Public expects doctors to be superhuman.

By Dr. Noorali Bharwani, Regional Chief of Staff, Palliser Health Region, Medicine Hat, Alberta. Published in the Medicine Hat News, Tuesday, February 16, 1999 Page B3

Doctors are greedy. Doctors’ practices are money driven. Doctors have no time to examine or listen to patients. Doctors push prescriptions. Doctors drive up utilization cost. Doctors drive up drug costs.

These days we hear more about doctors than politicians.

Recent reports about patient dissatisfaction with physician care does not help improve the image. Physicians are easy targets, as they cannot speak out in public without jeopardizing patient confidentiality.

This is a profession which, rightly or wrongly, is expected to bear the most direct responsibility for other people’s quality of life and the nature and timing of their deaths but is unable to defend its action in public.

If a person is not happy with the service he receives from a physician then he has right to complain. But this should be done in a manner which is fair to both sides. Every profession is governed by a code of conduct. Every individual is protected by the bill of rights and the process of natural justice.

The question is -which is the best venue to seek justice? Media? No. The venue should be such that both parties are heard appropriately and their rights protected.

We live in an era where public’s expectations are enormous. These expectations are further heightened by the explosion of knowledge and information on the Internet. In spite of cutback in services in an already underfunded system, physicians and hospitals are expected to perform as if nothing has changed.

Anecdotal episodes of alleged unsatisfactory treatment reported in the media do not prove that all doctors are bad or not caring. Doctors are just like other human beings with their individual styles and quirks. You may like some or you may not. Walk-in clinics are good to tie over a situation until you see your doctor but not a good place for continuity of care.

All the physicians I know are extremely caring and hard working. Thus, they not only drive themselves but also allow themselves to be driven relentlessly. On a daily basis they run a very tight schedule. They are type A personality, living dangerously with one foot in the grave.

Just ask a physician’s spouse and children how they feel about their lifestyle. On July 30, 1997 my daughter (then 7) wrote to me: “Dear Dad, You are the best dad ever. I wish I could spend more time with you. I also wish that you won’t working so much. Love, Alia.”

Doctors are under constant pressure to be superhuman. They are expected to provide service round the clock and be consistent, faultless and precise at all hours of the day or night. Medicine must be the only profession where this is expected. Airplane pilots and long distance truck drivers have to take mandatory breaks to keep their sanity and concentration.

A doctor is not infallible. He practices a very complex science with no fixed boundaries. There is no room for arrogance or one upmanship. The human body and mind is very unpredictable. From time to time, the physician will be challenged by the unusual, the rare, and the unexpected. He will stumble, just like any human being, if he is not totally in control of his thinking at all times.

For parents, there is no greater tragedy than losing one’s own child. Nothing in the world can compensate for that. Loss of a patient to a physician is as tragic. It takes a long time to recover from that experience. Medical schools do not emotionally prepare physicians for such tragedies.

Mediocrity is unacceptable in any profession. Physicians attend regular continuing medical education meetings. They go for courses to upgrade their skills. They are proud of the advances in medical science, but find it difficult to understand when patients complain because their (physicians) efforts are not always effective. At the same time the public fails to understand why a doctor cannot provide quick diagnoses and treatment.

Finally, communication. If there is an open dialogue between a patient and a physician about the expectations and the limitations of modern technology, then the outcome would be a happy one for both sides. Such discussion help prevent systems and individuals from getting complacent, inefficient or obsolete. Both parties should equally and openly be involved to achieve a happy outcome.

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Osteoporosis, a fall on an icy road, fractured hip, hospitalization, surgery, rehabilitation, nursing home……sounds tragic?

Yes. Falls among older adults, either at home or outside, have increased dramatically through out the world, says the British Medical Journal (BMJ). This is devastating to the patient and very expensive to our healthcare system.

In 1993, osteoporosis cost the Canadian health care system $465 million. This does not include the money spent on long term care ($563 million), and chronic care hospitals ($279 million).

The remodeling of bone (its formation and resorption) is a continuous process throughout life. When bone resorption exceeds bone formation, there is reduction in bone mass, density, and strength leading to osteoporosis.

In a review article in the Canadian Medical Association Journal, Dr. Brian Lentle says that a peak bone mass is achieved between the ages of 20 and 30 years. There after, men and women, lose bone at a rate of about 0.5 to 1 percent yearly. In fact, soon after menopause, a woman has 3 to 5 percent per year bone loss. The loss is less after the age of 65.

Can we prevent osteoporosis?

The Editorial in the BMJ says that regular exercise is probably the only method that may prevent osteoporotic fractures. Studies in animals and humans have shown that physical activity can increase bone mass, density, and strength.

The physical activity has to start early in life (before or at puberty) to have any beneficial effect in later life. The promotion of lifelong physical activity is essential, says the Editorial.

In one study, women aged 80 and over, strength and balance training reduced the rate of falling by more than 30 percent. Epidemiological studies have shown that both past and current physical activity does protect against hip fracture, reducing the risk by 50 percent.

Other studies have shown that estrogen deficiency plays a role in the loss of bone in post-menopausal women. Estrogen therapy reduces bone turnover. But many women are reluctant to go on this hormone because of side effects.

It has been shown that 50 percent of the women would prefer non-hormonal therapy (bisphosphonates). Some prefer to take Calcium, which helps sustain but not increase bone mass. Other medications used are: vitamin D and calcitonin.

How do you know you have osteoporosis?

There are number of methods, simple (x-rays and ultrasound) to sophisticated (dual energy x-ray absorptiometry) to measure bone density. Whether any of these methods should be used for screening or only for patients who are at risk of fracture remains controversial.

Osteoporosis continues to challenge the medical researchers. A literature search on the PUBMED revealed 17566 citations. This indicates that the last word is yet to come. If you think you have osteoporosis or are thinking of preventive measures then discuss this first with your family doctor. Do not consume large amount of Calcium or Vitamin D without medical advice. It can be hazardous to your health!

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Tamoxifen and Breast Cancer Prevention

“Dr. B, is there a pill to prevent breast cancer? You know my sister has had breast cancer and she takes Tamoxifen. Does the pill prevent cancer in women who have had no breast cancer?”

As always, Susan’s questions are right to the point. She has read recent reports about the benefits of Tamoxifen in women with a significantly elevated risk factors. She wants to know where she stands.

Susan, let’s look at the history of Tamoxifen – it’s usage, side effects – and then review the results of recent study undertaken by the Breast Cancer Prevention Trial (BCPT).

Breast cancer is usually hormone (estrogen) dependent. When indicated, women with breast cancer underwent surgery to remove organs which produced estrogen (e.g. ovaries) which helped control or regress the tumor.

Discovery of Tamoxifen reduced the need for these surgical procedures as the drug stopped the binding of estrogen to the tumor. In 1977, Tamoxifen was approved in the U.S. by the Food and Drug Administration for use in breast cancer. Thus began a new era in the treatment of this cancer.

“Dr. B, why did the researchers think that Tamoxifen would help prevent cancer in women who have no personal history of breast cancer?”

Tamoxifen has been used for 21years in the treatment of breast cancer. During this time, it clearly showed that it can reduce the risk of recurrent breast cancer and development of cancer in the other breast. The later finding encouraged researchers to start Breast Cancer Prevention Trial.

“Go on Dr. B, how did they do the study?”

Susan, BCPT enrolled 13,388 women at 300 sites in U.S. and Canada. These women were at a higher risk of developing breast cancer. They were randomly assigned to receive either placebo or Tamoxifen

The study – over 6 years – showed 45 per cent reduction of breast cancer in women who took Tamoxifen compared to the placebo group. It was also observed that these women have lower incidence of osteoporosis and coronary artery disease. Because of this significant finding the trial was discontinued earlier than expected due to ethical reasons.

“Doctor, what are the side-effects of Tamoxifen?”

Susan, some women developed cancer of the uterus, some had deep vein thrombosis (blood clot in the leg), and some had pulmonary embolism (blood clot in the lungs). About 15 percent of women suffer from: hot flushes, irregular menstrual periods, nausea, vomiting, light-headedness and dizziness.

One significant unanswered question is: For how long a woman can take Tamoxifen without increasing the chance of side-effects?

Women with breast cancer have been advised not to take Tamoxifen for more than 5 years as the risk of recurrent cancer and death were higher in women who took Tamoxifen for 10 years. The same cannot be said for women who take this pill for prevention. The study wasn’t long enough.

“So, Dr. B, can a woman take Tamoxifen for prevention if she is not part of a clinical trial?”

Last year, Susan, Editorials in the British Medical Journal and the Canadian Medical Association Journal discouraged women taking Tamoxifen outside clinical trials until further information was available on its risks and benefits.

But the authors, who reported the BCPT results in the Journal of National Cancer Institute said: Despite side effects resulting from administration of Tamoxifen, its use as a breast cancer preventive agent is appropriate in many women at increased risk for the disease.

Susan was keen on exploring the idea further for preventive measures and was referred to a medical oncologist.

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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Dangers of Winter

Winter is here! Some people have died. Some have exacerbation and/or complication of their pre-existing conditions. Some have broken bones. Some have flu. Some are depressed.

The lucky ones – if that is an appropriate word for them – are in Hawaii or Florida. Some are in Arizona or Palm Springs. Some are on a cruise in Bahamas or South America. Some are on the big mountains, gyrating down the slopes on their ultra super speed skis.

The big chill does create a new dynamics in peoples’ lives. As soon as the leaves start gathering on the ground, we are gripped with fear or joy depending on what we have planned for the snowy days.

But we carry on. Sometimes smiling, sometimes annoyed and sometimes angry. Each morning, we get ready for work in our best winter clothes. At work, the heating is on and the windows are shut. Your comfort level goes down. Your smile fades and your layers start coming off. You look out of the window for some inspiration and comfort. You see a pile of snow. You feel trapped

Do you find this stressful? Does this affect your health?

“It is well known that in all except equatorial regions, the death rate increases in winter,” says Dr Caralee Caplan, in the recent edition of Canadian Medical Association Journal.
About 50 percent of deaths in winter are related to coronary artery disease and blood clots in the brain.

Studies have shown that most deaths occur 24 hours after cold days. This appears to be due to brief rather than prolonged exposure to cold. Resulting in rapid changes in the blood viscosity, formation of blood clot and increase demand for oxygen by heart muscles.

Those who are already known to have coronary artery disease are prone to spasm of these vessels. This further aggravates the risk of heart attacks. Asthmatics run the risk of aggravating their condition by inhaling cold air especially during exercise.

The precise mechanism of cold-induced changes is being hotly debated by the experts. Engorgement of blood vessels and release of substances which produce spasm of lung vessels are responsible for asthmatic attacks.

Patients with Raynaud’s disease suffer significant spasm of blood vessels of hands and feet when exposed to cold. This occurs mainly in young healthy women. Their blood vessels are extremely sensitive to cold or emotions.

Dr Caplan says that no one is immune to the effects of hypothermia, frostbite and seasonal infections and injuries. In most of these conditions, the underlying mechanism appears to be the effect of cold on blood vessels.

Can we prevent heart attacks after shoveling snow and asthma attacks from winter sports? Yes. “The best prevention is, of course, avoidance,” says Dr Caplan.

Asthmatics, who want to enjoy winter sports, should keep inhalers (bronchodilators) handy at all times. People with heart problems should wear a light face mask to maintain a favorable air temperature and humidity during exertion. Warm clothings, mittens, gloves and socks should protect the rest of the body from the big chill.

Remember, better safe than sorry! We still have almost three months of winter to enjoy. Keep smiling!

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