CBC.ca | White Coat, Black Art tag:www.cbc.ca,2010-09-08:/whitecoat//349 2012-01-03T14:48:55Z Movable Type Enterprise 4.37 Chasing Cures: The Promise and the Peril of Medical Devices tag:www.cbc.ca,2012:/whitecoat//349.178986 2012-01-03T14:15:15Z 2012-01-03T14:48:55Z Brian Goldman http://www.cbc.ca/cgi-bin/MT4/mt-cp.cgi?__mode=view&blog_id=349&id=909 If you look at the technology that's coming down the pike, it's nothing short of astonishing.  A biotech company in South Korea is developing a breathalyser that can detect the non-invasive forms of the breast cancer in its early stages.  A small study of seventy women (35 with and 35 without the disease) showed promise. 

Trauma Pod is a self-contained suite of robots that allow emergency surgery by remote control.  It's a perfect fit for places like Afghanistan, where severely wounded IED victims can bleed out during an airlift to a field hospital.  The robots in the Trauma Pod will keep the patient's airway clear, stop any life-threatening bleeding, and take CT scans for diagnosis.  This is not sci-fi but is slated for full production in the next two or three years.  

Another device - Deep Bleeder Acoustic Coagulation or DBAC - is a powered cuff that wraps around a patient's limb, and uses ultrasound to both find and tie of bleeding arteries without human assistance.  It's coming in the next few years.

Given the promise of devices like these, you might wonder just what we have to be worried about.  Unfortunately, the answer is more than you might realize. 

Each year, the Emergency Care Research Institute or ECRI puts out a list of Top Ten Tech Hazards in health care.  Several medical devices made the latest list.  The number three hazard on the list is medication dosage mistakes made using devices known as infusion pumps.  These devices deliver everything from narcotics for pain relief to cancer chemo to antibiotics.  The US Food and Drug Administration and the Institute for Safe Medicine Practice Canada have received numerous reports of adverse events associated with the use of infusion pumps, including serious injuries and deaths. 

As reported by the US Food and Drug Administration, in that country, between 2005 and 2009, 87 infusion pump recalls were conducted by firms to address identified safety problems.  Also on the list of top ten tech hazards in health care:  medical devices meant for patients to use at home.  The problem is that many of these devices are very difficult for patients to master.

There are certainly examples of medical devices that are fundamentally flawed.  But it's also true that in many cases, the problem lies not just with the technology but the ways in which health professionals interact with the technology.  In 2006, an Alberta woman died of an overdose of chemo.  According to an analysis of the events that took place, one of the most important factors in the woman's death was that the nurses had trouble programming the infusion pumps; due to a programming error, the patient got full dose of chemo over four hours instead over four days. 

Number one on that top ten list I was talking about are alarm hazards including alarm fatigue.  TV medical dramas are full of heart machines that sound the alarm.  Studies show the more alarms like these ring out, the more doctors and nurses ignore them.  Alarm fatigue has reportedly led to patient deaths.

There's unintentional harm.  Then again, there's harm caused by malicious intent.  I'm not aware of any actual cases of patients being deliberately harmed but the potential is certainly there.  Late last year, medical device maker Medtronic asked software-security experts to investigate the safety of its insulin pumps after a new claim reportedly surfaced that at least one of its devices could be hacked to dose diabetes patients with potentially lethal amounts of insulin. 

Acording to reports, a research team at Intel Corp.'s McAfee said it has developed code that allowed it to gain complete control of the functions of one Medtronic insulin pump model from as far away as 300 feet - putting anyone who uses such a device at risk.  And it's not just insulin pumps we're talking about.  Experts believe that pacemakers, implantable defibrillators (ICDs), and neurostimulators are also vulnerable.

Given issues like these, what's being done to protect the public? Until quite recently, you could say that pharmaceutical drugs were far more regulated than medical devices.  That's changing, albeit slowly.  Last June, the Auditor General issued a report on the job Health Canada is doing regulating medical devices.  Among the main conclusions:  more than 45 percent of the time Health Canada does not meet its service standards for timely review of medical device submissions, thus delaying Canadians' access to the health benefits of these devices.  As well, Health Canada has not established what levels of activity are needed to protect the health and safety of Canadians.  In addition, while the Department has identified risks associated with medical devices already available on the Canadian market, it has yet to determine whether the risks that the inspections and the review of incident reports are designed to address have been adequately reduced.

As we have seen all too often with pharmaceutical drugs, along with benefit comes risk.  The same can certainly be said for medical devices.  My advice is to look forward to emerging benefits but stay vigilant for inevitable problems.

]]> Season Finale: Ask Dr. Brian Show tag:www.cbc.ca,2011:/whitecoat//349.177946 2011-12-30T14:00:00Z 2011-12-27T20:10:08Z A few weeks ago, we asked you to send us your questions about the way the health care system runs. As usual, you teased and peppered us with queries via emails, phone calls, tweets and postings to our blog and... Brian Goldman http://www.cbc.ca/cgi-bin/MT4/mt-cp.cgi?__mode=view&blog_id=349&id=909 A few weeks ago, we asked you to send us your questions about the way the health care system runs. As usual, you teased and peppered us with queries via emails, phone calls, tweets and postings to our blog and our Facebook page.  Welcome to our season-ending 'Ask Dr. Brian' episode.  

Listen Saturday, December 31 at 11:30 am (noon NT) and again on Monday, January 2 at 11:30 am (3:30 pm) on CBC Radio One. Or click the link below or download the podcast:

Ask Dr. Brian Show (Pop-up)

I'd also like to take this opportunity to thank all of you for listening to the show and for contributing to our blog and Facebook page.  I will be continuing as CBC Radio One's 'House Doctor' on afternoon shows throughout the country.  And you can always contact me on Twitter @WCBADoctorBrian. 

]]> For my blog, I wanted to focus on three questions that form part of the show.

Some patients find their doctors difficult to deal with.  Turns out some doctors feel the same way about their patients.  Check out thre first minute or so of this classic episode from Seinfeld.

The doctor in the scene is writing Elaine's epitaph as a patient.  That's Seinfeld's version of how people like me handle difficult patients in TV land.  Elizabeth of Halifax is convinced it happens in real life. 

She writes:  "Dear Brian:  I am just wondering why blacklisting is allowed to go on in the Canadian health care system? If we had real privacy then this would not happen. "

Elizabeth, officially, it's considered unethical to blacklist patients for any reason.  I've never worked in an emergency department that blacklisted patients, but I have worked in ERs that developed policies to deal with patients who are known to be disruptive.  ERs used to keep a file of difficult patients -- for example, people who pretended to be ill to score narcotic prescriptions.  More recently, the practice has been frowned upon because it violates patient privacy, is open to misinterpretation, and can result in patients being deprived of health care. 

That doesn't stop MDs from unofficially telling colleagues what they think of patients.  A geriatrician I know said oral blacklisting goes on all the time via phone and in person.  The targets are patients who fire off lots of frivolous complaints to the College of Physicians and Surgeons, the doctor's licensing watchdog.  He said it's especially prevalent among doctors who care for nursing home patients with families who frequently accuse the staff of physical and emotional abuse.

I do recall at least one fairly recent attempt at overt blacklisting.  Back in 2004, the American Medical Association debated a proposal that MDs in the US refuse to treat malpractice lawyers, their families and their employees except in emergencies. Despite a good deal of support for the proposal, it didn't pass.

Health care isn't just about poking and prodding, ordering tests and prescribing treatments.  It's also about documenting all of that - creating a record of what's been done to make sure no one missed anything and so that someone can step into your health professional's shoes if and when necessary.

That led Howard Kirsch of Montreal to 'Ask Dr. Brian' this question:

"What happens to patient records when a doctor either retires or dies suddenly?  I had surgery 34 years ago and the surgeon passed away nine years later.  At the time I didn't give it much thought. Now there is a problem in the area that was operated on and I would like to find the file that was in his office...but nobody has a clue as to what happened to it.   Fortunately, I have the surgical records from the hospital which I obtained years ago in case I ever needed them. Why is there no protocol to keep patient records for as long as the patient lives?"

Howard, there's no such protocol because - right or wrong - the current system centres around doctors - not patients. As long as the physician is alive, he or she needs to keep your medical records for a certain period of time.  In your home province of Quebec, doctors need to keep most records for just five years, after which they may destroy them.  Operation reports for major surgery -- for example, the procedure you had -- as well as pathology and other kinds of reports must be kept in that province for ten years.  Genetic test reports must be kept for a total of twenty years.

Other provinces have somewhat different rules.  In BC, records must be kept for seven years.  In Alberta and in Ontario, it's ten years, although regulators in Ontario say it's prudent to keep records a minimum of fifteen years because of delayed legal proceedings that can be brought up against the doctor. 

When a physician practising in Quebec retires or dies, the records are transferred to a records custodian. In BC, the records must be transferred to another physician or stored; in Ontario, they're transferred to another physician at the same address and phone number or retained through a commercial record storage company.  In general, the records must be kept as long as required were the physician still in practice or still alive. 

In my opinion, we'll only see a cradle-to-grave patient record when we as a society demand it from the state.

As an ER physician, this next pet peeve posed by Josephine Grayson of Toronto was meant for me.  She asks: "I've recently been in emergency several times with my father who is ninety-two.  My observation is that a series of ER doctors came by and asked the same questions.  Once admitted, he was then visited by another series of doctors who asked the same questions all over again.  Other medical staff do this too.  I appreciate that it was a teaching hospital, but why can't the information be recorded somewhere when it's first taken so that it can be reviewed by other medical staff?"

Josephine, I hear you.  When I took my ninety-year old dad to an ER at a certain teaching hospital in Toronto last summer, we had the same experience.  Your complaint is just one of many good reasons why Canadians need an electronic health record that is detailed and can go seamlessly from one health professional or one hospital to the next.  Until then, the more printed information you can bring like a list of medications, letters from specialists and recent hospital discharge summaries, the less you'll have to keep repeating.

Still, doing all that will reduce but won't eliminate repetition.  Nor should it. In some instances, repetition is good for your dad.  I'd be worried if the nurse who is about to inject an antibiotic or chemo didn't ask to make certain you're not allergic to it.  Trust me: lists of medication allergies can be misleading and sometimes downright incorrect.

Besides, when it comes to a history and physical examination, studies show there's no guarantee the person who first recorded their findings got them right.  You want as many physicians, nurses, residents and students as possible to get engaged in figuring out what's wrong with you.  You also want to be there to make sure each new health person understands the reason for the visit and what the treatment plan is.

Josephine Grayson also wondered if it would also be a good thing to leave an iPad or some other tablet at the patient's bedside to help cut down on the repetition of information.  Lots of hospitals are experimenting with tablets.  Still, there are a host of patient privacy and security issues that have to be worked out before they become standard issue at the patient's bedside.

Thanks to all of you for your fantastic questions.  And from the many who sent us queries, we drew three winners.  Elizabeth Martin, Judith Roux, and Susan Wells you'll each receive a copy of my book 'The Night Shift.

Before I take my leave, I wanted to thank the two talented people it's been my pleasure to work with last season and this.  If you like a particular episode and you're not sure why, chances are, producer Kent Hoffman is the reason.  He is a genius at putting voice, sound and music together like it was meant to be.  And, if you liked our passion for everything from PSWs to hospital parking to our recent town hall Generation Rx, thank senior producer Jean Kim.  The instant she gets behind a show, it will be done and done beautifully.

Have a safe, healthy and prosperous New Year!

]]> Generation Rx: One Hour Special tag:www.cbc.ca,2011:/whitecoat//349.178550 2011-12-27T18:22:40Z 2012-01-09T14:50:22Z Jean Kim http://www.cbc.ca/cgi-bin/MT4/mt-cp.cgi?__mode=view&blog_id=349&id=794 We received incredible response from you about our recent town hall "Generation Rx- The Use and Abuse of Prescription Pain Medication" and today you can hear a special one hour version of the discussion.

Canada is one of the world's top per capita users of prescription narcotics. In Ontario alone, prescriptions for drugs containing oxycodone have risen 900 per cent since 1991. These painkillers can be highly addictive, and deadly if misused.

Dr. Brian Goldman hosts this town hall recorded at Brockville Collegiate Institute in Brockville, Ontario. You'll hear from a panel of experts who are working to address the problem of narcotic drug abuse. And you'll also hear members of the audience share their experiences, or the experiences of their loved ones, with prescription drugs.

Townhall-FBGalleryPromo-500.jpg

        Our panelists Christine Bois, Detective Shawn White and Dr. Andrea Furlan.
        You can read more about our panelists here.

Tune in to CBC Radio One today at 5pm (5:30 pm NT). Or click below to listen now or download the podcasts (Part 1 and Part 2): 
Generation Rx Special: Part 1 (Pop-up)

Generation Rx Special: Part 2 (Pop-up)
]]> Health Stories of 2011: My Take tag:www.cbc.ca,2011:/whitecoat//349.177084 2011-12-27T15:00:15Z 2011-12-19T15:47:39Z Brian Goldman http://www.cbc.ca/cgi-bin/MT4/mt-cp.cgi?__mode=view&blog_id=349&id=909 Concussions in Sports

Without a doubt in my mind, the number one health story of 2011 was concussions in hockey and other sports.  The story was bookended by the worrisome situation surrounding NHL superstar Sidney Crosby.  He received his first concussion in the NHL Winter Classic on January the first of this year in a game against the Washington Capitals and likely received his second concussion for days later when he was driven into the end boards by defenseman Victor Hedman in a game against the Tampa Bay Lightning. 

Crosby missed the rest of the season and only started playing again on November twenty-first in a game against the New York Islanders (check out this timeline).  We all know what's happened since.  Earlier this month in a game against the Boston Bruins, Crosby was hit in the head twice more and is again on the sidelines with 'concussion-like' symptoms. Recenlty, there have been gentle suggestions that the superstar consider retiring to try and prevent any long term health risk.

Crosby joins teammate Kris Letang on the shelf.  Philadelphia Flyers all star defenceman Chris Pronger is out for the season with 'post-concussion' syndrome.  Forward Claude Giroux of the Philadelphia Flyers - who recently passed Leaf forward Phil Kessel to lead the NHL in scoring, is also out with a concussion.

We learned a lot this year about the symptoms of concussion.  For instance, we know a lot more about the dizziness kept Crosby out of action.  What concussions robbed him of is the ability to keep from getting dizzy at high speed.  The other thing we know a lot more about is the brain damage caused by repeated blows to the head.  Chronic traumatic encephalopathy or CTE is a degenerative brain disease resembling Alzheimer's disease that is associated with repeated concussions and has been found at autopsy in the brains of former NHL fighters like Bob Probert. 

The most astonishing finding so far is from the Boston University Center for the Study of CTE: an autopsy of Derek Boogaard, a 28-year-old NHLer who died from a drug overdose in May.  The New York Times reported that Boogaard's autopsy showed "telltale" brown spots near the outer surface of his brain, which indicate an advanced degree of brain damage.  That such damage could be found in an active NHL player suggests the impact on some players may be far more immediate and that getting them out of the game a lot sooner may be in order. 

Breast Cancer Screening

After sports concussions, I think the story with the biggest impact is the Canadian Task Force of Preventive Health Care guidelines on breast cancer screening that women age 50 to 74 should have mammograms every two to three years, instead of annually, that women age 70 to 74 should have mammograms every two to three years instead of no recommendation, and that women under the 50 should not have mammograms at all. The task force also said that clinic breast examination and breast self-examination are not recommended since they have no benefit.  These guidelines apply to women at average risk of breast cancer - not women with a family history of breast cancer or have tested positive for the breast cancer genes BRCA1 or 2. 

It's a big story for women because it eliminates needless testing and anxiety without increasing the risk of dying of breast cancer and because it highlights questionable over-testing a time of scarce health care dollars. 

The story that affected me the most was the discovery that the so-called link between MMR (measles, mumps, rubella) vaccine and autism was a fraud.  In 1998, a scientific study published in The Lancet (and since retracted) found that MMR vaccine could cause autism in perfectly healthy children.  The study led to an anti-vaccine movement in which parents refused to vaccinate their kids. Outbreaks of diseases like measles and mumps in Europe and elsewhere could be traced to vaccine refusal. 

Then, in early 2011, journalist Brian Deer wrote an article published earlier this year in the British Medical Journal showing damning evidence that Wakefield committed deliberate fraud.  Despite this evidence, some parents continue to believe that MMR causes harm, which is why this story affected me the moast. 

What To Watch in 2012:

For 2012, I've got my eye on a new strain of swine flu that's been identified in the US by the Centers for Disease Control.  The Center has confirmed several cases of infection with this virus, a swine-type influenza A virus of the H3N2 subtype. The cases have been spotted in Maine, Indiana and Pennsylvania, with the first case appearing last July.  As far as I can see, so far, no cases have been reported in Canada. 

Another story I'll be following this year is the shortage of prescription drugs that doctors and patients depend on.  There's a list includes cancer drugs cisplatin, doxorubicin, paclitaxel or Taxol and vincristine. There's also a shortage of antibiotics like tetracycline and cephalexin, acyclovir, a drug used to treat herpes and shingles, drugs for epilepsy, and anesthetics.  I predict his will be a huge story in 2012.

As you can see, there will be plenty of health news next year.  Happy New Year!

]]> Inspiration Show tag:www.cbc.ca,2011:/whitecoat//349.177103 2011-12-23T15:00:31Z 2011-12-23T15:06:44Z Brian Goldman http://www.cbc.ca/cgi-bin/MT4/mt-cp.cgi?__mode=view&blog_id=349&id=909 This week, let's put you and me in a holiday mood with stories around the general theme of inspiration -- what inspires people on my side of the gurney to do what we do and a bit about what inspires you. Med student and blogger Erin Sullivan talks about her medical hero: a remarkable physician who reached forward two generations to inspire Erin to become a healer herself.  I chat with a hero of mine:  a celebrated ER physician from Cape Breton who schools me on how to make better doctors by getting them to sing their way through med school.  And, we meet a second year medical student who battled a serious form of cancer by painting it. 

To listen to the show now, click on the button below or download the podcast.  Better still, join us Saturday, December 24 at 11:30 am (noon NT) and again on Monday December 26 at 11:30 am (3:30 pm NT) on CBC Radio One.

Inspiration Show (Pop-up)


A century ago, medical students studied liberal arts in addition to medical subjects like anatomy. But, with scientific and technological progress 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.

In 2009, 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.

Ever the Rennaissance man, Stewart has gone back to school to do a Master's in history at Dalhousie University. His thesis? The influence of the media on the creation and development of emergency medicine. Now, he wants me to be one of his mentors.  Needless to say, I'm honoured about that.

Ron Stewart is a living, breathing example of someone who has inspired me to be a better ER physician.  But some of us aren't fortunate to have a mentor who is alive and well.  That was the problem facing Canadian Erin Sullivan, a former RN who currently blogs and studies in third year med school at the University of Limerick in Ireland.  You may remember Erin from our show from earlier this season on the language used by doctors and nurses to talk to you and each other.  The doctor who Erin most revered -- her grandfather -- was long gone.   Turns out his personal legacy wasn't.

Another for physicians and other health professionals, students and residents to do that is through art.  A Canadian art exhibit called White Coat, Warm Art is an annual showcase of exquisite pieces of work.  We caught up to a recent exhibit in Toronto last summer.  It's aim is to capture the experience of learning and practising medicine.  It helps as well if you've been a patient, as Michiko Maruyama - now in second year med school - well in every respect. 

Art does more that provide support and comfort to medical students who just happen to be patients.  Art studies have long been part of the schooling of plastic surgeons. And recently, a study found that surgeons trained in art apprecitation have better command of visual details in the operating room.

If you'd like to look at some of Michiko's work, click here: Michiko's Medical Daily Doodles. And this here's where you can find out how to submit to next year's White Coat, Warm Art art exhibit: Call for Submissions. 

Happy Holidays!

]]> Dr. Brian Hosts Cross Country Checkup on January 1st tag:www.cbc.ca,2011:/whitecoat//349.177812 2011-12-21T19:12:40Z 2011-12-21T19:24:10Z Brian Goldman http://www.cbc.ca/cgi-bin/MT4/mt-cp.cgi?__mode=view&blog_id=349&id=909 White Coat, Black Art wraps up its sixth season on December 31 and January 2.  But that doesn't mean I'll be hanging up my microphone.  Join me Sunday, January 1st as I guest host Cross Country Checkup.  We'll also be hosting coverage on line at cbc.ca.  Details to follow.

As we enter the New Year, Canada's health system -- now 47 years old -- is ailing. Health ministers and finance ministers across the country have all huddled to discuss the prognosis and later in January, it'll be the first ministers' turn.  Which is why Checkup has called me in for a little doctorly help.  

Our question for the day:  How well is the system working for you ...and what are your expectations looking ahead?  We want to know what you want and need from our health care system.  We also want to know what's working well where you live.  Call WCBA at 1-866-648-6714, post to our blog, our Facebook page or my Twitter account @WCBADoctorBrian.

]]> Not the ER Mailbag tag:www.cbc.ca,2011:/whitecoat//349.177555 2011-12-20T21:34:24Z 2011-12-20T22:19:21Z Brian Goldman http://www.cbc.ca/cgi-bin/MT4/mt-cp.cgi?__mode=view&blog_id=349&id=909 I've worked in the ER for nearly thirty years.  There have been lots of efforts to shorten the wait. Still, it bugs many of you enough to be a major factor in your decision to go or not to go to the ER and - if you actually get there - your decision to stay.  Last week on White Coat Black Art, we did a show about what we call 'ER-avoidance'.  I visited Halifax to check out a pilot project that has paramedics helping frail seniors avoid a trip to the ER by making house calls to local nursing homes. 

There are patients who avoid ER in the first place.  Then again, there are patients who put the effort and time into going but leave the ER before the doctor sees them.   Veteran ER physician and White Coat, Black art contributor Dr. Bruce Campana talked about patients who "leave without being seen".  After that, we heard from you.

]]> As I discussed with fellow ER colleague Dr. Bruce Campana, one of the major reasons why patients leave without being seen is that they are made to wait too long.  One of the reasons for that is the speed with which people like me are able to "move the meat", a crude expression we use to talk about pushing patients through the system.

Campana talked about the need to restrain intoxicated patients with potentially serious ailments who - in his opinion - aren't able to understand the consequences of leaving due to their intoxicated state. 

That prompted Norman Sim of Victoria, B.C. to send this email: "In your broadcast of December 17th I think you and Dr. Campana misrepresented the role of nurses in preventing intoxicated patients or other patients with altered levels of cognition from leaving the ER AMA. In my province depriving ER patients of their ability to make decisions, including the decision to leave the ER, requires a physician's order under a mental health statute. Frequently physicians in my ER saddle nurses with the unreasonable responsibility of preventing an uncooperative patient from leaving without first issuing the requisite statutory order. Our security service will not restrain a patient without such an order, why would you suggest nurses should? Step up to the plate Drs. Goldman and Campana. If you want patients restrained from leaving because you think their ability to make decisions may be impaired, issue the necessary order else do not expect nurses to expose themselves to the legal liability of acting without the protection your order would provide."

Graham sent this email:  "What our system doesn't recognise is that there's a strong relationship between wait time and utilisation.  My experience in this field come from modelling computer systems where the conventional wisdom at the time was that performance of storage subsystems deteriorates suddenly when utilisation rises above roughly seventy per cent capacity.  This is not to say that we should solve the problem by having emergency staff working at that capacity. They should spend all of their time doing important work; the key is to divide this work into their urgent work, presumably dealing with waiting patients and not-so-urgent tasks while important, do not need to be done right now. The key is to find the right numbers and the work to fill the not-urgent part."

Susan Eck of Toronto sent this email:  "The most important thing I learned from your book is that an emergency doctor can see on average only between two and five patients per hour.  I've asked several people since what they thought and the answers range from twelve to twenty-five per hour.  Now that I know what really to expect I have become a lot more patient. Please let others know too."

Doug Peterman of Stratford, Ontario writes:  "I just listened to your piece on ER wait times with interest, and wanted to add this wrinkle to the discussion:  Our GP went out of business without warning and without notifying us.  We only discovered this when the pharmacy refused to renew our prescriptions.  His departure also meant we were no longer supported by the health network clinic in town.  There are no drop-in clinics in town.  There is a doctor shortage in Stratford, so it hasn't been easy finding a new GP -- we finally found one in a town forty-five minutes away by care.  In the period without a doctor, I was aghast to find that our only option for getting prescriptions renewed in Stratford was to go to the ER and convince the ER doctor to help us.  I know we have a doctor shortage, but this seems an insane waste of ER resources as well as everyone's time.  Thanks for reading -- love your show!"

Mary Cooper of Surrey, B.C. sent this email:  "As the show pointed out,  people leave ERs early for many reasons.  I don't know if the fact that they leave because they are sick was mentioned.  When you feel sick, the last place you want to be is in an ER for any length of time. It is the most uncomfortable, disturbing place for a sick person to be and every minute of extended time is tortuous. Sitting in a room full of people in severe pain and/or expressing very negative feelings can only be tolerated for so long before one must leave in order to decrease one's own level of discomfort.  People go home to get away from a scenario that after a short time becomes an additional cause of their discomfort.  Also, people leave because of the parking fees.  Sure it may be said that if you own a car the parking cost shouldn't be a problem but not so.  At a rate of four dollars per hour or more, sitting in a room for hours becomes prohibitive.  These days, many people who own cars are just paying for the expenses to operate it out of necessity but are not walking around with extra cash for parking. It is a burden on the sick and a great inconvenience as well.  Spending an amount such as twenty-four dollars to park in order to sit in an ER for the hours it takes to wait for medical attention is too onerous.  Personally, the only time that I have avoided the negative experiences in ER have been when an ambulance had to be called to deal with my situation and to get me to a hospital.  On those occasions I was treated immediately."

Michael Taylor of Ottawa sent these comments:  "The general public doesn't understand the reasons for wait times. They sort of rationally understand that the extra-sick people should be seen ahead of them, that that must be what is going on to explain why they are waiting so long.  They don't actually see the ambulances come in and don't see paramedic crews doing CPR.  They have no insight into the arguments emerg docs have, every day, to get the required tests in a timely fashion (especially on evenings, nights and weekends), to convince a specialist to see an emerg patient before rounding on the recovering patients upstairs."

"They often don't really understand that, done in an expeditious manner, blood tests, an ECG and maybe an x-ray, along with the doc's careful consideration of the acquired facts can easily take the better part of 2 hours. And that's always after having waited to see the doc. You should explain the waits for tests, the wait caused by having to call in a technician to do an ultrasound at 11 pm. People think that there's a radiologist just waiting for their case to show up. There's also the wait for a bed, that's delayed by the wait for discharges, the wait for long-term care beds. The wait for home care, the wait for organizing palliative care. It's far more complex than than the average person realizes."

"Among the "Left Without Being Seen" patients there is definitely a risk that some take home a disastrous outcome, but the vast majority are probably making a good decision, deciding to treat themselves and/or see a practitioner in a different care setting in a more tolerable context."

"We all have similar stories: people who've been told that same morning that they have a cold, don't believe their doc and queue up in the evening to wait several hours to see the emerg doc and be told the same thing (this is common). I've once met a man who was sent in by his GP for us to remove one stitch from his finger.  It's all important. In the trenches, we continue to deal with increasing demands on our time and resources, from the people who come in, to the Ministries who feel we should do more. We do it, of course and we all still love what we do."

We heard from budding health professionals too.  Monica Aikman of Regina sent this reflective email on her experience as the mother of a child she worried about enough to take her to the ER.  She writes:  "What an excellent show today (as always)! As a student nurse, I'm starting to witness the challenges of working in overcrowded departments.  I feel for the staff, dealing with long hours and often challenging patients."

"But today I'm writing you as a parent.  One day last year, my toddler had a course of antibiotics and after the first dose, broke out in a head-to-toe rash with a fever.  He had reacted before, so there was a chance it was an allergic reaction.  We called the Telehealth, and then our Pediatrician and both recommended taking him to the ER, and so off we went."

"After six hours, we had still not seen a doctor. Our child was inconsolable.  Blisters had formed in his mouth, his fever was elevated and he wouldn't drink water, and hadn't for hours.  Since it was now deep into the night, we were all miserable and exhausted, and cramped in one of six packed, tiny makeshift, curtained exam rooms.  The elderly lady in the curtain over kept demanding the RN to "shut that damn baby up!"  We approached the RN ourselves many, many times and begged her to give us some pediatric acetaminophen, just to help him at least sleep through the long wait.  She refused.  I know she can't give meds without orders, but it seems like if she had advocated for us, the entire exam area would have benefited."

"We finally gave up.  It was just too much.  My feeling was that  my own minimal student nursing skills were  better than nothing and at least at home I could medicate and monitor him myself and then call 9-1-1 if things got worse.  To be safe, I didn't give him any further doses of antibiotic.  Any doctor hearing this is probably thinking, "blisters in the mouth?  Not allergic, probably just viral."   I figured the same thing thanks to Dr. Google.  And I am guessing it was an uncomfortable situation more than it was a serious situation."

"But the problem is that, I will likely hesitate before I bother with the ER again.  And as we all know, in some conditions, delay can be dangerous. I would have been happy not to take up ER time.  I know how valuable it is and I don't want to be that parent who clogs it up with a simple pediatric malady.  Any doctor could have made the diagnosis upon examination.  But here in Regina, it seems there isn't any choice."

As usual, thank you so much for sharing your thoughts with us.

]]> Not the ER Show tag:www.cbc.ca,2011:/whitecoat//349.176895 2011-12-16T21:32:15Z 2011-12-28T18:08:31Z Brian Goldman http://www.cbc.ca/cgi-bin/MT4/mt-cp.cgi?__mode=view&blog_id=349&id=909 That we go to the ER expecting to wait a long time has become part of the culture of medicine.  It's almost a cliché.  I've worked in the ER for nearly thirty years.  There have been lots of efforts to shorten the wait.  Still, it bugs many of you enough to be a major factor in your decision to go or not to go to the ER and - if you actually get there - your decision to stay.  And that's a problem if your health is on the line. 

This week:  a bit of what we call 'ER-avoidance'.  I visit Halifax to check out a pilot project that has paramedics helping frail seniors avoid a trip to the ER by making house calls to local nursing homes.   There are patients who avoid ER in the first place.  Then again, there are patients who put the effort and time into going but leave the ER before the doctor sees them.  Veteran ER physician and White Coat, Black art contributor Dr. Bruce Campana helps me get inside the heads of these ambivalent patients.  And, we have reaction to Generation Rx, our town hall earlier this month about the epidemic of prescription painkiller abuse. 

Click on the audio link below to listen now or download the podcast.  And tune in Saturday December 17 at 11:30 am (noon NT) and again on Monday December 19 at 11:30 am (3:30 pm NT) on CBC Radio One.

Not the ER Show (Pop-up)
]]> You've got a sore belly, or the beginnings of what you think is the flu.  You leave a nice warm bed in the middle of the night to come to emerg.  You register.  The triage nurse does a bunch of blood tests.  You take a seat in the waiting room.  And wait and wait and wait to be seen by the doctor.

'Should I Stay or Should I Go?' by The Clash could be their theme song. Most stay no matter how long it takes to get seen. But some don't.

In ER medicine, we call them patients who "left without being seen." Studies have shown that depending on the hospital, the time of day, and other factors, between one and twenty percent of patients leave the ER without waiting to see the doctor and find out what ails them. One particular study from Ontario caught my eye.  It concluded that the highest rates of patients who leave can be found in the busiest ERs and in hospitals where patients are seen by residents.  More people leave during the midnight shift than at any other time. The same study found the patients most likely to leave are between the ages of fifteen and thirty-five. 

Patients who leave without being seen are more patient  than you might imagine.  The Ontario study I was talking about before found that on average, people wait one hundred and three minutes before deciding to leave.  At my ER and others, we've brought in nurse practitioners and physician assistants so there are more people to see you.  The lesson for patients is to wait it out.  But the lesson for people like me is to shorten the wait. 

There are patients who leave the ER because they can't stand the wait.  Imagine if they could avoid the trip in the first place. That was something paramedics in Halifax wanted dearly.  Too many patients and not enough hospital beds in that city led to clogged ERs and medics who waited - sometimes as long as an entire 12-hour shift - to hand over patients to ER staff. Since last Spring, they've tested out a pilot program at fifteen nursing homes in Halifax.  Specially trained paramedics see and treat seniors at the nursing home, sewing up cuts, treating dehydration by giving intravenous fluids, saving the senior and the system a needless trip to the ER. Recently, I paid a visit to Halifax to meet Darrel Bardua, a senior paramedic with the program.

According to data presented in the Canadian Medical Association Journal article linked above, in the pilot program, ninety-eight of one hundred and thirty-five seniors in long term care facilities were spared a trip to the ER. The program in Halifax has been so successful it's moved beyond nursing home residents.  Now, paramedics visit patients in police custody and have plans to do the same for people who live in shelters, and patients who attend Halifax's mobile street health van.

]]> Concussions and NHL Hockey: Past the Tipping Point tag:www.cbc.ca,2011:/whitecoat//349.176850 2011-12-16T18:25:04Z 2011-12-17T03:39:06Z Brian Goldman http://www.cbc.ca/cgi-bin/MT4/mt-cp.cgi?__mode=view&blog_id=349&id=909 Until now, the NHL has exhibited a form of inertia common to organizations seeking to maintain the status quo.  It has used time-honored techniques to accomplish these aims.  These include taking advantage of gaps in scientific knowlege on the causes of sports concussions as well as disagreements between experts as opportunities to play for time.

Case in point:  in a disturbing series of articles and interactive videos published earlier this month, the New York Times documented at the time of his death at age 28 that NHL enforcer Derek Boogaard had evidence of severe CTE (chronic traumatic encephalopathy), a condition that causes emotional lability and cognitive deficits not dissimilar to Alzheimer's disease.

Clearly, repeated blows to the head are often associated with CTE.  And yet, when asked to respond to the NY Times series, NHL president Gary Bettman ssued a statement saying the findings in Boogaard's death would not result in additional steps to curb fighting or immediate steps to try and reduce the number and severity of concussions.

"To know what took place in a person's life to determine what may or may not have caused a particular injury is something that's going to take years for people who have the expertise in this field begin doing," Bettman was quoted as saying shortly after the articles appeared. "It's way too premature to begin drawing conclusions."

Don Fehr, executive director of the NHL Players' Association, said this following publication of the articles in the New York Times: 

"The findings released by Boston University to the New York Times regarding CTE found in Derek Boogaard's brain, and the forthcoming medical journal article, should be seriously considered by everyone associated with the game.  It is certainly important information that we will be discussing with the Players."

In my opinion, the phenomenon of concussions in professional sport in general and the NHL in particular needs ongoing study.  But the need for study does not absolve the NHL and the NHL Players' Association of the responsibility to take action now.

In a blog, former NHL skilled tough guy Jeremy Roenick blames hits involving elbows, shoulders, hits from behind near the boards, and jumping off the ice at the moment of impact as factors fueling the increase in concussions.  NHL Senior Vice President of Player Safety Brendan Shanahan has his work cut out for him.

There are suggestions that current and former NHL players consider litigation as a way of making the impact of concussions as damaging to the league and NHL teams as it is to players.  Elbow and shoulder pads can be softened immediately to reduce their effect on vulnerable players.  Innovations like the concussion collar conceived by Dr. Joseph Fisher could reduce the impact on the head.

All of the above could help set NHL players and the league on a safer course.

One voice heard across Canada this Saturday could galvanize action.  If this weekend, Don Cherry uses his Coach's Corner segment on Hockey Night in Canada as a bully pulpit to inspire the NHL and the Players' Association, it would be one voice too many too ignore.

Your move, Mr. Cherry.

16/12/2011 2235:  A previous version of this blog entry has been corrected.

]]> Park Your Frustration: Update tag:www.cbc.ca,2011:/whitecoat//349.176637 2011-12-15T21:03:57Z 2011-12-15T21:35:30Z Brian Goldman http://www.cbc.ca/cgi-bin/MT4/mt-cp.cgi?__mode=view&blog_id=349&id=909 On October 29, 2011, WCBA devoted an entire show to the trials and tribulations Canadians face with hospital parking.  On our blog, we posted a lengthy letter sent by Pamela Leeb to Dr. Robert Bell, CEO of University Health Network.  In it, she described receiving a $450 parking ticket when she parked her car across the street from Princess Margaret Hospital in Toronto, where she was undergoing cancer treatment.  Leeb received some good news.  Click below to read Ms. Leeb's letter and its impact.

]]> Kira Leeb sent us this email of a letter she helped her mother Pamela Leeb draft to Robert Bell, CEO of University Health Network:

"Dear Dr. Bell:  I was recently receiving my treatment in Princess Margaret Hospital and read your commitment to ensuring the hospital environment is disability-friendly.  Of course, I applaud this commitment and would like to bring to your attention a situation that would increase your ability to deliver on this commitment."

"I am an 83 year old woman who is now receiving regular treatment at PMH.  A few months ago I obtained a disability permit and am obviously still learning about its benefits.  As I find it difficult to travel via transit etc, I am now in the habit of driving to my treatments.  On this one day, I made the unfortunate mistake of parking directly across from the Murray Street entrance in one of the two spaces that I thought were designated for disability-permitted parking despite also saying "no standing".  I have enclosed a picture of the sign."

"To my surprise I received a $450 ticket!  There is no question this will be a stretch for me to pay.  However, given the lack of clear signage I have decided to fight the ticket in court.  The police have told me the court date could be 6 months to a year away.  In any event, when I questioned security personnel and others at PMH, they told me that others had also received such a ticket but they did not really understand the problem and could not explain it to me."

"On my own, I investigated further and found in the Driver's Manual the full meaning of the parking sign.  If you are truly committed to making your hospital environment disability-friendly, I am hoping that you will consider posting a VERY PROMINENT sign warning patients that these spaces are not parking zones - they are time limited "drop-off" zones for patients.  The parking sign itself does not even specify the time-limitation and even in the Driver's Manual it says "pick up and drop off only" with no specification of time limit.  As I mentioned, I plan to fit this ticket."

"My concern is that others who receive these tickets have no capacity to address these issues and frankly, nor should they have to from my perspective.  While I understand that this is a municipality issue, I am not confident that any action will be taken to clarify the signage any time soon.  Given your stated desire to ensure the environment of the hospital, I felt that my best option was to write to someone already committed to making a difference in patient experience."

"At a minimum, a clear sign outlining the parking issue related to the Murray Street entrance would be very much appreciated, both inside and outside of the entrance.  Any other action that you think might help warn your patients of the issue and minimize the extent to which patients are subjected to these fines would be very very welcome.  Please let me know if I can assist in any way to help you further deliver on your commitment to ensuring a disability-friendly hospital environment."

We just received this email from Pamela Leeb's daughter Kira:

"Hi Brian:  I'm at Princess Margaret Hospital with my mom and wanted to update you about her parking ticket issue."

"She did end up receiving a letter from the hospital but not from Dr Bell.  However the letter did say they were following up with the city to see about the parking sign.  Of course the letter didn't contain any sympathy and said there was nothing they could do for her re the ticket."

"But the mislabled, confusing sign has been changed!  In the month or two since your program aired, CMAJ published an editorial, and health policy collumnist Andre Picard followed up with an article in the Globe and Mail about parking issues, the city has responded!  Mom is feeling very happy that some action was taken."

"She is still saving to pay the four hundred and fifty dollar ticket if it comes to that.  No court date has yet been set.  But she says she almost doesn't mind paying now that something was done."

"Thank you for the platform your show provided.  I'm sure it was the catalyst more so than her letter. Sincerely, Kira."

Kira and Pamela, the congratulations go to the two of you for your persistence.  On our hospital parking show, a spokesperson for the consumer watchdog group Which? in the UK told how it embarrassed hospitals there into doing better.  

"Don't just complain and do nothing about it," Which? spokesperson Jennie Driscoll told WCBA back in October of this year. "Anybody having a problem, push back and tell them what you thought was wrong."

If you have your own 'push back' story about hospital parking, post to this blog or write to whitecoat@cbc.ca.

]]> Unfinished Business Mailbag tag:www.cbc.ca,2011:/whitecoat//349.176172 2011-12-14T15:10:32Z 2011-12-27T18:26:59Z Brian Goldman http://www.cbc.ca/cgi-bin/MT4/mt-cp.cgi?__mode=view&blog_id=349&id=909 Our show this week featured three stories of what we call 'Unfinished Business'.  Earlier this year, a BC hospital bet and lost big on one.  We asked the President of the hospital's charitable foundation what went wrong.  We had more from Generation Rx: our town hall last week examining the epidemic of  prescription drug abuse that's spreading across Canada.  And, we got reaction from Ontario's Minister of Health and Long Term Care to our debut episode this season that looked at the increasingly complex nursing jobs that personal support workers do at retirement homes in the Province of Ontario.  Click oin the link to sample your reaction to the show.

]]> Generation Rx, our town hall on the use and abuse of prescription pain relievers, continues to generate strong reaction from you.

Kay Stephenson-Wrack sent this email:  "One of the biggest problems with prescribing controlled substances like OxyContin is that so few doctors know how to help their patients quit.  "Addiction" and drug dependence become a self fulfilling promise.  I know!  After six hip replacements, two strokes, a knee replacement, and spinal stenosis I know how to do it!  Although methadone and fentanyl are their own misery to wean-off, OxyContin can be quite uneventful.  Encouragement helps, and directions like "just quit" do not!"

Glen Millis of Calgary writes:  "I wanted  to know or would like to hear a recovering addict face those who turned them on to drugs, and explain why it was a good thing to try drugs.  Perhaps it could be a talking point to young ones to ask friends who suggest drugs.  Will you be there for me whan I am 30 and homeless? Will you pay my bills if if I become unemployable?  I hear of students urging friends to try drugs because they are not wanting to do it alone.  Thanks for listening."

Sam Brown of Oshawa sent us this:  "I waited avidly for your Generation Rx show.  I listen to your show because usually you are willing to say things other people will not, and take things from all sides.  I was saddened because your show could have been a public service announcement for why we need the new governement narcotics watch program.  I have chronic, near-disabling migraines, along with another neurological condition.  Unfortunately, the meds I take for both of these interact, and also the doctors who treat both generally refuse to contact one another, resulting in uncoordinated care.  I get about twenty migraines a month, which would have rendered me unable to work by the age of twenty-three.  Thus, my doctor is attempting to manage them with narcotic meds.  I know this is not ideal given my age and their addictive potential.  I take the situation very seriously, watch my dosing, watch the number of days in a row I take the meds, etc. I have now been able to keep a steady job, and am I do not believe showing signs of addiction.  However, the attitudes of health care workers and the general public grow stronger towards the idea that people like me should not be on painkillers.  I feel at your show you did not have any strong advocacy for people who do have legitimate use for pain drugs, except in the case of "people dying of cancer".  In my case, either I am not receiving properly coordinated care by my doctors, or this is the only treatment available for me, I am not sure which."

We received this lengthy email from Roger Mitchell, a family doctor and GP anesthetist from Cranbrook, BC:  "I very much enjoy your well thought out and eloquent program.  I am writing as a colleague.  I am "an almost retired GP anaesthetist" I have worked most of my career in northern and western Canada and most recently south eastern BC. The problem I would like to address is the dirty little medical secret which is pandemic across all of Canada. I hope a program like yours might spur some action. The problems are centred around inadequate and non-timely pain intervention.  I have had the joy of reducing or eliminating an individual's  pain. This is one skill every MD should possess, but unfortunately the new wave of MD's are ingrained with the fears of patient "addiction" and or drug abuse and the ever present College on our backs. Hence these fears have made cowards of us all.   I have lied to get patients admitted overnight for observation following surgery when really all I wanted to provide was good analgesia. But there are no acute beds for this, and by bed blocking for analgesia, I interfere with the following day's major case which is a day admission for a big surgical procedure.  I have seen similar and equally horrible suffering endured by terminal patients, who are desperately under narcotized. Their MD's had no clue about how to safely administer the plethora of available options. Given you have so eloquently presented the perils of liberal narcotic dissemination, please consider reviewing the very real and much bigger issues of inadequate pain treatment. 

You may recall two years ago we did a show on the terrible affliction of chronic pain.  In it, we interviewed a woman who found relief from her pain in the form of an electrical stimulation device implanted in her spinal column. 

David Petepiece of Williamstown, Ontario wanted to tell us of a very different outcome.  "My neck was injured in a fall at work.  First the non invasive approaches like physio and drugs, then surgery to do a spinal fusion which only made things worse.  I was living on narcotics until I heard your show on chronic pain and the story of a woman who got great relief from a neuro stimulator.  My internist had never heard of one but googled it in her office.  Soon, I had a referral to a hospital based pain clinic, underwent two trial implants to see if it would work for me, psychological tests to see if I was crazy, finally, the full implant surgery took place and my journey into hell started.  For three months my surgeon and his associates failed to recognize I had developed an infection around the stimulator electrode which was pressing on my spinal cord. Gradually I had trouble walking, required so many narcotics I was hallucinating, lost feeling in my hands, was falling down outside in the cold and could have frozen to death but no one realized what was happening.  I went to a physiotherapist who did some tests, said something is very seriously wrong neurologically and faxed a letter to my surgeon.  I headed to the hospital.  Finally ,the surgeon realized I was infected and did emergency surgery to remove infected bone, tissue and the stimulator.  Now I am left with a scarred spinal cord, cannot walk properly, have many other issues due to spinal cord scarring and again need lots of narcotics to survive.  Please share this story so that others who rely on the information on your program know the down side to the 'good stories.'"

We also received several comments in response to my interview with Adrienne Bakker, President and CEO Royal Columbian Hospital Foundation.  The Foundation's B.C. Vacation Home Lottery sold just forty-four thousand tickets instead of the anticipated one hundred and twenty thousand -- for a three million dollar loss.

Margaret Young of Ottawa writes:  "In addition to confirming my decision of some time ago never to participate in this racket (only twenty percent return to the hospital!), Ms. Bakker said something that I reacted strongly to  She repeated a frequently-heard statement that "If you don't have your health you don't have anything."  What nonsense that is.  First there is the obvious issue of what is "health."  After all, most of us have something wrong with us at various times, and these health problems often compound as we age. I've just passed through 14 months of awful health.  Did I ever feel that I had nothing valuable in my life?  Not for a minute!  I'm a  senior and I see around me lots of people with hearing and sight losses, arthritis, and many other problems.  Do they mope around thinking that because they don't have their full health they have nothing?  Absolutely not. They are as active as possible and eager to wring as much joy from life as they can, no matter what the state of their bodies."

Jill Whitaker Portugal Cove-St.Philips in Newfoundland and Labrador writes:  "I've never been much of a fan of hospital lotteries; the phrase `water down the drain' crosses my mind.  It always seems much more sensible to me to send a donation equivalent to the price of the lottery ticket to the hospital.  After all, the likelihood of winning is pretty remote - and doing it my way, at least I get a tax receipt.  I'm also not funding a company that manages the lottery and keeps a large percentage of the ticket price so the hospital gets far more money.

Our interview with Deb Mathews, Ontario's Minister of Health and Long Term Care, generated comments on both sides of a divide.

Karin Sonne of Toronto writes:  "I used to work as a PSW, mostly doing home care and primarily palliative care and was asked to do many things I should not. I refused to do so, telling them to call the office to have someone qualified sent out.  I know some of my colleagues would go ahead anyways."

Ben Lehman of Peterborough, Ontario writes:  "When I heard your story recently on PSWs it made me wanna speak up about my girlfriend who is a psw in Peterborough and what she deals with.  She recently quit her job because of she is a gentle and caring person, and thats why she wanted to do it to help others.  Where she worked on a regular basis watched other PSWs abuse, neglect, and assault the residents, she was threatened if she said anything.  The union wouldn't help her.  The worst was that fellow psws formed a clique that she wasnt part of.  She cared about the people she served.  I think more needs to be done to regulate not only the psws but the people that run the courses."

Don Francis of Richmond writes:  "I just listened to your interview with "Jen" and the Hon. Deb Mathews.  The segment  was misleading and incomplete. It was incomplete in that it did not make any mention of the the new Retirement Home Act while praising the regulation and control in Long Term Care.  It was misleading when Dr. Goldman, with Jen as a prop made it sound like all retirement homes use only unregulated, untrained personnel to distributed medications.  This misrepresentation ignores the requirements of the new Retirement Home Act and the established standards as subscribed to by members of the Ontario Retirement Communities Association. I have owned and operated a retirement home for over twenty years.   Dr. Goldman should be better effort informed before he trashes a whole industry."

On the program, we said that unlike long-term care facilities, retirement homes exist in a regulatory grey zone.  But in Ontario, that is about to change. 

Mary Ferguson of the Retirement Homes Regulatory Authority based in Toronto writes: "Ontario is in the process of opening a regulator for retirement homes in 2012 so it would be a good opportunity to look at what is planned, how it will impact seniors, PSWs and the retirement homes sector.  Saturday's follow up session failed to speak with spokespeople for the homes - just PSW and Deb Matthews, whose terrrtory is nursing homes.  For a  balanced view of what Ontario is doing and how the province's deal with it differently, we would be happy to work with your producers to develop the information and connect you with some sources who are knowledgeable."

We look forward to speaking with the regulator some time in the new year.

]]> Rescue on Hospital Grounds tag:www.cbc.ca,2011:/whitecoat//349.175778 2011-12-13T14:16:44Z 2011-12-13T23:07:59Z Brian Goldman http://www.cbc.ca/cgi-bin/MT4/mt-cp.cgi?__mode=view&blog_id=349&id=909 If you collapse at home, you call an ambulance.  Surprisingly, if you collapse meters from the hospital's front door, you call an ambulance there too.  At many hospitals, it's customary for nurses and other hospital employees not to aid bystanders who collapse outside the hospital's sliding doors.  Several publicized incidents and a public outcry have made hospitals rethink that approach.

]]> On Dec. 2nd, a woman collapsed a hundred meters from the main entrance of the Chinook Regional Hospital in Lethbridge, Alberta.  A passerby ran into the hospital expecting to get medical assistance.  Instead, a receptionist called 911.

According to a man who witnessed the incident, the woman slumped to the curb of a hospital parking lot not far from the hospital entrance.  At the time, she was clutching a big bouquet of flowers and her purse. 

The witness attended the woman. When two other passersby arrived to render assistance, he went into the hospital looking for help.  First, he approached a hospital porter and then a receptionist.  The receptionist said she would summon help, and the man went back outside the hospital to check on the woman's condition, thinking hospital personnel would soon arrive with a stretcher. 

"I went into the hospital three times looking for help and assistance saying, 'We need to get the people from the emergency department to get a gurney out there and get her right now,' but they wouldn't do it. Instead they sent security guards to secure the area," witness Tony Stephan told the Lethbridge Herald.

It took roughly fifteen minutes for paramedics to arrive, put the woman on a stretcher and drive her to the emergency department - a short distance away on the hospital premises.  In the interim, no medical staff from the hospital rendered assistance.  Meanwhile, witnesses say the woman was turning blue.  A peace officer who attended the scene said the reason why she survived is that a witness knew how to do artificial respiration and started doing it before paramedics arrived.  The woman was admitted to the hospital's intensive care unit.

Vanessa Maclean, medical director for Alberta Health's South Zone, the health region that includes the hospital in Lethbridge, said there is no written policy stating that hospital employees are not supposed to haul patients who collapse outside the hospital to the ER.  However, Maclean said that in general, paramedics have been summoned to respond to patients who collapse outside the hospital.  

MacLean said officials are reviewing the incident and that they'll be happy to review their findings and how and whether they might do things differently in the future. 

Andrew Will, acting senior vice-president of CRH, told the Lethbridge Herald that the hospital is committed to improving the current practice.  He said immediate steps have been taken to ensure better communication and response, but the hospital plans an indepth look into the incident in order to implement a new policy for medical emergencies that happen outside of the building - one that spells out exactly who from the hospital does what in a similar situation.

I should point out that there's a big difference between patients who collapse inside the hospital and those who collapse out the hospital.  Hospitals feel a keener sense of responsibility for anyone who collapses inside the hospital.

If hospital personnel are to respond to emergencies outside the sliding doors, the policy has to be air tight.  First responders need to be designated; so too are the people tasked with bringing everything from a stretcher to a crash cart containing rescue equipment.  If a patient falls down a concrete stairwell, you better bring a board and a cervical spine collar in case you need to stabilize the spine.

See what I'm getting at?  It actually makes a lot of sense on some level to call paramedics.  ER personnel like me are good at triaging and treating critically ill patients once they get onto stretchers but not so good at is getting them onto stretchers safely.  Suppose the woman we've been talking about suffered an injury to her neck or another part of her spine.  You need to carry her while protecting the spine.  That's something paramedics do every day but something people like me might muck up because we do it once in a while. 

Then, there's the issue of who lifts the woman up onto the stretcher.  No hospital wants a nurse with a bad back doing a lift like that unless they want a major worker's compensation case on their hands.  Back injuries are among the biggest occupational hazards among nurses.  Once you're doing this, you probably need a dedicated team on standby.  That can be expensive to maintain.  And where do you draw the line?  Fifty meters from the ER?  One hundred?  Once you say one hundred meters, you're not going to say no to someone who collapses one hundred and ten meters from the hospital.

At the hospital where I work, we have a protocol spelling out who goes where to rescue patients who have collapsed inside the hospital.  For instance, if a patient suffers a cardiac arrest in the lobby of my hospital, an ER nurse is responsible for bringing the crash cart from our ER to the patient.  As the ER physician on duty, I run the arrest. 

I can remember answering the call to rescue would be patients who have collapsed in a taxi or other vehicle that has pulled up in the drive way beside the ER.  Someone grabs a wheelchair or a stretcher from inside the ER and we manage to bring them in.

It's clear to me that hospitals are prepared to take another look at how they handle this sort of situation. 

Doreen Wallace, an eighty-two year old woman, collapsed and broke her hip on Oct. 8 of this year as she left the Greater Niagara General Hospital in Ontario after visiting her dying husband.  At the time, staff believed only paramedics were allowed to bring patients like Wallace into the ER, and so they called 911 while she lay on the floor, face-down, in pain. A surgeon helped her into a wheelchair, but only after the ambulance finally arrived was Wallace taken to be treated.  Following the incident, the hospital conducted an investigation  and concluded that the quality of caring missed the mark and that some employees showed poor judgment.  In November, the hospital issued a statement spelling the steps it will take to make certain it's clear that when a patient collapses on the premises, staff should respond, not paramedics.

That these incidents are being well publicized makes it even more likely hospitals will be changing their approach in the future.

Just know that a policy like that will work fine until the day such a rescue is done poorly by hospital personnel.

]]> Unfinished Business Show tag:www.cbc.ca,2011:/whitecoat//349.175030 2011-12-09T13:55:06Z 2011-12-09T17:58:44Z As we prepare to close the books on season six later this month, we have some things we want to get to before memory fails us; stories we've done this season that deserve a proper response, a second look, or... Brian Goldman http://www.cbc.ca/cgi-bin/MT4/mt-cp.cgi?__mode=view&blog_id=349&id=909 As we prepare to close the books on season six later this month, we have some things we want to get to before memory fails us; stories we've done this season that deserve a proper response, a second look, or maybe even a good first look before time runs out.  

Our show this week serves up some unfinished business. These days, hospitals are always looking for ways to make some extra cash to offset that seemingly inevitable deficit. Think hospital lotteries are a license to print money?  Earlier this year, a BC hospital bet and lost big on one.  We ask the President of the hospital's charitable foundation what went wrong.  We have more from Generation Rx, our town hall examining the epidemic of  prescription drug abuse that's spreading across Canada.  And, we have reaction from Ontario's Minister of Health and Long Term Care to our season debut episode on personal support workers and the work they do at retirement homes in the Province of Ontario. 

To listen to the show download the podcast, or click on the play button below.  You can also tune in Saturday, December 10 at 11:30 am (noon NT) and again on Monday, December 12 at 11:30 am (3:30 pm NT) on CBC Radio One.

Unfinished Business Show (Pop-up)

In October, we devoted an entire show to the cost and inconvenience of hospital parking.  In some cases cash-strapped hospitals charge dearly to park to help balance the books.  But that's not the only scheme they use to raise some lucre.

]]> Many hospital foundations run lotteries.  Take the one run by SickKids Foundation. Last year, the lottery was a big player in helping SickKids Foundation raise nearly $58 million to help pay for everything from clinical research to a renovated ER.  This year's winners will be announced on December 19th.  If you want to buy a ticket and a chance to win a house, a luxury car, a dream vacation or maybe all three, you're too late! 

For hospital foundations, it sounds like a 'can't lose' proposition. But before they start doing their happy dance, they may want to hear this cautionary tale.  Earlier this year, the Royal Columbian Hospital Foundation in New Westminster ran the  B.C. Vacation Home Lottery.  But ticket sales ran drastically short.  Despite this last minute appeal by Adrienne Bakker, President and CEO of the Royal Columbian Hospital Foundation, the lottery sold just 44,000 tickets, a little over a third of the 120,000 expected sales.  Instead of a one million dollar net win, the Foundation sustained a three million dollar loss.

The foundation had run lotteries before (partnering with another hospital over a fourteen year period to raise fifty million dollars) and re-entered the market following a three-year hiatus.  Adrienne Bakker said the foundation did its homework a market research firm told the foundation that a return to the lottery business would be successful.  Bakker says the lottery's biggest problem was bad timing.

"Within about a week of launching, another hospital lottery launched," says Bakker. "That was not what our intelligence told us."

"I also think perhaps the economy was against us.  Even though we tested the market on a hundred dollar single ticket, I don't think that did us any favors with the economy."

As for a potential win of one million turned into a three million dollar loss?  Bakker says it means postponing capital projects that would have been paid for with lottery profits.

"What I can tell our donors is that none of the moneys that they've designated for specific projects or equipment or any other purpose at the hospital have gone to cover this lottery," says Bakker. 

"There's always a risk for every hospital," Bakker says.  She thinks it's easy for hospital foundations to get addicted to lottery dollars.

Will Royal Columbian give the lottery another shot any time soon?

"To tell you the truth, I really can't say at this point we would consider another one," concludes Bakker.  "I don't think it's something we should re-enter because it's not unique anymore.  I think we've become too dependent on these types of vehicles. We really need to be engaging directly with donors."

Our next bit of unfinished business has to do with personal support workers or PSWs, the subject of our full edition season debut episode back in September. 

Depending on where you live in Canada, you may also know them as home support workers or health care aids.  These unregulated health care workers are trained to provide personal care - from feeding to toileting, transferring people from a bed to a wheelchair, and other tasks like housekeeping.  Some PSWs work in hospitals or for home care agencies, but most work in nursing and retirement homes.  Nursing homes are strictly regulated - but many of you were surprised to learn unlike nursing homes, retirement homes operate in a regulatory grey zone.  And it's at these retirement homes where we found PSWs who say they're expected to perform duties they aren't qualified to do, like injecting insulin or administering narcotics.

You may remember hearing how Jen, a PSW who works in Ontario, was tasked with giving out prescription medications with which she was unfamiliar. 

"It's scary," Jen told WCBA back in September.  "Everyday, that you get a new resident, you have new pills to deal with, some that you have no idea what they are or what they do or if there's a possible side effect." 

Jen talked about sneaking a smart phone into the retirement residence where she worked so she could google unfamiliar medications to learn more about them.

We played some of Jen's interview to Deb Mathews, Ontario Minister of Health and Long Term Care.  Our show on PSWs aired during the recent provincial election in Ontario, and so we were unable to obtain reaction from the government to the show at that time.

"That is a very troubling clip you just played for me," Mathews told WCBA.  "No health care worker should ever be put into a position where they feel that they're compromising the health and safety of their patients or their own personal safety."

As for the operators of retirement homes that compel PSWs to perform nursing duties that they may not be qualified to perform?

"Well, I would say that they're taking a very big risk," she added.  "They really should not be supporting a practice that isn't safe."

But if retirement homes are taking a big risk, as the Minister puts it, it's a risk that exists in part because retirement homes aren't regulated nearly as strictly as long term care facilities.  And that won't be changing any time soon.  In terms of regulations, a retirement home is little different from your own home.   Unlike nursing homes, don't assume that the PSW looking after you or your loved one is qualified to perform nursing duties like injecting insulin or doling out medications.  It's the job of the home's director of clinical care -- typically a registered nurse or registered practical nurse -- to make sure duties like these are done properly.

For our final bit of unfinished business, we have a bonus segment from our town hall "Generation Rx: The Use and Abuse of Prescription Pain Medication". 

And mark your calendars: on Tuesday, December 27th at 5 pm (5:30 pm NT) we'll bring you a special one hour edition of the town hall, here on CBC Radio One.

]]> Generation Rx: Mailbag tag:www.cbc.ca,2011:/whitecoat//349.174829 2011-12-08T17:47:58Z 2011-12-09T16:28:07Z Brian Goldman http://www.cbc.ca/cgi-bin/MT4/mt-cp.cgi?__mode=view&blog_id=349&id=909 ]]> Heather Morgan writes:  "Thank you for your show on the use of prescription pain medication - Generation RX. It revised my anger once again that in this province (Ontario) prescribing pain medication is the only thing that doctors appear to have in their arsenal for treating pain. Instead of dealing with what is causing the pain, and dealing with the root cause, we throw pharmaceuticals at the problem and nothing more."

"I have a very direct experience with this. I had an induced labour with the birth of my son. I ended up with three epidurals and a C-section. The back pain that resulted was excruciating. My son is nearly three years old and I still suffer from terrible back pain. I asked my obgyn if there was some physiotherapy he could send me to. He said if I didn't have private insurance there was nothing that was covered. He wrote me - a new nursing mother - a prescription for oxycodone. I said "That's it? That is my only option?", "Unfortunately, yes", he replied. My back went out completely several times, to the point where I couldn't even stand up or walk, much less pick up by growing baby. My partner, who works freelance, could not afford to take any time off work, but was forced to since I was immobilized. I found an amazing chiropractor who used a number of different modalities to help me so that I could function again. But the cost was one hundred dollars per session. I needed many more sessions, but simply could not afford them."

"I wonder now if I will end up needing back surgery at some point.....clearly costing the health care system a great deal more money than had I been able to go through the full chiropractic treatment at the beginning of the problem. Or even if half of it was covered, I could have had twice as many treatments than I was able to afford.  Prescribing drugs to deal with certain types of pain, rather than addressing the source of the pain and trying to correct it, seems completely crazy to me, especially when there are vastly superior ways to deal with these varying types of pain, other than prescription opioids. Modalities that would SAVE the health care system money in the long term, and reduce the risk of abuse from prescription pain medication, thus saving society at large more money in the long run. If this growing problem doesn't demonstrate just how much we are under the thumb of the pharmaceutical industry, I don't know what does."

Tom Hickie of Fredericton, New Brunswick writes:  "Kudos for the program about OxyContin abuse this is a problem that has been rampant for a long time with little public attention. About six years ago I did my own research on the subject, I approached known drug users, prostitutes and others and asked them about their drug use. The common anwser was a bit of crack and dialaudid or oxycontin. One woman that I picked up hitch hiking was on her way to get some drugs from her son. One inmate in a provincial jail died from a drug overdose and five hundred pills were found concealed on his person. One company that produces this garbage was fined for hiding how addictive this drug is. The amount available on the street seems unusually high and I wonder if the companies are by passing the pharmacies. Another problem is that pharmaceutical sales people get paid to sell the drug, doctors get paid to prescribe it and druggists to dispense it and they are all protected by law, the sellers of cocaine would love such a perfect system. Our police chase marijuana and illegal smokes wth a passion while often ignoring this drug. Thank you for the show and please keep this topic public."

Deborah Cumming, National Priority Advisor with the Canadian Centre on Substance Abuse sent this:  "Thank you for showcasing this important public health crisis. As a follow up to your town hall on prescription drug misuse, I wanted to share with you that the Canadian Centre on Substance is hosting a national meeting with multsectoral stakeholders as the next step towards developing a national strategy on prescription drug misuse. This meeting will be held in Ottawa February 1-2, 2012."

Christine from Tatamagouche, Nova Scotia sent this:  "My ex-husband was prescribed m-eselon for moderate arthritis of the hip. This is an opioid that was covered by our insurance company. My ex-husband became addicted. He is a professional and for the powers that be was able to keep it hidden from his peers. My teenage son was not so lucky.  He stole the pills and snorted them. He became an addict. He was in rehab 6 times but to no avail. He was an above average student and athelete who dropped out of high school in the middle of his last year,and was the student body president and captain of the basketball team. He now lives with a daily struggle of addiction, with no high school degree.  My marriage failed.  I do not have a great relationship with my son.  My family was fractured by this.  It truly has been the biggest challenge of my life and does not get discussed as people do not wish or uncomfortable talking. Thankyou for listening."

Dr. Jon Archibald OF Peterborough, Ontario writes:  "Having been burned more times than I care to admit I have now changed my approach to pain patients: if they're not dying from cancer and I don't see physical trauma I won't prescribe any. That oversimplifies it but I no longer give patients the benefit of a doubt if there's no evidence of nociferous pathology on for example xrays.  There should be more specialists in pain management who will manage these patients ongoing, just as so many facets of general practice have become complex to the point of meriting their own expertise."

Louise Carbonneau Vermeiren of Port Stanley writes:  "I listened to your town hall broadcast and you captured my interests. You see, I am a chronic pain sufferer. It has affected my life and disrupted it, turning it upside down, backwards and forwards in so many ways, that at times, it would be easier to just give up and check out. No I am not depressed, not at all, this is just reality. And no, drugs are not talking through me, I no longer take opioids or anything else that can alter my moods, anymore."

Robert Rensing of Duncan, British Columbia sent us this email:  "I listened with great interest to your program about oxycodone abuse, and I would like to make two comments: Oxycodone containing medications are certainly not the only medications that can cause addiction and its terrible results. It is too bad that the discussion focused on those drugs alone to the exclusion of mention of other drugs that can cause similar addiction problems. It certainly would have been of help to us parents to become more aware of the dangers of a variety of other addiction-causing medications. There was much good talk about the need for young people, parents, and the medical professions, to become much more aware of those dangers. But what about the manufacturers who, through aggressive marketing by their representatives, contribute in a major way to the spread and availability of those medications. Do pharmaceutical companies not have ethical, moral, and social responsibilities to help educate doctors, not only in the appropriate use of these meds, but also to include specific education on the dangers of addiction, and practical ways to avoid those by prescribing appropriate strengths, dosages, and quantities of them? Has the time not come to educate the pharmaceutical companies about their responsibilities as well."

Donald G.McLeod of Mississippi Mils writes:  "The mother who lost her son to Oxycontin said a very wise think at the end of the show.  "Think twice before putting your hand into..."  Wise because hidden in her words acknowledges that kids do risky behaviour.  It is probably comes with evolution of we that tend to be either innately collaborative or innately selfish.   Neither is wrong, they probably are both good for the species depending on circumstances.   But her wise statement reminded me of an article on teenage brains I read about in Scientific America Mind edition.  Kids are too rational.  They think if the have sex they will definitely get a disease. But the benefit is still better.  They need to practice understanding risk.  Exaggerating risk is in fact bad.  It seems to allow them to exaggerate benefit as well.  I think maybe the show should talk about the teenage brain and the need to practice making risky type decisions."

Margaret Hawley of Calgary asked a practical yet important question:  "My interest is one of effectiveness of painkillers, particularly when they are used in palliative pain cases or following a major surgery. My husband had a major problem with hallucinations after taking morphine based drugs after open heart surgery.  Is there any alternative to morphine based pain killers for such cases? Have painkillers improved in effectiveness over the past 20 years?"

Margaret, opioid drugs like morphine are the most powerful pain relievers in the toolkit.  Lesser options for acute pain include anti-inflammatory drugs and acetaminophen (sold under the brand name Tylenol and other names).  The main issue with these other medicaions is that that have maximum doses above which have no added benefit and perhaps more side effects.  That said, opioid pain relievers are not effective for everyone. 

Regarding chronic pain, opioid pain relievers are usually prescribed in combination with antidepressants and anti-epilepsy drugs. 

Larissa Barr of Toronto asks:  "I was wondering if you have names of people who are willing to come in to schools and speak with students about this issue.  As a teacher I find it much more useful to have a diverse group of people speaking to students, rather  than the usual teacher talking to students.  Plus, I think many teachers may not talk to their students about drug use because they feel that they do not know enough, understand enough, or feel comfortable enough to talk to students about drug use...therefore names of people who would be comfortable talking and teaching kids about drug use/abuse would be helpful.   Thank you and great show."

Larissa, I would contact the local police as well as the Centre for Addiction and Mental Health in Toronto.

Not surprisingly, we also heard from critics of the show.

Karyn Collins of Ottawa took us to task for talking about kids sharing prescription drugs at parties.  She writes:  "I am almost incredulous that you are giving a platform to the urban myth of "Smarty Parties" and kids learning to take drugs from their obviously abysmal parents. I have no doubt that both have happened, but it totally undermines your credibility to broadcast these comments as though they were prevalent amongst teenagers today. The myth of Smarty Parties has been around since I was a teenager in the 1970s; everyone had heard of them but no one had been.  How many dead kids would you really have if this was common recreation?"

Karyn, our town hall included comments from Talia, a seventeen year old senior high school student who spoke with complete confidence about the buying and selling of prescription and illicit drugs where she goes to school.  Regarding the death rate, the overall number of prescription opioid-realted deaths, while small compared to the total prescribing of opioids, is on the rise, and is directly correlated to the increase in prescribing of opioids on provincial welfare entitlement programs.

Phil Rumble of London, Ontario thought the panel of experts was incomplete.  "I am normally a fan of your CBC radio program, however I must express my surprise. Your town hall program regarding opioid abuse did not feature a pharmacist on the panel!  Much of the discussion was regarding Oxycontin - a PRESCRIPTION only medication- and yet there was no pharmacist present. Health care will never become a "team" approach until all the "players" are present."

Marilyn Holt from Barrie, Ontario sent this:  "Two comments came to mind as i listened to your first town hall program, First, pharmacists should be part of this discussion. Although banning a drug such as oxycontin is not a sensible idea, surely there should be a limit on amounts prescribed. Despite the obvious inconvenience to patients, perhaps prescriptions of dangerous drugs should be limited in size, e.g. no more than twelve tablets at a time. What sort of doctor would prescribe one hundred tabs? What sort of pharmacist would fill that without checking. Second, there is some irony here for me. i'm a sixty-seven year old female and I've been plagued with severe headaches all my life. Mostly migraines, though not all. i take inderal on a regular basis but have never really found any of the migraine medications to work well. I often end up in emerg receiving injections of gravol/demerol.  My main problem has always been that my doctor wouldn't prescribe strong pain medication for me.  Very occasionally, she'd give me twenty Tylenol 3s, but never anything stronger. Honestly there have been occasions when I think I would have bought them on the street if someone offered them. That's definitely a 'tongue-in-cheek' comment, but refusal to allow pain meds can be ass dangerous as prescribing too much."

Ken Weatherill of Delta, British Columbia writes:  "I am a retired high school teacher who worked mainly with high risk youth.  I found the townhall broadcast to be very unbalanced.  Using words like addictive, epidemic, deadly, wide spread, out of control and ban  creates an atmosphere of  fear which the youth involved ignore and the majority cannot relate to.
Whenever a knowledgeable person came and spoke to a smaller group in a less formal setting with lots of opportunity for questions and comments, youth responded with attention and interest.  If adults create an atmosphere of judgement, youth will trust their friends. If adults create an atmosphere of trust and respect, youth will make good choices and call when needed rather than leaving things until they are really out of control. Without fail, after a small group discussion with and expert, there would always be one or two youth who would stay back and ask to speak with the presenter. Next time, bring a public health nurse, social worker, youth worker or counselor to a round table discussion with a grade nine class and record that interaction.  It will not only ensure a lively half hour but will also result in at least three more youth making better decisions at their next party."

Frances Abbott of Montreal writes: "I have done research on pain and analgesia for thirty-five years.  Overall, from family, friends and students, I have learned that undermedication  with strong analgesics is the rule, not the exception.  It took two years and the intervention of my medical brother to get my dad two OxyContin at bedtime for neuropathic pain in the feet.  Both my brother and I explained the objective of treatment to him many times - to improve function - and he finally got it, and is able to medicate for function."

"Overall, my impression is that most physicians knowledge of pain control could be written on the back of a matchbook.  I agree that the very concentrated slow release formulations are dangerous.  My understanding is that they should never be prescribed for conditions associated with pain that resolves in the short term.  In drug education, the message usually does not say enough about the pharmacology of the drugs.  From the police officer on your panel and others I have met, their focus is on trying  to scare teenagers.  They, and others who make their living off of drug control and research, try to magnify the problem.  There are certainly hundreds of people who do not receive sufficient opioid analgesics to permit function for every person taking illegal OxyContin."

And finally, some you thought the town hall completely missed the boat on explaining things from the point of view of someone with an addiction disorder.

Rick from Burlington, Ontario sent this email:  "I was intrigued that in your townhall you didn't include one addict as an expert on addiction. The people that where one the program have many valid points but really don't seem to understand the psyche of the people who become addicts. without that understanding the problem will never go away. Addiction is both physical and mental in nature. you can help someone withdraw from the physical effects of drugs but without that understanding of the mental, emotional nature of addiction, the addict will not be cured and will probably go back. I've been clean from alcohol and crack for twenty three years and understand our desire of a quick clean fix for the problem but it just isn't that easy and a few of the answers I heard I can guarantee would drive an addict further underground."

John from Ladysmith, BC writes:  "I'm a long time fan of White Coat, Black Art and will remain so as it's one of the best looks at medicine in Canada today that I know of.  It's not because of that that I'm appalled at the broadcast this past Saturday.  When I first entered recovery in 1983 one of the things I learned was that doctors got something like two hours of classes on addiction during their training.  From  both you, Doctor Goldman, and Dr. Andrea Furlan,who set the prescription guidelines, at least in Ontario, it doesn't sound that the situation has improved one bit.   None of the panellists touched on the complex dynamics of addiction, why people use, what the risk factors are of addiction and why people continue to use even though they KNOW it's wrong.  From Dr. Furlan's description of opiate withdrawal she may be an expert in pain management but she's not on issues like withdrawal because she horribly overstated both the length and severity of opiate withdrawal."

"I'm equally appalled at the parents of these kids as they don't seem to know to lock certain medications away from anyone it's not prescribed for, something I thought everyone knew and something routinely done by parents when I was a kid.  And no, things were NOT wonderful back then.  Nor was one of the simplest ways to avoid the first step of addiction (trying the drug) mentioned by any panels which is lock the darned stuff away.when the person it's prescribed for and, that, should any be left over after the course of treatment that the meds be returned to the pharmacist for disposal.  We aren't talking ASA tablets here! [smiles]. Addiction doesn't just happen.  There's a reason one of the slang words for dependency is wired.  Some receptors in the brain literally get to the point where they need the drug to function which is what we see in the physical manifestation called  withdrawal, as I'm sure you know.  The brain has literally rewired itself and withdrawal is symptomatic of, one could say, the brain madly rewiring itself to function without the drug of choice. The police officer, God bless him, had the same answers to the problem as they did 40 years ago when I graduated from high school and got my last "lesson" in how horrid drugs were."

"The single improvement there is his evident empathy for and concern for the addict other than the "write them off" attitude of police back then. Addiction is complex, as I mentioned.  It runs in families, if one goes by large numbers of twin studies done over the past two or three generations whether by a child being brought up in a highly dysfunctional family atmosphere or is an inherited thing.  I don't know, I'm not sure anyone does.  Though it seems that if a child is brought up in a family with one addict (and that includes alcoholism) they have something like a 40% chance of developing an addiction themselves when compared to the general population and where both biological parents are it increases to nearly 70%."

"Don't go overboard about the effects of withdrawal. Compared to other drugs it is very short and doesn't have all that much discomfort.  The patient needs to eat and drink but it's all over in less than a week, often less than 3 days.  Compare this to alcohol withdrawal which takes up to a week, has symptoms like the DTs and can be deadly unless medically supervised.  Or benzodiazapams which can take weeks or months. But opiate withdrawal is minor."

"I can say, without a word of a lie, that addicts and alcoholics are the strongest and, often, the most moral people I've ever encountered and their lives as thieves, prostitutes and liars had damaged them as much or more than the addiction itself.  There's a very good reason that when we reach the Step on making amends that, as a sponsor, I tell my sponsee that the first person on that list needs to be themselves.  After that making amends to others is more genuine and more likely to me met positively. By the way, people were breaking into drug stores to steal T3s long before more powerful opiate drugs came along.Thank you for a wonderful, informative and fascinating program."

]]> Your Next MD Will Be a Woman tag:www.cbc.ca,2011:/whitecoat//349.174199 2011-12-06T13:51:49Z 2011-12-06T14:33:51Z Brian Goldman http://www.cbc.ca/cgi-bin/MT4/mt-cp.cgi?__mode=view&blog_id=349&id=909 editorial in the Student British Medical Journal asked whether it's a trend that's gone too far.  Not me.  I think we need to get past the obvious gender politics and ask how this phenomenal trend will shape health care in the years to come.]]> According to the editorial, the picture in the UK is unambiguous.  Data from medical schools in the U.K .show that over the past four decades the number of men entering medicine has doubled, whereas the number of women has increased ten-fold. 

The increase means women are in the majority across UK medical schools, with acceptance rates of fifty-six per cent women in 2010.  In general practice, women doctors are set to outnumber their male counterparts in the next four years. The trend affects specialists as well.  At the moment, twenty-eight percent of specialists in the UK are female. When the 2007 female cohort of specialty trainees enter practice, female specialists will total fifty-five per cent of the workforce. 

As the editorial states, the "feminisation of the medical profession" in the UK is a fact.  It's been described as a" tsunami of women coming through." 

We're seeing similar trends in Canada.  During the past decade, women have been drawn to doctoring in ever higher numbers.  Medical education statistics collected by the Association of Faculties of Medicine in Canada show that women make up nearly sixty per cent of students admitted.  The imbalance is greatest in Quebec, where women make up more than seventy per cent of students at francophone medical schools.  In 2002 at McMaster University's medical school, women made up nearly seventy-eight per cent of students entering freshman year.

Experts in education and sociology have long been interested in what's behind the numbers.  Part of the answer has to do with achievement.  In secondary school, these days, girls do better than boys.  Higher marks mean a higher grade point average (GPA).  Med schools that rely on GPA as the factor driving who gets in and who doesn't are accepting more women than men. 

Another factor is the desirability of medicine as a profession.  Some believe that medicine is becoming a less attractive career option for men because it's perceived as less prestigious than it was previously.  They feel that doctors aren't held in as high esteem as before.  Some point to factors such as decreased autonomy and increased regulation and control as reasons why men are less interested in becoming physicians.   

The people who run medical schools are very concerned about the lack of men entering medical school.  For the past few years, medical and other professional faculties have taken steps to address the gender imbalance.  The kinds of questions that were once asked about what's holding women back are now being asked about men.

As massive a shift as this carries some important implications that health care planners must take into account.  An overwhelming preponderance of women could lead to a shortfall of doctors.  Research shows that female physicians are more inclined than men to work part-time.  Moreover, they're more likely than men to take several years out of practice to raise a family.  Until recently, they also avoided certain specialties, such as surgery, in order to balance the demands of work with home life. 

We don't know whether this tendency to work less than men will be an enduring trend.  Surveys by the Canadian Institute for Health Information have concluded that both young women and men MDs want to work fewer hours and have more work-life balance. 

To me, there are far more important implications to consider.  The editorial in Student BMJ compares the rise of women in medicine to something known in the marketplace as a disruptive innovation.  That refers to a product that comes into the business market targeting an area underprovided for, at a lower profit margin.  Initially, the product exists as the margins of the marketplace.  Sales take off slowly.  In time, the product becomes more well known.  In time, it dominates the market. 

If that's what's going on with women in medicine, then who knows what health care will look like in ten or twenty years?  The thing is, we're looking at the potential for change through the lens of a male-dominated health care system.  Change the leadership to female, and things might change drastically.

Take health care human resources, for example.  Compared to men, I think women are less hierarchical and more comfortable working in teams without an obvious team leader. 

Today, I'd be very suprised to hear a president of a male-dominated provincial medical association call for more nurse practitioners and fewer doctors.  But in a system dominated by women physicians, I could easily envision the president asking a provincial government to do just that.  They might reason that more nurse practitioners would permit women physicians to achieve better work-life balance. 

If women become dominant players in the operating room, that might be another place where things change drastically.  I'm not suggesting that surgical techniques will change.  What I am suggesting is that the way work is done in the OR and who does what might be transformed. 

Many studies show women dominate in specialties such as general practice, paediatrics, and palliative care.  So far, that's not the case in cardiology, gastroenterology or surgery.  But if they do, then how they deliver care in those areas will change medical practice in ways that aren't clear now.

Just another reason why the next few years in health care will be very interesting.

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