Dr Death

Over lunch this week, my preceptor and I headed out into the community to make a few house calls. Yup, you heard right. On occasion we hit the road to visit patients who can't make it in to the office. Or, at least, can't easily make it into the office. This usually consists of palliative care patients and the occasional melodramatic Italian granny who enjoys making a show of staying in bed making enthusiastic proclamations to God and having her extended family wait on her hand and foot.

On this day in particular, the road show consisted of one of each of these typical patients. As we left the home of the Italian grandmother (with a bottle of homemade wine in hand as a token of the family's appreciation) I scanned the file of the palliative patient. A 72-year-old man with a diagnosis of metastatic gastric carcinoma. Since the time of his initial diagnosis he had been through the roller coaster of surgery, chemo and radiation, each treatment bringing the family hope until the test results came back... it was still spreading.

His appearance was startling. His face, gaunt and angular, smiled at us as we came through the door. Snaking out from under the covers were numerous lines, many of which his life was dependent on-- one drain from his peritoneum draining his ascites, one from his chest draining the recurrent pleural effusions, the catheter draining his bladder and the IV replacing all the fluids being drained out. An uneasy balancing act. In spite of the hard round belly protruding from his t-shirt, the skin hung off his bones in the characteristic manner of rapid weight loss and muscle catabolism. With the exception of his grin, he looked as though he had died days ago.

His wife beamed by his side.

"He's feeling much better," she told us, "all we need to do is get him back on his feet!"

My preceptor and I exchanged uneasy looks. He had already briefed me on the fact that the family didn't seem to really accept his dismal prognosis. He gently explained to the couple that he really wasn't expected to get any better, and that we should likely discuss what the plan was if he were to get worse.

"Well, we'd bring him to the hospital!" the wife said, confused. "And take him back here as soon as he improves."

The patient was still full code. Most cancer patients are made DNR long before they reach this point. This man's family wasn't willing to give up their hope for a miracle.

"Oh," the wife exclaimed, "I almost forgot. Our home care nurse was telling us that we should get a referral for Dr. X. She's supposed to be an expert in pain control, and she'll come right to the house."

My preceptor blanched. "I don't think we're quite there yet."

The wife was confused. "What do you mean?"

He backtracked. "I just don't feel that there's anything she can offer your husband that I can't do for you just as well. His pain is well controlled right now. I just don't think he's... sick enough... for that at this point."

My preceptor is a good family doctor. His patients trust him. In this case, his word was enough to appease this family.

In the car on the way back to the office, I questioned him about this. Who was this doctor? A palliative care physician? Why not consult her? Maybe it would save us from driving 20 minutes out of town to check on this man on a weekly basis.

"The family isn't ready for that step."

"What do you mean?" I pressed further, "what could it hurt?"

My preceptor sighed. "Every patient I've referred to Dr. X. has been dead within 48 hours of seeing her."

I digested this information. Then it dawned on me what he was trying to say.

"You mean... she helps them die?"

"I'm not saying that. I have no way of knowing..."

"But that's what you think."

He nodded. "When the family is ready to let go, I'll involve Dr. X. But right now, as long as he's pain-free and the family believes he'll recover, it's not time."

We sat in silence for the remainder of the trip. As much as I believe that people should have the right to end their own lives when they see fit, to be faced with it in reality was awfully sobering.

I still have so much to learn.

Is This Reverse Sexism in Medicine?

Sexism in medicine is nothing new. Even years before someone coined the phrase "evidence-based medicine" medical research largely ignored women. Or, researchers studied their disease of choice in a sample population of healthy young men and simply assumed that the results could be generalized to women. In short, women were considered (in the eyes of medicine) slightly smaller men.

No more. In fact, anyone with a pulse has no doubt noticed that last month was Breast Cancer Awareness Month. And if your neighbourhood is anything like mine, everything that would stand still long enough got a pink ribbon pinned to it. It's nice to see a woman-specific disease garner such attention, although I have to admit I'm starting to think that the pendulum is swinging a bit too far in the opposite direction.

Not to take anything away from breast cancer-- it's a horrible disease (although the much touted "1 in 9" statistic is a bit misunderstood). As is any cancer. But I think many people would be surprised to know that lung cancer is still the number one killer of both men and women. And both the incidence and the mortality are still increasing in women. Much less talked about, much less publicity, much more death. Why the discrepancy? Maybe because it's easy to 'blame' lung cancer on smokers, whereas breast cancer can't be blamed on any particular lifestyle choice.

But it's not breast cancer that is irritating me today. Last year, Gardasil was approved in Canada. Gardasil is a vaccine that effectively prevents against human papilloma virus types 6, 11, 16 and 18. HPV, also known as genital warts, is a sexually transmitted disease (or sexually transmitted infection in the new, more politically correct terminology) that leads to cervical cancer in women. HPV types 16 and 18 together account for about 70% of cases of cervical cancer. The other two subtypes of HPV, 6 and 11, account for 90% of cases of genital warts.

My concern is in the way this vaccine is being marketed. Women, telling women, that this vaccine will prevent most cases of cervical cancer. True. But this vaccine isn't approved for use in men. Is it wrong that I'm bothered by this? Fair enough, the repercussions of cervical cancer, which kills one woman a day in Canada, are significantly more severe than the repercussions of genital warts in a man. But who do you think is passing this virus to women anyways? Targeting only half of the population seems shortsighted. Not to mention the fact that any man who has ever suffered an HPV outbreak would likely donate a kidney for the chance to turn back time and avoid the outbreak.

The following anecdote is not for the squeamish-- I remember seeing a 23-year-old guy in the emergency room during my surgery rotation last year. He had, essentially, a cauliflower growing out of his anus. His genital wart outbreak had not only made his penis nearly unrecognizable, but had formed a protrusion from his rear forming a 10 cm lumpy mushroom. Food analogies aside, this had a significant impact on his life. The smell, a combination of infection, bleeding and inability to clean feces from this mass had caused embarassment to the point that he hadn't left the house in 4 days. He was in the emergency room begging to be seen by a surgeon earlier than the consult that had been set up for him the following week. If there were a vaccine available that would have prevented this guys outbreak, how upset do you think he'd be if he were told it was 'women only'?

And it's not just the fact that the marketing has been directed solely towards women. The vaccine itself, a product of pharmaceutical giant Merck, hasn't even been approved for use in men and boys. Medicolegally, a doctor is not permitted to administer or prescribe it to males.

If I were a guy, I'd be right pissed.

In the interest of all of those blog-readers with sensitive stomachs, I opted to make this post image-free. You can all thank me later.

The Return of the Difficult Patient

He came back today. The guy who called me 'honey' and wouldn't accept my diagnosis that his cough was viral. For a refresher, click here.

I was ready for him this time. I wasn't going to put up with being spoken down to, or condescended to. I'm a lot more confident now than I was 11 months ago when we first met.

It was easy. He was just constipated. I took a focused history, examined him, and wrote him a script for Lactulose. I told him to keep taking the Colace he had tried to avoid future logjams. It was, all in all, a very civilized exchange. He thanked me for my advice, and I turned to leave the room.

"I hope this works," he said as he reached for the doorknob, "I mean, you're a really cute chick and all, sweetheart, but I don't wanna have to come back."

Sigh. So close.

Open Season

Finally, after years of trying to convince people that the flu shot is actually beneficial, the message has apparently gotten through. Now, instead of running from the shot, people are lining up for it. It probably has more to do with the idea of bird flu coming to North America and wiping out life as we know it (please note the slightly sarcastic tone here) than with the public health benefits of vaccinating against influenza, but I'll take it.

It's about time the message concerning the benefits of the flu vaccine has been accepted. I've been touting it for about five years. Arguing with people who are convinced that it gave them the flu. Arguing with people who had a cold or a gastroenteritis after getting the flu shot and took that as proof that it didn't work. Trying to convince people that even if they don't think that getting the flu is a big deal, they could easily pass it to people before they know they have it-- and for those people, it might be a very big deal.

The problem with trying to push vaccinations in our society is that we live in a culture and time were the rights of the individual are prized above all else. The idea that something might be for the greater good of society is a foreign concept if it means sacrificing one's own personal rights. Introducing any foreign substance into our bodies has a risk, however incredibly small. Trying to convince someone that the risks associated with the elderly woman behind you in line at the supermarket catching the flu because she touched the counter right after you did are serious enough to warrant the barely-significant risk to you getting the flu shot... well, I might as well be speaking Greek.

And therein lies the problem. The idea of a greater good doesn't compute. Why should I get the vaccine if I don't care if I get sick, right? What other reason can possibly warrant vaccination? Why should I care if I accidentally pass the flu to an asthmatic kid who ends up in the hospital?

This is particularly the case with health care workers. In some paramedical fields, flu shots are mandatory for work during the winter months. This, predictibly, leads to tremendous indignant outcry. People don't like being forced to do things-- and being told that they don't have a choice makes people's backs come up. Unfortunately, though, I can see why making it 'mandatory' is necessary. The repercussions of a paramedic, nurse or doctor (particularly doctor, as calling in sick is often simply not an option) passing the flu onto patients who may be high risk for complications can be catastrophic. And even for those who don't have any particular objections to getting the flu shot, life can sometimes get in the way of good intentions. Making it mandatory and administering it at work catches the people who might remain unvaccinated out of apathy.

I got my flu shot last week. My husband, the paramedic, is still unvaccinated. And he won't hear the end of the nagging until he sucks it up and gets the shot. As we all should.

The Match, Redux

It happened. Again. But with a much better outcome.

So after the horror of the first match (see this blog's first three posts in August 2005 for details), I was understandably apprehensive this time around. As Novemeber 2nd approached, I had convinced myself that not only would I not match to my first choice, but I wouldn't match to any of the four programs where I had interviewed. In fact, I had already begun to think about where I'd like to set up my first locum... somewhere in the region between Sudbury and Sault St. Marie, in a Family Health Network that used electronic medical records-- preferably Mac based. I'd work in family medicine but pick up shifts in rural emergency rooms until I could either challenge the emergency medicine certification exam or apply for one of the re-entry positions later on in my career. I was clearly prepared for the worst.

Instead, I matched. Not only did I match, but I matched to my first choice program. The program with the residents that I liked, the program that was well put-together, the emergency room that saw a significant amount of volume, critical and trauma, the city with the reasonable cost-of-living and proximity to all of the outdoor pursuits that we love, and the proximity to my husband's family. Things couldn't have worked out better. My leap of faith, changing programs from emergency medicine to family medicine, paid off. Now I'll be finishing my family medicine residency in June, and will follow it up with my one-year emergency medicine fellowship which will qualify me to work in pretty much any emergency room in the province.

The only somewhat-sad part is that neither of my friends from medical school who were applying for the PGY-3 emergency medicine ended up at the same centre as I did. But I know for sure that at least one of them matched, so I'll be happy for them even though it would have been nice to train with either of them.

And as a nice perk, since I will have passed my family medicine board exams by that time, I can moonlight while completing my fellowship year. The debt will like that.

Life is good.

LMCC-II

Every year at about this time, residents in their second year of training all unite in a common purpose-- to pass the LMCC-II. See, the Licensing Medical Council of Canada has devised a sadistic two-step test that we must pass in order to be licensed to practice medicine independently in Canada. The LMCC-I was written just weeks after graduating from medical school. It is the longest, most exhausting multiple-choice exam since the MCAT. For those of us in 'traditional' medical schools, the exam is just a formality. Very few people fail, and no one really feels the need to study-- after all, isn't that what we've been doing for the past four years? For the non-traditional medical schools that don't do much formal teaching and rely mostly on small group learning, this exam is often stressful and weeks, if not months, of time are dedicated to preparation.

For many of us, the LMCC-II is the first time we've done any formal studying since the LMCC-I. The LMCC-II is very different from the LMCC-I in that the formal is along the lines of an OSCE... they're all simulated patient stations. So in each room is a standardized patient (i.e. an actor) and an examiner. Each station is 10 minutes long, although in some of them the scenario stops after 5 minutes then you have 5 minutes to answer written questions on the station. Sound like fun yet?

I can't complain too much, though. Family medicine and emergency medicine residents definitely have the advantage here. All we do is manage 'the undifferentiated patient'. Our life, essentially, is the LMCC-II. Other specialties, on the other hand, aren't so lucky. Pediatrics residents haven't touched an adult since medical school. Psych residents... well, let's just say that 'the physical exam' isn't really part of their repertoire. Anaesthesia? Ninety percent of the time their patients are asleep. These are the specialties that crammed... some of them using valuable vacation time to prepare for this ridiculous waste of time.

Waste of time, you ask? How could an exam that makes sure that doctors graduate with a minimum level of competency be a waste of time? Well, consider the origins of the exam. In the olden days, as I've mentioned in previous posts, the first year of residency was a common 'rotating internship' year. After this first year, doctors in Canada were granted a general practice license allowing them to moonlight in walk-in clinics and hospitals while they did specialized residency training, a huge help in supplementing their income. Sometime about 20 years ago they abolished this rotating internship-- now, we can't practice independently until we pass the exams specific to our specialty. Either through the Canadian Council of Family Practice (for family medicine) or though the Royal College of Physicians and Surgeons (for other specialties)-- the exams we sit at the very end of residency. So the government of Ontario has managed to take away moonlighting, and whenever our union tries to raise the subject of getting it back we're told that we can't fight for better working conditions for residents if we're going to turn around and try to tell them that residents have enough free time to moonlight. Bastards.

So since the LMCC-II no longer certifies us for a general practice license, and we can't practice until we pass our specialty-specific exams anyway, this late October day amounts to nothing more than a $1400 cash grab.

Damn, I hope I passed.