White Coat, Black Art

Things You Don't Tell Your Doctor Can Kill

Posted by White Coat, Black Art on November 20 at 11:16 AM

Medically speaking, there's nothing funny about a rectal exam. We use it to check for an enlarged prostate and rectal bleeding. But the moment I don a pair of disposable gloves, many people get embarrassed. Tomorrow, WCBA devotes an entire show to what we call unmentionables. They range from perfectly natural bodily functions to behaviours you wish no one ever found out about -- including us.

That's Saturday, November 21 at 10 am (1030 am NT), with rebroadcast Monday November 23 at 1130 am (330 pm NT) on CBC Radio One.

Colorectal cancer is the second leading cause of cancer-related deaths in Canada. Yet many of us are mortified at the thought of getting checked you know where. A few years ago, the Colorectal Cancer Screening Initiative Foundation had an awareness campaign to encourage Canadians to get tested. Their slogan? 'Don't Die of Embarrassment.'

Now, the Colorectal Cancer Association of Canada has set up a cross-Canada tour aimed t informing the public about the signs and symptoms of colorectal cancer as well as the other diseases of the colon. Here is a link to the Association.

Dr. Preventino, the Colorectal Cancer Association of Canada’s visiting professor – a puppet – greets all visitors and guides them on their voyage through The Giant Colon. During their journey, they will view everything on a large scale, from Giant Hemorrhoids to Giant Polyps and much more! The three-dimensional interior also features Ulcerative Colitis, Rectal Cancer, Diverticulitis, Crohn’s Disease and Advanced Stage Colorectal Cancer.

The Giant Colon is a 40 foot long, 8 foot high, pink inflatable walkthrough reproduction of the human colon.

This photo shows polyps inside the Giant Colon. A polyp is an abnormal growth of tissue projecting inside the colon. Colon polyps are an uncommon cause of symptoms such as bleeding. The main concern about polyps is that they might contain tiny colon cancers. Polyps can be removed easily during a colonoscopy. Usually, once a cancerous polyp is removed, you're cured of that particular cancer.

This photo depicts hemorrhoids inside the Giant Colon. Hemorrhoids are swollen veins. When enlarged, they cause pain. They're also a common cause of minor bleeding.

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Rush to Discharge? Don't Rush to Judge!

Posted by White Coat, Black Art on November 19 at 04:26 PM

It's been one of the top news stories across Canada for a couple of days now.

Monty Vann, a 60-year-old man, had a brain tumour surgically removed at the Health Sciences Centre in Winnipeg on Oct. 8. According to a report on CBC News' web site, the surgery was considered high risk because Vann, who is blind, also suffered from heart problems.

Here is the article.

Vann's family says that on Oct. 10, two days following surgery, the hospital discharge the man. He told hospital staff he wasn't ready to be discharged. However, after being told he'd be responsible personally for further charges in hospital if he didn't agree to leave, Vann left hospital on the morning of Oct. 13.

Less than 2 hours later, while being taken home in his brother's car, Mr. Vann suffered a stroke and had to be readmitted to hospital. A spokesperson for the hospital says his current stay is considered indefinite.

Whenever we hear a story like this, there's a tendency to rush to judgement. Here, we have a man who had just had major surgery and was pleading to remain hospitalized. Lined up against him were immutable forces urging him to move on and make room for someone else.

To judge the circumstances, we need all the facts. That said, as the host of a show whose mandate is to give an insider's look at the culture of medicine, I'd like to provide some context for the facts as we know them. I have no inside information regarding Mr. Vann. However, I do know a thing or two about the system.

Over the past twenty years, the provinces have taken somewhere between thirty and forty percent or even more hospital beds out of the health care system. This has been done for a number of reasons. First, for many conditions, prolonged bed rest isn't needed. Laparoscopic or keyhole surgery has taken care of much of that. A generation ago, if you had your gall bladder removed, you had a big incision on your belly; you were admitted for ten days to two weeks, and didn't return to work for six weeks. Today, you get three tiny incisions on your belly. Smaller incisions mean much faster recovery. Most of the time, you can go home the same day, and are back at work a few days later.

Second, in some cases, medical science has learned that prolonged bed rest actually makes patients do worse. For example, when I graduated from med school, we admitted heart attack patients for a month to six weeks of bed rest. Today, we'd never do that, since prolonged bed rest leads to poor recovery and can even cause blood clots.

All that said, there's no question that fewer hospital beds mean more pressure to discharge patients as quickly as possible so that other patients can be admitted. Remember, for every patient who needs a few extra days in hospital, someone else in town, across the province, or elsewhere, can't be admitted.

On the other hand, all of us have encountered patients who have refused discharge when all objective evidence suggested they were more than ready to go.

Does that mean I support the idea of pushing a guy who has just had brain surgery out the door? Certainly not! Some of my worst mistakes as a physician have occurred when I was determined to send a home a patient who was just as determined to be admitted.

Health Sciences Centre is a teaching hospital. Some reports suggested that a resident or residents looking after Mr. Vann got into an argument with him prior to his initial discharge. I can tell you that residents often feel pressure from their mentors to make room for new patients by pushing admitted patients out the door. When the dust settles, I do hope the senior doctors take at least some of the responsibility for what happened.

The facts in the case of Mr. Vann will be known soon enough. The fact the hospital CEO has rushed to apologize suggests mistakes were made.

If lessons are to be learned, I do hope the people involved are paying attention. Right now, I can't imagine anyone involved feels too proud or happy about the way things have turned out.

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Moral Distress: Questions and Comments from the Mailbag

Posted by White Coat, Black Art on November 18 at 10:46 AM

Last week’s show on moral distress generated quite a bit of feedback and some questions from you.

We received many emails from nurses who work on the front lines. Lisbet Rygnestad of Victoria BC sent us this:

"I was initially a pediatric nurse in the emergency department at a great children's hospital in Vancouver, BC, where I always felt fully supported and relatively well resourced. I have also worked and lived in Nepal & India, and now live on Vancouver Island where I am one of the only two Street Nurses in Victoria, working in a different world from the pediatric hospital. I love my job and I love my clients, but am unfortunately consistently disappointed by how the general public (including people close to me) view my clients sub-human, not deserving of the same care as they are, not deserving of the same empathy as the kids I worked with. To me, at the core of nursing, is that a nurse is a patient advocate. Your show helps me to continue to reflect on my practice - something I feel is absolutely key to being a good nurse - and challenge myself. I love being a RN and am passionate about my chosen career, despite the challenges. Perhaps the challenges are part of what I enjoy? For me, being a RN is a great career because of the constant learning, diversity of positions, and possibilities of growth."

Cathy Ringham, a registered nurse and PhD candidate from Vancouver Island University sent this email after hearing our show:

“I am looking at research on moral distress and compassion fatigue in neonatal intensive care nurses as that has been my area of work for many years. Hearing you speak about your own moral dilemma/distress as well as the candid sharing of the students put me right back into many times and places where I felt the same gut wrenching turmoil. What were we doing to tiny, barely viable babies, following orders barked out form a paediatrician who felt compelled to save at all costs? You are quite right that repeated experiences of moral distress would lead nurses to find something else to do. The other option is that they stop feeling, pull back from any emotional investment in their work because it hurts too much. This really concerns me. What happens to the quality of patient care when you can no longer feel your own feelings or recognize what the patient must be feeling in their vulnerable state? I do not think it is much different for physicians although as you point out it is the nurses who often carry out orders from someone in a more powerful position or follow "rules" they have had no say in. I think what nurses do, the discipline of nursing, is unique making the experience and ramifications of moral distress particular to our work. I am curious if you feel that compassion fatigue is the next step beyond moral distress or a separate entity. I agree with your guest that burnout is quite different from either of these but what about compassion fatigue? I would like to find some solutions or at least raise the awareness of moral distress and its effects on nurses and the health care system. The question is how to tackle the problem! I would love to hear your thoughts!”

Cathy, we did a show last season on burnout and compassion fatigue. The University of Alberta Hospital Ethics Service and the John Dossetor Health Ethics Centre host past podcasts of White Coat, Black Art. Click on the link immediately following, and then scroll down to the show dated November 17, 2008.

Here is the link to past podcasts.

As you know, moral distress pertains to situations in which you have a clear sense of the right thing to do but can’t because of outside constraints such as the system or a supervisor who doesn’t support your decision-making. Compassion fatigue also known as a Secondary Traumatic Stress Disorder is a term that refers to a gradual lessening of compassion over time. It is common among victims of trauma and individuals that work directly with victims of trauma. It was first diagnosed in nurses in the 1950s. Compassion fatigue does not require decision making – frustrated or otherwise – to occur.

We also heard from other people who aren’t health professionals yet encounter the problem of moral distress too.

Rev. Cal Wake, Coordinating Chaplain of the Ottawa-Carleton Detention Centre, sent us this: “I listened to your program on moral distress with great interest. As a prison chaplain, I see this all the time in the nurses who work on the front lines. They struggle in a harsh environment and my hat's off to them for how they cope. My question: Could you suggest any websites or articles that would help me as a chaplain understand more and address this with the health care professionals I care about?”

Rev. Wake, I suggest you begin by connecting with individuals who have made the study of moral distress a particular interest of theirs’. The College & Association of Registered Nurses of Alberta convened a conference last year on moral distress.

And, here is a decent article on moral distress.

Aaron Smith, a listener from Northern Vermont, suggested that health professionals would feel less moral distress if they took a moment to put themselves in the position of the patient. He writes: “Remind health professionals of the "Golden Rule". Ask, "How would they feel or what would "they" want done in the situation, were they the patient". This as helped everyone involved, patients and staff, in my many hospital experiences. May sound like common sense, but you'd be surprised how many times folks forget these things."

And finally, Simon Qiggaittuq sent this wonderful post that was directed specifically to me.

“Your opening statement of tubing was a very excellent introduction, and coming from a blind individual my reaction. You were mentioning on the last day you had to learn how to do "tubing," and you also mentioned that you had trouble doing it. Then your instructor pushed you aside and did it in a matter of 20 seconds. Which tells me, he or she wasn't watching you carefully enough to observe to watch out for: where you were having trouble inserting the tube, and therefore wasn't able to tell you where you were having your problems inserting the tube. The instructor is supposed to be a teacher, coach, trainer, and most of all observers, to see where you're having trouble with anything. Your instructor sounded like the Wayne Gretzky of the medical field, and not all the hockey players of the game can be Gretzky. And that also means in any work related job, we need to be efficient.”

Simon, thank you for that observation. I wish I’d received it long ago, when I found the experience of learning to intubate a patient so frustrating and so traumatic.

And, thanks to all of you for sending in your comments and questions.

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Wasted H1N1 Vaccine = No Problem? Puhleese!

Posted by White Coat, Black Art on November 16 at 10:13 AM

Today's Globe and Mail has a page one story citing reports that hundreds of doses of H1N1 flu vaccine have been thrown out because the costly drug had hit its expiration date. According to the story, some provincial officials estimate that as much as 2 per cent of the vaccine has been discarded. Officials claim that there are particular challenges trying to distribute this particular vaccine. Unlike the seasonal influenza vaccine, the H1N1 has a short shelf life and can't be saved because researchers don't know whether it retains its efficacy.

“We are running a very efficient program,” Anne Marie Akins of Toronto Public Health told the Globe and Mail. “But no matter how hard you try, there's going to be some waste.”

Sorry, Anne Marie, and all the other higher-up officials who are charged with distributing the vaccine to all Canadians who want and need it. As you recall, the Federal Government purchased 50.4 million doses of vaccine containing adjuvant -- more than enough for all Canadians to receive it. So far, despite years to prepare for a pandemic, governments at all levels have failed miserably to make, distribute and administer the vaccine in time to prevent illness.

In Toronto, nasopharyngeal swabs have been running at 50% positive for H1N1 for the past three weeks. That's the usual indication that the peak of the outbreak has arrived and is often a harbinger that the number of positive cases is likely to subside soon. In other words, the majority of vaccine will likely be administered after outbreaks of H1N1 have occurred.

What really galls me and should gall you about the wastage of the vaccine is that officials seem so inured to the idea of wastage. In my opinion, that's a product of a monopolistic system that has few if any incentives to be efficient.

I'm not saying we should bring in competition from private providers of health care. What I am saying is that just because it's funded publicly doesn't mean health care in general and vaccine distribution in particular has to be inefficient.

On our show earlier this month, we profiled three family practices that are using new and even old techniques to improve efficiency. Fee for service and public funding of health care are no impediments to making things work better.

A couple of weeks ago, Canadians were squawking that members of the Calgary Flames, Toronto Maple Leafs and the Toronto Raptors had early access to the H1N1 vaccine. Well, consider this: the wasted dosages of H1N1 would have easily vaccinated every professional sports team in Canada.

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Moral Distress: This Week on WCBA

Posted by White Coat, Black Art on November 13 at 03:52 PM

Have you ever had the sick feeling you wanted to make the right decision ethically, but couldn't because your boss or the system in which you work wouldn't let you? That's called moral distress, and it's something people like me feel all the time.

Moral distress is especially common among people in health care who tend to take orders rather than give them. Studies show as many as 80% of nurses experience moral distress at work. It's one of the main reasons why nurses quit the profession.

Last winter, I had the pleasure of traveling to Nanaimo, BC, where my host was Stephanie Buckingham, a professor of Nursing at Vancouver Island University. She asked me to do a q and a with her students. After the q and a, I sat down with Stephanie and several of her students for a little q and a of my own.

What transpired was an extraordinary discussion of moral distress that affects nurses on a daily basis. You'll hear about the kinds of issues that adversely affect the care you receive, and the struggle of young nurses to reconcile that with their nursing ethics.

I wanted to extend a special note of thanks to Stephanie. She has provided a safe, inviting place where students can reflect upon the work they do and the choices their jobs force them to make.

Catch WCBA Saturday November 14 at 10 am (1030 NT) with re-broadcast on Monday November 16 at 1130 am (330 pm NT) on CBC Radio One.

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WHO Tamiflu Guidelines Already Outdated?

Posted by White Coat, Black Art on November 12 at 10:29 AM

The World Health Organization had this to say about Tamiflu, the antiviral drug used to fight H1N1:

GENEVA, Nov 12 (Reuters) - Antiviral medicines can prevent the onset of severe disease from H1N1 flu and should be given to pregnant women, very young children and people with underlying medical problems who fall ill, a World Health Organisation official said on Thursday.

"In at-risk groups, in order to prevent progression to severe disease, antivirals need to be administered early," Nikki Shindo of the WHO's global influenza programme said. "This also holds for otherwise healthy people who show progressive symptoms," she told a teleconference. "Patients with penumonia also should be treated with antiviral medicines, antibiotics, oxygen, and balanced fluid management." (Reporting by Stephanie Nebehay and Laura MacInnis).

That advice is useless to front line physicians like me. We're trying to prevent one person in thousands from needing to be put on a ventilator, and we have no way of knowing who is going to end up needing one. That's why a lot of front line doctors -- including me -- have been prescribing Tamiflu to everyone who has symptoms of an ILI (influenza like illness) and especially those who have a fever when we see them. I've been doing that for months.

What astounds me is that public health officials are only telling doctors to do it now!

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H1N1: Finally Some Common Sense

Posted by White Coat, Black Art on November 12 at 09:50 AM

Thank goodness! After weeks of H1N1 hysteria, finally, we're seeing a couple of developments that leave me with the distinct sense that you're getting some perspective on the pandemic.

Today, an EKOS poll done for CBC News finds that Canadians are evenly split over the federal government's handling of the swine flu, but more than half believe concerns over the risk of H1N1 are exaggerated. The poll found that fifty-three per cent said the level of concern about swine flu is exaggerated, considering the real risks involved with the virus. Thirty-seven per cent said the concern was consistent with the level of risk, and 10 per cent said the level of risk was understated.

As well, the headline in today's Globe and Mail reads "Cost of vaccinating nation hits $1.5-billion and climbing". For the first time. Among the cost overruns itemized in the article, the cost of immunizing us has gone up from an estimated $16 per Canadian to more than $30 and climbing.

What do these two developments mean? I hope they mean you've developed a healthy skepticism about the key messages coming from certain public health figures about the severity of the pandemic and the sense of panic people are feeling about the need to rush out and get the vaccine. More important, I hope we can now begin to ask the tough questions we should be asking about our response to this high volume low acuity outbreak.

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Reaction to Re-inventing Family Medicine

Posted by White Coat, Black Art on November 11 at 08:53 AM

Time pressure is the norm at many a GP’s office these days. If you’re like many patients, you’ve had the unfortunate experience of calling to see the doctor, only to find that the next available appointment is two, three, or even four or five weeks again. Check-ups are in a different category altogether. Some family doctors report that they’re booking annual physicals three months in advance. For those physicians, if you need to see the doctor today, try a walk-in clinic or ER instead.

And when you finally do get an appointment, the wait doesn’t stop there. Patients seem to be crammed into impossibly tight ten-minute windows. That’s a schedule most MDs find very hard to stick to. That means you spend extra time in the waiting room as your doctor gets further and further behind.

Lucie Desbiens writes:

“Listening to Dr. Goldman's broadcast on waiting to see the doctor on Sat. Nov. 7th, made me yearn for my old family doctor of 28 years, who retired 4 years ago. I was able to see him most times the same day, after office hours or the next day for me or my children. Now with a new young doctor, I am told to get used to the "new culture" of medicine. Our family had to be "approved" by this newly graduated M.D. before becoming a patient, and since we were healthy, she took us on. She turned away many friends who were ill at the time of her interview. My family's efforts to make appointments with her are very frustrating at times with no appointments being taken for 2 weeks and to call back to be told our appointment will be in 3 to 4 weeks. If we are 5 minutes late, our app. is cancelled. With cases such as ear infections and strep throat, we spent many hours in the local hospital ER. After trying to see her for over one year, I finally got in, to be met by a replacement doctor that day since she had taken the day off.”

This week, WCBA featured three family physicians who adopted three different strategies with the same goal in mind: increase the number of same day appointments and zero the wait time at reception.

We had a lot of reaction to our interview with Dr. John Pawlovich, a family physician from Fraser Lake, BC. His solution to long waits is to see up to 17 patients at a time in a Group or Shared Medical Visit. In case you missed it, listen to this week's podcast.

Diane Dawber of Toronto writes:

“Group appointments are an interesting idea. Back up a step and think of group meetings to do what you can for yourself (diet, nutrition, environment and exercise) before you take up the doctor's time. Our group (mostly disabled teachers, nurses, etc.) has been meeting for the past 14 years. We have done extensive research (reading and trying out what we read) into what we can do for ourselves and, in the process, improving many chronic conditions. In fact, the University of Toronto Medical School in conjunction with the Environmental Health Clinic at Women’s College Hospital studied us last year. It found that the Health Pursuits Reading/Study Group is the only model of a support group in the medical literature that actually helps people, with Fibromyalgia, Chronic Fatigue Syndrome and Multiple Chemical Sensitivities, improve health. Since these are time-consuming cases for doctors, we think we have something that will help reduce the doctors' loads and system costs. Because these are multifactorial problems, we have developed tools to help people discover how to individualize their diet, nutrition, and environment. We are working on exercise and movement tools now.”

Arleen Simmonds of Kamloops, BC sent us this:

“Just look on the Internet and see how many support/discussion groups there are from everything to cancer to anxiety. The members of these groups discuss and support one another in all the illnesses plus the social, relationship and other spin off issues. I think the medical profession might just be catching on to what patients have been doing for themselves in their isolation from that all round care we used to experience years ago. And they'll make money too you say? Just one woman's opinion.”

A number of you focused on the money aspect of group medical visits. Ken Weatherill of Delta, BC made this observation:

“I think the group sessions are just a cash grab with the physician looking for ways to increase per patient billings. If a family physician has a hard time remembering all of his/ her patients now, imagine being able to see dozens more. I believe physicians (like pilots, truck drivers, etc) should have a limit to the number of patient visits they can reasonably and healthily attend to in a year. I think they should be fairly compensated for that but should not be put in a position where they have to increase patients to make more money. Would your physician entertain group sessions if, as a full time physician, he were capped at, say, 2500 patients and $500,000 per year?”

But most of all, you loved the idea that GPs aren’t just complaining, but are finding ways to make the system work better for them and for you. Wendy Bradley of Vancouver writes:

“Doctor & Nurse Partnerships: Love it. Group appointments: Love it. These are brilliant ideas, doctors, & show. We need all hands on deck to figure out how to make our sick health care system well, and that means doctors, nurses, bureaucrats, and patients – working collaboratively. It's not brain surgery, and it's actually fun! Come on, Canada! Keep the innovative ideas coming, and help the good ones take root!”

Couldn’t have said it better myself.

Thanks, as always, for letting us know how you feel.

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More on This Week's Show: Is Fee for Service the Problem?

Posted by White Coat, Black Art on November 09 at 08:50 AM

This week's episode of WCBA talks gives three solutions that help family physicians stay on time and take better care of patients. In Hatchet Lake, NS, Dr. Jeff Colp hired Patsy Smith, a registered nurse, to help see more patients per hour. In Edmonton, Dr. Ernst Schuster used a provincial program called AIM (which stands for Access Improvement Measures) to improve office efficiency. And in Fraser Lake, BC, Dr. John Pawlovich started seeing some patients with similar health problems in a group setting, and found he could see up to 17 such patients in a 90 minute block of time -- far more than he could see one on one in a conventional office setting.

A number of you have commented that the problem with all three family physicians profiled on the show is that they work fee for service. Fee for service means the physician is paid a flat fee per service provided that is negotiated between the province and provincial medical association. Get rid of fee for service, they argue, and the problem of wait lists to see your family doctor will go away.

The first point I want to make that while Drs. Jeff Colp and Ernst Schuster work fee for service, Dr. John Pawlovich does not. He is paid a flat fee per year per patient on his roster. That fee is expected to cover all services that he provides his patients. In BC, physicians who are on fee for service and those like Dr. Pawlovich who aren't on fee for service have adopted group medical visits. That tells you fee for service isn't the deciding issue.

Likewise, many physicians who are paid a flat fee per patient per year have hired registered nurses to help them take better care of patients. Once again, fee for service is not the deciding issue as to whether or not to hire a registered nurse as part of the team. And in Alberta, a physician doesn't have to work fee for service to improve efficiency in his or her office.

That doesn't mean I'm in love with fee for service. In fact, I think there are lots of problems with that kind of payment. I have no doubt some physicians game the system to maximize their income. But if you think that doesn't happen with salaried physicians, you're dreaming in HD! A guaranteed salary with no incentives for productivity encourages physicians to work to the lowest level necessary to earn the income.

To me, the biggest problem with fee for service is that fees are so tightly regulated by a system hung up on stopping cheating physicians that there is no latitude whatsoever to get paid more when they deliver more complex services. The result? Complex services get tossed aside because they don't get reimbursed properly. And physicians see more quick and easy patients to subsidize the tough ones.

Would a salary get rid of that? I don't think so. Salary or fee for service, there are only so many hours a day and days a week. Unless you expect a salaried MD to work overtime for nothing, the work isn't going to get done simply because the physician is paid a salary.

More important, by focusing on the fee for service angle, you're missing half the story. True, two of the three MDs we profiled are earning a bit more money. But they're also delivering much better care of patients. They're doing more screening, counselling and health promotion. The fact they're more passionate and energized about their work means they deliver even better care.

Sounds like win-win to me.

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Three Ways to Shorten the Wait at your GP

Posted by White Coat, Black Art on November 06 at 03:35 PM

In our first season of WCBA, we did a show about why you wait weeks to get an appointment with your family doctor. And if you manage to get an appointment, why you cool your heels in the waiting room while your GP runs further and further behind.

This week, WCBA travels across Canada to find meet three family physicians who have found three unique ways to improve efficiency and shorten the wait.

* Dr. Jeff Colp, a family doctor in Hatchet Lake, about 15 km south of Halifax, took the province up on a pilot program in which Colp hired Registered Nurse Patsy Smith to work in his office. The result: he sees 2-3 more patients per hour, takes home less paperwork, and takes better care of his patients.

* In Edmonton, Dr. Ernst Schuster, a leading family doctor in Alberta, got the bottlenecks out of his practice through an efficiency program run by the province. One big change? He's gotten rid of procrastination. When he sees a 50-year-old man with a sore toe, he maximizes the appointment by doing blood work as well as checking for common conditions like high blood pressure and diabetes.

* Meanwhile, in Fraser Lake, BC, Dr. John Pawlovich has found a way to clean out his waiting room. He sees up to 17 patients at one time and in one room. It's called shared or group medical visits. Think of it as group diabetes or group cholesterol.

Three different innovations with the same result. Each physician has seen wait lists drop to zero. Now, same day appointments are the rule, rather than the exception.

It's nice to know family doctors are finding ways to take better care of you.

Catch the show on Saturday at 10 am (1030 NT) and Monday at 1130 am (330 pm NT) on CBC Radio One.

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