My Ongoing Moral Dilemma.

We were warned early.

"Beware, young medical students. Beware the evils of big pharma."

We were naive, didn't understand. Why worry? We already knew that the big pharmaceutical companies had deep pockets. Heck, our clinical education centre, with its state-of-the-art examining rooms all interconnected by closed-circuit television was partially funded, and thus named after, one of the biggest. Big pharma wasn't politically correct. We were told to avoid it, to tell those drug companies to keep their pens and notepads... we weren't interested. We were directed to sources of information such as www.nofreelunch.org which reminded us that accepting a pen emblazoned with the name of a drug company was akin to whoring their products on street corners. *shiver*

But then I started to wonder... says who? We should be educated enough to be able to make treatment decisions based on the interests of the patient rather than the drug rep, right? Ah, the drug rep. The interchangable shiny, happy people that are sent out in legions by big pharma to woo physicians into pushing their products on unsuspecting patients. They are all well-groomed, well-dressed, attractive and just friendly and personable enough to be engaging without seeming slimy. Armed with the latest statistics proving the superiority of their drug over the competition, a shiny SUV and a case full of free samples, they are common in medical circles. You can often see them congregating in small herds at the local Starbucks wearing well-tailored suits, chatting on their cell phones, typing on their tablet computers and downing 5$ lattes between visits to doctor's offices.

Back to the subject at hand. Is big pharma truly evil? My only exposure to them through medical school was during my family medicine rotation. I was in a small town, deep in the Ottawa Valley, and I met the rep for Lipitor. I was particularly interested at the time as it was a drug that my father had been on for many years. She had articles comparing Lipitor to the other statins (newbie note: the statins are a class of drug that decreases your cholesterol levels, thus reducing your risk for heart disease) in terms of effectiveness and relevant clinical outcomes. She could easily site the latest statistics, and made a convincing argument for the superiority of her product over the other statins. I wasn't completely naive... I knew that there was a considerable amount of bias in the presentation of the information. All you had to do was consider the source to realize that it should be taken with a grain of salt.

Gone are the days when drug companies were allowed to wine and dine doctors in style. New government legislation prevents many of the golf junkets and resort weekends that used to be the norm. Now the most you can hope for is a fancy dinner followed by a presentation, hidden under the guise of "Continuing Medical Education". For doctors who are outside of an academic centre, one could argue that these dinners are helpful in keeping physicians up to date on new research and new drugs. One could also argue that it simply puts us in a pleasant post-prandial state to soften us up for the barrage of propaganda that is sure to follow.

The recent book entitled "The Truth About the Drug Companies" is a compelling read. Written by the former editor of the New England Journal of Medicine, it talks about all the very things I've mentioned. It addresses the myth of "research and development costs" as a justification for exorbitantly high drug costs, the manipulations of the patent system to help protect brand-name drugs and prevent the affordable generics from coming to market, and most relevant to me, the marketing of drugs under the heading "education". Hmm. So even if I don't think that listening to a drug rep schpiel will affect what drugs I perscribe to my patients, research has shown time and time again that it will. Of course it will. Otherwise, why would big pharma sink so much money into it?

The doctor I work with currently meets with 2-3 drug reps a week. They often bring us lunch. They always bring samples of the latest, costly drugs. They often leave us with educational materials, some bearing the name and logo of their drug or company, some not. Where am I supposed to draw the line?

Sigh.

Whose Penis is it Anyway?

So I did my first circumcision this week. It was the little newborn that I had helped bring into the world just two days before, having a family medicine preceptor who is one of only a handful of family doctors who still has the balls to do obstetrics. He was adorable, in spite of the dry cracked skin and long nails that are a hallmark of a baby having way too much fun in there to arrive in the world in a timely manner. The poor mom was over a week overdue and PLENTY tired of being pregnant.

I had been dreading the procedure since the mom's 38 week prenatal visit, when she asked how soon the baby could be circumcised. Apparently, the town where I am doing family medicine is still a bit behind the rest of the world, and circumcision is still pretty common. I, as you may have figured, am VERY against the procedure. But I kept my mouth shut and assured her that Dr. D's general practice, assuming that the baby is healthy (and male, obviously) was to perform the procedure on day 2, just before mom and baby are discharged.

I hated every second of it. From the moment the baby was strapped down to the the board until the last exhausted scream as his poor, bloody little weenie was packed with gauze. Why do people still do this to their kids? I wonder if so many parents would be eager to circumcise if we made them watch what we have to do to their little ones. The worst part is prying the foreskin off the glans... it isn't supposed to retract that early, and it just LOOKS painful. Dorsal penile nerve block be damned, that kid had to be hurting.

Honestly, I don't know the history of circumcision. I don't know what bonehead decided it was a good idea to slice off the foreskin, or what the initial purpose was. That's why I try not to judge people who still circumcise their sons for religious reasons... if that's the way you choose your covenent with God, so be it. I still don't agree, but I can't judge something I don't understand and haven't done my homework on. So this is really going out to all those people who decide to have their boys circumcised "so that he'll look like daddy", "because it looks better", "so that they other boys won't make fun of him in the locker room" or, the one that drives me RIGHT up the wall in 0.3 seconds... "because it's cleaner".

ARGH!!!

The Canadian Institute for Health Information reports that in in 2003, less than 20% of infant boys were circumcised. Even back in the heyday of circumcision (around 1970 or so), the rates hovered around 50%. So if anyone is getting made fun of in the locker room, it's not the boys with the turtlenecks. They're now the majority. And they have been for quite some time. Even if daddy is circumcised, looking different is hardly going to leave a lasting scar on the child. First of all, baby penis does not look like adult penis. It just doesn't. Second of all, how often are little boys and their fathers sitting around comparing penises (peni?)? I'm the first to admit that I lack the equipment in question, but I'm somehow doubting that this happens.

There is also a common thought out there that circumcision prevents diseases and foreskin complications in later life. This argument is flawed on many levels. Let's address a few of these 'diseases' individually. The only thing that circumcision has been PROVEN to reduce the risk of is urinary tract infections-- and even then, only in the infant period. A UTI is an infection that can usually be treated easily with an antibiotic, but that can develop complications in babies. The incidence of UTI in infant males is 1-2%. The incidence of complications of circumcision is 0.2-2%. Hmm.

And the other stuff? There isn't enough evidence to say that circumcision prevents HIV and penile cancer. Not according to the Canadian Pediatric Society, anyway. And the incidence of phimosis (when the foreskin gets stuck over the glans) is far too low to consider circumcision as a valid preventive measure.

Using the argument that circumcision is a preventive measure at all is flawed. If we routinely removed parts of our bodies that had the potential to cause problems later, we'd all have our appendix and gall bladder removed at birth. And hell, while you're at it, why not remove both breasts? They only cause problems in the long run...

And circumcised men are "cleaner"? Ugh. Don't get me started. Any crease or crevice on the human body has the potential to be pretty gross if it's not cleaned properly. Do you think girly bits are self-cleaning? No. Boys with foreskins learn to clean them the same way they learn to clean all the rest of their nooks and crannies. Seriously, people... it's not brain surgery. Pull foreskin back. Clean. Let go. Honest, that's all there is to it.

The bottom line is that this is an unnecessary cosmetic procedure performed on infants who are unable to give informed consent. And this decision is often based on the parent's preference, which is based on their experience. Is this fair to baby boys? I don't think so.

But that being said, I'll keep my opinions to myself and tell parents only that the Canadian Pediatric Society's current position is that there isn't enough evidence supporting circumcision to recommend doing it on medical grounds. So the decision is up to them. But I'll also tell them that less than 20% of newborn boys in Canada are being circumcised these days. And if they ask my opinion, I'll tell them that I think it's unncessary. And then I'll stand quietly by while another infant boy is strapped to a board and the Gomco clamp is fitted over the head of his penis. But there's no way in hell I'll ever perform one myself.

(This post is dedicated to my uncle Andy, who wanted to hear my rant on circumcision. If you're circumcised, Andy, I'm sorry. ;-) )

Patient of the Day

Last week, I saw a girl in the office. She was young, 14 or so, and had come in for her first pap test. She had been recently started on the birth control pill, and had the same boyfriend for 3 months (apparently an eternity when you're 14 years old). We had the talk about safe sex, and the obligatory "the pill doesn't protect you from STD's" talk. I did the physical, I did the pap. Pretty uneventful.

Her results came in today. She has chlamydia.

I am horrified by this. All of it. I can't believe that a 14-year-old is having sex. I am stunned that she has an STD. I was further blown away by her admission that 'she has a little weed on weekends'.

Apparently, I grew up in a bubble.

Quick Update

Remember my run-in with the surgery chief resident? The one when he put me on call on my vacation and threatened me when I protested?

(If you don't, here's a refresher... http://drcouz.blogspot.com/2005/12/perfect-example-of-why-im-getting-hell.html )

Well, this morning I met with the program director for general surgery. I had a member of the union's contract compliance team as my escort. I told him what had happened with the resident. He said that he had heard about it from the resident, but had been informed simply that 'the matter had been resolved'. He apologized for what had happened on behalf of the chief. As expected, the director stuck up for the chief, saying that "this behaviour is very our of character for him" and that he's usually "a really nice guy". Um, sure dude... wanna check with the nurses on that one? They refer to him as The Pompous Ass.

Anyway, as I told the director, although I don't stand to gain anything by complaining now, I just want to ensure that this won't happen again to the next off-service scut-monkey. The union guy made it clear before we left that they had intended to take this to formal grievance, but that I was happy just making my concerns known. So I looked good.

Not entirely satisfying (I doubt the chief will get so much as a slap on the wrist) but at least I did the right thing.

Just in case anyone was curious how that all worked out.

An Interesting Conversation

Well, interesting in my opinion, anyway. As I've mentioned before, I am a union representative. This basically means I attend a meeting every 6 weeks or so. Running for the position was a last-ditch attempt to drum up some enthusiasm for the aspect of academic emergency medicine that interested me the least... administration. It was an attempt that failed miserably. So now, every six weeks, I attend meetings that are largely spent listening to the same few people talk (the ones who are obviously loving the sound of their own voices, mostly) while the rest of us try to pay attention. This month's meeting was actually pretty interesting. Partly because it was the 'road trip' meeting and wasn't in Toronto like all the others, and partly because the bulk of it was spent debating what stance we should take as a union on the privatization of the health care system in Canada. But more on that later.

After each meeting we go for dinner. I was sitting with a second-year peds resident and a second-year obs/gyn resident, the latter I knew fairly well. We were talking about which obstetrician at our academic centre we would want to deliver our own children. There was some gossip, some banter, and then I mentioned that if I was a low risk pregnancy, I'd likely opt to be delivered by a midwife.

Well, you'd think I had announced my intention to give birth in a hot tub in the middle of the next union meeting. Both the budding obs/gyn and the budding pediatrician looked horrified. Immediately, they felt the need to share stories where an 'obvious' complication arose and the midwife failed to call for help. I explained my reasoning-- I honestly feel that midwives give more complete care than obstetricans do, particularly in the post-natal period. In an academic centre, the obstetrician walks in to supervise the resident for the last few minutes of the delivery unless something goes wrong. The labour & delivery nurse is the one guiding you through the process, and it's not like you get to pick your nurse. If you get a good one, it's a great experience. If not, tough titties. By delivering with a midwife in the hospital, you have the best of both worlds. You have the low-intervention, attentive, one-on-one, continuous care of a midwife but if something goes wrong and help is needed, the obstetrician is just steps away.


The two other participants in this conversation were horrified at how irresponsible I was being with my future baby's care. The obstetrics resident didn't understand how I could trust my midwife to know when something was wrong. Um, dude? That's what they're trained to do. And moreover, I told him that it was awfully pompous of him to assume that a midwife with 15 years of experience delivering babies would be less qualified to detect a potential problem than him, with a year and a half of obstetrics under his belt. In fact, as a second year resident, his total time in obstetrics was likely less than six months, all told. But somehow, he figured that he had been magically granted the ability to detect impending problems in labour and delivery and fix them in such a timely manner that he could single-handedly assure a good outcome.

Maybe I'm exaggerating slightly, but all but that last sentence was completely true. What is it about medicine that often refuses to acknowledge the contributions of other members of the health care team. Why would this guy be so threatened by the idea of a midwife offering comperable care in low-risk pregnancies? It's not like there will ever be a shortage of patients requiring obstetric care. It's not like midwives will ever be allowed to perform c-sections. It's not like this guy even intends to spend his life delivering babies... he intends to focus on gynecology as a career. But yet, the idea of a midwife being able to detect late decels in a rhythm strip as well as he could put him immediately on the defensive.

Why can't we all just get along?

My Very First Difficult Patient

It's not that unusual a story for family medicine. A guy calls, describes symptoms that are pretty clearly viral in nature (stuffy nose, sore throat, productive cough, yellow sputum) and demands an antibiotic from his family doc (my preceptor). The doc sends a message back through his office staff that the man should treat his illness symptomatically and recommends a decongestant and a cough syrup. The man calls back and angrily demands an antibiotic since 'that's worked for him before'. The doc sends another message through his staff that if the guy feels that he needs an antibiotic he should come in for an assessment. The guy called back a third time, made a fuss, but agreed to book an appointment.

Somehow, I ended up seeing him. He was an older guy, gruff, and confrontational as hell. He wanted an antibiotic and asked for it by name. Apparently, they give it to him at the walk-in clinic whenever he asks for it. I examine him... swollen lymph nodes, red throat (no white exudate on his tonsils), ears clear, chest clear... clearly viral. I explain this to him, as well as the dangers of antibiotic overuse. He doesn't want to hear it. He's being rude and condescending, and keeps calling me 'honey'. I am seething. I want to tell him that I find being called 'honey' offensive and that I would prefer if he would call me by my given name. I want to tell him that if he thinks that he knows more about medicine than I do than he's welcome to prescribe his own damn antibiotics. I want to tell him that he's an ass. But I smile and nod, and try to reason with the bonehead.

Finally, I give up. He's obviously not taking my word for anything, since I'm just a little 'honey' who clearly doesn't know what she's talking about. So I have my preceptor come in, who repeats all the same stuff that I just said. The man leaves without antibiotics.

Will he simply go to a walk-in clinic to get what he wants? Maybe. Did I chicken out of the confrontation by having my preceptor come in and tell the guy that he didn't need antibiotics? Probably. Will I handle this differently next time? Most likely. I just haven't figured out how yet.

The More I Bitch, the More Things Stay the Same

You all heard me whine and moan about two months of surgery. Part of what kept me sane through the ordeal of hundred-hour work weeks, run-ins with senior residents, 5am wake ups and endless panic was the knowledge that it would get better. That I would get my life back. That I would someday see the inside of my gym once again, that I would enjoy leisurely evenings cooking dinner while drinking wine with my significant other, and that my dog would know me as more than the mysterious stranger who slept in 'his' bed. This was an even greater promise when I learned that in the place of pediatrics, which I was initially scheduled to do in January and February, I would instead be doing family medicine. No call, regular hours... a regular nirvana for an overworked, increasingly bitter resident who could only dream of the promise of re-discovering those parts of her that had nothing to do with the practice of medicine.

Hmm. Not so much.

Thanks to my commute to my small-town community-based preceptor's practice, I am effectively gone from 7am to 7pm. Not much different from surgery. And although I definitely don't miss the panic that comes with patients who crash in the middle of the night, I miss the post-call days where I am liberated from the hospital at noon (or thereabouts) and able to see the light of day. Still haven't seen the gym. Learning how to use my slowcooker. Still unfamiliar to my dog. Le sigh.

But that's the only negative so far... I am enjoying family medicine WAY more than I expected to. What I thought would be a means to an end has actually been surprisingly enjoyable. I think this is due, in large part, to the fact that I'm working fairly independently. I see patients on my own and if their problem is relatively small and uncomplicated, I deal with it and send them on their way. Otherwise, I consult with the boss before letting the patient go. Rarely, he comes in and sees them with me.

The biggest shocker for me is the variety of problems that this family practice sees in the course of a day. I've been there a week... sure, I've seen a few upper respiratory tract infections and more depression than you can shake a stick at, but I've also seen a neat case of Raynaud's phenomenon in a teenaged boy:

A newborn with an umbilical hernia:

And many other equally interesting things that don't make interesting pictures.

My interesting case today was a guy who came in angrily demanding antibiotics for his obviously viral illness. A common scenario in family practice, and a chance to hone my conflict-resolution skills. Heh. Actually, had he been my patient (rather than my preceptor's, technically) I would have been a lot less polite. Particularly since he kept calling me 'honey' in an incredibly condescending manner. NOT the way to charm me, I assure you.

The best thing about family is that it gives me a chance to rant (even if in a subtle way) about all of the things I feel strongly about: Childhood vaccinations, flu shots, circumcision, weight loss, inappropriate use of antibiotics... and it's my JOB. And yes... all of these rants will eventually be shared with faithful blog readers, I assure you.

Just opening the door to a world of ranting. Heh.

Mysterious Blog Readers

Writing this blog has opened the door to a whole new obsession... the site meter. Since the day that a helpful reader pointed me to the site that would allow me to track who is coming and going from my blog, I've been checking it more often than is likely healthy.

So with a few clicks, I'm able to learn where people are coming from and how they found me. How they found me is under 'referrals', which more often then not says 'unknown'. Unless they link to me directly from another page (rather than type in my URL or use a bookmark) this usually doesn't tell me much, but occasional it's pretty amusing. I find out who has a link to me on their page and who found me other ways. The most fun is when someone comes across my page using a search. Here are some recent searches that have (sometimes inexplicably) led to my page:

• How do you know when an appendix ruptures?
• Medical spouse (maybe this person was looking for LavaLife?)
• Unusual emergency room stories
• CaRMS plastic surgery residency programs
• Pediatric resident
• CCFP(EM) (the program that I am now headed towards-- a family medicine residency with an extra year of emergency medicine training at the end of it)
• Whipple procedure
• Post-op complications
• CaRMS match

Just to name a few.

Another neat feature that I'm having fun with is the 'location' feature. That lists the last 100 visitors to this site by where they come from. I continue to be puzzled at the number of people who read my blog from the states. From Arkansas to Wisconsin, they make up almost half of the hits to my site. Why? How are they finding me? I'm intrigued. Particularly by the regular reader from Vincennes, Indiana who seems to come by to check things out every few days. Hello! Thanks for reading.

No to mention the hits from places in the world where not only do I not know anyone, but some I'd be hard-pressed to find on a map. Recently, readers from Saudi Arabia, Pakistan, Japan, the UK and Germany have stopped by. Cool. Please don't make any snap judgements on the Canadian medical system based on my rantings. It's really not that bad. Particularly in Alberta. ;-)

It's a small world after all.