Random Thoughts

Haven't been posting too much lately. Have been too focused on longer posts and not enough on the many little thoughts kicking around in my head.

Sunshine
It's sunny again! Also, I get to walk to my placement for a couple weeks, which is amazing. I used to walk everywhere - for a while nearly an hour each way to-and-from work - and I loved it. It's been a nice change of pace to be getting some exercise in the sun, especially given the lack of exercise I've been getting otherwise.

Overdiagnoses
Medicine suffers from both a hive mentality as well as a lack of accountability for those who choose to follow their own path. Many conditions are overdiagnosed in the population, some due to widespread misdiagnoses by broad swaths of clinicians, others due to outliers whether ahead of the curve or behind it. Psychiatry is particularly susceptible to these problems, given the subjective nature of the field. I'd like to draw attention to one diagnosis that I've seen more than I would expect and in situations that don't seem to be applicable: Borderline Personality Traits.

True Borderline Personality Disorder is very disruptive and can be exceptionally hard to treat even with the emergence of DBT as an established, evidence-based therapy. Borderline Traits are, by definition, not significantly disruptive. There's room for this diagnosis, but often I've seen it employed when a patient is simply difficult. Borderline Personality Traits in isolation don't typically get treated, so perhaps it's not the most troubling diagnosis. Still, I find this trend a little too close to pathologizing traits which are, at the end of the day, not really a pathology, just something we as clinicians don't really like very much.

Hockey!
It's playoff time! The junior team I support is crushing it. The AHL team I'm supporting - bandwagon style mind you - is doing pretty well too. The NHL playoffs are actually interesting, with Chicago, LA, and Anaheim all bowing out in the first round! I only went 5/8 in my first round predictions though, so that's pretty bad... picked the Blackhawks and Panthers, which didn't work out. Also picked Anaheim and I really wish I hadn't, because I've always thought Nashville gets dismissed too easily. They're a really good team now that they have some real forwards in Forsberg, Johansen, and Neal. Looking forward now to the 2nd round match-up between Washington and Pittsburgh, not because of any Crosby vs Ovechkin bull, but because both teams are playing really, really well right now.

Naturopathy
The story of the Albertan parents who tried natural medicine for their child with meningitis is everywhere, so it's worth taking a second to touch on. There's a role for "natural" interventions, traditional medicine and alternative medicine. It can and frequently does co-exist with conventional medicine without much difficulty. However, it's hardly a harmonious co-existence. Fault for this can be placed on both sides, but the fault is far from symmetric. Conventional medicine is too dismissive of what benefits can be gained from non-conventional approaches. At a sheer minimum, placebos work and while there's moral hazard in actively participating in prescribing placebos, I don't think there's anything wrong from encouraging people to use their own placebos, if it seems to improve their quality of life. Reiki is high-quality bull-crap, but it's not going to hurt anyone so long as they still use conventional medicine when appropriate. Our resistance to alternative approaches means we're providing what is likely adequate, but suboptimal care.

The flip side is that non-traditional medicine overpromises. Most non-traditional interventions are not based in evidence and some can be quite harmful, but a balanced, honest discussion of pros and cons does not appear to be forthcoming. Worse, many practitioners seem unaware of the problems with the treatments they're offering (and getting paid for). That can lead to some serious issues, as the Alberta case demonstrates. These are fortunately not that common, but still far more common than they should be.

Point is, on both sides of the aisle, conventional medicine and non-conventional medicine, we could do a lot more to work together for the benefit of our shared patients. However, there should be no false equivalence - we need to change our attitudes, they need to change their actions.

Investment vs Consumption in Healthcare

It's no secret that healthcare budgets these days are under stress. As provincial governments look with concern to current healthcare costs, as well as to potential future healthcare costs with our graying demographics, there's plenty of incentive to minimize spending within the medical community.

While I disagree with some of the approaches being taken, it's a worthy goal - not everything in healthcare is cost-effective, and there's good reason to think that freeing up money for other social expenses could be more be more beneficial than many direct medical expenditures. It's also an opportunity to dig into the role of medicine in our society and what we actually expect for the rather large sums of money we throw at our healthcare system.

Healthcare comprises both elements of investment (expenses which are expected to yield an economic return) and consumption (expenses which are not expected to yield an economic return but which hopefully confer benefits to longevity or quality of life). That's a bit too sharp of a split - in reality, all healthcare should be improving the quantity and quality of life of patients and most expenses tend to have some sort of an economic return, even if that return falls below the medical expense and wouldn't be worthwhile as an investment alone.

However, the degree to which we priority each element - investment vs consumption - tells us a fair bit about how we view healthcare's role. These priorities in turn can dictate how much we spend on healthcare overall.

Right now, in Canada and much of the rest of the western world, the focus is on consumption. When people rally for better access to medical services, it's usually for the immediate impact on patients' quality of life. Likewise, when analyzing an intervention's merit, we tend to focus on cost-effectiveness, using metrics like cost per Quality-Adjusted Life Year (QALY). These capture quality of life gains, and analyze all medical interventions as though they were consumptive in nature, but generally ignore economic returns on expenditures.

It's difficult to view and analyze healthcare from an investment perspective, however. For one, it's really hard to accurately measure return on investment when it comes to medical interventions - QALYs or similar metrics are much easier to determine. Second, doing so requires making judgments on the economic worth of individual people (or groups). Most of us are pretty uncomfortable thinking of human lives in economic terms. Physicians especially try to avoid these judgments, as they can devalue certain groups, especially the vulnerable and those in need of the most help.

Yet, there are some broader programs that make no direct judgment on individual worth, yet would have clear beneficial investment components in addition to their meaningful improvements on quantity and quality of life. Mental health is a major one. It hits adolescents and younger adults frequently and is a significant impairment when it comes to productivity at work or school. Individuals who are not currently working are also at high risk for mental health problems, particularly the elderly with dementia and/or depression, of course, but compared to many other medical services we provide, the benefits from investments in mental health more frequently affect individuals who could be more economically productive if optimally treated. When we start making the hard choices about which programs and services are worth funding, it may be worth putting a higher emphasis on economic returns - it might make our tax dollars go a little bit further and lessen the burden of our healthcare expenditures.

I'm rambling a bit, so I'll wrap up by saying this: we want to be healthy and our medical system is a major part of that. However, healthcare does more than just improve health and other social services play a big role in improving health overall. It's worth taking a step back every once in a while to reevaluate our priorities in medicine, to be critical about what how best we can serve the societies we live in, and how some parts of our healthcare system - even the helpful parts - might not be worth the cost when compared to alternatives.

Likes and Dislikes in Psychiatry

Finishing my Psych block, time once again for a reflection on the rotation with my "Likes and Dislikes" series.

1) Oh regular hours, how I missed you

After months of long, drawn-out hours, Psych has been an oasis in the desert. My days were typically 8-9 hours long with the odd day ending quite early. Start times were reasonable. Even the 24-hour call shifts weren't bad, at least by comparison - they were technically home call, so I got to leave the hospital on occasion, and generally got more sleep than on other rotations. I had the odd shift where I got only a small amount of rest, but it didn't feel that exhausting, maybe because I was rested going into it and had time to recover afterwards.

You never quite realize how tired you are until you're not tired and on Psych, I felt rested for perhaps the first time in months.

2) Once again, I like talking to patients

This long into clerkship, some themes are start to reoccur, and this is definitely one. When I can help a patient just by talking to them, I feel great. This is what I got into medicine to do! Psych provides a lot of those opportunities. Even when counselling isn't the main role Psychiatrists fill (other mental health workers seem to do that more often), it's a big part of a lot of interactions with patients and as a result, I thoroughly enjoyed those interactions.

3) Well, maybe not all patients...

The one part about Psych and patient interactions I didn't like was that the exchanges often had an adversarial component to them. When many patients are being admitted to hospital against their will, it kind of comes with the territory. The mental chess that gets played in some cases - while extremely interesting - was also rather draining. I understand that the conflict between patient and provider has a purpose, and that in working against a patient's wishes the physician is doing their best to help the patient, but it's not necessarily something I want to be doing on a regular basis.

It became obvious to me fairly quickly that my preferred patients were those who had ego dystonic conditions - the ones that they want to fix, like depression or anxiety. Individuals who didn't recognize or didn't want to fix their mental health issues weren't as interesting to me. I'm glad there are people dedicating their lives to helping these individuals, because they do need help, but I'm not sure I want to be one of them, at least not on this frequent of a basis.

4) The Happiness Test

I find Psychiatrists in general to be a bit of an eccentric group, so it's sometimes hard to tell their emotional state, but for the most part, the people I interacted with passed this test with flying colours. They were happy! Not joyous per se - this wasn't rainbow sunshine land like Peds was - but they seemed contented at the least.

I wrote off Psych as a potential specialty to match to almost immediately. The reasons behind that choice seem misguided and trivial now - if I had to give a Top 5 of specialties to match into right now, Psychiatry would almost certainly be on there. They say you can't really tell if you're a fit for a specialty until you see it first-hand. In this case, I agree.

Between Optimism and Cheerfulness

The Ontario Medical Association sends me magazines from time to time, and while a lot of the material doesn't apply to students, it does give some insight into the lives, activities, and viewpoints of a subset of practicing physicians. One article by Dr Darren Larsen caught my eye, and you can find it in blog form here. In short, it's a spirited defense of cheerfulness and optimism, in response to a perceived criticism from a colleague.

I consider myself an optimist. I believe that things, overall, are getting better and that there's a lot we can do to make them better. In that sense, I agree with the article - it's very important to keep a positive outlook on life! More importantly, I don't believe, as Dr Larsen asks at the beginning of their post, that optimism alienates people.

However, being optimistic wasn't the full criticism. The comment was that Dr Larsen was "as usual, overly cheerful and optimistic". And while he ably defends his optimism, he ignores the slight against his cheerfulness, and these are two very different traits.

Cheerfulness can be a problem. Cheerfulness can make others feel worse about their own negative feelings. Worse, seemingly cheerful individuals can disguise their own negative emotions under a veil of cheer. In the workplace, overly cheerful individuals are often viewed as annoying. Cheerful individuals may be the least productive. When helping patients in despair or experiencing depression, or trying to rally physicians - many of whom are also going through despair or depression in the form of burnout - cheerfulness might not be the best emotion to display in order to reach these people.

In smaller doses and over time periods, of course, cheerfulness is great. But on a regular basis, at high intensity, cheerfulness may simply be inappropriate. Same goes for every other emotion, attitude, or mood. None should ever be present always, but all can be useful depending on the situation. No one wants a coworker who's angry all the time, but there are instances when anger is appropriate! Equally true for fear, and sadness, and disgust...

You know what? I just realized half-way through this post that I'm trying to put in words what "Inside Out" already said far more capably in movie form. Anyway, go and watch that movie, it's amazing.

In any case, Dr Larsen ends with a quote from Winston Churchill who says "For myself I am an optimist – it does not seem to be much use to be anything else." On this I am in complete agreement. However, few people would accuse Churchill of being overly cheerful. There are times to be cheerful. There are times when cheerfulness is inappropriate or unhelpful. As we strive to make improvements in our lives and the lives of others, it's worth drawing on the full range of emotions available to us - even the negative ones have their role.

Poorly Trained Surgeons

Wanted to share this post, about concerns with surgical resident competencies. This is presented in a US context, but I've heard many of the same worries in Canada. Put simply, a good portion of fellowship directors (and other attending surgeons) believe that a fairly significant number of graduating surgical residents are not competent to perform important surgeries independently. Worse, many of these surgical residents agree.

The kicker for me, however, is this paragraph:

"The lack of confidence stems from the gradual increase in supervision of residents over the last 15 to 20 years. In yet another blog post, I pointed out that many of today’s residents rarely if ever operate independently during residency training. To realize you are on your own as a full-fledged surgeon without ever having performed a case by yourself must be frightening."

I've had a few glimpses of this myself - residents, even residents far along in their training, rarely get a chance to operate in a truly independent manner. It's all dependent on the attending surgeon of course, some are more comfortable letting residents take a larger role than others, but the overall proportion seems skewed against letting residents really gain independence. I've seen first-hand a PGY-5 start off leading a surgery, only to be bumped when the first, relatively minor complication arose. That's not a great way to get that PGY-5 to a point of competency when they graduate in a year (for the record, the PGY-5 was excellent from a surgical perspective relative to their peers, I really can't fault the resident here).

More junior residents had it even worse. For the most part they were assisting with the odd opportunity to do some small parts of the surgery, but opportunities were generally based on whoever else was in the room (fellows and senior residents getting priority), attending comfort, and other considerations beyond the resident's control such as timing. The skill level or educational requirements for the resident only rarely seemed to factor into things... they mostly just got left with whatever scraps of learning they were lucky enough to gather.

When it comes to a procedure - any procedure - the only way to gain competency is to do it, on your own, over and over. Sure, supervision is essential, especially in high-risk procedures, which includes pretty much any surgery, but supervision could be a lot more arms-length than it currently seems to be for surgical residents. More importantly, progression could be a lot more deliberate and standardized, rather than set by the whims of the attending on the day, whims that could hold a resident back from performing tasks they're fully able to complete - or tasks where trying to complete it is the next step in their education - while on the flip side, could push a resident to attempt a task they're not ready to try, yet they do because it may be their only chance at it in quite some time.

Back to the article - the author makes a suggestion that, while logical given the current constraints, hits at the profound dysfunction in a lot of medical education:

"All you can do as a surgical resident is to try to scrub on as many cases as possible and take care of as many patients as you can. With luck, you may have faculty who have enough confidence in themselves to allow you some autonomy and decision making in the OR and when managing patients pre-and postoperatively."

In short, work harder. Hope your superiors let you learn.

Time and time again, I see this pattern, and it's far from being unique to surgery - medical education providing ineffective or inefficient instruction, with the only proposed solution being sheer volume of exposure. Residents dutifully follow this approach, doing everything they can to gain competency, but their options are often limited - too many learners, not enough procedures to help with, many other responsibilities and only so much time in a day. Volumes can only go up so much.

At some point, those doing the instructing need to be held accountable for poor outcomes of their learners, but even they are typically victims of this dysfunctional model of medical education. They weren't often taught in an effective or efficient manner and, more importantly, few are ever taught how to teach. The system perpetuates itself, unfortunately.

Houses of Cards

Between Internal last block and Psychiatry this block, social factors have featured pretty prominently. It's been a good demonstration of the importance of having a support system and personal resources in maintaining health, as well as a fairly meaningful lesson on the limits of modern healthcare when these social factors are absent.

What struck me was how someone who seemed to be leading a reasonably complete life could have that life fall into complete disarray if just one critical support piece is taken away. That support might have been a job, a vehicle, a family member, a friend, any number of things - but once it was gone, health started to decline quickly. Many times it was a snowball effect, where losing one support would result in other supports falling away either directly (eg spouse dies and they used to be the driver in the family) or indirectly (eg person loses job, has episode of depression, loses interest in activities, loses supportive friends associated with those activities).

Listening to some patients' stories, I can't help but see us all as giant houses of cards, seemingly well-constructed when everything's going well and each piece is in place, but quickly collapsing into a big heap of nothingness when just one piece is pulled away.

Granted, I've seen many instances where a patient recovers quite well despite losing a major support in their lives, where the other supports they have simply fill in the gaps or new supports are marshaled to help. Still, take away one more support from some of these patients and it's a short path to being in a very difficult situation. It's important - critical, I would say - from an individual perspective to develop social supports and to have personal resources available. Yet, even well-supported patients can falter if their life sustains just the right combination of minor insults.

My reaction to this is to push for adequate institutional supports. When everything goes south, what should we have in place to pick people up? And to what degree should the healthcare system be involved with these institutional supports, particularly in Canada, where healthcare is one of our primary institutional support systems? We've got a pretty complex network of publicly and privately funded resources for patients or people in general when they need help. These resources do a lot of good. But they have their limitations too, and plenty of people fall through the cracks. Those cracks could use some filling in.

Education Levels and Medical Compliance

Came across a comment that patients with lower education levels were more significantly likely to make poor medical decisions. It's not the first time I've heard a statement along those lines, not by a long shot.

However, in my admittedly limited experience, I've found this to be completely, 100% false.

Sure, there are people with less education who make dumb medical decisions. Plenty are non-compliant with medical advice. But there are also a good number of people with LOTS of education who make dumb medical decisions or who are non-compliant with medical advice. This is especially true of healthcare workers. They say doctors make the worst patients, and so far as I can tell, this is absolutely true!

I'm speaking in generalities of course, as I've met many healthcare workers and physicians who took excellent care of themselves and made intelligent, carefully considered medical decisions. Still, in general, people of all education levels can make idiotic decisions when it comes to their health or their medical care, just as people making good medical decisions can have any level of education.

We pre-judge people a lot in medicine. It's part of our training, not without reason. However, this element is one when I try not to make too many assumptions. Education is a poor guide to medical decision-making, so far as I've seen.