Saturday, March 31, 2012

Willard Gaylin and Bioethics

While bioethics has been a topic of discussion from ancient times it was only in the 60's and 70's that it developed as the discipline it is today. It's beginning point in modern times was considered to be a question by a Pope about the ability of anesthetists to prolong life. Some have indeed argued that bioethics has arisen out of the fear of technology which was predated by the fear of science itself.
Willard Gaylin is a psychiatrist who with Daniel Callahan created the Hastings Centre in 1969. The Hastings Centre was dedicated to bioethics and the interest of the patient and bioethics and public policy.  Willard Gaylin obtained his BA from Harvard, his MD from Case Western Reserve University and became a psychoanalyst. He was a clinical professor of psychiatry at Columbia Medical School, Professor of Psychiatry and Law at Columbia Law School and an Adjunct Professor at Union Theological Seminary.
He is quoted in the movie Gattaca, the best movie to date on the discussion of the place of applied genetics in society.  "I not only think that we will tamper with Mother Nature, I think she wants us to."
He has written some 20 books. 2003 he wrote Perversion of Autonomy, Coercion and Constraints in a Liberal Society. He also wrote "How Psychotherapy Really Works".

Medical Professionalism Charter 2002

Lancet and the Archives of Internal Medicine in 2002 published the Medical Professionalism Charter 2002 renewing committment to patient care as primary, committment to patient autonomy and a committment to social justice.  Harold Sox, Annals of Internal Medicine, Feb 5, 2002.
I studied community medicine and public health and served in the areas of greatest need. I wrote a paper on Social Responsibility for the Canadian Journal of Psychiatry. I served in the north where doctors simply would not go and in asylums where psychiatrists couldn't be recruited. I worked pro bono for years in many areas and with the dangerously insane and the infected and questionable.  I got on well with doctors who had done missionary service. My colleagues who were most successful and most lauded in awards and promotion were highly particular about concern for the richest of patients.  Indeed, the doctor to the king, has always gone a lot further than the doctor to the poor. I've been an outsider stigmatized with the same stigma that my patients experienced.
Now I see that 'social justice' is part of the 'new world of order' in the 'profession'.  Irks me, considering how much heat I have taken personally for championing lost causes and fighting for the disenfranchised and going where doctors wouldn't go.  I was told by one of the head doctors in the Canadian Medical Protective Association that I was the most persecuted doctor they knew while at the same time I was told by a former head of the Canadian Medical Association that I was possibly the only  psychiatrist with integrity in the province.
I muddle along.  I love medicine and the practice of medicine.  I daily though seem to be fighting government for services for my patients, patients who as ignorantly as I assume those services are available to them as part of the social contract and the taxes we pay.  There have been no elective hospital beds and no nurses and demands for everything political but health care.  I feel like a cop who goes from fighting crime to guarding parking meters.
The charter makes a committment to patients, a committment to honesty with patients, committment to patient confidentiality, committment to appropriate relationships, with patients, committment to improving quality of care, committment to improving access to care, committment to just distribution of finite resources, committment to scientific knowledge, committment to maintaining trust by managing conflict of interest, committment to professional responsibilities.
It has been my experience the authorities pay lip service to the 'committment to honesty with patients."  It's a crock. My own experience and the experiences of my patients testify to the hierarchal dishonesty in the system. Twice I have had doctors lie in their care for me to cover up their errors and save their asses. It's a routine failing in the system.  I have witnessed it routinely.  It's as if there were two ledgers in the health care system, one for the patient to read, and one for the authorities. The same system applies in the baurocracy with secrecy and close doors and clandestine discussions.  Until there is a 'culture of honesty' there will only be the appearances in this regard. The reason I am following the Julian Assange case and Wikileaks is that it speaks to our very own governments real position on honesty to those who are served.  There is too much power in secret societies to expect this to go away with flowery words.
Committment to just distribution of finite resources - I can be committed to anything but in the end the rich and powerful get the kidneys or whatever. No one I know is standing in their way and all of the beaurocratic authorities have been there to assist in this.  Committment to scientific knowledge seems to be mostly whatever scientific knowledge is fashionable.
I am hopeful regarding conflict of interest.  I was forever getting into trouble objecting to the conflicts of interests in patient care. People were doing all manner of dirties locally and I was getting into all manner of trouble bringing it to the attention of the authorities. It was al most like 'no publicity is bad publicity'. Caught red handed the perpetrators of heinous wrongs went right on doing them at increased profit.
Now I don't see this so much.  Partly because I've taken to looking the other way like most of my colleagues always did.  Partly because pharmacists are calling themselves 'professionals' and people are expecting them to act in a less cavalierly tyrranical manner than they have to date so the heats off the doctors and moved to the pharmacists and perhaps others in the system rich on conflict of interest.
Committment to professional responsibilities is a vague thing. The more I 've been committed to my profession the more I've been criticized.  As a specialist and subspecialist I've devoted another 6 or more years of loss of income and study to being trained at best for my patients while my colleagues who didn't do further training remained with position authority and gained more money and power. Today it's common to see the highest ranking professional being ordered about by the lowest common denominator in the health care system. The patient and the doctor are least welcome too often.
I think the charter is a good thing. I wonder about the language. It seems a lot of work and yet it doesn't appear to add much to the code of ethics for physicians . I am not sure I agree with words like 'justice' being used in medicine given such short thrift the word got in legal circles. Blind judges are one thing but blind surgeons are another.
Since 2002 things don't seem to have got much better in the patient care area despite this fine manifesto and I fear mostly there are fewer and fewer hands to do the work while more and more people seem to be getting paid vast sums to talk about the problems of the patients.
That said the charter overall seems fine unless it is used as too many such papers have been used, to beat doctors and deny patients. The devil is in the details.

Cafe Pacifica and Italian Opera

What a lovely evening. Laura was beautiful.  The venue was superb. The view of Coal Harbour at dusk was spectacular.  We came in with young men and women singing opera to a solo pianist. The buffet was the best, reminding me of the buffet dining I fondly remember from the Marianas Islands.  My dad loved buffet and he would have loved this, not just the soldier fish or steak medallions but the pasta and sauce made individually before your eyes. I loved the music and the food and the company.
I haven't died either. The person beside me died, some 25 years ago,  of botulism mushrooms,  when we were in the restaurant situated here before this.  Despite change of management and staff and everything about the place,  I haven't been back since. I was called IMG 0886 the morning after because I'd ordered the mushrooms like the person next to me,  only to change my order to escargot at the last second. They died, I lived. And though any restaurant could have a horror story like that, personally I never returned till tonight. . Obviously this is a different restaurant and different time. It took awhile for me to over come my superstition.  Maybe the opera dispelled the demons.The opera was magnificent. Now I'd bring anyone here to celebrate Vancouver.IMG 0887IMG 0888

Bioethics and Responsibility as a meta virtue

I've just read this paper, Responsibility as a meta-virtue; truth-telling, deliberation and wisdom in medical professional" by Y M Barilan, Journal of Medical Ethics, 2009 35:153 to 158.  I fear criticising it because it's so obviously the work of an academic and my experience is that academics are the most barbaric infighting politically correct personally ambitious and intolerant of criticism.  It would be 'wise' therefore to praise and celebrate this 'big boy' whereas it would be 'truth-ful' to critical of his writing.  Indeed he is sufficiently learned that he might even take comfort in the idea that anyone has taken the time to read him.  Academics group in like minded cults in contrast to clinicians who face the 'maddening crowds".
His paper is unnecessarily byzantine with jargon.  He uses language in an exclusive way like a dictionary salesman might.  Yet he has true nuggets in the rubble that are well worth the read.  Despite a deliberate read I wasn't quite sure what his 'agenda' was by the end of the paper.  His topic was 'Responsibility as a meta-virtue" and frankly I enjoyed his discussion of the aspects of Responsibility and the history of responsibility. He became circumstantial and tangential after that.  It's like there were three papers crushed into one as if a salesman wanting to get customers put a fish and a lollypop and a single french fry in a jar in hope of selling the fish.  Odd.  The ribbon he put around the jar was "the new discourse on Professionalism and Responsibility'.
He begins by talking about the Medical Professionalism charter 2002.  I don't know this.  It's a 'multi group effort from both sides of the Atlantic.  I became suspect there. He likes 'multi group' activity. He likes stuff thats on both sides of the Atlantic. What about the genius of a single mind and that which is on both sides of the Pacific.  I am never alone in a committee but as a physiican or a patient I am alone or at most with one other.  I'm not the sort therefore that likes ghettos or regiments.  Out in the wilderness my encounters are lonely affairs.  Academics are safe in bed at night when the real work of medicine is happening in split seconds. When they are themselves ill they might not even be present to consult the doctor who decides to keep them alive because that's the truth he has when they are in a coma.  Of course if he has a 'living will' fantastic! But without a living will he's often making decisions for both himself and the patient at the time of greatest loneliness.  Later a committee will decide his decisions with all the genius and arrogance of committtees. And academics will talk of committees in committes and be safe till that day they face truth.  It was a practice of the 19th century to record the dying words of great men. I would love to know the dying words of academics, perhaps especially bioethecists.
The charter contains a list of 'responsibilities' referred to as 'committments' to replace the words 'duties", "obligations' and "oaths'.  I'm a dinosaur and fear rises up inside me reading this because I know that the first victim of Nazism and Communism was 'language'.  Barilan celebrates most 'flexibility' and loves 'liberalism' so I think he's is one of those academics but I don't know.
He captures my heart when he goes on to focus his discussion on 'truth telling and responsibility' .  The next section is an entertaining look at the history of the word 'responsibility' and it's use philosophically.  He records the various meanings of the word. I have a love of the great Oxford dictionary that gives the multiple meanings of a word with the origins.  The word simply means 'accountability' but I'm not sure how this relates to professionalism.  His discourse is about the relation between doctor and individual patient yet it doesn't get to the crux which is the changing nature of the relationshiip in context. I've already said that when I am alone with a patient in coma with no previous history I am 'alone' in my decision making accountable to myself and my ethics.  When I am with a compis mentis patient discussing plastic surgery I am at the mercy of the vanity of the patient and the relationship is no different from that of a hair dresser.
There's a wandering romp through history which I don't exactly buy as it is so ethnocentric and assuming of all manner of historical presumptions that I feel like a hypnosis patient being asked all along to accept a thousand ideas about history and relationships before we get into the gist of whatever he's trying to say.  I know enough history to see his 'selection bias' through this part of his paper and to know that "the divine right' of kings was no different than 'survival of the fittest' of Darwin.  I'm king and you're not is all the bully needs to know and philosophers who live in the real world ape the big kahuna.  There's a different take on reality than that of Alexander Hamilton as I prefer the idea of Abraham Lincohn anyway . He said the 'price of greatest is responsibility'.
It irks me when he says words like 'evolving' technologies. Being on the Pacific Ocean versus the Atlantic Ocean I am not so limitted by the idea of 'evolution' either divine or Darwinian.  Yet I am asked to accept this and accept such expressions as 'pacification of the west'.  What has this got to do with 'responsibility, I ask reading this entangled and unpacked jargonesque hodge podge of convoluted reasoning.
Somewhere in this I find pearls like definitions of Jas Jonas 'formal responsiblity' and 'substantive responsibility'
Then there's a leap to summarization, more I think for the writer who has lost his way than the reader who must be another philosophy academic to have lastded this far.
1)Responsibility to fulfil promises
2)Responsiblility for our actions
3) Responsibility to committ ourselves to contribute to the redress of injustice
Whoa!  Stop the train.  That shopping list is simply Responsibility is 1 and 2 and we all agree with that and then suddenly this political radicalism assuming injustice and angry still at daddy leaps in literally out of nowhere.  I'm sorry I am a responsible person but I may disagree with you as to what you consider injustice and that's a whole other discussion a bit like the weird history lesson you ascribe to as normative.
Then there's this division into self -centred responsibility and 'other centred moral language and I'm lost.  "Self centred" comes with a shopping list and I can't help but think my teachers in philosophy and religion, some of who are experts on the examples in the shopping list would look askance at having Thomas and Aristotle included in one group or the other.  "Self centered ethics and other centered ethics do not necessarily contradict each other;yet they embody differences in language and attitude , such as the difference between charitably helping or eradicating slavery." He says Weber calls this the "ethics of responsibility'.
Then he quotes Barth and Kierkegard as holding the 'self as essentially reflective'  I was frankly surprised to see my dear friends Kierkegaard and Karl Barth mixed into this pirates cast .  Bit like adding garlic and onion to a bland vegetarian soup.  Better for the taste at least.
Then he jumps around to an interesting notion of 'Three Kinds of Moral Problems and the Examples of truth telling.
Stern and Papadikis lay out three examples of 'professional attitude'.
1) student tempted to cheat on his exam
2) a medical clerk who is tempted to copy the residents notes
3) a doctor who contemplates deception in order to make an insurance provider pay for a mammography.
Kant he says (and I do love Kant) "psychological strength to resist the non moral inclinations as the essence of virtue.' He makes an aside here that essentially says the world hasn't changed much.
He sees the first two as easy but disagrees with lumping the third into this.  He argues there's a moral argument on the side of deception. As a clinician I don't think he gets the idea that a 'mammography' isn't 'treatment' and that the three examples are indeed all of a kind. Instead of a mammography a doctor can do daily breast exams and have relative benefit. he can hold a fund raising for the price of the mammography. There's a lot of choice. I know because I've been faced with this. Further my female colleague felt that mammography was abuse of women and thought women should be offered herbal compresses instead so it's far more complex .
But he's an academic and academics love to appeal to the ladies and mammography was a 'brand' until it was shown that mammography was causing unwarranted surgery and possibly in and of itself dangerous.  Oops.
Now out of the middle of this somewhat convoluted again discussion we leap back to
The Various Meanings of Responsibility in Medical Care.
(I just came from a trial lawyers conference where the judge waxed poetic about the irrelevance of so much information to the case in hand - I feel like her at this point - I thought we were discussing responsibily in Medical Care. Isn't this a medical ethics paper.)
It is to be recognised that doctors reading this paper might be better putting their attention to finding a cure for cancer or reading the latest copy of Nature or Science.  I'm not sure I'm going to feel good at the end of this paper. It's become like one of those cop television shows where you watch it and the ending comes and you realize it was completely unbelievable and filled with spoilers and everyone knew the butler did it and didn't Hitchcock do this already).
1) Responsibility as committment to excellence, holistic state of the art efforts - see I get the committment to excellence but don't get how this is a what 'responsibility' is necessarily but even if I accept this and 'state of the art' the word 'holistic' has a very chequered past in the medical community. "Holistic" health care providers were advocating eating cat poop for the treatment of diabetes and other such nonsense for years before 'evidence based' practices shut down their charlatanry.  At the same time other 'holistic' pratictioners were doing some good things. But it's this word put in this list that raises my hackles. I wrote papers defending holistic medicine at one time till I saw the unruly behaviour of some holistic practieoners and stood at the graveside of their 'clients' and 'customers'.  It's big business 'holistic' is and as 'packed' a terms as 'organic' to doctors who intrinsically have to know the 'truth' and want to avoid 'weazel' words and want to know what exactly you are saying.  Because we deal in dosage. A nanosecond off and a death occurs. It's a 'precise science' this art of medicine and this waffling wandering convoluted mishmash of terms is at times frightening.
Then we hear "the deliberative method unofficially adopted by bioethics is coherence oriented - reflective equillibrium." Whoa.  "unofficial' 'adopted' 'equilibrium'. The emperor has no clothes. Why not buy this spicy set of jargon.  Worse I suspect this person would want me to listen to their explanation of this and I'd be again amonst 'born agains' asking each other if they were 'baptised in the blood of the lamb' and who was born again enough to be a Christian  or whatever hair splitting cherry picking "I 'm in, you're out" argument they could get into. Where are Arendt and Buber when you need them.
So excuse me I'm not buying that 'the chief instrument of responsibility is deliberation.' "broad inclusiveness of participants and an ambience of mutual respect and freedom of expression combined with richness of argumentation have been shown to be conducive to successful deliberation."  What are you smoking? Are we all going to sing kum ba ya right here and then do a break dance.  What gives.
I am responsible when I cut this tumor and I don't cut the artery beside it.  The patient is responsible when he lives or dies.  Get real.  This is where the rubber meets the road in medicine.
Caring Responsibility is another heading
Here I am impressed because there's a clearer consideration of what he says are 'first order' virtues and 'second order' virtues. My clinical practice is a deluge of instant by instant choices made under the fire of illness and time and the pressure of a hundred judges all watching.  Surgery used to occur in theaters with dozens of on lookers.  Judges today resist cameras in their courts. Will ethicists one day be put in reality television studios and asked to make a decision which if right results in patient living and if wrong results in patient dying.  I don't think so. Critics are a dime a dozen but very few want to take the position of the doctor or patient.  It's a lonely lonely business.
Of course in those great instutions called universities and private rich practices where money is no concern and everyone has foresight, it's marvellous to sit down and put the feet up on the desk and have a good round table discussion. I love it if I'm paid for it as much as I'm paid when I have a knife in my hand. I love it when there is no other demands. It's probably why retired doctors and old people like myself love ethics. Bit like old soldiers winning the wars they lost first time round.  Great place to gather and avoid a golf game.
"the substantive good of the patient takes precendence over the minor good of the doctor."  I held my bladder and bowels to save lives and didn't sleep for days to keep babies alive.  Missed eating more often than not so now eat more than I should.  I am told I was a 'workaholic' and that 'I was 'sick' to sacrifice myself and my health for my patients. My patients lived mind you.  There was a tremendous amount of 'neglect' going on at the time. I remember I was the only doctor who would go to the north despite a recruitment campaign for 2 years. I saw thousands of Indians and Inuit and got TB and went through the ice and nearly drowned and walked wet across the tundra, sometime there was a plane crash. Not that long ago I saw a murderer , last week Ithink, threatening on crack and angry because his partner died.  I don't know what the sickness is that my street people bring. So many have new untreatable viruses and bacteria. Some of my family and friends won't visit me where I work. It's too dangerous for healthy people.  Few doctors come there. I remember when I worked in the provincial asylum I only saw the administrator leave the 'administration' bunker and come on the wards , once.  Let's face it good people don't like the sick. There's all the stigma too.
I like that he sees that 'free market providers strive to persuade consumers to accept less and pay more.'
Then he goes on to say Doctors Responsibility is a 'meta virtue'.  I don't know why it's suddenly 'meta' when it's still in doubt that it's a 'virtue'.  Its certainly not a 'virtue' of beurocracy or academia where if the shit hits the fan everyone is in cover your ass mode instantly and passing the buck is the norm.  Doctors always are there with the patient or the patient is alone with a loved one closest.
Good discussion of virtue though .A "virtue is chosen and cultivated habit of action and of perceiving the world and reacting to it emotionally'.
He argues weakly , because he seems to know that 'flexibility' is a popular buzz word, that 'flexibility will allow doctors to regard the occasional deviation from the norms and virtues as a virtue in its own right and not as an onslaught on their core identity and communal values."
"If this sounds like a call to anarchy" he says, then goes on to say essentially anarchy is okay in moderation but take two pills and call me in the morning.
Funny business.
Lets please everyone and make everyone happy and include everyone and slither and slide to avoid being caught holding to any position.
Yet everyday I have a prescription pad and the medication I prescribe is deadly and I ask 'prescribe or don't prescribe'.  The herbalists and holistic doctors and masseuses and ethicists don't deal with life or death moment by moment. Every prescription I write carries the potential to do harm or help. Every few weeks I encounter an allergy that I didn't know and my patient has a reaction to some thing that hasn't been reported and I ask myself again and again could I have told. My old surgeon friend finds it harder to enter the ring.
"They must also need to deliberate in a formal professional setting such as an ethics committee."  (Here's the brand that's being sold.  Here's where we need less nurses and less MRI's and less doctors and more ethicists and administrators and oh yes, more committees.
Yet I'm still waiting for the committee , meta analysis, which indicates the apriori decision of ethics committees coupled with evidence based outcome measures.  I know several decisions that came from ethics committees that ultimately lead to the death of the patient. I am asking of course that committtes hold themselves to the same accountability and responsibility standards as individuals.
Would a medical ethicists accept say 1/6th of the lawsuit cost as part of the committee decision making when one false decision in an otherwise illustrious career can cause a doctor to have to leave medicine. My favourite, greatest obstetrician colleague gave up medicine completely taking early reitrement because he couldn't afford insurance.One US state, millions of people were without any obstetricians because the standard that that state held the doctors to was 'perfection'.  Mothers therefore had to travel to other states to deliver babies much like marriages are done in Israel.
I recommend you read this paper if only because the author is from Tel Aviv. I think Tel Aviv is one of the greatest cities in the world and this paper raises a great many concerns.  Like most things doctors are having things done to them behind their backs and decisions are being made about 'profesionalism' and 'virtue'  Scarey stuff really.
I find no one asks the soldiers what they think and rarely do the doctors in the front lines get asked what they think and sick patients aren't that forthcoming.
This paper would be best separated into three papers and the paper given in it's parts to a random selected group of patients and doctors who would then be asked what they read. If there is any evidence of consensus on reality then perhaps the author could be described as a person who knows a duck is a bird. At this point I'm not sure anyone outside an academic bubble would have a clue what he's saying or be able to agree or disagree with him because he's really wanting to please everyone.  Yet life and death are simply not weazel words.

Clinical Records in Courts

I didn't have a clue what lawyers did with all my clinical records. I assumed they read them. I assumed also the lawyer for the other side in disputes read them.  What I didn't know was that if they were to be used in discovery, in mediation or in court they had to be 'admitted'.  I imagine my records now  as a little stick figures, sometimes very fat little stick figures,  not allowed in some places because of the stuff they are carrying that no one wanted to hear about or a judge decided shouldn't be disclosed.  That said the lawyers who presented enlightened me to what could and could not be used in court, which parts, what a doctor could say based on another doctors opinion and even what a doctor could say about the notes of a dead doctor.  Fascinating legal stuff and all evidently reasonable as regards to 'evidence".
Not being a lawyer and not having to be concerned about the specifics  of the cases which were presented in synopsis and had the lawyers about me hot, I tended to think about just what I did put into notes and how I might word things in future if I thought they might be called upon. It also gave me more ideas about what courts were really needing in my notes.  These are the notes I took at the Trial Lawyer Association of BC Conference.
I must admit too that Jill Dougan had me sitting up straight when she reported that all professional associations have recommendations regarding note taking. She put up the notes from the College and I rapidly scanned them confirming I was in the ball park. It was a close call and a near panic because I can't remember ever reading the College notes on note taking. I found I enjoyed the rest of the presentation as my panic subsided.
The CD of the conference had alot more detail and was referred to repeatedly in this presentation.  I just wrote down bits that referred to me and am sure the lawyers would have taken far more extensive notes. It just gives a glimpse of the presentation.
Use of Clinical Records at Trial
Jill Dougans and Toni Rempel
Pihl  Law Corporation, Kelowna, BC
March 31,2012
Trial Lawyers Association of British Columbia
Essential Soft Tissue Injury Conference
Jill Dougans started in Vancouver, called to bar 1987, put on her first Trial Lawyer Conference some 20 years ago...has been litigator and arbitrator
Toni Rempel BA (Pol St) LL.B
Consider what is relevant according to Rule 7.1
scope of discovery
Trial Management Conference (TMC)
Items you may wish to consider
1 document agreements appendix 2
2 joint book of documents
  1. notice to admit
  2. Hyperlinked index and documents on a CD (appendix 3)
Clinical Records and Trial
Used at discovery and mediation
Evidence - long list of how to enter clinical information into testimony
Loynyk v Yeo 1988 Can Ll3101 BC CA
Mctavish v Boersma, 1997
Cunningham v Slubowskie et al, 2003
British columbia vs Harris
Samuel v Chrysler Credit, 2007
Edmondson v Payer, 20011
section 42 of evidence act
  • if clinical records are admitted then questions of what in clinical records can be admitted
  • admissable if made at time, by someone with duty to record, and with knowledge of the business
  • doctors direct observation, medical advice, investigations are
  • in absence of expert opinion - diagnosis in clinical records is admissable as diagnosis but not as the ‘true’ diagnosis
  • if a meteriorlogist records that it was raining - whether he saw the rain or other meteriologist - document is admissiable, however if he saw an accident on way to work and recorded that that’s not admissable because he wasn’t in duty to record
  • ‘hearsay’ in clinical record not admissable
In McTavish what is said to ER doctor attending is more reliable than later assessment
Clinical records - don’t have the questions or contexts, and were recorded for different purpose - not as reliable
As doctors often don’t recall meeting with the patient - clinical records are used to attempt to refresh doctors memory - courts require precise wording - testimony must come from testimony not reading
An expert may rely on hearsay
Mazura v Lucas 2010 BCCA 473
A trial can reject records admitted by consent at trial
-Samuel v Chrysler Credit
-clinical records should not be used unless counsell has identified ‘specific’ portion for a particular reason
Records admitted by consent at trial - connot object on appeal
-Smagh v Bumbrah - 2011,
Except if layperson
Use of Clinical records in medical malpractics cases
Cojocaru v BC Women Hospital - ordered an appeal
Brito v Woolley - was so upset that state of clinical records so said costs, but appeal overturned
Clinical Records and Professional Requirements
  • all colleges contain professional expectations about records, how they are kept

Panel Discussion and Questions and Answers

Facet Joint Rhizotomy and Chronic Pain

Neurosurgeons and rocket scientists are right up at the top for me.  Rhizotomy is a procedure in which the nerves around the facet joints are treated to relieve pain. The facet joints are the lumps you feel along either side of the spine from the head to the butt. Neurosurgeon. Dr. Richard Brownlee gave a superb presentation at the Trial Lawyers Association of British Columbia Essential Soft Tissue Injury Conference. I was using my light weight Macair and didn't have an external cd drive with me. The woman lawyer beside me was hauling a heavy weight lap top but had the CD presentation made for this presentation displaying on her screen. The slides were terrific. I watched them on the big screen but was thankful I had the CD to look at later.   Dr. Brownlee was as succinct as I've known neurosurgeons to be. No waste of words, excellent almost military clear  communication, what needs to be said, is said without the frills and whistles. Answering questions he was brilliant.  Very informative. Obviously a highly accomplished clinician and a surgeon and no doubt a source of profound relief for so many patients.   My notes give a glimpse of the subject and the nature of the conference material.  I would suggest people who are interested attend the conference and get the CD's next year. In lieu of that, see the presenters.

Facet Joint Rhizotomy
-Dr. Richard D. Brownlee
Welcome Back MRI and Pain Management Centre
March 31 2012
Trial Lawyers of BC Essential Soft Tissue Conference
MRI’s early - shows the disc tear or ligament injury in first 3 months
Won’t necessarily change the treatment but might have significance for legal matters
Unless you treat the psychological part as well as you treat the physical some people aren’t going to get better -some people are just so angry at the insurance companies
Facets - little joints of spine
superior articular process
inferior articular process
Vertebrae at front of spine
Facet joints at back
Cervical spine -zygophaseal joint
Facet Capsule
Synovium and fluid
these joints are prone to arthritis and wear and tear getting older and change of fluid with aging
Degeneration of the cartilage in the facet joint can be pain generators
Synovial cyst
Capsule tear
Synovial impingement
5-40% of back pain is facet pain
50% of whiplash pain is facet joint pain
MRI images show degeneration
White is water on mri
Back pain - or neck pain - soft tissue or facet joint
Leg pain - more likely pinched nerve
Facet Joint Syndrome
Ghormley 1933
Back pain resulted from nerve root compression - today it’s not so much the pinching of nerve but the osteoarthritis and inflamation and transmission of pain to the mind
Nothing pathognomonic -extension or twising, or activities requiring flexed posture
No neurological abnormalities
Lumbar facet Joint pain
Local tenderness over facet joint, stabbing, burning, aching, back hips,thigh or calf
Referred pain - studies have shown where it can be referred
Low back Pain
40% in older population
15% in younger population
Cervical facet pain
neck pain, shoulder pain, upper back, cervicogenic
Bogduck - done alot of research
Apri and Bogduck 1992 -
Chronic Neck Pain - commonly facet joint
C2-3 and C5-6 most common levels
Post mortem facet studies, people killed in car accicent
intr articular hemorrhage
capsular tears
miniscular tars
bone and cartilage fractures
Diagnositic Imaging
alot of people have degenerative change and don’t have pain
Some of people most disabled by pain have healthiest looking back on MRI in contrast those who don’t have complaints might have worst images
When it comes to ordering MRI’s - tends to be that doctors don’t like to order unless surgery is to be considered
sources of back or neck pain
discs - annular tear, herniation
facet joints
Diagnosing Facet Joint Pain
Hirsch 1963 - produced back pain by injecting joints with hypertonic sailine, relieved pain with local anesthetic
Facet joint Injection
25% false positive by this method
Bogduck, 1980 anatomic dissections showed each joint innervated by 2 nerves
Medial Branch Blocks
  • 2 local anesthetics
  • anesthetic block
  • Comparative anesthetic block - person comes different times
  • short and long acting anesthesia - send home and have patient record pain relief hourly
Facet Rhizotomy
percutaneous thermocoagulation of the facet joint
Van Cleef -1999 - comparison
Drefuss t al 200 - at 12 month 60% and 80% improvements
Needles are xray guided
Can’t see nerve but based on anatomic studies of Bogduck
thermal coagulation of medial branch to facet joint
alternating current, 80 degrees celsius, 90 seconds
have to be careful not to damage the vertebral artery
complications are extremely low - less than .1 %
good pain relief for months to years (1-3 years)
can be repeated with equal efficacy
medications - narcotics, nsaid, seizure,etc
dynamic stabiization - major procedure , I do lots but takes 3-4 hours and 3 months to recovery so rhizotomy often better as it can work as well, but still good  in right people

Chronic Pain and Temporal Mandibular Dysfunction

When people get whiplashes their jaw can be involved. This can lead to chronic pain in face and neck or complicate whiplash pain. Dentists and othodontists have noted this.  Today at the Trial Lawyer's Association of BC Essential Soft Tissue Injury conference a physiotherapist presented on this covering the topic neatly and succinctly with relevant and useful slides.  These are the notes I took and of course they don't cover all the material. The conference offered a CD with the various lecturers notes on that my own notes tend to remind me of what I thought was useful clinically and give a glimpse of what kind of information this conference covered clinically.
Essential Soft Tissue Injury Conference
March 31, 2012
Physical Therapy Treatments for TMD: Giving Hope to your Patients and Clients, Angelica Reeve, MSc,PT, BSc PT MACP
19th Street Physiotherapy Clinica
TMD - Temporalmandibular Dysfunction
TMJ is the jaw joint
connect mandible to temporal bone of skull by articular disc
Opening mouth requires mandible to slide forward and rotate - makes the disc very vulnerable
Muscles of mastication
temporalis - one of the reasons people complain of headaches
lateral and medial pterygoid
Temporal mandibular dysfunction
-collective term
  • intra-articular (inside joint)
  • Combination
5 categories of very minimal to very severe
trauma -direct trauma, derangement, adhesions
micro trauma -indirect blow, whiplash, bruxism, adhesion
Mechanical dysfunction - trauma, bruxism, muscle imbalance, posture
Osteoarthritis - any of the above
Signs and symptons
loss of range of movement or locking
joint noises
pain - tmj, fascial,earache
pain ful neck
sudden change in bite
decreased hearing, blocked ear
Whiplash - hyperextension and hyperflexion
High incidence of TMD with cervical spine disorders
Five times more likely to develop TMD
20% of recorded cases TMD main complaint
Deep cervical spine muscles can be involved  in whiplash and contribute type i fibers versus type ii more common in superficial muscles
Muscle imbalance
-loss of spatial awareness
posture changes
forward head posture has been found to be correlated to TMD
involves positive retraining
deep neck re posturing
Need to taught how to sit upright
Chronic pain
-provides more of a challenge
-change in hard wiring of brain
-increased sensitization
-anxiety and depression
Homunculus in Somatosensory Cortex
Homuncular Man = more face and hand
Chronic TMJ Pain can be associated with problems
  • fascial expression recognition
-two point discrimination
-loss of expression

Personal Injury and Myofascial Pain

Dr. Mark K. Frobb is a pain management physician with a special focus on Orthopedic Medicine Rehabilitation. He was also the co chair of this Essential Soft Tissue Injury Conference put on March 30 -31 at the Vancouver Convention Centre by the Trial Lawyers Association of British Columbia in association with the Family Medicine of BC.  His presentation was one of the most informed and extensive addressing controversies and certainties alike.  His slides were excellent. Talking with him between sessions he was jovial and down to earth with a quick wit and astute ability to key into questions being asked him. He was a superb communicator. He is an executive member of the Medicolegal Society of British Columbia and President elect of the the Canadian Association of Orthopedic Medicine.
My notes do not do justice to his presentation. I was busy reading the slides and listening with rapt attention to his fascinating insights rather than taking notes. Therefore, they're really just a few things captured here and there.  The Trial Lawyers Association of BC provided a CD with the notes and other information relevant to the conference. Having attended another one of these conferences a few years ago I needed a wagon to carry home the vast collection of notes that different speakers had provided. I thought the CD was considerate given that some of us older sorts had had personal injuries and could well carry home a cd easier than all the binders of previous years.
Myofascial Pain: Relationship between Pain, Impairment and Function
Dr. Mark K. Frob
The Essential Soft Tissue Conference, March 30, 2012
Myofascial pain syndromes are characterized by regional muscular pain patterns typically involving groups of muscles which functionally control complex movements in a specific anatomical area.
14.4% of general population suffer from chronic musculoskeletal pain
myofascial pain syndromes in variaous studies account for 21 % to 93% of pain
History: Myofascial Pain Syndrome
-Dr. Janet Travel and Dr. David Simons 1977
  • Dr. Janet Travel served Dr. J. F . Kennedy
  • Dr. Janet Travel Clinical Professor of Medicine wrote on trigger points in 80 and 90
-Dr. David Simons - aerospace - work on weightlessness in space
Aerospace medicine
Together two of them - produced what remains the bible of myofascial pain
Myofascial Trigger Points (MTrPs)
taut muscle bands t latnt MTrp to active Mtrp
24 to 54% of asymptomatic individuals have latent trigger points
MTrPs - palpable taut bands, equisitely tender, range of motion of taut muscle limitted
#1 cause - axial skeletal asymmetry
Poor Posture
-sleep deprivation
otherwise radiculopathy, deficiency diseases, hypothyroid,
It presents with a story
Localized muscle tenderness
regionally referred pain
stiffness and limitation of range of motion
sensory distrubance - paresthesia
autonomic phenomena - sweating or decrease, temp changes
recognisable localized knot
‘jump sign’ - patient jumps when you touch
‘twitch response’  - muscle twitches when you touch it
muscle weakness without atrophy
Clinical investigation remarkable by it’s absence
No specific lab tests
infrared or liquid crystal thermography can show increased blood flow at trigger site
Electrical studies may show abn
But we don’t use them in clinical investigation - done as research
drying needling - intramuscular stimulation
trigger point injections - local anesthetics, saline, sterile water, botulinum toxin, corticosteroids
neural acupuncture - injection at the acupuncture points - xylocaine
  • if it’s going to work its going to work as first treatment
electrical stimulation
Has a rule - if you see benefit but it doesn’t keep getting better after three visits benefit may have peak
non steroidial anti inflammatory medication and cream
tricyclic antidepressants
Nociceptive VS
Central Pain ()Neuropathic)
20-30% of patients with chronic myofascial pain will have concurnet or comorbid central pain characterics
ie hyperalgeisa
Central Pain Characteristics and comorbidities as described by Dr. Gouw
Pharmacology of Neuropathic Pain
a variety of meds , including cannabinoids
Disability and Impairment
AMA Guides to the Evaluation of Permanent Impairment 5th edition
Activities of Daily Living
self care
physical activitiy
sensory function
non-specialized hand activeity
sexual function
= loss of use oor derangement of any body part or organ system or organ function
only those impairments interfering with ADLS
not all impairments interfere with ADL
=alteratioon of an individual capacity to meet personal social or occupational demands statutory or otherwise
-pain is subjective
-pain can exist without tissue damage and tissue damage can exist without pain
a patient can have a well established pain syndrome without identifiable organ deficit
eg migraine
Need to assess credibility and pain behaivour
Need to balance indivdiual self reports and clinical judgement of examiners
Pain Behaviours - non verbal behaviour
  • primarily observed
  • congruent with established conditions
  • consistent over time and situation
  • consistent with normal anatomy and physiology
  • we’d like to find agreement among caregivers
-pain exists in more than one anatomic area and warrant clinical attent
-exists past expected treatment
-ccuases clinical distress and or impairment
-psychological factors
-symptons not intentially produced or feigned as in factitious disorder or malingering)
not better accounted by a mood, anxiety or psychotic disorder
Testing Instruments
clearly document history
use of pain related impairment worksheets (PRI’s)
Functional Capacity Evaluation -work simulations