Lullabies and Lawsuits: How Sleep Deprived are Medical Residents?

Maybe the question is moot. Of course medical residents are sleep deprived. It's practically in the job description. We know it's not healthy. We know it's not a sustainable lifestyle. But it's the way it's always been done.

Stories of sleep deprivation are legendary among residents, who often share them as though they were badges of honour. One obstetrics resident spoke of falling asleep while driving home on a particularly straight stretch of highway. One of my medical school classmates confessed to driving off the road on the way home from a 36-hour shift. 'Post-call' wasn't just a description our work schedules, but a state of mind and an excuse of all sorts of mental dysfunction. It was part of the rite of passage.

In the States, this has been a much more heated topic of discussion. Since the Libby Zion case in 1984, where the death of a young woman in New York City was found to be at least in part related to extreme fatigue on the part of the residents responsible for her care. The woman's father has attacked the system responsible for the training of residents and has contended that the hospital was grossly negligent in allowing residents to practice medicine in a state of extreme fatigue. Between the Zion case and the subsequent Bell commission, the face of medical training in the US has changed dramatically in the past 20 years.

Medical residents have all worked with old-school physicians who are quick to recall the days of 'internship', where the interns were literally living in the hospital. Marriage was prohibited (at least unofficially) and the interns were paid peanuts-- occasionally out of the pockets of their supervisors. These doctors went on to become old-school doctors who never really left the hospital, and were always accessible to their patients. Admirable to some, but these are the same guys who had three wives by the age of 50 and often a brood of children to whom they were a virtual stranger. In my experience, these doctors (many of whom are now at or well past retirement age yet still hang on to hospital appointments, unable to imagine life without medicine) do not look fondly on the current crop of trainees. We're soft, our training was watered-down, and we have the audacity to feel entitled to a life outside of medicine. As I've said before, most of today's young doctors aren't willing to subject themselves to a life of 14-hour days and being on call 24 hours a day at the exclusion of family, friends and mental and physical health.

Now, residents in the US follow the 80-hour work week, as legislated by law. The rules limit residents to an 80-hour workweek; prohibit any single stretch on duty of more than 24 hours, which must be followed by a full 24 hours off; and require at least 10 hours between shifts and at least one full day off a week. To most other professions, this is still a hellish schedule. To a Canadian resident, this is a cakewalk. In Canada, the rules are less complicated-- 'in-house' call (meaning when you work overnight in the hospital, usually with little to no sleep) is limited to one every four days. So on this 'on-call' day, you start with your team (start time could be anywhere from 6am to 8am, depending on the rotation) and you work through the day and night. On your 'post-call' day you must be excused from your duties by noon. Ideally.

These rules are haphazardly enforced. Particularly in surgical specialties, where the old-boys-club rules, leaving the hospital when you are post-call is often viewed as a sign of weakness. Many of the surgical residents don't feel that they should leave, for fear of missing an interesting case. So they work a usual 12-14 hour day after putting in a full 24-hour shift. Or, in the case of orthopedic surgery (the ultimate 'old-boys-club') they consider their call 'home call' (meaning they sleep at home and come in when needed) even though they end up spending the entire night in the OR more often than not. This allows them to be on call every three days, rather than every four days. In the province of Ontario, the Workplace and Contract Compliance Committee that is run by the resident's union is impotent in cracking down on abuses unless someone comes forward with concrete proof. And no one wants to be 'that guy'.

Ironically, the new laws aren't being implemented in the US without resistance from the very people the law is intended to protect. Residents resent being forced to restrict their work week to 80 hours, saying that their 5-year residency becomes a 3-year residency if they're forced to work 25% fewer hours. They worry that continuity of care is compromised, and that their learning is affected if they are unable to see anything through.

True, in theory. But in my experience, the stuff that residents stay post-call for has nothing to do with continuity of care. They stay to scrub in on that day's OR, or to attend clinic. Once rounds have been done and the day's plans set in motion, attention turns to the new cases. And a resident staying to scrub in isn't the one who will be called when a patient on the floor crashes anyway. That's why we have handover, so the new team will be fully informed regarding the active issues and unstable patients. Sure-- ideally, residents will always be available for 'their' patients. But that's not a realistic scenario. Maybe we should look at improving handover rather than extending resident shifts.

The other argument against the shorter work week is that patient care suffers from having less staff on. I'm not really going to argue with the fact that patients suffer when hospitals are understaffed. What I am going to disagree with is the fact that this is the responsibility of the residents to correct. Having been in the position of being responsible for two floors of very sick (and occasionally unstable) surgical patients, one half floor of pediatric surgical patients, overnight OR's and surgical consults for both adults and pediatrics through the ER during my general surgery rotation just a few months after graduating from medical school, I know all too well the feeling of panic as I put out fires and prayed that everyone would just stay alive until morning when the people who knew what they were doing would be back in the hospital. I still feel that it is totally inappropriate for such a junior resident to be faced with so much responsibility with nothing but 2-3 buddy calls with a senior resident to prepare them. If one of my parents had been a surgical patient in that hospital and had crashed with only a very junior resident to manage their care, you can bet I'd be pushing to change the system. Very loudly, and with a team of lawyers behind me. Sad that tragedy has to occur before the system is re-examined.

As for the staffing shortfall, maybe the Canadian government should look into expanding the roll of nurse practitioners, opening up more residency spots and hiring hospitalists to help shift the load from the shoulders of trainees. It can't be an impossible task-- in Europe, the average work week for residents and physicians hovers around 60 hours per week. In Scandinavia, an unheard-of 40 hours of work per week.

Just because something has 'always been done' a certain way, doesn't mean that changing it won't make it better. I don't think the American system is necessarily the solution. And I don't actually mind the way things are done here. But as recent studies have shown that sleepy residents are more likely to make medical errors than residents who aren't sleep deprived, it's clear that the system is in need of a tune-up.

A Laugh for the Holiday Season

Brought to you by Doc Around the Clock.

How to Tell if you Might be a Drug Seeker

Hope you laugh as much as I did. Happy Holidays to all.

'Tis the Season

Because I've been looking to blog and haven't had much to talk about over the weekend, I'm joining in the fun after being tagged by Dr. Wes. I still don't know what the heck 'meme' means, but apparently this is one. In honour of the season...

1. Hot Chocolate or Egg Nog?
Given a choice, probably the hot chocolate. I'll drink Egg Nog if it's diluted 50/50 with milk, but I don't crave it or anything.

2. Does Santa wrap presents or just sit them under the tree?
He wraps them. Unwrapping is half the fun of receiving!

3. Colored lights on tree/house or white?
White is my preference, but lights are lights... I love all of them!

4. Do you hang mistletoe?
Nope-- my lips are spoken for, and I haven't been married for so long that I need a reason to kiss my husband!

5. When do you put your decorations up?
My family tradition is to do the deed the first weekend of December, but now that I end up spending holidays traveling to see my mom and my inlaws it doesn't seem worth the effort. A little Scroogey, I know.

6. What is your favorite holiday dish?
Turkey. Save me a drumstick. And my sister's patented marinated mushrooms.

7. Favorite Holiday memory?
When we were kids my mom made a massive advent calender and under each day of the month there would be a small felt bag that contained three identical little gifts for my sisters and I. It made the whole month feel like Christmas!

8. When and how did you learn the truth about Santa?
The truth is highly overrated in this case.

9. Do you open a gift on Christmas Eve?
I have in the past, but don't right now... and Mr. Couz and I haven't really decided what traditions we'll be passing on to our own future kidlets.

10. How do you decorate your Christmas Tree?
With a collection of ornaments that mix old and new, tasteful and tacky, meaningful and not. Again, we're still working on establishing our own traditions.

11. Snow! Love it or Dread it?
Love it! It would be un-Canadian to say otherwise.

12. Can you ice skate?
What Canadian hasn't skated the length of the Rideau Canal at Winterlude? Of course I can skate. Can I skate WELL, however, is another question altogether.

13. Do you remember your favorite gift?
Would it be unromantic to say that it was the deep freeze that my mom gave me last year?

14. What’s the most important thing?
Remembering the reason for the season and spending time with loved ones.

15. What is your favorite Holiday Dessert?
It's all about the Buche de Noel.

16. What is your favorite holiday tradition?
Christmas morning-- opening stockings first (my family makes a fuss over stockings), then sitting down to a Christmas Brunch which always features my sister's rocking marinated mushrooms, a huge fruit salad, Montreal bagels and smoked salmon. Damn. Now I'm hungry.

17. What tops your tree?
It used to be an angel with black wings that I made in pre-school. Now it's a much nicer angel that doesn't have nearly as many memories attached to it.

18. Which do you prefer giving or receiving?
Giving, although with so little time to shop it becomes stressful. I'd rather do away with presents altogether and just make it about family.

19. What is your favorite Christmas Song?
Angels We Have Heard on High

20. Candy canes, Yuck or Yum?
Love 'em. We're lucky if there are any left for the tree.

I won't be tagging anyone-- most of the blogs I frequent have meme-d already (is that a verb?) and I don't want to be responsible for putting pressure on a relative stranger.

More real blogging to come later.

The Clothes Make the Clinician

While stopping at a nearby Tim Horton's on the way to work, I saw a resident that I recognized. I smiled politely and waved while I struggled to remember her name-- or, at least, where I'd encountered her before. I studied her from my spot in line. It was 7:45am, so I knew she wasn't in surgery-- she would have been at the hospital long before now. She was nicely dressed, so she wasn't likely to be in anaesthesia. Anesthesiologists would either be wearing scrubs to work or dressed casually, intended to change once they got there. Couldn't be emergency medicine, or I'd know her. Family medicine and pediatrics were unlikely, as she was wearing a slim skirt and stylish sweater. Family and peds residents tend to dress more casually, as a general rule. Must be internal medicine. But wait... as she stepped away from the counter, I noticed her feet. Black heels that must have been 3 inches high. No way would an internist, or anyone in ward medicine for that matter, suffer through a 12-hour day in impractical shoes. Not to mention that running for codes would be next to impossible. By the time she greeted me I had it-- psychiatry. Stylish outfit, impractical shoes, lack of white coat (not that she'd be wearing it outside of the hospital, I'd hope)... it all added up.

It's amazing how much you can tell about someone by the way they dress. It's probably something that's true everywhere, and not just within the confines of the hospital. What we wear to work has been a topic of conversation since we started medical school. My medical school, as I've mentioned before, is a little on the traditional side. A little stuffy, a little old school. Initially, the only guidance we were given pertaining to dress code was: Men should be attired in dress pants, a dress shirt and tie. Women should aim to match this level of dress. Whatever the hell that means. Soon after trading in our classroom uniforms of jeans and t-shirts for the 'business casual attire' appropriate for patient encounters, it became clear that we needed more guidance than that. One of my classmates was reprimanded in third year for dyeing her hair pink. Another for wearing a midriff-bearing top (seriously... who thinks that is appropriate?). I can only imagine what other transgressions were unearthed as the year went on, since we seemed to get regular 'warnings' regarding our attire throughout clerkship.

There will always be those who just don't give a shit. One of my classmates, upon deciding that he wasn't going to go through the match but would rather travel the world and save it from a grassroots level, stopped 'playing the game'. He started coming to clinics and rounds unshaven, dressed in jeans (if it was a 'dressier' day) or some variation of workout clothing. He was reprimanded on more than one occasion and couldn't care less. When they have nothing to hold over your head, there's not much the 'powers that be' can do to make you dress better. Now he is a community medicine resident working on his Master's of Public Health and I have no doubt he WILL save the world someday... and he'll probably still be dressed like a bum.

This has become an issue discussed in the media as well... a recent American Journal of Medicine article actually tested the effect of a doctor's attire on the doctor-patient relationship. Not too surprisingly, when doctors were dressed casually their patients had less confidence in their clinical abilities and were less likely to share important medical information with them. What did surprise me a bit was the fact that the white coat won out over regular professional dress. The results are discussed in this article: When Young Doctors Strut Too Much of Their Stuff

This has been on my mind recently as well. When I switched into family medicine I soon adopted the uniform of khakis/cords on the bottom, sweater on the top. Comfortable, not TOO casual, and fairly effortless. Soon, however, I found myself reverting back to the slightly more formal dress pants, shirts with collars (although sometimes under sweaters), blazers and jackets... just generally more professional. I don't necessarily feel like I'm conforming to the mold, I just feel that professionalism comes more naturally when I'm dressed the part. It's like my 'uniform'. Part of it might be because I have so much working against me-- I'm female, and I look much younger than my age. Being female doesn't seem to matter much to anyone but the odd elderly male patient, but many of my patients have remarked that I 'don't look old enough to be a doctor'. I usually reply with a polite smile that I'm older than I look and leave it at that. But when I'm dressed more professionally, I don't seem to get the comments nearly as often. I know the piercing in my nose (a small, tasteful stud) doesn't help. So I do what I can.

Hey, in an ideal world we'd be judged based on only our clinical skills and ability to relate to our patients. But if my patients have more confidence in me when I'm wearing pants that are Dry Clean Only, it's a small price to pay.

Besides, in the emerg it's all scrubs, all the time. Heh.

Can I be Friends with my Patients?

I am putting this out there. Not only to fellow residents, physicians and medical students, but to the public at large. Is it possible to be friends with your patients?

It has happened a few times in the year I've been working in this community that I've just really hit it off with a patient. They're always my prenatal patients-- they're female, close to my age, and in many cases just damn cool people. I meet with them monthly during their early pregnancy, then every two weeks, then every week... you get to know a person pretty well when you spend that much time with them. Then, at the end of it all, I get to play a key role in one of the most important events in their lives. They like me. I like them. Often, I like their husbands too. And I'll find myself thinking of how much fun it would be for my husband and I to hang out with them. Last week, one of my prenatal patients who is nearing the end of her pregnancy joked that she'd buy me a beer when all this was over if I could get her through the birth without tearing. Meant as a joke, I know. But when you think about it, would it really be wrong? On one hand, I know things about my patients that I don't know about my friends (for example, I've never seen Vitamin K's va-jay-jay, even through she's been my best friend for years... and we like it that way). On the other, it's not like I'm thinking about people's embarrassing medical issues when I bump into them on the street.

My preceptor has some overlap between his friends and his patients. They were all friends first, though, if that makes a difference. Which I don't entirely understand. There is no way in hell I'd go to a friend to have my paps done, no matter how professional he or she was about it. In fact, Dr. Boss has even delivered the babies of his friends and coworkers. Again, too much information. But they have no problem with it.

Sigh. Can't wait to do emergency medicine full-time. This isn't an issue when you don't get to know your patients.

So Much More Than a Driver's License

I've recently been on both sides of a very sticky subject.

First of all, I'm convinced that the city in which I live is home to all of Canada's very worst drivers. People sit in the left hand lane driving 110 kph, oblivious to people trying to pass. No one thinks to actually indicate turns before they make them. Half of the drivers in town seem to be endlessly looking for an address. The worst, I'm sorry to say, seems to be the elderly. They crawl along city streets, braking for no apparent reason at random intervals. They come to a complete stop while merging into faster traffic. They seem to forget that you can turn right on red lights. They'll pull halfway into a lane from a parking lot and then stop when they see oncoming cars-- this subsequently blocks the lane as they don't seem to understand that the fact that half their car is already in the lane means that traffic can't proceed. It's aggravating, sure. And I admit that I am not the world's most patient driver. I've often voiced the opinion that it seems that many of the people on the road probably shouldn't be. Particularly those over 80 years old. In fact, I think that after the age of 75 drivers should have to pass a road test at least every two years to renew their licenses.

Now I know that age doesn't determine driving ability. There are shitty drivers of all ages. There are dangerous drivers of all ages. But when I see a car that appears to be driven by someone who can't see over the steering wheel, has an altered level of consciousness or some combination of the two-- well, more often than not the driver is of very advanced years. Although experience does improve driving ability, age does not. As a person gets older, reflexes slow, perception is decreased and judgment is gradually impaired. Sometimes these alterations are obvious, and sometimes not. Many elderly people have fairly good insight into their declining abilities-- they will stop driving at night, on the highway, in poor weather-- eventually, they give up their license entirely. For others, it's not a voluntary situation.

Last week one of my patients came in with his wife... he is in his early 70's, and although our communication has been a little hit-or-miss in the past I've never really doubted his judgment. The reason for his visit was difficult to tease out from his broken English, but it seemed that a few weeks after a routine visit to his ophthalmologist he had received a letter from the Ministry of Transport (DMV for my American readers) asking him to come in for a 'review'. The patient was, understandably, confused. He attended the 'review' as requested and was required to attend a seminar. After the seminar, he was provided with numerous forms and papers, some of which had to be completed by his family doctor. That's where I came in. As I figured it, the ophthalmologist probably notified the MOT that my patient shouldn't be driving. I think it was awfully unprofessional of him not to have given the patient himself a head's up as to his intentions to contact the Ministry, but knowing the problems I've had communicating with this guy in the past I wouldn't be surprised if he had explained everything and it just hadn't been understood.

It didn't take long for us to determine that there was no WAY this guy should be on the road. When the nurse tested his vision using the Snellen Eye Chart (at left), he was unable to see the chart from 3 meters away with his left eye. Or his right eye. Using both eyes, he was able only to correctly identify the "E" on the top line. And this was his corrected vision-- with his glasses. Scary.

I went into the room to meet a very indignant Mr. E. He had no idea why the Ministry had contacted him in the first place, and didn't think there was any problem with his vision. He read the eye chart fine, he believed. Unfortunately, as in my last appointment with Mr. E., there was no reasoning with him. I explained that it wasn't my job (or the eye doctor's, for that matter) to determine his fitness to drive. All we did was evaluate his health, and report our findings to the MOT-- they did the rest. Which is exactly what I did. I filled out his forms-- I outlined his diabetic control (not good, but no hypoglycemic episodes that we were aware of), his cardiac status (afib, cardiomyopathy and CHF, all controlled with medication) and the results of his eye exam. I noted that although he did not show any overt signs of dementia, we were not able to complete formal testing due to language barriers and he did occasionally show signs of impaired judgment. I carefully documented that the patient has been advised not to drive. Which I did. Mr. E. was crushed.

"What am I gonna do?" he asked, looking at me imploringly, "how am I gonna get around?"

I turned to his wife, who seemed to be taking in the situation with resignation. This was not a surprise to her.

"Do you drive?" I asked her.

"Yes."

I looked back at Mr. E. In one visit, he had lost a good chunk of his independence and his freedom. Suddenly, he looked very old. Although I knew that he was honestly not safe to be on the roads, I felt awful for having to change his life so abruptly. He shuffled out the door, and his wife stayed behind to thank me. She had suspected as much for the past year or so, she said. But he didn't listen. She would take his car keys until the MOT officially revoked his license, she said.

I did what I had to do. But I still feel lousy.

Happy Blog-day to me. Although technically my first post to this blog was August of 2005, my counter was added in December. This post officially marks 100 posts to my blog. That's a lot of complaining.

And in one year, my blog has seen more than 35000 hits. Cool.

A model for change, or a dangerous precedent?

An Emergency Department in Florida has come up with an interesting way to curtail inappropriate use of the emergency: fees for non-emergent presentations. Remembering all of the times I had to bite my tongue to prevent myself from asking a patient "and what about your 3 month history of intermittent loose stools did you think constituted an EMERGENCY?", I have to applaud these kinds of initiatives. But I've also come to learn something important in practicing family medicine-- not everyone has the knowledge to differentiate the dangerous illnesses from the ones that are simply inconvenient.

Looking at it from the patient's point of view, it's a different story. Particularly things like abdominal pain, headache, bleeding of any kind... when all you can think of is the worst-case scenario, it's easy to get carried away. What if that headache is a brain aneurysm? And it bursts and kills me instantly because I didn't get it looked at immediately? What if my abdominal pain is a giant tumor, eating away at my insides? And a simple pill would have cured me completely, if only I had been seen in the emergency department?

Exaggerated, sure, but not by much. I've seen some crazy cases of ER abuse. Among my favorites: One frequent flier came in one afternoon with the chief complaint... "hungry". Apparently she became accustomed to the hospital meals that were passed around emerg to the patients. So when she got hungry, she came in. By ambulance, no less. Another favorite anecdote is the story of a healthy 32-year-old guy who came in with an interesting story-- apparently he had started a weightlifting program 2 months previous and wanted to see a doctor because his left tricep wasn't getting any bigger. I couldn't make this shit up if I tried.

But just when I had it bad, my husband started working shifts as a paramedic. Damn-- if I thought some of the stuff in the ER was an abuse of the system, I was shocked to hear about some of the calls that we don't see. The staff docs I've worked with assure me that you eventually become immune to it. We'll see.

Apparently, people are supposed to get charged for inappropriate use of an ambulance. In Ontario, people are charged for any use of an ambulance (I think it's about $100) but misuse of an ambulance is supposed to be charged about $350. I say 'supposed to' because it's just a rumour I've heard from a few paramedics. Apparently, there's some form that the emerg doc is supposed to fill out if the problem is clearly not emergent and they'll be charged the higher fee. Problem #1 with this situation is that no emerg doc I've ever spoken to has heard of this alleged form, let alone filled one out. Problem #2 is the fact that no one forces these people to cough up the money, whether it's $100 or $350. So more often than not, the bills go unpaid and the abuse of the system continues.

Although I think that this Florida hospital has the right idea, I fear that the fees charged would wind up in the same place that our 'ambulance fees' do... and nothing will ever change.

Reflections of a Bad Day

As I sit here on the couch, wrapped in flannel and fleece and drowning a bottle of Cabernet Sauvignion (I never said I had good coping skills ALL the time) I'm thinking back to what made it bad. No one thing in particular, I guess. So here are some random musings on my day.

It started like any other day. Almost. The alarm went off at 6am-- I sleepily asked my husband to hit the snooze button to buy me another 7 minutes of sleep. The alarm clock is on his side of the bed. The alarm was silenced, and the next time I opened my eyes the clock read 6:21am. Damn.

I'm on the road by 7:30am for the commute out to the community where my family practice is located. The commute itself is a point of contention, as I've repeatedly asked the Department of Family Medicine to put me up in an apartment there (as they do for all of the other community-based residents) which they have inexplicably refused to do. I can't even get a call room in the community hospital. Our 'compromise' is that I am reimbursed $600 a month for travel expenses for a commute which is easily an hour each way. I hate my commute. Particularly on days like today, when a sudden drop of temperature coupled with the winter's first dusting of snow made for a long drive.

First stop-- community hospital, where I round on my inpatients while my preceptor plays hockey. After the death of our palliative patient the day before, our only remaining patient is an elderly demented gentleman who consistently believes he's in Ireland and the year is 1928. I stop in to say hello and write an order to hold his digoxin, as his heart rate is 42bpm.

Then I head across the street to the office. I am fully booked with an average of 4 patients an hour. It's already 9am, but my first patient is 20 minutes late. Not a great start to the day, as I see my second patient first and squeeze my first patient in when she finally arrives. She is an 83 year old woman whose second toe had inexplicably swelled to double its size the day before-- she's finding it difficult to walk as a result. It doesn't look like gout, doesn't seem painful to palpation, she doesn't remember any trauma to that foot... I'm puzzled. I send her for an x-ray and feel useless.

A few patients later, I'm greeted by a stonefaced woman and her 14-year-old daughter. She's angry that I'm not Dr. Boss (my preceptor). I explain that her appointment was made with me, not Dr. Boss, and that should have been clear at the time that she booked it. She's not interested in seeing me. She agrees (extremely reluctantly) too allow me to see them once she's made aware of the fact that seeing Dr. Boss would delay her appointment by another two weeks. The problem today is the fact that her daughter has been refusing to go to school. She has missed so much school this year that her mother is in danger of losing her government assistance payments. I wasn't aware that school had become optional for teenagers, but apparently I was expected to compensate for mom's lack of parenting skills. Needless to say, the visit did not go well.

Another few patients go by and I'm faced with an elderly gentleman with severe spinal stenosis. Imaging suggests that his case is surgical, but no one is willing to perform delicate spinal surgery on an elderly man with COPD and cardiomyopathy. But he's in pain. Shooting pain down his legs. And the medications he's regularly taking for pain aren't working anymore. What he needs is a medication specific for neuropathic pain, but none of them are covered on ODSP and him and his wife can't afford them. I load them up with samples and schedule follow-up in two weeks. I am half hoping that the new medication won't work so the problem doesn't boil down to one of finances alone.

I spend lunch writing notes, consult letters and answering phone messages from people demanding referrals that aren't warranted and investigations that aren't indicated. For the majority, I give in. I don't have the time or energy to argue, and I don't feel I can pass the buck to the office staff.

The afternoon started with a 20-year-old guy who had a 2 day history of gross hematuria. I must have asked a thousand questions trying to tease out some previous symptoms that would support my suspicion that this is a post-infectious glomerulonephritis, but came up with nothing. I sent him off for bloodwork and urinalysis and felt perplexed. Another swing and a miss.

The day was complete with a visit from a patient who was caught by the pharmacist a week ago trying to get a refill of narcotic three days after filling a prescription that should have lasted a month. When the truth came out she confessed to longstanding abuse of Percocet, Duragesic patches and Tylenol #3's. Now her liver enzymes are through the roof and I'm very suspicious that it can be blamed on the chronic acetaminophen abuse. What she really needs is a confirmation of the radiculopathy that caused the chronic pain to begin with, a referral to a hepatologist, a referral to the chronic pain clinic and some liver imaging (and maybe a liver biopsy). But these things take time. So we meet, go over her pain diary, review her meds use and wait for things to get done. It's frustrating how slowly things move sometimes.

I saw my last patient (thankfully, a relatively simple cough that seemed viral) just before 5pm and sat down to write my notes and tie up my loose ends. With any luck, I could be on the road at 6pm and home by 7pm. But it was not to be. One of my prenatal patients called just before the phone lines were transferred-- she thinks her water may have broken. And it's important to confirm it, because she's GBS positive and will need antibiotics if they have. I make arrangements to meet her at Labour and Delivery back across the street.

Thankfully, she shows up quickly. One sterile speculum exam, an AmnioStick and a quick look under the microscope, and I've confirmed that her membranes are intact. No amniotic fluid here. I reassure her and head out.

Another hour's drive home. There's nothing on the radio, and my iTrip can't find a free radio setting to broadcast from. It's a long hour. By the time I get home, I have about an hour until I'm off to bed. I can't believe I have to do this again tomorrow. Sigh.

Oh Please.

I stumbled across an article describing the 'dangers' of the new Wii video game system from Nintendo. Finally, by inventing a video game that requires players to get their asses off the couch, there might be some hope for a generation whose main form of exercise is walking from the TV to the fridge.

Instead, people are overdoing it. And as a result, giving themselves the kind of injuries you'd expect to see when sedentary people suddenly spend hours on end doing things their body isn't accustomed to. Not to mention the damage that flailing limbs are doing to nearby lamps, pets and people.

So the litigation-savvy people at Nintendo are doing just what you'd expect-- warning people that it's safer to play the Wii from a seated position on the couch.

Don't worry, childhood obesity. The Wii won't be a threat for long.

Entitlement

Anyone who has ever taken a class in medical ethics knows about the concept of 'justice' as it applies to medicine. Justice is one of the four prima facie principles of ethics (the other three, if you're interested, are autonomy, beneficence and non-maleficence). Justice can be described as the fair adjudication between competing claims. And what does this have to do with what I'm rambling about today? I'm glad you asked.

Recently, I've noticed an increasing sense of entitlement when it comes to Canadians and their health care. Many Canadians living today don't remember a time when there was no universal health care system. I know I don't. And I'm thankful for it. Although it has its flaws and omissions, I love the fact that everyone walking into the emergency room is treated the same. Basic health care is guaranteed for all-- at least in theory. And serious illness or accident doesn't automatically mean a six figure bill.

Recently one of Canada's national newspapers ran an article hidden deep in the first section about a 40-something year old man who had been diagnosed with terminal lung cancer. The article focused on his delayed diagnosis. Apparently, after a lifetime of being otherwise healthy, he developed a chronic cough. Although he had none of the symptoms that are often considered the 'red flags' that would raise suspicion for cancer, this cough persisted through various failed treatments and investigations. Early in the investigation of the cough, a chest x-ray was performed. It was clear. By the time the cancer was diagnosed it had metastasized throughout his body. The article concluded with the man's family doctor apologizing to him for missing the diagnosis, and the patient lamenting the health care system for not investigating his cough aggressively enough to diagnose his cancer.

Another example I heard of second-hand. A woman's husband had been diagnosed with esophageal cancer and she was understandably devastated. She was angry with their family doctor, who she believed had been 'covering up' his cancer with anti-reflux drugs rather than taking his complaints seriously. Had the doctor acted sooner, she believed, her husband would have been diagnosed while the tumor was much smaller and more easily resectable.

These two cases have a lot in common. In both cases, the eventual diagnosis was a rare condition-- particularly in the age group in which these two men were diagnosed. In both cases, there were many diagnoses that were much more likely. And in both cases, the standard of care was met. The first case could have been easily explained with a diagnosis of chronic allergic rhinitis. Particularly after the initial chest x-ray was clear, without any weight loss, night sweats, fevers, smoking history or other aspects that would be more likely to suggest serious illness, a chronic dry cough in a healthy young man is many times more likely to be an allergic rhinitis or reflux. Both of which, although there are treatments available, can sometimes be very difficult to control.

In the second case, again the red flags just weren't there. Although the wife complained that the family doctor just 'covered up' the problem with medications, if the reflux responded to medication that should be diagnosis enough. The standard of care is not to scope everyone who comes in with symptoms of reflux, but to save the invasive testing for people with other worrisome symptoms-- trouble swallowing, weight loss, a history of lye ingestion (okay, now I'm reaching). But the reality is that most people with early esophageal cancer DON'T show any symptoms. That's one of the things that makes the survival rates for esophageal cancer so poor. My favorite source of clinical practice guidelines, the GAC Guidelines, clearly states that in the absence of dysphagia, bleeding, weight loss, choking, hoarseness, and chest pain, no further diagnostic testing is indicated for cases of GERD that respond to medical therapy.

In both of these cases, the patients felt that they deserved further testing. They feel angry and cheated by the system that is supposed to ensure their health. And although I understand that people given diagnoses such as this (and their loved ones) often have a knee-jerk reaction to find someone to blame, it makes me sad that this blame always seems to fall on the shoulders of family doctors.

One of the many problems with a universal health care system is that it is, by definition, universal. Everyone should be treated equally, in theory. So every 40-year-old with a cough should have a right to the same investigations. Depending on the situation, that often starts with eliminating the scary things and fixing what can be fixed. In someone who doesn't have any red flags, and who has already had a clear chest x-ray, expecting the medical system to pay for a bronchoscopy or equally invasive low-yield test is unrealistic. In the second case, a system that sent everyone with symptoms of GERD to a surgeon for endoscopy would not only create horrendous wait times for endoscopy, but would also be prohibitively expensive. A system which allowed everyone to be investigated without compelling indication to do so wouldn't be sustainable. This will mean that some cases will be missed. But it will also save much unnecessary testing, particularly invasive testing which isn't without risk itself. The key to screening for disease is to balance out the sensitivity of the test with the specificity. That means taking into consideration things like the prevalence of the disease, the potential for meaningful intervention (i.e. there's no point in detecting a disease early that we can't do anything about anyway) and the cost of the test. This doesn't mean much when the diagnosis missed was you or someone you love, but that's the way it works.

And unfortunately, the family physician is the gatekeeper. The one who decides who warrants further testing, and who doesn't. Although there are guidelines to fall back on, in the end it often comes down to a gut feeling-- is there something about this person's complaints that just doesn't sit right?

The problem is, what's best for society isn't necessarily what's best for the individual. And medicine isn't just a science, but an art. But in my opinion, both of these patients were treated appropriately. What happened to them sucks, no doubt. I wouldn't wish cancer on anybody, particularly not lung or esophageal cancer. But there is no one here to blame. So maybe we should stop looking.