Canadian Medicine

Nine days after the Alberta Tories captured yet another majority in the provincial election, Premier Ed Stelmach yesterday announced his .

One of the biggest changes is a portfolio swap between Dave Hancock, who was Minister of Health, and Ron Liepert (right), who was Minister of Education.

As was the case after the province's most famous trade -- the $15 million the Edmonton Oilers received in exchange for Wayne Gretzky -- what everyone wants to know is, who won? Will Mr Liepert be a better health minister than Mr Hancock was, or is healthcare getting short shrift?

DAVE HANCOCK
Mr Hancock wasn't wildly popular as health minister -- but, then again, he wasn't hated, either. There was some talk of Mr Hancock potentially losing his seat in Edmonton-Whitemud this year, but the results ended up going strongly in his favour.

Two major infection-control scandals in Vegreville and Lloydminster may have hurt his cause as health minister. As well, the Alberta Medical Association (AMA) had butted heads with Mr Hancock over Bill 41, a piece of legislation passed in December that gave the government the authority to take control of professional regulatory bodies, including the College of Physicians and Surgeons of Alberta, in emergencies like those in Vegreville and Lloydminster. Nevertheless, the AMA said both before and after the election that it would be happy to continue working with Mr Hancock.

RON LIEPERT
Judging from Mr Liepert's Obama-like as health minister -- "Change has to take place" -- he's got big ideas. According to the Canadian Press, Mr Liepert will deliver an "action plan" for the province's healthcare system within the next month.

But really, it sounds like more of the same: "The current system is not working and it's not sustainable. It's obvious that more money hasn't produced a better product."

Based on the little that's been said so far, Mr Liepert is suggesting that the government control spending by implementing aspects of the 2002 , which include increased competition in the healthcare sector and alternative revenue models -- code words in most circles for increased privatization. that "he read the Mazankowski report this week and finds its recommendations are still as relevant today as they were when the report on reforming Alberta's health care system was released eight years ago." He also mentioned the 2002 (PDF), which suggested charging Albertans a health insurance deductible of up to 1.5% of their annual income.

Now, the Alberta Medical Association is pushing for a renewed focus from the government on improving access to physicians, by providing more resources for training and recruiting doctors, nurses and healthcare workers. AMA president Dr Darryl LaBuick told me earlier this week about his priorities for the next session of parliament. "Some of the big areas are, of course, first of all, improving our primary care networks, access to primary care, and recruiting an adequate amount of physicians to our province, in general practice and specialties, surgery, psychiatry, pediatrics. And a more stable electronic medical record environment in the province."

According to of Mr Liepert, opposition members are concerned about his style of governing.

"Part of what we're looking for in the health-care system is a need for predictability and the need for steady management and we've got a NASCAR driver, so hold on," said Laurie Blakeman, Liberal health critic.

"He's a NASCAR kind of guy, likes it fast and loud, fast and loose and puts his boots up on the desk and shoots from the lip."

Blakeman is skeptical about Liepert's knowledge in the health field, she said, since he doesn't answer questions or give meaningful input in the legislature.

Only time will tell whether healthcare will emerge the winner of this cabinet swap. But if Mr Liepert sticks to his word and moves forward and announces his plans as quickly as he has promised to, then we may know very soon whether this swap will benefit Albertans.

OTHER HEALTH NEWS
Also included in Mr Stelmach's announcement yesterday was the appointment of first-time MLA and former emergency physician as Mr Liepert's parliamentary assistant.

Dr David Swann, a Calgary Liberal MLA, with solid support. He's a fairly safe bet to continue on as the Liberal environment critic.


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The highlight the best scientific imaging from research around the world. Peer into the internal structure of an HIV particle, see how sperm develop in the testes or the life and death of prostate cancer cells (right).

Genome Alberta and Genome Canada launched a similar project earlier this month: a digital art contest with a prize of $1,000 for first place. Its bent is decidedly more aesthetic than scientific though, since organizers ask that submissions depict the "intersection of science and society."

Of the three entries so far, which you can vote for , one features a giant angel and another a giant turkey super imposed on a field of DNA entitled 'Getting Ready for Christmas.' Maybe each should come with an artist's statement to clarify these visions of science intersecting with society.

The field looks wide open and the deadline for submission is April 13. The winner will be announced at the in Calgary this April and may be featured here.

Photo: Colour-enhanced scanning electron micrograph by Dave McCarthy and Annie Cavanagh
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has a new online book group called . Visit on the social networking site for book lovers, Shelfari, to check out our medical fiction and non-fiction library.

Why do doctors write?
Anton Chekhov, Arthur Conan Doyle, W Someset Maugham (right), William Carlos Williams were all medical men who sought and found fame and glory through their writing.

Today, Michael Crichton, Robin Cook, Vincent Lam (left) and Kevin Patterson carry on the tradition. Increasingly, medical men (doctor-writers are still primarily male) are turning to journalism, with writers like Jerome Groopman and Oliver Sacks dominating the pages of the New York Times and the New Yorker, feeding a new insatiable public interest in all things medical. And even more recently, doctors have taken to blogging - that most democratic of forums - as an outlet for their writerly urges.

Our new book group, , explores the question, "What makes doctors write?"

(For a backgrounder, check out and the ruminations on the topic.)

Our first discussion: Should doctors stick to what they know and write only about medicine? Join the discussion .

Here's a list of a few of the doctor writers we've profiled in the past in the :

: The former soldier, MD and novelist from British Columbia when he an article about a soldier's death in Afghanistan for an American magazine.

: The Toronto emerg doc hit the Can-Lit bigtime when his book, Bloodletting and Other Cures, . Margaret Atwood loved it.

: An encounter with sci-fi classic Day of the Triffids turned this aspiring MD into an aspiring sci-fi writer.

Surgeon-cum mountaineer-cum writer was mentored by the famous mountaineer Alfred Noyes and settled down in Whitehorse to write books about mountains.

Visit for more medical books we like.

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Here's a sampling of some of what we here at Canadian Medicine are talking about lately.

• Some clinical trial participants in Prince Edward Island have been left out in the cold -- literally. Halifax dermatologist Barrie Ross tested a rheumatoid arthritis drug called anakinra to treat the rare disease familial cold autoinflammatory syndrome, a genetic disorder that causes patients to "feel like they're freezing from the inside out," . But now that the trial is over -- a big success, by the way -- the afflicted patients can't afford the $15,000-per-year medication. The government is "looking into the issue."

• A recreational drug that had previously been mostly unknown is now becoming more popular in Canada, alluringly named "foxy methoxy." The appropriately named drug, a hallucinogen in the same family as magic mushrooms, is said to make one feel foxy -- or, , it "can draw its users into sexual temptation." Want to learn more? I've found two very different explanations of the drug for your perusal: one, a on foxy from the University of Maryland's Center for Substance Abuse Research (some more slang terms for the drug: "Trash, Dip foxy, Roxy, Yum Yum, Muffy, Excite-bike, Five9"); the other, several definitions of foxy methoxy (including a sample usage of the term that I defy anyone to explain to me: "Three schwags of fox to my nug grill! I blaze three foxes to my grill and nugged a dome past the schwag face!" Huh?)

• Nine days of recruiting by Saskatchewan officials have netted the province 297 Filipino nurses. One concern for the recruiters was how to assuage the nurses' fears about the weather in Saskatchewan. "They shuddered at the temperatures but were excited," one official . "They thought the images of frost on the trees and the frozen river were beautiful." At a time when the brain drain and health human resources poaching are major concerns, the province wanted to ensure it was recruiting ethically, so a policy was developed to recruit no more than 10 nurses from any one hospital in the Philippines. ("When you're going into another country, it is imperative to act ethically and ensure you don't leave their system in chaos.") So spreading the brain drain more thinly is somehow more ethical than decimating just one or two hospitals? According to the Saskatchewan officials, their "consideration" was "much appreciated."

• Do doctors prefer men to women? It seems so, at least when it comes to recommending knee replacement surgery, according to a in the Canadian Medical Association Journal. "Physicians are prone to the same automatic, unconscious and ubiquitous social stereotyping that affect all of our behaviour," write the team of Toronto researchers. How far we've come... Particularly notable about this study, besides its dispiriting results, is its unprecedented methodology. For the first time ever, researchers sent real osteoarthritis patients as part of "Operation Knee" to visit unsuspecting physicians to measure gender bias, instead of using actors, .

• A woman whose 18kg tumour wasn't being treated quickly in Ontario decided to get treatment in Michigan, but the provincial government has refused to refund her $60,000 bill. "It's ludicrous," the woman . "Where's the judgment and the integrity in all of this?... I'm disappointed with the bureaucracy of it all."

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Dr Sanjay Gupta, CNN's resident doctor, graces the cover of our March issue, which is now . Dr Gupta, who's a brain surgeon in his spare time, about his thoughts on the US presidential candidates' health platforms, his near-death experience in Iraq, his opinion of Canadian medicare and the burning question: who's sexier, him or fellow CNN-er Anderson Cooper.

Also in this issue:
• Making sense of contradictory reports about
• Meet the . She talks about her hopes and gripes and why she sold the farm
•? (What do you think? Take our Poll, on the right side of this page)

Click read more to see our full table of contents

National Review of Medicine, March 2008, Vol 5 No 3

FULL TABLE OF CONTENTS

PATIENTS AND PRACTICE

Inpatients die oftener than those in ED. Better training needed on wards

Too-low type II glucose kills. False, says rival trial

For women, urinary incontinence is underdiscussed and undertreated

Top-down infliximab beats step-up steroids, doubles remission rate

What to tell your patients

N-acetylcysteine beats other meds at fighting common scan side effect

Errors riddle 50% of death certs. Poor training blamed

New versions of old drugs fight rhinitis better

US doc’s program pays $1 a pound. Temporary fix, says Canadian expert

Open talk is key to allaying family fears, says MD. There is a middle way

Grassroots pain programs empower patients, ease family doctors’ burden

PRACTICE MANAGEMENT

New laws make apologizing to patients safe. What you need to know

POLICY AND POLITICS

Q&A with the American neurosurgeon and CNN correspondent

QC docs cheer Castonguay ideas, but gov’t wavers on bold reforms

Grit plans rife with half-baked schemes, charge analysts

Dr Anne Doig talks to NRM about her election win, her plans and her six kids

Mixed-pay clinics still short on data, many MDs remain wary

ADVANCES IN MEDICINE

Risks persist and longterm effects are unknown, warn experts

Montreal hospital latest to get $4 million assistant. Complications slashed

Sensitive device spots “twitchy” airways, easier on kids

Stick/non-stick, on/off gadgets are all about control

PHYSICIAN LIFE

Dr Gabor Maté’s new book is a gritty glimpse of Vancouver’s mean streets

An excerpt from Dr Gabor Maté’s new book

Chatham, Ontario, docs waltz their way to new MRI. “It was a highlight of my life”

PHYSICIAN WELLNESS

February is finally over. Did you get a day off?
PLUS NRM Quiz: How family-friendly are you, doctor? Take the quiz online or click for a printer-friendly PDF version

PERSONAL FINANCE

Dealers slash stickers but costs still 20-30% higher than US

DEPARTMENTS
Castonguay throws Quebec docs a lifeline
Discord on ACCORD
Wait times impatience, doctors’ decision-making autonomy, the Chalk River crisis, and more
2008 federal budget forgets healthcare
Was Calgary MD-politician a Russian spy? Plus, more news from coast to coast to coast

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Welcome to Grand Rounds, the weekly anthology of the best writing from the medical blogs.


THIS WEEK'S TOP THREE

1 From Nurse Ratched's Place comes this week's most salacious post: "." Apparently a new survey conducted by Britain's Nursing Times found that one in 10 nurses think having sex with a patient is just fine, and one in six say they know a colleague who's done it. The controversy has been exacerbated by comments from Lord Mancroft, who called British nurses "grubby, drunken and promiscuous." But Nurse Ratched's Place author Mother Jones, RN isn't convinced: "... nurses are not sex crazed kittens looking for a hot date. We’re too old and tired to go to wild orgies after work. Sorry perverts. Start fantasizing about something else."

2 Training to become a doctor is akin to learning to sing opera, writes a Canadian med student in the Caribbean who , at Anatomy on the Beach.

3 We're willing to bet that husband and wife MD bloggers Dr J and Dr H, at Adventures in Medicine, are the northernmost physician bloggers in the world (check out the map to see where they are). They've made the bold claim that their hospital, in Iqaluit, Nunavut, has . The menu features such delicacies as arctic char fillets and caribou stew. But locals prefer the recently re-opened burger joint called The Snack: "LDL is up, HDL is down, but people are happy."


DOCTORS ON DOCTORS (or anyone else on doctors)

Dr Steven Palter, from docinthemachine, the six most commonly misinterpreted handwritten medical orders.

The UK's four-hour goal for emergency room admissions is a nice idea, writes Mousethinks, but it's resulted in some very creative . ER Nursey says American physicians with the same kinds of time limits, unfortunately.

MormonMD if med students are all addled on Adderall and then for 11 paragraphs about why he never has time to go see a doctor. "Getting the smallest of chores done can become a mammoth task in the face of an 80 hour work week," he writes. "However, the fact remains, the things I really want done, get done, seeing a doctor does not."

Dr Kishore Visvanathan, a urologist from Saskatoon, Saskatchewan, has to med students who do rotations with him.

Rita Schwab patient safety recommendations from Johns Hopkins researcher and physician Peter Pronovost, the man who's been pioneering the use of checklists in hospitals. (We wrote about his checklist project .)

A new study on sleep deprivation in MDs a bad case of the yawns. "I sleep less than anyone in my family or my friends. Is this a good thing? I don't know but it does allow me to indulge in blogging and reading and writing and yawn!!!! I'm tired."

Barbara Kivowitz at In sickness and in health a doc who seems to have skipped her patient-centred care seminar.

Patient-centred care? Poppycock, say the folks at who write: "Patients (and their care) ARE at the center of the health care system but at the same time we must recognize that patients are not paying the bills.... When patients pay the lions share of the bill they can and do have more say in their level of care."


MEDICAL SLANG

Before reading , all the term "Toxic" evoked for Canadian Medicine was our fave pre-meltdown Britney Spears . Now we know that, at least among Filipino doctors and nurses, it's a catch-all adjective that roughly translates to any hellish healthcare-related person or situation. Hmm, maybe the folks at LA's Cedars-Sinai Medical Center could relate.

Is medical slang GPO (good for parts only)? Check out our take here.


JANE AUSTEN'S DEATH AND OTHER MEDICAL MYSTERIES

For more on the Jane Austen mystery, check out our post ""

"I understand Jane Austen had both trigeminal neuralgia as well as joint pain," .

"Has anyone suggested that Jane Austen might have had acute intermittent porphyria?" asks Dr Kenneth F Trofatter, of .

We were pleased by But You Don't Look Sick's of the Jane Austen biopic Becoming Jane which compared it unfavourably to the BBC's Pride and Prejudice. We agree (although we confess we do like James McAvoy as a stand-in for Colin Firth).

than Jane Austen, but we liked it: "A disabled man entered a hospital for care. He died. A multidisciplinary health care team may have hastened his death...that's sick. That's predatory. That's appalling. It's against the law. And it's wrong." Nuff said.


SEXING UP THE fMRI DOSSIER

Enough contributors wrote about fMRI that we had to give it its own section. We know, fMRI is very sexy. We don't think Canada can afford fMRI machines. Does this mean Canada's not sexy? Don't answer that.

The Samurai Radiologist's science side was turned on by that mapped brain differences in jazzers playing straight or improvised music. But the musician in him vows to "routinely deactivate major portions of my prefrontal cortex when I'm away from work, and let my instruments and my body move through the music on cerebellar cruise control alone."

Our psychiatrist friend at How to Cope with Pain is also , in her case a study in which chronic pain patients "watch their fMRI readout, then use coping techniques to modify the fMRI readout," she writes.

ScienceBase on why guys are bigger video game dorks than girls. Another fMRI study looked at male and female subjects while they played video games. Geek receptors in the guys' brains went totally nuts, apparently. (Canadians collectively ask: pretty please America, can we borrow your fMRI machines when you're done playing World of Warcraft?)

And speaking of video games, Dr Shock to an electric shock add-on for Xbox and other video games called Mindwire V5, which allows you to "feel the game" while you play. Subjects from V1-4 trials could not be reached for comment. If Mindwire needs testers, Canadian Medicine hereby volunteers its services.


OTHER POSTS WE LIKED

Canadian physician Dr R at My Med Jokes . "She said; 'Down below, the man has two holes and the woman has three holes. The baby comes out of that third hole. Any questions?' We looked at each other, feeling perplexed."

While we're on the subject, check out Hugh Laurie (in his pre-House days) and Stephen Fry's absurdist take on sex ed:


Vancouver's Dr Martina Scholtens, of FreshMD, recently recounted : "Me, to a patient who has just detailed his heroin addiction: 'How many alcoholic drinks do you have each day?' Patient, with disgust: 'I'm no boozer! I don't touch the stuff.'" In her free time, Dr Scholtens is an avid knitter; here's the list of her , including knitted brains (this one is by American physician Karen Norberg), a uterus and a digestive tract.

Removing a pyogenic granuloma from a patient's lip at an underequipped Guatemalan hospital is for Dr Paul Auerbach, a Stanford professor and wilderness medicine expert who blogs at Healthline's Medicine for the Outdoors. Be warned: gruesome photos ahead.

A heartbreaking story about treating Mr Schwartz, a former accountant who became homeless as a result of the medical costs associated with his late wife's breast cancer treatment, .

Nova Scotia-born Dr Val Jones retired Canadian Senator Michael Kirby (pictured left), one of the country's leading health policy experts, on her blog Dr Val and the Voice of Reason. This audio Q&A is a great introduction to how the Canadian healthcare system works, among other things. about his new role as head of the Canadian Mental Health Commission, his proposed booze tax and being an irresponsible grandfather.

Fever-autism connection? David Williams at Health Business Blog pediatric neurologist Michael Segal for his take on the recent autism-vaccine decision in the US: "Vaccines often trigger some fever, and fever can trigger episodes of many inherited metabolic diseases, so the link between vaccines and autism may be more than just coincidence."


THE NEXT GRAND ROUNDS

Thanks to everyone who submitted, either on one of our disparate themes or on any healthcare-related topic.

If you like what you see here at Canadian Medicine, please feel free to stick around and check out some of our other posts. You can subscribe to receive Canadian Medicine by email by entering your address here:

To find out who will be hosting Grand Rounds next week, check out the .

Update, March 12: Next week's Grand Rounds will be hosted by , an American doctor and comics aficionado.


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When I was researching my , or HIFU, one patient complaint kept propping up: there’s not enough information out there on this prostate cancer treatment or its side effects. A couple of patients I spoke to from the United States -- where the treatment is still unavailable (it's approved in Canada and Europe) -- struck out on their own in search of info and decided to go for the treatment, with mixed results. Here are their stories:

A prostatectomy? That's barbaric!
Chicago businessman Peter Wenz got diagnosed with prostate cancer a year ago. “Someone from an online support group suggested I get a colour flow Doppler test done and in the process, the urologist found a second tumour at the apex of my prostate,” he says.

The tricky location of the second tumour limited Mr Wenz’s treatment options to radiation and androgen deprivation -- which, according to , actually makes the cancer spread -- until he brought up HIFU. His urologist encouraged him to pursue the option, and shortly afterwards Mr Wenz jetted to Germany for the treatment.

The procedure was a success and a test showed that his PSA levels were undetectable -- the cancer was zapped. Although he did develop urethral strictures, he chalks those up to the transurethral resection of the prostate (a procedure that was done along with the HIFU in order to speed up the recovery). Three months and a few dilation treatments later, Mr Wenz is doing well -- erectile function is normal and urinary function is getting there. He is on his way to a complete recovery and has become a big HIFU advocate.

“Compared to all other modalities, only HIFU and cryotherapy specifically target the cancer cells, you just go in and only destroy that area,” he says. In fact, he believes those minimally invasive procedures will change the way prostate cancer is treated in the future. “The day will come when radical prostatectomies will be looked at the way we look at lobotomies. It’s barbaric -- it completely destroys the quality of life!”

Not sold on it
Sixty-nine-year-old Fred Gillick was diagnosed with prostate cancer nearly 12 years ago. He was initially treated with external beam radiation and seed implants, but four years later, cancer reared its ugly head again. His doctor told him there was nothing more to be done, but Mr Gillick had heard about HIFU through a cancer support site. So he went for it. Unfortunately, the previous radiation treatment had left its mark on him and the salvage procedure just made matters worse. He is now impotent, in constant pain and wearing a permanent catheter. And his cancer is still there. “There’s very little hope,” Mr Gillick told me in a phone interview.

Strictures of hope
Firefighter and paramedic Eric Sondeen is one of those patients who chose HIFU. The Boulder, Colorado resident got the call a year ago, on Christmas Eve. His PSA levels were through the roof — he had prostate cancer. His urologist suggested HIFU, so Mr Sondeen did what most patients do these days: he went online.

"I did a lot of research and it looked like the best option," he recalls.

Since the treatment is not yet approved in the US, though clinical trials are underway, Mr Sondeen joined the ranks of medical tourists and headed to the Dominican Republic — with his urologist. All was well in the beginning, the cancer was flushed out and everything was in working order.

But at month four, trouble struck. Mr Sondeen developed urethral strictures — scar tissue was clogging up his urethra, making urinating difficult and downright painful. It's got to the point that he now has to self-catheterize on a regular basis to empty his bladder.

He now says he wishes he'd weighed his options a little more carefully — and not believed the hype. "The incidence of urethral strictures is actually closer to 20% according to one study," he says, "rather than the 2% presented to me and my doctor."

Mr Sondeen is now looking into repair treatments. But, despite his difficulties, he remains optimistic about the future of HIFU. "I think I was among the percentage of people to take a bullet for this so we could all learn about it," he says. "I wouldn't want to throw the technology out with the bathwater."

JUST THE FACTS
For more information on HIFU, visit Dr Ian Brown’s clinic website and Dr William Oravan’s clinic. Both offer detailed information on the procedure and who is most likely to benefit from it.

Another great site is Australian Terry Herbert’s . It offers sufferers a forum to discuss their experiences with various treatments on an ongoing basis. Patients exploring their options can look up the treatments and see the longterm prospects of each. It’s all there: the good, the bad and the ugly.


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