Physicians and Second Opinions

I like Susan. She is a good patient. She comes to the office well prepared. She can describe her symptoms well. She has a list of questions to which she expects answers. It saves me time. I wish all patients can be like Susan.

Her husband Dave is different. He likes his doctor to take responsibility for his care He likes his doctor to do all the worrying. His doctor is very obliging. Dave thinks all doctors should be like his doctor.

My brother is my accountant. I do not think he rates me very highly as a client. He is my big brother and I trust him. I let him do all the thinking for me to keep my finances healthy! He says, “My little brother, I wish you would be like my other clients who do their home work and come prepared with the right information and questions!”

This shows that patients, doctors, clients and other professionals come in all varieties.
To receive optimum service, we have to strike a right balance between expectancy and reality. The flow of good will has to be both ways.

“Doc, how can we get the most out of a visit to doctor’s office? Most doctors are overbooked, they are running late, in the middle of a physical the pager sets off, then the phone rings because another doctor is on the line, then it could be emergency department or labor quarters! Do you guys ever stop?”

Two common complaints we hear about doctors are: 1. They do not spend enough time with patients and hence do not listen to their complaints 2. They do not refer patients for a second opinion soon enough if they are unsure of diagnoses.

Recently, on CHAT 6&3 News series called MEDICAL MOMENT, I have been using a new slogan: “Help your doctor keep you healthy!” Is that possible? Let us examine this further.

The time factor. A doctor’s office is overbooked not because he loves to kill himself or that he hates his family; but he tries to accommodate as many patients as possible including last minute urgent appointments. So, he ends up seeing more patients than he had planned for. Then some patients take longer to be examined than others.

By the end of the day, the poor receptionist is expected to have done the job just right – keep everybody happy. I wonder how often she succeeds!

Getting a second opinion. A family physician, as primary care giver, is expected to know everything from brain tumors to ingrown toenails. Of course, this is not possible.

Depending on his experience and comfort level, he will get a second opinion if he is unsure of the diagnoses or if you are not happy with his findings or conclusions. He has to be careful that specialists or Alberta Health do not accuse him of crying wolf too often.

So, how can you help your doctor keep you healthy? Make sure he knows why you are there. Do your homework to save time. Ask him questions if you are not satisfied with his findings or conclusions.

For continuity of care, walk-in clinics and emergency departments are not good. Stick to one family doctor if you like him and trust him. Establish a good open honest dialogue. Try it! See how it works.

So, next time you step out of your doctor’s office, see if you can say: My doctor is the most wonderful human being on this earth!

(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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“Doc, it’s my heartburn. I am getting sick and tired of this,” said Dave as I settled down on my chair. “Doc, can we get this under control?”

Sure Dave, we can. First, we should try and understand what is heartburn. What is the mechanism behind this symptom? Does it need any investigations? Then we can talk about treatment.

“Ok Doc, shoot!”

Esophagus is a long hollow muscular tube. It is about 40 cm long in an adult and crosses the chest behind the heart and in between the lungs. It connects two separate anatomical areas: mouth above the neck and the stomach below the diaphragm (in the abdomen).

Esophagus allows food, drinks and saliva to go down in to the stomach but prevents stomach contents to flow back. This control is achieved by the upper and lower esophageal sphincters.

Heartburn is a burning sensation felt behind the middle of the chest. It is worse in certain positions (bending, lying down). Certain foods, obesity and anxiety can aggravate the symptoms. The sensation of burning is created by the reflux of stomach contents – usually acidic – into the esophagus.

Why does the lower esophageal sphincter (LES) fail to prevent reflux? The mechanism is complex. But simply put, the LES tone may be decreased or there may be inappropriate relaxation of the sphincter. The normal anatomy of the LES may be disturbed by obesity or hiatus hernia.

Hiatus hernia is a condition where by the junction of the esophagus and stomach (site of LES) slides up into the chest through the opening in the diaphragm from its normal position in the abdomen.

Reflux or heartburn can occur with or without hiatus hernia. Hiatus hernia and heartburn each occurs in about 30 percent of the population. Therefore some overlap can be expected.

About 35 percent of the population have experienced heartburn in their lifetime and about 10 percent suffer from this at least once a week. Most people treat themselves with off the counter medications and do not even complain to their doctors.

Should we investigate all patients who complain of heartburn? Clinically uncomplicated heartburn does not require investigation to start with. This is first treated with advice on change in lifestyle (lose weight, reduce or stop smoking) and off the counter antacids. Elevation of the head end of the bed will help keep the acid in the stomach when lying down.

Dave follows this advice for six weeks and is no better. “Dave, let us try acid reducing medication. If this does not help in the next couple weeks then add a prokinetic agent. This will empty your stomach better and strengthen LES.”

Dave is no better. Now he has difficulty swallowing. He is anemic. He has pain in the middle of the chest. These are features of complicated gastro-esophageal reflux disease. He is booked for gastroscopy and biopsies to check for ulcer or cancer.

Gastroscope is a lighted flexible instrument to examine the lining of the esophagus, stomach and duodenum. This test is done under mild sedation. Dave has a moderate size hiatus hernia with inflammation and ulceration. Biopsy reveals no cancer.

Dave is given a new prescription with higher dosage for acid reducing and prokinetic pills. Iron pills are prescribed to correct anemia. Dave responds to this treatment very well. He is now on maintenance therapy.

Dave could have had gastroscopy earlier if he did not respond to medications prescribed or relapsed after initial positive response. But his symptoms advanced rapidly and cancer was strongly suspected.

“Thank you, doc,” said delighted Dave. “I am glad there is no cancer.”

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

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

Injury Prevention

Before you read any further, shut your eyes for a moment and ask yourself: During my life time what have I done to prevent injury at home, at work and in my community?

Now open your eyes and read the following. You will have something more to think about. About a man named Francescutti and a City called Safety. And they have something in common!

Francescutti – who is he? He is Billy Graham of the church of injury prevention. What’s his mission? His mission is to prevent injury at home, on the roads, at work and everywhere.

Preventing injury is everybody’s business, according to Dr. Louis Francescutti, Chair of the Advisory Body for the newly established Alberta Center for Injury Control and Research. He was speaking at the Annual Meeting of the Safety City Society of Medicine Hat and District held at the Moose Lodge on Family Day.

A City called Safety – is a non-profit organization supported by the United Way, Palliser Health Authority, Methanex Corporation, CanCarb Ltd., Community Credit Union, Medicine Hat Maritimes Club and the Moose Lodge. Besides these major sponsors, there are numerous other contributors who keep the Society going.

But this is not enough, says Dorothy Patry in her annual report as Board Chair. More money is required to make real progress in reducing rates of injury in Medicine Hat and Alberta. Out of an annual budget of $80,000, about $50,000 is raised from bingo, casino, playhouse raffle and other fundraising activities.

The Safety City Society of Medicine Hat and District was established 19 years ago as a project of the Gas City Kiwanis. The Society’s goal is to reduce the incidents of predictable and preventable injuries and death to the children of Medicine Hat and the surrounding 200 km. radius.

Dr Francescutti said that Alberta has one of the worst injury rates in Canada. One way to prevent injury is to teach children at very early age before they pick up bad habits from adults who never had similar opportunity to learn about injury prevention.

He highly commended the work done by the Society and exhorted the government agencies and private corporations to pitch in more money. He said the government cutbacks are exhausting the volunteer force who cannot be expected to work for free all the time.

Safety City’s programs are aimed at Kindergarten to Grade 6 children. There are about 11 safety programs such as: helmet awareness, seatbelt safety, and traffic safety. Children are taught how to be safe at home, in a bus, in winter and when riding a bike.

Last year, 19,717 children had the benefit of these programs compared to 2600 in 1981. It is estimated that by year 2000, total expenditure for the Society will be $89,850.

Dr Francescutti urged the doctors to get involved in preventing injuries rather than just treating them. He urged the police to be more vigorous in enforcing speed limits and compliance at stop signs and traffic lights. He said the firehalls should be converted into injury prevention centers as the firefighters have done a good job in reducing the number of fires and have very few fire related calls.

He praised our hospital based ambulance service as a model to be followed by other cities in providing optimum use of paramedic services.

Dr Francescutti works as an Emergency Physician at Royal Alexander Hospital in Edmonton. He founded the Injury Prevention Center at the University of Alberta Hospitals where he is an Assistant Professor. He developed the award winning multimedia injury prevention program for teenagers called HEROES.

The Safety City is eager to have more donations and volunteers to help in the education of our future generation. Dorothy Patry believes that it is possible to make our city and the district a safer and happier place to raise our family. What a wonderful thought on a Family Day!

So the best thing we can do is to teach our children safe habits and support the good work done by Safety City of Medicine and District.

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

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.

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