Medical Post Articles

Raise your hand if you spent a little extra time watching the news last week. Hold it high if your sense of shock was matched only by your disbelief, and that sense of incredulousness crept into your professional life where you found yourself checking Breaking News between patients.

Yeah, me too.

What happened to our friends south of the border will take time to fully analyze, but one thing is painfully clear; the attack on government buildings was an assault on the foundation of their democracy. Whether you blame Trump, the mob mindset, or other nefarious entities is not my point. Rather, I’m concerned how our taken-for-granted freedoms and our way of life suddenly appeared vulnerable. Which is something many of us would never have contemplated in our lifetimes.

Why should we? After all, the cold war ended years ago. We won. The threat of nuclear annihilation has receded. The possibility of an invasion (i.e. Red Dawn) is not even on the radar.

But, as smarter people than I have pointed out, democracy is a fragile thing. Or, as the playwright Sam Shepard once said, ‘You have to take care of democracy. As soon as you stop being responsible to it and allow it to turn into scare tactics, it's no longer democracy, is it? It's something else. It may be an inch away from totalitarianism.’

Democracy needs regular maintenance. Like a car with scheduled oil changes, fresh tires and a tune up. Democracy needs careful vigilance, the rule of law, and unwavering public support. How else can it withstand constant erosion by the twin forces of neglect and autocracy.

It’s been said that the most effective form of government is an enlightened despot. Sorry, but I’m not willing to take that chance.

The 2020 report of the Varieties of Democracy Institute found that the global share of democracies declined from 54% in 2009 to 49% in 2019, and that a greater share of the global population lived in autocratizing countries (6% in 2009, 34% in 2019) (1). Just look at the trends in Eastern Europe to see how quickly this process can evolve.

We are constantly educating our patients, telling them how important it is to get their vaccinations–that if we let our guard down, polio, pertussis, and all those potentially deadly diseases can return with a vengeance.

Democracy is no different. Just because we’ve lived under its protected roof for generations, shielded from despots, political thugs and middle-of-the-night visits from secret police, doesn’t mean it’s going to stay that way. Rivals and enemies have not taken their ball and gone home. They’re still waiting in the wings. Anyone watching what’s happening in Hong Kong right now? How much time do you think those teenage and twenty-something activists are going to spend in prison or ‘re-education’ facilities? All because they exercised their freedom of speech.

For a brief moment last week, we saw something that should scare us. An event that pulled back the curtain on an uglier way of life, where hard-fought liberties are discarded, and the rule of law has as much influence as a speeding ticket.

So, take a moment to reflect on what we have. Vote when you get the chance. And give democracy one big hug.

Can we take a moment here? To savor the last month?

Unless you’ve been living under a rock, 2020 has been an annus horiribilis. Under increasingly strict guidance, many of us were advised to ‘shelter in place’––not that we had an option to travel anyway. We watched the pandemic creep across the globe, watched the mortality and morbidity numbers rise, watched the trusted voice of science and reason become weaponized for political ends, and did our best to minimize risk while caring for our patients.

Several months into the shutdown, my son forwarded something he saw on the internet that summed the year up perfectly. Loosely translated it said, to whoever started playing Jumanji in January, please finish your turn.

Despite all the negativity, all the dysthymia and disappointment, I believe there is a silver lining hidden in 2020 that we haven’t fully appreciated. Two silver linings actually.

The first doesn’t need me to shine the light on it. I’m talking about the successful development of a vaccine. In record time. I’m sure there are experts reading this article that could speak to the issue better than I (read: ID and Public Health gurus) but I believe, looking back years from now, people will speak about the vaccine with a sense of awe, and in the same breath as the creation of the internet or the end of the Cold War, or any of the seminal moments of the past fifty years. A vaccine in ten months? Really? We haven’t even hit the first anniversary of the beginning of the pandemic and we’ve formulated a potential cure. Everyone involved in the process deserves a pat on the back. (I’m talking scientists and techs, not the politicians). Congratulations ladies and gentlemen, you’ve accomplished the equivalent of stepping on the moon.

The second silver lining can be found south of the ‘49th parallel’. Some of you may have noticed an election several weeks back. Yes, I’m referring to that confusing partisan exercise that underscores their democracy every four years. True, at times it can be difficult to sift through all the rancour, all the nationalism and self-interest, to find those precious nuggets.

But did you notice that over 150 million people voted––the most in fifty years––and many thousands of them waited for hours in long lines to exercise their democratic right? That’s not a sign of the usual apathy, that’s a symbol of passion. No matter their motivation, they actually stuck it out. In the midst of a pandemic.

Practising social distancing, many voted by mail. Many more pounded on doors and dialed phones numbers––on both sides. It was somewhat satisfying to see that the major networks, endowed with their talking heads, couldn’t exert enough pressure to convince voters their interpretation of reality was the correct one.

And in the end, everything reverted to the mean. To the center.

This is politics, of course, and many will describe the results in concert with their own beliefs, depending where they sit on the political spectrum. However, the voters rejected vindictive nationalism as well as left-wing activism. They reverted to the norm.

And they did this without massive riots or major civil disruption. Without widespread voter fraud. In the weeks that followed, state officials––Republican and Democratic––followed the will of the people and verified the results.

No judge—Democratic or Republication appointee –allowed flimsy court challenges to upset two centuries of established law.

I know the final count in the Senate is not complete, but the most likely result is a divided Washington where both parties will have to work together and––dare I say––compromise.

Welcome to the beginning of the end of 2020.

Milly celebrated her 90th birthday last Saturday. (all names and addresses have been changed) On Monday she called the office complaining of excessive fatigue and feeling depressed. Since Covid had her nervous about stepping outside, I promised to drop by on the weekend and check on her. She had a long history of anemia (diet related) for which she occasionally needed a transfusion, and hypothyroidism.

Her house sat on the same street as my old rugby pitch so I knew the area well. Plus, I had been there many times in the past to treat her husband’s cardiomyopathy.

I knocked on the door. No answer.

Opening the door, I called, “Milly?” Still nothing.

I walked into the tiny living room and there she was curled up on the 1950’s couch with her favorite blanket. All eighty-five pounds of her.

The homecare worker had found an equally comfortable position in the adjacent chair and was snoring to beat the band.

“Hello, Milly,” I said a little louder.

Milly’s eyes slowly opened and, upon seeing me in the doorway, waved me in. Her homemaker yawned and stretched before reaching for her Tim’s coffee.

“Hello, Doctor,” Milly said. “Would you like some tea?”

#

COVID has certainly changed the way I practice. Virtual Medicine, PPE’s, Screening Questions, Plexiglass Barriers. And house calls.

The viral threat has many of my patients running scared---some have barely left their homes since the pandemic began. These include the elderly, the immunocompromised and those with comorbidities.

I try and handle as much as I can over the phone but, by and large, they’re sick people and it’s hard to diagnose CHF and COPD virtually. So, they’ve been integrated into my new pandemic routine—the one that begins every Saturday morning. After finishing hospital rounds and tidying up the nursing home, I load up my venerable medical bag (circa 1980’s) and head out on the road.

#

I sat down beside Milly and we made small talk for a few minutes. I told her the last blood tests were normal, and then I gently moved the conversation around to Frank, her husband who I had to put in a nursing home six months ago (dementia). That’s when the tears started. Stuck in the nursing home, Frank had missed Milly’s birthday, for the first time in their sixty-eight years of marriage. I reassured Milly that Frank was doing fine. Plus, I’d arranged for her to visit him on Monday. The rules had been loosened and they could actually meet in the same room, rather than just wave at each other through a window.

We talked a little more and I gave her a flu shot. By the time I left, she had her smile back.

#

Several of my colleagues who I spoke with are also doing more home visits. The new normal reminded me of the stories I heard when I first started practice, of how Family Doctors (or, as they were more commonly called back then, General Practitioners) worked in the fifties and sixties. They did everything in the patient’s home including deliveries, palliative care, and all kinds of procedures. If they couldn’t fix the problem, they bundled the patient up and drove them to the ER, where they continued their work as there were no staffed ER departments in the city.

#

The next two patients lived uptown. Marione, a 55-year-old, initially presented in my office a year ago with a growth in the back of her throat which turned out to be malignant. (Her thirty years of smoking might have been a factor.) She went through the gamut of treatment, including a partial mandible resection and bone graft. Now, she was losing weight and had taken on that thin, shallow look. We both knew where this was going. I talked to her about nutritional supplements, but then realized she really wanted to discuss her boys and their problems. Since they’re my patients as well, I promised to talk to them. I asked about her pain and she told me she’d been using more PRN’s. I counted the pills in the bottle, worked out a new dose of MS Contin and told her I’d come back next week to see how it helped.

Cyril and Kay, 94 and 92 years old respectively, always watch for me to pull up before putting out some cookies and muffins. I discharged Kay from hospital last week after she collapsed on the floor and Cyril couldn’t lift her. In the ER, she was diagnosed with pneumonia. On day three, she felt better and threatened to sign herself out if I didn’t send her home. (She can be quite spunky at times). During the house call, I checked her chest and reminded her to finish her antibiotics.

Two months after completing his radiotherapy for esophageal cancer, Cyril looked remarkably well. I remembered the house call, when Kay was complaining of abdominal pain, he mentioned that he had difficulty swallowing. He also had a fifteen-pound weight loss. I called a GI colleague who was kind enough to see him on short notice. Cyril’s back eating and he’s gained eight pounds.

Both of them are tittering on the edge. Problem is, when one goes, the other will be forced into long-term care, and both would rather die than leave their home.

I called their son and gave him an update before I left.

#

I often wonder, what did doctors do back in the day when they ran into similar problems? I have the luxury of calling GI for Cyril, and ENT for Marione. What did physicians do without backup? What kinds of expectations did patients have?

#

My last house call of the day was outside the city. Upper Quintin Road. I think Upper in this case is synonymous with tire-eating potholes.

As we used to say in Medical School, Agnes is an example of a patient with a positive functional inquiry. It doesn’t matter the question or the system as the answer is invariably yes.

I sat down and reviewed the usual complaints with her and several of her children before moving on to the reason I came; her daughter’s phone call about Agnes’s swollen ankles and increasing SOB. A quick examination revealed worsening CHF. I gave her an extra dose of Lasix and call the pharmacy to change her daily regime. She thanked me but then got to the main reason she wanted me to visit her today: her blocked ear. I checked and sure enough, it was full of wax. Luckily, I had a syringe and basin. I borrowed a towel and, a couple of water injections later, Agnes delivered something Shriek would have been proud of. Agnes proclaimed she could hear again.

I gave her a flu shot and started packing up when one of the daughters asked, “Doc, you wouldn’t happen to have an extra one of those?”

I smiled and withdrew a flu vial and more needles from my bag. This wasn’t my first rodeo. Agnes has five adult children living in her house.

“It’ll cost a cookie each,” I said. As if I didn’t know I’d be carrying a full bin of treats on my way out anyway. But that only happened after I looked at Victor’s new mole, reordered Sally’s cholesterol medication, and treated Wilbur’s arthritic knee. I had a vision of The Walton’s in my head as I walked out the door.

#

My best guess is that I’ll be engaged in this pandemic routine until the vaccine arrives like a knight on a white stallion. Only then will these patients feel safe to come back to the office. Until then, I’ll have to survive on tea and cookies.

Missed appointments are one of those aggravations that we’re all forced to deal with, an annoyance that can ambush us when we least expect it. After dealing with them for years, I’d say they probably rank somewhere between ‘insurance forms’ and ‘a sick secretary’ on the ‘I’d rather be in Bermuda’ scale.

On one hand, a no-show isn’t so bad. One less patient makes my day a little less crowded, a little less onerous. Besides, it’s not like they went out of their way to irritate me, like the last driver who cut me off. Rather it’s like a sin of omission, on the severity scale, similar to skipping your mother-in-law’s third wedding. And who can blame you for that?

On the other hand, you can’t ignore the subtle jab that takes aim at the relationship you thought you had with the patient. You ask yourself, Why would they miss an appointment?

I pull the chart on each patient that skips because I want to ensure it’s not something important that’s going to be missed––like a cancer diagnosis or an abnormal pap. Oftentimes, I’ve asked them to return to (insert reason here—check blood pressure, reassess sugars, replace cast). Obviously, my request has been superseded by something more important in their life. I wonder if their priorities would change if I offered free coffee? Or paid them? How much would it take to tip the scale.

Then comes the hard decision, what to do? Do I track them down and get them to rebook, giving them a chance to skip out again? (visions of Lucy jerking the football away from Charlie Brown). Or, do I say ‘Well, he’s going to have to survive with that diastolic over 150’, or ‘he’ll call when the skin around the stitches turns black.’

But I digress.

It’s funny how work-ins always show. Patients who call in a panic and are squeezed in on the same day. No problem. And the ones you tell to come back in a week to check their pneumonia or unstable angina, they have a pretty high attendance record, too. Which makes me think; maybe rebooking patients is like the second rule of thermodynamics. The further away you get them to rebook, the less important it seems. More disorder, less compliance. I wonder if Stephen Hawking had a formula for that.

I feel bad for those patients who would have parachuted into an open appointment in a heartbeat, if someone had bothered to let us know they weren’t coming. My cynical side reminds me that anyone holding an unlimited insurance card (Medicare) can pick and choose who they see and when. There’s always an after-hours clinic or an ER open, much to the chagrin of the doctors working the late shift.

But just like everything else in medicine, there are exceptions to every rule and missed appointments are no different. I’ve discovered a cohort of patients who present with a mental health crisis--panic attacks, PTSD, depression—and require hours of counselling. Anyone who deals with these patients knows how difficult it is to peel back the layers and find the problem, rewire their coping skills, and infect them with a sense of optimism. Changing strategies to get their job, their marriage, their life back on track. After months of counselling, you start to see improvement . . . and then it happens. They miss an appointment.

Just another no-show? Not this time. I found this patient group to be different. In this case, the no-show is a cure in disguise.

And I can live with that one.

My first patient of the New Year, John, limped into the office in his usual sweat-stained gray hoodie and track pants.

“Doc, I got it all planned.”

“What’s that, John?”

“Weight loss. I’m really going to do it this time.”

I kept my poker face firmly in place. John stood five and a half feet and weighed over three hundred pounds. He had tried every diet on the planet. Of the last three nutritional appointments I set up, he missed two.

“What’s your recipe for success this time?” I asked, mildly curious.

“Exercise,” he announced proudly. “I’m going to leave the house every morning and walk all day.”

“All day?” I asked dubiously. John needed a second wind just to tie his shoes.

“Yep, it has the added advantage of keeping me away from the fridge.”

“Two fridges,” I corrected. He bought the second one at a garage sale last fall.

He smiled sheepishly, like a child caught in a lie. “The second one is just for my beer.”

I nodded, like he had won the argument. “Is there anything I can do to help?” Education, cajoling, and begging hadn’t worked in the past.

“That’s why I’m here, Doc. I need a note.”

“Oh?” My spidey sense always activated when I heard those words. “What kind of note?”

“A note for work,” he said, flashing me a wide smile. “If I’m walking all day I can’t work. I need to go on disability.”

He saw my incredulous look.

“It’s just to get started, Doc. Say six months or so.”

I sighed. Nine o’clock and I already needed a drink.

#

“I’m serious, Doc. This time I’m going to kick the habit. No more cigarettes.”

Taking a sip of coffee was just a ploy to buy a few seconds. Ray-Anne’s nicotine stains could be mistaken for nail polish. She weighed ninety pounds soaking wet and vibrated like an addict in need of a fix–which essentially, she was.

“We’ve tried Champix twice already,” I reminded her. And before that Zyban and several patches. “You always missed your follow-up appointment.”

Ray-Anne leaned over my desk, sucking expresso through a straw. “Sorry about that, I was busy. But this time, it’s foolproof. I already did a test run.”

I groaned inwardly, dreading what was coming.

She smiled. “I had some leftover pills and took three.”

“You did what?”

“Yeah, and when they wore off, I slapped on some patches.”

I took a breath. “How many patches.”

“Two or three, depending on the time of day. And if was feeling a bit antsy, I chewed some Nicorette gum.”

Only then did I notice her blood pressure on the chart. It was going to be a long day.

#

“I’m going to make some big changes this year, Doc.”

“How’s that, Russell?” I asked. Russell was the fittest fifty-year-old in my practice. Since I diagnosed him with diabetes last year, he lost forty pounds, joined a gym and changed his diet.

“I want to get off all those pills,” he said.

“Ah.” I glanced at the chart to confirm what I already knew. “You’re only on two pills.” One for diabetes, one for cholesterol. “With all the positive changes you’ve made, I’m not sure what else you can do.”

“Two pills is two too many,” he said. “I read on Google about these new medicines.”

“What medicines?”

“Lavender and CPD. Not only will they cure my diabetes and cholesterol, they’ll help my hair grow back and give me more energy in the, you know, personal department. Could you write me a prescription?”

I felt a headache coming on.

#

“You actually got a bike?” I couldn’t keep the surprise out of my voice. “I didn’t know you liked to ride.” Edna was seventy going on ninety. I made housecalls on her because she too frail to get out. The most exertional thing I ever saw her do was knit.

“Oh.” She waved a dismissive hand. “It’s not a real bike. It’s the kind you plug in.”

A light went on. “A stationary bike. What do you need that for?”

She took a sip of tea. “Well, my son gave me this one because he received two of them at Christmas, and he says they’re the best thing to hang your laundry on.”

#

Mary had dark circles under her eyes and always presented with her major complaint being fatigue. Long hours at work and four kids may have had something to do with it.

“You’re burning the candle at both ends,” I said. “Remember, we discussed making some changes in the new year. Like stop with the procrastination and get a better sleep routine?”

She stopped texting long enough to give me a look. “Alright doc, I’ll set up a routine. But can I put off the procrastination until next visit?”

It’s an easy thing to miss, especially when you’re scrambling to deal with a full waiting room or finish that last consult. The days are hectic and we’re always running behind, which makes a subtle nuance like this easily overlooked. And yet, it’s a reminder of the kindness of the human spirit. I’m referring to the simple ‘thank-you’, of course. It’s the parting comment the patient utters when our visit is over--when I have my hand on the doorknob, when my brain is already rushing ahead to deal with the next set of problems or the next patient. In that moment, it’s an easy thing to gloss over.

Too often, it hangs in the air and grows stale as we both move on to our next challenge.

I got thinking the other day; how many ‘thank-you’s’ have been murmured within the confines of my examination rooms? For that matter, how many hand-shakes and how many teary-eyed hugs. Thirty years of small offers of gratitude--for trying to help.

But it’s more than that. The expression lives in the trinkets and gifts that appear at Christmas or after a medical crisis. The bottles of home-made wine, jams, cookies and cakes. Fudge and pie. All to send a message: you are appreciated. I’ve got shelves of porcelain reindeer, a bird clock, hockey pucks signed by retired NHL players, and wooden carvings from Brazil my wife refuses to take home. None of it could be auctioned at Sotheby’s, but that makes it even more valuable, like your six-year-old’s drawing of daddy and mommy. I dare you to throw that out.

And then there’s hunting season. In the last month, I’ve sampled deer burgers, moose sausages and beer meat. Those of you practicing near a coast probably know a thing or two about a lobster feed, or how big scallops can be.

But at their core, they are still expressions of gratitude––thank-you’s wrapped in a pretty or an edible coat. I remember several times trying to refuse, saying I didn’t require that bottle of bubbly or that motorcycle made out of lego parts. To which the patients took offense, and refused my refusal. They had an opportunity to go beyond a handshake and, dammit, they were going to do it. I felt dutifully chastised. But it was still a thank-you—for helping out, for being there, for going the extra mile.

What’s the bottom line? Simple. Savor those moments. Reach out, make eye contact and seize the gift hovering in the air before it goes stale. A simple thank-you means a lot. We’re lucky to have that bond with our patients.

Diary of the last Family Physician in Canada (with apologizes to anyone who keeps a real diary)

January 2019

Dear Diary,

Went to work today and was pleasantly surprised by my hypertensive patients bringing in their blood pressure readings. Usually, it’s like pulling teeth to get them to keep track of their numbers, but now their Fitbits do it automatically. Even better, my diabetics have all switched to the new Freestyle monitors and drop off a printout of their weekly sugars. It’s crazy, all the guess work we employed over the past thirty years has gone out the window. Now, for the first time, I have accurate numbers. Isn’t medicine great?

September 2019

Dear Diary,

Weird day. A diabetic patient called my secretary asking for my cell number. Apparently, he’s been getting low sugars at night and wants his sensor to send me up-to-the-minute notifications when they happen. I didn’t know that was a thing. My secretary explained that it wasn’t possible with my flip-phone.

Another patient requested a CT of his chest after he downloaded an auscultation app that told him he had a right-sided mass. My nurse asked if he had an app to biopsy it. He wasn’t happy.

December 2019

Dear Diary,

Patient complained he couldn’t book his appointment online. I smiled pleasantly and said we weren’t equipped to do that sort of thing. He gave me a quizzical look before informing my WIFI must be down in the waiting room because he couldn’t get a signal. I asked him if that was the same as a payphone. We used to have those in the waiting room.

March 2020

Dear Diary,

Remember when the pharmacies started handing out sheets of side effects with their pills? Well, this is worse. There’s a new drug app called Drugs-R-Us and it’s driving me crazy. The patient feeds in his medications and if there’s a potential side effect or interaction, the phone screen turns red and a skull and cross-bones starts flashing in rhythm to Drake’s latest single. Unfortunately, the app doesn’t discriminate between frequent and rare reactions. Hey, don’t take Biaxin for that pneumonia, it might cause hallucinations and lung embolisms. And Plavix for that new stent? Are crazy? It may throw off your taste buds.

I spent all day on the phone.

April 2020

Dear Diary,

My Hospital Administrator called me today and said our numbers on the website Rate-Your-Hospital were going down. She told me to get my Instagram, Twitter, Pinterest, Snapchat and Facebook up to date. I asked her how to spell them.

Communications liaison called me an hour later with the same request. I asked if I could borrow his kids to program my social media life.

Medicine is challenging.

June 2020

Dear Diary,

Got some bad news. The pharmacy next door just laid off all their pharmacists. Word is the creators of Drugs-R-Us just released an updated version that makes the pharmacist’s role redundant. I miss working with them. A computer answers my calls now.

August 2020

Dear Diary,

Tried to write a prescription today for a bladder infection but the patient told me the dose was wrong, that his creatinine clearance was too low. I asked him how he knew that and he said his new app does the calculation. He said everyone is using it. I changed the dose and realized my days treating kidney and bladder ailments were over.

October 2020

Dear Diary,

Patient showed up asking me to take off his cast. I took one look at the beehive-looking thing on his leg and asked him who put that on. He said he did, after looking it up on YouTube. I couldn’t argue with the X-Ray result.

In unrelated news, the ER is replacing some of its staff with teenagers. Apparently, they’re better at navigating the net to find the best treatment options.

November 2020

Dear Diary,

Pretty easy day. All I had to do was sign prescriptions my patients had prepared after reviewing their diagnostic apps. I played hardball with a few––refusing to sign anything until the diagnosis was confirmed by the their new SPET Scan app.

Yeah, I can be a hardass at times.

December 2020

Dear Diary,

Got a complaint from the College. They said I was billing twenty percent above the norm for patient counselling. I asked what else I was supposed to do since the new apps are doing everything else. They told me to enter a surgery residency.

January 2021

Dear Diary,

Got a shocker of a surprise today. Arrived at work to find my office had been replaced by a combo reflexology salon and vegan diner. (I guess that lingering question about retirement has been answered.) I didn’t know what to do so I went in and applied for a job.

They said I wasn’t qualified.

Medicine sucks.

Medicine is a demanding vocation. Every patient expects you to be at the top of your game. On several levels. Intellectually, a physician must be able to mold a myriad of patient symptoms and tests into a correct diagnosis. Emotionally, patients want a caring, compassionate human being to talk to, regardless of what’s going on in the physician’s personal life. Administratively, physicians can’t miss a single test result or forget to order a single drug. Ninety-nine percent right doesn’t cut it. For the patient’s sake, we strive to be perfect. And that can be very draining.

In the same vein, we only have so much energy to draw from. Every patient we see removes a portion of that energy––some more, some less. Without proper work-life balance and a chance to recharge those batteries on a regular basis, physicians risk burning out.

How do we prevent that from happening?

People talk about the importance of exercise, a proper diet and down-time. These are all vital, however if we step back and look at the forest rather than just the trees, there is one factor that I feel is more important. And that is a regular, carved-in-stone routine.

Setting your schedule to something that works for you (35 hours/week, 40, 60) will determine if you have a long career or crash out after losing the love. Like a runner who knows where the finish line is, or a student who knows the time of his last exam, it’s important to know when your work-time ends and your off-time begins. Humans are programed this way. We work better when there’s a designated end point.

I have colleagues who plan their weeks around hard days in the office, and take half days off accordingly. Every week they have a set schedule––a balance of work and recharge/personal time––and they function within those parameters. When you know how much energy you’ll need going in to the office/OR/clinic (because you know how many patients are booked or how many surgeries are scheduled) the stress is easier to manage, and the following down time will recharge those batteries.

The other aspect to consider in the balance decision is the quality of the work. I’m not a neurologist but I can’t imagine seeing only headaches all day, or an orthopod treating solely back pain. I think it’s important to mix it up. For myself, inpatients and house calls get me out of the office, as do nursing home rounds and occupational medicine. It uses a slightly different skill set, in a slightly different environment.

Over time, constant confusion, unexpected problems, and changing expectations have a draining effect both mentally and physically (i.e. being on call for long stretches, emergencies, and complicated cases). Regular sleep, an exercise program, and time to relax and recharge serve to counteract those effects but only if used on a regular basis¬¬––in a set routine.

Last point; the schedule can change to mirror the stages in a physician’s life. The idea of a set routine is carved in stone but the routine itself is malleable. I wouldn’t expect a sixty-year-old to work the same hours as a thirty-year-old (or want to). Nor should a physician recovering from surgery jump back on the horse before he’s fully recovered.

Set the conditions for your practise before they’re imposed on you by your caseload. In other words, define your work/life balance and work within those parameters. It’ll serve you well.

After reading some of the recent comments concerning pharmaceutical reps, I decided to take a hard look at the issue myself. Should I continue seeing reps? Does the process afford me a net gain or net loss? So, I sat down and wrote out the pros and cons. The cons were easy. When I see reps (booked at the end of my day), I’m usually drained and just want to go home. It’d be whole heck-of-a-lot easier to sneak out the back door.

But then I wrote out the reasons why I should continue. Let me be clear, I’m not trying to change anyone’s mind, I just wanted to look at my reasons for doing what I’m doing. So, here they are in no particular order.

1 I learn something every visit. It’s true, I consider it a mini-CME. Whether it’s the latest paper, an expert opinion, a packaging change or a price drop, it’s rare the rep doesn’t bring something new to the table. Of course, it’s slanted toward their product. Doesn’t matter. Facts are facts. A peer reviewed scientific study is a peer reviewed scientific study. I’ll file that tidbit of information away with the rest of the facts I know about the drug.

2 They provide great handouts (tear-a-ways); Kegel exercises, low cholesterol diets, lumber spine exercises, you name it. This helps me help my patient. And, no, the name of a drug on the paper doesn’t bother me. In the ‘old days’, they used to bring replicas of knees and shoulders, as well as fantastic anatomical posters. Not a day goes by where I’m not picking up a knee joint or pointing to something on a poster. (and this is where your child’s ear infection is . . .).

3 The rep is not a snake oil salesman or the devil incarnate, he or she is just trying to do their job. If I tell them I’d don’t believe in their product, they have to accept it. If I ask them for more information, they’ll get it. The only problem I had occurred years ago when a District Manager accompanied the local rep and tried to pressure me into prescribing his product. I simply suggested it was time for him to leave and then continued my discussion with the local rep who was, to say the least, a tad embarrassed. I believe we all know where the line is, and I have no problem dealing with any incursion. I can’t ever recall a rep suggesting I use a product off label or inappropriately. On the contrary, I’ve found the vast majority to be hard working, respectful and trustworthy.

4 Samples. Not near as good as they were years ago when they dropped off birth control pills, antibiotics and blood pressure pills. But a large part of my practice comes from high priority neighborhoods and they don’t have drug coverage. I do my best to provide them with samples. When I call the rep and ask for help for my patients, they do their best to help.

5 They support CME events. Sorry, but after a long day in the office, I’m not going to a rubber chicken dinner. I will go to a sponsored event where the food is good, I can converse with my colleagues, and the lecture is given by a specialist I know––one who’s not biased by the company paying the shot. Which brings me to the major issue . . .

6 Ethics. Yeah, I know the argument––docs are malleable. We can be bought. I can’t comment on those studies that make this claim (I’m just a lowly solo doc on the front lines), but I can point to thirty years of practice, dealing with hundreds of colleagues. Most of the CME talks in my city are given by local specialists, people I consider experts in their field. Looking back on all those talks, I can state unequivocally that I’ve never witnessed any bias on the part of the speaker. Some might call me naive, that brainwashing is a subtle process based on the data presented. That’s one opinion. All I know is I come away with a few pearls of wisdom that are based on scientific fact, that I will use in my practice.

Some might claim I should get my CME from other non-pharma sources. Well, I do that, too. I take several weeks off a year to go to conferences. I pay the registration fee, and the plane and hotel fees. I scramble to find a locum to cover my practice, pull favors to get someone to cover my inpatients, and trade my call so I can do it when I get back. And then, during the work week, I can go to a restaurant up town, hear a good talk, have a great meal and go home to my own bed.

I’ve had the parents of local drug reps as patients, and I’ve put them on a competitor’s drug. Why? Because it was a better choice. I don’t believe I can be swayed by parlor tricks or a free pen (when they used to give out free pens). I believe the majority of docs across the country are like me––they assimilate all the facts, no matter the source, and make the best decision for their patient.

In the same vein (excuse the pun), when I’m going to vote, I want to listen to all the political parties, not just the one I like. As well, I don’t want to throw speakers out of debates because I disagree with their opinion, or start burning books. I need all the facts to make the best decision. Information is good, especially in the hands of bright, highly educated individuals.

Looking at the big picture, I think I will stay the course. Perhaps the pendulum has swung too far since I stated practice. I confess I do miss the free pens and sticky pads. But overall, seeing reps is a net benefit for me and my patients. Bottom line, I place my faith in medical professionals to make the right decisions.

The vast majority of physicians trudge to work every morning, listen to a multitude of patient complaints, and do their best to help. They go the extra mile, and that includes squeezing in sick patients when the office is overloaded and the secretary is threating to quit.

They do it because that’s what they’re trained for, and because they’re secure in the knowledge that someday they can comfortably retire and live off the savings they diligently put away with their friendly MD advisor. For the forty-plus percent of docs across the country who’ve entrusted their savings with MD, you know what I mean. Over the years, you’ve made friends with your advisor, had regular meetings in his office––or he’s come to you if you can’t get away. He understands your risk tolerance and your retirement goals, and you’re comfortable taking his advise because you know he’s not on commission like other advisors. He has no ulterior motive, no bonus package if he sells enough shares in Company X.

It’s been said that MD is the jewel in the CMA crown, that it’s the main reason many docs remain in the association. I can see why. Over my thirty years of practice they’ve made a score of improvements¬––new and better funds, low MER’s, assigned fund managers, estate planning, risk assessment, and much more––all with the best interests of physicians first and foremost. Expert advice. No pressure. Totally confidential.

Physicians deal in unknowns. We don’t know what kind of patient will walk through the door, or what diagnosis we’ll see next. We don’t know how the markets will move or when taxes will be raised (JT’s and BM’s proposals notwithstanding), but at least we can sleep comfortably knowing our investments are in good hands.

Right?

I’m not so sure anymore.

Like most docs across the country, the sale of MD Financial caught me off guard. I was shocked, and more than a little troubled. I felt like mom and dad just sold the family cottage without talking to any of us kids. Damn! So much for my plans.

We’re told that, because of confidentially, no information could be disseminated beforehand. What about before the beforehand––I don’t recall anyone sending out a survey asking members if we were cool with the possibility of selling the ship. We are the membership. We should have been consulted.

We’re told members will have many more investment options, more products and services that will enhance the value. I cry foul. MD has the best customer satisfaction record in the industry. Members are happy with the services. Members are happy with the value.

If you want to add more services, just add them! You’ve only been doing it for decades.

The examples given of new opportunities––to kick start medical careers and address physician burn out––seem absurd to me. I mean, really, a major bank is going to help advise a new thoracic surgeon how to set up his or her practice, or council a family doctor at risk? Heck, I can’t get them to cover depression and anxiety in their employees now, despite filling out reams of paperwork.

Nothing will change, they say. MD will remain independent. Isn’t that what China said about Hong Kong? Tell me I’m wrong but we’re talking about a big bank here. What did they promise, ten years of non-interference? Even if they stick to their word, what the heck happens after that? And the employees? I’m told they have a one year job guarantee. I’m sure that’s doing wonders for company morale. The guy I’m trusting with my retirement has no job security. I’m picturing every advisor across the country grinning ear to ear, thinking, ‘Great, I’m finally working for that behemoth I’ve been pining for my whole life.’ Heck, my advisors came FROM the banks because they wanted to work for MD––its sterling reputation a huge draw. They loved the idea they could focus on the client not the commission. I can’t imagine they’re very happy. Ask yourself this question, if MD employees are let go, who hires their replacement?

Which leads me to this; why does the CMA need 2.6 billion anyway? And who gets the money? Several of my colleagues have asked the obvious questions; are bonuses being paid out based on the sale? Or, is the money going to be fritted away on pet projects? Or, is the CMA going to wave our fees for the next ten years? I’m waiting for the details in the next newsletter.

Maybe there’s an opportunity here. Maybe some business savvy docs will go out and start a new ‘MD Financial’, with the same philosophy and the same independence as the old one. And maybe us docs can migrate over and support the new old version.

I admit it, I don’t want to hear the top-down platitudes of how this sale is a new opportunity or the next phase of our journey. I just want my comfortable, secure MD back.

In my family practice it’s not uncommon to receive a consult with something like: “Mrs. Jones is a 79-year-old patient of yours admitted to ICU last week with CHF. Despite medical intervention, her condition is deemed palliative. Family is in agreement. Would you accept in transfer?” Or, in a similar vein: “Mr. Smith is a 58-year-old patient with metastatic bowel cancer on oncology who’s decided to stop chemo. He’s unable to manage at home due to increasing bone pain. We consulted palliative care but there are no beds available. Would you accept in transfer?”

The common theme in both cases is that medicine and oncology have done all they can and would like their beds back.

Some may ask if this is simply a cheap way to lighten their load by offloading patients. I don’t think it is. In fact, I believe transferring these patients to my service is a win-win for everyone.

How? Well, let’s talk about Mr. Smith. Oncology loves the fact I can take him off their hands and free up some space for someone who can actually benefit from active treatment. It’s also better for Mr. Smith because he sees a familiar face in charge of his care during his final days, someone he knows well and already has a connection with. That by itself is worth its weight in gold. The ability to blunt the sharp edge of anxiety simply by sitting on the side of the hospital bed and having a conversation is not something an oncology resident meeting the patient for the first time can easily do.

I may have a 30-year history with the patient, and a bucketful of secrets between us. Maybe I “got him off the smokes” when he was in his 30s, made that house call to treat his pneumonia during that ice-storm on his 40th birthday, and counselled him until he regained his footing after his wife’s death five years ago. Like most of my patients, we have a history together. Validation is in the smile I see when I walk into his room on rounds.

Transferring him is also better for his family, who can sense that doctor-patient bond and it eases some of their angst. It provides family members a certain level of comfort to ask questions or express their concerns, instead of bottling them up when faced with a stranger in a white coat.

And what if I need help with symptom control, or end-of-life issues? No problem, my palliative care colleagues are just a consult (or phone call) away.

I understand this is not an option in many urban hospitals where family docs don’t have privileges. I think that’s a shame. The old cradle-to-grave mantra is fraying around the edges. It’s a loss of a piece of medicine at a delicate time in a patient’s life.

And I’d be remiss if I didn’t mention the final benefit. I said it was a win-win for everyone, and that includes the family doc. Getting a discharge summary about a patient passing away in hospital can leave me with mixed emotions. Guilt: Did I miss something? Remorse: Never did thank him for all those Christmas presents. Regret: I’ll miss his jokes about me passing medical school despite a terrible golf swing.

Being part of the process is akin to tying off that last loose end. For the family doc, it’s a sense of closure. Especially after years of consultation, putting out fires and lending a helping hand. It’s a personal touch, like at the end of a visit when a patient stops to shake your hand and say “thank you” before he walks out the door.

I must be missing something. I may be just a Family Doc trolling the front lines of health care, but after following the oscillations of the tax debacle these past few months you’d think even I’d understand what the Liberal Government’s endgame is. But honestly I don’t.

Some of you might call me naïve and that this whole process is just one big money grab. My colleagues recant the same mantra; the government doesn’t have a revenue problem; they have a spending problem. It’s their insatiable thirst for capital that’s forced their hand, seeking out new sources of income.

But that would miss my point.

Let’s start at the beginning. The ‘consultation period’ beginning in the middle of summer doesn’t pass the smell test--last time major tax changes were instituted, the government of the day took years to ‘get it right’. I can’t imagine hauling all the experts off the golf course in August to create an improved tax system. But that’s just me.

The Liberal’s follow-up message, that we were an army of tax cheats allowed JT and BM to paint a big target sign on our backs. This technique carries a long historical footnote—create a common enemy and unite the people against them. (Down with the pro-corpers!)

Then, as grassroots organizations began to mobilize and protest, the government dug in their heels. They claimed the high ground, that they were defending the concept of ‘fairness’. And those irrelevant facts about maternity leave, retirement planning, sick days, student debt, are just that, irrelevant. Ignore all those business studies that compare salaried government employees with self-employed docs. The public doesn’t have to know the details. Trivial matters like benefit packages and tax free income splitting simply detract from the message.

But let’s put the Finance Minister’s personal finances aside for a minute.

After a groundswell of opposition, the Liberals relented—we think anyhow. Has anyone seen the details of the plan yet?

Having said that, if we just look at passive investment revisions, we should be happy, right? I mean, they only apply on a go forward basis now. So, am I happy?

The answer is a hard ‘no’. Physicians are ethical, hard working, caring individuals (kinda goes with the job). Just because it no longer affect many of us ‘senior types, doesn’t mean our profession and our patients are safe. The long-term effects of these proposals include the very real possibility of decimating our health care system.

In other words, those warnings we’ve been shouting from the rooftops have not gone away—they’ve simply been pushed back ten years. A local survey said 80% of our docs would either retire, move away, or slow down. Why? Because there’s no incentive to work hard—the more you work, the more the government will lighten your wallet. Bottom line; they’re punishing success.

If I was graduating today I would be more than upset, I’d be looking to move south.

Unfortunately, students right now are more concerned with learning how to reduce a shoulder than the details of BM’s tax changes. But that will change when they enter practice. Once they learn that the Liberals have extended their working careers by a decade or so, increased their annual income taxes by thousands of dollars, and taken away any incentive to see that extra patient or take that extra shift, they’re going to be ticked. And I don’t blame them.

Which brings me back to my point. I don’t understand the Liberal’s endgame. In the beginning, they ticked off physicians by their proposals and by inferring we were tax cheats. (And for the record include, dentists, lawyers, entrepreneurs, small business people, etc). Later on they almost taxed the benefits of employees (since rescinded), getting under their skin.

Then they modified the proposals to bypass the current crop of self-employed individuals to order to have a go at the next generation of entrepreneurs, professionals and small business people (and by extension their families, friends, and employees.)

I ask you, does that seem like the best way to court votes?

If the Liberal’s endgame is to stay in government, they just alienated large chunks of the population. I’ve been listening to the sound of votes being flushed since this fiasco began.

Some of the talking heads on the news say it’s all a communication problem. I don’t buy it. I mean, how can you have a viable communication strategy made out of straw? They haven’t done the math, consulted with the experts, or vetted their own personal finances. (Sorry, had to get in one comment about Finance Ministers)

I picture the brain trust in the Liberal war room staring at voter demographics. They’re holding martinis in one hand and black markers in the other, which they’re using to scratch out group after group.

Doctors

Dentists

Lawyers

Entrepreneurs

Businessmen and women

Anyone who wants to work hard

Anyone who wants to start a business

So, I have to ask, do they really have some kind of masterful plan or they doing this on the fly? What is the upside of continuing down this dead-end road and losing votes? My wife never accused me of being very bright, but, please, what am I missing here?

“The toilet’s broken.”

I sighed and put down the paper. “Okay, I’ll have a look.”

“Ah, no.” She tilted her head quizzically. “Not a good idea. It’s an old toilet. How about we call a plumber?”

“Are you crazy?” I glanced outside at the raging snowstorm. “Do you know what those vampires charge on a Saturday, especially in this weather? I’d have to work an extra ER shift to cover the cost.”

She rolled her eyes, reminding me of my secretary when I asked her to squeeze another patient in. “Haven’t you got rounds to do?”

“Nope, did them while you shoveled the walk this morning.”

She glared. “Is that why I never got any help?”

I started for the bathroom. “I’ll check what the problem is.”

“That’s what you said last month when the dryer broke.” Her words carried just the right amount of of sarcasm. “And how’d that work out?”

I waved my hand behind me. The dryer incident wasn’t my fault. It’s those cheap foreign parts that couldn’t stand the touch of a hammer.

#

The running water sounded like a fire hose. If I opened the window, I’m sure the neighbors could hear it. And I thought today would be free of any diagnostic conundrums.

I gingerly lifted the lid off the tank, and was rewarded with an arterial gush of water that soaked my shirt, the wall and half the rug.

“Don’t forget to shut off the water,” my wife called.

“Thanks.” I gritted my teeth and used the nearest towel to soak up the mess and then buried it at the bottom of the laundry hamper. It took several minutes to bend myself into a pretzel under the bowl and shut off the water.

Once I was able to remove the lid safely, I began a comprehensive examination. Being the astute clinician that I am, I spotted the problem immediately; the hanging chain-thingy had jammed and was preventing the rubbery hole-pluggy gadget from closing.

Reaching deep into the tank, I tried to pull the chain free.

Somebody rapped on the door. I jumped. The chain snapped.

“Everything okay in there, honey,” my wife asked.

I stared at the broken chain in my hand, the other half dangling in the tank. There was only one possible answer. “”It’s all good, dear. Almost done.”

Damn. The patient wasn’t dead yet, but now he really needed intensive care. I tiptoed out of the bathroom and took the backstairs to the garage. Like a good surgeon, I needed my instruments. I grabbed my trusty screwdriver set, my universal adjustable wrench, pliers, and a racket set still in its plastic cover, just in case.

Sneaking back into the bathroom, I used the pliers to crush both ends of the chain together. The rubber stopper-gadget fell into the hole. I grinned; Doctor Huxtable and famous his tool belt had nothing on me. I was Doctor Plumber.

The handle seemed a bit tight so I opened the valves and tried a test flush. Meeting unexpected resistance, I gave the handle a solid tug. Something screeched inside the tank before the flush started . . . and didn’t stop.

Frustration mounting, I turned the water off and examined the patient . . . and quietly swore. The shortened chain had pulled the rubber stopper up with enough force to split it in half. Now I had to replace it.

“Be right back, dear,” I said, grabbing my jacket and keys at the door. “Need to get something at the store.”

“Something like a new toilet?” she asked mischievously as she read the paper.

“Funny,” I muttered.

#

“You need a what?” The pimply-faced kid at the Home Hardware Store stared down his nose at me. “A rubber thing?”

“Yeah.” I tried to inject a measure of confidence into my tone. And failed. How do you talk to a condescending teenager who stumbled into puberty about twenty-four hours ago? “You know, for a toilet?” I had spent twenty exasperating minutes searching for the stupid thing on the shelves.

“Oh, a toilet?” He smirked. “You don’t by chance mean a flapper?”

“Uh, yeah.” I had no idea.

He reached up and pulled something off the wall that looked remarkably similar to the rubber piece I demolished at home.

“What about the chain?” he asked.

“I fixed it.”

His eyes narrowed. “You did what?”

I felt the eyes of the other patrons on me; other husbands out on a Saturday morning getting replacement parts. I could just imagine what was going through their heads. This guy did what to his toilet? He doesn’t know what a flapper is?

I leaned forward and lowered my voice. “I, er, pinched it together . . . ”

The kid grinned, revealing a set of silver braces about the same width as my broken chain. “Good luck with that. Without a new chain, the flapper will leak all day. Don’t you know that?”

I glanced around and caught a few disparaging looks. If I was a member of the club, I just got expelled.

I bought both parts and got the hell out of there.

#

If it were a true surgical case, I would have killed the patient.

I played with the chain for hours, trying to get it the right length so the flapper would fall naturally in place. I figured bowel surgeons had the same problem––trying to get the lengths of colon to line up just right. Or maybe finding the perfect dose of meds that lowers blood pressure but doesn’t cause syncope.

Well, if there was a happy medium here, I couldn’t find it.

Come supper, I quietly packed my instruments, pronounced the patient, and slunk away.

My wife hid a grin behind her hand. “Anything I can do?”

“Yeah. Call the plumber. I think the nurse at the hardware store gave me the wrong stuff.”

My fingers were slowly going numb as I took down the Christmas decorations on a minus-ten degree Sunday afternoon. That’s when my neighbor decided to stop by. I could tell she was bursting to tell me something, and, after a few minutes of pleasantries, she spilled it.

She just retired.

Thirty years with the company and she was done. No more business trips. No more Monday mornings, or staff meetings, or HR problems. She was practically vibrating as she listed off the positives.

“What’s the plan moving forward?” I asked.

“To do absolutely nothing,” she replied with a huge grin. “Well actually, I just joined a gym. And then maybe we’re going to start travelling.”

I congratulated her before climbing the ladder to remove the lights from the roof (in Chevy Chase fashion). If I didn’t finish today, it’d be another week before I had time. But as I peeled light clips off the gutter, I started thinking about the conversation.

She and I have a lot in common. We’re about the same age. (Okay, full disclosure; she’s a couple years younger.) Like her, I’ve got thirty years in (not counting my eight years of post secondary education).

But that’s where it ends. Unlike my ecstatic neighbor, I have no concrete retirement plans. Sure I have hopes and dreams, but there’s no circled date on my calendar.

What would it feel like to have an end game, I wondered? To know exactly where work ends and retirement begins?

For us fee-for-service guys, it’s a strange concept.

We work because we’re trained to, and because of debt, and because there’s always another patient knocking on the door. Plus we love the diagnostic challenges that comprise our days.

But that’s not the mindset of many of my patients who are in what I call the peri-retirement phase of life. Most are just putting in their time, coasting toward the finish line.

Now don’t get me wrong––after thirty years, the financial pressure to keep going has lessoned. It’s the responsibilities that haven’t. So, as I pulled Santa and his reindeer off the lawn, I envisioned a different reality where I could eliminate call from the equation. (I’m sure my surgical and internal med colleagues might have an opinion on this) How much would that lighten the load?

If the Liberal government can restrict how much you earn (read: proposed tax changes), why can’t they enact laws that restrict how much you work? Maybe one of those age plus years-of-service calculations that exist in other jobs¬¬––like once you hit the magic number eighty you no longer have to do inpatient care.

And what if the Medical Society were a union? Can you imagine what rules concerning call schedules and working hours would exist? Wouldn’t that be interesting?

Once I stored the big, plastic Frosty in the garage, my idle musings really went off the deep end. What if I retired from the office and just did walk-in clinics or surgical assists? Holy smoke! What would I do with all that free time? Without proper preparation, I’d probably go into withdrawal. Probably have to enter a twelve-step program or something.

And full retirement like my neighbor? Not even on the radar. Which make me wonder, which of us chose the better vocation. Oh, and did I mention her indexed pension?

As I put the ladder away, I realized there was an upside to the whole thing. I had forgotten about my cold hands.

The truth hurts. And by that I mean students can be a pain in the butt. Admit it, they disrupt our daily routine, monopolize our free hours, and even nudge our prefrontal cortex out of its comfort zone.

With every patient there are introductions to be done, explanations to be had and investigations to be debated. All of which takes time, and those hours have to come from somewhere. As anyone who has ever taught students knows, lunch is shortened, supper is delayed, and spouses are left twiddling their thumbs.

Which begs the question, why do we do it?

Why sacrifice our precious downtime, or spend extra calories on extended mental gymnastics? Don’t physicians have enough on their plate? Or put another way, as a clinical coordinator why don’t I have more difficulty finding preceptors for my clerks? Why do my colleagues still take my calls? Or even admit they know me?

After pondering the idea the other day--as I waited for my clerk to finish a half hour physical so we could finally get back to the hospital and discharge the patient who had been patiently waiting for three hours--I came up with four good reasons. I realize there are more; medical authorities talk about recruitment for example, but I want to bring it down to a personal level.

First, we get something out of it. Man is a selfish creature; therefore there must be secondary gain. But if you’re thinking about money, you’re reading the wrong article. No doc gets rich teaching students. In fact the reality is you’re more apt to take a pay cut when you accept one into your practice. No, what I’m referring to is knowledge. Doesn’t matter if you’ve just hung your shingle or finally installed indoor plumping, there’s a wealth of knowledge to be gleaned from working with students. Medical science advances daily and learners can be the best conduits to the most current drugs, studies, guidelines . . . you name it. And they’re cheaper than a CME (most times). So, if you still think those newfangled antibiotics, Penicillin and Ampicillin, are great, consider taking a student under your wing. Your patients will thank you for it.

Second, it shakes up a stale routine. The old axiom, a change is as good as a rest, really does apply. Throwing a new element into the office mix is a good thing, especially when that element is a young, keen, energetic student. Learning is important to them, and those positive vibes rub off on everyone. The vast majority of my patients enjoy talking to students, and what’s more, they enjoy having their case discussed in front of them. When I started teaching I wasn’t sure how that part of the process would go over. However, in my years I’ve not had a single patient put his hand up and say ‘thanks, doc, but I don’t want to know anymore about me. Just tell me what to do.’ In fact they love hearing all those details you usually keep to yourself, about the anatomy, physiology, treatment options and so on. Maybe for the first time they see how you think on several levels, and how much effort is invested into their care. It’s a win-win scenario.

Third, your patients may get better treatment. I’ll admit it; despite my best efforts I don’t always nail the diagnosis on the first try. I may not choose the best drug or test, or even worse, not follow the latest guideline. In Family Practice, every patient is different, and sometimes our excuse for deviating from the norm is because they can’t afford the best drug, or they refuse to follow the guideline. (‘Doc, do I really need a pill? My sugar is only nine.’) Having a student discuss the case allows both the patient and I to revisit those prickly details--not two months later at their next appointment, but right then and there. And sometimes just hearing the evidence from another medical authority is enough to sway the patient. Sure, they’ve been my patient for twenty years and a diabetic for ten, but one speech from a medical student and they finally agree to take metformin. Go figure.

I’ve taught clerks and residents for twenty-eight years. Part of my job is to recruit new teachers and solve any problems that come up during the rotations. From what I’ve witnessed, the vast majority of students and teachers have a positive experience. And to that point, I’m constantly amazed how the learning process works. Clerkship and Residency are like a series of mini-apprenticeships strung together--producing a well-trained physician.

And that fourth reason? Looking back at my clerkship and rotating internship (yes, they still existed), I remember every rotation and every preceptor. What does that say about the impact we have on students? And, as one of my recent students said in a thank you letter, he hopes one day to have the opportunity to ‘pay it forward’.

Which makes me wonder--maybe we don’t need the first three reasons.

Excerpts from a conversation with Workers Compensation: (Based on an actual case)

Clerk: Thank you for talking my call, doctor. There were a few questions we had regarding this claim. First of all, your writing was hard to decipher. Does your diagnosis say severed tree?

Doctor: (chuckling to himself) Ah, no. It says sprained knee. My patient, Mal Linger, injured his right knee at work.

C: And where did this injury occur?

D: (a tad impatient) I just told you, at work.

C: But where does the claimant work?

D: I’m rather busy here in the office. Don’t you have this information on file?

C: I’m sorry, doctor, but that’s the responsibility of another department. I just speak to physicians. Now, where is Mr. Linger employed?

D: He’s a gravedigger at the cemetery.

C: It says here you saw him after the injury.

D: Yes, I saw him the next day?

C: Not immediately afterward? Why did you make him wait?

D: Probably because it happened at 3 AM. Mal works the graveyard shift.

C: It says here you put him off work. Couldn’t he perform light duties?

D: I suppose I could have asked him to only shovel the light dirt.

C: (after a slight hesitation) And the reason you removed him from the workforce was because of his knee?

D: (making a strangled sound) Yes, because of his knee.

C: His right knee?

D: (sound of a deep breath being taken) Yes, the right knee that was swollen, red and tender. The one that he couldn’t bear weight on. The one that looked like a stretched sausage about to explode in the microwave. That one.

C: You realize Mr. Linger might be considered a frequent flyer with compensation benefits. Last year you placed him off work for a month after he lost three fingers under a bulldozer.

D: Yeah, I remember. Pretty sure he wasn’t faking that one either.

C: Next question, doctor. (Sound of paper rustling) When will he be able to return to work?

D: Hard to say. He’s about fifty percent better today, after two weeks. I’ll keep his home treatment plan going and recheck him in two more weeks.

C: So, back to work in four weeks?

D: That’s not what I said--

C: You can’t fool me, doctor. Fifty percent every two weeks adds up to one hundred percent in a month, even with the statuary holidays.

D: Listen, I’ll see him in two weeks and let you know.”

C: I’m sorry, doctor, but that’s not possible.

D: Excuse me?”

C: According to the answers you gave me, the process dictates we’ll be taking over.

D: What are you talking about? He’s getting better under my care.

C: Your timeline is too long. According to the process he needs an urgent referral to our chronic knee program.

D: What chronic knee program? It’s only been two weeks.

C: Oh, doctor, the patients love our program. Mr. Linger will have intensive physio, a personal home OT assessment, regular massage therapy, and get an urgent MRI.

D: But he already had an MRI last week. Everything’s fine.

C: Doesn’t matter, doctor. The process says he needs a recent MRI . . .

D: Did I mention it was last week?

C: . . . And it will be on both knees.

D: Both knees? What the hell for? He only injured his right one.

C: It’s all about the process, doctor. Would you like to speak to my supervisor?

D: I sure would. This is ridiculous, and a tremendous waste of resources.

C: I’m sorry, but my supervisor is out on Pat leave. Would you like to leave a message on his voicemail?

D: (sound of fabric tearing) Listen, whatever your name is, Mal is recovering fine. He doesn’t need to enter this intensive knee program. Next you’ll want him to see a surgeon.

C: Thank you for reminding me. Having a consultation with an orthopaedic surgeon is part of the process.

D: (to himself) I can’t believe this.

C: One last question, doctor. Can you confirm your mailing address?

D: (sarcastic) Let me guess, keeping mailing addresses is someone else’s department.

C; Oh, no, doctor. We all do this. You see, we’re sending out the annual invoices. Unfortunately, there’s been a substantial increase in the premiums this year. But you can understand, it’s the only way to fund our programs.

“Is there a doctor onboard?” the blonde stewardess asked.

I cringed. It was bad enough we were seated in seats designed during the Spanish Inquisition. After three hours, my legs had lost all feeling. Beside me, my wife silently mouthed ‘no’. This was not on our vacation itinerary.

“Please, we need a doctor,” the blonde repeated, standing in the aisle beside me, as though she could read my mind and this was just a test.

I waited another minute, hoping for an eager resident to jump up and wave his arms. Alas, no such luck.

“I’m a doctor,” I said, in my best doctor voice. “What’s the problem?”

My wife sighed and went back to her Sudoku. The stewardess gave me a once over before turning around. “Follow me,” she said, though it sounded more like an order.

At the back of the plane, nestled between used beer cans, and stacks of overpriced mickeys, sat somebody’s blue haired grandmother. The poor old doll was gasping for air.

“Mrs. Wryback told me she had low sugar and was feeling weak,” the stewardess said. “So I took her back here and gave her some peanuts --which she promptly spit up--and started getting short of breath.”

“Alright.” I stepped forward. “Let’s have--“

The blonde held up her hand. “One second, doctor. First, I need to ask you a few questions.” She pulled out a pen and pad of paper.

“Questions? What for?”

“Company policy, doc. Now, what’s your full name?”

Too shocked to protest, I told her. She wrote it down. Seconds passed. The patient coughed weakly.

“Citizenship?”

“Canadian.”

“Purpose of trip?”

“Uh, pleasure.”

“Malpractice number?”

I felt my face blush. “What do you need that for?”

“Regulations. We’re in international airspace. Mrs. Wryback could sue us from any country. Believe me, doc, you don’t want to serve time in a Russian jail.”

My jaw nearly hit the floor. “Russian jail? I’m just trying--“ I took a breath. “Listen, she’s getting worse.”

The stewardess placed both hands on her hips. “Alright. Just don’t screw up. I’d hate to take the stand against you.”

Speechless, I bent down and took the patient’s pulse. 140. Respirations. 45.

“Do you have a stethoscope?”

“Nope.”

“Any oxygen?”

“Sorry, container leaked.”

“What about medications?”

“Locked in the cockpit with the guns.”

I blinked. Guns? What kind of plane was this? “Give me what you’ve got. Quickly.”

I tried to reassure the patient, but she just stared at me with wild eyes and gurgled incoherently.

A minute later the stewardess returned and handed me a worn black bag. “The captain wants to know if he should return to Toronto.”

I glanced at my watch. “We must be over the southern US by now. If we have to land, aren’t there closer cities.”

She shook her head. “Sorry, doc, but we ran out of immigration forms. Can’t land without the proper paperwork.”

I felt like I was living in wonderland with Alice. I reached into the bag and pulled out a stethoscope. “You do have one!” I held it toward her accusingly.

“Oh that,” she giggled. “I thought you asked for cantaloupe, like you were hungry or something.”

Jaw muscles tight, I pulled out a bottle mineral oil, a metal speculum and an expired package of Viagra. “Is that it?”

“Yep, that’s all the emergency supplies we have onboard. Did you want one of the guns?”

I almost laughed . . . until she didn’t. “No, I think I’m okay.”

The patient’s chest revealed little air entry, and an inspiratory stridor.

“How many peanuts did you feed her?” I asked.

She looked at me and then at the gasping patient. “What peanuts?” she asked meekly.

A short Heimlich manouver and out came a partially chewed nut. It landed on the Viagra.

Mrs. Wryback got up and punched me in the arm.

“That’s for flirting with the stewardess while I almost choked to death.” She stomped back to her seat.

The stewardess scribbled a few notes on her pad. “That will be all, doc. You can return to your seat now.”

I glanced at the mickeys wrapped in cellophane. I needed a drink.

The stewardess guided me away. “Sorry, doc. No drinking while on duty.”

“But I’m on vacation! Besides I just saved a patient.”

She patted my arm. “Don’t worry. The airline will probably send you a coupon for free headphones. Have a nice flight.”

Monday 9:34 AM

The lanky farmer in a sweat-stained t-shirt walked in and plunked himself down on the examining table.

“Doc,” he said, “I need your help. Me and the missus got to arguing again last night. This time she darn near nailed me with the frying pan.”

The doctor smiled. “I told you before, LeRoy, stay low and keep moving. You’re less of a target.”

“Yeah, I got that, Doc. Problem is this time she screamed something about the kids not being mine before stomping off to her mothers. I need your help.”

The doctor inclined back out of halitosis range. “Sorry to hear that, LeRoy. Could she be right?”

“Well, I ain’t rightly sure on that one. Never did figure out where all that red hair come from . . . ”

The doctor made a note on the chart. “Can’t see how I can help you on this one.”

The farmer leaned forward, his dirty hands leaving fingerprints on the doctor’s desk. “Well, Doc, I got to thinkin’ and I figure two can play at this game. She’s coming to see you tomorrow for her yearly paps. She says them boys might not be mine. Fine, you tell her they might not be hers either. That’ll set her back some.” He grinned a gap-toothed smile.

“Ah, LeRoy,” the doctor said, reaching in the drawer for the air freshener. “I delivered both your boys. You were there. In fact, so was she.”

LeRoy tapped his temple and winked. “Don’t matter. All we got to do is plant the seed, Doc. You tell her they might be someone else’s and she’ll come running back home faster than a greased pig to the slough.”

“Ah, LeRoy, I can’t--“

The man stood. “Sorry, Doc, gotta run. Thanks for this.”

10:14 AM

A balding, thirty-something male slouched into the room. He moved awkwardly, like he had a fifty-pound ball-and-chain on his leg.

“You don’t look happy today, Rickey,” the doctor said. “What seems to be the problem?”

“Wife made me come. Don’t really want to be here.”

The doctor leaned back in his chair, a smile tugging at the corners of his mouth. “Ok, why don’t you tell me why she sent you?”

“Uh, she says six kids in five years is enough, and nothing’s going to happen until I address the issue.”

“I see.” The doctor used his hand to cover his grin as he reached for the consultation pad. “You want a vasectomy.”

“I don’t. She does.”

The doctor hesitated with his pen poised over the paper. “Uh, Rickey, I won’t refer you if you don’t consent.”

Rickey groaned and rubbed his hands together, like a miser down to his last two coins. “I wish I had a say in this but I don’t.”

“You’re the patient, Rickey, you always have a say.”

Rickey took a deep breath. “You don’t understand. She went out to the baby barn last night and brought in my hedge clippers--the one with the heavy wooden handle and long metal blades. The damn thing’s been outside so long, the metal is half rust. Well, she put it under the bed and said if I don’t talk to you soon, she’s going to wake up one night and do it herself!” He gulped. “Damn, I didn’t sleep a wink!”

Rickey walked out of the office two minutes later with the referral in hand.

2:59 PM

A mother leaned over the desk eye level with the doctor. “I’ll allow you to give Charles Reginald the tetanus and pneumonia vaccines, Doctor, but not the measles one.”

The doctor glanced at the newborn cooing softly in his Burberry outfit. “Mrs. Hightower, the controversy about the MMR vaccine has been settled. The initial reports--“

She held up her hand. “I know what you’re going to say, but I’ve also learned the drug companies are paying you big money to push these vaccines.”

The doctor’s jaw dropped. “Drug companies?”

“And,” she waggled a finger at him. “I happen to know four kids in my older son’s school who have ADD, and they’ve all had the measles vaccine.”

“But every kid--“

“Don’t patronize me. I did extensive research on Google. There are babies in this province who suffer from gas, seizures and, worst of all, loose stools--all because of this so-called vaccine. Not to mention, my entire yoga class is totally against it.”

The doctor let out a long sign. “Well, I’m not one to argue with an entire yoga class. Have a nice day, Mrs. Hightower.”

3:20 PM

“Hey, doc, is that door closed?”

“Leo, when I do prostate exams, you can trust that the door is always closed. Why do you ask?

“Because, Doc, we don’t want to start a stampede.”

The doctor couldn’t perform the exam until he stopped laughing.

Hanging out the shingle--- First day on the job. Shake hands with retiring physician. Note the bemused look on his face as he slips out the door. In the parking lot he jumps in the air, does a heel click and sprints towards his car. Curious.

With some trepidation I see my first patients, a family of snotty nosed kids and a mother who admits to a gambling addiction. She proceeds to haul out a bag of narcotics and a suitcase full of disability forms.

That night I dream of my predecessor’s bemused expression.

5 year anniversary-- Head throbs like a tuba during music class as I struggle out of bed for Monday’s office. Weekend passed in a blink of an eye thanks to a couple of twelve-hour ER shifts and a sick, pregnant wife at home. She blames me for bringing the flu home from the office. I figure my own chills and rigors will pass as soon as I find the Biaxin samples. I’m sicker than the patients I’m treating.

10 year mark--- The significance of today is completely lost as I tag-team with my wife to deliver the kids to their multiple games. How can three kids be involved in 17 different activities? Growing up, I was involved in just one. We called it ‘play’, and it seemed to work just fine.

I’m hoping the hockey game ends on time or I’ll be late for the Afterhours Clinic again. My pager goes off. It sounds like a whistle and play on the ice comes to a complete stop. Everyone looks at me.

15 years--- They talked me into coaching another year. I must be insane. Every week I’ll be rescheduling offices just to make the games and practices. Rumor has it my secretary has put a contract out on my life. Thank God I left the ER a couple of years back. Probably should have refused that Nursing Home request.

Received a letter from the city asking me to provide medical coverage for the National Spelling Bee. Only two weeks they said. In the middle of July.

Up all night delivery babies. Wife’s birthday completely slipped my mind. Tried to apologize but couldn’t find her. I think she went shopping.

20 years--- Finished term on Medical Executive. Discovered it was all a ploy from administration—offer physicians fancy titles and they’ll willingly serve on ten more committees. Devious buggers.

Senior members of call group retiring. My nurse goes out on mat leave. I think it’s a conspiracy.

Lost car in parking lot the other night. Blamed it on my cholesterol pill.

25 years--- College shock! And I thought High School Graduation was expensive. Had to convince my banker I was paying for education not a new house.

Government clawing back fee schedule, blaming it on the economy. Tried to contact local MLA but he was attending seminar in Dominican.

Don’t recognize half the faces in the Departmental Meetings anymore. Thought they were students. Made the mistake of saying as much. Won’t say that again.

30 years—Finally got out of group call. Had to fake some chest pain but it was worth it. Now get to sit in doctor’s lounge every morning and reminisce about the ‘good old days’.

Drug cupboards full of pills with funny names. Don’t have a clue what they do. Called pharmacist but they want a fee…

Tried to send e-mail on son’s birthday but had to ask wife what his name was. She almost choked on her nachos.

35 years-- Wife says I need to find a hobby before she evicts me. I tried computers but every time I brought it to the store to get it fixed, the adolescent nerd with the clindamycin skin laughed and snickered with his buddies.

A thought strikes me; I don’t need a hobby, I have 35 years experience telling people what’s good for them. The answer is simple.

I run for office.

My name is Michael, and I’m an addict. Actually I’m the worst type of addict, a PPA—a peppermint patty addict. I can say it now, but it took me years to admit my affliction.

Truth be told, I started at a young age, stealing those individually wrapped, mouth-watering peppermint patties from my younger siblings at Christmas. And if the holidays were bad for thievery, Easter was pure hell. My finicky fingers found their way into every brightly coloured basket in the house. From there I discovered those secret hiding places where Mom stashed the Red Wrap boxes containing row after row of delicious chocolate goodies. I knew then I inherited my addiction from her.

Make no mistake, I still have my standards. I refuse to indulge in those skinny, chemically infused generic versions found in the big-box shopping malls. No, those are for the plebeian masses. Call me a snob, but I’m a true follower of thick, rich peppermint engulfed in pure milk chocolate. You know, the ones that can be classified as their own food group.

For years, I held my addiction in check, keeping surging dopamine levels locked away in the closet of my mesolimbic system. Unfortunately, as we get older, resistance becomes futile. My defence mechanisms, evolved from caveman days, were no match for modern commercials and crafty marketing firms. Elevated neurotransmitter levels busted out of that closet long ago. Now I purchase every box of those delicious Delectos I can put my hands on. Beware white-haired grandmothers dawdling next to the candy rack: I will steal the last box of patties from your cart.

My patients sniffed out my weakness early. A box of the good stuff will buy you an appointment the same day; two boxes will get it within the hour, even if I have to send old Abel and Della Cornfield home to clear space. You don’t want to know the going rate for Viagra samples.

Intervention

Two years ago, my wife forced me into APPA—Addicts of Peppermint Patty Anonymous. She said it was the only way to save our marriage, and preserve my pancreas.

During my first APPA conference I realized mine was

not a solitary problem. The weekly meetings are standing-room-only and held in the hospital amphitheatre. Security guards frisk everyone at the door and we are forced to march past special candy-sniffing canines. I quickly learned that

PPAs hail from all walks of life, although there is a preponderance of used car salesmen, lawyers and talk show hosts—those with syrupy sweet personalities. I even witnessed our local endocrinologist attending for a while,

before they caught him selling and banished the SOB for life.

My wife joined our sister organization, ABBA (At Bat for Brainless Addicts). I understand they have monthly meetings which the local fudge and chocolate store caters, and they sing karaoke versions of Mamma Mia and Dancing Queen. Once a year both groups get together for our annual meeting, the APPA-ABBA conference. (If you can say the acronym correctly three times you win a free pretzel.)

At home, to hide my affliction from the kids, we use

a lot of code words. For example, instead of saying, “Honey, I’m going to the APPA meeting tonight,” I say, “I’m going for a PP,” to which my daughter rolls her eyes and proceeds to gag.

I confess, I’m nervous about the future. Statistics show that PP addicts relapse at a rate of 95% per year. . . .

I’m not sure what that means, but I don’t have time to contemplate the issue at the moment. My wife wants me to pick up some peppermints . . . er, I mean milk, from the store.

Wish me luck.

The article advocating the abolishment of the white coat caught my attention. I had no idea the famous garment, through no fault of its own, had become a symbol of all that is wrong with the medical profession.

The fact that it causes such consternation among medical students is note-worthy. With the sheer volume of information to memorize, the late nights on call, and the constant flow of sick patients, I can understand how the hem length of a smock became the straw that broke the camel’s back.

While perusing the article, I was ecstatic to read that medicine is moving away from its ‘paternalistic’ approach, although I wasn’t sure exactly when that change began. I guess I was too busy treating patients to notice.

I confess, the point about white coats becoming a barrier between physician and patient was a part of my practice I never considered. For years I mistakenly believed the physician’s attire, including the white coat, infused patients with reassurance and hope. Reassurance that someone with the knowledge and training was caring for them; hope in the fact the bond between physician and patient would alleviate suffering and promote healing. But perhaps that’s just my two-and-a-half decades of patient care talking. I defer to the expertise of others.

Since hanging my shingle, I’ve watched colleagues don the white coat on hospital rounds or in the office thousands of times. The more established physicians tend to wear them more than their younger cohort. I respected their decision (perhaps foolishly in hindsight) because I believed it was based on the physician’s personal knowledge of his or her patients, intuitively understanding what would best put them at ease.

I admit I do not wear the white coat much these days, but I can see how the traditional garment can, as the authors postulate, serve as the major component in legitimizing the medical profession; antibiotics, vaccines, cancer cures and peer-reviewed scientific papers notwithstanding.

If the coat ‘enforces stereotypes and social hierarchies’, I’m all for getting rid of it. In my naivety, I thought my family medicine and specialist colleagues were simply trying to help their patients. Little did I know they harbored selfish, alternative motives. How could I have been so blind?

However, on one issue I felt the article fell short. It didn’t specify how I should react towards other professionals wearing similar white coats. Despite the years of working cooperatively in the patient’s best interest, it appears I was guilty of perpetuating a falsehood. Should I resent the other professionals? Admire them? Or inform the Pharmacists, Physiotherapists, and Occupational Therapists how patronizing they appear in the eyes of the patients? I never commented on their attire in the past but I now wonder if that was a mistake? Perhaps I should have taken a more authoritarian stance and demanded change.

It is silly, really. Unbeknownst to me, my choice of clothing could produce a ‘lack of consideration on the wards.’ I simply can’t let this happen. Truly, the cover is more important than the book’s contents, form rather than substance, fashion over function.

Now that I have gleaned what useful pearls of wisdom are to be found in this article, I can make the appropriate changes and get back to the work at hand.

I’m sure my patients will appreciate it.