New doctors need to give up sense of entitlement

There are more doctors than ever before; yet two million Canadians can’t find one.

  image: davegranlund.com

An estimated 30,000 Kamloopsians don’t have a family doctor, although only about one-half of them are looking if national averages apply.

Something doesn’t add up. Why can’t Canadians find a doctor if there is a surplus? It’s complicated.

First, recent graduates of medical schools can’t find the residency they want. Without a residency, they will never become doctors.

This year, 2,980 will graduate from Canada’s 17 medical schools. They will compete for 3,308 residency spots. That would seem like every graduate should get a spot. However, 917 of those spots are in Quebec which means that there is a shortage for English-speaking graduates.

Then there is the arcane process of matching graduates to residencies which leaves some out. Health reporter André Picard says:

“But matching a graduate to a residency spot is a complex process, overseen by the Canadian Resident Matching Service (CaRMS). Medical students apply to CaRMS in one or more specialties; committees select who they wish to interview and rank them; graduates rank the programs and, finally, an algorithm spits out a match, and the student is legally bound to take that residency spot (Globe and Mail, May 1, 2018).”

Graduates have become pickier. They get assigned in residency specialties where they don’t want to work. As a result of preferences and the complexities of CaRMS, 115 graduates are unmatched this year. Jobs are waiting for them -there are 78 unfilled positions, 65 of them in family medicine.

The unmatched graduates have invested a lot. They have accumulated an average debt of $100,000 during four years of training. Taxpayers have invested a lot. We are on the hook for their subsidized education. The cost of training a medical student is $250,000.

Also, some graduates want a regular job where they work only 40 hours a week as in a hospital in a so-called “hospitalist” position. At $150 an hour, a hospitalist makes $300,000 a year with no overhead. Compare that with a doctor in his own private practice. After paying staff and rent, a doctor would have to earn $400,000 a year to take home that much -and they’d work longer hours with less medical equipment and fewer support staff such as nurses. But there are only so many hospitalist positions.

One-half of Canada’s physicians focus on sports medicine or palliative care says Dr. Danielle Martin on CBC’s the Current:

“. . .they’re not practicing what we would think of as full scope full service cradle-to-grave primary care family medicine, and that is what those people who are lining up at Dr. Pengilly’s clinic and asking [for a primary caregiver].”

Doctors need to abandon their sense of entitlement says Picard. We need more general practitioners, especially in small cities and rural Canada. Enrolling in medical school doesn’t entitle graduates to jobs wherever they want, in the speciality of their choice.

“Becoming a doctor is hard,” says Picard, “It’s also a privilege. We need a system that ensures the right doctors are working in the right places, not on where personal desires can trump societal needs.”

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Self-administered death made easier

A new drug in Canada will make medically-assisted death easier. It can’t come soon enough.

image: Bayshore Healthcare

If I had a terminal illness that made my life a living hell, I would want medical assistance in dying (MAID). Since it has been legal in Canada since 2016, it should be easy. All I have to do is find a doctor who is willing to administer the drugs. And then make sure I’m living in the right place -that’s where things get tricky, as Horst Saffarek found out.

Horst Saffarek lived in a Catholic residential care facility in Comox, B.C. When his lungs began to fail, he wanted help in dying. The publicly-funded Catholic institution wouldn’t allow MAID at their facility, citing moral principles.

Horst was becoming frailer each day and breathing became difficult. His daughter, Lisa Saffarek, told CBC’s The Current:

“It’s scary, you know, especially when you can’t breathe, every moment is scary.”

Horst was faced with the choice of essentially suffocating to death or he could be transferred to a facility that allowed MAID. He was transferred to Nanaimo where he would have to wait ten days as required by law.

I can only imagine the terror that he was going through: struggling with every agonizing breath and seeing relief being delayed.

“Dad was obviously very frail,” said Lisa Saffarek, “We did need to transfer him. He was ended up, you know, his oxygen levels were falling, and we wanted to try and meet his wishes.”

The transfer from Comox to Nanaimo, an hour and a half ride by ambulance, was gruelling. Horst Saffarek died the day after the transfer without the comfort of MAID.

Not only was Horst Saffarek’s suffering needlessly prolonged, but his family felt anguish as well. Lisa and her sisters had planned to spend the last moments of their father together but they were robbed of that:

“But it just – it took away from us being able to celebrate dad and just to enjoy our last moments with him.”

The law protects doctors by allowing them to opt out of MAID. Institutions have no such legal option. Religious healthcare facilities receive public funding same way that others do. If a procedure is legal, and public funds are involved, how can an institution prohibit it?

In small centres like Comox, religious healthcare facilities are the only ones in town. Because they employees are not necessarily religious, and neither are the patients, the title “religious facility” loses meaning. In reality, they are public facilities with an historic religious origin.

The solution is to take matters into one’s hands. A new drug has been made available to make that happen. Secobarbital, the most common drug used in many countries, is now available in Canada. Unlike existing drugs that can take a long time, Secobarbital is fast-acting, doses are a relatively small in volume, and self-administration is easy.

Existing drugs can take hours, even days, to work. They taste bad. They don’t work if they cause nausea and vomiting, or when the patient falls asleep before consuming the large volume required.

For those who suffer from an agonizing terminal illness but live in remote or small communities where there is only one doctor who doesn’t provide MAID, or they live in a care home that decides to flout the law, Secobarbital could provide relief.

Horst Saffarek’s experience leaves me wondering why I should suffer the vagaries of the anachronistic legacy of institutions, and other’s moral values, that impose themselves on my life and death. Whose life is it, anyway?

 

 

His health, her health

Medications affect women differently than men but you wouldn’t know it from prescribed drugs.

Take the sleep drug Ambien, for example.  After the drug had been placed on the market, it was found to have a dramatically different effect on women. The U.S. Food and Drug Administration found that five times as many women were experiencing driving impairment eight hours after taking the drug. As a result, doctors now prescribe “sex-specific” Ambien which is a lower dose. In Canada the drug is sold under the name Sublinox. But sex-specific prescriptions are the exception rather than the rule.

Doctors prescribe the same drugs for men and women even though they have only been tested on men. Researchers have known about this weakness of drug trials for a long time. Dr. Marcia Stefanick, professor of medicine at Stanford University explains:

“Indeed, drug metabolism, tolerance, side effects and benefits differ significantly between the average man and woman for many widely prescribed medications, with women having a 50 to 70 per cent higher chance of adverse reaction (Scientific American, September, 2017).”

Despite knowing of the difference, few women are included in trials. In a review of 258 trials of cardiovascular treatments, only 27 per cent of the participants were women, and of those only one-third were reported by sex.

Despite years of “Red Dress” campaigns, most people and many physicians still think heart disease is a man’s disease. They are surprised to learn that heart disease is the number-one killer of women, far exceeding deaths from breast cancer. Physicians are less familiar with the symptoms of heart disease in women. In men, the main symptom is chest pain, whereas in women symptoms can include back pain, nausea, headache and dizziness. Women’s symptoms are seen as “atypical” because men don’t report them.

Chauvinistic blindness excludes half the population.

Heart disease also involves the build-up of plaque in the arteries. Men, and older women, tend to suffer from a blockage in one location. Younger women are more likely to have diffuse plaque along the entire artery with the same effect. Because a local block is not found in a younger woman, she could be diagnosed as “free from of heart disease” even though at risk of a fatal heart attack.

The other sex is sometimes overlooked in trials. Men are often neglected in studies for ailments thought to be unique to women. Osteoporosis, characterized by reduced bone strength, is considered a woman’s disease because white women are twice as likely to suffer a bone fracture as white men. As a result, fracture prevention trials include few men. But one-third of hip fractures are in men –and they have worse medical outcomes than women

Men are more susceptible to viral, bacterial, parasitic and fungal infections than women; the exception being sexually transmitted infections such as HIV and herpes which is more prevalent in women. However, women’s resistance to infection comes at a price. Women constitute 70 per cent of cases where a robust immune system attacks her own body in autoimmune diseases.

Professor Stefanick lauds the Canadian Institutes of Health Research for promoting the inclusion of sex and gender in drug trials and wishes the U.S.  Government would do the same. She adds:

“We need further mandates, through policy and funding restrictions, to ensure that female biology makes it into textbooks and testing protocols.”

Blockchain could improve food security

The future of cryptocurrencies such as the bitcoin might be unclear but the technology behind it is solid. Blockchain is the digital ledger where bitcoin transactions are kept. It’s transparent, secure and open for all to see.

    image: Realty Biz News

The origin of blockchain is mysterious. Some person, or group, with the anonymous name Satoshi Nakamoto is credited with inventing blockchain. Who this person is remains obscure.

Blockchain’s usefulness goes beyond cryptocurrencies. Its property of transparency could improve food security. Sylvain Charlebois, professor in food policy and distribution at Dalhousie University explains:

“Blockchain technology allows for users to look at all transactions simultaneously and in real time. In food, for example, a retailer would know with whom his supplier has dealt. Additionally, since transactions are not stored in any single location, the information is almost impossible to hack (Globe and Mail, December 13, 2017).”

If you are buying pork chops in a grocery store, for example, and wanted to know the complete history the animal before you buy, you could scan the QR code on the label and within seconds know the date of the animal’s birth, use of antibiotics, vaccinations, and where the animal lived. (QR codes are a type of bar code in the shape of a square.)

The Public Health Agency of Canada reported earlier this month that 21 people became sick after eating romaine lettuce. While PAHC knew what caused the illness (E. Coli 0157) they didn’t know where the lettuce came from. Tracing contaminants can be a matter of life and death.

“Every year, more than four million Canadians get food poisoning. In recent years 474 cases of [the deadly disease caused by E. Coli 0157] have been reported annually,” says foodqualitynews.com.

Big Food is considering blockchain as way of tracing contaminates. Wal-Mart sells 20 per cent of all food in the U.S. and tested blockchain compared to standard methods of tracing food. They traced the source of mangoes in one of their stores using the standard method and it took six days, 18 hours, and 26 minutes to trace the fruit back to its original farm. Using blockchain technology, it would take 2.2 seconds for anyone –consumers and suppliers alike- to find out anything they want. And it would prevent good food from being thrown out.

“During an outbreak of a food-related health scare, six days is an eternity,” says Prof Charlebois, “A company can save lives by acting quickly. Blockchain also allows specific products to be traced at any given time, which would help in the reduction of food waste. For instance, contaminated products can be traced easily and quickly, while safe foods would remain on the shelves and not in landfills.”

Blockchain won’t be implemented without the involvement with everyone along the food chain. The record will only be as good as the data entered. Giants like Wal-Mart can force supplier participation.

Governments could also force compliance. With the health of consumers at stake, regulated participation would make the records complete and useful.

Cryptocurrencies may be a fleeting gimmick to have investors part with their money but let’s not throw the blockchain out with the bitcoin.

Doctors beware: this opioid is not listed

Doctors rely on Canada’s Controlled Drugs and Substances Act as a guide in prescribing drugs. Tramadol is not listed there but that could change soon.

image: Tramadol dropshipper

Tramadol is a sneaky drug, as Dr. David Juurlink discovered when a patient with a shoulder injury was prescribed tramadol. On the positive side, tramadol relieved the shoulder pain. Then problems starting showing up says Dr. Juurlink:

“The first sign of trouble arose three months later. His shoulder pain gone, the patient assumed he no longer needed tramadol. He was wrong. Shortly after stopping it, he developed debilitating insomnia, shakes and back pain – something he’d never experienced before. Irritable, exhausted and functioning poorly at work, he soon found the solution: All he needed to do was keep taking tramadol, and these problems went away (Globe and Mail, November 27, 2017).”

There are two outcomes of being hooked on drugs. One is a physically dependence, such as exhibited by the above patient. The other is addiction in which a patient’s health deteriorates and their behaviour is transformed –what we usually think of as addiction. This patient needed the drug for no other reason than to avoid the debilitating effects of not taking the drug.

The reasons why tramadol is not listed are complex. First, the way that it affects patients depends on their genetics. Tramadol acts as if it were two drugs. It relieves pain using the same mechanism as aspirin does but for some with a particular enzyme, it converts to an opioid. Only 6 per cent of Caucasians have the enzyme, whereas 30 per cent of those of East African or Middle Eastern decent will experience opioid conversion.

Tailor-made drugs, specific to a patient’s genetics, hold future promise. That would allow doctors would know in advance whether a patient has the enzyme or not. For now doctors roll the dice in prescribing tramadol.

Second, when Health Canada last reviewed tramadol in 2007, during the era of the Harper government, a libertarian regime affected policy. Manufacturers of tramadol lobbied Health Canada directly and indirectly to keep the drug off the list. Manufacturers peddled the “dual mechanism of action” of tramadol without disclosing just what that meant. Indirect lobbying came in form of financial support to at least one patient advocacy group who wanted to keep the drug freely available.

The Holy Grail of pain-killers would be one as effective as opioids without the side effect of addiction. Researchers have been looking or more than a century. The German drug company, Bayer, marketed a cough suppressant derived from morphine under the trademark Heroin in 1895. It was marketed as being non-addictive.

More recently, OxyContin was marketed as a pain-relief drug “without unacceptable side effects.” Doctors believed that they were prescribing a safe drug but OxyContin proved otherwise. Patients who took it for pain relief got hooked and when prescriptions ran out, they went to the streets in search of substitutes.

Under the Trudeau government, Health Canada is considering placement of tramadol under the Controlled Drugs and Substances Act –where it belongs. Whether it is listed or not will be a test of a government’s resolve to put the health of Canadians above commercial interests.

No going back on abuse of women

What was once a trickle has become a torrent of reports from women of how they were groped, fondled, molested, assaulted, raped, and verbally abused; how they fought off the unwanted sexual advances of men.

   Sergeant Vicky-Lynn Cox. Photo: CBC

High-profile reports have come out of the entertainment industry. Actress Daryl Hannah told the New Yorker about the consequences of rejecting film director Harvey Weinstein’s advances: “We are more than not believed – we are berated and criticized and blamed.”

Harassment and assault on women takes a toll. Globe and Mail columnist Elizabeth Renzetti talked to dozens of women:

“Some of the women I heard from are in their 60s, 70s and 80s. The pain they carried through the years is palpable. In many cases, they knew what was happening to them was wrong, even if the culture at the time was more accepting of predatory behaviour. Often they told no one. They felt shame for not speaking up or acting. Sometimes that shame has been corrosive though the years and, in other cases, women have pushed it aside (November 18, 2017).”

It’s not just the world of entertainment. Women from many walks of life are speaking up. Sergeant Vicky-Lynn Cox of the Canadian Armed Forces told CBC Radio’s The Current:

“My first incident, without going into detail about my first incident, happened three weeks into the military. From that point on I didn’t really sleep soundly for the next 20 years. I’m approaching on 21 years of service. So I’m recovering from that. For years and years, I didn’t say a thing and for years and years I tolerated the environment around me because of the love of my country and the love of my work.”

Three Canadian comediennes spoke to The Current about the problems they faced. Michelle Shaughnessy said that male comedians think bad behaviour can be excused by saying that it’s just a joke:

“I know there was one incident where a colleague who was a friend, like I think it was kind of like the equivalent of like a drunk dial type thing. Actually sent me like a picture of their penis like the middle of the night, when obviously they had been drinking too much . . . you can mention it to these guys and their first defence is ‘were all comics. It’s a joke.’”

Women who were once afraid that they wouldn’t be believed, who were told “that’s the way it is,” are now speaking up.

It’s no joke. A shift in culture is happening. The more women who come forward, the more that others will be encouraged to do so. And as more women move into positions of power in corporations, government, police, clergy, and the military, the more they will be believed. “The tide is turning,” said Leeann Tweeden, the former model who has accused Al Franken: the high-profile writer, comedian and senator. It’s not enough that Franken “feels terribly” about the accusations.

I have a selfish reason to see the end of bad behaviour by men. I want to live in a society where women don’t have to suspect and fear men. The predatory and toxic actions of men are a burden on us all.

My beef with Canada’s new food guide

Canada’s new food guide is being influenced by agencies whose chief focus is the consumption of their products, not our health. Food industries and a branch of government, Agri-food Canada, are resisting proposed changes by Health Canada.

     Proposed food label. Image : Globe and Mail

Health Canada wants the new food guide to “shift towards more plant-based foods,” less red meats, and to limit “some meats and many cheeses” high in saturated fats.

These are sensible recommendations but not what Agri-food Canada wants. They are in the business of promoting the sale of red meat and dairy industries. AAFC officials wrote a memo marked “secret” in which they worried:

“Messages that encourage a shift toward plant-based sources of protein would have negative implications for the meat and dairy industries (Globe and Mail).”

Yes they would have negative implications but the health of Canadians trumps the meat and dairy industries.

Canada’s food guide is widely respected. Seventy-five years after its first launch, it’s the second most requested government document after income-tax forms. It’s distributed to dieticians and doctors for patient advice, and to schools and hospitals for creating meal plans. The new guide will be around for a long time, so it’s important to get it right.

The current guide, revised in 2007, had a number of flaws. It recommends juice as a serving of vegetables and fruit. It recommends two servings of “milk and alternatives” and two servings of “meat and alternative.” Juice is not a substitute for whole fruit and vegetables. Too much red meat and saturated fats are unhealthy.

There are problems with the “Nutrition Facts” label as well. The serving size is not standard so that breakfast cereals, for example, may appear to have similar calorie content but, in fact, differ because the serving sizes vary.

Health advocates recommend that the new Nutrition facts label be moved from the back to the front of the package, and that foods which are high in salt, sugar, or saturated fats have a “stop” or “yield” sign. At a meeting with Health Canada in September, food and beverage industry reps were furious. They called the warning a “big, scary stop sign,” and that the signs were overly simplistic. They prefer detailed labels on the back rather than blunt symbols on the front. A lawyer for the food industry argued that Health Canada was not giving Canadians the respect they deserve: “They’re not idiots.”

Canadians are not idiots but they’re not nutrition specialists either. The food industry would rather have detailed specifications on the back because many shoppers find them hard to interpret.

The food industry complains that plain symbols like stop and yield signs would make consumers think they are “like a chemical warning sign.”

But warning symbols are appropriate because some foods are unhealthy. More than one-fifth of Canadians are obese. Diet-related chronic illness costs our health care system $7 billion a year. Heart disease and stroke are the leading cause of death.

Under the Harper government, the AAFC held sway. When Health Canada wanted to revise the guide back then to “choose local or regional foods when available,” the AAFC vetoed it. We’ll see how determined the Trudeau government is in shaping a healthy food guide. Will the government defend the health of Canadians or the food industry?