Merry Christmas Message

In our little corner of the world, Christmas morning has arrived with a little snow on the ground and a definite nip in the air. We have had a wonderful year on Prince Edward Island, and with the arrival of our second Christmas, we have come to appreciate and enjoy the warmth of our small town even more. The island has allowed us to slow the speed of our lives, given us the chance to look around, and reminded us of the joys of daily living. It has given us the chance to learn who makes our food and buy from them directly. It has given the opportunity to see the needs of others and help. It has reminded us of the spirit of community and encouraged our inclusion. It has released us from the bonds of time by asking us to sit for an hour when we drop by for a visit. In short, our little corner of the world has helped us return to the values and ideals that we believe in our core. It is our sincere hope for each of you, that this opportunity to return, refresh and re-energize comes you way, and in so doing renews the joys of your life and living.
Merry Christmas to you all….…..Gil and Nancy

Do the right thing.......

There has been a profound change in my practice since I left Texas, hospice and palliative care have become a very significant portion of my practice. This change has left me with deep questions regarding the practice of medicine, and has left me considering the obligation to ‘Do the right thing’.

When the focus of your practice is to diagnose and treat with an eye toward recovery, the right thing is a bit more obvious. Your charge is to figure out what is ailing the patient and make it right as quickly as you can with the least amount of harm to the patient. It is a balancing act between beneficence and harm. Harm comes in many forms, cost (for unnecessary tests), radiation (CT scans), pain (invasive tests), misdiagnosis (finding the wrong thing, or finding something incidentally that leads you on a goose chase), and side effects (every treatment has a risk). You are always balancing this against the good you are working to accomplish, asking yourself if these things are really needed in order to help the patient heal.

How does this change when your role is to help someone have a ‘good death’? The purpose is no longer recovery, but to comfort, and that changes the equation. Comfort care seems very straight forward when presented as such. You provide care to the patient that brings them comfort, relieves their suffering, and makes them at ease. At first glance this does not appear to be that difficult, and in many cases it is not. The symptoms that the patients have are such that they can be managed without any direct risk to their well being and care is provided with a minimum of risk.

When pain is a significant symptom, then the situation changes, the risks increase and the chance of harm is ever present. Most patients fear the suffering associated with pain. Pain is a great teacher; it is there to keep us alive. Pain is there to make us release the hot object, struggle against the trap, fight against the darkness. Pain is an intrinsic element of humanity, it is the great equalizer. The treatment of pain is a first order priority in the care of the hospice patient. In the minds of many, the control of pain is essential to a ‘good death’. The unfortunate risk involved in the treatment of pain is the hastening of death. The medications that are used to treat pain, narcotics primarily, all have side effects that include depression of the respiratory system, that is, they slow your breathing, sometimes fatally. The inclusion of anti-anxiety medications often makes the respiratory problem worse, and unfortunately many people have a great deal of anxiety as they approach death.

How do you balance this equation, providing for the comfort and care, but avoiding the ultimate harm? It is easier when the patient looks you in the eye and tells you what to do “I do not want to suffer, and I do not care if the medicine makes me die sooner”. But what of the patient who asks you to “Do what you think is best”. What is best? How can you know? What is best for this patient? Do you work to relieve the suffering knowing you are shortening their life? If that time is but a few hours you might not worry, but what if it is a few days, a few weeks? What if the treatment you provide gives complications that increase the suffering of the family? How do you balance these equations?

Currently the province of Quebec is having a vigorous debate on euthanasia ( CBC, Forum, Government). This debate is also happening in Europe on a larger scale (BBC , Research Article) and in the United States as well (Grid on Legal Efforts by state, Annals of Internal Medicine ). I suspect this debate will continue throughout my lifetime as it has throughout the lives of others. However, my question for now remeains, when does the provision of care and relief of suffering cross that line, and how will I know if I am doing the right thing?

On not knowing everything………

We make decisions every day, most of them without any consequence at all. What are you having for lunch? Going for vacation? Getting your friend for Christmas? These decisions may take a lot of our time, but the outcomes do not usually make a large difference in our lives. What happens when the decision has greater implications? What happens when your decisions may impact the health and welfare of others? How comfortable are you with the unknown? When you clearly do not know something does it make you uncomfortable? Does it make a difference if this is public or private ignorance?

In medicine we often have a chance to review these thoughts as we go in to the ‘office’. As a family physician, often you are seeing the undifferentiated, the patient who has not been seen before for the problem at hand. These patients could have anything, and often do. This is the heart and soul of family medicine, and more than anything else, it is this aspect of the profession that I often find the most difficult in the long hours of the night.

When students ask me what they should do for a living, I often ask them how much tolerance they have for the ‘gray zone’ of family medicine. By the time that they have spent six weeks with me in the hospital and clinic, I usually have a good feeling for their tolerance of the uncertainty that caresses every action of your day. Those with minimal tolerance are encouraged to pursue specialties where, to quote one of my local dermatologists, you can ‘know more and more about less and less’. This whittling of the number of problems that you are responsible for allows you to focus in on a subset of problems and become expert in these diseases. You learn to recognize the intricate variability of a presentation of each of those diseases, learning the common and uncommon presentation of ‘your special illnesses’. When a patient arrives in your office with a consultation, your role it to determine if this patient represents one of these diseases or not, provide advice on the management of the disease if it is in your realm, and if the patient does not have anything in your specialty identify what they do not have and return them to the referring physician. As a family physician, these patients are often back into you office with a long list of what they do not have and you are back to square 1.2 where you restart your diagnostic processes again, the gray zone of uncertainty has returned.

Students who truly relish the gray zone, exhibit significant comfort in the zone, and are willing to work hard to develop tools to improve their work in this zone become the rural physicians of old. These folks work on ‘gut’ instincts at times taking a chance on a hunch when the data is not always there, but the feeling that you have is undeniable. This is a skill that some are born with, but most develop over time as a side effect of lessons learned. These lessons come through every patient that passes through our clinic, every specialist report that lands on the desk, every specialized test that you have ordered. What is important is how you supplement this instinct, and that is something that has changed over the last years.

In 1996 I worked in a small rural clinic at Dugway Proving Ground in the west desert of Utah. I had received the minimum training needed to not be outright dangerous to people, but I had hardly received what would be called sufficient training. In this location I performed the duties of a rural family physician, taking care of any and all that came through my doors. In my examination room I kept a copy of the Merck Manual so that I had the best compact source of information to assist me with the diagnosis and treatment of my patients. It served to help me fill in the large gaps in my knowledge base as I saw my patients, and I often took it off the shelf while the patient was sitting on the table. I knew what my limitations were, and had no difficulties letting the patients know that my fund of knowledge had definite limitations. This was one of the driving forces behind my desire to expand my knowledge base, complete my training, and my enthusiasm for on-line evidence based medicine.

In order to work well in a rural clinic and do so without waiting years to develop the fund of knowledge that comes from practice, you must have a series of tools at your disposal to help you shrink this zone of uncertainty. For my part, DynaMed, PubMed, and ePocrates serve as my peripheral brain. They help fill in the gaps in my knowledge base, remind me of things I once knew, and help me to become a better physician. Despite these tools, there are still times when you find yourself faced with patients for whom you simply run out of good ideas. These patients are the ones who haunt you as you sleep.

As a family physician, even the presence of these tools may leave you with a patient for whom you still do not have an answer. These are the patients that drive you to study more, to deepen you fund of knowledge. These are the patients that leave you with a feeling of inadequacy as you pull on your hair at night trying to figure out what may ultimately be unknowable. In a rural setting, this absence of knowing can eat at you as you see the patient routinely and feel you inadequacy tugging at your sense of self. What is left is often something very different than you might want something somber and reflective as you look back on the day a thoughtful player in this world.

The beautiful flame fractal on this page came from the following website

http://lojjic.net/gallery/1000words/20031208-flame-fractal.jpg

Fresh Pressed Cider and other Glories Fall

Dew has been coating every outdoor surface for the last few weeks, the folks in town have experienced a couple of light frosts, trees have exploded with vibrant color, and my usual attire has been modified to include my waxed cotton fedora and rain jacket. Fall has arrived on the island my friends, and with it comes the annual apple harvest, a true treasure of the season. Fortunately for us, there is a local orchard that is just down the road, and on my route to and from work.




Apples are something that I was not expecting to find all that different. After all, an apple is an apple right? Well, I must admit, that was prior to tasting apples fresh from the tree. The apple season starts around the end of September with the earliest apples being the Jona’s Red. These apples are exceptionally juicy. When they are fresh picked, they are crunchy and sweet. They soften over 3 days by which time the juice can be seen running down chins as people enjoy them. Just about the time you are really getting used to having them fresh daily, their season is over and the Cortlands and Honeycrisps have arrived followed quickly by the Spartans and MacIntosh. It is apple heaven, and the arrival of the MacIntosh heralds the arrival of fresh pressed cider.




Let’s talk about cider for a moment. If your image of cider is from a large glass jug in the store, then you are as mistaken as I was regarding the joys of fresh cider. The cider from our neighborhood orchard is pressed and slightly filtered but not pasteurized. It is a blend of the late season apples and has a crisp sweet-tart flavor that is extremely refreshing. Like the apples, it is here for a short while and then gone again. It is like the harvest season, it arrives with a bang and is out the door almost as quickly.




The fall also marks the harvest season for the crops you have nurtured along all summer. Our little garden has treated us well, and with a little luck I can extend the season through until the snow flies. We have had plenty of broccoli, bell peppers, lettuce, and jalapenos from the garden for the last 2 months. I planted things in succession so the crops have arrived in a staggered fashion preventing us from being overwhelmed by any single crop (jalapenos excepted). The tomatoes have had a bit of a rough time, primarily due to my late planting and a cool wet summer. We have gotten some from the vines, but for the most part they have remained green and firm, teasing us with their unrealized potential. The carrots have gotten long and firm, growing deep into the loose soil, and I was genuinely surprised by the number of potatoes that I was able to harvest from four small plants. The corn looked great, but we let it sit out one night to many and the raccoons came through and helped themselves to every stalk, lesson learned. Thankfully, the local vegetable stand (Webb’s vegetables) had plenty of corn for us and they did not get raided by varmints. Their stand has gone from offering lettuce and corn to late season tomatoes and pumpkins. It is a popular spot on the main highway and they are always busy with customers dropping by for weekly produce for as long as Webb’s can keep it coming.

Of course another glory of the fall is the exuberant display of color the trees put on when the days begin to shorten. My favorite color has to be the vibrant red and fluorescent orange of the sugar maples. These line the roadway on my drive to work so I find that I must focus exceptionally hard on my driving so as not to be distracted by the show. It we are lucky and the winds do not blow too hard too soon, the color will stay around for a month. Like everything else, it will pass quickly so you have to enjoy the moment while it is here. That is the lesson of the island for us for the last year, and we are making the most of the moment while it is here.

A lot happens in a year……

Despite the truth the calendar flaunts, the fact that a year has elapsed since our arrival in Canada is surreal. In fact, it was only when I was answering a question about how long I have been on the island that the realization of times passage hit home.

“One year, as of today”

Granted, a few days has passed since that statement brought me to a stop in my tracks, but the time has allowed for reflection of the year passed and with that reflection comes today’s post.

Nancy asked me what I had learned in the last year. The easy answer was the use of standardized units for lab values (different from the US system), as well as the odd names for all those drugs that I spent time learning, plus a whole bevy of new ones that are not approved in the United States. However, that answer would not really get to the truth of the last year and while placating some, would not be satisfying.


Universal health care is good for people. I have come to more firmly believe in this over the past year. It is not perfect by any stretch, and I am sure there are other places that do this better than Canada, but the Canadian model of care, providing some baseline level of care for everyone is better than the system I came from. The Canadians value the community, and therefore they value coverage for everyone, even if it means that you pay more to cover someone else. They accept this fact and feel that the end result is worth the price. The end result is that people can be seen and treated before things get very bad. Now, the downside is that not everyone has a Family Physician or NP looking after them because there are doctor and nurse shortages here as there are everywhere else. However, you can be seen without worrying that it will break the bank, and you know that if you get sick, the cost of your recovery will not leave you in poverty before you are ever well. Things do not move at the speed of light, but that also means that the doctor or NP has to think twice about ordering some expensive test with a waiting list. Not everyone who has a migraine headache gets an MRI to rule out a cancer.

Practicing medicine is fun. With the removal of the bountiful paperwork that seemed to reproduce on my desktop in Texas, I have re-discovered that I enjoy practicing medicine and taking care of patients and their families. It is the same joyous feeling I had when I practiced in Dugway Utah, that feeling of connecting with and helping out patients every day I went to work. I do not feel like an overpriced administrator, and I certainly do not feel that I am being given paperwork as a way to discourage ordering a test/study. I get to sit down and talk with my patients, listen to their stories, and take care of their needs. The fact that my panel is stable means that I am seeing the same people over time, therefore, once I get them caught up on their prevention, I have additional free time to chat about other important things like their kids and grandkids, the state of their farm, the lobster catch, and of course commodity prices. This provides a great deal of insight into the inner working of the island world, and with that comes a deeper understanding of the inherent worries of the lives of the islanders. This knowledge allows me to understand them in ways I was never able in my previous practice. It has brought the joy back to my practice and that is invaluable beyond measure.

Life outside of medicine is important. The change in pace over the last year has been the most surprising thing on this journey. When we arrived last year we did not understand how people could spend all their time ‘Up West’ and rarely venture to Summerside or Charlottetown. The idea that you had everything that you needed ‘Up West’ seemed ludicrous when we arrived, after all, how anyplace could ever have ‘everything you needed’. The interesting thing about needs and wants is that once you have taken away the drumbeat of advertising, slowed down enough that you notice the change of the seasons, the number of things that require travel to obtain reduces on its own like a neglected garden. It is the deceleration of time which allows you to look beyond the demands of tomorrow to see the glories of today. As time slows, you can see the world, listen to the wind, and connect with the earth in a way that cannot be rushed. This modifies you sense of need, and provides a deep sense of fulfillment in your routine life that no longer has room for the unnecessary. You begin to live each day with joy and purpose, that is, you begin to look at your day differently. You ask yourself if the things you are doing are really worth spending one of your precious days upon the task, or if the time would not be better spent on something more important. These changes percolate into the way you work so that you begin to ask the same questions of the tedium that intrudes upon you day. Your realization of what is and is not important allows you to put medicine into a place in your life, no longer the shadow over your life.

The year has taught us many things, has slowed us down enough to look beyond the ordinary to see it for what it truly is, wondrous beyond the imagination. So much in such a short time, makes you wonder what we will discover next!

County Fair

Summer would be incomplete without a county fair, and so far we had not had a chance to take in one of the local fairs. It seems that every time we wanted to go to a far something else got in the way. Well today we made up for lost opportunity and took in a day at the Prince County Exposition. This exposition has been an annual event since 1926, and it is exactly what you would expect from a county fair. Yesterday was the judging of all the home economic contests. The baking, sewing, knitting, cooking, gardening, farming competitions had all taken place, so we had the chance to wander through the various halls looking at all the goods. Now I know that some of you are probably chuckling a bit at the idea of strolling through the exhibition of crops, but I tell you, if you have horses, finding out who won the hay contest is very important. It is also nice that you have the chance of taking a close look at the hay, and it was definitely a cut above. Since the contestants name and address were on the entry slip identifying the hay, we wrote it all down and will be calling soon to place an order.

Today, the focus of the fair was on the livestock competition, so we got to take in the farm animal judging as well as the horse show. It was cute to see all the 4-H kids competing. The afternoon held the delight of another horse pull, always a very good time, and then the evening had the best of all, a live concert by a local group, ‘The Grass Mountain Hobos’.

The Grass Mountain Hobos are all local lads who have been playing together for over 10 years, and their work has paid off in the form of an East Coast Music Association Bluegrass Album of the Year. They play bluegrass music in a way that makes even those with an allergy to such music have a good time. In watching them play I am reminded of my favorite bands Brave Combo, in that these guys are exceptional musicians, and enjoy their craft as much as the audience does. I recommend them unapologetically as a must listen album. So take a moment and head over the their website and listen to a little joy from Prince Edward Island .

The Festival of Lights

The rain delayed the festival one week from the original date, but the promise of a good time, glorious weather and fireworks made the delay worthwhile. One of the summer activities on Prince Edward Island is the local festival. Every town seems to have a festival that celebrates the distinctive quality of that region. For Tignish, it is the Irish Moss and for O’Leary, the Potato Blossom and so on.

Northport has the Aquatic Days with the Festival of Lights, and it celebrates the fisherman. The festival includes the blessing of the fleet, lobster boat races, the fisherman skills contest, and then the Festival of Lights. The Festival of Lights is a competition wherein each fisherman decorates his boat with lights and after dusk, all of the boats line up and parade past the wharf. The boats are judged and a winner is selected. Afterward, the firework display from the end of the wharf concludes the evening. Nancy and I had been invited to help David decorate his boat then head out with him for the competition.

Every year, David comes up with a theme, and the theme for the boat this year was the Canada Games. We gathered to prepare the boat for the big event. It began with the lights, over everything. The team taped lights along the gunwale, the cabin, and then the assorted ‘games’ items. We brought a basketball hoop and decorated it with lights, a kayak secured to the side of the boat, and a bike that was secured to the top of the cabin. Everything had lights and was wired back to a generator in the rear of the boat. In the center, a podium was created on which the athletes stood. The Christmas lights looked good, but the problem was going to be the people and mobile props (basketball, tennis balls, paddles, and medals). For these items, and the athletes themselves, we affixed numerous glow-sticks to make things stand out.

It was a big effort, but it paid off in the end as ‘Pass me Knot’ took first prize in the parade of lights. It was interesting for Nancy and me as we sat watching the fireworks. It gave us pause to reflect on just how different this July was from the one a year earlier. It reminds us of the adventures had, and yet to come. For more photos of the festival and preparation, head over to the Flickr site (click on one of the pictures to the right).

Just a horse Crazy Couple

The Danny Ellsworth Memorial Horse Pull

Most people are crazy about something; it is just a matter of figuring out the thing that you seem nuts about. In my case, it is horses, anything about horses. With this in mind Nancy and I found us sitting in the rain watching draft horses pull huge amounts of weight. It was not a planned event, mind you, but rather one of those serendipitous things you run across in life if you are looking.

It started innocently enough with a drive to Tignish to see if the Co-Op store was open so we could look for a desk for Nancy. Well, it was Sunday, and since Tignish is predominantly Catholic, the stores in town were all closed up tight. As we drove through town, we noticed that there were hand-lettered signs indicating a horse pull was taking place in town. We followed the signs and wound our way back past the park, and onto someone’s farm where we found the event. It was the first annual Danny Ellsworth Memorial Horse Pull. It seems Mr. Ellsworth was mad about horse pulls and so after his death, the Island Horse Pullers Association decided to have an event in his honor.

Now, for those of you that have never been to a horse pull (as we ourselves had not been prior to today), it is a fairly simple process. The goal is to pull a specific weight for a distance of 72 inches (6 feet). You have two attempts at each weight, and during each attempt you can pull once (i.e. the horses can pull forward once, but once they step back, the pull is complete). To mark the distance to be pulled, a six foot chain is fixed to the back of the sled with a pin that holds down a spring loaded flag on one end and a stake on the other. The judge drives the stack into the ground, and once the sled has moved past the length of the chain, the pin comes out and the flag pops up indicating the completion of the pull. The teamster who is driving the horses has to keep them straight so that they do not get disqualified for leaving the track, and the hitcher has to make sure that the metal hitch gets properly placed on the sled at the start of the pull.

It all sounds easy enough, but as we sat there watching, it became apparent that it was not as easy as it appeared. The horses are all very excited about getting to pull, and as the driver is trying to position them near the sled so the hitcher can attach them to the sled, these horses are getting more and more worked up. Some of the teamsters were able to calm their horses and allow things to proceed with ease and grace, others seemed like one step short of total chaos. Once attached, the driver sounded off and the horses start to pull for all they are worth. Mind you, some of these horses were pulling two to three times their combined weight. It was impressive!

Even more impressive was the fact that each of these horses was turned out neatly, well cared for, and excited about the job at hand. The drivers seemed to have the best interest of the horses at heart as several bowed out of competition if their horses had seemed to struggle with a particular weight class. As we arrived, the weight being pulled was 5200 pounds (20 cement blocks at 200 pounds each on a sled that weighed 1200 pounds), and the winning horse from the mid-weight class pulled 8000 pounds 68.5 inches and the team of horses weighed in at 3190 pounds.

We watched, enthralled, for a full two hours until the event was complete. It was magnificent to see these horses at work, and for a couple of horse crazy people, it was a little slice of heaven. To see all of the photos, click on the scrolling photos to the right.

Spring Lobster Season

The lobster industry on PEI is big, in fact some would say it is THE industry of Prince Edward Island. The industry itself usually lands $10 million worth of lobster, and there are various industries attached to the management of that lobster until its arrival in your home in its various forms. However, it all starts with a fisherman and his traps working in one of two seasons on the island, spring for the northern side of the island and fall for the southern side.

David Lewis has been a lobster fisher for as long as I have been a physician. He purchased his “gear”, that is his license to commercially fish lobster, in 1995 at the close of the spring season. He has been fishing lobster ever since as an independent fisherman. David is also my neighbor and it is in his old family homestead that Nancy and I make our current home. After a couple of false starts, I finally had the chance to go out lobster fishing with David and his crew (yesterday), and it was a blast. I wanted to go out fishing because I take care of lobster fishers. I see and treat them for a variety of illnesses and injuries but I have done so for the last year not really knowing what they did in their job. I have found over the years as a physician, that if I know the kind of labor done in a particular job, then I am better able to treat the individual patients, and I am better able to help them with their chronic diseases. David gave me the chance to find out what a lobsterman does on the water.

A day spent fishing
The day begins at 4 am as I clamber into the truck to head to the port with David and his son Derek (who is spending his first year post High School fishing lobster). After the obligatory stop for a coffee at the Alberton Bakery we are off to the wharf. Once there we meet the rest of the crew, Chad who has been working with David for the last 8 years, and Shawn, a High School student who works on Saturdays during the season.

Everyone jumps onto the boat and immediately begins working without any instruction. Lunches are stowed; mooring lines are cast as the engine fires up. It is less than five minutes from arrival to departure from the harbor and into the waters surrounding the northern point of the island. As we leave the harbor, David begins educating the novice on all the tools of navigation for his fishing boat, and the crew set up the deck to receive lobsters and reload the traps with cut bait.

Navigation on the fishing boat takes two forms, the innate knowledge of the captain and the combination radar-global positioning satellite system. It is the latter that he begins to explain in detail. The global positioning function allows him to plot several important details for our travels. First he has a plot for the return to port. This is important since if the weather is foul or foggy, he can return to port without worry that he will run aground or become lost. The maroon plot line that curves a graceful arc across the screen also happens to describe our travel out of the port. The second function that is available to him from this system is that each of his traps is plotted as an individual waypoint on the system. He can travel directly to the trap even in the densest fog as his system allows him to adjust the screen so that it displays a circle that is 15 meters around the boat. Additional functionality of the system are that it also has a map overlay function so that those of us who are land oriented can find out where we are in relation to our landmarks from shore. Finally the radar function allows him to see the other vessels in the area, again to protect him in the fog.

It is ten minutes when we arrive at our first trap-line for the day. In all we will visit 60 such lines, moving those that did not produce as expected. It is roughly 4:25 am when the first trap comes out of the water. As the boat slides up to the buoy Derek leans out and hooks and drags it on board. The line is quickly fed over the pulley and into running winch which quickly hauls the first trap to the side of the boat. David grabs the trap and as he dead lifts it with his right hand, the left follows the lead line that attaches the trap to the trap-line. He deftly pops this over and off the pulley as Chad grabs the trap from him and begins to off-load the lobster within. As Chad finishes with the lobster, the trap passes to Derek and Shawn who remove the old bait and load it with fresh bait fish. All the while, David is keeping the boat as still as possible to avoid entangling the trap-line in the propeller. In short order all the traps are in place, and the second buoy is on board. At this point Chad has turned his hand to the second duty, measuring and counting the lobster from this trap-line. He calls out the number of each type, market or canner, and David records this in his journal. He is looking for something on the order of 3 and 13 as a minimum for the trap line, and if it is underperforming he will move it to a new location. Once the market lobsters are separated from the canners, their claws are banded to keep them from attacking each other. If the trap-line has performed well, then David will replace it in the same location. The first buoy is back into the water as Shawn and Derek watch the line play out, keeping watch for snags that will entangle the traps. As the line plays out each trap is dropped off the boat and into the water until the last one is in then out goes the second buoy.

This assembly line of activity proceeds for roughly half the traps that are near the Northport area, and then it is a 20 minute ride to the next location for his traps. This is further south starting in the region of Lenox Island down to Summerside. During the break, the crew gets a pot of water boiling and an entire 24 count package of hot dogs goes into the pot for a snack as they head to the next section of traps. Everyone is pretty happy as the younger members of the crew eat far more dogs than David. For myself, I eat one, but since the ocean is a bit rough, and I am a novice, I figure it is more prudent to have some water and let food wait for calmer seas.

Once the traps have been fished, David steers for port. As he does so, the crew begins to clean the boat of all the debris of the day. The decks are scrubbed and washed, the cabin is wiped down, and all the loose gear is stowed away and generally picked up. By the time we arrive back in harbor, it does not look like they have been working at all, except for the cases of lobster. Once in harbor, we await our turn to off-load our catch and take on more ice and more bait. The total weight for the day was 851 pounds of lobster. David is happy, although like any fisherman, he

would have liked a bit more catch, but this is a good day. As he backs the boat into the slip and the mooring lines are re-attached, the crew gets the lobster together for the orders that they have received while out fishing. As with all lobster fishers, David gets a few personal orders for lobster while he is out fishing, and he is more than happy to put some back for you. If you ask nicely, he will even boil them for you in salt water and cool them down in fresh ocean water. It is what he did for ours, and let me tell you, there is nothing better than lobster prepared this way.

As I arrived back home, I realized that my sense of still being on the boat was with me whenever I would move or turn suddenly. An interesting sensation……..

Spring Arrives on Prince Edward Island

Today marks as clearly as anything the arrival of spring on Prince Edward Island, it is the beginning of the spring lobster season. The photo you see comes from Dolly Silk at French River as the boats are leaving the harbor (taken from Island Morning website of CBC ). We have been watching our neighbors working hard getting their traps ready for the season. The traps are a combination of wood and net and are far heavier than they appear, and once they are water logged and full of lobster, it becomes apparent why most lobster fishers have broad chests and strong arms.

Today is trap setting day and it gets started just as the daylight starts to peak over the water. The fishermen all head out at the same time and head to their preferred areas to set their traps. They are allowed to set 275 traps per license and tomorrow they will pull up their first lobster. The weather today could not be better, it is a bit cool, but the wind is mild and the sun is out. It is altogether a better day than yesterday, when the wind was whipping the waters around the island in what would have been a very rough day at sea.

The signs of spring have been arriving daily for the last two weeks. It began with the arrival of the small song birds at our feeder. They have been here for roughly 18 days and seemed occupied with the seed during the last storm we had two weeks ago. It was just after that storm when the second sign of spring arrived in the form of a pair of robins where were pulling worms from the frozen ground (much to my amazement). The snow from the last storm literally vanished with the arrival of warm rain followed by the glorious sun, and that is when things really seemed to get busy.

The melting of the last snow saw the resurgence of the islanders in the outside world. It was as if they had all gone into hibernation and as the sun returned, they burst onto the scene with a sense of energy and frenzy. They are all over the place, all engaged in outdoor activities- raking yards, clearing flowerbeds, repairing lobster traps, fishing oysters, walking the roads, hanging out in yards. The arrival of spring marks an increase in activity that is fascinating. It is hard not to get involved in the same activity, and as such, I began to clear the flowerbeds (more on this in the future).

So, as the fishermen head out today, let me wish you all a very pleasant and happy spring from the Gentle Island of Prince Edward and I will try to post as many photos of spring as I can over the coming weeks.

Healthcare difference part II……….Rationing in the US

Anticipating the differences between the US and Canada, I focused on the rationing of healthcare. When most folks I know talk about the difference between the delivery of health care in the two nations, rationing and quality are two differences that stand tall among the potential pitfalls of a nationalized system. Rationing occurs in both systems, the prime difference is the transparency with which it occurs in each system.

Rationing in the United States
Many people are surprised to learn that rationing of healthcare resources does in fact take place within the United States, and the absence of transparency is why most American do not recognize the rationing. The rationing of healthcare in the US occurs in two forms- insured and uninsured.

Uninsured
If you are unfortunate and lack health care insurance in the United States, then by definition you ration the health care that you receive from the system. You ration your healthcare because you have no choice, it is simply too expensive to be sick, and even more expensive to purchase insurance. So like most folks when money is short, you do without things that seem to be luxuries. This means that you do not enter the healthcare complex until you have no choice, and enter the system when your health has deteriorated to such an extent that you must enter the system because you are simply too ill to do otherwise. This illness may be something seemingly innocuous such as a bad case of the flu, or something more complicated. In the end, it means a trip to the emergency room/urgent care/walk in clinic for the help. Often the choice of where to enter the system is dictated by the available cash on hand, with those who have the fewest resources shunting to the emergency department for their care. Unfortunately this means that they are entering the system at the most expensive point.

This makes little sense economically but it is one of the only ways people can be guaranteed that they will be seen and treated, and it is the Emergency Medical and Active Labor Act that makes this possible. This obliges the emergency department to make sure that the patient does not have any life threatening illnesses and that they are medically stable before sending them home. This does not mean that everyone has to be treated, but in a practical sense, everyone is. The line between diagnosis and stabilization to treatment is very small, so it makes little sense not to just finish the work. This is in part why so many people arrive for prolonged waits in the emergency departments across the US. Patients who have more discretionary spending often go to the Urgent Care or Walk In clinics to be seen for their minor ailments. These clinics are far more efficient than the Emergency Departments, but payment is expected at the time of service. In both cases, the treating provider has no obligation to care for the patient beyond their encounter, that is, they have no obligation to look after the long term chronic health care needs of the patients they treat. In essence they are rationing the care they deliver; they do not deliver the long term care.
If you need hospitalization and you lack health insurance, then this prospect is a nightmare. The EMTALA obligates the hospital to admit you to the hospital, stabilize you condition, and then look toward discharge. Hospital costs are such that even an overnight stay in the hospital may cost you over $1500 which for a family of four with two working parents earning $50,000 a year will find difficult. Additionally most folks without insurance work in jobs where there is little if any paid sick time, so there is the burden of lost income for the period of time you are hospitalized as well as any time spent recovering after you leave the hospital. In fact recent studies (prior to the economic slump) indicate that health care expenses contribute to bankruptcy in 50% of the cases and when looking at housing problems (failure to pay rent or mortgage payment), 25% are due to healthcare expenses.

The Insured
If you are one of those fortunate enough to have insurance, you are still subjected to health care rationing, but unlike the uninsured, it is often a more complex form of rationing that takes place. It is not called rationing in the usual sense; it is couched in terms such as “covered services”, “preferred provider”, “pre-existing condition”, and “denied claims”. Here is how it plays out from the perspective of a physician inside a very organized integrated health care network.

When a patient presented to be seen in the clinic everything went very well as long as I did not ask the system do more than it was prepared to accomplish. In other words, if I saw the patient, diagnosed the condition, and treated it then there was no particular problem. However, if I wanted to involve other providers, provide more than one type of service on the same day, or provide care that was outside of the usual scope the rationing began. As an example, if I a patient can to me with a mole on their skin that was concerning and I determined that the mole should come off, then proceeded to remove this mole during the same visit, it was often not paid. What this meant to the patient was inconvenience, in that I would diagnose them and have them come back on another day for the procedure that should have taken place at the same time as the initial visit. If I wanted more specific testing it often required additional paperwork to be completed in order to justify the service. Often this would involve a phone call to someone who would approve the service. These same steps were required when medications outside of the formulary were required, or when a referral to a specialist was indicated. These additional steps increased the time line for a patient to obtain the services, and each step provided an opportunity for the insurance company to decline the coverage. Often after a claim had been submitted, additional paperwork would come through that would essentially be asking if the condition being covered might have been a pre-existing condition. If you are unfortunate enough to be found to have received services for a pre-existing condition, then the claims will be denied and you will be stuck with the bill for any services that can be related to that condition, after the fact.

An additional component to the rationing of health care for the insured patient is the conditions and services covered as well as the amount of coverage for these conditions. The fact that you have insurance is not a guarantee that you will receive treatment. If you need treatment for a condition that is not covered by your plan then you are out of luck. Likewise, the type of treatment that you may be eligible to receive will depend on the terms of you plan. These terms may change without your notice, and you may be left holding the bag. Finally, if the cost of your care exceeds the threshold of the plan, then you insurance runs out and ceases to pay for any additional costs. This is in fact rationing. If you have insurance and you do not need much then you get what you want without any real trouble. If you have significant needs, then it is likely that the insurance company will ration your access until you run out of coverage or they find a link to a pre-existing condition that allows them to decline payment for the claims. If you are uninsured you really only get acute treatment and nothing more, at great cost.

In the case of the US, the rationing that occurs is done in a manner that is not transparent and is without any recourse. You cannot vote out the people who have rationed your healthcare, you cannot sue the insurance company that has decline your care, and the majority of people cannot afford to get sick. In a system where healthcare is nationalized transparency is a key element to the rationing of care…..more to come.

Comparison Shopping for your Health Care System Part 1

In the end you are still taking care of the patient

Since I have been in practice in Canada for six months I thought it might be time to reflect on the similarities and the difference s between the US and Canadian system of health care. As a reminder, I am a Family Physician. This means that I take care of whomever walks through my office door to the best of my abilities regardless of age, sex, or ability to pay. I see everything, and refer to specialists when I am out of my comfort zone, or have run out of good ideas. So a good place to begin our review would be in the typical clinic day.

The View From Texas

When I practiced in Killeen for Scott and White my day started in clinic around 8:30. I would see a patient basically every 15 minutes until 12pm, break for lunch, and start at 1pm and continue until 3:45pm. This resulted in seeing about 26 patients a day give or take (depending on how many physicals I had that day).

I usually arrived earlier in the morning to try and answer all the patient messages, look over lab results, complete forms, and answer e-mail prior to the first patient of the day. I dictated my charts as I went and that usually took 2-3 minutes per patient so I spent roughly 10-12 minutes of each visit with the patients. During that time you would try to complete all the work that needed to be done for this patient. The presence of the electronic medical record allowed me to review all the visits since the last time I had seen them as well as all the specialty visits. It also let me look and see if they were up to date on their labs, preventative care, and such. Some days the computers worked well and this did not take much time, other days they were slow and it became difficult. In general, my patients were older with my average patient being late 60s early 70s with the occasional child thrown in for variety. If a patient needed a procedure done often it happened during their visits, or was quickly scheduled for my dedicated procedure day.

The days felt very busy and I usually returned home feeling fairly worn down. I usually left the clinic in Killeen after 4:30 or 5 pm and then headed to the house. As part of my practice in Texas I did the occasional delivery usually in the wee hours of the night, and one week of every six was spent working in the hospital taking care of the hospital service. On the whole, the patients that I took care of in clinic and in the hospital were older sicker folks.

The View From Prince Edward Island

My practice in Canada is usually starts around 7 am with hospital rounds at the Alberton hospital where I see my one or two patients, then I drive to O’Leary for hospital rounds on my one or two patients. I arrive at the clinic between 8:30 and 9 am to begin my clinic day. I see a patient every 15 minutes from 9 am through 11:45 and then from 1 pm until 3:45 pm give or take I see between 23 and 25 patients a day depending on the number of work-in patients.

During the visit you work on many of the same issues as I did in Texas, catching up on preventative health care, reviewing labs and such to monitor chronic illnesses, and cajoling patients into changing their lifestyles. Since the notes are handwritten, there is no time spent dictating the chart (and thus no time spent signing off on dictation). Since it is a paper chart, there is a bit of work to keep the flow-sheet organized so that you do not have to dig through the chart each time you want to review preventative care. Because of the manner in which the clinic is arranged, it is difficult to perform procedures in the clinic, so I often send those to myself when I am going to be working the urgent care clinic. You still have the usual lab to sign off on, as well as the consults to review and such, but the paperwork that seemed to be such a large part of my practice in Killeen is not here. I do not have any pre-approval insurance forms to complete, and I cannot think of the last time that I had to complete a Pharmacy Assistant form for anyone. The patients do not seem as ill either. I have some terribly sick patients (i.e. the renal failure alcoholics with diabetes) but they are not as big a part of my practice as they were in Texas. The pharmacy does not fax forms to me for refills, they either refill the medications for one month and have the patient make an appointment to be seen, or they call me directly during the day and I give them the go ahead. This relieves all the pharmacy paperwork that I had from Texas and it was a huge chunk of my paperwork.

There are some distinct differences in the prevalence of certain medical conditions, specifically thyroid disorder, crohn’s disease, celiac disease, and cancer, but I think that these represent the effect of a small isolated population (after all there was no direct connection to the mainland until 20 years ago). I usually complete all my work by 4:30 or 5 pm and head home. I am no longer delivering babies so I do not have those night-time calls. There are two duties that I did not have in Texas that are part of my practice, the Urgent Care Clinic and the Emergency Room. On average I have one call in each location weekly. Usually they are back to back where I work the UCC one day and the ER the next. The hours for the UCC are from 8 am to 8 pm and the volume is variable. The ER is a 24 hour shift, and volume is steady but manageable. As influenza has arrived in our part of the island, the UCC and ER have become very busy places. Despite the addition of daily hospital work and the shifts in the ER and UCC I do not feel as tired as I did when I was in Texas.

Quelle est la différence?
The question in my mind is why am I less fatigued than when I was in Texas. I have been giving this a great deal of thought over the last weeks and I have come to a couple of conclusions.

First, the ever present push in Texas to see more folks all the time felt like a weight on you back. The addition of 3 patients a day meant an additional 15 people a week really seemed to increase the work load (especially when you translate that into the additional dictations, labs, and pharmacy faxes).. Where I feel like I have the time to talk to folks here, I never really felt that previously.

Second, the patients have a different level of expectation in Canada. In the US I always had the feeling that patients wanted everything done all the time whether they needed it or not. I felt like I was always counseling patients about why they did not need antibiotics, an MRI, or a CT scan. The sense of entitlement that I felt form the patients in the US was always present as was a continuing concern that someone was going to file suit for the care that you provided. I am not saying these are rational feelings, but they reflect the feelings of the day when I was practicing. As well, my conversations with my colleagues during lunch confirmed that others felt the same way. The patients here do not demand that everything be done, and if you are sending them for extra tests, they do not fret if these tests take a couple of weeks to get accomplished. With the malpractice laws in Canada, the frequency of litigation is low, and patients do not seem to view it as a lottery like chance for a big win.

Finally, paperwork here is not nearly as onerous as it was back in the Texas. I know it goes against what I initially expected from a government run system, but the amount of paperwork that flows through the clinic is not nearly as copious. This burden was one I did not really appreciate until it went away, and I do not miss it one bit.

Well that is the first view of the similarities and differences. I will post more on this subject over the course of February and try to continue to fill in the gaps so you get a good feel for what is working and not working in both systems. Stay tuned.