Frustrated, incorporated

How’s that for a 90s shout-out to Soul Asylum? In all seriousness, it’s a fairly accurate description of a recent ER shift I recently worked. All the examples listed below are true stories. They are frustrating. They are perfect examples of people not claiming ownership of their own well-being. This is a reminder that we are all still responsible for our own individual health care.

The night started by seeing a sweet older lady that spends 6 months of the year in the warmer climates of the American south. She has good health insurance coverage for the half year she’s abroad. Last week she was walking with the assistance of her Zimmer frame (colloquially known as a “walker”), but a few days ago, she had more difficulty and pain and couldn’t get around as well. This prompted her to visit her local American hospital. In true American fashion, they ordered every test under the sun except for a prostate test. Specific to her situation, they had performed x-rays and even did a computerized tomography (CT, or “cat” scan). So when asked what the American doctors discovered, her answer was she didn’t know. She hadn’t paid attention because she had decided to return to Canada. Her son picked her up from the airport and drove her straight to the Emergency Department in her Canadian hometown. Fortunately we were able to get a diagnosis with not having to do as many tests, but the entire visit could have perhaps been avoided all together since she received a full work-up south of the border.

A few patients later, I met a pleasant lady who had called an ambulance because she was having a bad headache and saw that her blood pressure was very high. After speaking with her, I learned that a few months ago she decided on her own to stop taking her blood pressure medication, against the advice of her family doctor. In fact, she had called an ambulance and came to our same Emergency Department 4 days prior for the exact same complaint! According to the notes of her treating physician for that first presentation, they spent a good deal of time making sure it was in fact just high blood pressure not being treated. There was quite a thorough work-up. He prescribed her one of the blood pressure medications she was no longer taking and recommended she have a follow-up appointment in 2 weeks to gauge how her blood pressure to the re-introduction of the medication. As the story unfolded, she actually didn’t start taking the medication again until the evening that she came back to the Emergency Department. Coincidentally (or not), as we kept an eye on her vital signs, her blood pressure began to come down to a safer level without us having given her anything at all – she had already started the treatment by finally taking the medication she was supposed to have been taking all along! The visit could have been avoided all together had she resumed the medication as recommended to her when she was seen 4 days ago, or better yet, if she had not stopped taking her medications to begin with.

The final example in this edition of the Doctors’ Rant goes along the same theme. A middle-aged gentleman came to our Emergency Department complaining of belly pain. Not an overly unusual presentation except for the part where this same middle-aged gentleman was in our same Emergency Department earlier in the day, and was diagnosed with pancreatitis. This involves swelling of the pancreas, an organ in the abdomen that secretes enzymes, such as insulin. The treatment for pancreatitis calls for pain control and bowel rest. Once upon a time it was common to treat people suffering from pancreatitis by fasting, thus allowing the inflammation to settle. Nowadays the evidence agrees more with soft light diets rather than fasting. Our middle-aged gentleman opted to have a meal of cheezies, a bologna sandwich, 2 ice cream sandwiches and cookies. Unfortunately, most experts would not classify this as a light or soft diet. This resulted in our middle-aged gentleman having a recurring flare of his abdominal pain prompting him to return to the Emergency Department. This visit could have also been avoided had he adhered to the instructions from the first treating physician.

As you have my surmised, the theme of today’s rant is about Emergency Department visits that could have been avoided had individuals took ownership of their health care, and followed the recommendations given to them at their original visit. I’m not attesting that all advice given by every doctor is absolutely spot-on every time, but when basic instructions are suggested and they are ignored, only to cause further discomfort, the individual should be at least part liable. It’s just a travesty that resources, money and time are wasted on repeat offenders who did not bother listening to the advice to help them take care of themselves.

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What’s the cost of peace of mind?

Everything has a cost, including every aspect of the health care system, even if you don’t directly “pay” for it such as in our system. Some things have a dollar figure, some things are priceless. But what is the cost of having peace of mind? Is there a value that can be placed on such a request?

Very often, patients come in requesting specific testing just to “find out” if they have a particular condition or diagnosis. This puts me in a difficult position: I have a duty to my patients, but I have an authority and responsibility to society, ie: the system. On one hand, I do want to ease any discomfort presented in front of me, and that includes mental anguish. However, on the other hand, sometimes these requests are frivolous and are not a necessary expenditure to the system. And if we are in a situation where we’re trying to reduce costs in order to prevent privatization, we have to start drawing the line somewhere.

There are 3 requests in particular that I often get asked, and they are presented below, in no particular order.

Can I get tested for Celiac disease

With the rise in gluten-free awareness and more product availability, there has been a substantial increase in the number of individuals (and families) exploring a gluten-free diet. New studies are coming out showing the benefits of such a dietary change, though it’s still controversial as to whether the gluten-free component is the winner, or if it’s the reduced number of carbohydrates that’s indirectly making people feel better. Nevertheless, many patients who have previously had a diagnosis of irritable bowel syndrome (IBS) or gastrointestinal symptoms, have started their own gluten-free diets and have reported improvement of their symptoms. That is when they then come in to request testing for Celiac disease.

My answer is always the same, especially when there is no family history of Celiac. “How will the result change how you eat?” Even if they get the test, and it comes back negative (meaning no evidence of Celiac disease), all who have broached this subject unanimously tell me that they’ll continue to stay on a gluten-free diet. To which I reply, why bother doing the test if you are going to continue the treatment anyway? Some people “just want to know”. Others agree with this logic, and then retract the request. In Ontario, this has been more successful, since the test for Celiac, a tissue transglutaminase (TTG) assay is an out-of-pocket expense, meaning the Ontario Health Insurance Plan (OHIP) does not pay for it. Once people are fronted with the bill to get a test, the number of second thoughts has a drastic increase.

I want to get tested for allergies

This is probably the most popular request I get. Once upon a time, when allergy testing first became available, its purpose was to find the unknown cause for someone’s first anaphylactic reaction when the culprit could not be identified. If someone was stung by a bee and their face swelled up, we had a fairly reasonable idea that this person was allergic to bees. But if someone at a restaurant ate something and had a major swollen tongue, and we could not accurately figure out what it was in the meal that caused the reaction, that’s when an allergy test was prime.

Not many people had these attacks from an unknown cause. At least not enough to make a living out of it. So allergy doctors opened up their specialty to essentially anyone, in order to make more money. Now people could go and have a panel of potential allergens put on their skin, and have a prick test performed to see if there was a reaction, which would denote an allergy. The problem is, pretty much everyone will have some sort of atopic (allergic) reaction to specific things such as pollens, moulds, and dusts.

Add that with our commercial industry pumping out so many hypoallergenic and anti-bacterial products, our bodies just aren’t building the same immunity nowadays that they did generations ago. Seasonal allergies appear to be on the rise, as do food allergies. This might be a societal change, or, it might be we’re testing for it more. Whenever someone sneezes now, it appears they want to be tested. I am now seeing people who have had a rough go during the spring and summer months, and are requesting testing for allergies. They have tried over the counter anti-histamines. They have tried nasal sprays. They just can’t bare the outdoors during these times. So I ask them: “How will the results change your day to day living?” This question is often returned with a blank stare. The only sure cure for allergies is to avoid the allergen. That would mean living in a bubble, or staying indoors with the windows sealed; obviously, this is not a practical option.

Since people are already doing symptomatic treatment, or avoiding a particular food that they feel is causing them ill, just like the Celiac example, there is no relevant need to perform a test when the treatment is already being executed. Still, people “just want to know.” Unfortunately, this also expands to their children. Same thing applies in that they are preventing their son or daughter from being exposed to whatever they think is causing them symptoms, yet they still want their child to be tested. Please trust me when I say that this test is not the most pleasant for anyone under the age of 6. It’s probably not that pleasant for anyone under the age of 12. Despite these warnings, parents are still insistent, even though they have already begun doing what they would be told if the test came back positive, and will continue to do the same even if the test is negative.

I need antibiotics

This example is a bit of a tangent, but along the same lines of having peace of mind. Viruses account for the vast majority of colds, especially this time of the year. In the past, the medical culture had been just to give antibiotics. Over time, with or without the help of these antibiotics, people got better. People became accustomed to receiving antibiotics when they had a cold. As time has gone by, we have noticed a sharp rise in the number of bacteria that are resistant to the usual antibiotics we would prescribe. These are the so-called “super bugs”. We now realize that over-prescribing of antibiotics has lead to this widespread resistance.

Nevertheless, people still present to clinics and Emergency Departments with cold symptoms, requesting, and expecting to receive antibiotics. I would estimate that over 85% of the time, if not higher, they have a viral illness, meaning antibiotics would give them nothing except the risk of diarrhea (which is a common side effect of many antibiotics).

Despite my attempts to educate them, and never mind the fact that I was the one that trained to wear the white coat, they insist that I am wrong, and they need antibiotics, because that’s how it used to happen and they would get better. I’ll admit, doctors are not 100% correct 100% of the time. I especially do not preach to be the gospel on all things medicine. But we are trained not only through schooling and textbooks, but also through experience, and as the days, weeks and years collect under our belt, the on the job training enlightens us even further. I have become more and more aware of what is a viral versus bacterial infection, even when the hallmarks of a particular bacterial infection aren’t flashing in front of me. Call it gestalt, but doctors often possess it. Confirmation comes later once a swab or culture sample has been tested by the Microbiology lab; but that is an after-the-fact piece of knowledge that helps us for future presentations and diagnoses.

Yet people still want antibiotics just to “ease their mind” that they’re getting something. This practice cannot and should not continue, or else we further risk increasing the amount of antibiotic-resistance, which will come back to haunt us when we start losing the battle against those pesky microorganisms, and set us back 70 years.

That is not to say that new infections can come in on someone already fighting something else. If the body’s immune system is being occupied by fighting a virus, a bacterial infection could easily venture its way in and take advantage of the temporary freedom. So if your symptoms change or worsen, that could indicate just that, and medical attention should be sought. But also remember that viral illness, such as flu-like colds, can often linger for up to 2 to 4 weeks unfortunately.

Every medicine has a side effect. Every treatment has a side effect. Sometimes it is that very side effect that we want when we offer the treatment (ie: Viagra). But don’t forget that some of the effects of a treatment may not always be immediately evident, and may not always directly affect just the individual. Antibiotic-resistance and frivolous spending on unnecessary tests are prime examples of effects that venture beyond instant detection. So next time you go to your doctor with the sole intention of your visit to request a specific test, first ask yourself: how will the result of the test change your management? If your answer is “it won’t”, take the time to have a second look at if you truly do need that test at all. Sometimes your doctor will agree, but sometimes they won’t. Now you know why.

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Age of Entitlement

Flu season is upon us, and everyone is rushing – or avoiding – to get their flu shot. It also means it’s one of the fun times of the year when more people tend to come down with illness. Don’t worry, this is not a push to have everyone vaccinated against the flu. (Though if you’re pregnant, over 65, or have a chronic illness, you should!)

My rant today involves general demands and expectations from people and their families towards health care providers.

The case example is about a pleasant elderly woman that is in generally good health, and normally only comes in for routine checks every few months. One day she became ill, with a cold. Her daughter called to make an appointment, but was informed that the physician did not have clinic hours that morning, and was offered an appointment that afternoon. The offer was declined, but a request (read, demand) was made to have a pre-booked appointment the following morning. The clinic in question worked on the advanced-access system, so the daughter was asked to call back the next morning, and was advised a time of when to call early, in order to ensure the time she desired. She did not call at that time. She actually called nearly an hour after that time, and requested a specific time for an appointment that morning. By then, other patients had already scheduled a consultation and the daughter’s preferred time slot had already been filled. She was offered a later slot that same morning, but she declined, citing she “didn’t have time” to take her mother in, and proceeded to yell and berate the poor receptionist.

Obviously, there is more detail to the story, and surely from the other end as well, but the point is made. Once again, health care appears to have a “drive-thru” expectation. While this isn’t the Emergency Department setting, prudence still needs to be applied; why couldn’t, or didn’t, the daughter take her mother to the after hours clinic? Or if she was truly concerned that her mother’s illness was the emergency she believed it to be, why wasn’t a visit made to the ER? The daughter denied her mother care because it wasn’t convenient for her, and berated the health care provider’s office and staff for not being flexible enough. While the frustration is understandable – people tend to express fear as anger, even towards others, this is an obvious double standard: if you’re that concerned about someone’s health, it should have been dealt with sooner, not just when it was convenient. In true health concerns, missing work, or a vacation, or a pre-scheduled event, would never be questioned.

Now that the long-winded story is out of the way, that brings up the point of expectations from the public. Transcending clinics/offices, and Emergency Departments, even specialist’s offices no doubt, there is an overwhelming haze of entitlement from patients believing that they’re the only patient that matters, and society as a whole is less important than what’s happening to me, right now. A parallel example of this is what’s developed from the vaccine-refuser following, but we went over that last time.

Don’t get me wrong, it’s great that many individuals have such interest in their own health. It’s what we hope for many others to have, such as those that leave things until they’re on death’s door before finally going to a doctor, only to find out that it’s too late to do anything about it. I’m talking about the people that get angry, when a doctor rushes out to an emergency, or fits in a sick young child ahead of you. Back in the day, especially in the smaller communities, these “interruptions” were simply inconveniences, but accepted, and you were just thankful that it wasn’t you that was in that sickly of a state. Not so much anymore. We see this often in the ER waiting rooms, when people often forget that the triage system in place is not first-come-first-served, but rather the sicker patients are seen before those who are less sick. Or not sick.

I think the binding point is this: when you’re with the doctor, you ARE the most important patient that’s in front of the doctor. But when the doctor is not in front of you, remind yourself that there are other patients being seen. The doctor is not out golfing, or staring at themselves in the mirror thinking how much of a god they are. (We’ll save that discussion for another time).

Our country is only as great as the people within it, and our society is risking losing the qualities that got us to where we currently are. The world is a smaller and faster place nowadays, but that is not an excuse to forget human decency. Maybe that’s too harsh. We rely on others whether we care to admit it or not. Patients rely on their doctor. Doctors are nothing without patients. However, we are destined to devolve if we return to a me-only mentality, not just in healthcare, but in all aspects of society.

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No debate, just vaccinate

Our small community had a recent “mini outbreak” of mumps. Yes, mumps. Mumps should be one of those historical viruses by now that have been nearly wiped off the earth, coupled with smallpox and polio. But they’re not. In fact, their numbers are not diminishing but actually rising in some places. Why, oh why…

Rather than write a generic post about the virtues of vaccinations, I am simply going to reference some great articles and blogs that currently exist. There are all excellent and worthwhile reads. Vaccines are not a government project to control the population. They are not an invention by Big Pharma just to become rich. Vaccines save lives. Vaccines prevent infections. Vaccines decrease morbidity. Vaccines improve quality of life. VACCINES DO NOT CAUSE AUTISM. Vaccines increase life expectancy. Vaccines are not perfect, but are certainly one of the greatest advances in medical science.

The graph below is an excellent example of how the MMR vaccine does NOT cause autism. It simply shows how correlations work. All the facts on the graph are true. Though they have nothing scientifically linking them together, when we place them on the graph, they look convincing, don’t they?!

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A great explanation of the value of vaccines is written here on Violent Metaphors.

Here’s another great example, though less scientific, but gives the perspective from from the lay person.

Why would I post something like this? Because we still see people infected with diseases that could and should have been prevented. Vaccination programs are cheap, and their rewards from a health expenditure savings is immense. Yet people still choose to not protect themselves, and by doing so, prevent protection from those that don’t have the luxury of such a choice.

There are many good valid posts. But I shall leave it at that. Please think hard before declining to vaccine yourself or your children. It’s not something that just affects you.

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Kick the habit

We live in a free society and I wouldn’t want it any other way. We as individuals have the right to smoke and the right to enjoy a drink. Interestingly, if cigarettes and alcohol were introduced on the market today, it’s highly unlikely they would pass FDA approval.

Tobacco and ethanol have been a long-standing part of our and many societies. It’s no wonder that many people enjoy each, and have become addicted to each, be it proper addiction or habitual addiction.

But what is the public opinion on those receiving a government cheque, and use it to fulfill their need for each? More than a few of welfare and disability recipients smoke and/or drink. And while people are free to make their own choices, it can get frustrating when many of these people continue to make these choices in the face of their medical issues. Their earnings are meager, and the decision of spending their money on cigarettes or alcohol versus medications often arises. Unfortunately, it’s the medications that usually lose out.

One case stands out, involving a woman in her 50s who came to the Emergency Department for chest pains and ended up having a serious heart attack in the department. We resuscitated her for over 2 hours before stabilizing her enough to have Interventional Cardiology step in. The end result was positive; she spent a few days in the Cardiac Intensive Care Unit in a hypothermic coma, and eventually recovered and was discharged. When she was next seen, after her very near brush with death (though in theory she had been dead a few times until she was revived), she was still puffing away at her cigarettes as if nothing had happened. Her main complaint? She was upset that her chest hurt (from the hours of compressions keeping her alive).

When someone takes up a habit like smoking or drinking, they may or may not have started with the full understanding of the health risks involved. But I find it hard to believe that they would remain oblivious to such risks over time. Thus, once a life-threatening event occurs, it would be a great wake-up call to kick the habit. But this doesn’t always happen. And smoking, for example, continues. Most likely, they will wind up back in the ER again.

Healthcare dollars are now being spent to treat someone who made the choice not to treat them self. If someone comes in, such as in the example given, and are successfully resuscitated, they are given a second chance. But what if they don’t take the opportunity to make a healthy choice for their better? Should the public be liable to keep funding their continued medical problems when an obvious risk-reducing solution was ignored?

Doctors take an oath to do no harm and pledge a life to help humanity. But doesn’t humanity have a responsibility for their own individual health? Our system is struggling to stay afloat, and healthcare dollars are becoming scarce. We need not continue to spend money over and over again on issues that should be avoided with smart decisions.

This opens the next debate: should those individuals receiving government aid be required to attend programs aimed at kicking their habits? Should their dole be reduced by the amount used to purchase cigarettes or alcohol? But by doing so would most likely worsen the situation, as many would still choose to smoke over buying other necessities.

I unfortunately do not have the answer. And I’m not necessarily in support of the government imposing restrictions to freedoms. But I feel too many people are taking advantage of a healthcare system that they themselves are not contributing to, and if they want to help do their part, it starts with making that smart decision to kick the habit, ideally now, or at the minimum, following a scare. Take advantage of that second chance. There’s no guarantee of a third.

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Physiotherapy needs to be covered by provincial plans!

I really wish I had the balls to write this as an open letter to the Ministry of Health, or to all provincial Ministries of Health. I even wish we had the funding to make a long-term research project to prove this. Sigh.

One of the best allied health services available is physiotherapy. Unfortunately, it is not covered in many provinces, and those that do offer a publicly-funded physiotherapy programme, see huge waiting lists of months to years.

If we think about it from a cost-effective point of view, it should be a no-brainer to offer this as a widely-available and publicly-funded service.

Let’s use a very generic and common injury-related issue:

My back hurts

Person X goes to see their doctor because they have a sore back. They’re given a prescription for anti-inflammatories and maybe some muscle relaxants.  Maybe they’re even offered a referral to a physiotherapist! Unfortunately, like many people out there, they don’t have health insurance for non-provincially insured services. This means they can’t afford the $40-100 per session rates to see a physiotherapist. This is very understandable, but a shame. This is where a publicly-funded service can fill the void. And it’s not as if there are not any professionals available; there are many many out-of-work physiotherapists, who often leave their province/country to seek employment elsewhere.

Back to our example. Mr/Ms Sore Back now can’t work. They may no longer be able to afford their prescriptions either. Work is being missed. Now since they’re not taking their pills or engaging in any active rehabilitation, they’re still in pain and not improving. They apply to go on Provincial Disability. How much is that costing the system now? What is the cost of a few readily accessible physiotherapy sessions versus putting someone on disability, so now medications are now on the provincial tab. These medications often evolve from simple anti-inflammatories to opioid analgesics. We’ve also lost a productive member of the workforce. All because there is no accessible physiotherapy offered.

How many visits to the Emergency Department or Family Doctor’s office can be avoided by individuals being able to properly rehabilitate themselves back to pain-free productive members of society? Too much health care money is spent on pain killers and useless diagnostic imaging tests for issues that could be effectively remedied if early active rehabilitation was available and accessible.

How many broken hips or joint replacements could be prevented if physiotherapy was available at the early onset of balance or arthritic symptoms? We wait too long for joint replacement surgeries and health authorities can barely afford to run Orthopaedic programmes.

I certainly believe in the value, usefulness and effectiveness of our physiotherapists. I just wish the Ministry of Health did too.

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ER: the “E” stands for Emergency

Maybe the most famous of all medical departments, helped of course by the many fiction and reality TV shows, the beloved and hated Emergency Department. Let me say it again, Emergency Department.

Unfortunately for the majority of users, it has turned into more of a Convenience Department. Drive-through medicine.

I couldn’t see my family doctor because I don’t get off work until late

Fair enough, people work, and you need to work in order to make a living. But if your reason to come in to the Emergency Department was not urgent or debilitating enough to prevent you from going to work, maybe you should take a moment and reflect if it is truly an emergency still. In other words, you’ve waited through an entire work shift, perhaps this can still wait to see your family doctor or a walk-in clinic?

I need my prescriptions refilled

Sometimes in exceptional circumstances, I agree, this may be an emergency. Though 99 out of 100 times it usually isn’t. When it comes to health care responsibility, you are responsible at the top of the list. This means you need to realized when your pills are running low, or if you don’t have any more repeats. Your family doctor, or the original prescriber of your medications knows best why you’re on a particular treatment. Some medications require periodic follow-up to ensure they’re a) working, b) giving you more benefit than adverse effect, and c) still required. Seeing someone new may be more convenient, but sometimes safety may be compromised.

I need my pain pills

I suppose this does feel like an emergency, and sometimes it is, however, please refer to the above explanation. Safety may sometimes be at risk. Furthermore, most Emergency Departments or walk-in clinics won’t prescribe or refill opioid medications (ie: narcotics). Why? They shouldn’t. When properly being prescribed an opioid medication, such as codeine, oxycodone, morphine, hydromorphone, and fentanyl, there should only be one prescriber. These are controlled substances that the government monitors to prevent abuse and misuse. Multiple prescribers can sometimes red flag the user as well as the prescriber. Even going to multiple pharmacies to fill controlled substances can raise red flags. If the pain medication is for legitimate reasons, don’t risk being cut off from a necessary source of pain relief by drug-seeking.

But I don’t have a family doctor

Then get one. Sometimes easier said than done, but there are many resources out there to assist in finding one. For instance, provinces often have means to match people to doctors accepting patients, such as Health Care Connect in Ontario. Get yourself on a waiting list. Remember, you’re still responsible for your health!

I don’t need a family doctor, I never get sick

Obviously you’re right, and you being in the Emergency Department clearly supports that. Just because you have a family doctor doesn’t mean you need to see them every month or even every year (though it would be recommended). The point is that you have one to go to in the event you have a non-emergent issue, such as a cold, cough, sore knee, or feel depressed. Unless of course you feel you might harm yourself or someone else – that is a true emergency.

I’ve had this issue for (weeks, months)

Once again, hearing a story like this is a clear contradiction to the term Emergency. If your shoulder has been sore for 3 weeks, why did you pick today to come in? I often hear replies that border the Convenience Department analogy. Your family doctor is a very capable professional able to perform many diagnostic investigations. If something is not right, and you’re feeling off, and it’s not going away for days, or weeks, or months,it would be wise to see the health care professional most familiar with you first. And as previously mentioned; if the issue is something that hasn’t disabled you or greatly altered you today, or yesterday, or the last few weeks/months, it probably isn’t an emergency.

Why does it take so long to be seen?

Because too many people come to the Emergency Department for non-emergencies. Which reminds me of a great posting I once saw: when you’re in the waiting room, bored, and impatient, waiting to be seen, be thankful you’re not the person that’s just been rushed in, ahead of you.

Bottom line is the Emergency Department, in an ideal setting, is for emergencies. Your family doctor, their after hours clinic, or a community walk-in clinic is more than capable of handling non-emergent issues. And if by chance you happened to go to one and your situation is found to be an emergency, they’re excellent at making contact with an Emergency Department to expedite your work-up and treatment.

On a different note, and one that we should all be aware about, is health economics. Our taxes are high to support our social health care system. Health care costs a lot of money that we don’t have. If you go to the Emergency Department for a cough, or something that’s been lingering for weeks or months, you’re costing the health care system over 1000% more (yes, there are 3 zeros) than having gone to your family doctor or a walk-in clinic. Makes you question why we can’t offer many services on the health care dollar, eh?

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Opening Rant

Let’s give blogging a try, but first, a quick introduction to share the basics; I am a Canadian physician, I have worked in 30% of Canadian provinces and focus in primary care. I love what I do. The more I delve into my profession, the more I am becoming frustrated; we can do better. Our system can do better. We as a profession can do better. We as a population (ie: the patients) can do better. Perhaps this blog will just be a medium to vent steam. But maybe, just maybe, some ideas can develop into more, and change could inspire improvement into our oft-examined social health care system.

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