Diverticular Disease

Dear Dr. B: Recently I was in hospital with left lower abdominal pain and fever. I had intravenous antibiotics and investigations showed I had diverticulitis of the colon. Thanks to my doctor I am feeling better. Can you please tell me more about diverticular disease and diverticulitis and how can I be cured of this “disease”? Yours Mr. DD.

Dear Mr. DD: Diverticular disease of the colon is a very common condition. But is it really a “disease”?

No. Many people have this condition and have no symptoms and are not even aware of its presence.

What does the term diverticular disease mean?

This means there are little sacks or pockets sticking out of the wall of the colon – called diverticula (if multiple) or diverticulum (if single). Usually, they are multiple and are mainly concentrated in the sigmoid colon in the left lower abdomen. There may be more in the rest of the colon. In Latin the word diverticulum means a wayside inn – presumably a place of ill repute!

Diverticulosis of the colon was first described in 1849. So it has been with us for a long time. But why do people get this condition is not very clear. It is an acquired condition. One textbook of surgery says that it is reasonable to believe that colonic diverticula develop at weak points in the bowel wall under the influence of increased intraluminal pressure.

Many other hypotheses have been advanced but one most convincing is the spasm of the muscles of the wall of the bowel with irregular contractions of the affected part that increases the intraluminal pressure.

This condition is very uncommon under the age of 35. Above 35 years the incidence increases steadily so that by the sixth decade nearly 30 percent of all patients have diverticulosis.

What is diverticulitis?

This is inflammation of the diverticula. Mr. DD, this is probably what you had if you were in hospital with pain and fever. Usually, the condition responds to antibiotics. Sometimes there is relentless inflammation and one may end up having emergency surgery because an abscess has developed. Emergency surgery involves removal of piece of infected bowel and temporary colostomy.

There are many complications associated with diverticulosis and diverticulitis. These are bleeding, bowel obstruction due to narrowing of the colon, perforation and peritonitis, fistula (tunnel) formation between the colon and urinary bladder, vagina, and small intestine. Diverticulosis does not turn into cancer but it can hide cancer and make diagnoses of cancer difficult.

Uncomplicated diverticulosis is generally believed to be without symptoms and is discovered incidentally during barium enema or colonoscopic examination. Ill-defined symptoms of abdominal discomfort, gas, bloating and some change in bowel habit are difficult to ascribe to diverticulosis. But could be part of the spastic bowel syndrome.

Doc, how can I get rid of the condition?

There is only one way to do this is to surgically remove the affected piece of bowel. When is the right time to do this depends on many factors including associated symptoms and complications. The best thing is to get a surgical opinion. Planned resection generally requires no colostomy.

Mr. DD, I hope this gives you enough information about your problem. Eat a healthy diet of fruits and vegetables, keep your bowels regular and discuss your options with your family doctor or a surgeon.

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Ailing Healthcare System

A physician’s performance is affected by many factors. One of the most important factors is the systemic deficiency in the health care area. Most physicians work very hard to compensate for these deficiencies to provide excellent care to the patients. This, of course, comes at a personal cost to the physician’s own health and quality of life..

Let us look at some of these deficiencies in our health care system.

1. Shortage of physicians:

In 1993, there was one physician for every 528 Canadians, compared with one for 541 today. Almost 47 percent of family physicians under 40 are female. Not all of them work full-time. Each year, 650 Canadian doctors move to U.S. Today, Alberta needs 333 full time doctors and rural Canada needs 1652 doctors. Are we ever going to have enough doctors?

2. Specialists are getting older and working longer:

Canadian Medical Association data show that almost 49 percent of all active general surgeons are older than 55. Forty one percent of general internal medicine specialists, 40 percent of ear, nose and throat specialists, and 39 percent of obstetricians and gynaecologists have relatively old specialists. Seventy two percent of general surgeons older than 55 and 73 percent of general internists work more than 40 hours per week. As we continue to be short on all types of specialists, these numbers are going to get worse with burnouts and early retirements.

3. Nursing shortage:

Canada is in the grip of a serious shortage of registered nurses. This is expected to get worse over the next few years. The most comprehensive national study, published by the Canadian Nurses Association, predicts a shortage in Canada (except Quebec) of between 59,000 and 113,000 by 2011. Quebec has its own nurses association and they are predicting a shortage of 11,000 nurses between 2001 and 2015. Are we ever going to have enough nurses to look after us?

4. Shortage of other health care professionals:

Currently there is a significant shortage of speech therapists, occupational and physiotherapist, ultrasound technicians, MRI technicians and many other non-physician, non-nursing specialists in health care fields.

5. Shortage of doctors in rural areas:

Many Canadian physicians are reluctant to work in rural areas because of high level of on-call, long distance to secondary referral centre, lack of speciality services, too few family doctors, absence of equipment such as x-rays and laboratory services, difficulty in obtaining locums, no ambulance service, inability to provide services such as obstetrics and general surgery, sparsely populated catchment areas etc. Is this ever going to get better?

6. Shrinking medical schools:

There has been steady decline in the size of first-year classes at Canadian medical schools during the past 15 years. In 1997, 1577 students enrolled in first-year classes, compared with the peak of 1887 students in 1983. The number of applicants to U.S. medical schools has dropped by 18 percent since 1996, while the number applying to Canada’s 16 schools declined by eight percent in the same period. Why? Because potential medical students have more career opportunities in non-medical fields, have fear of difficulties in health care system, and are afraid of huge debts associated with medical education.

7. Shortage of acute car beds:

As a result of massive bed closures over the past ten years or so, there are now only 1.74 hospital beds per 1,000 people in Calgary and 1.70 beds per 1,000 people in Edmonton. This is a substantial decline from 1993, when the provincial average was 4.7 beds per 1,000. Similar shortages are felt outside Calgary and Edmonton.

There are two other issues not dealt with here: funding and waiting times to see specialists and get investigations done. All in all not a healthy picture of our health care system. But all types of health care professionals work hard at great personal cost to provide good care to the people of our province. Hats off to them and their families!

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In the last column, we briefly mentioned the Physician Achievement Review (PAR) program. Some of you may have already participated in the program to evaluate your physician’s performance. Here is some background information.

In 1995, the College of Physicians and Surgeons of Alberta established the Physician Performance Advisory Committee to set up a proactive process to review physicians’ performance regularly and facilitate life long learning.

“The committee selected the program name Physician Achievement Review to denote supportive purpose and the goals of describing professional accomplishment and improving practice,” says Dr. William Hall, Chairman of the Physician Performance Committee in an article in the Canadian Medical Association Journal.

After going through several stages of development and pilot studies, the program was implemented for all physicians in Alberta in February 1999. There are 4700 physicians in Alberta, and it is planned that approximately 20 percent of physicians will be assessed each year over a 5-year cycle.

Is this program necessary? Is there any evidence that the quality of care provided by the majority of physicians is not up to the best standards acceptable to the College?

Every organisation or profession has few “bad apples”. Through the complaint process, the College has power to discipline such “bad apples.” Then why create the PAR program?

The College says, “Alberta’s doctors rank among the best in the world. In training, expertise and commitment to the highest standards of practice. And we all want to keep it that way”. PAR is designed to provide doctors with information about their medical practise through the eyes of those they work with and serve. The unbiased feedback is enormously helpful to the doctors, who will be able to build on their strengths and correct any possible problems, says a College document.

How does the process work?

The participating physician completes a self-assessment questionnaire and recruits 25 patients, 8 physician colleagues, and 8 non-physician co-workers to fill questionnaires. These questionnaires are processed by an independent body (Customer Information System –CSI) to maintain confidentiality.

The questions relate to the physician’s clinical knowledge and skills, communication skills, psychosocial management, office management, and collegiality. The CSI reviews the questionnaires and reports to the Survey Subcommittee. The Survey Subcommittee is responsible for contacting and advising physicians whose profiles are flagged. The committee also refers physicians for individualized assessment when appropriate.

It is quite an elaborate process with many committees and subcommittees. PAR ensures confidentiality of patient records and protection of the patient-doctor information. Studies by the University of Calgary have demonstrated that PAR is very effective. There is no cost to the taxpayers. The program is funded by the physicians.

But who is going to benefit the most from the program: the College, the physicians or the patients? Would such a program identify serial killers like Dr. Harold Shipman? Is the program trying to identify good and bad practices only? Would the program benefit the vast majority of physicians who are conciouscious and hard working anyway? Well, only time will tell.

What do you think? What is your definition of a good doctor? Is the College doing a good job to fulfill its mandate “to serve the public and guide the medical profession”? Do you have an opinion? Send it to me by e-mail or at 821A-5th Street SW, Medicine Hat, Ab T1A 4H7.

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Medical Errors

Perfection in medical practice is a laudable goal. But not achievable at all time. Some errors and complications are inherent in medicine although the medical profession promises to do no harm.

But what about people like Dr. Harold Shipman? Also known as Dr. Jekyll. He is a British general practitioner known as the world’s most prolific serial killer. A recent audit of his practice in Hyde, Manchester indicates that he is responsible for the deaths of as many as 345 of his patients – average of one patient a month for more than 20 years.

He is reported to have been a dedicated and congenial physician. His victims were older ladies.

An article in the Canadian Medical Association Journal (CMAJ) says that Dr. Shipman’s crimes first came to light in 1998 when a local GP contacted the coroner about what he saw as an unusual number of deaths. A local undertaker also voiced suspicions, but there was insufficient evidence for police to proceed.

The article says that Dr. Shipman had one conviction before when he started his practice in 1974, at Todmorden, West Yorkshire. He was convicted of dishonestly obtaining drugs. His practice partners had noticed that he was signing prescriptions for narcotic drug that his patients never received.

How did he get caught for his latest crimes?

He got too greedy and picked a wrong kind of patient. His victim was the former mayor of Hyde, Kathleen Grundy. Grundy, 81, had left Shipman 350,000 pounds in her will. Grundy’s daughter, a lawyer, got suspicious and contacted the police. Shipman was investigated and charged with murdering 15 of his patients. Now he is serving 15 life sentences.

Are there many Shipmans in the medical community?

“Everything points to the fact that a doctor with the sinister and macabre motivations of Harold Shipman is a once-in-a-lifetime occurrence”, says UK’s chief medical officer, Dr. Liam Donaldson, in the CMAJ article.

That may be true. But an article in the British Medical Journal says that medicine has thrown up more serial killers than all the other professions put together, with nursing a close second. Dentistry too has had its notorious characters, yet among veterinarians homicide seems to be almost unknown.

The article goes on to name numerous physicians over the years who have been convicted of multiple murders all over the world. The author of the article makes a case that the medical profession attracts some people with a pathological interest in the power of life and death. These physicians also include Nazi doctors who engaged in ethnic cleansing and the Japanese doctors who engaged in biological warfare.

The author says that the health authorities are becoming more vigilant in monitoring health professionals’ activities. And currently there are two major police investigations into multiple deaths in hospital – one in France, the other in Britain.

The British government has established a new agency – National Clinical Assessment Authority – to intervene rapidly when suspicions emerge about a medical practice instead of waiting for the licensing body – General Medical Council – to act.

In Canada, each province has its own licensing body to monitor physician practices and complaints. So far they seem to be effective. But we have to be vigilant. The College of Physicians and Surgeons of Alberta has also established the Physician Achievement Review Program (PAR) to improve the delivery of medical care in our province. We will discuss the PAR program in the next column. Until then stay safe and healthy!

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