Author: noorali

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Physician Health Matters

Yes, physician health matters because physicians are a valuable human resource.

Few days ago, I was in Ottawa attending 2006 International Conference on Physician Health. It was organized by the Canadian Medical Association (CMA) and the American Medical Association (AMA). The conference was attended by delegates from Canada, U.S.A., Europe, Australia, New Zealand and many other parts of the world.

This year’s conference was 18th in the series since its inception in 1975. This year’s theme was: Physician health matters: preserving a valuable human resource.

The delegates at the conference heard about the latest research on physician health, about new skills to survive and thrive in their career and learned about the progress that is being made around the world to protect the health of physicians.

The organizers of the conference say that by raising physician health issues at an international policy level, the conference seeks to promote a healthier culture of medicine and decrease the stigmata associated with the physician ill health, thereby decreasing barriers to physicians seeking timely personal care.

In 2003, a survey conducted by the CMA found that 46 per cent of Canadian physicians were in an advanced stage of burnout. Physicians feel they have to work harder and longer hours because there is a shortage of medical manpower. With the information overload there is a significant pressure on physicians to satisfy the public and there is constant political battle within our health care system to obtain fair share of resources to provide good patient care. All these factors do affect physicians’ personal and mental health and their capacity to deliver good patient care.

In order to help physicians understand the importance of looking after their own health, CMA set up a Centre for Physician Health and Well-being (cma.ca/well-being). Since then every province in Canada has established programs to help physicians and their families cope with stresses of work and encouraging healthy behaviours within the physician population as a whole.

At the conference, I was pleased to learn that every physician in Canada has access to a physician health program. In Alberta, it is called Alberta Physician and Family Support Program. The program has a toll-free number and a physician or a family member can call this number for help 24-hours-a-day.
As we know, prevention is better than cure. In the last few years, medical students, interns and residents have been in the driving seat promoting ideas on physician health and well-being. They are educating themselves at an early stage of their professional life to look after themselves and their families. They have learnt to reduce the hours they work, they have learnt to say “no” when they are tired and they have learnt to balance their lives.

I belong to a foolish generation of old doctors who took pride in working round the clock. Readers of my column and those who have read my book, A Doctor’s Journey, are well aware of my trials and tribulations with my own health. I learnt my lesson too late. In the last four years I have tried to change my practice and find a better balance in life.

It is hard to break old habits. After all work is a kind of addiction. It takes about one to two years to “detoxify” oneself. During this process one needs an understanding health-care administration, understanding colleagues, good friends, and a devoted family. Count yourself lucky if you get all four groups rooting for you during your down time.

Remember, as one door closes, another one always opens. So be brave doctor, do not forget to heal thyself first.

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

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Annual Flu Shot

“Yes, it’s time again, it‘s time for your annual flu shot,” said a friend in an e-mail. So I made an appointment to see my family doctor and got my flu shot last week. And my family has been through the same process.

This annual ritual is very important. As a health care provider I get my flu shot free. The same privilege is granted to adults and children with serious health problems. People who live them also get free vaccination. Those who are 65 and over are vaccinated without any charge as well. And children six months to 23 months and their families are vaccinated free.

As you may know, there is a reason why these groups of people are vaccinated free of charge. They live or work in an environment where people are sick, are vulnerable to the flu virus and their capacity to fight the virus is not great. They need to be protected. So if you are in one of these four groups or if you know somebody who is in one of these four groups but hasn’t had a flu shot then encourage them to do so. You will be performing a big service.

It is very important to prevent influenza, which is a major cause of outpatient visits, antibiotic use, hospitalization and death, particularly among those older than 65.

Studies have shown that elderly people residing in nursing homes, influenza vaccination can be 50 to 60 per cent effective in preventing admission to hospital and preventing pneumonia and 80 per cent effective in preventing death. Canada’s National Advisory Committee on Immunization (NACI) recommends that both staff and residents of long-term care facilities be vaccinated against influenza.

Among healthy adults, such as the staff of long-term care facilities, vaccination may be 70 to 90 per cent effective in preventing influenza, and it reduces absenteeism from work. Furthermore, the studies say, vaccination of staff reduces the mortality rate among residents of long-term care facilities. No wonder annual influenza vaccination is recommended for both staff and residents of long-term care facilities.

More than 20,000 residents of Palliser Health Region were vaccinated last year. That is a good number but we have a population of around 100,000. What about the rest of the population? What sort of barriers do they face? Is cost of the vaccine a barrier?

In Canada, the publicly funded vaccination programs to prevent influenza are risk-based rather than based on universal immunization. Alberta, the richest province in Canada, should be able to fund universal vaccination programs for all Albertans. But the government’s priorities are some where else. Only Ontario and Yukon fund universal influenza vaccination programs. This allows physicians to recommend vaccination for all their patients. This is important because the effectiveness of influenza vaccine is strongest in healthy people, among whom cases of influenza are reduced by up to 70 per cent.

Studies have shown that the universal influenza immunization program in Ontario has been associated with higher coverage for people with high-risk chronic conditions than has occurred in other provinces. This suggests that universal immunization may increase vaccine delivery to high-risk groups. So universal immunization programs appear to be good for healthy individuals as well as for people with high-risk chronic conditions. A win-win situation. Hopefully, one day Albertans will be in the same win-win situation.

In the mean time, make sure you get your flu vaccine today! I have had mine. Make sure you have yours.

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

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Inflammatory Bowel Disease

Dear Dr. B: I was recently diagnosed with inflammatory bowel disease (IBD). I have been advised to stay on medication for IBD for the rest of my life. Why do I have to do that? What happens if I take it only when I have a relapse?

Answer: First, we need to clarify what is IBD. IBD covers two forms of intestinal inflammation: ulcerative colitis and Crohn’s disease. It has nothing to do with irritable bowel syndrome (IBS).

Ulcerative colitis is inflammation of the colon and rectum only. It does not affect other parts of the gastro-intestinal tract. Crohn’s disease can occur anywhere in the gastro-intestinal tract, from mouth to anus. The most common sites being the terminal ileum and the colon.

Exact cause of IBD is not known. IBD is associated with wide variety of complications which may affect the bowel or other parts of the body. There is no medical treatment to cure IBD. Therefore bringing the disease under control and maintaining remission is very important to prevent complications. But attaining and maintaining remission is a big challenge.

After appropriate investigations, in 80 to 90 per cent of the cases of IBD your doctor should be able to tell you whether you have ulcerative colitis or Crohn’s disease. Sometimes it is hard to differentiate between the two.

Most common medications used in the management of ulcerative colitis are: 5-ASA (aminosalicylates) and corticosteroids. Patients who do not respond to these medications are then managed by azathioprine, 6-mercapturine, methotrexate, cyclosporine or infliximab.

5-ASA is the first line of treatment. Episodes of remission and relapse are very common in ulcerative colitis. Studies have shown that those who take their medications on regular basis are fivefold more likely to remain in remission than those who are not compliant.

There are many advantages to maintaining remission in ulcerative colitis. Abdominal cramps, diarrhea and blood loss are not pleasant symptoms to have every few weeks or months. It may also reduce the risk of colon cancer by half in compliant patients. It is important to remember ulcerative colitis is a pre-malignant condition. Corticosteroids are good for short term use but should not be used for long term remission because it has many side-effects.

Ulcerative colitis can be cured by surgically removing the whole colon and rectum and having an ileostomy for faecal passage. Surgical option is entertained only if there is a risk of cancer, if cancer is found in the colon, if the disease is not responding to medical treatment or patients develop complications. Overall, in ulcerative colitis, very few patients need surgery.

Drugs used to induce remission in Crohn’s disease are the same ones as used in ulcerative colitis. First line of treatment is 5-ASA but it is not as effective in Crohn’s as it is in ulcerative colitis. Most patients end up getting corticosteroids. But corticosteroids have many side-effects so it should be used only for short term purposes.

If the patient has recurrent episodes of flare-ups then azathioprine or methotrexate is effective in maintaining remission. There is no consensus as to how long these medications should be continued as they can be associated with side-effects. The next line of treatment to maintain remission is infusion of infliximab every eight weeks.

There is no simple way to keep Crohn’s in remission. Eighty per cent of the patients with Crohn’s will eventually require surgery as they become resistant to medical therapy or develop complications. Surgery does not cure the disease. It only removes the diseased segment of the bowel. There is high rate of recurrence of the disease after surgery. Within 15 years, more than 70 per cent of patients will require a second operation.

Unfortunately, in IBD, taking pills is a life long commitment without any guarantee of cure or episodes of relapse.

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

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Breast Cancer Awareness

October is breast cancer awareness month.

Today’s column will be little different. Read the question and ask yourself how much you know about breast cancer. Then read the answer and see if there is something new to absorb.

Q. How many women will develop breast cancer in the U.S.A, Canada and Australia?
A. In U.S.A., one out of every eight women will develop breast cancer in her lifetime compared to one in nine in Canada and one in 11 in Australia (TIME Magazine).

Q. Breast cancer rate in Palliser Health Region is higher than the provincial rate – true or false?
A. False. The incidence and mortality rates for breast cancer observed in our region are similar to the provincial rates (Cancer in Alberta 2005).

Q. What is the survival rate for women with early-stage breast cancer?
A. Nearly 98 per cent of women with early-stage breast cancer will live five years or more thanks to regular mammograms and improved treatments.

Q. What is Tamoxifen?
A. Tamoxifen is a drug which can lower a woman’s risk of breast cancer by 35 to 50 per cent. It reduces the risk of breast cancer recurrence and the chance of a new breast cancer starting. It can stop the progression of breast cancer (breastcancer.org).

Q. What is Herceptin (trastuzumab)?
A. It is a drug approved for the treatment of women with advanced-staged breast cancer. It also helps women with early-staged breast cancer by reducing recurrence rate by 50 per cent (CMAJ, August 16, 2005).

Q. What is Femara (letrozole)?
A. It is used by post-menopausal women who have finished five years of tamoxifen therapy after breast cancer surgery. The drug significantly reduces both the recurrence of breast cancer and distant metastases (CMAJ, March 24, 2005).

Q. How can a woman reduce the risk of breast cancer?
A. Drink alcohol in moderation, avoid obesity (obese women are twice as likely to die from breast cancer), women at risk for breast cancer should avoid estrogen hormonal therapy, do regular breast self-examination, have regular mammograms, have your physician check your breast once a year at least.

Q. Is antibiotic use associated with an increased risk of breast cancer?
A. A study published in 2004 suggested that premenopausal women who used antibiotics for urinary tract infections had an elevated risk of breast cancer compared with women who did not use antibiotics. The authors concluded that additional studies are required before the implications for clinical practice are clear. So, the jury is still out (CMAJ, June 22, 2004).

Q. Is exercise effective in reducing the risk of breast cancer in postmenopausal women?
A. Several articles have been published showing an association between physical activity and breast cancer prevention in post-menopausal women. It also helps in the reduction of cardiovascular disease and diabetes (CMAJ March 2, 2004).

Q. How reliable is mammogram in detecting breast cancer?
A. Sensitivity of mammogram depends on several factors. Overall sensitivity of mammogram is 70 to 90 per cent. It is only about 50 per cent in women under the age of 40. Less than 0.5 per cent of women will be found to have breast cancer on screening mammogram. If mammogram picks up a suspicious lesion then the chances of it being cancer on biopsy will be 90 per cent (CMAJ, January 18, 2006).

Q. Why do 35 per cent of women with locally advanced breast cancer wait more than three months before seeking medical attention?
A. Fear, belief that symptoms might be benign, belief there was nothing to worry about because they did not have a family history of breast cancer and belief they were too young to get breast cancer were cited by one in three women who eventually came to the Toronto –based clinic (The Medical Post, January 10, 2006).

So, how did you do?

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