Drawing the Line

One hard thing about residency is figuring out where to draw your line. And I mean this in a few different ways.

First, you have to figure out how much of "you" you're going to give to your job. In medicine, it's awfully easy to have your job become your life. Not to say that this doesn't happen with other jobs. But in medicine, where the job becomes your life for certain periods whether you want it to or not (see posts from 11/05 - 12/05 when I was an intern on general surgery for a shining example) you sometimes feel guilty for not throwing yourself in headfirst. Unfortunately, there are very few (i.e. none that I can think of) residency programs that are not harbingers of the future. What I mean by that is that if you're working your ass off for five years, you're kidding yourself if you think life will be sweet once you're done. In all of my toughest rotations, the staff were there too-- coming in on weekends to check on their patients, getting phone calls in the middle of the night informing them of significant changes in their patient's status, staying well past 'normal' working hours to get things done... and these happened when they weren't on call.

The second line that you need to learn how to draw is the one between 'personal you' and 'professional you'. I have heard enough stories of doctors who routinely have neighbours showing up on their doorstep asking them to look at their child's rash, or asking for a note for work to be wary of mixing the two. I'm hope that for me, a part of that will be avoided by the fact that I go as Mrs. Husbandslastname socially and Dr. Maidenname professionally. Currently, only two of my neighbours are aware of what I do for a living (and neither of them were told by me). That being said, I don't live in a very close-knit neighbourhood and people generally keep to themselves. If I lived in a smaller town rather than a mid-sized city, my Clark Kent persona would likely be far more difficult to maintain.

Which leads to line number three-- prescribing to self and others. By 'others', I mean people who don't fit the formal definition of patients... friends, family, co-workers, and acquaintances. We've all done it at some point. When a coworker asks for for a quick script for Cipro for a UTI-- she's had one before, and has all the symptoms, and is really uncomfortable. Most of us wouldn't think twice. But are you comfortable asking the coworker the same questions you'd ask a patient? Sexual history? Discharge? Painful intercourse? None of us would do a pelvic on a co-worker, but I've seen more than one case of genital herpes initially misdiagnosed as a UTI. What about even more benign stuff-- a script for physio to make an insurance claim? A req for bloodwork for a friend who needs her thyroid levels checked regularly but can't get in to see her family doctor for another week?

That complicates things. For those without a family doctor, something as simple as getting a prescription refill or a referral could mean hours sitting in a walk-in clinic to be seen for seconds by a physician who lets them talk for less than 30 seconds before scribbling a script and leaving the room. But that doesn't make me any less responsible for my actions if I choose to interpret the guidelines loosely.

And there ARE guidelines. The college policy states that:

Physicians should not treat either themselves or family members, except:

• For a minor condition or in an emergency situation,

and

• Only when another qualified health care professional is not readily available.

Unfortunately, these are very open to interpretation.

So for now, some residents will have no qualms about prescribing to friends and coworkers. Others will refuse in the spirit of erring on the side of caution. For the rest of us who fall somewhere in between, we need to figure out through trial and error where our own line will be drawn. And the sooner we figure out where our personal boundries lie, the easier life will be.

Apparently I Wasn't Clear That it Was MAJOR Surgery...

So I saw a patient in my office. He was a middle-aged guy asking if he could be circumcised. I inquired as to his motivation and he explained that he had recently converted to a religion where circumcision was the norm. In addition, he and his wife had recently had their newborn son circumcised-- again, citing religious reasons. The whole exchange was pretty routine. He had clearly done his homework on the procedure and was already fairly knowledgeable about the risks, the procedure and the recovery afterwards. He wondered if he could be referred to the same physician who had circumcised his son. I explained that infant circumcision and adult circumcision were very different procedures performed with very different techniques, and that adult circumcision would be performed by a urologist in the operating room. I emphasized that this is not a minor procedure, that it is often performed under general anaesthetic. Due to my anti-circumcision bias, I admit to often emphasizing the risks and the complications associated with this elective, cosmetic procedure. I also explained that as this is no medical indication for circumcision, he would be required to pay for the procedure out-of-pocket. He nodded, picked a urologist, and I filed the consult request.

Fast forward about a week. I had taken a few professional leave days off to study for the CCFP exam (T minus 5 weeks and counting) so on my first morning back I sat down with my supervisor to catch up on any issues that had come up during my absence.

"You saw Mr. A last week, didn't you?" he asked me.

"That was the guy asking about getting circumcised, right?"

"That's the one. He got circumcised."

"What?" I was confused. There was no way he could have gotten in to see a urologist that fast for a non-emergent situation, let alone be seen, booked and had the procedure performed.

"Apparently, he decided not to wait."

My preceptor explained-- he had gotten a courtesy call from the ER while I was away. Our patient was being admitted for observation after significant blood loss. Apparently, my patient and a friend (which begs the question... what kind of 'friend' would agree to assist in something like this) decided that it would be a good idea to simply pull his foreskin out over the glans, press it down against a cutting board and 'circumcise' him with a newly-sharpened carving knife. No anaesthetic. Ouch.

He underestimated the bleeding. After attempting to stem the flow of blood with direct pressure for a considerable length of time, he became increasingly light-headed and his 'friend' called an ambulance.

Sigh. Where is Darwin when you need him?

The Defectors

The Canadian health care system is hemorrhaging. We're losing doctors faster than we're gaining them. In fact, an estimated 30% of Ontario doctors are leaving within 2 years of completing their training. It is fairly safe to assume that the majority of these doctors end up in the U.S.

Why? No big mystery. Much of it comes down to money. There is more of it in the States. Docs south of the border are paid considerably more (in the private system, at least) than here in Canada. Higher income brackets also pay less in taxes in the U.S. In many specialties, the resources are easier to come by-- anecdotally, I've heard of docs being lured with the promise of less call, shorter wait times for investigations and specialist consults, labs filled with willing grad students to complete your every academic bidding, shiny new clinics with nurses (also making more than their Canadian counterparts) and physician's assistants happy to take the scut and paperwork off your hands... a virtual utopia for a new physician.

Do I begrudge them leaving? Not at all. I'm sure some of them have reasons that stretch beyond the almighty dollar. Family, geography, politics, weather... who am I to judge their choices? Good luck in your future endeavors and pay your bill at the border.

Um... bill, you say? What bill would that be?

Well, let's see. Medical school, in spite of tuition deregulation, is subsidized by the Canadian taxpayer. Your spot in medical school was intended to fill a need in Canadian society. Although clearly an imperfect science, the number of spots available to train Canadian physicians is supposed to be a prediction of the number of doctors that will be needed to serve Canadians down the road. When a young physician reaps the benefits of training in the Canadian system, it doesn't seem fair to then head to greener pastures for personal benefit. Compare the cost of medical school tuition in Canada (from $3500 yearly to $16000 CAN yearly, depending on the school) to the cost of medical school tuition in the U.S. (over $30K USD at non-state-funded universities, the only ones that will accept Canadian students)... it would be crazy to go to the U.S. for medical school when you could score the same degree for a fraction of the price here at home. But to then head down to the States to earn significantly more after benefiting from a taxpayer-subsidized education? Not cool.

I'm not saying that doctors in Canada should be shackled to the CN Tower. Hey... if you want to go, go. If you're moving solely for the financial gain you're probably not the kind of physician I'd want treating my family members anyway. But on your way through immigration, please write a cheque to the Canadian taxpayers for the balance of your education. That way it can be reinvested in the system and used to train future physicians who will stay-- or at least be put towards strengthening the system in general. Really. The way I see it, it's the least you can do.

A Quick Note on Alternative Medicine

I have to admit that my recent forays into the world of alternative medicine have made me far more bitter towards the movement. Being repeatedly attacked will do that to you. But I'm not quite so bitter as, for example, Orac, who publishes a yearly compilation entitled "You Might Be an Altie" (Altie being slang for person who has a strong belief in alternative medicine). This year's edition is up to over 100 points, and is available for your amusement and/or aggravation here.

Those of you who know me know that I'm the last person to jump on any alternative-medicine-bashing bandwagon but more than a few of these hit home just based on my most recent experiences alone.

#3. If you accept without questioning vague and/or poorly documented anecdotes and testimonials as sufficient evidence for you that an "alternative" therapy can produce remarkable results "curing" cancer, heart disease, autism, Alzheimers, heart disease, etc., but routinely brutally nitpick and then dismiss well-designed randomized, double-blinded Phase III clinical studies for conventional medicine, you just might be an altie.

#7. If you make claims for a product or therapy like, "strengthens the immune system," "restores balance," "detoxifies the liver," "cleanses the colon," or "cleanses the blood," you may be an altie.

#14. If you are utterly convinced that autism is a "misdiagnosis" for mercury poisoning, despite the fact that epidemiological and basic scientific studies do not support this hypothesis, that the number of new autism cases in the U.S. has not shown a sign of falling since thimerosal was removed from vaccines three years ago (ditto Denmark, where thimerosal was removed in the early 1990's), and that autism does not share the symptomotology of mercury poisoning, you just might be an altie.

#20. If you believe that vaccines "don't work," that they "hurt the immune system," or that they are a major cause autism or other chronic diseases, you just might be an altie.

#21. If you routinely use Whale.to or Cure Zone as sources for medical information, you just might be an altie.

#24. If you underwent conventional therapy for cancer and then underwent alternative medicine treatment but attribute your survival and present cancer-free condition to the alternative medicine and not the conventional therapy, you just might be an altie.

#38. If you say your healer "is too busy people making people healthy" to conduct evidence-based trials but have never met a single person helped by them, you might be an altie.

#43. If you believe that chelation is a valid treatment for autism, Alzheimer's disease, coronary artery disease, or any medical condition other than heavy metal poisoning properly documented with appropriate symptoms and laboratory tests, you are well on the way to being an altie; that is, if you're not one already.

#51. If you talk about the pH of the "body," you're either an altie or have access to a very large blender.

#68. If you think natural is synonymous with good then you're probably an altie.

#69. If you tell me not to touch my apple because it's covered in pesticide while you're eating a Big Mac, you may be an altie.

#86. If you believe the plural of anecdote is data you are probably an altie

#87. If you believe alternative and complementary therapies cannot adequately be studied using randomized, double-blind, placebo controlled trials because they miss the essence of the therapy, as was recently suggested in an article in the BMJ, you are almost certainly an altie.

#110. If you believe polio was not wiped out by vaccination, and that FDR in fact had EPV .. you're an altie ( and probably posting on whale.to)

Now clearly I don't agree with everything on the list (Orac clearly has no faith in the training or practice of naturopaths and chiropractors) it still was good for a giggle. I think that the majority of the disagreement between my way of thinking and his, however, is based in geography. I am above the Canada-U.S. border, he is below it. In Canada, there is one English-language school of chiropractic medicine and it is fairly conservative in it's teachings. The people who graduate from it are well-educated and will work wonders with low back pain and headaches and don't necessarily believe that they can cure your gallstones through spinal manipulation. In the US, a general rule of thumb seems to be the further west the school, the more radical the school of thought. There is much more variability in the quality of US-trained chiropractors.

It's the same deal with naturopaths. In Canada, the only nationally accredited school of naturopathic medicine is the Canadian College of Naturopathic Medicine in Toronto. It's graduates aren't all anti-medicine (although some are), and are incredible when it comes to complementary care. I think quite highly of them and admire their work. Again, according to Orac "you are considered a 'doctor' with a diploma-mill ND". Not true here, where to call yourself a naturopathic doctor you'd better be a CCNM grad.

Guess we do things differently up here.

What Happened to Childhood?

It's nothing like I remember. I remember walking to school-- just a few blocks to elementary school and less than 2 kilometres to high school. I remember playing outside all day, making up games with other neighbourhood kids until mom called us in as it got dark. I remember finding pop in the fridge and knowing that meant that mom and dad were having people over.

At the risk of sounding incredibly old, being a kid is entirely different now. Parents drive kids to school even just a few blocks away. Unstructured, unsupervised play time seems to have gone the way of Crystal Pepsi and cassette tapes. It's just... different. And those differences are just the tip of the iceburg.

Child obesity has been in the news a lot lately. Along with the disturbing statistics are the discouraging findings-- dieting and food restriction in childhood and adolescence not only fails to result in weight loss, but actually results in a long term increase in BMI. So what can we do that will make a difference?

There are 5 very specific factors which have been shown to accurately predict a child's risk of obesity. The problem is figuring out how and when to identify these factors. Should we be asking about them at the 18 month well baby visit? Should they be added to our Rourke sheets? If we wait until 3 years, is that still too early? Will it be too late?

Here are the 5 factors:

• Consumption of more than one 6-8oz sweetened beverage per day (coke, Gatorade, fruit juices... anything sweet)
• Media time (including TV, computers, video games... even cell phones qualify)
• Parental presence at dinnertime (one or both parents sitting down with kids to eat)
• Unscheduled active time (time spent being active that does not include formal team sports)
• Fast food consumption more than once a week (regardless of type-- Subway sandwiches vs. chicken fingers vs. Big Macs)

Some of these (such as the fast food) are pretty predictable. Others, such as parental presence at the evening meal, are a little surprising. And no doubt just reading these made a lot of parents out there feel pretty darned defensive. But before I get a flurry of comments defending their fast food eating/juice drinking/absence at mealtimes, I need to remind people that these are not rules-- there is no God of obesity looking down on us with a checklist and cursing children who don't follow them with poor health and excess fat. These are guidelines for how to reduce your child's risk, and a place to start examining old habits if your child is starting to fall into the 'overweight' category.

I don't claim to have all the answers. And maybe I'll be more sympathetic when I have my own children to feed. But right now, I cringe whenever I hear a mom complain that her picky toddler won't eat anything but McDonald's french fries. Why does a 2 year old know what McDonald's french fries taste like? I can't help but feel slightly judgmental (and then immediately guilty for feeling judgemental) when parents bring an obviously overweight child into my office. Unless this child is independently wealthy and buying their own food, the responsibility falls squarely in the parents laps. They control what is available to eat in their house. And, for better or for worse, the parents activity level is the biggest predictor of how active their kids will be.

I don't claim to have all the answers. I'm certainly not immune to concerns over body weight-- it's been at the forefront of my mind for as long as I can remember. I remember being 8 or 9 years old and refusing to wear a purple striped top because I believed it made me look fat. I don't want that for my kids, and I wish I knew how I could ensure that weight won't be a problem for them. I know I can't guarantee it, but I'll do the best I can by not having unhealthy foods in the house, being active as a family, limiting computer/TV/video game time and making sure that Mr. Couz or myself is there to sit down to dinner. And when my patients come in asking me to put their chubby kids on a diet, I'll give them the same advice. I just hope that will be enough.