White Coat, Black Art

Thanks for Listening and Stay in Touch

Posted by White Coat, Black Art on December 29 at 12:10 PM

This week’s special talkback episode is the final show of the 4th season of WCBA. Before we wrap, I’d like to thank an enormously talented group of people who work behind the scenes.

Chuck Jutras, Rodney Millington and Bill Knott work in operations. Our technicians were Tim Lorimer, Anca Stan, and Carlos Van Leuwen. Heather Rowe, Michelle Cho and Francine Fick do our scheduling and made sure we get to air. Peter Christiani made sure we had cash. Thanks to network producers Sean Prpick and Neil Morrison as well as staff producers Carma Jolly and Nicola Luksic for helping add to what you get to hear on the show. Thanks to Angela Misri, Lily Mills and Ananda Korchynski for keeping our web site and podcasts humming.

Much deserved appreciation also goes to our Executive Producer at Radio Current Affairs Linda Groen and her trusty assistant Donna Hymers.

And finally, a big salute to the two incredibly talented people who worked each week putting the show on the air. To producer Dominic Girard, I really appreciated your enthusiasm and your playfulness with sound. If you want to know what I mean, check out Dom's audio montage of Cold War and Flu War sounds heard on our Swinefeld episode on September 19, 2009. And to senior producer Quade Hermann, thanks for your steady leadership and for putting up with me coming into work after nightshifts in the ER.

Beginning in January, you can find me in the ER at Mount Sinai Hospital in Toronto. I do hope you won’t have need of my services any time soon. I’m also putting the finishing touches on my book about my career doing night shifts in the ER to be published soon by Harper Collins Canada.

If you want to stay in touch, my Twitter account is WCBADoctorBrian. I’ll be launching my own web site shortly and will post details on my Twitter account.

Podcasts will remain posted on this web site for several more weeks. Or, you can leave us an email at whitecoat@cbc.ca.

Have a Healthy and Happy New Year!

Check out Swinefeld.

Check out Brian's Twitter Account.

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Talkback: Our Final Show of the Season

Posted by White Coat, Black Art on December 23 at 03:52 PM

This week, WCBA airs the final episode of our 4th and best season ever. We're giving the show to you as our way of saying thanks. Join us for our special talk back episode.

We asked you to tell us one thing you'd like your health professional to hear and you didn't disappoint us. We play the best of those submissions on our show.

Today, Peter Goodhand is CEO of the Canadian Cancer Society. Twenty-two years ago, his wife was diagnosed with incurable form of cancer. At the time, Peter sold medical devices, which gave him something of an insider's perspective when he and his wife were thrown headfirst into the medical system. Goodhand's wife was told she'd live three years. She survived twelve. Along the way, he learned some valuable lessons for health care providers that he shares on the show.

And we have a feature interview with writer-broadcaster Patrick Conlon. His longtime partner Jim O'Neill spent 15 weeks in hospital with a respiratory illness that nearly killed him. After he recovered, Conlon wrote a book based on his experience -- The Essential Hospital Handbook: How to be an effective partner in a Loved One's Care.

I'll be back with a final goodbye next week. Meanwhile, here are the links we promised you courtesy of the Canadian Cancer Society and My Leaky Body:

Check out Cancer Connection.

Check out Cancer Information Service.

Check out My Leaky Body.

Check out Patrick Conlon.

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Medical Technology or Heart: Let's have both

Posted by White Coat, Black Art on December 23 at 03:30 PM

Our penultimate show of the 4th season of WCBA was all about the impact of medical technology on the craft of medicine and the relationship between you and me. From the invention of the stethescope to the MRI, health professionals have been in a struggle to stay human in a technological world.

It’s easy to see the arguments presented on the show in two extremes. There are those of you who believe technology answers all of the great medical mysteries. Then again, there are those who believe in the laying on of hands and that some things should remain beyond our technical prowess.

This show would not exist if it weren’t for your passionate responses. Every once in a while, we receive an extraordinary email or letter that illustrates the danger of veering too far towards either extreme. In response to last week’s show, we received this email from a woman whose identity we are protecting at her request.

" Hi, I listened with great interest last Saturday (December 19) as the impact of technology on the modern practice of medicine was discussed. There seemed to be some question about whether medical information provided by technology would replace the information gleaned as a result of the doctor/patient relationship. A kind of "science" versus "the arts" conflict was being set up.

What do I want? The art of healing or technology? Let's have both. And let's have both grace and speed for the thousands of Canadians awaiting compassionate and effective health care."

My wish is that the writer of that email enjoys peace, happiness, and a long life. And the same to you!

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What Makes a Well-Rounded Healer: A Little Song…A Little Dance?

Posted by White Coat, Black Art on December 22 at 09:43 AM

A century ago, medical students studied liberal arts in addition to medical subjects like anatomy. But, with scientific and technological progress (check out last week’s WCBA to hear what I mean), more and more courses like pharmacology and clinical medicine crowded out the medical school curriculum.

Recently, there's been a gradual recognition that what med students gained in scientific knowledge was lost in basic human wisdom. The famous Canadian writer Robertson Davies once told an audience at Johns Hopkins University in Baltimore that physicians must balance between the ability to look at a disease and to see the patient who bears the disease. That morphed into the concept that both the sciences and the humanities are integral to medicine, and that's how the Humanities in Medicine Program at Dalhousie University came into being.

It has programs in art and the history of medicine. It boasts an annual Medical Mystery Novel. It's a 66-day contest in which students compete to build a clever mystery novel in 11 sentences. They've also got a music program complete with a musician in residence and a full chorus in which students join forces with members of the community. Plus, there's a male group of featured singers from med school called the Testostertones (aka the 'T-Tones') and a female group of called the Vocal Chords.

Recently, I attended a rehearsal of the full chorus as well as the Vocal Chords and the T-Tones -- both made up of first and second year med students. For some, it's the first time they've had a chance to sing. Others have sung or played professionally and have amazing voices. They have fun, but they take their performances seriously. Some bring the perfectionism you see in doctors to their music.

Much of the credit goes to a mentor of mine named Dr. Ronald Stewart, a Professor Emeritus in the Department of Emergency Medicine at Dalhousie University who recently retired as Director of the Medical Humanities program Ron still runs the music program.

Ron is a true Renaissance man. Born in Cape Breton – where he learned to play bag pipes – he went to UCLA where he was one of the first physicians in the world to do a residency in ER medicine. He set up the ER residency program at the University of Pittsburgh. He was a medical adviser on several top-rated medical shows including shows like 'Marcus Welby' and 'Emergency'. At a time in his career when most MDs might have slowed down, Ron came back to Nova Scotia to be health minister. When he was offered the chance to become Director of the Humanities in Medicine Program at Dalhousie, he grabbed it.

Ron says there’s not a lot of scientific proof that medical students who indulge their interest in humanities become better physicians. At least not yet. But he points to a study showing that surgeons who study art appreciation become better surgeons because they develop better attention to visual detail. To Stewart, it's inevitable that more proof will come as more studies are undertaken.

I'm totally biased but I certainly believe in the concept. Back in medical school, I wrote for and appeared in ‘Daffydil’, the annual comedy revue put on by medical students at the University of Toronto. That was where I first heard an audience laugh at my jokes and where I caught the bug to write. If it weren't for that, I probably wouldn't be writing in this space.

For more on the Humanities in Medicine Program, listen to my ‘House Doctor’ column this week on your local CBC Radio One afternoon show. Or, check out the program’s web site at Dalhousie University.

As I was writing this blog entry, I received an email from Andrea Gauster. She’s a first year medical student at Queen's University and an indie singer-songwriter. Now that her exams are finished, she’s getting back to her other career trying to promote her music. Andrea has just released a Christmas single entitled ‘Christmas Without You’ and is currently working on her second album – during study breaks of course.

Radio 3 has featured the music of Andrea Gauster. To learn more about her and to hear a sample of her work, check this out.

Next time you're in the examining room and you want to break the tension, why not ask for a song?

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High Tech's Impact on Health Care

Posted by White Coat, Black Art on December 18 at 04:51 PM

If I had just a dollar for every patient I see in the ER who asks for an MRI, I’d be rich. Patients and doctors alike have bought into an assumption that more and better technology makes for better health care.

On this week’s episode of WCBA, we examine the role technology plays in health care and ask whether more tech in medicine means less craft. As medical historian Stanley Reiser says on the show, the debate over tech versus craft is as old as the stethescope.

On second thought, we shouldn’t be dreading the future – especially when you find out the kinds of breakthroughs that are just around the corner.

Case in point: Think off-the-shelf body parts are science fiction? Within our lifetimes, we may be ordering new kidneys from a store or a catalog. Researchers at Wake Forest Institute for Regenerative Medicine in North Carolina were the first in the world to custom build a replacement bladder in a lab and transplant it successfully into a human being.

There are people walking around today with laboratory-built bladders, thanks to the Institute, and its’ director, Dr. Anthony Atala.

Here is an extended interview he did for WCBA. And catch our show on Tech Versus Craft Saturday December 19 at 10 am (1030 am NT) or Monday December 21 at 1130 am (330 pm NT) on CBC Radio One.

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Make this holiday season a healthy (and boring) one

Posted by White Coat, Black Art on December 17 at 03:40 PM

Just when you thought we were done with the doom and gloom of H1N1. Once again, David Butler Jones, Canada’s Chief Public Health Officer, is trying with Grinch-like zeal to take another run at the pandemic.

Here’s what the good doctor has to say:

“Shaking hands and sharing a hug and kiss with family and friends is a common practice around the holidays. Obviously, this is not going change – but be mindful of how germs and illnesses like the flu spread. Since you’ll be shaking hands and hugging frequently, try to wash your hands regularly throughout the evening and avoid touching your face.”

Gee, thanks. As I wish at happy thirteenth wedding anniversary to my beloved wife and lean in for a kiss, I’m supposed to be mindful of germs.

“Double dipping is when you dip something into a sauce (such as a potato chip or carrot stick into dip), take a bite from it and then dip it again. Double dipping is a quick way to spread infectious disease, such as H1N1, so avoid it. Also avoid sharing utensils with another person if they’ve been near your mouth and try to ensure that buffet tables are out of reach from children’s hands.”

That advice is funny when you’re talking about George Costanza. To me, the advice is both patronizing and kind of dumb. As a general rule, discouraging double dipping is okay. As a way of preventing H1N1, it’s silly. If no one who comes to the holiday party has H1N1, then avoiding the dreaded double dip won’t prevent swine flu. If you have H1N1, the last place you’ll feel like showing up is a holiday party. See what I mean?

“If you’re hosting guests over the holidays, make it easy for them to enjoy themselves and stay healthy by preparing your home. Have plenty of alcohol-based hand sanitizer, liquid soap (avoid bar soap) and disposable paper towels available for guests to wash their hands. A little preparation on your part can go a long way to keeping your family and friends healthy during the holidays, and at any time of year.”

Excuse me? Did he tell us to buy soap and disposable paper towels? Er, I guess I can spring for some.

“While socializing with family and friends, remember to avoid sharing glasses because when you share glasses, you also share germs. Try using items that distinguish glasses, such as drink charms, to make sure you can easily identify which glass is yours.”

If Butler-Jones had stopped at not sharing drinking glasses, I could have lived with it. Giving us tips on how to identify the drinking glass that contains my partially consumed beverage seems a tad condescending.

“Getting the H1N1 flu vaccine and the seasonal flu vaccine is the best way to protect yourself and your loved ones from both the H1N1 flu and the seasonal flu viruses. Protecting yourself by getting the vaccines might be the easiest way to enjoy the holiday season without worrying about catching or spreading the flu.”

Finally, the pitch to get the vaccine. I’m not going to touch this one. You decide if you want to get it now that the dreaded second wave of H1N1 is done like dinner. As for the third wave, do wake me when it’s over.

And have a happy holiday!

Here's the PHAC tip sheet.

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Reaction to Our Show on Chronic Pain

Posted by White Coat, Black Art on December 17 at 11:40 AM

We’ve had quite a response to our show on chronic pain. Not surprisingly, we received quite a few emails from people for whom bodily pain is a daily occurrence.

Ian MacKinnon from Nova Scotia sent us this email:

“You show on chronic Pain almost made me cry. It took almost a year of living with severe pain and seeing a pain specialist to motivate my GP to give me pain killing drugs like Gabapentin and Percocet. I got side affects but not much pain killing. Then, my GP referred me to a methadone clinic and that doctor gave me the ability to live with my body. I am not sure how much more I could have tolerated. Currently, my pain is at a level I can deal with, and I have a MAJOR supportive family. I am disabled and I have heard "you don't look desabled" so many times. We all suffer in silence.”

We received this email from Joanne Bury of Redbridge, Ontario:

“I listened very intently to your programme today on chronic pain. I live with chronic pain and have for many years. I have Fibromyalgia - pain and fatigue have ruled my life for the past 20 years. I have been unable to work since 1993 and spent until 2003 raising my two daughters on Ontario Disability Support Program Income Support (ODSP). Now I get by on less than $900 a month disability pension with the CPP. I have always felt that my pain and my poverty were intertwined. I am in pain everyday. I walk; I go to Yoga once a week, yet the pain never goes away. Doctors do not like patients like me because things don't change and I am always in pain. I feel for anyone in pain, but I especially feel for those like me who also are poor. It just magnifies everything.”

Joanne, you’ve reminded us that chronic pain takes a staggering economic toll on society and on individuals. In my opinion, the lack of ready access to effective treatments and multidisciplinary pain clinics is not only mean-spirited; it’s also shortsighted in a financial sense. Studies show that the longer pain lasts, the less likely pain sufferers will be able to return to work, and the more likely the pain will affect the patient’s quality of life.

Erin Walsh of Ottawa made this important point:

“I enjoyed your recent show on chronic pain. I do feel, however, that you focused on patients who had chronic pain as a result of injury, and neglected to mention patients who have pain conditions that don’t come from injuries, such as patients with neuralgia. We're not often seen as having a real problem, especially since our pain isn't always ongoing. I once had a friend who is a doctor dismiss my diagnosis of neuralgia by saying I had tension headaches. I don't know if I've ever had a tension headache, but I know that over the counter cures tend to work for that, yet do not work on my neuralgia. An attack usually results in a week of unimaginable scalp pain, many areas of my head being sensitive to the touch, and the stabbing pain in the back of my head several times a minute for those seven days."

Sorry, Erin. We weren’t trying to suggest that chronic pain always begins with an injury or surgery. I’ve seen many patients with chronic pain that has no obivouis cause.

We also heard from families of pain sufferers. Darlene Brownell writes:

“I just had to write and say thanks for your show today. My mother also suffers from chronic pain, has been for close to 10 years and is on some very heavy narcotics. As I am young and healthy I find it difficult to understand her situation sometimes. After hearing others on your show today describe very similar situations it really helped me find more compassion again for her and her situation. I would very much like to learn more about this topic and if there is any possible solution out there. If there is anything you can recommend that would be greatly appreciated.”

Darlene, we've gathered some useful web sites at the end of this blog posting.

On the other side of the gurney, we heard from the people who care for patients with chronic pain. Matt Graham of Canmore, Alberta, writes:

“Thanks for this program. I think you nailed the complexity of the problem of chronic pain and also the growing powder keg which is opioid (narcotic) prescribing. I heard a little bit of the idea that there are alternative approaches beyond medicine to coping with pain. I work in an interdisciplinary pain clinic that has two programs. One is a return-to-work program where clients get education and training in changing their perceptions about their pain while trying to develop the physical strength to return to work. Pam Squires made some good comments about training clients to think about returning to some kind of meaningful functioning rather tahn eliminating their pain. The other program is to help clients whose narcotic use has not led to discernable improvement in their quality of life. To determine the extent narcotics are benefiting, patients are tapered off narcotics while measuring how well patients function without them. Then, they are reintroduced if doing so improves their ability to function. It's a very hard work but I am regularly blown away when people are able to develop skills and mindsets to cope with the suffering related to pain and how this then leads to a sense of confidence and skillfulness to cope day to day.”

We also received a great deal of advice from people who have found relief.

Deborah King writes:

“I had a long experience with chronic pain in my sternum (breast bone) after an acute chest infection, followed by pleurisy and then costochondritis. My family doctor wanted me to take pills for this. I did try one prescription and was terribly ill for days. I happened to be driving by a doctor’s office in my town and saw a sign for an acupuncturist. I was desperate, so I made an appointment to at least discuss my pain issues. It was my luck to begin treatment with a skilled doctor. He was a trained medical doctor in China, but did not retrain for Canada. He practiced acupuncture, herbal medicine and Chinese massage here. I put my trust in him because I had no other alternative. I became pain free and was able to return to work full time. I am a high school teacher and continue to work without difficulty. I can even work in the garden, etc. like I used to. As I listened to your program, I thought it would be helpful for doctors and patients to try other alternatives. I also wondered why medical professionals don't talk to each other at conferences so they can share their successes. When I asked my doctor about this, he said that Western doctors don't believe in his kind of medicine. It saved me from going over the edge."

Deborah, acupuncture has a fairly well established place in the arsenal of treatments for chronic pain in Western medicine. The Acupuncture Foundation of Canada Institute (AFCI) provides accredited teaching of acupuncture to health professionals. I’ve taken one course with AFCI. To your larger point, health professionals who see and treat lots of patients with chronic pain do tend to share ideas on the latest treatments.

Next year, the International Association for the Study of Pain (IASP) is holding the 13th World Congress on Pain in Montreal. This is the largest gathering of experts from around the world on the treatment of pain. The conference runs from August 29 until September 2, 2010.

And finally, we’ve had some additional comments on spinal cord stimulation, the electrical current that Adrienne Luksic uses to control pain caused by nerve damage that resulted from breast cancer treatment.

Catherine Dunne of Toronto sent us this email:

“I wanted to comment on the women who has found pain relief from her implantable spinal cord stimulator. She may very well have a unit made by Medtronic which is the company I work for, although not in our neuro division. Neurostimulators are an approved modality of therapy for pain management. However, despite these technologies being approved by Health Canada they are not universally available to patients. The government refuses to fully fund the technology and thus each patient must submit to a 'compassionate request' to government for the device and I can assure you the process is awash in red tape and the patient is not always granted approval. I recently met a patient who has suffered from debilitating back pain for many years and was in essence rendered incapacitated by the large doses of pain meds he needed just to be able to get out of bed. He was unable to get a pain pump funded, and when he offered to pay for it himself (he was a man of means), he was refused because doing so was counter to the Canada Health Act! This is the staggering inanity of bureacratic hippocracy that is our so-called socialized health care envrironment. It would appear that the gov't would prefer that you stay on addictive drugs and then put you on the disability payroll instead of returning you to full life working and paying taxes I say it's time for 2 tiered health care; not that such a system doesn't already exist in this country."

There are three vendors of spinal cord stimulators. They include Medtronic, Boston Scientific Neuromodulation and St. Jude Medical. Other sources of information include the Canadian Neuromodulation Society and the Canadian Pain Society. I’m a member of the latter organization.

Again, we aren't endorsing any of these treatments. Judge them on their merits and make up your own mind.

For more information, check this out.

And this.

And this.

And this.

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More About Chronic Pain

Posted by White Coat, Black Art on December 14 at 10:19 AM

WCBA’s show Saturday and today at 1130 am (3:30 pm NT) on CBC Radio One generated some reaction from people who either have chronic pain or know someone burdened by it. There were many pleas for more information about implantable neurostimulators. It’s a treatment that Adrienne Luksic said relieved her pain tremendously.

Adrienne developed chronic pain due to nerve damage that came as a result of surgery for breast cancer. She tried numerous forms of treatment, including pills, physiotherapy and acupuncture. None worked. But then, she heard about an implanted neurostimulator and decided to give it a try.

WCBA does not endorse treatments such as these. However, since many of you asked for more information, we thought we’d oblige.

The treatment is often referred to as a spinal cord stimulator. It’s a portable device that emits an electrical current that has electrodes that are implanted surgically into the spine in the space that surrounds the spinal cord. The patient controls the device, which can be worn on a belt.

Most often, spinal cord stimulators are given to people with chronic pain following back surgery and to people with pain caused by nerve damage or disease. There are substantial downsides to this form of treatment. In one study, nearly one in five patients had complications from the surgery, including infections, bleeding at the site at which the electrodes are inserted, as well as nerve and even spinal cord damage. Sometimes, the operation itself can cause pain.

Spinal cord stimulators are expensive, often costing tens of thousands of dollars up front for the device itself and for the operation needed to implant it. However, proponents point out that the cost of the surgery is offset by savings in prescription drugs that are no longer needed to treat pain.

These devices are implanted by neurosurgeons. If you are interested, ask your family doctor for more information.

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Preview of Our Show on Chronic Pain

Posted by White Coat, Black Art on December 11 at 12:12 PM

Physician and humanitarian Dr. Albert Schweitzer once described pain as “a more terrible lord of mankind than death himself.”

Current estimates suggest that one in five Canadians suffers from chronic pain severe enough to require treatment. Some studies have estimated that chronic pain causes more disability than cancer and heart disease combined. Despite this, many Canadians suffer in silence, as their pain is both under-appreciated and under-treated.

There are many reasons why this sad state of affairs prevails here in Canada and in many developed nations. Health professionals receive very little education on managing pain effectively and safely. And there aren’t nearly enough experts in pain management or specialized pain clinics to meet the needs of Canadians.

Pam Squire is one such physician. The Vancouver-based family doctor has made it her life’s work to learn as much as possible about treating pain and help as many patients as time permits.

For Dr. Squire, managing pain with narcotic painkillers means managing the risk of addiction. Before prescribing narcotics, she says she always asks up front if the patient has ever been addicted to alcohol and other drugs. Some patients are offended by Dr. Squire’s direct and candid approach.

This week’s edition of WCBA examines the problem of unrelieved pain and the impact on patients. You can catch the show on Saturday, December 12 at 10 am (1030 NT) and again on Monday December 14 at 1130 am (3:30 pm NT) on CBC Radio One.

Meantime, here's a bit of what Dr. Squire says to her patients:

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Swine Flu Not Very Deadly

Posted by White Coat, Black Art on December 10 at 04:31 PM

As we've been saying for months, H1N1 is far less deadly than feared by flu-watchers when the outbreak began last April. That's according to a study published today in the online issue of the British Medical Journal.

The H1N1 pandemic of 2009 is 1/100th as lethal as the 1918 Spanish flu and nearly 1/10th as deadly as the flu pandemics of 1957 and 1968.

An analysis of cases reported to the British health department found that an dn estimated 26 of every 100,000 people infected with the H1N1 influenza A virus that causes swine flu died. That is a death rate of 0.026 per cent. By comparison, the fatality rate for the 1918 Spanish flu pandemic was two to three per cent, compared with around 0.2 per cent for the pandemics in 1957-1958 and 1967-1968.

"The first influenza pandemic of the 21st century is considerably less lethal than was feared in advance," England's chief medical officer, Liam Donaldson, and his co-authors from Britain's Health Protection Agency wrote in the study.

On the show and in a previous entry of this blog, I quoted an estimated death rate of 1 per 250,000 people infected with H1N1. Some of you took me to task for reciting that figure. All I can say is I didn't make it up. The figure was an estimate based on a small number of deaths at the time. Some of you may be tempted to conclude that a death rate of 26 per 100,000 people infected is many, many times more than 1 per 250,000.

If you do, you're missing the point completely. 1 per 250,000 or 26 per 100,000, it doesn't matter. Death in both cases is an extremely rare occurrence. Fortunate indeed is the society that can get excited about a difference as trivial as that!

Read this.

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