Six Month-ish Update

Yeesh, has it really been since July that I last posted? Will have to remedy that. I'm also considering retitling this blog, perhaps something along the lines of "Evidence-Based Musings", an admittedly somewhat lame play on "Evidence-Based Medicine". Anyway. I do want to write more about urban issues with perhaps the odd intervening medicine topic.

As for some of the things I've been up to:

• Returned to NYC in August and visited the High Line and numerous sweltering subway stations
• Did a bunch of medicine and some anesthesia rotations
• Travelled to exotic locales such as Saint John, Hamilton, and Ottawa, and this winter Saskatoon and St-John's
• Finished watching the first four seasons of Breaking Bad
• Become obsessed with Community

I suppose that doesn't sound so impressive. Two weeks ago I did go to a fairly uninspiring presentation on gluten given by a pair of local naturopaths, though. It started out well enough with some basic descriptions of GI anatomy and function, but eventually betrayed the usual focus on "Health by Restrictive Diet" that advocates eliminating or reducing gluten intake due to the non-inflammatory "inflammation" of "gluten sensitivity". In other words, gluten is evil in itself, and clearly you must avoid wheat and barley and stick to rice and quinoa (though they weren't too keen on carbs in general). Certainly that's true if someone has Celiac disease, but otherwise one wonders if they ever decide that phenylalanine is similarly unhealthy. (They'll soon discover that the required diet for PKU includes absolutely disgusting unpalatable supplements.)

Later on in the Q&A period they demonstrated what was a disturbingly limited understanding of sarcoidosis, a disease they listed as among those supposedly associated with Celiac disease (it isn't). They said it was "autoimmune" and that it might affect the lungs. Probably. Ugh. Earlier they had missed the rather more significant associations with liver and (very serious) biliary disease. But whatever. At least they made sure to warn an apparently skeptical man about the anticoagulation dangers of omega 3 supplements. I can't say I put any instructions about *that* in any of the perioperative consults I dictated this week.

In any case, I couldn't really bring myself to be the jerk who asks vaguely hostile questions from the back. I did give them many disapproving looks, however, and overall I was actually disappointed that they didn't provide better information and how lacking their knowledge seemed to be on basic topics. It was well meaning, but it didn't give me a lot of confidence in the kind of nutrition advice they give.

Medical Mistakes and Such

I've been working a lot in the past two weeks, so I haven't gotten around to my planned Development in Halifax series, but I will get to it soon.

Right now, though, I'm watching a TED talk about physicians' mistakes by Brian Goldman. As ever, Dr Goldman delivers a good talk, and in particular reveals one of his own mistakes.

I enjoyed the talk, but I must say that I have a very different approach to my own learning and clinical decision-making. Dr Goldman says that he always strove to learn "everything" and memorize as much as possible so he'd make the right diagnoses and plans.

My way of going about learning and practice is quite different - I am concerned mainly with knowing enough to make good decisions and avoid bad ones. The further I get into training, the more I become aware of the limits of my own knowledge and the necessity with not becoming too comfortable with what I do know. I don't think it's really true that medical knowledge changes with quite the speed that is often described - there really is no substitute for a good history and physical examination, and - crucially - taking the time to actually do one, along with looking for additional history (e.g. old charts) if available. As one of the ICU fellows was telling me last week, being a good physician is not so much about knowing the most, but rather taking the time to be thorough and careful. Good decisions come from good information and the simple question "what else could this be?".

But you can still make a call that turned out to the wrong decision in retrospect. We can't know everything that will happen and many, many conditions do not "declare themselves" earlier or clearly enough that they cannot ever be missed. The important thing is to make decisions that address the worst case scenario while not overcalling the situation so much that you subject a patient to ultimately unnecessary tests or interventions. That's not always an easy balance to make, and you won't be immune from "good faith" mistakes, but it's the safe approach.

Back to Hali...

I was walking around downtown this afternoon, and I started making note of the various vacant lots and sites under development. In particular, I noticed the proposal for a new TD Centre between Barrington and Granville. There were a few other random spaces that seem ripe for development... aside from the gaping hole on Argyle where the fabled convention centre is to be built and the nondescript vacant lots for which Skye Halifax is planned.

It occurred to me that it'd be interesting to catalogue all the development/construction (or stalled development/construction) around downtown and even on the peninsula generally so... that's what I'm going to do. With pictures!

In general, I'm very much "pro-development" and as much as I want to see heritage buildings and architecture preserved, I find the various "Save the View" types tiresome and obstructionist. Current regulations are so ridiculous that an imperceptible one inch (or thereabouts) intrusion into the "sight lines" from the Citadel is slowing down redevelopment of Fenwick Tower. Downtown (and peninsular Halifax generally) needs development, residential and commercial, and it needs investment from the city and province. The new Central Library is an excellent start - how about a new Discovery Centre? More recreation facilities? Revamped transit terminal? Mandate that new office construction occur here?

Anyway, I'll start off with downtown with likely a brief foray up to Spring Garden. Then maybe the North Commons/Gottingen or Quinpool. I've seen a lot of great things happening in Halifax over the last decade and especially in the last four years - but there's much more to do.

"She's going into shock!"

This phrase seems to be turn up a lot in movies and television shows, especially of the scifi variety. "Shock" in this sense usually coincides with a character suffering some injury or sudden insult and then wildly convulsing or acting delirious or any combination of the two. I was just watching the pilot of Firefly earlier and there's a scene about half-way through where Kaylee gets shot by an Alliance agent:

She gets shot in the abdomen and, understandably, collapses, after which all the other characters hover over her. She starts to seem delirious at which point Simon declares that she's going into shock and a few seconds later says she's doing to die. Now, while it's true that altered mentation (delirium to loss of consciousness) is one of the first signs of shock, Simon curiously doesn't seem to take any vitals or make any efforts toward fluid resuscitation. Later he extracts the bullet* which doesn't treat the "shock" either... so, if Kaylee's delirium is indeed a sign of shock, just what else comprises it? Well, here's definition of shock:

• Inadequate supply of oxygen and nutrients for basic homeostasis at a cellular level
• Reduction of effective tissue perfusion leads first to reversible and then if prolonged irreversible cellular injury
• Not "low blood pressure"

And these are the defining features of shock:

1. Mentation: depressed
2. Respiratory Rate: increased
3. Blood pressure: decreased
4. Heart Rate: increased
5. Arterial pH: decreased
6. Urine output: decreased

In other words, shock means that there's inadequate flow of oxygenated blood to vital organs. This can happen for any number of reasons, but Kaylee's case is simple enough - blood loss from the gunshot wound. Simon and Mal both recognize the seriousness of a "stomach wound", though I wonder if this was more an example of the writers' superficial understanding that getting shot in the belly is a Bad Thing than anything deeper. Having said that, Simon doesn't actually treat the "shock"; he administers no fluids at all and there is no talk of transfusions or even surgery to stop any bleeding. And if they do not have saline or whatever the Alliance equivalent is on Serenity, one wonders why. These guys are constantly getting shot at - you'd think basic resuscitation supplies would be a must.

Fortunately Kaylee survives (she even lives through the movie where Simon sustains his own inadequately treated GSW vs. abdo), somehow, and this being TV, the writers weren't inclined to kill off one of the attractive female characters in the pilot. Not that Joss Whedon would ever kill off a major character...

Anyway, it's all pretty bad medicine, though it's not quite as bad as the usual medicine on, say, Star Trek. "Shock" in that case invariably looks like someone being, well, shocked, usually with much theatrical writhing around and screaming. Still, I am partial to the Trek physicians as characters (well, some of them), so here's a fine scene featuring the holographic Doctor from Voyager, surely that show's only consistently redeeming character:

*Technically he shouldn't be doing this either. A gunshot wound ("GSW") to the abdomen is an absolute indication for an exploratory laparotomy. Kaylee's wound just left of the midline could affect any number of structures - bowel, kidney, ureter, spine, to say nothing of different nerves and vessels, most significantly the left iliacs and the abdominal aorta. Retrieving the bullet isn't a bad idea, but it's not really the main priority.

Poorly-thought-out Policies from Politicians

In this case, Stephen McNeil, NS Liberal leader:

Liberal leader Stephen McNeil says the Liberals introduced three bills in the legislature today that would increase the number of doctors available in underserviced communities in Nova Scotia. "The time has come for the NDP government to consider new strategies around our province’s doctor shortage," says McNeil. "We already have the resources here; utilizing these resources more effectively will lead to the retention of physicians in underserviced parts of Nova Scotia."

So far so good, I suppose, and certainly retention of physicians in rural areas - which, let's face it, is what "underserviced" means - is a worthy goal. However, let us look at the substance of McNeil's proposals:

McNeil’s bill would see the creation of 10 new residency positions for Nova Scotia students who have chosen to attend medical school abroad. Currently, those students are labeled as foreign applicants and the fact they want to return home for residency doesn’t factor in. "We have Nova Scotian doctors who want to come home to start their careers and instead of finding a way to make that happen, we put up a roadblock."

Hmm, well, this is troublesome for a number of reasons. In the Newly Trained Nova Scotia Doctors Act, the exact phrasing pertains to "medical students originally from (NS) who have completed an undergraduate medical degree in a medical school outside of Canada". I should note first that the Act should pertain to medical graduates not students. But it also fails to define what is meant by students "originally from the Province". People born in Nova Scotia? Or who finished elementary school here? Or high school? What about undergrad degrees? How is this to be defined?

To take myself as an example, I've lived in NS since 1998 with only a one year interruption but I was born in Toronto. I completed high school and most of my post-secondary education here and was admitted to medical school as an NS resident. Yet it could be argued that I am not "originally from" Nova Scotia. So... what's the definition?

There's another problem with this proposal inasmuch as it is explicitly discriminatory in the most fundamental sense. International medical graduates (IMGs) may apply for Canadian residency positions around the country, often only for specific spaces designated for them. To be eligible to apply IMGs must be Canadian citizens or permanent residents (though there are some extremely limited spaces for visa students in Quebec). McNeil's proposal aims to discriminate among IMGs on the basis of where they are "originally from", which could be (accurately) construed as unlawful discrimination against legal immigrants and, indeed, any current or prospective Come From Aways. I have my suspicions for the motivations behind this idea*, but it is simply untenable as it stands.

In addition to legislation which provides free tuition for 20 medical school students who are willing to work in underserviced communities, McNeil is also suggesting an enhancement to the third year curriculum at Dalhousie Medical School.

Let's address the "free tuition" idea first. The amendment to the Health Act does not state whether these 20 spaces would be additional to the current Dal cohort in Halifax (~80 spaces per year). This probably wouldn't be an issue for capacity, but it's debatable whether we need to increase undergraduate training that much (if at all) given previous increases the past few years. More to the point, 20 more undergraduate medical education spaces will require 20 more residency spots, making this proposal a good deal more expensive than might appear.

On the other hand, regardless of whether these would be additional spaces, the poor students to sign a contract for free tuition over four years would be making something of a Faustian bargain. The proposed Return-of-Service would require that graduates commit to five (5!!!) years of practice in an "underserviced area" in exchange for tuition. That is, five years of service for about $60,000. I can't imagine why anyone with a brain would sign such a contract. Paying tuition is not a problem for medical students - student loans aside, banks fall over themselves to offer lines of credit - at prime - on the order of $150-200,000. And for all that tuition paid we receive tax credits that can be carried over into the future. My combined federal and provincial tuition and education credits are now well over $100,000. Nova Scotia is a great place to live, but I also value my basic mobility rights and, frankly, there are plenty of likely "underserviced" areas in this province that I wouldn't move to under any circumstances.

But now the last proposal:

Under the Liberal bill, third year medical school students would have the option of being introduced into rural rotations over a longer period of time - exposing that student to rural training earlier in their career. According to the Canadian Journal of Rural Medicine, physicians who were immersed in a rural environment during their undergraduate or post-graduate training are two to three times more likely to become rural doctors.

Certainly the Rural Nova Scotia Physicians Act contains some laudable ideas - though I'd take issue with McNeil's notion that the legislature has the authority to determine any aspects of the Dalhousie undergraduate medical curriculum. The major problem is that Dal has already established a "Longitudinal Integrated Clerkship" based on... wait for it... immersing third year medical students in a rural area for a longitudinal clerkship, as distinguished from traditional rotations. Students would experience different services (surgery, internal medicine, psychiatry, obstetrics, etc.) while being linked to a single primary care unit. Of course, this has been developed for (I think) Miramichi, NB, but there's no particular reason it couldn't be introduced to a location in Nova Scotia at some point in the future too.

Bizarrely, the Act also calls for rural placements lasting "approximately" 36 weeks during third year. I'm not really sure what to make of this, as Phase 1 (Med 3) of Clerkship is 55 weeks in length, with 48 weeks of core rotations, 2 weeks of elective, and 3 weeks vacation. Of course, of that period students can already spend up to 29 weeks in rural placements. Do we really need legislation calling for another 7 weeks, especially coming from individuals who don't display much knowledge of the, ya know, existing curriculum?

"By focusing on their education cycle, from entry into med school to post-graduate training, we can start those Nova Scotia doctors on a career path here in our province,” says McNeil. "A doctor for every Nova Scotian - it has to be a priority."

Good intentions. Unrealistic and unwarranted plan.

-----

*This idea almost certainly arises from well-connected individuals with offspring who have gone to the Caribbean or Ireland or wherever for med school and who have the ear of McNeil or other Liberals. It is currently quite difficult to return for residency after graduation from a non-LCME school (essentially any school outside Canada and the United States, though there are non-LCME-accredited US schools), and - as it stands - any non-LCME graduate is considered an IMG. Recently there have been some lobbying efforts for favouritism for so-called Canadians Studying Abroad - i.e. IMGs who are not immigrants and - in general - were unable or unwilling to gain admission to a Canadian medical school. In BC, this has been spearheaded by BC Liberal (hmm...) MLA Moira Stillwell - ahem, Dr. Moira Stillwell - whose son is attending medical school in the UK. One wonders just who is pulling Stephen McNeil's strings on this issue.

Only Nixon could go to China...

But evidently Rob Ford can't go to the Pride Parade.

Yes, I should start writing about Hali again. I think the anti-development movement is a worthwhile topic for next time.

Rob Ford loses on transit. Again.

It's been a tumultuous few weeks in my own life, such that I haven't been posting as much as I'd like.

Some important events in the larger world have occurred in the meantime.

First, the month-long transit strike here in Hali ended:



As a sort of bonus, bus and ferry service will be free until the end of March. I made use of the ol' No. 7 today to go up to the Hydrostones. Of course, since my Dal bus pass lasts until the end of April, free service is somewhat redundant. Happily, Dal has provided all of us impoverished students with a $33.04 rebate on our transit passes. Yay.

But the big news is that Toronto City Council voted 24-19 to build the Sheppard East LRT, thus rejecting Rob Ford's unfunded and unfounded subway plan (at this point, all he was proposing was a useless extension to stops east to Victoria Park instead of building an LRT all the way to the edge of the zoo).

To quote Steve Munro:

This is an important day for Toronto. We are on track for an LRT-based plan and for a more detailed evaluation of our transit future than we have seen for decades. Talking about one line at once, about fundraising for one project at once, is no longer an accepted way of building the city. Leaving the debate to a secretive Provincial agency is no longer acceptable, and the City is clearly setting out on its own review. Co-operation is essential given the funding arrangements, but Queen’s Park must stop hiding from the transit planning and financing files.

Of course, as Hamutal Dotan noted in the Torontoist, Rob Ford's reaction was predictably obstinate and incoherently combative:

“The election starts now.”

That was Rob Ford’s response this afternoon, when asked by reporters how he felt about today’s transit vote—a vote in which council overruled Ford’s wishes and opted for light rail rather than a subway for Sheppard. A vote that, by any realistic measure, was devastating for the mayor.

The mayor, in short, has not, will not be persuaded. What happened at council, he remains convinced, is overreaching by an unruly group of councillors who are actively subverting the will of Torontonians by ramming light rail down residents’ unwilling throats.

[...]

As a councillor, Rob Ford was always the lone wolf in City Hall—often quite literally a minority of one when it came to votes. As a mayor, he seems to be reverting to that position, with even his supporters and allies working around rather than with him. It isn’t because they haven’t tried. The mayor is increasingly isolated at City Hall, and it’s an isolation of his own making. Never one for policy details, he is trying to govern in platitudes, and increasingly, he is doing it alone.

Anyway, I cannot imagine how Ford expects to be able to continue a "campaign" for his unfunded unwarranted subways without proposing new revenue tools. Spreading half-truths and outright lies and a naked disdain for those damned streetcars is really not something that can be sustained for 2-and-a-half years.

Is that all Ford's mayoralty is about? Listening to the "People" who say they "want subways"? Does he have any vision or any ideas for bringing the city together?

(These are rhetorical questions as the answers are Yes, Yes, and No, definitely not.)

Of course, said campaign may all be moot if Ford is removed from office due to his clear violation of the Municipal Conflict of Interest Act. That would unfortunately remove the spectacle of his flailing about until 2014, but then we can't always get everything we want.