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.

Flame in the Dark

It's been ages since I've posted, but I've had some thoughts about what I'd like to write about on this blog. I'll get to that in a moment.

On Tuesday at 1pm I will learn what I'm fated to do for the next five years. The Canadian Resident Matching Services ("CaRMS") website will then reopen and I will learn where I have matched among the six programs I ranked. In general, I have at least a 95% chance of matching in the first round, so I shouldn't worry too much. Not that that means I will be completely at ease until I know one way or the other.

But that's not really what I want to talk about here. For the past several weeks at least I've been absorbed by the ongoing battle over transit in Toronto and the direction of the city more generally. Rob Ford is - without question - the worst mayor of Toronto in history, and quite possibly one of the worst most ineffectual politicians in the country. He is, at present, still pushing for "subways" and/or exclusively underground transit expansion in the city, namely for a Sheppard subway extension east to Scarborough Town Centre and west to Downsview and for a wholly-underground Eglinton LRT. The latter was to be funded with $8.4 billion in provincial money originally intended for the Transit City plan developed before Ford was elected and which he declared "cancelled" on his first day in office.

I haven't mentioned how the Sheppard subway extension was to paid for because no such funding plan exists. Ford has variously claimed that it could be done with (possible) money leftover from the Eglinton line, along with considerable private money (air-rights, "expected" development charges, and other measures which do not actually exist or provide sufficient funds). This week he appeared to be open to parking taxes and some other revenue instruments that would be absolutely necessary, but later backtracked. In any case, it really doesn't matter because Ford has no plan to fund any subway expansion anywhere, and he has now once again ruled out additional taxes to finance not only the construction but the considerable operational and maintenance capital costs such an extension would impose. And that's really not a debatable point. While Rob Ford's idea of transit planning is drawing lines on a map and claiming the private sector will pay for it, we cannot have new subways without new taxes. Anyone claiming otherwise is lying, stupid, or - most likely - both.

Otherwise, I should mention that despite Ford's unilateral and never-ratified "cancellation" of Transit City, on Feb 8th City Council voted to restore most of the original Transit City plan was restored: an Eglinton LRT underground through the centre of the city only, a Finch West LRT, and (probably) a Sheppard LRT, though this is still to be decided by Council on March 15 following an "expert panel" review of subway vs. LRT options. In the meantime, TTC Chair and (former) Ford ally Karen Stintz has moved to reconstitute the TTC board and - one hopes - purge it of Ford's sycophantic cronies.

In any case, I think the strength of Ford's argument is best shown by the video below:



Yes, he did say subways get people "out of their cards" around 1:45. His argument amounts to this:

1. Surface transit does not help gridlock and makes it worse.
2. Gridlock/traffic congestion is bad.
3. Only underground transit is fast.
4. People want transit that is fast.

Therefore, since subways (or "LRT-style" underground trains) are underground, they are fast and don't make gridlock worse. As a consequence, people want subways.

That's about as far as Ford's thinking goes, and one wonders why we don't extend this logic to buses. Subways for everyone! On your doorstop!! I suppose he also opposes the fact that substantial portion of the existing TTC Subway travels above ground:



Anyway, I suppose we'll see what happens. I quite like surface LRTs as are planned for Finch West and much of Eglinton. I wish we could have something similar in Halifax (though I'd settle for the resumption of bus service from our month-long strike... topic for another post!). Comments like these from Rob Ford suggesting that streetcars (his usual term for LRT) would "ruin" the city angers me to no end, not least because areas of downtown with said streetcar lines are among the most attractive and liveable neighbourhoods in the country much less the city.

So if you haven't guessed yet, I'm planning to reorient this blog toward urban affairs and transit which, it seems, are my main interests lately. I'd like to talk about development in Halifax (primarily on the peninsula) especially, but I'll be keeping a close eye on goings-on in Toronto, the city of my birth.

For more information on the transit debate, check out these links:

Transit Timeline
Christopher Hume
- Toronto Star columnist on urban affairs
Royson James
- Toronto Star columnist on city hall politics
Steve Munro
- Prominent blogger and Toronto transit activist - excellent resource for all things TTC-related

Jack Layton, 1950-2011

My friends, love is better than anger.
Hope is better than fear.
Optimism is better than despair.
So let us be loving, hopeful and optimistic.
And we’ll change the world.

The Land Is Strong...

That, anyway, is the kind of campaign Harper seems to have been running, with the caveat that said land is only strong with him in the PM's chair. All told this didn't really work for Trudeau back in 1972 and Harper's ship has probably now sailed.

I can't say I expected this, not at the outset of the campaign (which if I'd written a book about my thoughts at the time, the title "A Time for Cynicism" would have been apt), not two weeks ago, not when I voted in an advance poll on Good Friday.

At the very least, Jack Layton and Olivia Chow will be moving into Stornoway after Monday and 24 Sussex isn't out of the question either. I wonder if anyone in the country could have anticipated this a month ago. If only I'd made some appropriately wild predictions at the time...

I feel bad for Ignatieff. He's a good guy and I was impressed by his early campaign. On the other hand, his failure to call Harper on his anti-coaltiion BS was beyond disappointing. It will be a shame when he resigns as leader, which almost seems inevitable at this point - unless, perhaps, he were to become a cabinet minister in a Layton-led government? I still can't believe I'm writing that as an actual possibility rather than a vague hypothetical.

Surgery Makes Me Sleepy

I originally wrote this back in January, but I present it here with additional comment.

And by that I mean the rotations themselves, not the experience of being in OR. Though watching residents close abdominal incisions for the 12th time is not the most stimulating experience. Getting up at 5:30 daily - as I have been now since last Monday thanks to the Friday/Sunday call monster - requires early bedtimes, something I've managed to get used to. Today I zonked out about 9:30/10 in the morning and woke up suddenly at 11:27. Remarkably I was only about 10 minutes late to meet a friend for lunch at 11:30. But such free time is so rare these days.

*****

I'm not sure why I didn't finish this post, but it was - likely - a matter of time. Or lack thereof. I've enjoyed all of my rotations since the new year began. General surgery was a lot of fun and very, very busy. My evaluation went really well and it remains a serious consideration for me. I enjoyed neurosurgery less - some very interesting cases and a couple great times getting to be first assist in the OR - but the lifestyle is probably among the worst of any specialty and the residents are overworked. I enjoyed working with the staff, though.

Emergency medicine was a good rotation. I did it at a smaller regional hospital with much more limited specialist support. Saw a large variety of patients and presentations, practised some useful skills (LP, more IVs, suturing, reduction of fractures, incision and drainage, MSK exam), and generally learned a lot. In the end, though, I didn't really like it. There's no rhythm to each shift. You just see patient after patient, many of whom don't require further tests or treatment, determining their "disposition" and making that crucial admit or discharge decision. Not much follow-up. Not enough complexity. At least for me.

I started plastics this week and I'm impressed daily by how well organized the rotation is. Lots of formal teaching and ample experience working in fast paced clinics. I can't complain about the amount of OR time either, even though I'm not getting a lot of skills practice there. Fair to say that I like everything about the rotation. I have been interested in plastics in the past - not really sure I still am. It's very interesting, of course, but the competition to get a residency spot is pretty intense and I probably would miss the medicine available in something like gen surg or, of course, internal medicine.

I suppose that leads to what kind of career I'm considering. That can be left for another post though.

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...

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.
  

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:

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.

Megacode

Well, sort of:



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

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.

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 Pediatrics Obstetrics and Gynecology (Exams) Year 3 Elective (Christmas) Surgery and Emergency Medicine:           General Surgery Neurosurgery Emergency Medicine Plastics

And then... (Exams + OSCE) (Break) Family Medicine Psychiatry (Exams) Internal Medicine: Geriatrics Neurology 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!

Hmm

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.

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.