Laughter

“Laughter is the closest thing to the grace of God,” says Karl Bath (1886-1968).

We all agree that laughter is good medicine. But our life is a race against time. And we are looking for instant results and gratification. There isn’t much time to stop and laugh.

Physicians are no exception to the rule. In fact, physicians have to deal with sickness, disease and death all the time. So, do they find time for laughter?

Many patients have excellent sense of humour. These patients have a positive outlook in life. They generally do quite well with whatever illness they have. They make our lives very easy and comfortable. They show us that we, as physicians, should lighten up and look at the funny side of medicine.

Physicians are lucky that they have a magazine completely devoted to making them laugh. Every physician in Canada receives a magazine called “STITCHES – The Journal of Medical Humour.” It has 160 pages. Almost every page has a cartoon or two. Physicians write most of the humorous articles.

In the February issue of the STICHES, there is an article by Simon Hally: “Where there is a smoke – A modest proposal for discouraging tobacco use.” He says that for some smokers –like teenagers- the risks of smoking are too remote to be effective deterrent. Hally says the real key to an effective anti-smoking program is to make the risks more compelling and immediate. He suggests the following plan:

1. Tobacco manufacturers must be required by law to insert a small explosive charge at random into every, say, 100th or 200th cigarette they produce. The explosive shouldn’t be powerful enough to be dangerous – the objective here is to protect people’s health, not harm it – but it should be loud and smoky and very startling. This would bring a nasty surprise and embarrassment to the smoker. If the smoker happens to be a teenager then the effect of embarrassment would be immediate.

2. These explosives should be booby trapped with greenish, gooey substance. When the teenager smokes, the substance would explode on his face and on his designer clothings.

3. Some of these explosives should be booby-trapped with foul smelling gas, dye that will stain teeth, or substance which will give the smoker 48 hours of horrible breath.

Do you think this will stop people smoking? Especially teenagers?

***

Here is a doctor joke from Dr. Howard J. Bennett, a paediatrician in Washington, D.C. who has written books on medical humour. In one of his articles in the STITCHES, he relates the following joke:

A doctor died and went to heaven, where he found a long line at St. Peter’s gate. As was his custom, the doctor rushed to the front, but St. Peter told him to go back and wait in line like everyone else. Muttering and looking at his watch, the doctor stood at the end of the line.

Moments later, a white-haired man carrying stethoscope and black bag rushed to the front of the line, waved to St. Peter and was immediately admitted through the pearly gates.

“Hey!” the doctor said angrily, “How come you let him through without waiting?”

“Oh,” said St. Peter, “that’s God. Sometimes he likes to play doctor.”

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How To Quit Smoking

“Getting kids to butt out” was the topic of my column last week. We also discussed Medicine Hat School District No 76’s “Tobacco-free Environment” Policy A-38. Today, we will take the subject little further.

We know that no one starts smoking after the age of 20. Most smokers start smoking in their teens. We know that 91 percent of youth believe smoking is addictive. We know the two reasons why teens start smoking are: peer pressure (“be cool, man!”), and curiosity.

So, how can we stop teenagers from picking up this habit? And help smoking teenagers kick the habit?

Prevention programs depend on creating public awareness of the serious health consequences of tobacco use. But the Alberta Cancer Board says: “It is now recognized that awareness alone is not enough to alter behaviours. For example, it is ineffective to teach children that smoking is bad for you if the students then go home to parents who smoke, or go to the mall or other public places and see widespread social acceptance of tobacco use.”

To encourage and help people become and remain tobacco free, it is also necessary to create a supportive social environment, says the Cancer Board. Does our school system have such supportive social environment?

Ninety percent of everything we do is habit, says Kurt Hanks in “Motivating People”. Much of motivation involves changing someone’s habits. People are usually quite comfortable with their established patterns and routines. So how can we change them?

To change someone’s habit pattern, you have to substitute a better habit pattern. We have to show them that their time and money can be spent on better and healthier things. Besides that, personal motivation plays a big role.

Personal motivation is the single most important factor that determines a person’s success or failure in quitting cigarettes, says Dr. Edward Beattie, Jr., M.D. in “Toward the Conquest of Cancer.”

The man or woman who is highly motivated to stop smoking – for whatever reason – will be successful while those with weak or moderate motivation often do not succeed, says Dr. Beattie. Personal motivation also determines whether a smoker who has quit will backslide into smoking again.

The teenager does not fear cancer or other illness that may strike him in 20 to 30 years. But he does fear being “uncool”, not knowing how to handle a cigarette, and not being an “in” member of his social group, says Dr. Beattie.

It is never too late to quit smoking. The risk of death decreases soon after quitting and continues to do so for at least 10-15 years. After that, the overall risk is nearly the same level as for never-smokers.

Therefore, it is very important for schools to have programs that focus on prevention and elimination of smoking in and around schools. This should involve parents, teachers and students. We should also create a supportive social environment for teenagers to keep them away from this deadly disease.

The task is not easy. But the parents and teachers should get together and organize some serious preventative measures that we can all try and make it work. Does anybody talk to the kids who stand across from their schools and smoke? Do their parents know they smoke?

Finally, let us remember that cigarette smoking is the largest single preventable cause of cancer. It is also the largest single preventable cause of illness and premature death in Canada. Smoking accounts for almost 30 percent of all cancer deaths and kills almost 3,500 Albertans and 45,000 Canadians each year – more people than killed by heroin, cocaine, alcohol, AIDS, fires, murders, suicides and car crashes combined.

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Teenage Smoking

Each morning, if you are driving by one of the junior or senior high schools, or dropping off your child at one of these schools, you will notice a group of students hanging out and smoking across the street. Many parents, who do not want their children to pick up this deadly habit, find this very disturbing. It is a scary sight –especially at eight o’clock in the morning.

Come to think of it, five or ten students seen smoking outside their schools represent a very small minority. I know there are many more students who smoke, but are not seen “showing off” first thing in the morning. Perhaps there are few teachers at each school who smoke. But my impression is that the vast majority of teachers and students abhor smoking. But is that enough?

Medicine Hat School District No. 76 has a “Tobacco-free Environment” policy A-38 which says: “Effective August 31,1994, the use of tobacco products in the buildings of the Medicine Hat School District No. 76 is prohibited. The senior high school principles will designate a smoking area on the school grounds for senior high students.”

The Superitendant of the Medicine Hat School District No. 76, Dr. Dave Beresh, says that this policy applies to students, teachers and other staff members as well. This prevents students and teachers going in the neighbourhood back alleys to smoke.

Some parents look at this differently. They say this policy encourages smokers to continue to smoke and slowly poison the beautiful work of nature, personally and environmentally, and eventually cripple the cardiac and respiratory systems. As the smoker develops chronic illnesses, he not only becomes a burden to his own family but to taxpayers in general by extensively draining the already drowning health care system.

Smoking is extremely addictive. Perhaps the “tobacco-free environment” policy does not want to drive the smokers underground by banning smoking completely. We face this sort of dilemma in life all the time. How to strike a right balance between achieving results and not upsetting any segment of society. But one has to do what is best for the majority of the people.

What do smoking parents tell their children about smoking? What do smoking teachers tell their students about smoking? What do health professionals tell their patients about smoking? One can only guess!

In a 1999 survey, Health Canada noted the following:

-27 percent of Albertans aged 15 years and older were smokers – two percent higher than the national average.

-27 percent of Alberta male and 28 percent of Alberta females were smokers – the same as the national average for males, but five percent higher than the national average for females.

-25 percent of youth aged 15-19 years are currently smokers.

-91 percent of the youth believe that smoking is addictive.

-54 percent of Canadian Aboriginal teens smoke

Why do teens start smoking?

Mainly two reasons: peer pressure and curiosity. But almost no one starts smoking after age 20. So, can we make teenagers understand the dangers of smoking and prevent them from taking up the bad habit? How can we help teenagers who are already smoking? What do you think of the of School District No. 76’s “Tobacco-free Environment” policy?

Let me know. We will discuss this further next week.

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Colonoscopy

Recently, Dave turned 50.

Over the years, he has been very conscious of his health. He eats low fat, high fibre diet. He believes in the dictum, “Those who live by the sweets, die by the sweets.” He is careful about his weight. He exercises regularly – 30 minutes each day, five times a week. He gets his prostate checked.

“So, Doc, what’s missing? Is it time for colonoscopy? Is it the best test for prevention and early detection of colorectal cancer?

Dave has no risk factors and no symptoms of colon and rectal cancer. So, here are the questions:

1. Should a 50-year-old asymptomatic individual undergo screening tests for prevention and early detection of colon and rectal cancer?
2. If yes, what is the best test – is it colonoscopy?

It is unfortunate that prevention and early detection of colorectal cancer does not get the same publicity as breast and prostate cancer. Last time media paid some attention to this subject was when the former U.S. President Ronald Reagan was found to have precancerous colonic polyps. That was many years ago!

Some young prominent Canadians have had colorectal cancer. Recently, Pamela Wallin, 48, broadcaster and author was diagnosed and treated for colorectal cancer. Former leader of the Alberta Liberal Party and Leader of the Opposition in Alberta Legislature, Lawrence Decore, died from colorectal cancer at a young age. Former Premier of Prince Edward Island, Joe Ghiz, died of colorectal cancer at age 51 (1945-1996).

Answer to Dave’s first question: Yes, there is evidence to suggest that asymptomatic 50 year olds should undergo screening for colorectal cancer.

Answer to Dave’s second question is not that straight forward. The screening tests recommended by the Canadian Task Force on Preventive Health Care (discussed here on August 9th) for asymptomatic people over the age of 50, who are at normal risk, are:

1. Annual or biennial (every two years) fecal occult blood tests (to check for non-visible blood in the stool)
2. Flexible sigmoidoscopy (an office procedure) – probably every five years.

Unfortunately, one-quarter of colorectal cancers or serious precancerous lesions may be missed by these tests.

Colonoscopy is considered the gold standard. Some experts suggest colonoscopy every 10 years for asymptomatic individuals after the age of 50. In an editorial in the New England Journal of Medicine (August 23), Dr. Allan Detsky of University of Toronto says, “I recommend a single screening colonoscopy at the age of 50, with perhaps another in 10 to 15 years if no precursor lesions are found.”

But can we afford colonoscopy for all asymptomatic Canadians over the age of 50? Probably not! Then what should one do? The best thing is to discuss your concerns with your family doctor and he can assess your risks and order appropriate tests. Blood test – CEA –is not a good test for screening and is not recommended for this purpose and should not be done.

Although screening for colorectal cancer should begin routinely at the age of 50, adherence to recommendation is 50 per cent or less. This is unfortunate and there is no mechanism to ensure better compliance.

In Canada, colorectal cancer is the third most common cancer. Both sexes are equally affected. Last year, about 17,000 Canadians were diagnosed with colorectal cancer and about 6500 died from this disease. So, Dave, you should undergo screening and my recommendation would be colonoscopy.

Have I had one? Yes.

Dave is a composite character representing a typical patient.

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