I trained as a medial student and intern in 3 different labour suites, caserooms whatever you
The unifying feature of caserooms was the The Board.
While The Board slightly varied between sites, there were constants. The patient’s name, attending physician, Gravida and Parity, gestation and dilatation. There was usually room for other info such as pre-eclampsia or VBAC. It was such a valuable source of information for seeing what was going on and predicting workload. The Board when I was junior was a blackboard with chalk. Lately it is a whiteboard. Such a low tech but effective way of communications.
At Vancouver General Hospital which did OB in the early 1980s, the medical students had to keep The Board up to date, which meant constantly having to bother the nurses about what the dilatation was (they didn’t tell you when they did vag exams, because you might want to do it yourself, which after all was one of the reasons you did an OB rotation) lest you get yelled at the crabby soon-to-be-former OB resident.
When I came to my current medium size Catholic hospital 13 years ago the board had become more streamlined than what I remembered. Dilatation and gestation were not charted, but it at least had the patients name, attending physician, gravida and para. They also wrote a big E next to the patient if there was an epidural. Very useful for anaesthesia when you came in on call.
Something as effective and elegantly simple as the board was bound to come to an end of course.
Several years ago, I was called for an epidural and looking on the board saw that her last name was 3 letters long. I went into the room but noticed she had a different name more than 3 letters long. Back to the desk I went. No I was told the 3 letters are the first three letters of her name which for privacy purposes we are now only allowed to use. I rolled my eyes and did the epidural. Of course as I commented many people nowadays have 2-3 letter last names, plus it is highly likely that you will have 2 people in labour at the same time who share the first three letters of their last name (McDonald/McDowell. Chan/Chang). Other people whose opinion counted more than mine must have weighed in because they started putting on the full name again.
About two years ago I got called for an epidural. At our site they never tell us the patient’s name only the room #. “Room 5 wants an epidural” they tell me. I walked past The Board and noticed that the patient had the same last name as one of the obstetricians. Of course when I walked into the room the patient had another name. It turns out that for privacy now they were now only posting the name of the doctor on The Board. Twice as it turns out under patient and under physician.
The day before yesterday I walked onto the ward and The Board had shrunk to about 1/3 of its size. “Why is The Board smaller?”, I asked. “Its an accreditation standard, “ I was told. I am not sure why it should matter at all to the accreditors but apparently it does. The Board is now literally tiny. Whereas you used to be able to stand back of the nursing station and read it, you now have to go right up to it.
This presumably is in the name of privacy. My mother always told me if you had nothing to hide, you didn’t need any privacy. I wonder how many patients really cared about their names being flashed up on The Board. People after all pay to put birth announcements in the newspaper. Labours are live-Tweeted, Facebooked and Instagrammed. Plus I am sure in the past if people wanted the anonymity, they were accommodated with a pseudonym. And if you’ve figured out that your husband’s mistress is in labour at this hospital you can probably find out which room she is labouring in.
At the same time, we actually have made labour a group activity. It is not unusual to have multiple family members in the room, or hanging around the hallways (usually talking outside the call room) while the mother is in labour. I frequently have to ask for all but one of them to leave when I do the epidural. (As department head, I had to deal with a complaint about one of my colleagues doing just that). My father on the other, even if he had wanted to, was not allowed to see any of the births of his 4 children, which may explain why I grew up so messed up.
And there is the issue of depersonalization. I seem to remember during my OB rotations that I actually knew the patient’s name. Now most patients are referred to by their room number. I even find myself writing the room number on the patient label I collect for billing so I can tell them apart.
Of course in the 21st century we could have replaced The Board with something electronic that might even be an improvement but I’m not holding my breath on that
The Edmonton Journa didn’t publish my letter but I have a blog:
My wife and I cancelled our subscription to the Edmonton Journal.
Since moving to Edmonton in 1992, we have subscribed to your paper. I remember it as an excellent paper with balanced coverage of local, national and international news and issues. The large Saturday and Sunday editions were a true joy to read, taking several hours.
Over the last few years, the quality of the paper has declined, there is no longer a Sunday edition and the size of the paper has decreased to the point where the flyers deposited in our mailbox along with the paper are often larger in size. In addition the national and international news and opinion section has been outsourced to the National Post.
Worse was the behaviour of the Journal during the election and in the run up to the election. On at least two occasions the UCP was allowed to buy full page ads on the front page of the journal giving the impression that this was news not advertising. During the election various PACs were allowed to buy full page ads in the news section of the paper. In addition the Journal endorsed the UCP which is really not surprising although disappointing.
I realize that papers depend on ad revenue to survive and am not naive enough to expect that advertisers and owners of newspapers will always agree with me. I realize that their coverage of news of their editorial opinions will always subtly reflect the bias of the owners and advertisers. I have always enjoyed reading the other point of view if only to mentally rebut it (and occasionally agree with it). The Journal in the past has always presented a diversity of opinions and tried to present both sides of the story. It is clear however that the promotion of a single agenda is now being blatantly pushed not only in editorial content but also in the way that news is being presented. This is reflected in the Journal ignoring certain stories and by presenting opinion as news.
For the past few years, I have noticed that the Globe and Mail’s coverage of Alberta and Edmonton issues is more thorough and balanced than that of the Journal. The Journal has now become a newspaper which features the worst aspects of the Edmonton Sun and National Post. Quite frankly most days, now I find myself going straight to the comic section which is actually still quite good.
I have read newspapers since shortly after learning to read. As I mentioned above, I still find the Globe and Mail to be a high quality source of information and entertainment. Recently while visiting Victoria, I read the Times-Colonist and was thoroughly impressed with quality of the journalism.
Newspapers have been observed to be under siege with competition from the internet and other platforms. I have always preferred to read a paper and I suspect that a significant number of people do not read newspapers any more not because of the internet but because the content in newspapers has become so awful.
About a year ago I applied for a licence in my neighbouring province (where I was born, went to school and worked for a while). This was an interesting experience which I should blog about some time. The caper was in addition to having to get a criminal records check, having to be fingerprinted. This was because apparently a sex offender has the same birthday as I do.
I quixotically phoned the agency, knowing that it wouldn’t change anything but I needed to yell at someone on the phone. They were very polite; it was like I wan’t the first person and I went down to my local police station and good fingerprinted. Interestingly enough, so many people need to get fingerprinted now that our police force has a free standing office which does nothing but fingerprint people.
And I wrote this letter.
“Thank you for your letter and for the time your two employees took trying to explain it on the phone. It is nice to know that I am not suspected of being a sex offender.
For your information, I was born in British Columbia, grew up, attended medical school there and practised medicine there. I have practised in Edmonton since 1992 and have been at my current hospital since 1996. I have lived in my current house for over 10 years. I have paid both federal and provincial income taxes as well as property taxes. I have a drivers licence. I recently renewed my passport for 10 years. (I provided a notarized copy to the CPSBC). I have a Nexus card. It is my understanding that every year I have had criminal records check through the CPSA. I also had one when I got a visa to go to Rwanda to volunteer teach. I show up in Google searches of my name. It is not like I have hiding for the past 40 or so years.
I accept however the possibility that during this time, I may have lived a double life involving nefarious activities under another name leading to my acquiring a criminal record. It is also possible that I continued to work and raise a family while incarcerated. An alternative explanation might be that I used my time while incarcerated to learn how to construct a time machine which I used on release to travel back in time and create a new identity.
Seriously I think that people who exploit the vulnerable especially those who abuse children are the lowest form of humanity and if by getting fingerprinted, I could prevent one such incident of abuse, I would happily get fingerprinted every day. The truth is that this policy is not about protecting the vulnerable; it is a make work project for the public safety industry and a cash cow for the RCMP and local police forces. Even the nice lady who spoke with me on the phone acknowledged that this policy has resulted in a huge increase in the number of staff needed to maintain it and one wonders how many nurses or police officers could be employed with the money necessary to employ these people. The other and more concerning issue is that policies like this are primarily designed to give the appearance of doing something about the problem rather than actually doing anything about it.
It further needs to be noted that saying, “we’re only enforcing policy” is a somewhat empty excuse when you are the ones who made the policy. It also sounds very much like “we are only following orders”, an excuse that was deemed invalid around 1945.”
While I'm not necessarily proud of going on the wine tour on my father's last day on this earth, I am not ashamed also.
Would I have been ashamed if in an alternate universe, he had not broken his hip but rather had had a huge myocardial infarction or stroke on that day while I was out wine touring.
As I said, it still bothers me that he died alone but I got to see him the week he died and spent a lot of time with him during his last two years alive. I would rather remember him as he was when he was younger because the last two years weren't really that great for him or for us for that matter.
While anaesthesia doesn't get involved in end of life very often, I did do general practice for 3 years and also anaesthesiologists get to do 6 months of internal medicine so I saw my share of death watches where the entire family assembles around the bed of a dying parent or grandparent in various stages of awareness and pain. Overall, I didn't get the impression that anyone, patient or family got any comfort from the practice.
My father died last June 2. He was 94 and it shouldn't have been unexpected. As I was to find out, it was still difficult.
I go on a few medical and teaching missions nowadays. In 2011, I went with CASIEF to Rwanda for 4 weeks (a total of 6 weeks away between pre and post-cations). My parents were pretty old by then, so I believe I told them, if something happened while they were away, I was not coming home. Therefore every time I visited and left my parents I was like I was saying goodbye forever.
Between placing my parents in various levels of care over the past 2 years I have actually been visiting about every month, which is more than I saw them when I was attending university in Vancouver, a ferry ride away.
Anyway I was on my way to the Canadian Pain Society meeting in Montreal. On arriving in Montreal, I turned on my phone and my brother had texted me to tell me that my father had fallen and broken his hip. We were still in the airport. "Do you want to fly back?" asked my wife. No, I said, it won't make any difference. He will have surgery in the next couple of days which he may or may not survive and whether I am there or not will not make any difference. And besides I had said my goodbyes. I kind of had the sense that this was it. He was going to die and it would be the start of an inevitable downward decline.
After some consideration, I decided that after returning to Edmonton, the Friday, I would fly to Victoria on Saturday to visit Saturday and Sunday. I had a busy next week planned. A medicolegal in Calgary on Monday, Pain Clinic in Grande Prairie Tuesday and Wednesday , a medicolegal in Vancouver. Thursday and one in Kelowna on Friday. Now I could have cancelled all this but really it really wouldn't have made any difference would it?
So I flew out to Victoria Saturday am, rented a car and went straight to the hospital. My father had had surgery by then. I never ever learned whether he had a hip pinning or a hemi-arthroplasty or whether it was a GA or spinal. He was in a private room and was pretty delirious. He did recognize me. It was very interesting because in between bouts of delerium he actually made sense and was talking about politics which he loved doing. He had a bundle of newspapers which he clutched tightly, not letting the nurses take from him. I also went and visited my mother. She kept on asking where he was and I kept on telling her he had broken his hip.
I visited again on Sunday. The nurses said he had had a bad night and he was lying in bed but recognized me. I spent a little time with him and then drove back to the nursing home to see my mother. I asked the staff at the nursing home if it would be okay to bring her over. I had mixed feelings about this. She was already not terribly able to walk even modest distances and I would have to park and walk over to the hospital with her. The other thing that worried me was what I would do if she refused to leave my father's bedside. Nevertheless, I took her, we walked slowly over to the hospital and up to my dad's room. By this time the nurses had hoisted him into a chart and he was in a deep sleep. We say there for almost half an hour, my mother and I. At one point my father opened his eyes but didn't seem to recognize us and went back to sleep. After half an hour, my mother said, "that's not my husband is it?" and we left, stopping for coffee and a snack at the coffee shop in the lobby.
I returned my mother to the nursing home and spend a little time before leaving. I had a flight in the late afternoon and so had lots of time. I could have visited my father again but I thought what difference really would it have made.
I later flew to Calgary, then to Grande Prairie, to Vancouver where my wife met me and then to Kelowna where I had a medicolegal Friday. My son lives in Kelowna and we had planned to spend Saturday in Kelowna and leave in the evening. My son works Saturday so we couldn't visit with him that day but took him and his girlfriend out to dinner Friday.
My wife suggested we do a wine tour Saturday and we found a taxi driver who did private tours and who would take us to the airport afterwards. We were just on the way to our first winery when my brother phoned me. My father was apparently now septic from at UTI with decreased blood pressure. He gave me the pager number of the hospitalist. I paged her and she phoned back right away. By that time we were outside of our first winery. She confirmed what my brother told me, I confirmed his resuscitation status and suggested that if he didn't respond to modest amounts of fluids not to do anything.
We went into my first winery. "I hope you don't think," I said to my wife,"I am being callous by tasting wine when my father is most likely dying." She didn't think so.
Wine tours are really just an excuse for getting drunk during the day and we did that quite happily and I am may have even forgotten about my father. At one point our driver suggested we visit a craft brewery which we did. Outside the tasting room, my phone went off. It was the hospitalist. My father's blood pressure was now worse, falling to as little as 40 systolic. I told her that I understood and that he would probably die. I then phoned my brother and told him, I didn't think my father would live out the day. I am not usually good by the way at predicting deaths.
For some reason I decided to taste a flight of beers and I ordered them and took them out to table outside. Then it hit me, my father was going to die. I started crying. People were looking at me. I got myself together and then tasted my craft beer. Why waste it.
We finished our tour and went to the airport. We flew to Calgary. At the Calgary airport while waiting for my plane to Edmonton, I phoned the unit. The nurse said my father was hanging in there.
Sometime while I was in the air between Edmonton and Calgary my father died. My brother left a message on my phone which was on airplane mode.
It doesn't bother me that my father died. He was 94 and had never adapted to nursing home life or my mother's dementia. He had a great life including 33 years of retirement on a comfortable pension. It does bother me that he died alone although I don't know that it would have made any difference or whether in his last hours he would have even noticed the company. I hope that during the hours he was unconscious before he died, he was having visions of his childhood in Sussex or meeting my mother for the first time.
My father requested that he not have a funeral. Some people I talked to thought that it was weird and that we should have something but we didn't. My brother got him cremated which is what he wanted. I assume he has the ashes.
I went to visit my mother a few weeks later. The staff had told her that he had died but of course she forgot this after getting quite upset. She of course kept on asking me where he was. I told her over and over he was resting. At one point she said, "What is he resting from?". "Arguing" I replied because that is what he loved to do and she actually laughed. When I went into my mother's room the book "Silk Roads" was on table in her room. I gave that book to my father the previous Christmas. He like to read in my mother's room. I really enjoyed the book. I hope he got far into it.
I decided last March to give up chronic pain. I blogged about it. I am now down to my last few clinics. I had continued to agonize about whether I was making the right decision. Until last Friday’s clinic.
The last pain clinic before Xmas is always interesting. People bring in baking, candy and occasionally liquor. (I have for years thought about asking them to donate to charity instead but this of course presupposes they would even give me a gift.). On the other hand it is a littler busy and you end of dealing with a lot of prescription faxing because people need early releases or realize their prescription is going to run out over Xmas.
Three things on an otherwise good day just pissed me off.
One of my patients has been going to the local block shop where she has been getting blocks. I have no idea what type of blocks or where because they never send me reports. I may have referred her there, it wouldn’t matter, they hardly ever send me their consults. Anyway she told me she was getting rhizotomy and she had been told to take 2 weeks off after it. Then the capper. She brought her disability form which they had told her to have me fill out. I was a little shocked and told her I didn’t fill out those forms. I told her to take them to her family doc, which I am not proud of. I should have told her to take them back to the block shop. She left disappointed, maybe angry. Probably the last time I will see her.
Next I get an email from my PCN pain clinic pharmacist. Another patient had a rhizotomy at the same block shop. This time I had referred her there. This made her pain worse rather than better. Funny how nobody doctors or patients considers that that might happen when you apply radio frequency current with a large needle. Anyway the block shop was refusing to prescribe any analgesics. After initially refusing myself on the basis of “you break it, you buy it”, I thought better and faxed in a prescription for hydromorphone. If you think that this is just a problem with one particular block shop; actually this is the best block shop It is mostly physiatrists, they actually examine patients. Just about everybody gets a block though. Did I mention her family doc has taken 14 days off over Xmas with nobody covering her practice?
Later that day a patient I see sporadically came in. He has a very complex pain and psych history. So his psychiatrist decides this is a good time to wean him off all but one of meds. Yes this includes narcotics but also included a lot of psych meds. Surprise, surprise his pain is worse and I am supposed to sort this out the Friday before Xmas when I’m going to retire in 3 months. “Did you tell this to your psychiatrist, “ I asked. Turns out he had seen the psychiatrist 2 days earlier but they had only talked about his mood. I suggested that he go back to his psychiatrist and ask to go back on his meds. As if this is going to happen before January. I have nothing against deprescribing, I think it is good idea sometimes as long as you are prepared to admit when it isn’t working. I know there are 2 sides to every story and his psychiatrist might have had a very good reason to want to wean him off. I of course don’t know because he never bothered sending me a copy of his notes. And he can’t say he didn’t know I was involved in his patient’s care, because I sent him a copy of my last progress note. I could try to phone him except that in 25 years I have never gotten through on the phone to a psychiatrist nor has one ever returned my calls. Not to mention it is Friday, Friday before Xmas.
Hey I know that disability forms are a pain to fill out and most of us think if a patient tells his employer he needs time off, they should within reason believe them. I also know that our colleges and people like David Juurlink have made the prescription of narcotics dirty. The point is when you accept care of a patient you should take responsibility for their disability forms and for the complications of your treatments. You should also communicate with your colleagues.
I thought that I was giving up chronic pain because I had lost my compassion. In fact I now realize that it is the whole medical environment that has finally. Not administrators, EMRs or lack of resources. It’s the whole “not my problem “ attitude that has malignantly affected medicine. Every week some patient tells me about their latest interaction with a physician, it could be their family doc or a specialist, and I think of how ashamed I am to be a physician. To be fair, there are some doctors who give their chronic pain patients excellent care, with whom it is possible to work with. The thing is, that these doctors are now so uncommon that they stand out.
So I will mostly be spending the rest of my career working almost exclusively with surgeons. I have written and thought a lot about surgeons, some of it in jest. Surgeons are economic with the truth, a little arrogant, tardy and make me work when I would rather not. But...surgeons give a shit about their patients at least for the time under surgery and frequently for a few days before and after their operation.
With getting older comes all sorts of anniversaries. I started medical school 40 years ago today.
There were the prelims of course, getting the letter of acceptance sometime in June, writing back to accept their offer and I believe there was a deposit cheque involved. There was also a trip over to Vancouver to pick up the microscope they said we had to buy. I quit my summer job a week early much to my father's distress; everybody except him thought I needed a little time before starting medical school.
Starting was simpler than for some. I had been at UBC for 3 years of undergrad already; I only applied to one school and planned to be either starting medical school or finishing off my degree. I had a room in the student residences. My friends had got a house off campus; I preferred to have the familiarity of residence and the ability to roll out of bed and walk to my classes instead of dealing with traffic or buses.
My recollection is I went over by bus and ferry on labour day. At UBC the week after labour day was registration week, a week of drunken debauchery before classes started the following week. No registration week for the medical school. Classes started the day after labour day.
So it was on September 5, 1978 that I found myself in a lecture theatre in the Woodward Building sitting in my usual seat at the back, looking around wondering if I knew anybody in my class. As people filed in, I recognized a few faces from lectures and labs and even somebody I didn't know all that well but had gotten drunk with a couple of times. I had a negative opinion of what I thought would be my future classmates. I expected a serious, hard working, cut-throat group of people. I expected the next 4 years to be a busy, hard and socially very boring time. (The summer before I started I was introduced to a visiting fiance of a co-worker as a medical student. "Oh," she said, "I know a few medical students....I don't like any of them." Great, I thought I've known you for a minute and you've already insulted me.)
Negative thoughts notwithstanding it was an exciting time, the culmination of three years of undergraduate always with a goal of getting into medical school. We were welcomed by the Dean who informed us that we were the chosen people and welcomed us to the great fraternity of medicine. We were then registered, and photographed. I am not sure whether we had further classes that day. There was a trip to the bookstore to pick up all the texts they said we needed, including the anatomy trilogy written by our Professor of Anaesthesia. I also bought an ugly short white lab coat.
I went to the Pit (the student bar at UBC) that night and ran into my old friends and got little drunk which meant starting my first anatomy lab the following day with a bit of a hangover, which I would not recommend but I survived the day.
Thursday afternoon was the useless touchy-feely course we took in first year and we were divided into groups of 8. The 8 of us sat in the room and some older adult asked us to tell the group something about themselves. It was a round table and the talk started to my right so I got to talk last. That was not good. The first 6 had all had incredible lives, attending schools overseas, volunteer work and they all knew exactly what kind of doctor they wanted to be (and that kind of doctor was not an anaesthesiologist or a general practitioner). Fortunately the person to my left, turned out to be a down to earth person, with an ordinary life, actually from Victoria although from a different high school. Then I told my boring life story and we went on to something else.
Later that Thursday we had a tour of VGH lead by 4th year medical students who seemed so incredibly cool, followed by a party in the Medical Student Lounge on 10th avenue. This party was by tradition put on by the second year class who had survived first year. They were, as I later learned, by UBC standards an intense group. Talking to them was somewhat anxiety provoking as they told us about the amount of work we could expect to do in first year (which was mostly true) followed by telling us that second year was worse (which it wasn't). This was very depressing but we had Friday morning off and the beer was cheap, so I got to have a few and made some friends in my class and I remember in the early morning a bunch of us heading off to Bino's on Broadway for pancakes before somebody drove me back to the campus. This was to be the first of many drunken parties in medical school.
Friday afternoon the first week was our 3 hour Biochemistry lecture and I was most impressed when Dave, my new dissecting partner loudly announced that the lecture would be continued in the Pit. It just happened to be the night of the second Ali-Spinks fight which was on the big screen and it was great to see Ali regain his title. Between that and running into my old friends, I think I closed the Pit down. Medical school was not looking bad.
First year was heavily weighted on Anatomy with 3 or more dissection labs a week, along with a histology lab and 2 hours lectures 3 days a week. It became apparent that most of us were in grave danger of failing anatomy if (or even if) we didn't work our buns off. This was memorization of trivial details on a scale none of us had ever encountered. It was, I am sure, humbling for all us, accustomed to being at or near the tops of our classes to have to shift into survival mode. The whole stress of the situation seemed to bring everybody together perhaps in the same way basic training brings together soldiers. We spent so much time together in those days as we all had same lectures and same labs. We usually ate lunch and had coffee together, and frequently drank together. People started inviting the whole class to house parties.
Our class was the largest ever at UBC with 88 students. There were supposed to be 100 but they weren't able to expand the anatomy lab to fit that number (which may have been galling to the 12 people who found themselves left on the waiting list the day after Labour Day). Also a first we had 33 women which was most ever at UBC.
I think back now on how little I knew of what was ahead. I knew nothing of details like specialization, certification exams or what was involved in being on call. I had no idea what an anaesthesiologist was. The only one I was aware of was the morose Australian on MASH, who always seemed to say, "Oim losing 'im Hawkeye". Looking back it is interesting of how little we were prepared for the world we were going to go into or that in which we live today.
I believe all but two of our class graduated although it took some more than 4 years. One poor fellow failed anatomy and the summer supplemental anatomy course and was turfed. The other developed schizophrenia in second year which was fascinating but depressing to watch. We all went away to internships, did locums, residencies, settled down in various parts of country, a lot of the class eventually washing up in the lower mainland. We had a 5th, 10th, 15th, 20th and 25th anniversary. Only about 40 people attended our 25th anniversary in Vancouver, surprisingly given the number who lived in the area. Nobody bothered organizing a 30th or 35th (maybe they did but didn't invite me). Two of my classmates work in my city. I used to see one, a neurosurgeon, a lot when I worked at the Centre of Excellence. The other a psychiatrist, I last ran into over 10 years ago. At least 3 of our class have died including my good friend Dave and also Phil who was in my dissecting group. (The fourth member of our dissecting group, contacted me a few months ago on LinkedIn and introduced herself as the other surviving member of our group.)
40 years on now, I can just look back to the excitement, the fear and the relief of those first days in medical school.
Sometime last month was my 25th anniversary of my first pain clinic. I was at the Centre of Excellence, and the person doing the Pain Clinic went on to better things. The Professor told me I could do the Pain Clinic until they found somebody smarter than me to do it. Problem was there was nobody smarter or stupider and 25 years later here I am, although not at the CofE. I should have had a party, moreover somebody should have thrown one for me.
A couple of weeks ago, I gave notice that in March 2019, I will be giving up most of my chronic pain practice and become a more or less full time anaesthesiologist again. Like many decisions there was no “last straw” moment, it was a series of small things.
One reason is that despite everything we complain about, being an anaesthesiologist is a pretty good gig, if only for this reason. When you see the hospital in your rear view mirror at the end of the day, unless you are on call, you know you are finished. No phone calls from the ward, patients, pharmacies or other doctors. If for some reason you want to go on a long vacation, you don’t have to arrange coverage and you know that you won’t spend your first two weeks back, putting out all the fires that started while you were away.
I have been pretty good about setting boundaries and have a great colleague who covers me when I am gone. Patients expectations about availability are less too, I get a lot fewer calls now. Still I have voicemail and a fax which go to my email which I check even on vacation and the hospital switchboard has my cell number. I could ignore them because switchboard is supposed to know when I am away and my voicemail greeting usually says I am away and who is covering but I still feel guilty, even when the problem is not one of my creating. For example I spent a great deal of time on my 60th birthday dealing with a patient who had messed up big time. I did this after the pharmacist from the PCN pain clinic emailed me to say he needed urgently to speak with me. Okay why was I checking emails on my birthday? Because that’s what I do.
I met a pain specialist from another centre about 10 years ago at an anaesthesia meeting. "I'm thinking of going back into anaesthesia", she said, "I want to retire soon and I can't handle the demands of my patients." Sounded strange at the time; most people give up anaesthesia and the call involved to do chronic pain, I almost did a few years ago. This encounter did plant the germ of this idea in my head.
The biggest thing however is that I realized a few months ago that I have lost my compassion. I no longer have patience for people who won't try do anything to help themselves, I no longer want to hear about problems that I have no way of solving. 90% of my patients are good people who try do everything possible and I have a treatment that might help them or is helping them. Like most things in life, it is the other 10% that take up most of my time, that leave me feeling drained at the end of the clinic. I don't want to be seen as blaming patients for their misfortune, its just that quite a bit of the time I have nothing to offer and don't really want to hear about it anymore. So often I want to say, "YOU have a problem, what are YOU going to do about it?"
Pain medicine and medicine in general have changed over the last 25 years that make it less attractive to practise. 25 years ago most of my patients had a family doctor, moreover they had a family doctor to whom I could make recommendations that they would follow. Now when I get a referral, I get the sense that the family doctor has washed his hands of this patient. That is of course if the patient has a family doctor and a significant number don’t.
Paradoxically we have way more physicians doing chronic pain than 25 years ago. This should make it easy. It doesn't. 25 years ago, I was almost always the first person to see a patient. Now quite often they have already seen one or more chronic pain specialist. Quite often they are still seeing someone else (I saw a patient a few years ago who was seeing 4 other chronic pain doctors; she was quite disappointed when I told her I didn't think there was any point in my following her as well). This would be nice if I actually had the records from their previous doctor so I could see if I had anything else to offer but that is the exception not the rule. Moreover some of my colleagues have developed boutique-type silo practices where they offer single modalities, usually interventional treatments. Quite often the patient is still getting these treatments but the expectation is that I will prescribe medication for them. Or one of my colleagues has started them on some toxic cocktail of multiple classes of drugs that I am supposed to unravel and continue. And with all this expertise floating around we should be able to work together in the patients' best interest? What universe do you live in?
So why don't I, as somebody suggested, just carve off the parts of chronic pain practice I enjoy and forget about the rest? If only it was so easy to tell in advance who was going to be easy and who wasn't. And the easy patient of course so easily becomes the hard patient. I have for the last few years been more selective in screening out referrals and in my new consults so that I am accumulating fewer patients I know I can't help with the resources I have available. But I have never been comfortable telling a patient that just because I can't do some lucrative procedure doesn't mean I can't try to help you.
It is hard to talk about chronic pain without mentioning the opioid crisis or epidemic whatever you want to call it. I still prescribe opioids for chronic pain, although not in the industrial doses some of my colleagues prescribe. So far I have escaped scrutiny from our medical licensing body. Every quarter I do get a list of patients who are over the recommended dose which I read with some interest. Talking however to some of colleagues who have undergone scrutiny and have had to pay 10s of thousands of dollars in "costs" of the investigation or fees to attend remedial courses scares me a little bit. I am less than 5 years from retirement, slowly building up my nest-egg. I look at some of my patients and think, "is patient X, the hill I want to die on?"
And of course with increased scrutiny from the licensing body, a significant number of referrals I get are dumps of patients who have gotten onto these industrial doses not to mention a number that are doing well on a reasonable dose and the expectation is that I will take them over in my solo part-time practice. Which of course I do because I am an old school doctor, who doesn't want to see patients go through narcotic withdrawal.
Narcotics still confuse me and I have no idea what the right answer is. I have mentioned above, that I have reluctantly acquired a number of patients on whopping doses of opioids. Most of these people seem to look okay. Their function like most chronic pain patients is not the best although I periodically find somebody who is actually working. Most of them are quite happy on the massive doses they are taking; they don't want to see a psychologist or attend a rehab program and they definitely don't want to come off their meds.
On the other hand I read a lot in the medical literature and on Twitter (where I get most of my medical info now) about all the bad effects of narcotics, and there is no doubt that there is some truth in all of this. The question is where is the balance because as somebody who follows a lot of patients on narcotics, clearly some of them benefit greatly from them with little or no adverse effects. Further I have seen a number of ugly cases of forced weans that ended up in my clinic. Our Workers Compensation board has recently become evangelical about weaning off opioids, at least once a month I have to spend 20 or minutes consoling a distraught patient who has been told they have to go to a clinic in a city 3 hours away to be weaned off their meds. They all think I have some magic clout with WCB.
Just something I don't want to be bothered with anymore.
In fact these patients are the most difficult for me to abandon. I hope to transfer those with understanding GPs back to their GP. Some of the complicated ones I am referring to some of my colleagues and my colleague who is taking over my clinic time will take over some. Our licensing body told me that as long as I gave them 3 months notice, I had no obligation at all to arrange follow up.
Chronic pain still confuses me. I still don't know what causes back pain or neck pain. I could be one of those people who says, "yes it's definitely your facet joints and every three months I will inject steroids into those joints or maybe just burn the nerves" but I know its not that simple. So I end up offering what I think might work, usually in my case trigger point injections and an antidepressant but feel like an idiot for doing so. I should be telling them to exercise and lose weight, like that will ever happen.
Patients often ask me about some bizarre symptom they are having. "Is this normal?" they say. "No", I reply, "it is not normal but it is not unusual." I have learned that patients have these symptoms, they are real; if they're making it up, that too is pathology worthy of treatment; and that in most cases I can only guess at the psycho-physiological mechanism behind it.
The lack of supportive infrastructure is another factor. I usually go to a pain meeting once a year where I hear presentations from psychologists and physical therapists and I come home excited and ready to help my patients. That is until I try to refer and find that my patients can't afford any of this and the very few practitioners in the public field have exclusion criteria that effectively excludes all my patients. Long ago at the CofE one of my colleagues came back from his Pain Fellowship (at Boston College, not Harvard as he now tells everybody) to join me in practice. "Where," he asked me, "do I refer somebody for inpatient rehabilitation?" I was polite and supportive. I didn't roll on the floor laughing. I told him that no such program inpatient or outpatient existed and that he better learn to live with that.
Periodically we get to meet with our regional admin. They usually tell us how much they support what we are doing and then we don't meet again. A couple of years ago when I last got invited, I was a little punchy. "Are you going to be giving us more resources, " I asked, "because if you aren't I really have no interest in attending any more meetings". And I didn't. It is not just not having new resources, it is not being able to access existing resources that bugs me. And it just galls me to see all the new programs that have sprung up for chronic diseases while we have been told there is no more money for chronic pain.
Things are a little better now, we do have self management programs and also some exercise programs. Thing is, these are all by self-referral and the likelihood of the passive fix-me-now pain clinic patient phoning the number and driving across the city (because they are never central) to attend one of these programs is close to zero.
Anyway, while I sometimes lie awake at night wondering if I am doing the right thing, blowing up 25 years of practice, I told somebody I was retiring (from chronic pain) and it felt pretty good. Maybe somebody will throw a party for me.