Doctors Running Late

I’m always running late these last years. That wasn’t always the case. When I began in medicine and psychiatry I was mostly on time.  True I’ve become older and slowed down some. A major shift in my urban industrial clock mentality occurred working in the country. There’s a more natural rythym closer to nature. Then working with aboriginal and Inuit in the north and on Polynesian Islands I was struck by the importance of the ‘flow’, time measured more by ‘wave’ than by’particle‘.

More often than not these days that which is systemic is attributed to the personal, especially in medicine and psychiatry where the administration remains in the ‘blame and shame’ mode while the field has moved light years forward out of the dark ages of legalism and power politics.

With that in mind, I considered the changes that made the ‘50 minute’ hour of therapy for the psychiatrist no more in fact.  

1.An American study found that specialists were expected by their authorities to do 90 minutes of activities before the patient arrived to state their ‘complaint’ to be addressed in the 15 - 20 minutes ‘visit’.   The increasing intrusion and side lining of the ‘patient’ and the “doctor’ by administration and insurance company priorities had got that outrageous.  The least important person today in Canadian health care is the patient and after The fact is best expressed by the black humor clinical joke, “You can kill the patient just so long as the chat and records survive!”  

Instead of myself and the patient in a 50 minute hour there’s now a whole administration, bureaucrats,, lawyer, media, state, insurance agents, ideologues, countless third party community concerns,police pushing the patient and doctor out of the hour and taking over the medical office.

2.When I started I was trained beyond the best of best, educated beyond my intelligence and frankly, pretty damn good.  I focused on the patient and patient care and doing the best job I could. Today I’m constantly looking over my back.  The Canadian Health Care System is the poster child for a ‘toxic work place’. It's a place of suffering for patients, nurses and doctors or indeed anyone on the front lines. I’m second guessing everything I say and do because not only am I expected to be perfect, incompetent tasks masters are  constantly moving the ball and changing the rules.

The College of Physicians and Surgeons is the licensing body.  They’re like  the ‘driver’s licensing bureau on steroids.  If you had to get into a car and juggle while driving watching your back all the time and having a million buttons you had to push randomly in the car because of some ‘possible’ concern of someone sitting in a committee, you would understand perhaps why it’s so hard to get the car out of the garage  especially  becaause one minute you’re told to juggle next minute to have your clothes on or off, next minute to go to Saskatchewan and next to Quebec. The administration is responding to media, politics and gastric indigestion with knee jerk reactions and asking high paid cronies to come up with scientific sounding nonsense that simply doesn’t work.  Every demand is threatening officious pedantic and zanier than the last.  

Meanwhile we’ve got a reasonable stream of recommendations and learning coming down from the university which unfortunately is often its own ivory tower because what’s done with poor rats and rich students doesn’t apply to a normal human practice. 

3.So when I started , I was phoned directly by a patient who asked to see me. I talked on the phone about what I did and what they wanted. This model is the same one still in place for lawyers and most other professionals.

In BC the government created a family physician referral process. In The British Columbia model the Family Physician is supposed to be the gate keeper and controller access to specialists.  (Nurses are now competing to displace the family phycian and control all access to doctors while other government administrators want to have access to doctors strictly controlled by an administrator politically deciding wait lists.)

In the past when I tended to be on time patients  had family physicians.  Then walk in clinics with ‘one visit one complaint’ signs changed the primary care model.  Decades back I’d get a referral from a family physician who really knew the patient. They’d send me a whole lot of pertinent information.  That’s rare today. I’m fortunate because I have worked with a collection of the finest family physicians and we had really good working relationships. Those left are now called ‘full service providers ‘. Those family physicians were not trying to ‘dump’ the difficult patients on to me. Today a third of patients don’t have a family physicians and in some psychiatric and drug and alcohol addiction populations 90 to 100% of patients don’t see family physicians. I am now often their only contact with the health care system. That wrecks havoc on the 50 minute psychiatric hour. Psychiatrists haven’t got the one visit one complaint rule yet. The closest thing we have to that is the pharmacological psychiatrist who has reduced psychiatry to the prescription pad. Not a problem for the rich or well insured because they have psychologists but the hoi polloi dont and that’s one of the elephants in the office no one talks about.

4. When I began I could say if I didn’t complete an assessment I’ll see you tomorrow. Now I’m booked 6 months in advance ,often double booked. I have dozens of people begging to be on the ‘cancellation’ lists. I’m not alone. The wait lists in Canada due to beurocratic incompetence and administrative mismanagement and government scandal are the longest in the civilized western world. I’m just a part of the mess. But if I stop and say lets continue it may be weeks or months before I see the person.  I can no longer count on this person having a relationship with a GP or family physician who themselves are frighteningly overworked. The patients are a whole lot sicker, more desperate, at higher risk of suicide (or homicide). 

5.When I started I could get a second opinion from a colleague that day or that week. All my mentors have taken early retirement, the best of the best burnt out and cynical about the system. The suicide of doctors is the highest of professions and two or three times the normal population. The College of Physicians and Surgeons is identified as the principle cause of suicide and yet there's no sense that they even acknoledge their deficits while demanding doctors admit fault and pay exorbitant penalties while they remain safe in  high rise bunkers of denial and poor communication.  

6. I’ve sent two suicidal patients to the emergency in the last couple of years and both were sent home rather than being admitted. Both killed themselves, one by hanging.  I don’t have any sense of ‘support’ in the system. I waited a year for a consult from a sleep specialist for a patient hypoxic with ptsd nightmares and severe heart disease needing medication which would affect their breathing and their heart rate and they were on a dozen medications from other specialists. In any sane system they’d have been admitted to the hospital. There were no beds. Canada has the least hospital beds for population in the civilized western world with administrations and politicians acute hospital beds for   homeless shelters and nursing homes . 'Bed blockers’ are the norm. There is a massive ‘revolving door’ hospital misuse and simply wrong ‘management’.  Meanwhile government overt destruction of the family has resulted in more and more people having no where to go where there is help when they are immobilized by disease.  My patients who post surgery as discharged to community nursing get phone calls rather than visits.  Countless papers point to this but administration in Canada is by political appointment , heavily influenced by post modern tokenism and very low on competence and meritocracy. There are simply no elections where it truly matters.

7.PM Justin Trudeau, is  a living nightmare for the Canadian health care system. For personal aggrandizement and to serve his globalist cronies he has marketed Canadian Health Care to the world inviting all the chronically ill, dangerously , angry, interminably entitled,  addicted and psychiatrically disordered to come to Canada. I and my colleagues already pushed to the edge are without discussion told to work ten times harder because the Trudeau government want's to give away for ‘free’ health care in hope of getting scab voters to keep his party in power.
He’s even claimed counselling can rehabilitate ISIS without listening to psychiatrists who know more than a drama teacher how much care is needed to rehabilitate our own vets let alone those who want to kill us.    Fewer resources are now being fought over by sick and well patients and activists feeling that they are ‘entitled to a daily MRI’ , angry that any doctor would question their right to the highest paid diagnostic tools, because to many health care is a ‘fashion ‘, a prop,  entertainment or commodity.   When the ‘worried well’ and the dying compete for resources the ‘worried well’ , the loud complainers , the entitled , the sociopaths and psychopaths win.  The really sick and the dying don’t have the energy to impress the Minister of Health.  By the time we’re old, sick and dying we’ve used up our resources. The young and angry and political and rich  know how to work the system. The Ontario Liberal Government just offered free pharmacare for the young who generally don't need it while denying the sick and old life maintaining and life saving medications. The despair that psychiatric patients commonly arrive with is  palpable.  It's worse than I’ve witnessed in all the years of my career. Yet my leadership tells me that I'm wrong to care.  They claim that professionalism is the callous disregard for humanity that they maintain. It's this heartlessness that gets them appointed by those above who seem only interested in cutting costs and saving money for their own dachas and jet setter trips. I see the homeless forgotten alone, alienated and very much aware of their ‘worthlessness’ and the ‘hopelessness of their situation’. The time the bean counters alot is gone before they can dry their tears. 

8. A compliant against the doctor like the increasingly  ‘frivolous complaint’s’ we see daily in todays ‘fake news’ takes up 30% to 50% of a doctors energy and time.  Thousands of doctors are now dragging themselves out of bed and going to  work because of the College of Physicians and Surgeons is backing up everyone who is ‘offended’ by anything.  Canada is world renown as the land of the ‘offended’ with the greatest whiners and complainers on the planet.  It’s probably because we’re doing so well. I’m no better. Ingrate. Complainer. Too often unappreciative of the advances.   

9.The cream of health care, the mild complaints, the mild to moderately ill have been taken by counsellors, nurse practitioners,psychologists and everyone but the doctor. The doctor’s share of the pie is now the sickest and most complicated. The case load of the specialist used to include some ‘easy’ cases but the family physicians ensure these are seen by themselves and the counselors. The health food store owners and the masseuses  get all those other people who are rich and need pampering.  These used to go to the family physician but now the anti doctor, anti education, anti authority crowd is trained to be paranoid by the self serving internet media with endless conspiracy theories that sell their latest snake oils.   Some easy cases got through the filter in the past but not today.  People with money go to the expensive health ‘food’ stores and the wealth of ‘alternative ‘ resources. Otherwise they get tourist medicine.  When they get really sick or when all those fashionable services don’t work, they show up for the ‘free’ health care. After Mayo Clinic didn't help they come to me demanding all my attention and care and angry that their taxes can't offer more than Stanford or Cambridge. Sick and dying psychiatric patients look for someone or something to blame and rarely have the community support and psychological acceptance that helps them through.  

The severity of illness in my practice today commonly includes  major psychosomatic illness dual diagnosis, aging populations and is a billion light years beyond what it was 20 years ago. And most of those patients know that if I don't see them no one else will.  So many patients that left my practice have come back and told me harrowing tales of the abruptness and factory ness of what is offered so often today.   That can by most private medical specialists and most family physicians today. The mismanagement of health care services has been such that we’re left with the heavy lifting whereas the ‘cream’ has been skimmed by everyone else. We who have the experience and are there on the front lines are the least likely to be consulted by the ideologies and those generating an endless list of the new professionalism and codes and protocols.  The mismanagement and divide and conquer of the administration takes  the rewards at the back that should have gone the  patients and those on the front lines. Administration has gone out of its way to ensure that the left hand doesn’t know what the right hand is doing.  When I began I’d get discharge summaries from hospitals but not today.  With all the advances electronic records and tech, the miscommunication is worse than ever I recall.  The EMR record is a major source of contention for doctors with it's major administrative benefits and it's major clinical deficits.  It's nearly impossible to scroll through in a timely way and find old data whereas with a paper file I could access original consults and relevant notes in seconds, usually with the patient not knowing what I was doing and continuing to talk.Now we both sit before a screen which sometimes freezes and often simply won't give me the data I want from the past. It's good in the here and now but it's somebody else's idea of what I as a specialist need. And most are set up for general practitioners and there are competing designs and lack of compatibility. A tremendous amount of time and energy and money is going into something I can see will be useful in a decade but right now, it's costly and timely and has me looking at a screen rather than looking at the patient.  

10.This last couple of years I’ve had amazing complications in patients because of the ‘herbs’ they were getting and the herb sales men are not accountable but I have to clean up their mess.  My patient seizuring after a ‘vitamin store’ ‘food’ is just one of many dramatic cases.  I rarely know all that my patients are taking as patients increasingly 'lie' about their 'lifestyle choices'.  I was really surprised by all the drugs a patient was found to be taking at the autopsy. Even our addiction medicine urine screens don't pick up all these new mail order 'herbs' which affect the pharmaceutical medications. We're suppose to know about side effects and take them into consideration but the 'competition' doesn't even care or ask.  Buyer beware is the norm except in modern medicine where the doctor is expected to be a mother more than a physician.

11  Everyone  now is an internet doctor.and they don’t want to be ‘cured’ as much as they want to become a consulting expert on their ‘illness’ . The demand for education of people with gr 12 education and a scanning of the internet is unbelievably time consuming especially when the patents smokes pot and you review your notes and see that you’ve been through the lengthy explanation three times previously.  Patients are increasingly argumentative.  They shop for diagnosis and demand treatments which are contrary to what the College dictates. The media has caused widespread paranoia among patients and the psychiatric patients and the drug addicted were already paranoid. 

12.There is still no patient accountability. It is there in the best health care systems in the world. The British system limits you to a list.  American Kaiser Health Care coordinates all the records.   Canada is very very far from the top in patient accountability  which is a cornerstone of care. In Canada patient's  don’t have to take advice, take medications, follow up,  but they can and do blame the doctor for their persisting illness and complain to the College of Physicians and Surgeons and their lawyers for their not uncommonly self induced illness.  Increasingly patients are rewarded like the illegal aliens.  The good patients who follow the rules and do the best they can are pushed aside by the  the ‘irregular’ patients who all too often are bullies.
If you’re considering resource management  it’s called a shit show but a doctor will be called in for unprofessional language because it's so easy to police the doctors than the malingerers, violently insane, and psychopaths. It's no different with the increasing gun laws that tax and control law abiding citizens while criminals get more and more arms and have less and less consequences for this.   Only the doctor is accountable for illness.  The doctor when he’s with a patient whose a ‘victim’ and ‘blames everyone’ then the doctor is more often than not now trying to avoid becoming the ‘cause celebre’ of the entitled activist. Increasingly these people  trust funds, criminal sources of money  or on disability ,but generally having infinite time and resources  to 'work the system'. and get the bureaucrats working and colluding with  them. Meanwhile the  the doctor  has hundreds more patients and a College and government representatives poised with guns to shoot them in the back if they are not perfect. Only one in a hundred general practice patients fits this description but they concentrate in a psychiatric practice and especially in a dual diagnosis practice.  Psychiatrists are the highest suicide risk in the profession and the College has general practitioners and lawyers talking to them rather than psychiatrists who governments distrust because their own personal insanity, early dementias and various addictions and character flaws are obvious to those trained to see the signs. 

Last month I was asked about a prominent patient who’d seen 6 psychiatrists that year and another patient who’d cut her throat and been discharged to the community to a walk in clinic without a psychiatrist or family physician to see her.  Naturally I saw the woman with the massive scar on her neck but pissed off the entitled woman shopping for the ‘right’ diagnosis and her boutique family physician showering on her whatever she wanted since they were both in the same ‘club’.  

13,Now if I see a person I might be the only one they see until I see them again in 4 to 6 months. I worked as a fly in doctor and all my assessments then were made knowing that no other doctor would be coming to the reserve or island for anywhere from 1-3 months. I was the only psychiatrist who would go to some communities over a decade because some of the drunk and drug addicts would shout 'kill the doctor' when a doctor arrived. I've run the lengths of reserves with shots being fired at me by guys screaming 'kill the whitey' not knowing who or what these people are about. I've been thankful for chiefs who said, "don't kill the doctor.'  All the while I'm just doing my job and afraid of missing some illness and leaving some person behind who really needed to fly out to the hospital with me.

It’s like that now in practice.  I don’t want to miss something. I don’t want to make a mistake. It’s not because i worry about an idiot in the beurocracy with too much ego and too little clinical skill or common sense but it’s the way most of us doctors are wired.  We don’t need this massive industry of watch the doctor any more than the police need a fortune spent double checking on them. But there’s so much more money in ‘policing’ the front line workers and not going after the pedophiles and wankers far from the front lines. I believe we’d eliminate ‘fake news’ if we simply drug tested the media and parliament and congress.    I’m so often afraid when I say good by to a patient at the end of an appointment that they won’t live till I see them again. The fentanyl epidemic has taken some of my young patients. 

14.The vast majority of patients who come to see me are frankly desperate.  They are really sick and they’ve seen a lot of low level help because the system doesn’t ‘triage’ patients like it used to. When there was a family physician who was rewarded for knowing patients and provided comprehensive care then that doctor would know who needed to see the specialist and ensure they got in to a specialist early rather than late. Now a patient will see a junior counselors or a nurse practitioner and muddle about until they see me.  I actually make the ‘correct diagnosis’. Half my patients in psychiatry have the wrong diagnosis or half the diagnosis when they see me. They have depression but mostly they’ve not told anyone about the sexual abuse, rape and how their partner is sleeping about or any of that sad garden variety domestic stuff that fuels daily anxiety. They'll the psychiatrist about the lump on their breast or the boss that's threatening them but they don't readily admit this to others happy to "chat' or worried about 'maintaining' their 'image'.  Hundreds of patients who were crack and opiate addicts were not diagnosed as such despite seeing countless others.  But then everyone is afraid of offending anyone by giving them an unfashionable diagnosis or by even taking a history The College of Physicians guidelines on Sexuality Harassment are so non specific that increasingly we're collectively back in the 19th century not asking women about sexual behaviour and subjecting them to the worst standard of female health care, which I saw given in Indian clinics where their husbands objected to even female physicians examining their wives.

I diagnosis the missed ptsd and head injuries, addictions, the thyroid disorders, cancer sometimes, hep C and a whole burden of illness that previously was seen only in the hospital practices. Psychiatric patients especially drug and alcohol addicted are least likely to wait for 10 hours in the ER or for tests. Some days half my work seems to be convincing patients to get the tests done other doctors ordered or re writing tests the patients lost.   Meanwhile the College and the lawyers are essentially telling doctors with winks and nudges , don’t dare ask about sex because some woman will be offended . Negligence is okay but we’ll deny everything because you’re on your own.  Negligence is the norm in the Canadian Health Care System but no one neglects to 'chart'. The CMPA to help doctors defend against the iniquities of the College one day said for every 15 minutes of health care a doctor should do 15 minutes of charting. Overnight half the medical care in Canada was replaced by charting, yet there is no more time or money allotted for doctors charting. The time and energy comes out of direct patient care. There's no 'fat' in the front lines. All the fat cats are the bureaucrats and they're not taking any cuts or giving up their power or control any time soon.

15.So the ‘ends against the middle’ fallacy, the one complaint which is a nut job rather than being representative results in ‘all women’ or ‘all patients’ being painted with the same brush. I do random surveys like asking my psychiatric patients when they had a full medical exam (we used to call these medical exams or physicals ,no pc is we have to call them 'full' like 'radical terrorists' instead of 'terrorists') . Ten years ago everyone I saw and asked that question had had one in the last couple of years. Now in affluent patients even the answer is 5 or more years. Mostly people just don’t want to face all the wait lists. We’re a really pressured urban society with no slack time in general so more and more people aren’t going to the doctor. They’re going to the gym sometimes but increasingly because the doctor is a walk in clinic rotating young doctor often with poor English and cultural ignorance there’s just less of a relationship there than with the local gym guy or girl.  So health is marginalized.

16.Obviously I could go on.  Whining complaining.  Bitching and lacking gratitude. But I’m late. Most of the best doctors I know are running an hour late now. I don’t think it’s our fault. Whenever I walk into a doctors office they are exhausted out of breath, stretched and crazy eyed.  They smile like soldiers smile. Some have that thousand mile stare. Others smile with the humor of MASH. But when I walk into an administration office they’re moving with elegance, some wearing 4 inch heals, one lawyer had a diamond a doctor couldn't afford with a year's income, there's a  luxuriousness, not a hair out of place,  academic speech, generally irrelevant, reminiscent of schizophrenics on psychiatric wards, all the time in the world on their hands, fat cats, sleek, paw licking, supine. I’m not surprised they’re on time.  They usually move in groups, don't meet alone, have locks on every door, cameras everywhere, thick carpets.  When I visit it’s obvious that they aren’t busy. Busy in their minds but not really busy.  I don’t know any doctor or nurse that isn’t busybody today . We’re killing ourselves and we’re burning out and we’re running late.  The stats don't show administration and bureaucrats killing themselves. Doctors are. 

17. There are a whole bunch of ways to get around all this. Most are ‘cherry picking’.  Many of my colleagues are seeing the same patients , dependent personality disorders, weekly.  Most are avoiding new patients. No one is accepting new patients though I still do. Quebec doctors see the least patients daily and get paid the same. English Canada doctors see the most patients.  Some actually refuse to see patients with insurance claims. Most won’t see or avoid being patients with drug and alcohol complaints. More don’t see personality disorders.  There have actually been signs ‘no borderlines’ and colleagues say, I don’t accept borderline personality disordered patients. No one is jumping up and down to claim the psychopaths and sociopaths who are no longer carried by the massive armed forensic clinics. One day a psychiatrist with a body guard is seeing the patient the next day they are being seen by a psychiatrist in the community with at most a little female MOA who didn't get the feminist memo to be like Wonderwoman and train in Kickboxing and protect her boss. My MOA's have quit because my patients were loud and threatening.  Why shares the pain and risk when you can just avoid all the heavy lifting.
The easiest practice is ‘mood disorders’. Call everything Bipolar II and play ‘let’s make the drug companies money ‘by randomly trying every pill in the pharmacopoeia till the natural history of the disease passes and the patient gets better or leaves.  “The variation of this is “, I can’t treat your depression but I’m really good at treating side effects so I’ll give you something else and make myself look good as a doctor alll the while we’re not addressing your depression or anxiety.  I will make you dependent on me. “I’m reminded of my mother saying if you don’t stop crying I’ll give you something to cry about.
The pain clinic exhaust its box of expensive investigation and treatments and 'fires' the patient who comes back to the family physician and psychiatrist even more jaded and disappointment. These new 'clinic's' don't have the notion that they are 'accountable ' for the patient but rather that they provide a 'treatment' and if that doesn't work the patient is 'somebody else's problem'. The "SEP" is the norm in the Modern Canadian Health Care system. The lack of family physicians is directly associated with the burden of chronic care and difficult patients with no 'solution' who gather in droves at the front lines and wail and keen far from the ears of the government offering 'free health care' to everyone else but denying the obligation to care for individuals who are 'outliers' and don't respond to the cheap standard 19th century approach. 

18. I’m going to be late so I’ll rush out today. People always complain about my lack of editing. I blog because ‘stream of consicousness’ takes less time. Editing takes a lot of time. This is a journal so it's what I want to remember when I someday ask myself what was I thinking and feeling back then. It's subjective. It's emotional reasoning and personal perspective but it's  a snap shot.
 I don’t feel I have time, today. Everyone wanting a piece of me and everyone wanting it ‘free’.  The irony there is that increasingly people think what we’re doing isn’t worth what the health ‘coaches’ do because they ‘cost’ money and ‘health care’ is ‘free’ but then no one goes to the doctor anymore unless they’re really sick or they want to get a second opinion on the internet where the doctors and nurses have left the private face to face health care rat race to become entertainment doctors.  So much of what I read in internet medicine is wrong and political and it's sad when patients find these sites that confirm their erroneous bias.    I even had a bureaucrat describe medicine as " just entertainment". They actually encouraged me to “act”like doctor rather than be a doctor all the while saying that they didn't want me to be inauthentic, while nothing more inauthentic could be stated.  Bureaucrats aren't trained in psychiatry, or psychiatric psychotherapy or psychiatric relationship therapy or advanced communication and obviously knows nothing about psychiatry or psychiatric patients but have all that arrogance that generalists have, like those patients of ours who having looked at the internet know more about their disease than all of us.  When it comes to specialist medicine especially psychiatry which I likened to three dimensional chess compared to the unidimensional chess model of doctor as daddy fixing mom's brain with pills.  The patriarchal nature of this 'i'm good, you no good' 'I'm well, you're not well', i'm police you criminal' 'My brain good, your brain bad' is so 1980's before all the research of transactional analysis and all the modern training in psychotherapy and 'behaviour change ' , but there's no arguing with these people. They have the gun so they need to be respected and doctors pretzel themselves and train themselves and waste years of their lives doing everything increasingly to serve the administration regardless of whether it truly helps the patients because the patients are increasingly the least important people in the new entertainment industry.   It's really sick and creepy from one perspective. But then it's all a matter of perspective because even psychopaths and sociopaths believe they are good people helping others. So psychiatrists like most good doctors learn and turn and twist and do everything including sacrificing themselves by suicide because we're people pleasers and good citizens now at the mercy of psychopaths and sociopaths. Besides it's all fake news and there's an epidemic of 'false witness' deceit and systemic retrospective falsification. 

19.It's now all about popularity. Entertainment paradigm. I once was the ‘most popular guy’ and as a family physician I was outrageously popular but I became a psychiatrist because it was the most challenging with the most needy patients and the most marginalized.  Most of my patients aren’t given time though increasingly these activist bullies, the new order of borderlines backed by the authorities, are getting all the time and more and more the really sick are being pushed aside.  Schizophrenics commonly just want to be left alone, not good health care but what is happening to so many because of lack of advocacy for them. When they closed the asylum the chronically mentally ill were pushed out onto the street to be preyed on by predators and live homeless because the asylum was shut down, another administrative blunder of untold proportion.

 20. f I don’t watch the snakes carefully they’ll complain and by complaining they ensure that if I didn’t give them the attention and time and money and whatever sociopathic fantasy they have, they’re make sure that no one else gets my time because they’ll have me tied up with the garrulous grovelling inexperienced administration.

20.Meanwhile I just want to help the really sick not the patients who know how to beat up doctors and suck the life blood and soul out of care givers.  The Celestine prophecies described these as ‘soul sucker’s" and they’re just a whole lot more resourceful today. The Prochaska “stages of change” model (precontemplation, contemplation, determination and action )strongly suggests putting resources in at the determination or action phase and patient’s coming to specialist in the past were at that point while increasingly patients today are into contemplation, happy to talk to the doctor as infinitismal, entitled to the time and unwilling to leave the office but equally unwilling to change their chronic negative behaviours or thinking. Noncompliance and non adherence to medical regimen in chronic lifestyle disorders the new norm of medicine that generalists and especially specialists face. 

21.Still 90% or more of patients are what makes it all worth it. They’re your neighbour and my neighbour. They’re the person who got into drugs and alcohol and wants out. They’re the schizophrenic afraid of their demons. They’re the bipolar disorder who took their clothes off in the board room and don’t want that to happen any more. They’re the patient with depression whose been really well treated by the generalists but now requires a specialists because they’re rare and unusual and I’ve been around so long I’m an old elephant with just these skills and can tell people what the rare case is and how to treat it.  More and more though I’m fighting an individual bully patient and their advocates with loud speakers, College committees, lawyers and  social workers, none of who will roll up their sleeves to fight disease but are more than happy to claim the limelight for beating up an already beat up caregiver. .  I'm begging for resources and saying yes, till one day, I say no and the hungry patients eats me the closest caregiver and the person who is most hated by the terrified ignorant government.  I'm the 'sacrifice' that Graves wrote about.  It used to be virgins that were sacrificed but now it's doctors.  Psychiatrists are especially yummy. 

21.Every day I wonder if I ‘m wasting my time and experience on a dying health care system ruled by bullying ideologues increasingly out of touch with reality loving their high pay for  moving chairs on the titanic.  It’s an aging population and the refugees are even sicker so the whole system was set up for a completely different sort of folk and illness.  

I’m going to be late today now too. Some days I just get preoccupied and have to push myself to go out the door and face the hostility and despair. I say I’m sorry like the "Dr I’m Sorry" in the classic medical skit. I’ve been seeing patients on the front line, tens of thousands,  for over 30 years. I’m one of the best trained most experienced clinicians with an enviable track record of successful clinical care and outstanding morbidity and mortality rates. I’m not alone. Most of my colleagues , both generalists and specialists are caring, highly trained often extremely experienced extraordinary men and women,  but they are running late too.

 I pray that one day I’ll finally catch up too.

Hail Mary, Mother of God pray for me in the hour of my death. 

When I 

Resilience and Easter

I feel sometimes when I’m actively being punished by barbaric antiquated pre modern science systems of control and abuse that I become too ‘heavy’.  I teach that in life we should learn from motorcyclists. Driving down the freeway at high speed on my Harley Electroglide I learned that if I look at a pile of dog shit or maneur or radical leftist Canadian liberal policy I will indeed collide with the shit and get shit on my shiny motorcycle and leather armour.  Yet if I don’t keep my eyes open and my head out of the sand I won’t know who kicked me. So to navigate as motorcyclists we note the government obstacles, the ignorance and outrageously expensive counter productive policies but avoid them personally.  We see the shit and go to either side of the obstacle.  It’s been said that I personally persist in driving right down the centre of the road proverbially, politically and poetically.  In this far left country of Canada with our radically left government I feel as emotionally and mentally homeless as the increasing numbers of physically homeless.
Psychiatry Grand Rounds, Neuroscience of Resilience, 3.14.18, Psychiatry Grand Rounds by Noshene Ranjibar MD and Justin Otis, MD said the first and best response to trauma was relational, community and sharing and parasympathetic.  In contrast to the local medical administrative disdain for AA NA and Church the presenters celebrated the community and rituals that helped people deal with trauma in the healthiest way, utilizing the parasympathetic autonomic nervous system.  The second line defence most known was the sympathetic fight or flight response, the characteristic response elicited by the British Columbia and Canadian administration policies which are legalistic, paranoid, and 17th century pre scientific era, control and power based.   The third response was the basal ganglia, reptilian, ancient ’freeze’ response .
They were discussing ‘burn out’ and how they had addressed their problems with physician burn out. It was uplifting to hear all the advances in psychiatry being brought to the department and administration level.  Locally I’d been exposed to the junior low brow approaches to systemic problems best described as blame, shame and CYA administration. This is classic communist and totalitarian fear based ‘negotiation by intimidation’ also seen commonly with people drunk and stoned. The rise in marijuana use in government is certainly a contributing factor. Marijuana may removed the empathic capacity of the higher brain function.
 British Columbia is the epicentre of crime, drug trafficking and money laundering of Canada. It’s competitor is Montreal made famous by   Chabonneau Corruption Commission which showed the Mafia and Biker Gang influence on French Canadian governments. The Canadian Health Care System is descending as Canadian debt sky rockets.
Well in the midst of this I thought I’d just add a blog with the positive images of ’spring’. Because I work in a highly toxic environment in a divided country with failing health care system and roaring corruption and dishonesty, I am forever doing everything to cope.  My patients are desperate and maligned and ignored. They’re terrified and the future is very bleak for the elderly.  They’ve all been promised everything by the political system and the lies of media ,only to find that they are old and homeless and that third world people feel greater happiness.
 I sometimes want a holiday because all my time off  is “recovering’ from the George III insanity of governement dictates.  Every day colleagues take early retirement complaining of the administration and the government. 75% of doctors would not recommend medicine.
Internationally Canada is known now as the most offended nation in the universe.
Everyone collectively and individually is guilty of a social offence as laws and bureaucracy exponentially increase.
I prayer daily, meditate, write gratitudes, look on the bright side, celebrate crusaders like Jordan Peterson, JJ MacCullough,Diana Davison. I pray for willingness to forgive because I don’t seem to be forgiving as the bolts of negative energy and punishment just keep coming, I shut out thoughts of suicide knowing these creepy callous fat cat elites want this in their secret hearts and I refuse to identify with the aggressor. Too many good people have been killed by these cretans. I pray. I talk to other doctors but everyone I most admire, the greatest of the great are disgusted like I am . The evidence is overwhelming that the problem is systemic yet they continue to personalize it. I walk the dog, my little blind therap dog. I am writing gratitude lists daily while moving through the daily malaise, constant threats hanging over me, I look for ways to escape, hear all the thanks and appreciation of family and friends, feel empathy for the many who are subjected to the ptsd of unfeeling workplace of superiority and rabid arrogance. I resist the strokes and hear aches such covert evil induces. I stop and breathe and look at the spring. These people are sick I say. Pray for them. Thought block. They sold their soul to the company store long ago. Shut their contempt for those who are still at the front out of your mind. Go to church. Go to meetings. Share hugs. Focus on the good. Avoid the shit. There’s a wide open road. Head out on the highway.
Christ is crucified. Get down off the cross we can use the wood. Soon it will be Easter morning. The metaphor is there. This too will pass. Sun always rises. Christ is risen. We’ve seen worse. We will survive . We will thrive. There’s always the resilience.Holy Spirit Come. Lord Jesus Christ. Forgive them for they know not what they do. Be like Jesus. Let the light heal. Invite the Lord into your heart. Let go and let God. Wear life like a loose wrap. Smile and the world smiles with you. Hallelujah Christ is risen.

God

“Plead thou my cause, O Lord, with them that strive with me, and fight thou against them that fight against me.
Lay hand upon the shield and buckler and stand up to help me.
Bring forth the spear and stop the way against them that pursue me, say unto my soul, “I am thy salvation."
Let them be confounded and put to shame that seek after my soul; let them be turned back and brought to confusion that imagine mischief for me.
Let them be as the chaff before the wind with the angel of the Lord scattering them.
Let their way be dark and slippery, with the angel of the Lord pursuing them.
For they have hidden their net for me without a cause, yea, without a cause have they dug a pit for my soul.
Let a sudden destruction, come upon them unawares, and his net that hath hid catch himself, that he may fall into his own mischief.
And my soul shall be joyful in the Lord, it shall rejoice in his salvation.
All my bones shall say, “Lord, who is like unto thee, who deliverest the poor from him that is too strong for him; yes, the poor and him that is in misery from him that spoilt him?"
False witnesses did rise up, they laid mto my charge things that I knew not.
They rewarded me evil for good, to the great discomfort of my soul.
Nevertheless when they were sick, I put on sackcloth, and humbled my soul with fasting;and my prayer shall return into mine own bosom,
I behaved myself as though it had been my friend or my brother, I went heavily as one that mourneth for his mother.
But when I stumbled they rejoiced and gathered themselves together, yea, the very abjects and those whom I knew not came together against me and slandered me without ceasing.
Like ungodly men they mocked continually, and gnashed upon me with their teeth.
Lord, how long wilt though look upon this? O deliver my soul from the calamities which they bring upon me, and my life from the lions.
So will I give thee thanks in the great congregation; I will praise thee among much people.
O Let not them that are mine enemies wrongfully rejoice over me; neither let them wink with eyes that hate me without cause.
And why? their communing is not for peace; but they imagine deceitful words against them that are quiet in the land.
They gape upon me with their mouths and say, “Fie on thee, fie on thee, we saw it with our eyes."
This thou hast seen, O Lord; hold not thy tongue then; go not far from me, O Lord.
Give sentence for me, O Lord, my God, according to thy righteousness; and let them not rejoice over me.
Let them not say in their hearts, “There, there, so would we have it; neither let them say, “we have devoured him"
Let them be put to confusion and shame together , that rejoice at my trouble; let them be clothed with rebuke and dishonour, that boast themselves against me.
Let them be glad and rejoice, that favour my righteous dealing; yea, let them say always , “Blessed be the Lord, who hath pleasure in the prosperity of his servant."
And as for my tongue, it shall be talking of thy righteousness, and of thy praise all the day long."
Psalm 35

I do love reading psalms when I am under duress.

Freedom of Information, Transparency, Confidentiality and Psychiatry

In Canada, a person may see a psychiatrist, directly or by referral to the psychiatrist by another doctor.  In British Columbia, the latter holds, and the psychiatrist reports his or her findings to the family physician, though increasingly as is the case, a walk in clinic doctor who may or may not see the patient again, as they are merely one of many doctors working  in that walk in clinic.
However, without the referral from the GP, in British Columbia, the Medical Service Plan,  the third party government insurance payment plan will not pay the psychiatrist.

If a patient comes to a psychiatrist, the doctor is required, because of the payment schedule to write a report.  This report includes a Mental Status Examination.  A mental status examination includes highly  intrusive questions about a person's cognitive abilities, thoughts, dreams, aspirations, resentments, obsessions, sexual fantasies and desires, among other things.
The psychiatrist records this 'confidential' information in their notes.  The notes used to be stored in locked cabinets but more often are stored in computers.  The "security" of these files is dependent on the institutions which have been notoriously slack in guarding patients information.
In private practice offices the 'security' depends solely on the computer savy of the psychiatrist and the trustworthiness of their staff.  The cost of "security", in my case 'thousands of dollars' ,is an ever increasing cost that few are able to manage in small businesses especially given the evidence that the 'rich' corporations are routinely failing in this regard despite their 'promises' and 'marketting' ploys.
 All psychiatrists who are trained as psychotherapists, especially those psychoanalytically trained as I am, (with additional formal training as a hypnotist, cognitive behavioural therapist, focal therapist, motivational therapist, mindfulness therapist  and strategic family therapist ) record 'process notes' and 'content notes'.
Process notes are commonly paradoxical and ironic with no 'validity' as 'fact' in contrast to 'content notes' which are facts however these 'facts' , in my case, commonly a statement by a patient are wholly referenced to context.  They have no 'true' validity without interpretation or as understood by a similiarly trained and experienced psychotherapist. I have seen the most horrendous misuse of psychiatric records with no one seeming to 'care' . It's indeed frightening the extent of this abuse.
The reports (in contrast to notes)  I share with the general practitioners selectively excludes a great deal of information that was provided in the interview and a great deal of information that was in the notes. This is 'normal' practice and done with no malicious intent or planned malfeance.  Insurance companies and courts knowing this 'norm' have taken increasing to demanding the 'notes' which they proceed to 'interpret' regardless of whether they have a 'code' or not.  The distribution of this material within these 'Borg like"  institutions makes mockery of the very term 'confidential' once a person signs 'a release of information'. 
Increasingly though, money and employment and legal action are all 'withheld' until the bullied patient is 'forced' indirectly to 'sign' the 'release of information' only learning then that the information they shared with their psychiatrist (it's worse with psychologists) about their sexual fantasies about guppies is now common knowledge in a law firm or insurance company. The more unusual or bizarre the behaviour (ie unique) the faster it's movement on the gossip mill.
All psychotherapeutically trained psychiatrists do the very same with regard to 'process' and 'content' note taking..  Note taking in this realm is also highly idiosyncratic but interpretable clearly by the note taker and commonly the patient given that it's in a context, of months or sometimes years of therapy.
Solely psychopharmacologically trained pschiatrists have an easier go of it as their notes are usually simplistic and akin to the standard 'content' notes made by family physicians.  I have been  a member of the Canadian College of Family Physicians and am a fully accreditted psychopharmacologist so I am very aware of the different modalities of note taking.
In the form of 'process' note taking it's more like poetry whereas the 'content' note taking is more or less like a 'laundry list'.  The new 'brain' doctors, solely interested in psychopharmacology, do not "mind" so much issues of confidentiality because they are mostly interested in the "symptons' and their notes commonly record bowel movements and 'feel good' 'feel bad' information.  Given the limits of their 'interventions' and their 'psychotherapy deficient"  'training' , asking many of the questions and learning the kind of psychosocial spiritual information essential to psychotherapy, has been construed by some clinicians as akin to 'assault' since the risk of exposure to the patient isn't justified by whether a person choose antidepressant a or antidepressant b  to treat the sympton. The medications in psychiatry are not disease specific but 'symptom' specific. The formal psychiatric evaluations were developped in an era when psychiatrists were more broadly and deeply trained than some of the recent approaches to mental disorders which rely mostly on sympton checklists suggesting a possibility for a wholly different less intrussive and less invasive psychiatric evaluation for psychopharmacologists. Indeed there is a movement afoot to have pharmacists take over this role leaving psychiatrists as traditionally to address the issues of diagnosis, broader biopsychosocial spiritual issues and provide psychotherapy specifically.
Within the bipolar field of psychiatry it is said that the psychopharmacologists would not recognise a lacunae if they were one and the psychotherapists wouldn't recognise as synapse if it was missing.
Most psychiatrists live between these extremes but the note taking and issues of confidentiality, boundaries and transparency reflect to a large degree the dominance or subservience of this body/mind or materialist versus mentalist spiritual split in perception.    A 'hug' for instance might have no place in the repertoire of a psychopharmacologist but be specifically highly beneficial judiciously and strategically used in the course of psychotherapy.
Psychopharmacologists simply don't do 'process' notes and 'lack' dynamic multidimensional consideration of the patient introjects.  They mostly treat the patient in a reductionist way as an 'organ' with 'brain disease' and don't normally address the 'mind', the dream person, the 'projection' and counterprojections, relationships in depth, rarely consider 'quality' over 'quantitative' considerations.   They would never consider  the patient has as part of a multidimensional being in a web of relationships coping with the mystery of life.   
Insurance agencies and legal processes are best understood in their reductionist function as dealing with matters of  materialist 'money' and 'consumer society values'.  The courts are souless entities not completely without humor though.   Indeed they go to great lengths to  put a monetary value on all manner of 'qualitative' aspects of life, their function being monetary based, their answers limitted by the prevailing cultural norms. They do not consider 'intrapsychic' phenomena and put the lowest value on matters such as 'quality' .  Loss of 'earning capacity' gets a higher return on personal injury than loss of 'quality' of life.
There is no judgement from me in this regard, just as statement of the limitation of the 'subjective' once it enters a world more concerned with an 'objective' measure.  At the subjective level what is 'private' is individually considered but the courts and insurance companies and strangers cannot even conceive of the concerns that more sensitive individuals might have regarding confidentiality. Some people live outside and some inside and bullies lack all sensitivity of this.  Psychopaths are defined by their lack of empathy and institutions often appear more psychopathic than human in comparison.  The corporation by definition though a 'legal person' lacks  any of the 'person hood' conceptualized by theologians and to a less degree psychiatrists. The 'legal person' is reptilian at best where as "person hood" in psychiatry engenders considerations of respect and appreciation and sensitivity at a level more mystical than base behavioralism.
When patients had family physicians for life and the family physicians files were confidential and the family physician and the psychiatrist were usually close associates, everything generally went smoothly.  Now a third of Canadians don't have family physicians, the family physician turn over is  high too. The 'walk in' clinic with even it's higher staff turn over and third party 'record keeping' and high support staff turn over with no necessity for training in 'confidentiality', no necessity for 'bonding', nor 'certification' and increasingly low paid 'phone girls' with the  lowest paid 'filing clerks', well frankly,   the medical "system" went to shit.  These changes aren't limitted to the medical system but run through society which is increasingly mobile and diverse. 
Patient's records no longer are by any true means, beyond appearances, truly confidential.  The key word here is 'appearances'  (Owen Barfield wrote a book, Saving the Appearances - it's been one of the most important and telling books I've read in my life.)

The Freedom of Information Act then came along, possibly to 'correct' the increasing divergence from what was once a sacrosanct 'principle' and now was a thing people only paid 'lip service' too. The Freedom of Information Act allowed any patient access to any medical files or reports with their names on them.
I have used the Freedom of Information act to access records pertaining to me and as with all who have used this was surprised  even horrified, by the mis information, false information and major areas of 'deletion' (for questionable reasons).  That said the 'gist' in my case was overall well meaning and mostly correct.
(I was reminded of the  Hitchhikers Guide to the Galaxy one line encyclopedia regarding earth, "Mostly Harmless".)

In contrast I've seen major errors in records in court documents and have had countless patients tell me about major errors in their 'files'.  At one point in my life I had some time in the evening and worked in a locked psychiatric facility so spent hours each evening reading files of patients who were incarcerated under the governor general act for heinous acts (a mother who killed all her children believing them fish, for instance).  The 'thread' ran true through years of hundreds of peoples involvement and reporting but the 'errors' were significant despite in many cases the brightest of the best and the best efforts.
 This is no surprise given perspective. A simple view of journalists mis reporting and gross errors on major networks is evidence of the carelessness in this 'media' and 'entertainment' industry.  Knowing in depth stories I've been involved with I am still amazed at how wholly wrong reporters can be and how much they misinform for some 'agenda' often not known to the naive citizen. Hence whole news agencies can be simply 'propaganda' outlets for a government, a political party, an individual or a general idea.  Similiar individuals reports on a patient in a psychiatric ward would often tell me more about the reporter than the actual patient. It was this reason that I began recording exactly what the patient said rather than 'describing'.
In another community case a woman had the same name as a known violent criminal and whenever she was dealing with beaurocracy this material, misfiled, caused everyone to mistreat her until through the Freedom of Information act she 'righted' a rather difficult wrong.  Dramatic examples are uncommon but 'to err is human' and reports and notes and files are full of minor errors. The question is whether these errors would change outcome or not and usually not.  In one of the psychiatric files I reviewed a man had killed a couple of people and over the years the number fluctated from one or three sometimes in the reports. It didn't matter, though the devil is in the detail, because he still wanted to kill all humans, and no medication or therapy had altered this.

Supreme Court Chief Justice Beverly McLaughlan is waging a one woman fight for 'transparency' in the courts.  A court reporter records what is said mostly but does not include the shouting and bullying by judges or the sideways glances and sneers and various other examples of body language that occur in the court.
Our elected officials are on camera in parliament.  We can watch them being little boys in questions and answer period or dozing.  It helps us remember our own humanity.
We've long had cameras in sports event. Real time 'play back' has been accepted  bythe 'referees' who balked at 'transparency' in the sports arena till someone woke up to the fact that the world is moving faster and we need 'real time' means of correcting errors.  When I reviewed the 'records' of the incarcerated the changes I actually did introduce could have been done years earlier if anyone had taken time then to note the 'errors' . 
In institutions 'reviews' are a gargantuan expense. All those I've done have been mostly pro bono but the difficulty with 'enquiries' is that given their 'agenda' , "terms of reference' and 'mandates' they often simply add a new level of error in the system.  Transparency is about catching the mistakes or areas of disagreement early. 
There are judges who really want us all to return to the good old days of  the 'back rooms'.  Given the 'deal' making now in the courts this is happening to a large extent given the costs of the old forms which cost so much mainly due to the unwillingness to embrace change and accept 'transparency'.
Freedom of information is costly.  It's costly to gather court documents and the 'cost' is where the penny stops.

"Only the rich can afford justice in Canada,"said my now dead friend,Lawyer Dugald Christie,  He was riding his bicycle to the Supreme Court of Canada to burn his robes once again to express his shame as a world renown barrister that the poor and now the middle class could not afford the costs of the courts in British Columbia.
It was equally true that only the truly rich can afford 'privacy'.  But even the paparazzi have made the lives of the rich and famous an open book . Then there is wiki leaks to compound matters, not to mention satellite imaging and fly by drones. 
Privacy was a thing taken for granted, like clean water years past, but today is a truly expensive commodity available to some and very limitted in some other circles. Those in the ghettos long ago said that their crimes were only known because they lived on the street and didn't have mansions on the hills to hide their perversions in.
(I was an expert witness in a court room named after and paid for by a world reknown pedophile whose philanthropy was equally well known)
However, one is taught, never question city hall.  I have personally found it wiser over the years to avoid confrontations wherever possible despite its tendency to find me.   This occurs because I try to defend truth and I defend my patients from abuse to the best of my ability.  My senior colleague laughs aloud when I complain because he says 'truth telling" is always attacked.  He points to his favourite example, Jesus.
The CMA Code of  Ethics states; 1. Consider first the well being of the patient. and 3. Provide for appropriate care for your patient ....including physical comfort and spiritual and psychosocial support.
I have been a  member of the Human Rights Association, the Canadian Civil Rights Associations, Psychiatrists Against the Political Abuse of Psychiatry, and  Physicians for Social Responsibility.
I don't believe I will ever be  forgiven by the authorities for finding famous BC Lawyer, Jack Cram, sane, when he was accused of being 'insane' for calling the BC court, a "Nazi Court'. The court's psychiatrist expert witness, found him "insane" which was at very least politically correct.
My colleague was jailed for her position against war while my other colleague paid dearly and was harassed to no end for his objection to the waste of young soldiers lives  'friendly fire' and 'accidents'.
The cycnical says "no good deed goes unpunished'.  I know personally the most heinous disgusting persons in positions of highest power yet I also know people I admire in those very same places. There's balance and homeostasis to always consider in this world where St. Paul, a great knower of human behaviour, said "we see as through a glass darkly". 

I am afraid of the courts, which is probably a healthy fear given the element of 'legal lottery''. There's a whole industry in the legal world of assessing judges prejudices, no different from what is done for batters in baseball.  It's the principal reason I say that a person needs a lawyer if they go to court because there's just too much 'back room' dealing, when it comes to 'picking a judge' or 'selecting' a jury.  It's all very much 'rigged' and 'arranged' and no longer the court of Solomon.  Given this complexity of the legal process and the increasing cost of lawyers, all manner of 'bullying' is possible for the rich relative to the poor.  However, when something, especially legal services are offered 'free' there is a great tendency for their abuse given the number of people with an axe to grind.
Lawyer Dugald Christie began the 'pro bono' legal services, getting me to accompany him to jails to provide pro bono psychiatric assessments, something I've done more often than I care to remember.  I think I'd be a millionaire today if I charged for all the pro bono services I provided people who couldn't pay.  Doctors have a long history of that. I'm not surprised the Law Society awarded Dugald Christie for his work with the poor. The lawyers I know personally and the judges I know personally know the value of men like Dugald Christie.

 I've experienced abuse of authority myself but have treated hundreds of patients who were physically and mentally abused by authorities, many who were actually physically tortured.  I served as the psychiatrist for the Residential School abuses treating dozens of Indians chiefs.
I have a serious respect for authority and great admiration for authority. I'm not one to romantacize mob rule and always liked the Beatles song "We don't want a revolution".   I've met 4 sitting prime ministers and dined with a number of judges including supreme court judges.  Those people I have known have to my mind made me confident that Canada is ruled by the finest of people and our institutions are safe and secure in the hands of the very best. There are naturally quirks and blemishes but overall, really, this is a great country. Vancouver is a great city.  British Columbia is a great province. Canada is my home and I am very proud of it.  But concerned.

Because of freedom of information and the clear message it has made regarding relationships between doctors and patients specifically, I have shared all my reporting with patients. It is my 'policy' to have patients read whatever I am writing about them and reporting about them.
This has resulted in my life being threatened in the office on several occasions. I reported that a man should not be allowed to have a gun and he became very belligerent.  I reported  that I believed a man was a pedophile and he told me he'd remove me.  It's clearly the down side of 'freedom of information'. I have had dozens of complaints to the College of Physicians and Surgeons because I have 'diagnosed' patients as having drug and alcohol addiction' and this has affected their employment or insurance.
The Canadian Medical Association Code of Ethics states 4. Consider the well-being of society in matters affecting health.  In psychiatry and addiction medicine this is especially relevant because fundamentally we are routinely asked if a patient is a risk to themselves or other or are 'competent' for work.  The CMA Code of Ethics demands nothing less of doctors, "Practice the art and science of medicine competently, with integrity and without impairment." 
Commonly patients see psychiatrists on referral by family physicians because of work related issues and the question of 'competence' and 'impairment' are therefore central to the examination.
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I have been asked by patients if what they say is confidential and I have at length explained that if they sign a 'release of information' for their insurance or go to  court and their records are subpoenead then whatever I record is going to be released.  I have repeatedly told patients that I can not 'lie' for them so find it ironic that I am called a 'liar' directly and indirectly on occasion because 'lying' is extremely lucrative in our society and I am not nearly rich enough to be a liar of any significance.

Patients ask me to lie knowingly or unknowingly routinely. I must assume that patients ask others the same thing.  It's never that overt.  But that's what it comes down to.  Similarly patients ask me for narcotics and increasingly to sign papers saying they can't work when it's not really apparent to me that they can't or can.
I once diagnosed patients as 'malingerers' but have been advised that this is no longer 'politically correct'.  I have had to pay enough thousands of dollars for diagnosing people psychotic and a danger to society only to have that very same society's overpaid representatives punish me for my conscientiousness.  When I learned that police for a time were avoiding responding to emergencies of various kinds, especially those involving violence, I certainly couldn't blame them. 
I was the only Canadian physician to work in northern manitoba reserves after a 2 year attempt to recruit because of the dangers. My colleagues are admittedly smarter than I am.  I am a spiritual fool.  I got tb, beat up, nearly drowned, was chased by polar bears, chased by a mob and was in a plane crash but looking back it was good experience if anything.   What's TB and PTSD compared to knowing you've done good.  It's certainly hard to continue to do good however with the pompous and mighty arrogantly condemning everything that's not overtly lucrative and safe. Only that which is 'valued' in a materialist way is 'protected' institutionally.
 I am very careful in my diagnosis, according to DSMIV and now DSMV and have always been considered one of the very best of 'diagnosticians' in physical medicine and especially in psychiatry.  It takes a lot of training, experience, and careful consideration to make 'correct diagnosis'   I've  found the courts at times no longer as respectful of the significance of diagnosis or why doctors consider this so important, yet they themselves make a major distinction between 'murder' and 'manslaughter' and expect society to respect their 'language'.   The courts have also never been accused of a lacking in hypocricy. Jesus did poorly in the courts of his day and it was his outrageous idea to say, "take the timber out of your own eye before you try to take the sliver out of your neighbours eye". 
Perhaps in this regard we have ourselves to blame in psychiatry because especially in the area of 'mood disorders' there are diagnosis with no inherrent validity lacking specifity and having no end of 'sensitivity'.  This has been an ongoing serious complaint especially internationally about diagnostic  'cookbook' approach much maligned by leading specialists and even discouraged directly by the APA and authors on the  DSM committees. 
Mostly I try to avoid conflict but increasingly the 'complaints process' of the college is such that any doctor who doesn't 'sign' or 'agree' with the patient is faced with a complaint which can cost the doctor on average $5000 to $10,000 even when they are cleared. I am routinely cleared of wrong doing, but never unscathed,  but the cost of doing 'the right thing' and being 'moral' and 'ethical' is millions of dollars loss of income. I don't' recommend it.  The richest colleagues I know in psychiatry are the greatest rogues I've personally known.  They're a minority and I know in my heart of hearts I don't want to be like them.  No amount of money can buy back a soul or cleanse one of their stink no matter how entertaining they are.

Further, the most ignorant and inexperienced, those in positions of being 'critics' , always imply or suggest that 'you could do better' and if 'you spoke softer' or 'phrased your questions' or 'chose the time' .then the 'triggering event' would not have occurred.  This simply is not true, and at worst, downright ignorant, pretentious and arrogant.  Everyone who is in the front lines knows that 'perfection' is impossible and only those 'critics' who avoid reality have such space station notions of life on earth.
Do anything to interfere with a persons income, freedom, sex or ambition and you will create a resentment. If 'kill the messenger is 'lucrative'  then this will occurr.  If there is no protection for the individuals who are obligated to tell the truth then people will eventually lie or walk away.
  
Today mentally ill and addicted patients are being again marginalized and ostracized because no one can afford their complaints. 
Cherry picking is the process where doctors avoid seeing sick patients.  Increasingly doctors are not only cherry picking their patients but they're cherry picking their practices finding any niche where they have the least contact with the front line.  Administrative medicine and  radiology have no shortage of applicants. 
Patients are 'black listed' by diagnosis such as 'Borderline Personality Disorder' (the kiss of death for a female patient) or "Antisocial Persnoality Disorder " (the kiss of death for a male patient).  Further the more diagnosis a patient has the less willing is a doctor to see them.  Commonly, some of the patients I see, have been 'rejected' by 30 to 50 psychiatrists.  This doesn't look good for me that I'm not the 'first choice' but it more a  reflection of my colleagues who try to spread the 'joy' knowing my willingness to accept multiple problem patients despite the high cost.  "I knew you'd see this person but I didn't want to burden you with yet another patient like this so tried to see if anyone else would take them on and no one would."   

The patient who had sex with 500 children is likely still very unhappy with me for reporting him to the authorities and assuring he was deported to the US where he was wanted for crimes against children in 4 states.  The stoned pilot who was required to get treatment and urine testing still tries to find ways to hurt me. There is a man who beat prostitutes leaving a couple near dead, in psychotic rages, and I don't believe that he has ever forgiven me for making the diagnosis of him that required his treatment.  I have on several occasions been threatened to remove from my reports information that a patient doesn't want but I have felt is necessary to the integrity of the report and the basis of the diagnosis.  I have never lied for a patient knowingly.  I suspect if I was the psychiatrist for Mayor Ford he would very surely disapprove of my diagnosis and likely hurt me more, as the richer and more powerful who have objected to certain diagnosis, have  more power to harm.
The matter of diagnosis simply was never such a serious matter for me in general practice except on those occasions when I diagnosed a person partially blind and they lost their driver's license. I remember too that when I worked one summer as the doctor in an STD street clinic people were often angry with their diagnosis and sometimes insisted that their diagnosis not be 'written' down, for fear their husband might find out.  This was an issue to in early years with the diagnosis of HIV.  Patients were so abused and punished for this illness then and so many were afraid to see doctors.  A major public health initiative had to take place before people felt safe about seeing doctors. This is true increasingly with addiction medicine and psychiatry in general. 
Addiction Psychiatry specifically is not a place that people are likely to go saying, "I sure hope this specialist finds out whats wrong with me?" as is commonly the case with other areas of medical specialty.
I have however spent years defending patients who were mis diagnosed especially when there  has been a conflict of interest and extreme predjudices or biases and made major errors for profit or through negligence.  
When a patient is in dispute with the courts, the patients lawyers and the lawyers for the other side subpoena the file and all information. A doctor must release their full and complete records or go to jail.
My psychiatrist colleague fought the courts in an attempt to conceal her 'notes' from the courts and lost. I believe she went to jail for a night or eventually simply caved before she spent a night in jail. It's a celebrated case. Indeed even ministers and their congregation communications are no longer sacrosanct and last I learned priests could not conceal what they heard in confession if subpoenaed.
The key in all this is 'what is recorded'.  So increasingly people don't record anything.  By contrast look at the notes of Louis Pasteur, Freud, Carl Jung, and Einstein.  Science is about 'records'.
The consequence of this 'approach' to the present problem is that it contravenes CMA Code of Ethics "Refuse to participate in or support practices that violate basic human rights.'  It's a basic human right for patients to get good medical and psychiatric care and yet if doctors can't 'record' what transpires for fear of misuse of the files,it's a problem. This is indeed is the tendency of 'medicopoliticolegalese' and political correctness yak yak.  The notes become 'spam' .
So when I share transparently, my reports with patients, they commonly ask is it necessary that I include some detail or other.  I then agree if its not relevant.  I do not let their employers insurance company know in the report that they had sex with a pig on friday night drunk if their job is not pig rental for a brewery outfit.  These are not far from true stories.  I've seen more cases of beastiality and various perversion and seen more unexplainable behaviour than I care to recall.  Maybe the SPCA has an invested interest but others interest would be prurilent.
Commonly people do not want their gp to know information that they have shared with me and I will not report information of a decidedly personal and private nature with a walk in clinic physician the patient may have seen once whose secretary chews bubble gum and is paid minimum wage.
I once had such a secretary for a while and she stole information and materials from my office and I learned that the police do not respect or prosecute theft of files from Psychiatrists office. So much for even physicians ensuring confidentiality of files since there is no consequence for the abuses. If one is concerned about private practice offices ,the institutions are a nightmare in comparison.
Indeed, the police  told me that they believe this sort of thing happens often but that I was indeed the first person to report it.  The cost of that exercise  was thousands of dollars.
Further I learned from dozens of colleagues that when they have fired 'help' they have been threatened with 'sexual harassment' allegations and have been extorted thousands of dollars.
I learned the hard way on that occasion that despite my best efforts with the highest level of security available, computer geeks up the ying yang, and locked files with chain of custody keys etc, a temporary help girl who turned out to be a crack addicted psychopath on the side, could breach all security and steal files without any consequences.

Most of us on the front lines are doing our best with very little resources and only the arm chair quarterbacks on Monday morning are right.  But then they don't have to be accountable for their actions as we on the front lines do. And everyone knows armchair quarterbacks are always right.

This is true of social media "confidentiality" too,  where increasingly communications are being openly 'interpreted' and used in all manner of ways other than that which was deemed their original purpose.  If one had been paying attention they would have learned our ally, the United States of America, under President Obama, has accessed all our electronic communication, that's every text message and email. This is not paranoia. It's just a fact regarding the lack of 'confidentiality' available to Canadians today and the 'appearances' which are continued till someone learns to deal with this game changing dramatic reversal of our lives.

Our insurance body, the Canadian Medical Protective Association, advisees us to write 15 minutes of notes for every 15 minutes of examination which has literally halved the available doctors in the country and doubled the cost of health care to every citizen. This followed a judge say, "if it isn't written down,it didn't happen".  "Loose lips sink ships".
I keep copious notes and records, typing as I do at the speed that people talk.
I do not believe there is any 'confidentiality' in the 'system' since I learned that the most confidential material the government collects is tax reports and with our tax information the following has happened
- over a hundred government departments have access to them
- in addition to the US,  there have been a half dozen computer attacks on the canadian government files, thought to originate primarily in a chinese military facility and all, not just some, but all information on Canadians has been accessed for foreign agents.

But if you had sex with father's mistress and told me, I recorded it.  That information and any other information that anyone has on you is available through the freedom of information act, however since this is the law, I've always shared what I write with patients and have been 'transparent' with the information I gather. When I write letters to doctors I will remove information which is not necessarily pertinent to their 'care' as I understand that to be.
I do this not to 'deceive' or through 'ill intent' but because I have a 'therapeutic relationship' with a patient and to maintain that we must have mutual respect.

This was a major concern when I was working with HIV patients and we were being asked to disclose information about patients that would get them 'fired' not because of a public health risk but because of the prejudice in their accounting industry against homosexuals or diseased persons.

Pscychologists, nurses, counsellors and all others care givers in Canada are under similiar strict requirements regarding shareing information with the courts at risk of jail themselves but in contrast I know that I am usually the most rigorous in explaining my limitations to patients.  Nobody wants to face reality that we are all really very naked today.  Even the emperor has new clothes.

Even lawyers are highly restricted in the lawyer-client 'priviledge' according to my Canadian lawyer friends. So while American TV has lawyers and police and Dr. House are doing all manner of silly business this is not true in Canada.

People say and write nonsense all the time in British Columbia.  We only consider them truly insane if they believe and act on the nonsense they sometimes spout.

Unfortunately in Canada, a young country, by any means, there is alot of "false witness', and people forget that the Ten Commandments given to Moses put 'bearing false witness' as up there with murder.

I take the matter of truth seriously and am not in the habit of 'bearing false witness'.  

The best news about confidentiality though is really most people don't care. They are in fact too busy minding their own business to care about yours. 

The great thing about Canada is we really do care, individually and collectively, and despite the lapses, we muddle along and with a combination of checks and balances, freedom of information acts, Honorable Beverly McLaughlan, the Colleges of Physicians and Surgeons, Dugald Christie, the Law Society, the Canadian Medical Association and psychiatrists things work out well overall.  The sun rises in the morning even though it seems a bit sooty and smoggy.  Truth prevails.  Good wins out in the long run. We are, if you are at all a student of history, doing way better as peasants than the vast majority of our forebears.
When I question my home I think of Cambodia where I just was and know that only a few years ago 3 million people, a quarter of the nation, were murdered by Aetheist Communist Pol Pot in 4 years.  This is simply not going to happen with Harper, Mulcair and Troudeau in parliament. Locally our courts and institutions aren't perfect but they are way better than the next best thing. 
That said, I'm concerned.

Thou Shalt Not Bear False Witness

Thou Shalt Not Bear False Witness Against Thy Neighbour is number 9 of the 10 commandments right up there with Thou Shalt Not Murder and Thou Shalt Not Commit Adultery. The most self righteous seem to conveniently forget this truth. Everyone can find redemption and we learn in the Bible that the murderer Moses could make amends as did the adulterer David. It's those that bear false witness though that are in the express lane for hell and may not even get to stop at purgatory.

Bearing false witness is ubiquitous in the post modern world of politics and law. Truth as objective and verifiable is lost to emotional reasoning, subjective bullying and opinion making. Social constructionism does the least construction but the most destruction following on the adolescent Marxist solution of promoting perpetual revolution.

The self righteous claim that AIDS is God's answer to homosexuality but it's far more likely if a vengeful God is kicking ass he'd be far more pissed by lies about weapons of mass destruction, oral sex not being sexual relations and the daily deceit in every court in the land.

While I've embraced the pluralism of modern society I am deeply concerned that loyalty to my group (tribalism and gangsterism) as being a higher value than truth, causes deceit to be acceptable across race, religious, gender and sexual orientation boundaries. This is the thinking of the Sociopath. Where once the highest things of society were considered angelic and lowest developments of society demonic, the bearing of false witness was the most demonic. Those who bear false witness against their neighbour are lower than pedophiles and somewhere down there at the bottom of human evolution along with the usurers. We should not have to share washrooms with them and hopefully soon the tatoo 666 that they have on their foreheads will appear as clearly as guns in the airport scanners.

In civilized countries the law says that those who bear false witness get the punishment that they would have seen given to their maligned neighbour. When did our courts choose to drag their knuckles and celebrate those bearing false witness. Purgery certainly doesn't get the sentence it once did when everyone knew that those who committed purgery couldn't be trusted as washroom attendants keep their jobs as CEO's and Cabinet ministers.

From where I'm standing, a vengeful God would send AIDS and Katrina and Tsunamis and economic crisis because of all the bearing of false witness that is going on in this land. If the courts and politics aren't soon reformed we'd be best to start building boats the dimensions that Noah used. I think today that's called the Space Shuttle and Space Station.