Sunday, April 29, 2007
Here are some pics that remind me why we wanted to move to Vancouver in the first place....
Finally, the new website for Nunavut Physicians is now up. I've linked it here and on the side bar. As I've said before it's a great place to work, and worth doing a locum in. Check it out...
Friday, April 27, 2007
For many Canadians an environmental identity is important. The idea of the Canadian wilderness is almost omnipresent in Canadian literature, poetry, and media. The idea of camping, cottaging and canoeing are part of Canadian collective consciousness. Whether we live in Toronto, Vancouver, Temiskaming, or Pond Inlet, we all seem to have the idea that the wild part of Canada is closely accessible.
In the past we may have assumed that our wilderness was so vast that it was immune to the effect of man, and exempt from our doings. Over the past 50 years it has become fairly clear that this is untrue. Severe erosion of shoreline on the east coast, dangerously hot summers in Quebec and Ontario, alternating floods and drought in the Canadian mid-west, the swath of destruction of forests by the pine beetle in BC; Most Canadians are aware of some element of local environmental stress.
The northern part of Canada is particularly vulnerable to environmental changes. Most predictive models show polar areas warming at a rate far in excess of tropical and temperate areas. In northern Canada this means changes in sea ice, changes in permafrost, changes in local vegetation, and northern migration of the treeline. All of these examples are already starting to happen. One of the tangible results of even the subtle early changes that have already occur ed is that the territories of large animals have shifted. Changes in the location of the floe-edge mean changes in where the fish, seals and polar bears live. Changes in seasonal sea ice, and increased freeze/thaw patterns means migration routes of caribou have shifted. From an armchair in the south it is easy to sigh with relief because these animals are adapting to changes. For a resident of the north, who may rely on these animals for sustenance it is a far different story.
It can be difficult for those of us in the southern part of Canada to remember that some Canadians still rely on game for food. In the south hunting is a guns debate, and an animal rights debate, but in the north it is really a food debate. When groceries cost 4 times what they do in the south (would you pay more than $10 for 2 litres of milk?), more economical means of food acquisition are called for and this means game hunting. This year in Iqaluit it was common to hear 'there's not much game this year', 'it's been hard to find caribou'. Traditionally a nomadic people could and would have followed the moving game, but settled life has it's own complexities.
As the environmental debate and agenda in Canada evolves I think we can learn much from looking northwards, towards people deeply involved with and affected by the environment. We can remember that it is not just a debate about cars, and florescent light bulbs, and industry and carbon taxes. It is a debate about food, and it is a debate about how we, as Canadians, interact with the wilds that are deeply part of the Canadian collective consciousness.
To finish, a little Canadian poem...
I PASS where the pines for Christmas
Stand thick in the crowded street,
Where the groves of Dream and Silence
Are paced by feverish feet.
And far through the rain and the street-
My homesick heart goes forth
To the pine-clad hills of childhood,
To the dark and tender North.
And I see the glooming pine-lands,
And I thrill to the Northland cold,
Where the sunset falls in silence
On the hills of gloom and gold!
And the still dusk woods close round me,
And I know the waiting eyes
Of my North, as a child's, are tender,
As a sorrowing mother's, wise!
by Arthur Stringer
Tuesday, April 24, 2007
There is a great mythology in medicine that patients 'ought' to behave rationally, and that they will somehow behave rationally if only they are compelled through argument of their physician. Rationality, through the physicians eyes, often involves the preservation of good health through the avoidance of detrimental behaviours, or through the treatment of disease. In the office this usually sounds like 'You should stop smoking', 'You should stop eating fried food', 'You should submit to screening for any number of various diseases', 'You should take better care of yourself'.
The usefulness of recognizing that this interaction is part of the is-ought problem is through recognition of the fact that much of the advice given by physicians is (in a philosophical sense) moral advice. The moral basis behind all of this ought advice is the presumption that patients ought to do what is best for their own health. In many ways this is a reasonable philosophical assumption; in other schools of thought the idea could be thought of as maximizing utility, or as a soft duty, within the confines of personal liberty.
The problem with this particular ought to is of course that it bears no resemblance what so ever to observable reality. Patients (in fact all people) simply do not make their choices in a way that optimizes health. I doubt I have ever seen a patient without a health impairing vice. People continue to smoke, lead stressful and sedentary lives, eat (delicious) fried foods, and generally take care of themselves poorly. Rarely is the moral advice of the physician heeded, though often it is given. You ought to do this, you ought not to do this, is a refrain throughout medicine. Often given, rarely heeded.
One of the premises of this medical moralism is the presumption that people will behave rationally. Again, this is a nice idea, but is in great conflict with observable reality. 'I know I've gotta stop smoking Dr. J.' my patients tell me. They have the capacity for rationality. They recognize that they are hurting their health. They recognize the implicit ought. '...but I just don't want to yet."
As a pretender to the hard sciences medicine gravitates towards rationality. In proving objective truth about health and disease it serves a great function. In inflicting the burden of rationality on to patients it goes too far. When I give my moral advice to patients, I am not surprised that they often take a pass. The rational thing to do of course would be for all of us to maximize our health. The problem is that rationality doesn't work well for non-rational people. So I understand why my patients wave at me with their cigarette in-hand when I walk to my car, as well as I understand why I continue to enjoy a big bowl of ice cream. Knowing what we ought to do, is in many cases simply besides the point.
Monday, April 23, 2007
Lately many hits on the blog have been from U.S. visitors. With that in mind I thought it might be interesting to post a few pics from Cuba, as Americans never get to see this very interesting place. Cuba has a very interesting history, worth reading about. At present it is a one party socialist republic, with Fidel Castro as Prime Minister. The cultural background is a fascinating mix of traditions brought to the island by both Spanish colonialists as well as African Slaves. Since becoming a socialist republic, Cuba has been under trade embargo from the USA. This has resulted in some interesting cultural twists in Cuba. For instance, the trade embargo has severely limited the import of cars to the island. As a result they have made the cars they have last, and the cars on the roads are mainly classics from the 40's and 50's, often with Diesel engines in them. This has also created a transportation shortage and there is wide spread organized hitchhiking and some very interesting buses, as partial solutions to the problem. Havana itself is a very beautiful place with much intact Spanish colonial architecture.
Cuba really is a fascinating place. Like any resort destination it is difficult to see the contrasts of poverty side by side with the often opulent resorts. Like so many things, tourism itself has both positive and negative implications for the local people. Below are a few pictures you might enjoy...
The resorts pool.
A camel bus in Havana.
Some European looking row housing in Havana.
A classic car, and it's proud owner.
A cigar makers bench.
The Tropicana show in Havana.
Time to return to real life....
Friday, April 13, 2007
I'm back in Vancouver now for a few weeks before heading up to Inuvik for May. It was an uneventful trip back and this time my luggage arrived with me. Mine is the one on the middle of the conveyer!
Dr. H and I are taking a week long trip to Cuba, so the blog will be a bit quieter than usual for the next week. Stay tuned when we get back for more posts!
Thursday, April 12, 2007
Oh, it was wild and weird and wan, and ever in camp o' nights
We would watch and watch the silver dance of the mystic Northern Lights.
And soft they danced from the Polar sky and swept in primrose haze;
And swift they pranced with their silver feet, and peirced with a blinding blaze.
They danced a cotillion in the sky; they were rose and silver shod;
It was not good for the eyes of man - t'was a sight for the eyes of God.
It made us mad and strange and sad, and the gold whereof we dreamed
Was all forgot, and our only thought was of the lights that gleamed.
Woodcut by Mark Summers
The Northern Lights are one of the treats of northern Canada. They are whimsical, and fickle, and appear only when they choose. When they do appear they are entrancing. On this last trip to Iqaluit I had a couple of occasions to see the northern lights.
When I am covering Obstetrics in Iqaluit, I typically sleep at home unless things are busy or someone is near delivering. Home is only a 5 minute walk from the hospital, and most of the calls back to the hospital are not emergent. Babies rarely deliver precipitously, and when they do they usually do with or without a doctors presence. Delivering babies is a nice job. Mainly I am there in case things go wrong, in case a shoulder gets stuck, in case of a post partum hemmorhage, in case of anything other than a normal delivery. Most deliveries are, in fact, normal and in those cases I am simply in the background and usually enjoying being present at the event.
beeeeep beeeeep beeeeep, my pager wakes me from sleep. I am a slow thinker in the wee hours and usually take a second to get my bearings. On the phone the nurse tells me Hi Dr. J., we have a 20 year old primup, just came in, she's having good contractions and is at about 8cm so no rush. No rush means I have time to add a layer of long underwear, because even a 5 minute walk is cold on a -30 C night. My walk to the hospital takes me out the front door of the apartment building, and down across a large gully. The bottom is dark and the edges keep the lights from the building from creeping in. No rush means there is time to look at the sky. Even without the northern lights the sky is big, free at the edges, not confined to a frame, untamed. Twice on this past trip that walk to the hospital was full of fire in the sky.
It's hard to explain what the northern lights look like. I had my camera with me both times, and probably could have taken a picture. My camera has lots of settings, and would probably capture an instant of the lights. It wouldn't capture the movement though, the dance of the lights. Regardless, I didn't take any pictures. There was time, I was in no rush after all, but it simply didn't occur to me. I stood and watched the light play in the sky, and after a while resumed walking. Into the hospital, to catch a baby, hoping to have no cause for my pressence in the end. Hoping the lights were a good omen.
Tuesday, April 10, 2007
There are only 2 ways to get cars into Iqaluit: By sea-lift, the yearly shipping of goods from Montreal to Iqaluit by barge during the summer, and by air. Yes, believe it or not, people do actually fly cars into the city. As Iqaluit has grown and become a capital city there has been an influx of cars. As there are only about 40km of roads in and around town, and no highways, it is a bit surprising that cars are as popular as they seem to be. I would guess that the number of cars per km of roadway in Iqaluit is approaching that of other cities in Canada. During my last cab ride, I was surprised to hear the cabbie say that we would be taking a detour due to rush hour. There are no lights in town, but the 4-way stop was 5 cars deep in all directions. With skills no less than I would expect in grid-lock at Bay and Bloor, he zipped through 2 parking lots, around the back of another building and cleared us of the rush.
When I arrived here in Iqaluit I expected to see cars focused on utility, perhaps pickups, perhaps small cars that would cost less to ship. What I did not expect to find here were Hummers. In fact there are 3 Hummers here in Iqaluit, and Volkswagen buses, and all sorts of other cars you would never expect to find. It seems that in such a remote place the novelty is not just owning a car, but owning a novel car.
Below is perhaps the most novel car of all. I have no idea what it is used for or why it is painted this way (if you know please enlighten me!), but it always makes me laugh.
Monday, April 9, 2007
Lately I have noticed an increasing number of posts on medical blogs about medical students and residents being treated badly by the people who are supposed to be teaching them. At "medschoolhell" (a domain name that already suggests poor treatment) we read about the cruel whimsy that many medical students are subjected to by those who have power over them. Over at Panda Bear MD we read about how a senior and experienced resident is treated poorly, and then made to pay (by unfair evaluation) for not accepting the behaviour as appropriate.
Almost all medical students and residents will be able to describe being abused in some way during their training. In many ways the medical training system is set up in such a way that this abuse is predictable. The medical education system is complex, and subject to it's own set of peculiar social rules. Some of the factors that lend themselves to various forms of abuse include:
- Medical education follows a strict hierarchical model.
- Most medical teachers have received no education in teaching.
- Many medical teachers were themselves trained in abusive environments.
- When subject to abuse, medical trainees are often forced to disclose up the chain of command, with the first disclosure often to the abusive person them self.
- Medical trainees can be subject to significant reprisals for reporting abusive behaviour.
Evidence based medicine is a mainstream medical concept. Clinicians attempt to practice what has been shown to be effective through well conducted research, while discarding those practices shown to be ineffective. For some reason, however, this thinking has not gained any hold in the realm of education. The idea of evidence based education, or teaching using techniques that have been proven to be effective, is simply not a part of medical culture. In fact most medical teaching is based more on culture than on evidence. As a medical trainee any lament of poor treatment is likely to be met with 'I had it harder in my day', from whoever lives one rung up the ladder.
In addition to the necessary learning of factual information, decision making skills, and physical techniques medical education undoubtedly provides a function of socialization into the doctor role. It is this reason more than any other that is used to justify the maltreatment of trainees as an initiation rite, vital to the future functioning of the trainee as a doctor, rather than simply abusive behaviour. In fact, while maltreatment probably serves a memetic function, passing the abuse forward generation through generation of doctors, there is scant evidence that any initiation rite, abusive or otherwise, plays any important role in the actual practice of doctors.
Maltreatment itself exists in at least 2 important categories; that which is part of a supposed educational process, and that which is not. The latter is easier to deal with (in that is more easily shown to be inappropriate), and includes overt rudeness, hostility, threats, degradation, sexual harassment and physical abuse. These behaviours are objectionable to society in a broad sense, and resonate as inappropriate with virtually everyone. It is hard to imagine that it would ever be appropriate for a bank manager to throw a stapler at a teller as a logical consequence for an error, yet it is not unheard of for a surgeon to throw a scalpel at a trainee who has made a mistake (both acts are probably criminal assault). Behaviours that are not socially or societally acceptable aught not to be justified as teaching or initiation. As a group of adults, doctors of any level of training should be required (and require of themselves) to treat one another within the bounds of normative behaviour.
Maltreatment in the guise of education may seem a stickier point, though once dissected is equally unpalatable. The act of pimping (for the uninitiated, the act of rapid fire questioning until the point of error or beyond), first credited to Dr. Walter Koch, is such an example. In reality pimping probably stretches back to time immemorial. Hippocrates probably pimped Polybus about which of the four humors was most responsible for abdominal pain, and indeed the pimpers will often try to pass off the technique as Socratic questioning, or learning through induction. The essence of the Socratic method of course is that it is a dialectic technique, and probably most applicable to philosophy and non-absolute arguments (though of course Socrates did use his method to extract mathematical ideology from the non-educated). Medicine, at least in the way it is usually taught, is absolute in so much as the doctor at the top is the one with the right answer. So as a Socratic dialogue, pimping seems to fall short.
The idea of teaching through negative reinforcement is also frequently used to justify questionable teaching behaviours. Negative reinforcement, as logical unpleasant consequences of an unwanted action, does exist in medicine, though the term is often used to mean public humiliation or shaming. Indeed negative reinforcement has been shown to be a successful educational strategy...mainly in rat models. Applied to adult learners however, negative reinforcement, shaming, and humiliation produce only short term behavioural changes, that usually reverse once the negative stimulus is removed (i.e. when you move on to a new rotation.)
As a medical teacher I am far from perfect. I have a short attention span at the best of times, and lack many of the 'answers' that students seem to be searching for. I am sure that I frequently frustrate students when I say 'there really is no right answer.', or go off on a tangent with a patient telling me about some fishing trip they took 5 years ago (really, that is more interesting than how many salads they are eating these days). I will say though that I make an effort to be patient with students, to tell them they are doing a good job, and to try to build up their confidence. I admit to them that I too forget the results of the COMMIT study, and still (somehow) manage to practice medicine. And above all else, when I see a student or resident being bullied (because I think in the end we probably all see that this is all just grade 6 style school yard bullying) I attempt to extract them from the situation.
I think it is high time that the EBM folks stepped up to the plate with a new initiative: EBE (Evidence Based Education). There is simply no room for bullying and antisocial behaviour in medical education, not only because it is morally wrong, but also because it is simply ineffective.
Sunday, April 8, 2007
Yesterday the pediatric resident who is in Iqaluit at the moment (Matt) had a chance to go out hunting with some local folks. They did the hunting, and he took some great pictures. He asked to borrow my camera for the trip, and in return let me post a couple of pics on my blog. So thanks for the pics Matt! Here are some pics from their trip. Hopefully I'll get to go out on a similar excursion sometime!
Friday, April 6, 2007
I first encountered the term as a medical trainee. Dr. J., my preceptor of the day would say, be careful in there. This one's a difficult patient. With the sage words of warning in hand, I'd cautiously open the door to the exam room and peek inside. Even though I'd been warned, I never knew what I'd encounter on the other side. Sometimes the patient on the other side was angry, sometimes demanding, sometimes threatening to sue. Sometimes, however, it was hard to figure out why the patient was supposed to be difficult at all. The term difficult patient seemed to me to lack precision, so I started thinking about what it actually meant.
Patients who demand narcotics often obtain a label of difficult (often in bold red letters on the front of a chart), and these patients comprised much of my early exposure to the 'difficult' crowd. At first I thought the term might mean 'any patient who makes me angry', and many of the so described patients did seem to push the buttons of the people applying the descriptor.
As I progressed in my training I ran into other groups of 'difficult patients'. One group had the special code name 'non-compliant'. Sometimes I would peek around the door to see a nice little old lady with diabetes. How are your sugars?, I'd ask. Oh they're fine, don't worry too much about me. I brought you all some cookies today!, she'd reply. Are you doing okay with your pills? Well, I don't always take them because I feel good most of the time. Pleasent as apple pie, and not taking any of her doctors advice, I was forced to expand the definition to 'any patient who makes me angry or doesn't do what I say'.
Still, there were more 'difficult patients' to come. In fact there was a whole othe group of patients who were perportedly difficult, and required forewarning. For this group of patients the preceptor of the day would pull me aside and say This is a difficult one! They have such and such diagnosis, and we've tried everything. The diagnoses in question were a short list: Chronic pain syndrome, fibromyalgia, irritible bowel syndrome, dysthymia and chronic fatigue syndrome some of the most common. And so, the definition expanded again to 'any patient who makes me angry or doesn't do what I say, or who I can't fix'.
The final group of 'difficult' patients the group many of my preceptors seemed to fear the most. These were the patients in whom the presenting complaint was vague enough or subjective enough that there was no clear path of medical action. And the definition expanded again.
By the end of my medical training 'difficult patient' had come to mean 'any patient who makes me angry or doesn't do what I say, or who I can't fix, or who I don't even know what to do with'. As you might imagine such a wide definition lead to a lot of difficult patients, and a lot of stressed out doctors. As a resident some of the offices I worked in seemed to have labled half of their patients as difficult in some way or another, and the doctors working in them seemed to be nearly pulling their hair out with the stress of it.
Now I'll admit up front that for whatever reason I have a certain fondness for some of these 'difficult' folks, but as I finished up residency I gave some serious thought to why these patients were considered difficult, and what I could do in my own practice to preserve my own (already thinning) hair. If you boil it all down to it's essence it seems that all of these so called difficult patients fall into 2 groups: patients who are in some form of conflict with their doctor, and patients for whom the doctor has no idea what to do with. For each of these situations I've tried to use a few simple stratagies to keep from getting stressed out.
Some degree of conflict is unavoidable, but conflict itself is manageble (although doctors tend to be a highly conflict averse group...that could take up a whole other post). The most important point in conflict management is that it takes 2 sides to really have any conflict worth writing home about. So if an issue is really not that important I don't join the conflict at all. I've found that there are a few easy things that I can do to make almost all of my encounters with so called 'difficult patients' actually very pleasent.
- Let the patient have their say. If I think a patient is angry because they feel unheard I try (and it's hard) to keep my mouth shut for 5 minutes and listen to their story. Usually the story is over in 2 minutes, and the frustration on both sides decreases.
- I give my best treatment options to the patient, but I don't take it personally if my patients choose a different path.
- I apologize when I have inconvinienced my patients, and I empathize when my patients are inconvinienced by things beyond my control.
- When I don't know the answer I say "I don't know the answer".
- I try to have a non-medical conversation with my patients on the way to and from the waiting room.
In the end I think some of my patients probably think I am a little simple, but for the most part I seem to have avoided much of the stress in practice that seemed so ubiquitous to me as a medical trainee. Sure my hair is a little thinner than it used to be, but I think that's mostly a matter of genetics, and I'm back to thinking of 'difficult patients' as the ones with 10 different diseases at the same time.
Thursday, April 5, 2007
There are a lot of issues here to be solved, many of which I have commented on previously. The challenges can be daunting, but one of the potential benefits of coming here longer term is that there are so many ways to be part of solutions.
I'm looking forward to getting back to spring in Vancouver, and Julia and I will be taking a short trip to Cuba in in April. After that I am up in Inuvik for 4 weeks. It will be interesting to compare the 2 places, and see how they differ.
Overall I'd recommend a locum in Iqaluit to any doctor reading this blog. The work is interesting, and it is a nice and supportive environment. It's definetely like nowhere else I have ever been, and it's a really enjoyable experience!
Sunday, April 1, 2007
Is it true? Would we all actually be happy if only we had enough? If only we all got to have a new big screen TV every year? Would a new Escalade make us all happy? Would that give us the perfect life? The perfect family?
The idea that we can all somehow, and someday achieve sudden, fabulous wealth (and therefore happiness) with no significant effort on our part is pervasive in our society. The lottery myth has replaced the American dream. No longer are we happy to work hard over our lives to secure a healthy, happy, albeit modest, life for ourselves and our families. Instead we want it all, and we want it now. For those of us who can't have it all we want a piece, and we're willing to trade pretty much anything to get it (health, time with family, long term financial security). All the time we know, in the back of our heads; One day I'll win the lottery, then I'll be happy.
The result is the accumulation of stuff, any stuff really, all of it bought and paid for to increase our happiness, most of it now eclipsed by newer, better and shinier models, and now nothing but subtle clues that we haven't kept up with the happiness shown to us on TV.
Stuff begets more stuff, but somehow fails to beget happiness. Is it because the stuff we got is the wrong stuff, or do we not yet have enough stuff? Maybe the stuff we have isn't new enough? Why didn't the stuff work like it was supposed to? Where is the happiness?
Maybe we were all duped. Maybe all of the stuff was just well packaged snake oil. Maybe stuff isn't the answer at all. If we all got rid of the junk and clutter of stuff in our lives maybe we would be a happier bunch of people. Maybe it's time we looked back into the sleepy blue glow of the idiot box with murder in our eyes.
Above statements represent only the views of the writer. Murder is not advised. Results will vary by customer.
For further reading on the subject check out Reversal of Fortune in this months Mother Jones.