, radiology is SO valuable.  You can find early tumors, follow pregnancies closely to prevent undue complications, treat certain illnesses. Overall, it is something that enhances patient care.  Overall, it is worth taking the time and strain to go beg for a test and it is worth the radiologist’s time to listen.  But, we still abuse the system far too often.

So, I think this rotation is a good wrap up of clerkship.  I am learning the art of waiting (for people to review with me, for images to become available).  I am gaining valuable skills in reading images.  And I think that listening to what goes on the department will give me a better idea of how to more appropriately use the technology we are so fortunate to have.

On Rural Medicine

I am leaving my beautiful rural community.  I am excited to be back with Patrick and company, to have a car again, to have options beyond deep fried food when eating out and to not have to pack and drive an hour and a half back and forth every weekend.    I however will miss the really nice apartment we have here and the gorgeous scenery that God produced in this little space.

The view from the living room window, where I sit to write.

In the past four weeks, I matched to my program of choice, learned that I didn’t forget all of Internal Medicine, discovered that rural hospitals (at least this one) run surprisingly smoothly and learned that, as they say, in a small town, everyone knows everyone.  I also discovered the cardiac disease capital of Canada (at least, it looks that way).  And despite not going to the gym for four weeks, I got epic workouts climbing “The Biggest Hill of All” on a daily basis.

Evidence of the abundance of fried food and the source of many of the heart attacks I see in emerg... "We sell fried food." Oh wow.

So, as much as I sometimes become frustrated with my school’s obsession passion for rural medicine, I must say I am glad that I have had the chance to work in rural communities for 12 weeks (technically 16, but the first four were epic fails in the rural department and turned out to be suburbs of my hometown).  The whole small community, everyone knows everyone and fewer resources really do make a difference, but there are definite benefits.

And thus, I have concocted a list of the great things about rural medicine, even though I will likely never practice in a rural community (unless God rearranges my plans, career choice and such… And to be honest, I would not be impressed if He did at this point).

  1. You get to live in a small town… Cheaper cost of living (in general until you go really north), less traffic, less pollution, and fewer distractions.
  2. Many rural communities I have been are beautiful (at least in Atlantic Canada).   Waking up every day to the view of the ocean or forest is something that is priceless.
  3. You can often walk places (and because there is no public transportation, you don’t really have a choice).
  4. You can learn a new activity… For instance, the community I did family medicine in was very big into canoeing and kayaking.  I had a few chance to go, but they didn’t work out.  Here, I had an impromptu skiing lesion when I had to navigate my way down “the Biggest Hill of All” in the middle of a freak storm.  At one point, I did a full-on split, and then fell over.  Thankfully no cars were coming (or I may not have been able to type this).
  5. The practices are often less busy and somewhat smaller.  This is not always true.  But, I have noticed on medicine, especially, the pace is so much more relaxed.  Going home at lunch on medicine would never happen in a bigger centre.  Unless you were post-call.  And even then, it is unlikely.
  6. Home call.  Never underestimate the value of sleeping in your own bed.
  7. You have a broader scope of practice.  The GP I did family with covered the local “emergency” (I used quotes because only 25% of the patients were legitimate emergencies), did minor procedures and had his traditional office practice.  The Internal Medicine doctors here cover the ICU and also their own subspecialty.  The Hospitalists here can do some emerg shifts, some deliver babies and still have a community practice.  The variety is fascinating to me.  I can see why people would prefer a community like this, especially if they like that kind of autonomy and those opportunities that are often lost in giant cities.
  8. People are more grateful.  Again, this is a stereotype.  But, people are glad they don’t have to go to town for care.  So, whatever you can do here is often just amazing.  Not always, but sometimes.
  9. You get a lot more follow-up, even as a specialist.  In a small town, people just happen to run into each other, so as you can imagine, people who wind up back in the hospital are likely to be on your service, or their family member is, or there is time enough to actually see them in clinic to make sure they are doing okay.  In big centres, people leave and sometimes you wonder what happened, but they go to a GP on the other side of town who is too busy to give an update.  We had a guy go home one week and get readmitted under us the next for two unrelated problems.  Another person came in to visit someone else and told us that she was feeling much better.
  10. You just plain have more time.  Most physicians out in the periphery are salaried, which means they don’t get paid for volume, they get paid for designated amounts of time.  Thus, people don’t feel obligated to book patients one on top of the other.  You get more time with people.  You can give better care.
  11. As a learner, you get more experience.  Now, volume is an issue.  I could have seen as many people in a week in a city, but because for the first three weeks, I was the only medical student on the service, I had free reign.  I managed the patients on my own, did my own consults and reported back to the doctor.  So much better than clamoring over five other people who wanted to do the same thing.

The peninsula as seen from my bedroom window.

So, rural medicine isn’t all bad… In fact it is really good for many, especially those people who live in those communities.