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.

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.

King Tut in TO

I've just noticed that an exhibition of King "Golden Pharaoh" Tutankamen artifacts is coming to the AGO this month and will be sticking around until April. Anyone else want to go? :)

Surgery is a Lifestyle

Or so says my elective preceptor, a general surgeon/surgical oncologist. Life is something you fit in around it. Things for me to ponder, to be sure, over the next two years or so. In the meantime, I'm loving my elective; in the new year I'll get some exposure to ENT/head and neck surgery.

At some point I need to write about non-medical topics, though. Before that point, I did notice something curious about some of the heart murmurs we've been learning about over the past few weeks. Last Tuesday I examined a patient with a very loud systolic murmur, indicating aortic valve stenosis. Every time this patient's left ventricle contracted, there would be a loud, transient whoosh as blood passed through his narrowed aortic valve. After listening for a bit, it suddenly dawned on me that the murmur sounded almost exactly like the alien signal from Contact.



Still a very cool movie - and now it provides a handy way of recognizing certain types of valvular disease.

Le mois d'Octobre

It's been a rather nice fall so far in Halifax. Nice, generally sunny weather (today's being a notable exception), and I've been enjoying Med 2 a lot so far. I've finally scrubbed into surgery and it's been great. Really great. I'll have to write more soon, but this appears to be the direction in which OR procedures are going:

Next time you go in for surgery, don't be surprised if the surgeon and staff introduce themselves before you go under the scalpel.

It's just one of the 26 tasks on a surgical safety checklist that hospitals across the province will be required to implement starting in January, because it has been proven to reduce patient complications and death.

[...]

The checklist includes common items such as requiring doctors and staff to check equipment, review patient information and resuscitation plans, and even identify themselves by name and role before they make their first cut.

The checklist will be mandatory for all surgeries in the province, and hospitals will be required to report twice a year on compliance.

The list is divided into three parts: tasks that must be completed before the anesthesia, before the first incision and before the patient leaves the operating room.

In case there's any concern that this sort of thing wasn't done previously, I can say that it's just a more systematic, formal way of approaching normal practice. But don't take my word for it:

"Everything on the checklist is a well-known standard of care," said Dr. Michael Baker, head of patient safety for the province, at a media briefing Thursday.

"There are no new ideas in the checklist," he said.

"The new idea is that the team needs to communicate and be obsessive-compulsive about the surgical process."

The video accompanying the article even has an example of a typical anesthesia monitor alarm. It helps remind me of the OR, and that I was taught (in Austria anyway) that the appropriate response to such alarms is to turn them off (I think it's an apnea alarm).

Bodyworlds Returns!

The Bodyworlds exhibit is coming back to the Science Centre:

Four years after BODY WORLDS 2 brought record crowds to the Science Centre, the new blockbuster exhibition, BODY WORLDS & The Story of the Heart, will open to the public on October 9, 2009 for a limited engagement.

See through the lenses of anatomy, cardiology, psychology and culture how the heart nourishes, regulates and sustains life. The exhibition will give you a profound insight into the human body, health and disease, and the intricate world of the cardiovascular system with over 200 human specimens including whole-body plastinates, organs and translucent body slices.

From the sound of it, tickets should be bought in advance. As usual, I expect to be in TO around Christmas time, and I think it would be fun to organize a group trip. It's not altogether cheap, but it's cool and it must not be forgotten that it featured prominently in Casino Royale. What more do you need?

Austrian Observations

Generally speaking, Austria is quite similar to what I'm used to in Canada, but, of course, different, and not just because all the signs are in German. A few brief notes:

• Smoking: Everywhere, that is. I don't know if there exists the concept of a "no smoking" section in Austria, but I have yet to discover it. Sure, you can't smoke on trains or on buses, but it's been only a year or so since smoking was banned in most areas of hospitals. It's possible that the Landeskrankenhaus Innsbruck is behind larger centres. Of course, since many on the surgical floor still smoke, the compromise was to put smoking lounges just off the OR hallway (I had forgotten just how awful smoke is in very confined spaces). It's not really airtight, though, so the scent of smoke tends to waft down the hallway.


• Shopping hours: Sunday shopping? Evening shopping? Like, after 7pm? Forget about it! Not possible, and even the local video store near me closes at 10pm weeknights. I'm sure some of the more touristy places in the Innsbruck Altstadt are open Sundays, but they sure aren't open in the evening. This would be a lot more inconvenient if my schedule was tighter, but fortunately I'm pretty much always done by mid-afternoon.


• Free lunches: Self-explanatory, and applies both on the OR floor and in the main hospital cafeteria. The food isn't great, but it gets the job done, so to speak.


• Coffee machines: Coffee vending machines, I should say. It tends to be expensive to buy coffee from bakeries, bars, restaurants, or coffee shops, as a small cup (about the same size as a Tim's small) will run you about 2 euros. Despair not, however, as you can get a cup of about the same size and quantity from a vending machine for 50 or 75 euro cents. Very reasonable, not to mention fast!


• Trains, trams, and buses: Fast, convenient, everywhere. Even Innsbruck, population just under 120,000, has an efficient bus and tram network (good for me since I take the bus at least once daily). I seldom wait more than about five minutes; the outside might be ten. There are night buses too, though I haven't taken any as of yet. Vienna similarly has an extensive public transit network: U-bahn, tram, bus. Innsbruck makes the buses in Halifax seem slow and inconvenient... which they are. Rail is the other issue here; you can take the train everywhere and it's reliable and comfortable. They'll even apologize if it's 15 minutes late (the norm for Via Rail!). While the train can be a bit on the pricey side, it makes day tripping very easy. (Concerning Italian trains, while they are not remotely pricey, let's just reiterate that one should never trust a bargain too much...)


• Language: In light of my less than stellar German skills, I've had an okay time managing here, primarily because most people seem to have some command of English. I'm working on improving, but it's slow-going, despite being surrounded by the language all the time. Arguably just as challenging is the local Tiroler accent, considered "quite strange" by some Viennese. I can probably get by simply by knowing "bitte schön", "genau", and "past".

I suppose that's all for now. Pictures to come later. Bis später!