Year: 2008

Posted on

Your Turn: A 10-point Marshall plan to right the doctor shortage

More than four million Canadians do not have a family doctor. Currently, Canada produces 2,300 new doctors a year but we need about 3,200 a year. How can we find 900 more doctors annually?

Canada has failed to use the services of the thousands of international medical graduates (IMGs) in Canada who are unable to practise because they can’t get a licence. There are also an estimated 1,500 Canadian citizens studying at medical schools abroad.

I propose a 10-point mini-Marshall plan:

1. A medical manpower czar should be appointed by the federal government. He should have a sufficient budget and manpower to undertake the task of making Canada self-sufficient in medical manpower.

2. The czar should create a registry of all IMGs who are in Canada but have no licence to practise. This can be done via the media.

3. The czar should conduct a survey of these graduates to find out what each one of them requires to be fully licensed.

4. From the responses, the czar should create conditions and provide financial help (in conjunction with teaching institutions, hospitals, licensing bodies and provincial governments) to assist these overseas-trained physicians to be fully licensed in one year.

5. Those who fail to get a licence should get one more try. If they fail again, they should be told to pursue other careers.

6. Those who accept government help should promise to work in an underserviced area for two years before they move elsewhere.

7. The czar should create a registry of Canadian medical students overseas. Again, the media can help get the word out.

8. The czar should survey these students to find out how many of them want to return to Canada to do their residency and practise here.

9. The czar should constantly stay in touch with these students and encourage them to pass LMCC (Licentiate of the Medical Council of Canada) when they prepare for the USMLE (U.S. Medical Licensing Examination). Canadian licensing bodies should accept USMLE as equivalent to the LMCC
exams.

10. The czar should offer them financial incentives to come back to Canada via signing bonuses. This can be done in conjunction with hospitals and provincial governments.

IMGs and Canadians studying abroad did not cost the Canadian taxpayer a single penny to train. So what is wrong with investing some money in them to absorb them into our system? That is surely better than spending thousands of dollars on Canadians who obtain their MD in Canada and then move to the U.S.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Posted on

Erectile Dysfunction May Be An Early Sign Of Heart Disease

Erectile dysfunction (impotence) may be an early sign of heart disease.

Greek researchers evaluated the incidence of asymptomatic coronary artery disease in 26 men with erectile dysfunction and found 23 per cent had coronary artery disease confirmed by angiography (x-rays of the coronary vessels).

Italian researchers studied 162 patients and found the prevalence of erectile dysfunction was high (66 per cent) among those with chronic angina and multivessel disease and low (18 per cent) among those who had had an acute myocardial infarction with only one vessel affected.

Patients with erectile dysfunction, with no obvious cardiac problems, are at a risk of a heart attack within two to three years. In these kinds of patients, erectile dysfunction is considered to be a warning sign of heart attack to come. For this reason, it is being suggested that patients with erectile dysfunction, with no obvious cardiac symptoms, should be evaluated for cardiovascular disease.

There are several reasons why patients with heart disease will have erectile dysfunction. Atherosclerosis (clogging and hardening of the blood vessels) narrows the blood vessels and reduces blood flow to your heart, brain, extremities and the penis. Reduced blood supply to the penis causes erectile dysfunction.

Certain medications taken for heart disease can cause erectile dysfunction (high blood pressure pills and diuretics). It is also important to remember medications taken for impotence may not be safe when combined with certain heart medications (for example nitrates). There is a connection between depression, heart disease and erectile dysfunction. Feeling anxious can also lead to erectile dysfunction. Fear of having a heart attack while having sex can lead to impotence.

Usually, this is an unfounded fear. After a heart attack, you can resume your sexual activity as soon as your doctor says ok. Sexual intercourse seldom causes heart attacks. Having sex with your usual partner in a familiar setting doesn’t lead to a particularly high blood pressure level or heart rate. Even if you’re at high risk of having a heart attack, weekly sexual activity only slightly raises the risk. In fact, regular sexual activity leads to a happy and satisfactory relationship and is good for your heart.

There are a number of risk factors that can contribute to both heart disease and erectile dysfunction. These factors are well known: diabetes, obesity, high cholesterol level, smoking and high blood pressure fall into this category. So, erectile dysfunction may have multifactorial cause and will require investigations and long term planning to get the situation under control.

Let us go back to the real life scenario – you have erectile dysfunction but have no other obvious health problem. What should you do?

First, you have to look at your personal scenario. Is your relationship with your partner stressful or unpleasant? Are you living or working in an environment which is depressing? Such factors will affect your performance in bed.

Your next step is to talk to your doctor. After evaluating your history and physical examination, your doctor will decide on what kind of investigations to undertake. Your doctor may decide to refer you to a urologist, a cardiologist or to a psychiatrist.

So, don’t be shy. If you are having problems maintaining an erection during sexual intercourse then see your doctor. It may save your life and your sex life.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Posted on

Traveler’s Diarrhea Can Cause Irritable Bowel Syndrome

Have you already planned a winter holiday? Besides getting your passport and appropriate currency, you need to think of getting your vaccinations updated and take actions to prevent traveler’s diarrhea (TD).

TD hits your system when you consume contaminated food and water. It occurs during or shortly after travel, most commonly affecting persons traveling from an area of more highly developed hygiene and sanitation to a less developed one. Food and water may be contaminated with bacteria, parasites or viruses. A similar but less common syndrome is toxic gastroenteritis, caused by ingestion of pre-formed toxins.

Studies have shown bacteria are responsible for approximately 85 per cent of TD, parasites about 10 per cent, and viruses five per cent. On average, 30-50 per cent of travelers to high-risk areas will develop TD during a one to two-week stay.

TD is generally self-limited and lasts 3-4 days even without treatment, but persistent symptoms may occur in a small percentage of travelers. Any diarrhea associated with fever and blood in the toilet requires medical attention.

Infectious diarrhea can have a long term effect on our system resulting in arthritis, Guillain-Barré syndrome (a reversible condition that affects the nerves in the body), and irritable bowel syndrome (IBS). IBS may occur in up to 30 per cent of persons who contracted travelers’ diarrhea or infectious diarrhea. Research is going on to determine if post-infectious IBS can lead to inflammatory bowel disease.

IBS is a complex disorder clinically characterized by abdominal pain and altered bowel habit. Its causative mechanisms are still incompletely known. It could be a person’s genes, psychosocial factors, changes in gastrointestinal motility and hypersensitivity of certain organs in the body.

TD can be self-limiting benign condition or may result in serious sequalae. So it is no rocket science to conclude that we should try and prevent TD by taking necessary preventive measures. Travelers should remember to wash their hands with soap and water prior to eating or meal preparation.

Eat foods that are freshly cooked and served piping hot and you should avoid water and beverages diluted with non-potable water. Foods like salads are washed in non-potable water. You should avoid that. Raw or undercooked meat and seafood and raw fruits and vegetables should be avoided. Safe beverages include those that are bottled and sealed or carbonated. Consumption of food or beverages from street vendors poses a particularly high risk.

What kind of medications can you use as prophylaxis against TD?

Studies from Mexico have shown Pepto-Bismol (taken on arrival at the destination as either two oz. of liquid or two chewable tablets four times per day) reduces the incidence of TD from 40 to 14 per cent, says one research paper. You should make sure that Pepto-Bismol is compatible with other medications you take. There is no conclusive evidence that use of probiotics is helpful.

E. coli is the most common type of bacteria which causes TD. Use of oral Dukoral vaccine (two weeks and one week before travel) provides protection against E. coli diarrhea for three months.

Use of prophylactic antibiotics has been demonstrated to be quite effective in the prevention of TD. Studies have shown that attacks of diarrhea are reduced from 40 per cent to 4 per cent by the use of antibiotics. But it is becoming difficult to decide which antibiotic to use as bacteria tend to develop resistance to antibiotics. For this and other reasons, prophylactic antibiotics should not be recommended for most travelers.

Three months before you travel, you should visit your family doctor and local public health nurse and discuss your travel plans. They will provide you with the most advanced information on how to have a healthy and happy holiday.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Posted on

Anal Fistula Can Be Difficult To Treat

This model illustrates various pathology of the rectum. (iStockphoto/Thinkstock)
This model illustrates various pathology of the rectum. (iStockphoto/Thinkstock)

Last week, I was in San Francisco, California to attend the Clinical Congress (convention) organized by the American College of Surgeons. It is one of the largest surgical conventions in the world. The convention lasts five days (Sunday to Thursday). By Wednesday afternoon, total registration for the convention was 14,397: 8916 were physicians and the rest were exhibitors, guests, spouses and convention personnel.

Not everybody is in one auditorium or room at the same time. Each room has its own list of speakers and topics for discussion. So you head yourself to a room which offers discussion on a topic which interests you the most. The conference was held at the Moscone Convention Center. It is the largest convention and exhibition complex in

San Francisco. It comprises three main halls with total of 84,000 square meters of space (900,000 square feet).

One of the symposiums I attended was on surgical problems of anus and rectum: cancer, fistula, fissure and hemorrhoids. Today, I will review the subject of anal fistula (fistula-in-ano).

What is a fistula? A fistula is an abnormal tunnel connecting two body cavities (such as the rectum and the vagina) or a body cavity to the skin (like the rectum to the outside of the body). Fistulas are usually the result of infection, injury or surgery. With an anal fistula there is a tunnel between the anus (and/or rectum) to the skin. A peri-anal abscess has a 50 per cent risk of turning into a fistula.

Anal fistulas do not generally harm the body. They are mainly a nuisance with some pain or discomfort and irritating intermittent discharge of blood, pus or stool. They can form recurrent abscesses which may require drainage under local anaesthetic.

Most of the time the diagnosis of fistula is made on the basis of classical clinical history and physical findings. Examination of the rectum may show an opening of the fistula onto the skin, the area may be painful on examination, there may be redness, a discharge may be seen or it may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula.

Treatment of the fistula depends on the presentation of the problem. If there is active infection or abscess then it needs to be treated with drainage of the pus and antibiotics. Once the infection is cleared the fistula can be treated surgically. If it is difficult to get rid of the infection then long term drainage can be established by inserting a seton – a length of suture material or thin rubber tubing is looped through the fistula which keeps it open and allows pus to drain out.

The treatment aim should be to prevent recurrence of fistula. Treatment depends on where the fistula lies, and which parts of the anal sphincter it crosses.

There are several options. Doing nothing – a drainage seton can be left in place long-term to prevent problems. But this does not cure the fistula. Fistula can be layed open under anaesthetic. Once the fistula has been layed open it will be packed on a daily basis for a short period of time to ensure that the wound heals from the inside out. Depending on the depth of the fistula, this option may affect continence if the fistula involves sphincter muscles. Most fistulas are superficial and can be layed open under local anaesthetic without much problem with continence.

Other methods of treating fistula are: using fibrin glue injection, using fistula plug, creating a flap to cover the internal fistula opening and using a seton to cut through the deep fistulous tract. Each method has advantages and disadvantages.

Some fistulas are very difficult to treat if they are caused by inflammatory bowel disease like Crohn’s disease. Any patient with recurrent fistula should be investigated for inflammatory bowel disease. Otherwise, most fistulas can be cured with patience and perseverance.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!