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Doctors and Dieing Patients

“A physician’s responsibility for the care of a patient does not end when the patient dies. There is one final responsibility – to help the bereaved family members. A letter of condolence can contribute to the healing of bereaved family and help achieve closure in the relationship between the physician and the patient’s family”, says an article in the New England Journal of Medicine (NEJM).

How often do we, the physicians, do this? Hardly ever. Well, I shouldn’t say that! There is always some body somewhere who does special things for people he cares about. Let me tell you about my own practice and how things have evolved over the years. This is not only about bereavement. It is also about caring and making patients feel good.

Let me start with a recent example. A patient who I had known for many years was hospitalised with complications from a long-standing illness. I was not directly involved in her care, but I knew she was in the hospital. From time to time, I dropped in to say hello, held her hand and spent few minutes talking about things in general.

Few days later, she died. I received a “thank you” card from the family for having taken care of her in the past and how much my visits and services were appreciated by the patient and the family. I asked my receptionist to give me her file so I could call the family and give my condolence. The file lay on my desk for two weeks and I never got around to phoning.

This is in complete contrast to what I used to do when I started practice 16 years ago. I had no children, my practice was not that busy and I had plenty of time to spend with my patients and their families.

I used to do my ward rounds twice a day. Morning rounds are usually “quickies”, as we are rushing to the office, or to the operating room. Evening rounds allowed me to sit with my patients and learn more about their illness and family. Occasionally, I sent flowers to patients who I had known who had major surgery. Some times my wife visited them in the hospital.

On weekends, I used to take my 5-year-old son to meet my patients. We had a white coat made for him and he would carry his plastic stethoscope in his pocket. Many of my patients still remember this. Even now they ask me how is my little boy doing (he is 14 now!). Few years later I started taking my daughter as well. Some time it was hard to control both and I heard a nurse say, “I didn’t know doctor’s children can be naughty!” That put an end to my family ward rounds on weekends!

As I got busy with my practice and my family, the evening rounds occurred only if a patient was sick and needed another visit to check his progress. The desire to rush home and play with my kids was irresistible after a long day in the hospital and office.

In the last 16 years, I don’t remember having written a letter of condolences to bereaving family members. Occasionally, I have phoned. Contact with the patients in hospital is now to a minimum. Most patients are discharged the same day or day after surgery. Due to long waiting lists, the pressure to see more patients in the office does not allow too much time to talk about other things. As a specialist, it is hard to know my patients more than what they come to see me for. That old style “family physician” type of relationship is hard to establish.

The NEJM article says that in the 19th century America, the process of grieving was detailed and elaborate. The doctor’s letter of condolence was an accepted responsibility and an important part of the support offered to the bereaved. But today, the pattern of mourning has changed and has become much abbreviated.

But the article makes a strong point to encourage physicians to find time and write a letter to bereaved family. It says, “Unlike expressions of condolence made by telephone or in person, a letter of condolence is a concrete gift that the recipient can and will review over and over”. I agree. But will I be able to do it? Only time will tell.

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Alcohol Use

Dear Dr. B: Some time ago, there was a discussion in this newspaper about the health benefits of alcohol. The letters to the editor has left me confused. Can you help? What does the medical literature say? Yours: A Heart Patient

Dear Heart Patient: Mankind has known the use and abuse of alcohol for many centuries. In fact, the term alcoholism first appeared in 1849 in an assay written by a Swedish physician, Magnus Huss, titled “Alcoholism Chronicus”.

Alcoholism is considered a disease. It is a compulsive addictive behaviour. Alcoholism means excessive and repeated use of alcoholic beverages. Ten percent of the population is dependent on alcohol. It costs the health care system millions of dollars.

Raymond Chandler (1888-1959) said, “Alcohol is like love: the first kiss is magic, the second is intimate, the third is routine. After that you just take the girl’s clothes off.” Where does the benefit stop and the harm start?

For many years, there has been scientific evidence to suggest that moderate amount of alcohol is good for our health. But physicians have been reluctant to publicize or promote this advantage. They are worried that some people will use this as an excuse to justify excessive drinking. The alcohol industry will use this to promote their products. And the promotion of the benefits will raise moral, religious and ethical issues and confuse and divide the people who otherwise would benefit the most.

But Dr. B, what are the benefits?

-There is overwhelming evidence that moderate alcohol drinking reduces sickness and death from coronary artery disease.
-Alcohol also favourably changes the blood lipid levels and makes the blood thinner.
-There is 24 to 53 percent decline in the risk of duodenal ulcer.
-It reduces death from stroke, reduces the incidence of blood vessel disease in the legs and arms, and reduces adult onset diabetes.
-Up to three drinks a day, alcohol reduces blood pressure in females but heavy drinking will have the reverse effect.
-Moderate drinking of wine, beer, and spirits can reduce the incidence of Alzheimer’s disease, and dementia.
-Alcohol alleviates the effects of stress.

Dr. B, what are the dangers of abusing alcohol?

-Alcohol is addictive – it’s a drug with complex behavioural effects that can be pleasurable or unpleasant, stimulating or depressing.
-Drinking during pregnancy causes fetal alcohol syndrome in the new born – a very serious condition.
-It can cause cirrhosis of liver, liver failure and pancreatitis.
-It can cause gastritis and bleeding .
-It can cause traffic or work related accidents – resulting in disability or death.
-Alcohol is implicated in more than 20 causes of death.
-It can cause cancer of the oesophagus, breast and other cancers.
-Alcohol abuse can destroy a person’s personal life, family life and capacity to earn a decent living.
-What is moderate drinking? Is it one, two, three drinks a day? Moderation for a non-drinker is different than for a habitual drinker.

Critics of alcohol use say that much of the protective effect gained from alcohol use in coronary artery disease can be achieved by other means – exercise, diet, avoiding smoking, and control of cholesterol level.

The question remains: Should the Canadian medical organizations and physicians publicize the benefits and the risks of moderate alcohol consumption to the Canadian public?

The best thing for you, as a heart patient, is to discuss your individual case with your family doctor or your specialist. I hope the information provided here will be of help.

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M.R.I.

If you listen carefully, then you can almost hear Dr. Ken Blair, Palliser Health Authority’s Director of Diagnostic Imaging, say with pride: “Heeeeere’s is MRI!”

Besides Blair, there are numerous people who are proud of successfully bringing the MRI service to Palliser Health Authority (PHA). We tend to criticize our health care system a lot. Perhaps with good intentions. We want more of everything. The human desire for more is some time insatiable. Some times that is good and some times not so good.

In case of MRI, it was good! Certainly the Government of Alberta and our local MLAs deserve a big “Thank you”. So do the public, the health authority, the health care providers and Dr. Ken Blair and his team of tireless people in the x-ray department (oops! it is called the Department of Diagnostic Imaging).

What is MRI?

MRI stands for Magnetic Resonance Imaging. In 1946, Bloch and Purcell demonstrated that some atomic nuclei respond to the application of particular magnetic fields by emitting or absorbing electromagnetic field. This was then used for analytic chemistry.

A Swedish physicist, Erik Odeblad, pioneered the medical application of this technique in the 1950s. In the next 30 years, much work was done on the MRI images showing human pathology. Initial emphasis was placed on imaging of the brain. But since 1980, studies of other organs have also been performed.

All MRI machines are constructed around a large magnet that provides a uniform, static magnetic field. There are no adverse effects reported from this and there are guidelines designed to prevent possible hazards. The only adverse effect reported is three to four percent incidence of claustrophobia.

Dr. Jay Daniels, PHA’s Director of MRI Services, says the technology uses a super conducting magnet which is kept to a temperature approximately four degrees above absolute zero, with a resulting magnetic field over 50,000 times stronger than the earth’s. No ferrous metal is allowed in the examination room as it could become a very dangerous missile in the presence of the magnetic field!

Within a week or so, the first MRI images will roll out of the new addition to the Medicine Hat Regional Hospital. Daniels predicts excellent availability for the patients of our Region with lower waiting lists than has traditionally been the case in Alberta. The examination time will vary from few minutes to 40 minutes depending on the body part being imaged.

Common indications for the tests are: chronic headaches, family history of brain aneurysms, possible spinal disc diseases, and arthritis of the back, knees and shoulders. Other indications depend on the clinical situations. Daniels says the MRI is safer than using ionizing radiation as in the case with x-rays. Patients with metal in the eyes, pacemakers, and cardiac leads however cannot be imaged. Orthopaedic hardware like metals in the knees and hips can distort the pictures if they are too close to the organ being imaged

Blair is very proud of “the first class state of the art physical facility, which includes not only the room for the scanner, but also an excellent patient reception and waiting area”. There is a great lack of trained MRI technologists in Canada. PHA was fortunate to recruit an experienced technologist for the position of supervisor and have trained two of the local staff as MRI technologists.

Blair is worried that public’s perception and expectation on what an MRI can do may be too high. MRI is not indicated for all undiagnosed conditions and is not a “magic answer” to people’s anxiety about their health. Each request for MRI will be carefully screened, says Blair.

And he is serious. He will not accept my request for a total body MRI to see why my golf swing is so bad! For that I may have to go to a private clinic! But seriously, MRI will make a difference to the health of PHA residents. So be proud and make judicious use of the new service!

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Sick Doctors

Do doctors have chronic illness? Of course they do! What happens to them when they have chronic illness but are not classified as disabled?

“Doctors who have chronic illness have a rough deal. As well as having to come to terms with their illness, they also face problems in their career. Inflexible working patterns, poor contingency cover, and colleagues who are “sympathetic until it affects them” often add guilt to an already difficult situation and leave ill doctors wondering whether they can continue working in a position that makes little allowances for their health needs,” says an editorial in the British Medical Journal (BMJ).

Even with chronic illness, most physicians are willing to provide limited service if allowed to do so.

In Britain, there are counselling lines for sick doctors but they do not get career advice. Now the BMJ has started Career Focus for chronically ill doctors. This service will “provide useful advice that will help them find a career option that suits their health needs.”

There is no such service in Alberta or Canada. In fact the situation is worse as most doctors are on fee-for-service contract with Alberta Health Care Insurance Plan (AHCIP). So, if a doctor does not see a patient then he does not get paid. If he takes a week off then there is no cheque in the mail from AHCIP. If he is not classified as disabled then his disability insurance policy does not pay him a dime!

The situation of chronically sick Canadian physicians was highlighted last August when a family doctor and psychotherapist, Dr. Suzanne Killinger-Johnson, clutching her six-month-old son, jumped in front of a Toronto subway train, killing them both.

Media and the people in general wondered why a bright, attractive, affluent, successful 37-year-old doctor would commit suicide and take her young son with her? After all physicians have it all! But if you don’t have good health then you don’t have it all!

There is a very high rate of depression among physicians. One study shows that from 1991 to 1998, the rate of suicide for British Columbia doctors was about 22 suicides per 100,000 people per year. The rate for the general population was just shy of 14 per 100,000 people. Female physicians commit more suicides than male physicians.

Is there help?

In Canada, there are several provincially based physician health programs that help doctors with stress related difficulties like depression, and other psychiatric, medical or substance abuse problems.

“From time to time we all face difficult or stressful events in our lives. Most of the time we can handle these challenges on our own. Other times they may interfere with our effectiveness, happiness, safety at home and work, or even our health,” says Alberta Medical Association’s Physician and Family Support Program document. The program provides confidential referral and counselling services for Alberta physicians and their families.

It is a good program. But is there help if a physician’s health is interfering with his career but he is not considered disabled or clinically incompetent? None! Who would want to give a physician hospital privileges if he cannot be on-call, cannot share the workload equally with his healthier colleagues, use health authorities’ limited resources disproportionately to the contribution he makes, block recruitment of younger and healthier physicians, and thus deprive the public of a “full meal deal” physician?

Few years ago, the Canadian Medical Association produced a document called “Charter for Physicians”. Under the item Quality of Life, in part it says, “Canadian physicians need access to appropriate resources for dealing with personal or professional problems that affect their medical practice.” But there is no mechanism in place to enforce the Charter!

Is there a solution to the problem? I haven’t seen any action provincially or nationally to help chronically ill physicians. It will have to come down to local level – a serious dialogue between the medical staff organisation and the health authority. And there seems to be recognition and some action locally to help doctors with chronic illness who are willing to provide limited service.

May the force be with them!

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