One finger in the throat and one in the rectum

In simpler terms

2006-04-03T10:32:00.000-04:00

Calvin commented the other day that understanding what the research I did in Australia was all about might be a bit difficult for those without a background in the topic. The Scientist has written a good article that explains the study and its impact. An even more basic (and more flattering) article about the research from Research Australia.

Answers to life's many questions

2006-03-31T01:41:00.000-05:00

Only 2+ weeks after his post, I found that I was tagged by Calvin; so here it goes:

Four jobs I have had:

Soccer referee
Bookkeeper
Door-to-door driveway-sealant salesman
Automotive plant worker

Four movies I can watch over and over:

Wayne’s World
Snatch
Top Gun
Catch me if you can

Four places I have lived:

River Drive Park, Ontario
Kingston, Ontario
Brisbane, Australia
Ottawa, Ontario

Four TV shows I love to watch:

Gilmore Girls
The Daily Show
The Block
House

Four places I have been on vacation:

Havana, Cuba
Le Gros-Du-Roi, France
Town of 1770, Australia
London, England

Four websites I visit daily:

University of Ottawa, Centre for Mediated Teaching and Learning
The Medical Post
Pubmed
BBC

Four of my favourite foods:

Sushi
Green curry
Olives
Cottage cheese

Four places I would rather be:

In the same city as my wife, wherever it is
On an evening ferry in Brisbane
Soccer training camp
The deck of the boat, anchored in shallow water somewhere

Four Bloggers I am tagging (all the blogs I read are already tagged, so I am tagging three people that don’t really have blogs but rather have MySpace pages):

Brittany McLeod
Courtney McLeod
Matthew Fletcher (trying to coax him back)
Tim Smith

Shameless self-promotion (but also a quick commentary on research science)

2006-03-30T23:32:00.000-05:00

This was a pretty good week to say the least. After one-and-a-half years and a near-scoop by a competing lab, the work I participated in during my Australia research stint has been published in Science (March 30th advance of print at http://www.sciencemag.org/sciencexpress/recent.dtl).

I am happy just to finally get something to print, but for my first paper to be in Science makes me ecstatic. And relieved. The pressure to get some good, publishable work done has been mounting on me as the months passed with no results from my Australia work. As someone looking at a prospective career in academic medicine, the empty space on my CV under publications was glaring at me. I know my competence and suitability for a research career cannot really be judged on anything but this all-important category; however, I also know that getting good scientific results sometimes requires a bit of luck, and it was worrying me that I needed some luck soon to help me fill this blank.

You see, I feel that in all of my research endeavours I have laboured equally and put an equal amount of thought and preparation into the work I was doing. However, the results have been widely varying. This may be due to a combination of factors, but more than anything I feel it probably wasn't due to anything at at all except pure dumb luck. You need the right project, with the right supervisor, with the right support staff, at the right time, and you need to bring the right skills, the right knowledge, and the right ideas to this project. This is exactly what happened in the case of my Australia experience, but I don't think it is anything that anyone could have planned out to make sure it happened the way it did.

I'm glad that I've always been lucky.

Not the only way

2006-02-17T20:01:00.000-05:00

Let me start by saying that I am not a proponent of the way that the United States delivers its health care. However, I am a strong proponent of full and proper debate about what we want out of our health care system and of a complete examination of the options available; I think that there is no one right way to provide health care, and that there is a lot to be learned by looking at innovative systems from around the world. This is why I have tried so hard to engage other students in a debate on these issues at my medical school.

In order for this country to be able to properly debate and decide on health care related issues, I think we need to first remove the phrase “moving toward a US model of health care” from the Canadian vernacular. I think it improperly frames the issue, and is detrimental to any possibilities of progressive thinking.

Here are a few reasons this phrase should be removed:

1) There could not be two more unique forms of health care delivery than the United States and Canada:
-Canada is the only capitalist democracy where the provision of medically necessary services is paid for solely by the public system-by law
- The United States is the only capitalist democracy without some type of national, public health care system.
1) The values of Canadians and Americans are diverging, not converging, which means that the health care system desirable by each nation will continue to be considerably different.
- Polling done by Michael Adams for his book Fire and Ice showed that Canadians were distinct from the United States on 73% of 56 values; with 43% of these values, the differences grew between 1992 and 2000.[1]
3) The highly different political organization of Canada and the United States are the ultimate causes of our different health care systems, which will stop either country from becoming too much like the other:
- The Canadian political structure has facilitated the emergence of a viable social democratic party at the provincial and national levels, which has been used as a channel by labour organizations and less advantaged groups at key historical moments to gain political clout and shape health care and other social policies.
- The U.S. form of federalism, which is marked by the separation of powers between executive and legislative branches and a complex system of checks and balances, makes the emergence and sustainability of state- and national-level third parties all but impossible, leaving organized labour and other grass-roots organizations with no place to go but with one of two parties, each of which have no real need to represent the disadvantaged.[2]

These are just a few of the concrete reasons why such direct comparisons of Canadian and American health care are not helpful. For a number of these same reasons, it seems more likely that an evolving health care system in Canada will have aspects resembling much of Europe or Australia. What is important is that we don’t let this perceived Canada-US dichotomy get in our way of having a healthy and open debate.

With provinces like Alberta now boldly going where no other province has gone before in its approach to private health care delivery, I am reminded of how Canada originally developed a publicly funded health care system in the first place: it took Tommy Douglas in Saskatchewan to make provincial changes and fuel a nation-wide debate about what the rest of Canada wanted from their health care system. Now that we have new ways of delivering care being experimented with in this country (or, as Alberta politicians would call it: The Third Way) let us now debate as a country what we want our future health care system to be, instead of simply saying that we don’t want it to be like the Americans.

_____________________________________________
[1] Adapted from Michael Adams Fire and Ice. The United States, Canada and the Myth of Converging Values (Penguin, Canada, 2003)
[2] Adapted from Cecilia Benoit The Politics of Health Care Policy the United States in comparative perspective (Perspectives in biology and medicine, Vol 46: 592-99)

Yet another post on personal organization

2006-02-17T18:20:00.000-05:00

I realize that I have already posted on this topic, but I know a number of people in post-graduate study who are going through psychological dilemas right now about the value of still being in school at the price of other missed opportunities. I know this feeling all too well, but have managed to really change my approach in the last year through some changes in my personal organization.

Post-grad students commonly have two conflicting aspects to our lives: we want to change the world, but we are often too busy to think or do anything outside of school itself. This can be a frustrating arrangement psychologically, and it can make us feel as if we are not getting what we want out of our time spent in school.

While we are- in fact- quite busy with school, there are definite personal organization strategies that can help us get more out of our many years of training. Although there are many books written on personal organization, they generally focus on one or the other of two main points: getting a system in place for organizing everything that you have-to and want-to do; and making decisions about what, amongst all of things you have on your plate, to actually spend your time doing.

In the first category, the general emphasis is to get all of the many things on your mind organized into a system that you can rely on, which will allow you to have all of your commitments, projects, and goals stored somewhere outside of your mind. I have written about this before, and although this is a simple idea, it has the potential for unlocking your mind from its constant need to remember everything you have to do, allowing it to concentrate on the things you have-to or want-to do right now.

A good book in this category is Getting Things Done by David Allen. It goes into some detail about how to get organized, but doesn’t get so structured such that you can’t adopt its principles into your own version of personal organization.

In the second category, the focus is on discovering personal priorities over and above doing anything else. The concept being that you should only bother organizing, planning and doing the things that are important to you, and by wasting less time on unimportant tasks you will be free to get the things done that really matter.

Popular in this category are the books The Seven Habits of Highly Effective People by Stephen Covey and Get Unstuck and Get Going…on the Stuff That Really Matters by Canadian Michael Bungay Stanier. Mr. Stanier also writes about similar topics in a web-based format at www.boxofcrayons.biz. All of these resources give inspirational ideas about how to decide what is important to you.

Separately, these two categories of books may leave you unsatisfied: either organized but still bogged down with seemingly unimportant tasks; or with a new zeal for only doing what is important, but too unorganized to actually get anything done. However, combining the strategies from both can lead to powerful, life altering, changes in the way you organize and spend your personal time- changes that might just harmonize your worldly ambitions with your day-to-day reality.

Bad vitamins

2006-02-01T23:09:00.000-05:00

The CBC recently broadcasted its investigations into Dr. Ranjit Kumar Chandra’s alleged fraudulent medical research[1]. The CBC claims, with some convincing arguments, that Dr. Chandra’s research career at Memorial University in multivitamins and immunology is littered with fraud. Although only one of his research papers has been formally retracted from literature[2], they claim that many more suspicious papers remain untouched. After watching these reports, two things strike me: if the claims are true, it was all too easy for this fraud to be committed; and even if the claims are untrue, it is presently far too difficult to properly investigate cases of academic fraud.

The lack of checks and balances in the peer review process are part of what makes such fraud possible, but in light of the recent high-profile retraction of Dr. Hwang’s stem cell research from the journal Science[3], I am hopeful that changes to this process are now underway in most medical science journals around the world. However, the other side of the Dr. Chandra story involves the inability to properly investigate the claims of academic fraud against him. Even with investigations at Memorial University apparently concluding that there was evidence of fraud in Dr. Chandra’s research, nothing further was done. I find this shocking.

But what could actually be done? Dr. Chandra published in many journals around the world. Clearly, it would take significant resources to look into all of these separate studies- resources that the individual journals or universities are unlikely to commit. Even if these organizations did investigate individually, who would then litigate the grand total of all of the evidence? There is no official body in Canada that could. This has two end results: fraudulent research remains part of the accepted scientific literature, and those who paid for fraudulent research have no way to get their money back.

Many other countries already have national bodies that can handle these sorts of cases. In the U.S., Finland, France, and Germany, the national bodies simply oversee all of the investigations and provide logistical support to the researcher’s institution, which is expected to actually conduct the investigation. In other countries such as Denmark, Sweden, and Norway, the national bodies actually conduct their own investigations[4].

I think it is time for those who are involved in Canada’s scientific community- universities, academic/professional associations, and scientific journals- to discuss a long term national solution to research misconduct.
________________________________
[1] The Secret Life of Dr. Chandra (Parts 1-3), The National (CBC), Jan. 30-Feb. 1, 2006
[2] Nutrition. 2005 Feb;21(2):286
[3] Science. 2006 Jan 20;311(5759):335
[4] MJG Farthing. 'Publish, and be damned...' the road to research misconduct. www.behindthemedicalheadlines.com

Clear your head

2006-01-18T20:43:00.000-05:00

It is so easy to get caught up in the crazy spindle of expectations that we weave for ourselves. These expectations can be just as easily created in moments of weakness, feeling the need to compare oneself to others and their accomplishments, as in moments of brilliance, with great ideas that beg for more attention. Recent examples from my psyche: I should read more; I should write more; I should get more international experience; I should learn more languages; I should do more research; I should start doing yoga; I should practice my clinical skills more often; I should start up a nationwide curriculum for health policy; I should follow up on that idea I had for an internet start-up company; I should, I should……

The problem is that while these expectations are easy to create, they are hard to dismantle- even if they should be; they persist in the back of the mind, a constant reminder of all the things not being done. What often results is a feeling of guilt, and it is this guilt that I think paralyzes many of us from doing anything at all- the “too much to do” syndrome.

I know this feeling. I’ve had it. I still get it sometimes. However, as I mentioned previously, I have recently been trying to stick to some of the main ideas of David Allen, author of “Getting Things Done”- particularly the habit of writing down the next action of everything I want to do. As simple as it sounds, writing all of these actions down, even for projects with no specific timeline tied to it, can help to get these things off your mind. If you get it all down, gone will be the constant feeling of guilt- because you know that you can’t forget about anything as long as you look at your list every once and a while- and your mind will be free to work on the things that you have decided are important at this moment.

Try doing this is you are feeling like you have too many things on your mind or if you have too many goals/projects for your own good. I was amazed at the immediate change it made in my life.

I will be back!

2006-01-04T11:14:00.000-05:00

It's been ages since I last posted, as Mr. CC has pointed out in a comment on Black Coffee Blues. It has been an intentional hiatus: I wanted to stop using my blog as an excuse to put off work I should be doing.

Now that I am back on track with my personal organization- thanks to Cam and his David Allen suggestion- I feel comfortable that in the New Year I can start the blog back up in a more organized fashion that doesn't promote procrastination.

Here's the official commitment: I dedicate myself to writing 1 post per week (and only 1 post per week!) starting next week.

UPDATE:

Okay, I was a bit ambitious with exclaiming that I would publish over the winter holiday break, since I was never near my computer. So, the posting should commence this week- look out for it :)

Oh, to do it all

2005-04-27T10:25:00.000-04:00

Dreams can be as big as we fancy them to be. We can aspire to write books, practice high-quality medicine, change health policy, be fantastic teachers, give thought-provoking speeches, establish ground-breaking knowledge, and have a wonderful family life. What makes all of these goals simultaneously manageable without being overwhelming is the fact that- deep down- we all figure that its impossible to do all of these things at once, and that we will be more than satisfied with only doing a few of the really important things.

Then along come people who show us that it is actually possible to accomplish all of these things at once.

I was at an OMA student's event on Monday at Queen's Park where we talked to some MPPs about medical student issues and listened to some talks from people involved in medical policy and the political process. We had a talk from a physician-MPP with numerous accomplishments in all of the aforementioned areas.

Without having many details about Dr. Shafiq Qaadri, and as much as I'm sure that he has sacrificed some aspects of his life for others, it is still unbelievable to me that he has managed to hold up a successful private practice, write books and articles, be an involved MPP, teach medical students, and have a fantastic family life.

Hearing him speak was simultaneously inspiring and overwhelming: The fact that someone can do it all makes me realize that it can be done but also makes anything else feel like settling for less than what is (apparently) possible. I think it was mostly inspiring, as I felt that my opinions about the medical community needing more people who try to think about medicine in the broader context were echoed in many of his comments.

Better late than never

2005-04-26T09:10:00.000-04:00

The CMAJ (Canadian Medical Association Journal) has started its first blog as an 'experiment' into what this medium can bring to the medical community. It is hosted by Dr. James Maskalyk, a former CMAJ editorial fellow now working with Médecins Sans Frontières in Bolivia.

They confess that Dr. Maskalyk is a pretty safe author to start the experiment with because of his proven journalistic skills; however, they leave the door open for possibly letting some less-qualified individuals host sites.

I hope that there is some interest in this idea from other Canadian members of the medical community, because most of the medical blogs that presently exist are American (some of my links on the right and the links therein). Although the issues discussed on these websites are often very relevant to our situation here in Canada, our healthcare system is notably different and could benefit from some more specific commentary and discourse.

Fame, influence...surgery?

2005-04-25T22:42:00.000-04:00

My big journalistic dreams are all coming to fruition in one week: I have written my first article for the medical school newspaper and I have been profiled as a medical blogger in a medical post article.

However, along with all of the fame and influence I receive from my writing come the inevitable misinterpretations and misquotations. According to the medical post, I now want to become a surgeon? Not only do I not really know what I want to do yet, if there was one specialty that I would rule out if I was asked to rule out something right now- it would be surgery. I have no idea where the journalist got that information.

Welcome to the press I guess?!

Physician-leaders

2005-04-10T15:53:00.000-04:00

The Medical Post ran an article last week about the lack of physician-leaders in Canada. Apparently, many medical societies across Canada have difficulty attracting enough people to fill their leadership positions. This leads to a nationwide situation like that in PEI described by the Post article:

"The clutch of politically active members of the P.E.I. Medical Society suffers from a 'whose turn is it this time?' syndrome, because they each cycle through all the board executive positions. "

I see an uncanny parallel here in medical school- with less than 1% of students doing more than 99% of the leadership activities. And to be honest- medical students are not extremely busy; there is plenty of free time to get involved in these types of activities. I think the real problem limiting both practicing doctors and medical students from getting involved is not being too busy, but instead it is their mind-set; in general, they are extremely focused mentally on the details of their individual practice.

Don't get me wrong, I understand that close attention to the fine details of medicine is an important requirement for safe and sound clinical practice, and that it should constitute a large part of medical education. I wonder, however, why so little attention is given to teaching/learning about the broader context in which this clinical practice is set; this is almost as important to comprehend because without a system that is structured to encourage and support the best and most effective aspects of medicine, the quality of the actual care will decline- no matter how well trained the doctors are in clinical medicine. This decline is happening, and while it has sparked increased debate in the public arena, it has apparently not stimulated enough physicians to take some action and get involved.

To be fair, I think it is difficult to expect people to get involved in leadership if they have never really been taught about the overreaching effects of health policy. The CMA does have an Office in Leadership in Medicine, which offers courses and training about leadership, but this only helps doctors become better leaders- it doesn't get more physicians interested in being leaders in the first place. I think that a larger health policy component to medical education would help solve this problem; as more medical students begin to understand how profound an impact they could make on the quality of care through helping to improve health policy, they will want to get involved in leadership positions.

After all, don't all medical students want to save the world? I know I do.

The most important doctor-patient relationship

2005-03-30T20:27:00.000-05:00

I have been away from the blog for a while again, mainly because I am not managing my workload very well. It's not that I am falling far behind, but with the two courses at Queen's requiring more involvement lately I have not managed to get on top of things enough to justify taking time to blog. In due time I hope to comment on a few health related topics, including pharmaceutical regulation (as mentioned in my last post), the language use in health policy, and the difficulty of too many career choices. However, I was home this weekend for Easter and came across a dilemma that I thought I should share immediately.

When I eventually become a doctor, I am supposed to "limit treatment of myself or members of my immediate family to minor or emergency services and only when another physician is not readily available" (CMA Code of Ethics, point 20). I understand this is to prevent conflicts of interest and other complications that can easily arise in this situation; however, I don't see how I will be able to shield my medical knowledge from becoming part of my interaction with these people. Although I don't intend to ever be a formal part of any of my friends' or family's healthcare team and I will never be the one actually treating them, I wonder if I am doing them harm or good when even discussing their health without knowing their whole clinical picture. Put otherwise: should I try as hard as I can to remove the doctor part of me from this interaction, or should I be as interested in their health as I would be if I was their doctor?

As I become more aware of common signs and symptoms of various pathologies, it will be difficult to not be reminded of them on various occasions when interacting with people outside of the clinic. When interacting with family and close friends, this problem may be compounded by the fact that I probably also know quite a bit about their health history. Considering we are always told in class that you should be able to make a diagnosis 90% of the time on history and physical alone, I SHOULD be able to diagnose at least some things having even limited pieces of these two types of information. What should I do with this information?

If a person close to me were to come down with something that I felt able to diagnose and recommend treatment for, I am not sure where I stand on my role. It is obviously best that I simply tell them to see their doctor or go to the emergency room. But what if their doctor comes to a different conclusion than I did? This doctor would undoubtedly know more about the whole clinical condition than I, and would therefore be better equipped than I, but I am not sure how comfortable I would be with simply agreeing with their decisions. Should I contact him/her and give my clinical opinion? At such a point, I almost become part of the clinical team because I am giving educated input to a colleague on their patient. Should I simply recommend that they ask for a second opinion? This would probably be good if the condition was chronic, but it may not be an option if the condition was so urgent that there was not enough time; also, there is always the possibility that the clinical situation could take a sudden turn for the worse while pursuing other opinions, and I may actually do harm by recommending such action. In short, I don't know what I would do in this situation. It's a good thing that I still have ages to think about it before I will know enough about medicine for it to become an issue.

In the situation that a friend or family member is perfectly well, but I recognize risk factors for a problem that could occur later on in life, I think my role is a little easier to define. Again, because of the fact that time would not be as much of an issue, I could easily recommend that they see their own physician- maybe with a few tips of what to disclose so as to catch the doctor's attention. However, our present healthcare system does not do a very good job at health promotion and disease prevention, and it may happen that the doctor is not doing all he/she could in this regards. In this situation, I think I would feel comfortable with actually recommending the appropriate non-medical activities to reduce risk factors (i.e. "you should exercise more"); for medical reduction of risk factors, however, I think the best solution would be to give them the recommendation to take to their own doctor to make a decision on (i.e. "you should ask your doctor if you should be taking low-dose asprin every day").

It's pretty easy to sit here at my computer and think of how I would deal with these situations when they are not coloured by any immediate emotions. However, this past weekend I didn't even think twice before discussing with a close friend/family member how I think they should manage their risk factors; the thought of that person eventually getting sick was so powerful that the fact that I didn't know their whole clinical scenario didn't even cross my mind.

A deep divide

2004-11-27T14:09:00.000-05:00

As you may have read, the members of the OMA have turned down the present form of the agreement that was negotiated with the Ontario government because 59% of votes cast by OMA members were against the agreement. The Ontario government has countered by saying that they will implement the agreement anyways (isn't that no longer called an agreement?!).

Anyways, the present politicking isn't the main issue that I want to write about. I am more interested in the way the vote was split. The overall numbers indicate that 51% of eligible OMA members voted and that 59% of the votes were "No"; however, contained within this overall figure is the fact that 50% of medical students voted, and 95% of their votes were "Yes".

This apparently caused a bit of an uproar with the OMA coucil, and a motion was put forward to exclude medical students from voting in any future referenda. Although this motion was shut down through support of the medical student vote from many representatives (including the OMA president John Rapin), it still concerns me that the council would even motion this to begin with.

I am simply one member of a very heterogeneous group that makes up the OMA; from medical students to family doctors to surgeons, each sub-group experiences the health care system in unique ways. Although we are members under the same OMA umbrella, the fact that our experiences are different would be expected to influence what we are looking for in an agreement and hence how we vote.

I voted in favour of the agreement because it is a good deal for medical students. I didn't feel the need to consider how this would affect all of the other types of doctors because I don't know anything about their present situation (i.e. I am not a doctor, I am a medical student). I would expect that each of the different sub-groups would vote for what's best for them, and in the end the OMA would have an overall vote that told them if the majority of their members think that they would be better or worse off with the agreement.

This is the pretty simple concept of voting, and I think that most doctors- including those on council- probably understand this. If it had turned out that surgeons voted much different than the majority of the OMA, I imagine council would simply have come to the correct conclusion that the deal had different appeal to surgeons than the rest of the OMA. This might provoke them to look at why, but I doubt that council would think to ban surgeons from voting.

The funny thing about coincidence

2004-11-16T18:35:00.000-05:00

It's remarkable how often coincidences will seem so mystical. When we hear astonishingly true stories of people dreaming of their Auntie Jane for the first time in years and then finding out in the morning that the Auntie had died the previous night in her sleep, we get a chill up and down our spine. It is really hard not to.

I recall reading a great book by Richard Dawkins entitled "Unweaving the Rainbow". In one chapter he actually did the statistics on a seemingly improbable event: buying an antique engraved watch and finding your mother's initials on it. Using reasonable assumptions based on the frequencies of names in phone directories, he came to the conclusion that if everyone in Britain bought such a watch, roughly 3000 people would get a watch with their mother's initials. He uses this and other examples to describe the PETWHAC- Population of Events That Would Have Appeared Coincidental.

Since Dawkins is a renowned evolutionary biologist, the really interesting part of the chapter was his analysis of the Darwinian roots of our awe of coincidence. He argues that our innate statistics were not built for today's society. Our brains evolved to navigate the best road between false negative and false positive errors in an environment that had much smaller population sizes and much more homogenous day-to-day experiences. The result is that we intuitively expect a very modest level of coincidence. However, in today's world, with an exponentially increased population size and a mass-media that connects a significant proportion of society, the chances of coincidence occurring are multiplied considerably. Our brain is unfortunately still essentially the same brain as our early ancestors, and we are stuck with outdated equipment for innately assessing coincidence. The only thing we can do is try to learn to be skeptical until we have taken time to actually think about the probabilities involved. But as Dawkins points out, this is "revealingly difficult even for sophisticated scientists and mathematicians."

Last week we were learning about Leukemia and I couldn't help but think about a childhood friend who had had Leukemia. She was probably one of my best friends until age 10. After extensive chemo, she went into remission. Shortly after, she and her family moved back to Northern Ireland, and we pretty much haven't heard from them since. When I got a phone call from my Dad on the same day I had thought about her saying that they had just emailed him because she was coming soon to work as a doctor at Sick Kids in Toronto (you can go into Medicine directly from high school in Ireland), I will admit I had a chill come over me.

Hopefully this doesn't tarnish my image as a "sophisticated scientist".

Time to add some thyme to my time here in Ottawa

2004-11-10T23:25:00.000-05:00

(Note: I'm not sure if thyme is considered a spice, but there seemed to be enough chefs on the internet who thought it was, so I'll take the liberty of defining it as such so that my title makes any sense at all)

I took Tuesday off. After a devastating penalty shoot-out loss in the intramural soccer finals in near-freezing conditions, followed by a night spent coughing up my lungs due to my current moonlighting occupation as cordial host of a weak form of Ebola, I felt like terrible when daylight eventually came to kick me out of bed. Although the lecture descriptions for the morning were tantalizing, I decided that a day of rest was in order.

After sleeping in and overdosing on Benylin DM-D cough syrup, I felt (un?) surprisingly well. Although my symptoms were temporarily masked, I decided it would be prudent to seek the appropriate pharmaceuticals to actually mend myself. As well, it seemed like a nice day to go to main campus (the health sciences faculty here is on its own separate campus, grouped together with a number of the major area hospitals, and is about 3 kilometers from downtown Ottawa, where the main campus is located).

After getting rejected for drugs by the family doctor at the university health clinic (since when do they not give out antibiotics like candy?), I decided that I should see what else main campus had to offer. Also-coupling business with pleasure because I am that kind of efficient- I decided that it would be a good idea to check in on my OSAP status with the financial aid people.

Walking around main campus brought me back to the days of undergrad: lounging students occasionally reading something other than 600 page, 10"x12", hard-cover, glossy text books; student newspapers writing about future leaders, stress management, and talking ferrets; display booths all over the student centre pushing various charities in your face; and...this is the big one...Tim Hortons coffee!

I realized how much I miss some of these things. As much as I love my new area of study and find most everything about it interesting, I am having a hard time with the level of medical saturation. The unfortunate reality of having the Health Sciences faculty on its own campus is that the environment becomes all medicine, all the time. This may enthuse some students, and may actually be a goal of the Faculty, but I personally don't subscribe to the theory that removing oneself from all things non-medicine is ultimately beneficial to one's education.

So it's time to take my education into my own hands. Time to spice up my life. Add a little variety. With the amazing amount of Arts and Culture in this city, it shouldn't be too hard. Time for some art house films, galleries, symphonies, museums.....okay, maybe I am getting a little carried away; as much as I would love for these things to be part of my regular lifestyle, that may not be feasible. It is probably best that I simply force myself to at least read about something non-medical in some of my time out of class, and make a major outing to something cultural on a less regular basis- maybe once a month.

With my new-found enthusiasm maybe I can start a new club: the non-medical, medical club. We can go to regular cultural events as a group, or, even better, we can take over a room in the actual medical school building, call it the non-medical room, and fill it with Arts, History, Economics, and Politics material. I wonder if anyone would join such a club?

Some positive spin to the Bush win

2004-11-05T01:34:00.000-05:00

After a three-week hiatus for a medical student "conference", homecoming weekend at Queen's , and a move from my downtown apartment to the 'burbs, I am finally back at my computer to do some blogging.

A friend of mine in Australia who forever loves us Canadians for our steadfast Liberal spirit has directed me to a website that reveals a fantastic opportunity that has arose as a result of Bush winning the US election. I feel it could be useful to many of my Canadian friends.

In short, it encourages single Canadians to marry endangered US liberals who are now "desperate to escape". The website requires a pledge from its members:

"Now that George W. Bush has been declared the official winner of the November 2 election and shall become the President of the United States for four more years of idiocy, I the undersigned, a Canadian citizen, pledge to liberate, through the legal and binding act of marriage, a willing citizen of the United States of America, of a gender of my choosing, and with one or all of the following political leanings: discouraged Democrat, reformed Republican, apolitical with limited world-domination tendencies.

In addition, I promise to help my new Yankee spouse to adapt to life in the great white north, keeping them safe from (gratuitous) invasion of privacy, and to provide him/her with a reasonable supply of Timbits."

I say to my single friends: go forth , do your duty for the world-wide Liberal spirit and pick yourself up an American sugar-momma/daddy in the process.

What's it all about?

2004-10-10T19:15:00.000-04:00

So here we are, moving towards the block of years in our life often associated with so-called career advancement. The question is, advancement towards what? I think many people don't really ask this question of themselves until they have advanced far enough in the wrong direction that they finally realize they are lost. This suspicion was confirmed on Monday in a talk given to us about how doctors often manage to let themselves become quite unhappy while advancing their careers.

In an impulse buy during the summer of 2003, while waiting for my younger brother in Indigo Books at the Eaton Centre, I picked up a copy of "The Seven Habits of Highly Effective People". Now, I'm not saying that everyone should rush out and buy this book, but I do think it contains some good pointers, especially with regards to finding the right direction and moving in it.

The two major points that I took away from it can be summed up thus: you need to actually think about what is the right direction for you; and you need to make time to move in that direction.

A great question that was asked of us in the session on Monday was, "why do you still want to get high grades if you can succeed perfectly well in medical school - and won't fail out-by getting average grades"? This is a valid question, as many of us are simply used to getting high grades, and probably haven't thought about how high grades may not be what we should strive for now that we are on a pass/fail/honours system and many residency coordinators would rather evaluate us on other factors. I think the fact that some students are still caught up in making the grade highlights how many people just keep-on-keepin'-on without thinking often about why the are doing what they do.

So this is where major point number one comes in: think about it. What is important to you? Why? To accomplish this, the book recommends writing a personal mission statement. This is not simply the listing of goals, but rather the detection our central sources of security, guidance, wisdom and power. Although I haven't actually written mine out, I think the process of thinking about my statement is good enough for me. You simply need to understand what is at your centre.

When you put some effort into thinking about a statement, you will find that two seemingly similar missions often have deep differences. For example it is really important to me that I become as good a doctor as I can be. On the surface, this would appear to be the same as wanting to do as well in medical school as possible. After further thought, however, these are quite apparently different. The activities that I should focus my energy on to be successful do not overlap wholly from statement to statement. Knowing extreme details of cellular processes for a limited amount of time probably doesn't qualify as part of the first mission, but does as part of the second; while the opposite can probably be said about learning to deal with very sick and dying patients and their families.

Without detecting these differences it is quite easy to be very efficient- by getting a lot of activities done in limited time- and still not be very effective at moving towards personal success because the activities do not relate to your true centre. But even if we know that certain activities are important and others aren't, we often will get caught up with doing the activities that are more urgent. This is where major point number two comes in: make time to do non-urgent but important activities.

The book defines activities based on the four combinations of urgent/not urgent and important/not important. Urgent and important tasks often consume people, because they are deadline driven projects. So exhausted from always meeting deadlines, such crisis managing people often spend any extra time doing not urgent and not important activities because they are burnt out and are looking for relief. Urgent and not important tasks also tend to grab people because they are urgent; they are tasks that press on us. The problem is, many of these tasks are defined as urgent and important by other people, fooling us to think the are the same for us. When they are not, they do nothing to fulfill our mission and waste our time.

Truly effective people spend the majority of their time in the most often neglected category: not urgent but important. We can't avoid spending some time attending to important urgent matters, but by not spending any time (or very little) on matters that are not important (this comes back to the first point about how we need to define what is important to us) we can spend more time on important but non-urgent activities. This should in time help to shrink the amount of effort spent on urgent and important activities because we have taken some time for preventative thinking and planning that will avoid them becoming urgent. On top of this, we will do more things that make positive differences in our personal and professional lives.

Sticking to my medical school theme: Researching career paths, electives, residency programs, supervisors, and the medical needs of Canadian communities is not at all urgent in the first years of medical school. These are, however, important things to know about before choosing a medical career, and will become urgent if left too close to the residency match. Taking some time now to plan how to collect all of the necessary information over the next few years is something that will probably prevent a crisis management situation in the future.

On that note, I think I am going to take a little bit of time right now to plan the electives that I want to take after winter break instead of trying to memorize the tissue distribution of Collagen I, II, III, IV, V, and X.

Surprise, surpise....

2004-10-02T01:23:00.000-04:00

Published in most newspapers today is a story (again, this link will only work for a few days)about Merck's removal of Vioxx from the market due to increased risks of heart attack and stroke. I think that we could have seen this coming a while ago, but that the lack of pharmaceutical transparency made it difficult; there were hints of this problem when some of the original studies were done (way back in 2000!) , but when the authors reported the study results they conveniently wrote around them.

The study I am writing of (Bombardier C et al. N Engl J Med 2000;343:1520-8) was undertook to prove that Vioxx (rofecoxib) was as effective a treatment for rheumatoid arthritis as its competitors (naproxen), but had less gastrointestinal complications. The study showed this quite effectively, giving equal effectiveness and a lower relative risk of GI problems happening in rofecoxib treated patients when compared to naproxen.

When examining the adverse events associated with the trial, the study does mention that the competitor's drug (naproxen) had a lower relative risk of myocardial infarction when compared to Vioxx. However, they explain this with some previously reported circumstantial evidence that naproxen is actually protective against such adverse events, and that the increased risks in the Vioxx treated patients are likely because "rofecoxib does not provide this type of protection".

As tricky as this wording is, I really don't have much of a problem with what was in this article. What concerns me is the information that was left out of the report. It states that "rates of discontinuation were similar with the two groups", which is true. However, they leave out the breakdown of reasons that the drug was discontinued, which is a bit more telling; these results had to be later dug out of the FDA records by some thankfully suspicious scientists (I couldn't confirm if these scientists had any ties with Merck's competitors...sorry):

Specific adverse events causing withdrawal from the trial:
Cardiovascular: naproxin 0.8% ; rofecoxib 2.7%
Congestive heart failure: naproxin 0.2% ; rofecoxib 0.5%
Digestive/Gastro-intestinal: naproxin 20.3% ; rofecoxib 15.0%
Edema: naproxin 0.3% ; rofecoxib 0.6%
Hypertension: naproxin 0.1% ; rofecoxib 0.7%
(numbers from McCormack and Rangno CMAJ • June 25, 2002; 166 (13) )

I think the originally reported similarity in overall rate of withdrawal is misleading. The GI-related withdrawal on the competitor's drug is much higher, which is the reason that Vioxx was made in the first place. However, this increased withdrawal rate is balanced out in the overall picture by the increased rates of cardiovascular-related withdrawal of patients on Vioxx. I think this should have been made more clear in the report. Can we really expect all of the trial results to be published? No, that would make for impractically large documents. However, the obvious omission of relevant information on the risks of the drug is concerning.

I think the problem that lies behind a lot of these reporting difficulties is the way that private agendas are entangled with the academic ones. Here is a piece of the fine-print published at the end of the Vioxx study I have been writing about:

"Readers should know, however, that 11 of the 13 principal authors (C.B., L.L., R.B.-V., B.D., R.D., M.B.F., C.J.H., M.C.H., T.K.K., T.J.S., A.W.) have had financial associations with Merck — which sponsored the study — and, in most cases, with many other companies. The associations include consultancies, receipt of research grants and honorariums, and participation on advisory boards. The other two principal authors (A.R., D.S.) are employees of Merck."

I don't yet have many solutions to this problem, but I really think we should put more thought into it. Maybe there should be a responsibility put on medical journal publishers to do more than simply add such a caveat in fine-print when publishing clinical trials; could it not be made a requirement that the journal look at the unpublished data held by the FDA?

Again, I don't claim to have the solution. I simply hope that we can get this mess sorted out sometime in my career.

Adding to the problem

2004-09-30T11:20:00.000-04:00

There exists in society this cliché that doctor's have terrible hand writing. In fact, I have had more than one person in my past tell me that I was fated to be a doctor because of my terrible hand writing (backwards logic I know, but apparently they were right). In my limited experiences in the health care environment, this cliché has been borne out in full. At first I couldn't understand why this was; upon further thought, however, it makes a lot of sense.

After watching a few doctors go about their daily practice, I have noticed two key things that should have been obvious: one, they don't have a lot of time; two, they fill out an inordinate amount of paper work. I think putting these two factors together is what generates pages and pages of illegible scrawl. This mode of speed-writing quiclky transfers from the clinic to the rest of the clinician’s life, and presto, we have another member of the club.

To counter this problem, many of the more streamlined environments have moved towards computerized systems that only require the physician to sign printed documents that contain all of the clinical notes etc. In my mind, this only solves half of the problem. It saves other healthcare people from having to read hurried pen scratching, but does nothing to fix the actual problem. What about all of those poor government worker's out there who have to read doctor's passport applications, drivers license renewals, and other Jurassic documents that still need to be filled in by hand? Are we simply going to make them suffer?

And now another addition to the problem: e-curriculum. It has to be said that until my genetics tutorial today (from which I am writing this post...) I had written next to nothing by hand. A few minutes ago I started to write out an answer that the tutor gave to a problem, and I was shocked at how bad my writing was- and this is my writing, which is bad on a good day.

Needless to say, I don't think doctors (especially those of us doing e-curriculum) will be shedding this stereotype anytime soon.

For the money?

2004-09-28T22:05:00.000-04:00

In a Life section article today, The Star has a story (sorry, this link will only last a few days) about a twenty-something year old person who was on the "well-beaten path to a doctor's salary when a colourful side trail [in filmmaking] beckoned". It goes on to say that "many so-called "enjoyable" careers, such as filmmaking, are rife with countless tales of failure, and don't often bring in big money", but "taking a job mainly for the dough can leave a person unhappy".

I should first thank the author for such insight. Who could have possibly known that going into a career solely for money would probably be a bad idea? I am fortunate to have come across this article, as I am- the article implies- one of those dark souls that need enlightenment on career choices.

I think that most of us chose medicine for other reasons. I personally opted for medicine over other careers that I was considering because of its deep humanity and its scope of possibilities. For me, these values come from many nights talking to my dad about his experiences in the completely unrelated field of management accounting; in these conversations I learned about the enjoyment that comes from helping a wide range of people out of distressful situations, and the necessity of variety in maintaining an interesting work environment. These are what I value personally, and I am sure my classmates and colleagues have many other, completely different, reasons for choosing medicine.

I think attitudes similar to those found in this article are far too prevalent in the media; it is unfair to assume people choose lucrative careers simply because they are lucrative.

Ah, push it - push it real good

2004-09-23T21:09:00.000-04:00

Today, we had a medical equipment sale at the University. One of the big suppliers was allowed to set-up-shop in the school atrium, and then proceeded to get the business of nearly the entire class. The prices seemed pretty good, so I don't have much of an issue with them bringing the sale to us directly. What was disturbing to me was the way that they were pushing a certain type of more expensive stethoscope, saying to those who wanted to buy the cheaper one that it really was "an entry level scope that is standard issue for nurses, not doctors". Using marketing ploys that play on some medical students' urge to have a higher status than nurses is pretty slimy, and made me feel a little sick about giving these people my money.

Put in my place

2004-09-23T07:58:00.000-04:00

I don't think that I was very pompous about the fact that I got into medical school, as I fully understand that- as of yet- I have nothing to really be proud of. In fact, all I have really done for the last 23 years is suck the government tit, going to school as I wished, having extended programming provided to me so that I wasn't bored, and having affordable tuition at university so that I could examine my interests in this and that until I was really certain that medicine was the calling for me; all the while, other people in society worked their asses off to make the world around me keep on going. However, I will say that I HAVE been a bit pompous in my thinking that I am intelligent enough to be a doctor, and that I really don't think it's going to be all that hard to become a good doctor. This all changed yesterday.

I started my first afternoon of electives yesterday, for which I have chosen to tag along with an academic medical oncologist who specializes in lung cancer. The job description pretty much reads:

(1) treat who you need to with known therapies in order to cure the disease or improve life
(2) try out new therapies on those who don't respond to the tried and tested methods
(3) tell those who are not responding to either treatment that they will soon die
(4) console families of dying or deceased patients
(5) make sure you publish some academic papers (or forget about promotion)
(6) teach pesky medical students about your job and convince them that 1-5 isn't so bad

The doctor that I was following was on "paternity leave" because he has a 6-week-old baby and his wife is also a doctor, so they have to share the time away from work; in this sense of the term, paternity leave means that he has to fit all of his old patients from 3 days-a-week into one day. Add to this the fact that his house just burned down, and that he is presently sleeping on an air-mattress on the floor of his in-laws, and you would expect him to be a worn-out mess. Instead, he was as warm and humorous as anyone I have ever met.

At the end of the afternoon, I was asked "so are you now wondering about why you want to be a doctor?", and I answered, "No, actually I am wondering about HOW I am going to be a doctor".

Trying hard to make the switch

2004-09-18T11:56:00.000-04:00

So I'm finally getting down to some serious studying (yes, yes, I know that it is already the end of week two), and I've run into a bit of a wall: e-curriculum. The medicine program here is all organized around the fact that we have paid the university an exorbitant amount of money for our laptops, and they feel obliged to make sure we use them.

As bitter as that last sentence may read, I am actually a proponent of the program; however, as a student who has relied on the same, paper-based studying methods for over 7 years now, I am having a hard time changing my habits. As I see it, there are two major transformations required to use this system effectively, and I am having trouble with both of them (one more than the other).

Firstly, the e-curriculum allows us to go to class armed with our own personal copies of the PowerPoint lecture on our laptops, and type our notes in the file directly. I say 'allow' because the faculty has been farsighted enough to still provide us all with paper copies of all of the slides (a 5 kg binder of paper per 6 week block, in case anyone is wondering), for those who feel that they still want to write class notes out by hand. I jumped right into the electronic notes, as I saw some immediate benefits, despite my terrible typing skills.

Foremost for me is the fact that years down the road I can go back and see the annotated lectures without having to pull a dusty, fragmented binder out of a storage bin in my basement closet (given that the software is all still compatible- but I'm not even going to open that box). I feel that if used effectively, this will give more value to my undergraduate medical education, as the information will not be lost after I have learned it once- unlike my undergrad biochemistry education.

The second benefit is unlimited space for notes; when annotating a printed page of PowerPoint lectures in the past, I always ended up running out of room to add more notes. Despite arrows linking all of my scribbles on the page to points in the slide, I inevitably had to leave some things out because I couldn't legibly add any more points. With the laptop, the notes section can be as long as one pleases, so I can type every word that comes out of the professor’s mouth that is not on the slide. Now I just have to work on being able to type that fast.

There is one major problem that I am having with this system though. In my paper-based past, I frequently annotated figures presented in slides with arrows, circles etc. to identify key features. Using PowerPoint, it is pretty hard to do this quickly enough to keep up with the pace of the lecture. One has to click on the 'add arrow' or 'add ellipse' buttons, use the touch pad to place it in the right spot, and then switch back to typing the corresponding notes. A bit annoying, yes, but a problem that I think can be fixed by better software, quicker typing, and the use of hot-keys. For me, these are not reasons to stop trying (or to not start in the first place).

The second requirement of the e-curriculum is studying from typed notes. Like most students used to memorizing (a.k.a. "learning") a lot of material, I find it most effective to write out my notes over and over, making them more concise each time. Optimally, in a paper-free curriculum, students could learn to type the notes out instead, or simply read and re-read the notes from the screen. Unfortunately, this is a step that I haven't been able to make yet. I still have been re-writing everything that I study, copying the material from the screen into a notebook used for studying only. I do see this as a failure to use the system to its full ability, as concise study notes would make a useful reference later on, and I think it would be best if they were also stored electronically. I hope to be able to do this by the end of the year, but it will take practice.

Having first hand experience with trying to adapt to electronic learning, I can see why the 'techies' are having such a hard time convincing older doctors to make use of the benefit of computers. I think it is well worth the effort though, as some of the available new technology has the potential to revolutionize care if used by willing, trained professionals; teleconferencing with patients in rural areas to do follow-ups and using instant-messaging based programs to discuss interesting cases with colleagues on the other side of the globe are just two examples that come to mind immediately.

PDAs are already becoming the standard way that residents and new doctors manage their patient's files, make medical calculations, and reference medical literature, which I think demonstrates that a push to get those of us now entering the profession comfortable with computers is definitely not a bad thing.

Yes, it is a stange name for a site

2004-09-14T10:28:00.000-04:00

When I started this site last weekend, I was aware that my choice of name might be a bit off-putting for some ("quick, quick, the boss is coming, close the window that has the words finger and rectum in the same sentence..."). However, besides being humorous, I think it is representative of a number of the key themes that will arise in my postings.

Firstly, the original source of the quote is Sir William Osler:

"Failure to examine the throat is a glaring sin of omission, especially in children. One finger in the throat and one in the rectum makes a good diagnostician."

As I mentioned in my first post, Osler is one of the original inspirations for starting this journal. I thought it appropriate to draw on him for the title, as his tradition of writing on life and medicine is one I intend to follow.

Secondly, the quote describes the activities required 125 years ago for a physician to make a complete examination. In my mind, a complete examination in today's world includes -more than ever- an analysis of healthcare policy and medical education. These are the throat and the rectum that I am going to stick my fingers into quite often in this journal.

Lastly, I think the quote conveys the idea that the study and practice of medicine may not always be glamorous. I have little idea what to expect over the next 8-10 years, so my posts will often describe those things about the profession that catch me off-guard. I can't predict right now if these posts will more often describe the gory aspects of medicine - involving rectums and other organs- or what life is like on-call, in debt, and living like a student until I am 30 years old.

Colonel Mustard, with the wrench, in the kitchen

2004-09-13T17:29:00.000-04:00

I've listened to the clues. I've seen a few cards. I'm ready to make my guess about who is going to kill the healthcare summit and how.

Colonel Mustard

To me, this is the character that best epitomizes the current mindset of my prime suspects: the premiers. In a militaristic fashion, using their power in numbers, with ulterior motives, the premiers are marching to war under the banner of healthcare. Just like so many wars (hmmm, can I think of any recent examples???) the real deal is money. The premiers want more dollars from Ottawa in general, and healthcare is a convenient way of getting public approval to demand it.

Comments by Paul Martin and Ralph Klien make it pretty clear that the parties are at the table for much different reasons.

Paul Martin:

"At the end of this we have got to walk out of here with a long-term plan so that we don't come back and argue about a bunch of numbers"

"If money alone could improve our health-care system, it surely would have succeeded by now"

Ralph Klien:

"Health-care renewal is not something we are here to start"

"Ottawa's commitment to partnership (with the provinces) can best be demonstrated by addressing the long-standing health funding inequity"

The Wrench

The murder weapon as I see it will be the numbers game played by the premiers. Clearly, by approaching the summit with an agenda that does not match its original vision, the premiers are setting the entire meeting up for failure. Furthermore, since the 'entire' meeting is televised, the boring back-and-forth financial speak is certain to make anybody in Canada who actually wanted to hear about the issues and take an informed view tune out immediately. No better way to throw a wrench in Ottawa's plans for a lively public debate on healthcare.

The Kitchen

The Globe and Mail today recalled how the 1981 televised debate about Canada's constitution ended up having its main compromises reached in a fifth-floor kitchen of an Ottawa conference centre. For me, it is becoming more and more obvious that any of the real deals that will be made at this summit will occur behind closed doors. As I see one of the main points of this summit being the public presentation of the issues surrounding healthcare reform, this type of dealing will murder the summit.

Dead. Lifeless. Useless.

As Osler would have

2004-09-12T08:20:00.000-04:00

As yet another twenty-something liberal academic starting a BLOG, I feel I should explain what I hope this will add to the web-publishing community.

From what I have seen, there are a multitude of fantastic personal journals being published by people from all types of academic backgrounds- history, journalism, politics, English, biology, math etc. - and this is creating a stimulating environment of cross-specialty idea exchange. However, I feel that there are a few groups that are underrepresented in this exchange, and that we could all learn more if they would join in. As a newly admitted member of one of these groups, I would simply like to join in.

Professionals- and medical professionals in particular- are notorious for "not having the time" to do anything but their profession. I am only in the first year of medical school and I may be naive to the demands of the years to come, but I still think that it is no excuse to be silent.

One of the most celebrated physicians of all time is Sir William Osler. His historical influence on the practice, teaching, and organization of medicine in Canada, Britain, and the United States is a result of his extensive writing. Although I cannot claim to equal his eloquence, and I cannot expect to equal his influence, I can attempt to follow in his footsteps through participating in the social dialogue.