Friday, December 10, 2010

Winter is coming...

Or, since it was -6 today, it's already here. No snow to speak of though. I've now finished one-quarter of my mandatory clerkship rotations. Only surgery, emergency medicine, family medicine, psychiatry, and internal medicine to go over the next 40 weeks. Yay. I did really enjoy obs/gyn, though, and there is something remarkably satisfying about being involved during what is generally a very happy time for parents and families.

Otherwise exams are done and I have a bit of a reprieve to contemplate the Big Questions about career choices and such. I've enjoyed peds and obs/gyn, prefer more acuity and more "interesting" cases, and I like patient care. I don't really see myself going into peds - the inpatient work is interesting, but general peds clinics are a lot of reassurance and issues like ADHD and constipation. Obs/gyn is another matter - I hadn't really thought of it as a surgical specialty as such before, but it certainly is. Gyne problems aren't especially interesting - but the oncology is - and obs is attractive for the reasons above. Still, it may be a bit too specialized...

In the end, it's still down to a more "medicine approach" to surgery (i.e. general surgery) or a more "surgical approach" to internal medicine (i.e. GI or cardiology). Neuro gets thrown into the mix too; even though it's historically been one of the least interventional specialties, it's changing rapidly. We shall see. For surgery, the real issue is the extent to which I can manage the early mornings over a long term. It sounds simplistic - I can certainly get up okay - but taking on such a daily schedule is five years of residency is something to consider carefully. Oh well. I managed fine when on gyne, and it will probably be the same come January.

On verra...

Saturday, October 16, 2010

One more week of Peds...

Some things I've learned whilst doing my pediatrics rotation:
  • You can never write too many notes.
  • There's always something you will forget to do or ask on history.
  • The kids *are* cute, but don't go sticking the otoscope in their ears at the beginning of the exam.
  • ++social issues
  • It's spelled "paediatrics" in New Brunswick.
  • Lectures via teleconference are of variable usefulness. We like the mute button though.
  • You will sleep at least a bit while on call.
  • You get used to taking first call quickly. Just call the staff.
  • Residents enjoy giving advice.
  • Late night grilled cheese (on whole wheat of course) is the best part of call shifts.
  • Clinics are sometimes interesting, but the floor is always better.
  • Nurses make excellent conversationalists day and night.
  • Handover is the most important part of the day... especially when you're handing over to yourself, or would be if you weren't post-call.
  • The "post-call" day can still keep you at the hospital til 5. That's afternoon teaching for you.
  • Code White announcements occur with alarming frequency. You will have come close to calling one.
  • The parents range from wonderful and congenial to... not so much. They are stressed and worried, though.
  • Normal babies spit up a lot.
  • A baby is always better heard crying than not.
  • Taking initiative is encouraged and welcome but may not be noticed.
  • There are lots of constipated kids out there.
  • Call room beds are extremely uncomfortable.
  • Scrubs are extremely comfortable. And wearing them all day makes up for having no effective post-call day.
  • NICU is a weird place. Especially since many of the babies don't have names chosen.
  • The staff are nice. So is Journal Club.
  • You may technically work as much as 100 hours one or two weeks of a six week rotation. Usually not nearly that bad.
  • An online system which includes orders and vitals is sublime. It will be missed.
  • Lastly, you will never want for homemade baked goods, candy, chocolates, or popcorn while working on the floor.
  • Oh, and boil water orders are annoying.

Thursday, September 23, 2010

Clerkship is great

We'll see how I feel after Fri/Sun call this weekend. And now a semi-random clip from Scrubs featuring everyone's favourite internist:

Wednesday, September 8, 2010

Last Post on the "Liberation" Treatment

Well, hopefully. I'm listening to this, an interview with an MS patient who underwent (I assume) balloon venoplasty in Bulgaria. He notes "gradual improvement", but his own descriptions of his symptoms do not sound entirely dramatic. Or notable at all really. The patient correctly notes that current studies underway aim to determine whether, in the first place, MS patients have "blocked" veins and whether there is an association between such "blockages" and MS. Since the so-called liberation treatment in principle treats such blockages, it seems, a priori, that determining the presence of such blockages and their association with MS is, ya know, paramount. You don't treat a "blockage" that has no clinical consequence and you don't treat someone for a blockage that they don't have. A patient with chest pain doesn't go straight to the cath lab.

I've also noticed something curious about most of the anecdotal reports of symptomatic improvement following (or even during!) the procedure; patients seem to report increased ease of movement, which improves with increased activity to some degree. I even came across a blog a while ago detailing a patient's course while following a physiotherapy regime post-procedure. On one hand, it seems clear that the "liberation" treatment conveys a significant positive placebo effect, to the point that patients report instant improvement on the OR table - which itself is as clear a sign as any that the procedure has no intrinsic therapeutic effect (repair of MS-damaged white matter on such an instant basis isn't just implausible, it's impossible). Conversely, it seems that patients see some improvement with increased activity and/or direct participation in physio, which is not altogether unexpected. If there are to be any trials of the "liberation" treatment, I think it would be prudent to control for such factors or even to include physio as a treatment itself. I'd bet money that patients attending and participating in regular physiotherapy do better on several functional outcomes than those who don't (controlling for MS progression variables), and that any effect attributable to physio would exceed any observed effect of invasive venoplasty (if there is any). Of course, in light of the questionable association between CCSVI and MS (i.e. pending verification from groups NOT associated with Paolo Zamboni), such trials of the "liberation" treatment are premature.

Monday, September 6, 2010


Well, sort of:

One week til being "on service" and getting a call schedule. Clerkship's pending...

Thursday, August 12, 2010

Alberta > Saskatchewan

At least insofar as the MS/CCSVI controversy goes:
Many people hope that CCSVI will prove to be the cause of MS but, at present, this idea is not supported by fact.
Alberta Health Services has compiled an excellent fact sheet about the issue, answering all the canards and faulty bits of reasoning brought up in the debate.

Tuesday, August 10, 2010

It Begins

Clerkship, that is. I'm excited to say the least. My rotations, beginning Aug. 30th and finishing mid-September 2011:

Introduction to Clerkship
Obstetrics and Gynecology
Year 3 Elective
Surgery and Emergency Medicine:          
General Surgery
Emergency Medicine
And then...
(Exams + OSCE)
Family Medicine
Internal Medicine:
Medical Teaching Unit
(Exams + OSCE)

Exciting! I'd like to do radiology for my elective, but I may have to settle for something else. We don't really get paid for clerkship, but there's a modest stipend ($2800) and $50/week for up to 12 weeks spent outside HRM. Total time off = 3 weeks over 55 weeks. I'm generally really happy with my schedule and rotations; not only did I get almost all my top choices, but I'm looking forward to being able to figure out the Great Surgery Question relatively early on. It's not like I usually see much of the sun in January/February anyhow. On y va!

Thursday, August 5, 2010


A small addendum to my last post (picture from here):

You know, it's really quite strange that Dr Zamboni is examining what look to be plain film CT or MRI slices in an old-fashioned radiology viewing room. First, why is he using such antiquated technology? I've never even seen such plain films, and I've looked at many, many head CT/MRIs this summer. Is this some sort of promotional picture for the media's benefit? Second, Dr Zamboni is neither a radiologist nor a neurologist nor a neurosurgeon and his papers concerning both CCSVI and the "liberation treatment" do not actually provide any data about changes in MS lesion distribution before or following treatment. So, what's up with this? It's certainly a nice stock photo of him doing something "doctorly", but I'm unclear. Some of the most recent evidence is not, however:
The first study, out of Germany, involved 56 MS patients and 20 healthy patients. Scientists did ultrasound testing and other imaging exams and found blood flow was normal in all, except for one MS participant. A smaller study out of Sweden that involved 21 MS patients and 20 healthy patients used magnetic resonance imaging to compare blood flow and reached a similar conclusion.

“In this quite small study we find no support for venous vascular surgical treatment and we are not able to confirm the Italian theory,” lead researcher Peter Sundstrom of Umea University in Sweden said.

Dr. Zamboni’s study of the degenerative condition involved 65 patients, who underwent angioplasty to clear blockages. Many in the medical community have been skeptical of his work because it is preliminary, with a small sample size, and has been heavily promoted before going through the rigorous research process.

Yet hundreds of MS patients, including a few Canadians, have travelled to India, Poland, Bulgaria and a few other countries for the surgery. Most say they have increased energy and mobility, but others have described little change. The treatment has led to injury in some cases.
Hmm, indeed.

Thursday, July 29, 2010

Head, Meet Wall

Well, Brad Wall, that is:
Saskatchewan Premier Brad Wall bolstered his support for a controversial multiple sclerosis treatment on Monday, predicting clinical trials could launch in the province as early as next year.

“I do believe there will be a solid proposal before the end of the year,” he said, urging other provinces to collaborate. “I think there’s a chance we’ll see potential trials in the new year.”

On Tuesday, Mr. Wall broke ranks with his provincial counterparts, vowing his government would finance liberation therapy, an experimental method of opening veins in the neck and spinal cord to combat the symptoms of the nerve-wasting disease.
While I do find it unseemly that politicians like Premier Wall have seen fit to intervene/interfere in research programs, the "head smashing" element comes more from the way the so-called liberation treatment has been treated in the media.

First, the very term "liberation treatment" itself sounds more like the work of a scam artist or at least a PR hack. Second, many articles or stories on the controversy seem to construct a narrative of desperate, hopeful MS patients set against skeptical neurologists (possibly in collusion with "Big Pharma") and governments. Certainly, most internet commentators seem to follow that pattern, arguing that the treatment (a sort of venous angioplasty) is common place (it isn't), perfectly safe (nope), and warranted even in the absence of symptoms or evidence of any connection to a disease process (definitely not). There is more than a little bit of lay person ignorance on display - conflation of arteries and veins, ignorance of anatomy and hemodynamics, and a lack of understanding of physiology. The general attitude that, since the procedure provides hope, and anecdotal reports have been favourable, we needn't bother with properly conducted clinical trials or research and simply began booking expensive imaging studies and scarce time in the cath lab for patients who may neither need nor benefit from the treatment. I think Colby Cosh at Maclean's has said it better, though:
How could anyone be so pessimistic? Well, even leaving aside the history of MS quackery and hype, there is no shortage of circumstantial reasons. The “liberation therapy” tag is an obvious mark of heavy con-artist and/or halfwit involvement in the publicity effort. Why not go all the way and just call the Zamboni technique “super amazing unicorn magic”? In newspaper accounts (and even in our own exemplary coverage), recipients of the therapy often report renewed energy without necessarily enjoying total relief from symptoms; this may not be a sign of the placebo effect at work, but it is certainly consistent with it. And it is hard to understand how the instantaneous improvements so often described by the “liberated” can possibly be consistent with Zamboni’s actual theory of MS etiology—i.e., that poor drainage of blood from the brain encourages, over a long term, the formation of cerebral iron deposits that then lead to immunological issues and demyelination of the nerves.
He's completely right on the last point, of course - even if the "liberation" treatment worked, the effects would not and could not be seen immediately, let alone within seconds or minutes of angioplasty (as seemed to occur with a woman interviewed on the National last night, who reported instant resolution of numbness in one finger). Hope is a great thing, and the placebo effect is non-trivial in these cases - to say nothing of the impact of individual psychology. However, as one of my colleagues has said in the past, "Hope is not a plan." Brad Wall should stick to politics, but should surely resist political pressure to interfere in things he shouldn't.

Wednesday, July 21, 2010

Reminding the Globe come election time...

The Globe and Mail writes in an editorial:
Good government is about leadership – focusing the population on the important challenges of the future, not distracting them with sideshows – and management: inspiring an organization to do the best work of which it is capable.
This was in reference to the news that the chief statistician has resigned due to the government's decision to eliminate the mandatory long-form census.

Now, in each of the past two federal elections the Globe has endorsed the Harper Conservatives when it came down to the wire. Yet I cannot think of a single time when they have shown the kind of leadership that this newspaper describes in the quotation above. I would hope that they remember this when writing their electoral endorsement prior to the next vote. The Liberals may be listing without a rudder, but I'd sooner have bland competence over the kind of authoritarian "vision" on display in the Harper government.

Saturday, July 17, 2010

Further to that whole census thing...

If Jeffrey Simpson is to be believed, I should have given Tony Clement a little less grief the other day:
Last fall, Prime Minister Stephen Harper decided his government would oppose the mandatory long-form census. Since then, nothing has changed his mind. His right-wing ideology and political instinct combined to make a policy that’s being denounced by almost every leading institution and commentator in Canada.

His decision was also opposed inside the government by Finance Minister Jim Flaherty and by Industry Minister Tony Clement, who’s responsible for Statistics Canada, the agency that administers the census.

Both wrote to the Prime Minister, underscoring the importance of the mandatory long-form census to compile the most accurate statistics on which so much public policy and private-sector decision-making depends. The issue went back and forth inside the government, but, as with everything in Mr. Harper’s Ottawa, the Prime Minister decides.

His is a government in which most ministers are reduced to silence, except for those kept on short leashes, and in which everything, down to astonishingly small details, are decided by the Prime Minister, and only by him. His mind can be changed, but only occasionally and usually only after the passage of time between his initial decision and a new one. In this instance, despite internal discussion, his initial decision has stuck.
So, as ever, I can assign the blame to Harper himself. Yet it seems plain to me that a cabinet minister in this position ought to have the courage of his convictions and resign. Flaherty too. Would that damage the Harper government? Absolutely - and so it should. Where are the conservatives who favour good policy over this asinine autocratic nonsense? Is it just about ideology?
Clement’s statistical illiteracy is so profound it gives one vertigo. The notion that simply making the sample bigger can’t fix a skewed sample is something undergraduates learn in first-year classes, yet is somehow beyond the mental grasp of a senior minister of a G8 country. And the comedic benefit of watching Clement fail first-year economics is undermined by the cold realization that he fundamentally does not understand the intellectual foundations of the files that he controls. When he is cornered by his intellectual betters, moreover, Clement’s instinct is to reach for the debating-hall comforts of cheap populism.


There are libertarians and there are libertarians. When it comes to Tony Clement and James Moore, theirs is not the principled and defensible small-government ideology of Friedrich Hayek and Milton Friedman. It’s more like the sweaty-palmed fanboy libertarianism forged by too many late nights in high school spent switching between the anti-feminist Nietszcheanism of Ayn Rand and the corporatist space fantasies of sci-fi writer Robert Heinlein.
I consider it a gross failure of the uttermost negligence by the press and - ahem - the Official Opposition that this cabal of morons remains ensconced in power.

Thursday, July 15, 2010

A few changes for health care

  • Eliminate pagers (replacement value: $375) in favour of secure hospital-issued mobile phones.
  • Move to electronic medical records integrating primary and hospital/specialist-based care. Family physicians don't need to be sent entire inpatient charts, but they need to have access to them when relevant. The reverse goes for hospital-based physicians and other health care workers.
  • How about handheld devices instead of print-outs of patient lists? What is not lacking is the technology so much as the integration of technology.
  • More long-term care beds and rehab facilities (community and hospital-based). Far too many patients waiting for ALC or rehab languish in acute care wards that do not provide an ideal environment for them. And it's wasteful.
  • Centralize referrals/wait lists to expedite investigations and follow-up. Triage these to determine who is waiting and why.
These's more, of course, but these are just random thoughts that've come up on my elective in the past few weeks. It's probably a good idea to hire more nurses too.

About that long form census...

It goes without saying that the Harper government's decision to eliminate the mandatory long-form census, replacing it with a voluntary survey, is beyond stupid. They claim that the mandatory survey is "coercive" and an invasion of privacy. Or something:
In a written statement Tuesday, Clement said the short-form census, which is still mandatory, will provide a sufficient demographic picture of the country.

"The government does not think it is necessary for Canadians to provide Statistics Canada with the number of bedrooms in their home, or what time of day they leave for work or how long it takes them to get there," Clement said. "The government does not believe it is appropriate to force Canadians to divulge detailed personal information under threat of prosecution."

Garneau argued Clement does not understand how scientific data is gathered or used, and that the census has to be mandatory to get responses from a wide variety of people. He said that information from the long-form census is essential for the development of sound government policies.
I'll leave aside the fundamental reasons why this is a stupid idea and address Clement's comments directly. First, it's worth noting that nothing in the census data will, in the end, reflect any individual information. Second, Clement's own examples seem rather important to me - commuting time, for example, is a rather good proxy for the likes of traffic congestion and patterns of daily movement. The question of where people work vs. where they live, and how far they must travel daily, is of pretty obvious relevance to urban planning, highway construction, public transit, and a host of social policy issues. I'm not sure what about such questions is overly "personal" either.

So what's the real problem? Well, while it's nice to think that a voluntary survey would achieve a sufficiently high response rate, this strikes me as doubtful. Currently the mandatory survey is sent to 20% of Canadian households (I presume these households are chosen randomly). The line from the government seems to be that a voluntary survey might reach a larger number of Canadians, and that this would be superior to the mandatory survey of 20%. This is, however, wrong. Any kind of survey of a population contains some element of sampling error. You can actually predict the size of this error by choosing an appropriate sample size. Now, 20% of Canadian households is a big sample. REALLY big. The sampling error implied by such a large sample is very small, so small in fact that increasing its size to 25% or even 50% of households will not make a significant difference. Happily, because this survey is mandatory, there is minimal non-response and so the results of the sampling are said to be "unbiased".

Unfortunately, a voluntary survey leads to an unpredictable degree of non-response bias in the results. Bias is a form of structural error in a statistic that cannot be eliminated by increasing the sample size (which is not important in this case anyhow). We can imagine that poor people (or wealthy ones) or anarchists or libertarians or contrarians or any other sort of socioeconomic or political group might be more or less likely to respond to a voluntary survey. That's bias. And it means that the results of the survey may not - and almost certainly will not - be representative or generalizable to the Canadian population. That's a demonstrably inferior survey sample - less reliable, less accurate, and in ways that are difficult to quantify. We can estimate sampling error fairly readily, but that does not hold for sampling bias, since it requires a great deal of information about the sources of bias. Of course, without the mandatory long-form survey, it seems unlikely we'd know why particular people failed to respond to a voluntary survey. Quite the catch 22.

So, Tony Clement, with respect to this:
“I am not saying it's every Canadian, but I am saying there are Canadians [who complained] and we should try to accommodate their concerns in a balanced way,” he said.

He added that he took the privacy concerns to Statistics Canada and asked they be incorporated into the next census. “They gave me options and we chose one of those options,” he said.

“This is a methodology that Statistics Canada offered to us and if it's good enough for Statistics Canada, it should be good enough for some of our critics.”
As I happen to know a number of statisticians, I'm rather skeptical that Statcan thinks this change is "good enough". At this point, I should note that indeed have some kind of degree: MMath (Statistics-Biostatistics) from Waterloo. I think that beats Tony's poli sci undergrad (I have one too) and law degree - at least insofar as these things go.

Saturday, June 12, 2010

Random Things...

I haven't posted in a while, though the time since my last entry has gone by swiftly (briefly: conference in Mexico, an OSCE, population health project, and final exam for the year). I've been following a few issues lately with a fair degree of attention, though. Starting off, there's the matter of the 2010 Toronto mayoral race:
Outspoken councillor Rob Ford leads a new poll that evinces a splintered electoral race with two clear front-runners and an indecisive electorate.

A new Globeandmail/CTV/CP24/Nanos poll puts Mr. Ford in first place – but just barely, and well within the margin of error.

The poll shows that 17.8 per cent of 1,000 Torontonians said they would vote for Mr. Ford if the election was held immediately, giving him a tiny lead over former deputy premier and energy and infrastructure minister George Smitherman, with 15.9 per cent.

Almost 40 per cent of those would-be voters are still undecided – but this poll cements a two-horse race between Mr. Ford and Mr. Smitherman, a long-time front-runner after he left his provincial post to run.

Deputy Mayor Joe Pantalone garnered a 10.1 per cent result; 9 per cent of those polled said they’d vote for Rocco Rossi if the vote were held immediately. Councillor Giorgio Mammoliti got 2.5 per cent; Women’s Post publisher Sarah Thomson earned 5.8 per cent of votes.
I'm going to say right off that I hope to hell that Rob Ford doesn't win. I don't think he will, of course, as this poll probably represents the ceiling not the floor of his support. Other than riding a wave of discontent over the usual "waste and overspending" talking points, he doesn't seem to have any particular plans or vision for the city, at least, none that I can find on his laughably amateurish website. He apparently wants to scrap Transit City in favour of subways, i.e. replace a less costly more comprehensive plan with one that is an order of magnitude more expensive and much slower to construct. How he expects that to be paid for is anyone's guess.

The rest of the field is not altogether inspiring - Smitherman seems okay, but his plans are a bit fuzzy - and since I don't live in TO, it doesn't really impact me directly, but the success of our largest city ought to matter to Canadians. Halifax's transit issues, for example, are a microcosm of what faces Toronto. Traffic is ever worsening and most of the plans to remedy it are not sufficiently ambitious. It's too early to predict the outcome of the mayoral election; it remains to be seen where the large number of undecided voters ends up.

Sunday, April 4, 2010

People in Toronto are Crazy

That's the only conclusion I can reach after reading this:
In his 29 years of ferrying people to Toronto Island, boat crew member Frank Corbin never saw passengers as agitated as they were this weekend. There was pushing, profanity and even punches thrown; at one point on Friday, the police had to be called in to help regulate the crowd.

Just blame it on the potent combination of unseasonably warm weather, a holiday weekend and thousands of Torontonians trying to get to Toronto Island.

That, and the fact that just one puny, puttering ferry was available to haul everyone across.

"It was very busy, much busier than normal," said Corbin, the first mate of Ongiara, the 220-passenger ferry. "We were not really prepared for the crowd, basically."

Lineups at the ferry docks stretched past the ticket gates as people waited for up to three hours before leaving dry land.

People became so frustrated they were rushing onto the boat or jumping queues.

At least one fist fight broke out Friday, Corbin said.

"(People were) very impatient," he said. "Rude to me, rude to the captain. They were swearing at the deckhand, calling him a lazy bum and using the f-word."
I don't blame people for being frustrated but... it's April 4th. They didn't plan on the temperature being 25 degrees and weren't ready for these crowds. That doesn't excuse the behaviour described above. And while they should finally build at least a pedestrian bridge (or two) to the Islands for precisely this reason, I can't imagine why so many people would be so set on going to Centre Island. It's not *that* great. I suppose people in TO are just starved for any contact with the lake... which doesn't really explain why Harbourfront is so underused half the time. In any case, ocean >>> lake.

Friday, April 2, 2010

Bad Ideas and Health Care Reform

Nope, I'm not going to be writing about Obama's recent success in passing health insurance reform. I'm cautiously optimistic about its impact, but those events have predictably brought up the subject of health care reform in Canada once again. As a general rule, newspaper columnists and pundits are not experts about anything and will typically provide - at best - some sort of conventional wisdom that doesn't bear scrutiny. David Olive's column about "five bright ideas to save the Liberal Party" is no exception. He posits, indeed, a health care "renaissance" as one such idea:
Skyrocketing health-care costs are a fixation of governments from Japan to France, all facing the same demographic challenge of an aging population as we do, but not content as we are in passively watching health-care costs gobble up 40 per cent of our economy by mid-century, likely sooner. Health care is perhaps the one major field most stubbornly resistant to reform in both quality (medical errors are rampant) and cost-efficiency. At least in its big cities, China is far ahead of North America in electronic medical records, which cut down on errors and costly duplication, and make “distance care” more practical.

As to the breadth of coverage, our imagined comprehensive Medicare coverage is anything but. It lacks the universal dental care of Britain and state-funded prescription-drug provision of France and Japan.

Just as caregivers have little incentive to rethink treatment, patients have little reason to adopt a healthier lifestyle of proper diet and fitness. A reinvented Medicare would impose means-testing and co-pays to provide that incentive. As part of that overhaul, universal care would be made truly comprehensive by embracing dental health and pharmacare extending beyond the seniors now receiving it.
Setting aside the general vagueness and lack of specifics in this "idea", it betrays both all-too-common simplistic thinking about these issues. Medical errors are rampant? I'd say they happen and are to a small extent unavoidable. As I wrote in the fall, there are numerous approaches to improve communication and cut down on errors, such as the addition of universal checklists to the OR. I'd hazard a guess that electronic medical records would play - at best - a small role in "cutting down" errors. We have many computer-based records systems as it stands, but in my admittedly limited experience paper charts are easier to flip through to find what you're looking for. I'm not sure where the duplication comes in either; if the past, oh, 30 years or so have shown anything, it's that computer infrastructure is expensive, high maintenance, and certainly not cheaper than paper.

Olive is quite right that we lack universal dental coverage (which I understand the UK doesn't have to the extent he implies) or prescription-drug provision... though drugs for certain chronic conditions and cancers are. He probably should have discussed drug costs in more detail, however, as if there's anything "unsustainable" (a common media refrain) about our system, it's drug costs - most of which are privately paid.

His last point is simply morally unjustifiable. On one hand, I'd say that good health is its own reward, and while there's no shortage of people who make bad choices (e.g. NEVER start smoking), there are many more whose jobs facilitate a sedentary lifestyle and it is a simple effect that people with low incomes and limited educations have the worst health outcomes. Another sizeable group of "frequent flyers" for health care suffer from genetic predispositions to different diseases. In short, Olive is advocating that sick people be punished for their poor health status, under the supposition that this will give them an "incentive"... not to be sick. I guess. I'm sure those with type 1 diabetes or rheumatoid arthritis would be happy to pay nominal co-pays if it would rid them of their conditions once and for all, but that's not how things work. I'm not aware that such incentives actually work anyhow, apart from having the documented effect of driving people with low incomes away from seeking health care. And that's a bad thing.

Sunday, January 31, 2010

Toronto vs. Vancouver

Well, not really. Nothing seems to generate vapid columns about common Canadian stereotypes than Globe and Mail columnists writing about any larger city - usually one of Vancouver, Calgary, Toronto, Ottawa, or Montreal. But usually Vancouver, I tend to think. Unsurprisingly, these never fail to generate lots of snarky comments from online readers. But first the offending article:
Please do not misunderstand me: I am not about to do the eastern-Canadian, passive-aggressive, Toronto thing that Vancouverites hate, which is to decry Vancouver as a beautiful but empty-headed woman you long to sleep with and then can't wait to ditch so that you can talk about something other than the muscle tone of her thighs.

Vancouver has always been unspeakably beautiful, but the Olympics stand to launch it into the global stratosphere.

At that point the city will completely replace Toronto and Montreal and (really?) Ottawa, which actually has more residents than Vancouver, as the go-to city in the mind of the world, when the mind of the world thinks of Canada – especially the mind of Asia, which is going to control most of the money on the planet for the next 200 years.
Yes, Vancouver will be the go-to city in the "mind of the world". I wish I could make such a turn of phrase up myself. The author goes on to describe a code of etiquette for city employees which apparently caused something of an uproar (I guess Vancouverites react badly to the implication that they're clueless and socially awkward), but that doesn't really bear mentioning here. The amusing thing is that the online comments invariably take one of three forms - people slagging Toronto, others slagging Vancouver, and a third smaller group of people calling for peace in our time.

This post reflects none of those positions. However, I did find this comment rather amusing:
By the way, an anecdote about Toronto subways to balance things up. I worked there for 5 years and, forgive me, but I don't remember everyone chatting to each other on the subway. Being thoroughly miserable in public was the order of the day - every day.
This, of course, is entirely accurate. Toronto is a big anonymous city. Vancouver is not nearly as big, but just as anonymous. I have come to realize lately that I'm not a "big city" person. Not anymore at least. I really enjoy visiting for days or weeks at a time, but that's about all I can manage. Everything's too spread out, too big, and there are too many people everywhere all the time. For all the enjoyment I get hanging out in downtown TO, most of the city consists of strip malls, character-less, cookie-cutter suburbs, and big box outlets. Oh, and lots of new condos. That all look kinda the same.

Vancouver is generally prettier, up to and including its suburbs like Burnaby and Richmond, but it's an appallingly expensive place to live and the stark class divisions between different areas of the city persists. Lovely place to visit, but I already live near the ocean, less than a 5-10 minute walk to the harbour or to Point Pleasant Park. I live within a 20 minute walk of almost everything I need, and most things are closer: several grocery stores, most buildings at Dal, the hospitals, my bank, drug stores, an excellent selection of restaurants, and, of course, an HMV. Not that I buy much there lately. If I need to go a bit further afield, I've learned that the buses are certainly adequate, and there are always lots of cabs - not that walking is usually a problem, as even downtown is only 20 minutes away at most.

So, yes, I love Hali. But there is a cultural element to this too. I hadn't fully appreciated it until I spent a year in Waterloo, but Ontario is... different. Smaller cities there are friendlier, certainly, but I didn't find K-W to be appreciably less anonymous. If Nova Scotia is friendlier - and I think it is - it's also somewhat less open, and there is a vastly stronger sense of history than most places in Ontario (I think!). Vancouver is even more ephemeral. If Toronto feels like it's in a constant process of reinventing itself (to varying degrees of success), Vancouver seems ever focussed on its natural beauty, "lifestyle", and - currently - the all important Olympics. Nothing too substantive there, and little more than handwringing over some of the worst social problems in the country.

Now, Halifax is far from perfect. Traffic problems are ever worsening, parking and living on the peninsula are fairly expensive (fortunately I only do the latter), and the less said about the sewage treatment fiasco the better. But it's almost the perfect size for a city. We just need some way of getting people on and off the peninsula more efficiently and without having to use their own cars. One day perhaps. One day soon I'll go home to the Valley too. Rural (or small town) living is perhaps a topic for another post, though.