SPIKEVAX Bivalent Covid and Omnicron Variant Vaccine (Moderna)

I just received my SPIKEVAX Bivalent -Original/Omnicron (Moderna) Vaccine.  I also had a regular Flu vaccine as the newest vaccine wasn’t available.  This was at Life Care pharmacy with Pharmacist Patel , all very professionally done.  

I prayed before the experience. 

As Christians we fear less about what goes in our body than what comes out.  Historically spiritual folk have survived poisoning and  handled snakes. I don’t think taking a 9mm in would be wise though.  

Half those I know are reasonably anti covid vaccines for themselves.  I know their concerns individually are likely valid.  The public health position is good too despite the fact that the leadership in Canada has been irresponsible and tyrannical making it difficult as a doctor to support their at times draconian positions.  I’ve had 2 covid and 3 boosters and a couple of other vaccines in the last couple of years.  I’m thankful and believe for myself I’m choosing correctly. If I wake up a beatle maybe not.  I loved Metamorphosis. 

I’m here a Starbucks having picked up the mail. I had a small mocha.  I ‘ve chatted with family and Laura.  I’m going to pick up lunch for Madigan and I. I have the afternoon off as I didn’t know how I’d react. Others have been tired and I was after one of the vaccines.  Glad to have so self love,

Loved being at the clinic this morning seeing patients. So enjoyed talking with Belinda and Karen and saying hello to Lydia who’d just returned from a Salt Spring weekend.  When asked why I don’t retire, I say I love working at the clinics.  The people at Royal Columbia Medical Clinic are skookum. Also like Mary Lou and Gary and Dr. Rogers at the Docside Clinic.  I always love seeing patients .  I’m a doctor . They’re sick. I love my work.  Do no harm and help.  I’m thankful but no longer want to deal with administration or tyranny of stupidity or the banality of mediocrity.  I used to get sucked into that drama but now seem to be able to avoid it.  Thank God

God is all of interconnected.  I am the bubble make me the sea.  We are the family of souls, Jesus our brother.  

I am waiting to enter heaven as the last to go through the door. I get to move one when those have gone before.  

I’m kind of coasting.  I don’t feel any need to face major challenges.  I think of working in the jails or for the military.  I wonder about what I’ve not done, the most difficult. I’m already working with the dual diagnosis.  I sailed solo across an ocean but don’t feel like sailing a 40 foot sailboat solo any more. 

I’m looking forward to driving my mini south for a work vacation.  I like the idea of wearing a sun dresss and swimming in a bikini.  Off work I’ll be completely off work. 

There was a medical emergency and I was wearing a dress and I thought I’m old.  I’ve handled dozens of emergencies on holiday, in planes, in trains and more.  But nothing like nails and stockings cause a pause.  Do I reallly want to get involved.  If no one else stepped forward I likely would. But I watched and the young couple who stepped forward had first responder training.  I didn’t need to so relaxed.  Au drab I might forget and serve.  

I want to soak up the rays and relax.  Increasingly I’m delineating work and limited the service. I’m on call but only to return calls every 1-3 days. I was on first call for decades for free and did hospital and clinic call in person countless days and nights for decades.  One in three and one in two. All our service as doctors was stolen by administration who continued to extend their empire while doctors did double time and overtime unpaid.  Recently our service has been denigrated by PM Trudeau who accused doctors of stealing with their RRSP’s.  The greatest most unethical tyrant in Canadian history attacks doctors and gives our personal protection equipment to China and allows the Communist Chines Military and the Communist Chinese Police to operate in Canada.  

I have these intrussive thoughts.  I am having a great day. Despite vaccine and working. It’s a good life. God is good all of the time. I m blessed by family and friends. I’m well fed and well clothed.  All is well. I have peace of mind and joy. I just need to block the past and future.  Resentment and fears break through into my day.  Carpe Diem.

One day at a time. God is in the present.  I need to be here and now. This is the gift of God.

Thank you Jesus. 

Sunday, Cariboo Bonanza Resort, Horse Lake BC

We have so enjoyed our stay here. Horse Lake is between Lone Butte and 100 mile House in the Interlake Region of BC.  I’ve had a lot of fun getting my Coronado XT pontoon boat with electric motor out onto the lake. I’ve fished but not caught anything. Everyone else around me did. Rainbows and Kokanee’s. I also bought a Chiappa 22LR /20 gauge over under shot gun, the “Double Badger”. I rode all over on my KTM 690 motorcycle and shot targets. I took some great bird picture with the Nikon Coolpix P1000.  I read some westerns and sci fi novels. I scrolled a lot of FB and added flippant thoughts and political commentary with knee jerk genius contributing to the cacapohonousbedlam of social media.

I felt blessed. I prayed. I was with my beautiful friend Laura who is easy on the spirit. Gilbert the blind cockapoo with injured back, valvular heart disease and congestive heart failure was a true source of joy. He had us up all night coughing and struggling to breathe. We phone Dr. Biernacki at North Road Animal Hospital and he told us is was the higher elevation in the Cariboo that had caused it.  He upped his diuretic furosemide and Gilbert’s been so much better since. Yesterday he was rolling up and down the hill and playing with his ball. We have a family of ducklings join us each day with their mom and he is just fascinated by their chatter.

We’ve had wonderful heart warming fires and beautiful sunsets. Everyone about has been so civilized.The resort attracts  international visitors as well as locals.  Rustic cabins in the uptown section and downtown RV camping where we are. Lots of old people and children.  Serious fishermen.  Not me.  I even sought the advise of the great fishing guru, Bill, to no avail.  I felt Sentimental hooking the worm.  I’d become a vegetarian again but their sentience disturbed me as much when I cut into a zucchini.  Not surprising, given my Irish roots, I loved potatoes here. I barbecued steaks and smokies and pork chops and had them with boiled potatoes and sour cream and mashed potatoes.  I made bacon sandwiches and bacon and eggs. I’ve enjoyed cooking.  I especially love barbecuing.  It’s been a wonderful vacation with that sense of cares dropping away.

I’ve worked some. With wifi and cellular service I’ve been able to connect to the Oscar Remote by computer and talk to patients on the phone. It was rainy some mornings and I was able to be of service and help.  I only thought about Covid and the catastrophes its brought to some people when I was working. Here its seems another world away.  I’ve seen the continuing corruption of Trudeau politics and Communist China and diabolical UN on Facebook but it’s at a distance. The background here is forest, lake and woodsmoke.  

This Adventurer camper has provided all the amenities with sewage hook up , running water connection, propane heat and hot water.  I’ve really enjoyed reading westerns and sci fi, rich allegories of good against bad.  Lots of tribal justice and revenge.  I then meditate on faith, hope and love.  Forgiveness is always a theme. Letting go. I’m older and still bothered by lustful and fearful thoughts and feelings. I struggle to let go of guilt and shame. Acceptance is a key idea today.  I have to remind myself I’ve not stolen millions from hard working Canadians to launder overseas with euphemistic projects, done any abortions or cannibalized my neighbor. On the balance sheet I’ve not been doing too badly especially this week when I’ve mostly been self critical for not getting up early and catching fish or getting up early and writing the great Canadian novel. I’ve been kind of lazy. I have slept in and napped. Walking Gilbert at his pace with his heart condition. I’ve bought a couple of pairs of sandals at Work Wear in 100 mile House.  I’ve bought a half dozen fishing lures that would have worked better if I had my line in the water more. I’ve kind of stagnated.  Lots of coffee and reading.  I’ve enjoyed my little corner here at the table stretching my legs out to rest my feet on the second drawer where I’ve put a cushion to create a self made couch. Laura has done cross words. Gilbert has slept.

I expect this is a kind of proto retirement. It’s a bit like a lot of my older and younger friends do.  I’ve thought about life and accomplishments. I put a decade into training at the highest levels and struggle like a number of colleagues and educated friends seeing others rewarded and given positions not on the basis of work and meritocracy but through cronyism and bullying and frank criminal behavior. I would have liked to loot a bigger tv. I obey the law and feel often like the Last Boy Scout.  When I’m with Laura I’m comfortable and feel a bit like my old man. I’ve followed in his footsteps, camping, hunting, fishing. He left me his love of the wilderness.

When I’m alone though in the city, I think  jazz and traveling to exotic lands.  I miss the theatre and television. I gave up a relatively hedonistic life of fun and pleasure for a life of calling and service.  That unforgettable moment praying in the University of Winnipeg chapel and my friend inviting me to come along and do the MCAT.  I thought Jesus was a healer but I wonder if I’d not have had a better life as a carpenter. I loved Herman Hesse’s Narcissus and Goldmund, discussing that very theme. 

A lot of the time I think of God and want to be closer, to know his will for me and to have the power to carry it out.  I look back on my life these days and it’s been full and exiting. I’ve been truly blessed. I celebrated 23 years of recovery this week and I’m in my late 60’s. For a guy whose been in plane crashes, sailed through hurricanes, been shot at , surrounded by Swat teams, stood up against all manner of social injustice , fought with really bad people and served the highest courts and spent days with Prime Ministers and Generals and Nobel Prize Winners and Olympic Athletes I’ve been truly blessed. God is good all of the time. But I’m never satisfied. I’m always feeling like I’m falling short of what I could be. I don’t want to be crucified like Jesus or his disciples. I’m a wuzz. Part of my reason for liking skirts and hair salons is because I’m old and feel vulnerable as an old man in todays culture and society.  I’m like an enlightened worm. Or a smart ant. I loved the metaphors of St. Francis. 

I don’t feel protected and don’t feel I can rest on my laurels.  I find myself think of Valhalla. I see the old men, the farmers and such, congregating in the MacDonald’s and A&W in the morning and think that may be me soon. I miss my brother Ron and his fish tanks. I miss my father and his fishing.  I’ve not the patience and confidence that they had. The men and women with children seem complete. The grandchildren give them meaning and purpose. I’m here with a dying dog and feeling that I’ve failed. It’s all in the self pity.  I’ve tried my best but been way laid by evil and corrupt bureaucrats and systems. Years of my life I’ve defended myself against lying psychopathic women and men.  I’ve been so disturbed that I’ve been caught in their low life games. I wanted to play the Glass Bead Game not Days in our Life.  There are times I’ve felt I reached for the stars but looking back so much has just been slogging through the mire of human existence. It’s all perspective and I’ve lived in fear and resentment and muddle.  There’s no merit in beating myself up. It’s tied to envy. I judge my insides by others outsides.

Now we’re leaving here. Packing up and moving to a lower elevation for the sake of Gilbert’s heart and lungs.  It’s an unknown destination.  We had booked this week but on a whim and due to the days July 1st came we took another week of vacation. I’ve not known this amount of unscheduled open time in years.  Again I think of this as a what retirement might well be like. Like a summer vacation in school days and each day an open slate. This truck and camper is like a land yacht and I actually enjoy it more than my sailboat, the land appealing more to me with better wifi and hook ups and the culture of Good Sam RV world. My parents loved the RV world and it’s a more appealing lot than the yachting world. I like the motorcycles and quads and all the dogs.  Life is good.  I am very grateful.  Now I must get stowed and on the road. 

Thank you God for another day in paradise. BC is God’s country and the views are just constant eye candy.  Thank you Jesus.  

ISAM (International Society of Addiction Medicine) 2019 Delhi India

This conference is truly a best conference.  The Pullman Aerocity Hotel is an excellent location not just for the rooms but also for the venue. Laura loves the elegant rooms with the grand bath.  I’m enjoying their expresso coffee provided by the in room espresso machine,  There’s also excellent wifi and we’ve loved room service.  

The venue is the very best, with a rock star stadium feel given the huge projections above the great stage   Most importantly the sound system is perfect. Given the variety of accents from Indian, English, Scottish to a wide variety of ESL European, this has been crucial for me, my hearing not the best to begin with.  The individual mikes have been working as well so we can actually hear the questions from the audience, a too common problem at so many conferences I’ve attended.

I love the huge Hall 1 but there are maybe a dozen smaller halls where I’ve enjoyed the more intimate setting for smaller group discussions. The lunches have been the best of Indian smorgasboard, a 5 star presentation for the taste.  There have been plenty of lounge spaces for colleagial discussions, often what truly makes a conference for me.  To be able to speak in person to one of the greats like Marc Galanter or RC Jiloha is so very inspirational.  

That said, the real joy has been in the speakers and their presentations, their insights and the evidence based research.  Therre were  dozens of speakers presenting at the same time in the various venues.  Consequently it’s impossible to attend them all though the desire is there.  I loved the presentation on the epidemiological surveys. and extent of the problem in India. 

India is 1.3 billion people, 80% Hindu but with a major mix of Muslims, Christians  Sikhs, Buddhists, Jains,  and others. By comparison United States is 330 million and Canada roughly 37 million. There are countless tribes and huge distinctions by areas of the north, south, east and west, with multiple languages despite Hindi being the official language. The joy for me, a Canadian, in India,  is that so many speak English so fluently, not just the educated by the common people as well.  I love to travel but feel so much safer and understand more when I can understand the people better.

India is a very ancient culture with generally high intelligence, highly educated with multiple languages and broad understanding. The urban centres are 21st century’s yet the rural regions are in places terribly backward.

When I was in Bombay more than 30 years ago that mixture of the space age juxtaposed with the ancient was what so fascinated me. It’s no different today  as my experience in Old Delhi showed, rickshaws and motorcycles.

The presenters surpassed themselves in the most prodigious and thoughtful research. Alok Agarwal reported the problem of heavy episodic drinking in the population with it’s strong association with accidents and fighting. Cannabis use was roughly 3% of the populations but mostly men.  However it commonly coupled with alcohol or other substances.  Opiate use, heroin, opium or pharmaceuticals was roughly 2%.  The telling news was that of those with alcohol dependence only one in 38 had received any treatment and one in 180 had received inpatient treatments. When one considers these percentages are of a billion and more, the actual numbers are staggering.  The size of the problem in India as it is all over the world being recognised by government and industry. The seriousness of it as a true emergency and crisis is evidence based. The costs are overhwelming, the loss of life and productivity are profound.  The surveys show that need and point to where best solutions may be found.  Dr. Pramrod Singh and Dr. Atul Ambekar also contributed greatly. Dr. Ambekar pointed out that cannabis and opium had been traditional and recreational with the British regulating this hundreds of years past but things had changed dramatically. The changes  in use the rise of heroin and disruption of community and family were all discussed at the conference with insights and solutions offered.

The chairs ensured the various presenters remained aware of the time. Consequently the meeting flowed like a river as compared to some meetings where the meeting has the feel of a big city traffic jam.

Psychiatry is commonly envisioned as a biological, psychological, sociological and spiritual field. So each of these areas were discussed. Advances in learning of the disease of addiction, presentation of neuro imaging and neuro pathways along with the various associated diseases ,such as AIDS, Hep C . This was where individual treatments were discussed with naltrexone, naloxones, suboxone and methadone cutting edge presentations.  Psychologically the contributions were more Indian with fascinating insights based on Veda and family changes. At the Social level there were marvellous presentations of treatment centres like Shafa and the whole realm of social psychiatry were discussed. Public health was so important. There was mention of 12 step programs and the loss of the relationships and alienation along with a profound discussion of the Gita idea of ‘attachment’ by Dr. Raju Hejala. He presented that in therapy he was effective in helping his patients see the self as not the drug or the addiction and become detached in their thinking from the addiction. 

Dr Khalsa formerly of the NIH thoroughly discussed the whole controversial issue of Cannabis as a medicine pointing out the paucity of research of the standard that the FDA would expect for a compound to be considered safe and effective. To be fair he presented what good had been found and the massive FDA associated research going on to find cannabinoid products that could add to our pharmaceutical tool box. 

Dr. Bunt did provide the most humorous sides showing the  big business of cannabis in the US with high end marketing and even a psychedelic  ‘church of cannibis’ underling that often for many cannabis is more a religion than anything else.

Dr. Nady el Guebaly, Order of Canada recipient and founder of ISAM presented on the need for more research and funding and the history of the rise of the drug problems in parallel to the decline in research funding. The present president of ISAM , Kathleen Brady addressed the issues of the rising crisis.. 

 The Indian Minister the honorable Mr. Gehlot gave a moving speech which was thoughtfully translated and provided in English as a hand out. It spoke so clearly and wisely of the problem and the government commitment

There were hundreds at the conference and I’ve only mentioned a few of the presenters , dozens and dozens speaking to different aspects of the problem of addiction. Dr. Elliott of Birmingham addressed the issue of tobacco use.  Dr. Montoya was especially interesting for me in his clear depiction of the problems and solutions. I was impressed to hear the preserntations on gambling and vaping.  It really was a solution focused conference. Fascinating hearing the remarkable advances in Korea, Iceland and Nepal just as examples. 

I’m missing a presentation now so will shower and get down to more.  So much genius in one location. So much hope too. Working in the DTES of Vancouver Canada in the midst of the fentanyl epidemic with so many young people dying despite our best efforts with opiate replacement therapies and abstinence therapies, it can be dreary.  Seeing and hearing Mr. Gehlot , an Indian Minister to 1.3 billion people speak so compassionately and seriously about the government involvement was uplifting. 

Also I loved seeing the World Congress of Psychiatry, Indian Psychiatric Assocition. Addiction Medicine, UN and WHO representatives at ISAM, all these organizations and more getting together to address this world crisis of immense proportion simply gave me, a lowly clinician, so much hope. I’ve also learned many things I can take back and apply immediately and perhaps make a difference in the lives of my patients who have lost everything to addiction and now are suicidal , chronically and sometimes acutely. For Suicide and Depression go hand in hand with addiction. But seeing the amazing faces of recovery and hearing the heartening successes from around the world was truly inspiring. 

I have learned

I have learned again that I have a great group of colleagues and friends from around the world and that I can call them at any time and know that they will listen and help me with any problems I might be encountering.  In retrospect I’d be wiser to reach out sooner rather than stew and worry and jury rig solutions on my own.  I know I have friends close to home but these friends I’ve known and shared with for 20 years have insights into similar problems and concerns. In one case what I thought was a local insane administrative problem reflects some ideological move which is happening far and wide and causing untold suffering for patients and doctors. Yet it’s an idea that has infiltrated the wee pee sized brains of the stupid and taken root like the holy words of Marx.  Some as yet unidentified health administration ‘prophet’ has infected these folk causing sickness in middle management, a kind of arrogant brain fever.  I am not alone. I felt so alone.  Yet British doctors and Australian doctors and doctors all across America and Canada are seeing the same insanity and the victims of the mental aberration don’t even perceive themselves as having this idiocy.  They collectively lack insight and react aggressively to anyone who tries to point out their derangement. They are definitely not willing to change and in the precontemplation phase regarding any willingness or motivation to change. So we do best to detach with love. Most of us can’t leave or don’t want to.  All of us seem most to love helping patients and serving our fellows so its a bit of a muddle right now for a wide variety of reasons, mostly the lack of education of management, their faulty models, aging populations, chronic disease and unfunded political promises. The tendency to ‘blame’ the individual doctor for systemic flaws simply reflects their own fear and aggressiveness.  It is best to stay safe.
I have learned that there are new medications that are indeed curative despite their side effect profiles and well worth a trial where all else has not been working. The costs of the new research are high but the cures are indeed amazing. There is hope for much with modern medicine. In the field of addiction where the reward site of the nucleus accumbens and dopamine tone are identified genetic studies and new medications are coming along. Some 10% of the population, maybe as high as 20% are affected severely by isolation and shaming. The existing legal approaches to the disease are wholly counter productive and politically there is a need to educate politicians, judges, and various others to appreciate the effects of shaming and isolation.  Primitive administrative models which rely on shaming and isolation, focusing on making individuals feel less than, are indeed the social mechanism that fuels addiction.  The monkey models of the effects of isolation and making one feel less than are amazing. The animals have no desire for cocaine before the mistreatment but after exposure to such regressive management become rapidly addicted.  The cost of addiction is simply widespread and misrepresented because of the tendency to see different organ or illnesses as separate when they have the same underlying abnormality of the reward mechanism.
I have learned that there is much benefit in exercise and that mobility should be more the focus than being free of pain.  Mobility is central to the human condition and once mobility is loss a wide range of illness follow.  Addiction is tied to loss of mobility so work with pain must emphasize mobility foremost.
I have learned that street fentanyl is a misnomer compared to the pure fentanyl used by anesthetists. The nature of the ‘fentanyl’ or ‘down’ used by patients is more akin to animal tranquillizer than opiate. I feel remiss in not being on top of the chemistry of these agents and will when I am home research this more as there may be insights to be had regarding addiction and substance.
I have learned more about the models of health care delivery and that there is a political buzz word ‘universal health coverage’ which doesn’t mean anything like people think it means. I have learned that Americans in general have no idea what the Canadian health care system functions like. It is apparent that the various health care systems around the world including the American handle emergencies and acute illness well but the problems arise in chronic care and rarer diseases.  It was truly fascinating talking with front line workers like myself about what would actually be done for individual cases and how similar the deficits were for the homeless and that access to medical care varied dramatically especially for the rural folk,  It was a wholly different discussion than the political disinformation and misinformation ideologically driven by media.
I have learned that I really like having discussions with colleagues about religion, politics and health care, and all manner of matters because not one of them belittled or abused me for an opinion different from theirs.  It was interesting that there were so many differing political opinions regarding the present President, those who clearly hated him and those who loved him but no one became violent or offensive but instead stated simply how the regime change was affecting them personally.  I was fascinated by how down to earth the people were and how gracious, more than me by a lot, those were who had been exposed to the 12 step. I found the parents and grandparents even more gracious and just a true joy to be around.
I have learned that the vast majority had benefitted from 3 to 5 year monitoring and that a restrained approach consistent with other socially affected models which didn’t demonize patients was truly effective.  Given that many diseases affect performance it was enlightening to see alcoholism and addiction compared with other illness and the kinds of monitoring which were appropriate for these.
I have learned once again that I learn more talking to colleagues with similar experience and training in a hallway than I do in a lecture theatre at my level of experience and age.  I am so thankful for the many conversations I had with senior colleagues, most now retired, two of my favourite psychiatrists sharing about their retirement this year, what they are missing, why they left, what their plans are.  I also learned that several enjoyed cutting back their practices and continue to work. I noted that most had moved away from the soul sucking models of management and were less driven by monetary concerns as by respect. I laughed at a colleague describing reducing his day because he realized he was too old to live long after treating more than one ‘death star’ patient a day whereas in his previous model of care he was treating a half dozen of these unmotivated chronically angry and demanding patients which he aptly named ‘death stars’.  I liked that together we could talk honestly and that political correctness was eschewed because we all were in the front lines and our compassion wasn’t just the matter of fancy word, virtue signalling and sound bites but reflected years of compassionate care and service.  Among ourselves no one derailed the conversation with the stuff that duels dealt with in the past but rather we discussed better what to do with ‘death starts’ and how best to survive and manage the experiences.  Interesting to me they were not limited to psychiatry but a common concern of specialists, if not more so than generalists.
I have learned that my colleagues are accepting care from their colleagues and many have had really good medical care, knee surgeries and heart surgeries and investigations and are alive today because of the success of medicine today.  That gives me hope as I age and fear the politics of health care and am afraid of dependency.
I have learned that I have been short and inconsiderate at times, allowed myself to be over extended and been insensitive to others. I have learned that I must review my own behaviour and responses daily and that I must apologize for my omissions and errors more quickly. I am aware that the deaths of my brother, my best friend and another close friend plus the severe illness and insanity of two close friends, the surgical removal of my dogs eyes has all caused me to be less attentive to those around me but that while I feel I'm running on 6 cylinders rather than 8 I'm not alone. Those others around me are normally equally stressed though differently. I have examples around me and an idea of the person I would most like to be and while the demands have escalated exponentially, and the number of angry and threatening and entitled people is disproportionate there is much I can do about my response. Daily review is something I have let slip and I need to be more proactive about this self reflection. My greatest mentors have died or are sick themselves so I must do more about shoring up my defences. Meditating more and praying more are showing benefit but I must exercise and surround myself with more positive relief from work given the death and disease where I am.  I must if I am to continue say no to the outrageous demands of the needy and co dependent and accept the adage physician heal thyself and be proactive and say no more not less. I have to put a premium on my spiritual well being and on my life because the truth is there are too many today who have not been socialized and they exist in low and high places.
I have gained so much hope and appreciated most the examples of my superiors and the laughter.  I loved learning all the personal challenges friends had and that they carried on. I am left wanting to emulate these men and women who have so often as indivduals and doctors set the example that has helped me carry on when I’ve been overworked, stressed, lonely and afraid.  I have learned that if they can carry on, so can I so I’m near the end of this conference looking forward to return.

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 

The Female Physician

The Female Physician

-by William Hay

I was in London at the time. My young wife and I were dancers. We had just bicycled across Europe. Now we were studying dancing in the dance capital of the world, working during the days to pay for night dance classes.  Both our teachers were world champions. Hers was Bill Irvin, world champion  of classic dance. Mine was Doreen Key,  Latin American world champion.  

We were young  athletes then. In top physical shape.   We moved like young animals.  She was a cat. I was more a wolf. Lithe. Powerful. In America we’d appeared on television. Individually, together, and chorus line.  Here the  rumour was dance was the next Olympic sport. We wanted to compete.  

She’d been a ballet dancer all her life . I’d come to dance as a teen ager from gymnastics,  martial arts and theatre stunt work.  Here we were, young,  in love, at the height of Mod.  It was the time of The Beatles and Rolling Stones.We shopped the boutiques on Oxford Street  We drank black and tans in English pubs, house wines in pate bars and cafes.  We didn’t do drugs.  We’d dropped acid in Toronto and smoked hashish in Morocco. The drug scene wasn’t where we were in London.  It was all about the  music and the dance and theatre.  

The  dark side was the IRA.  They were bombing fairly regularly.  The Queen spoke out against them.

We heard her on the radio.  We didn’t have a tv in the flat.  We were living  sparse. Tiny furnished flat, no kitchen, bath, sink and tub,   little table, 2 chairs, bed. The loo outside, across the entrance.   

“My throat hurts something fierce, “ I croaked one morning.

“You should see a doctor.” she said.

“Do you really think so?” I asked, hardly audible.

She put the back of her hand to my head.  

 “You’ve got a bloody fever.  Phone in sick and go to the clinic.”

This exchange happened in the bed.   It was winter.  We had to feed the meter to get heat. Mornings were always coldest.  Feeling sorry for myself I watched her get out of bed, her sweater over her short lingerie.  She fumbled about in the bottom of  her purse,   finding a coin for the meter.  She came back to bed.  I dozed.

There was warmth in the room and she was dressed when I got up  and got ready. We were always pretty quick getting ready. We didn’t like to spend money on heat.  Out on the street we joined the  the throngs of others heading towards the city trains.

I stopped at the telephone booth, hugging and kissing her before she continued on her way.  She looked back once and waved, giving me that incredibly beautiful big mouthed smile photographers loved.  She had on tan high heel boots that enhanced  her strong dancer calves,   dark tights, short  short blue mini skirt.  Above that  she wore the warm white sheep skin coat we'd brought back from Morrocco.  She always looked good.  Heads turned wherever she walked.  Sometimes she stopped traffic.

Now she was gone, lost in the streams of others heading up to London. 

I stepped into the red telephone booth, the kind that Clark Kent changed out of his journalist clothes into his Superman underwear in. I didn’t feel like Superman. I felt punked.  I phoned the office where I worked temporary letting them know I’d not be in today.

The clinic was further along, down a side street.  We passed it on the way to the our local pub.  Many an evening we’d gone there  for a pint.  There was always a crowd of friendly locals glad to hang out, glad to include us, glad to chat.  They served cheese and onion sandwiches or steak and kidney pies. The local pubs closed at 10:30.    I liked guiness.  She liked shanties. The double decker bus stopped across the street. We’d taken it once to a near by  theatre with a local group doing something modern. We preferred the West End. Whenever we could we’d stay after work in the city to take in a play Friday night.

“Can I help you?” the young girl asked me at the desk.  She wore a crisp white uniform and sat at an Olivetti manual type writer.  A couple of others were already in the waiting room. A couple of  old ladies. Frail, sitting together like white haired birds clutching their bags and brollies on their laps.

“I’ve a sore throat,”I croaked.

“And a cough and fever,” I added, to give  substance to my complaint.  

“Do you have identification?” she asked. I’m sure she could tell I was Canadian by my accent. The English were very good at hearing where you were from even in their own country or their own city.  Just by listening to a sentence or two, they seemed to know right off where hailed from, geographically as well as class.  Class was important in England.  We got lumped in the category, “colonials’, up some from ‘foreigners’.

I’d remembered to bring my passport. I gave it to her along with my other papers.    She set it down beside her manual typewriter and began efficiently punching and pounding the keys    She had flax blond hair  and what the English called a ‘peaches and cream complexion.”

“Here,’ she said, giving me back my passport and papers and handing me a  form,  “take this and give it to the doctor when she calls you.”  

“I took a seat beside the old ladies who smelt somewhat “old”. I imagined that if was my normal self it  it might  be an even more distinctive scent.  

I’d also heard the  girl say ‘her’ and thought about that. I’d never seen a female doctor. The doctor I’d had growing up was a man.  I’d not seen a doctor more than once or twice. I was usually very fit and not one to go to the doctor.   That was how sick I was. 

A moment later a mother and her child came out of the inner office at the end of the waiting room.  The  boy was licking  a red lolly pop. The mother thanked the woman doctor.  She followed her  little boy as he made a wide berth around  the old ladies as if fearing they might steal  his candy.

“Come along now,” said the taller than I’d imagined woman doctor. She wore comfortable shoes , black mini skirt, white lab coat.  The old ladies  moved quickly into her office showing more agility and speed  than I’d have thought.  They carried their bags and brollies with them.

Time passed. I  sat there listening to the sound of the traffic outside,  the rat tat tat tat of the girl’s typing. 

Finally the door opened.   The ladies leaving, thanked the doctor, profusely.  They each clasped prescriptions and managed still to carry their  bags and brollys.

“Come in,” she said, looking at me.

I stood and walked in.  A  big cluttered executive oak  desk dominated the room.  A rotating leather cushioned wooden chair sat behind the desk.  A couple of bare wooden chairs in front of it.   To one side was an examining table half hidden by a ceiling hung curtain. A glass and metal cabinet with drawers, some white gauze and stainless steel instruments just visible too. Otherwise the room was bare.  No pictures.  Sterile. Clinical.   

She took the form from my hand sitting behind the big desk and and gesturing for me to sit in one of the wooden chairs in front of the desk.  I felt it still warm from one of the last occupants. 

She looked down at the form, then up at me, 

“Sore throat?” she said. “When did it come on?”

“I think It began last night but it  was really sore  when I woke this morning,” I croaked.

“Nothing else?”  

“A cough?”

“Dry or wet?”

“Dry , I guess, “  I said, not certain.

She was in her late thirties, early 40’s.  Old to me then. Crow’s feet around her eyes.  Slight forehead wrinkles.  A somewhat sallow complexion.  Indoor sort.  A pleasant enough face. Thin lips.  No make up. Sensible looking.  Intelligent. Brown hair. Brown eyes.  

“Stand back there”  she said. I rose and stood where she’d pointed , directly opposite her desk, a few feet back from  the chairs. She remained seated.

“Take off all your clothes.” she said looking directly at me. She had an almost whimsical look in her eyes.  Serious enough enough but different. 

I removed my over coat and sweater. I didn’t know where to put them. There were no hooks apparent.  No coat hanger.  I piled them on the chair I’d just vacated.   I took off my white shirt and put it on top.  I didn’t wear an undershirt.   I stood there then  naked to the waist.

“Take off the rest. The pants and the underwear. I have to examine you.”  she said emphatically,  taking her eyes off me,  looking back at the form on her desk, making a notation with her silver pen. I continued to undress feeling her eyes back on me. I felt  awkward.  Very awkward.  I was glad for my loafers. They’d been easy to kick off.  Getting my tight jeans off had been difficult. I’d had to balance on one leg and pull.   Slipping out of my white briefs had been easier.  I left the socks on. The floor was cold.  

I stood there then.  A neat pile of my things on the chair in front of me.  She was still watching me.  She had glasses and a silver pen in her hand.   She twirled the pen  as she appeared to  study me.  I was completely  naked. I was embarrassed at my exposed genitals.  I hung my hands at my side, awkwardly.   Standing there , sort of at attention. Waiting.  Not knowing what else to do.  I’d never experienced anything like this.   She continued to look me up and down. She put her  pen down and brushed a strand of hair behind her ear.

Rising very slowly from her desk, leaning forward so her  cleavage showed at it’s best, framed by a touch of black lace bra.  She walked around her desk coming to stand close by my side.  She touched my arm with her hand as she listened with her stethoscope to the front and back of my chest asking me to take deep breaths. She moved  directly in front of me,   very close, her lab coat brushing my naked body.  Taking a wood tongue depressor from the lab coat side pocket she looked in my throat shining a light she’d taken from the  front coat pocket. The buttons on her white blouse were  undone. Her black bra and  cleavage apparent.  She was rather slim and tall. I’m 6 feet and she was almost as tall as I was.   

Her breasts were almost touching me as she put the tongue depressor in my mouth.  She said, ‘say ah “.  I said “ah."  She shone the pen light in my mouth before putting it back in her breast pocket.  She dropped the tongue depressor in a waste basket beside the nearby examining table.   Still very close , her breath sweet on my face, she slowly felt my throat with  fingers of both her hands. All the while she was looking me directly in the eyes.  Her eyes had a kind of twinkle.  It was if she was thinking of a private joke. If there was something funny , I was  missing it.  

She walked around behind  me then and stood for a time looking at my back side. I felt she  was looking   my buttocks and legs.  Then almost suddenly she again came around in front of me.  Looking me in the eyes, her face so close to mine, she reached down, touched my gonads and  stroked the  the underside of my penis with one long finger. She wasn’t wearing gloves.  I became immediately erect.  I’d been just hanging there. Now I was fully upright.. I felt my face go instantly red. 

She smiled smugly then. Up close and personal.

“You can’t control that, can you,” she murmured, tauntingly.  Judgementally.   She was still so close her clothes touched my nakedness. I stood at attention. Hands at my side.  A big boner between us.  My face blushing.  A moment passed. 

She gave me a look of utter disdain.  Then she turned her back on me.  She returned to sitting at her desk, crossing her long bare legs, staring straight at my erection.  I was looking away but felt her eyes studying me. 

“Get dressed, “ she commanded, finally  

I scrambled to do just that, as quickly as I could.  Gangly , awkward. embarrassed.  It was hard to get my feet and legs into my tight jeans standing. I did up my shirt watching her writing out a script.  I didn’t bother putting on my sweater or coat, just tucking them under my arm. 

“Take this,” she said, slipping the script into my hand, standing very close to me as I passed out of that room.   

I was really  glad to get out.  Glad for the prescription.  

It was Amoxicillin.  I pulled on my sweater and put on my coat on the street. A little further along I took the prescription into the apothecary.  I waited as it was filled. I paid for the prescription.   I took the first Amxocillin pill with tea I had at the corner cafe.  I sat there awhile wondering about the visit.  It felt wrong. Not good.

I walked back to the flat still feeling punk.  I put another coin in the meter and climbed  into bed with my clothes on.. I slept the rest of  the day. I don’t remember anything but getting up to pee and taking more antibiotics.

When she came home that evening I was feeling better. My throat wasn’t nearly as sore.  My voice was better too. 

She’d brought along fish and chips wrapped in newspaper bought from a  street seller.  She knew it was my favourite.

“I hoped you’d be able to eat,” she said, handing me the newspaper wrapped bundle.  

I thanked her  hugging her,  enjoying the scent of her.  She only wore perfume going but the natural scent of her never failed to excite me.  She just always smelt so good.  I didn’t kiss her because of my throat.   I hugged her close nestling my face in her neck and hair.  Whenever she was in my arms I felt I was home.

I appreciated it so much that she’d brought back the fish and chips.  I was hungry but hadn’t  paid any attention to it. We were often hungry in London.  Food was expensive. We didn’t have much money and counted every shilling.  With rent,  heat,  train fares, the cost of group and private dance lessons,  and our trying to save every pence to go to theatre on the weekends,  we never anything left over. We livd We both worked in offices temporary during the week. She took whatever overtime she could get. I worked as a bar tender weekends.

“You sound better.” She said.  “You looked so sick this morning I was worried.”    

“Did things go well at the doctor's?”    she asked

“Okay, I guess.” I said. “She gave me amoxicillin. I’m feeling better since I’ve taken it. I slept all day.”

“Did you get anything to eat.”  

“No, just the tea. I really appreciate the fish and chips” I said, eating with my fingers..

“You said, “She”.  Was it a lady doctor? And you said, I guess”. what did you mean.” she asked.

She was always astute. Sensitive, insightful, attuned to any nuance, picking up on every little shift in mood. It was like living with an emotional telepath.  A times it was  annoying.  Right then I appreciated it.

She’d sat down on the bed beside me and waited as I ate the fish and chips. 

I told her the whole story. The old ladies.  The mother. The little boy.  The office. The stripping naked. The doctor looking  in my mouth and then her stroking my penis. My erection.  What she said. My dressing. The apothecary and my coming home.

“Do you think that’s odd?” I said.  

“It’s most peculiar! “ she said.  “Was she good looking?” 

“Okay, Nothing like you.” i said.She smiled.

“Older lady, slim,  tall,  comfortable shoes, not bad looking.”

“Well she certainly was getting off on you.  I think she wanted you to fuck her and when you didn’t she was miffed.  Crazy horny English bitch.  I hope I never become like that.” she said.

“Do you have to go back to see her.” 

“She didn’t say so.”

“Good,” 

After that we settled down to read our books. We loved reading novels together. Made trips weekly to the library.

" Do you think you’ll go to work tomorrow.”  she asked.

“I think so”

I don’t remember when I fell asleep. Early, I think. I do remember her crawling into bed beside me. Her body was something incredible. Every curve and crevice special.  She flowed like warm lava.   Feeling her next to me, the two of us spooning in that little bed, in that chilly  room,  in that foreign city, all was right with the world.  She made me feel like home  wherever she was.  It was indescribable how comfortable and good I felt with her.  My life was perfect when she was with me.

it was many years later. Long after the divorce.  We’d come back to Canada. She danced out east. I’d gone west.  I  spent a life time studying medicine, living in laboratories, surgeries, call rooms  and libraries.  I had learned all the clinical medicine and skills a doctor must learn before it  dawned on me.

I think I was an intern doing a routine examination for a sore throat when it all came painfully tumbling back. I remembered her smug words , the disdainful look. “You can’t control that, can you?"

My skin crawled. For a moment I felt physically ill.  Dirty, humiliated.    Ssed.  It was a sudden.  An exact realization.  The opening of an old wound. An abscess popping. Pus leaking out. I don’t think I cried. Men don’t cry.

There was no way that examination had been ‘normal’. There was no ‘justification’ for what she’d done. There was simply no way in hell that any doctor could consider such an examination when presented with those symptoms. There was no way that was the way anyone was taught to do examinations.  I had to become a doctor myself to know that.  I knew. Beyond any doubt I knew.  All those years I’d given her the benefit of the doubt.  No more. I was angry. Crazy horny English bitch!

More years passed.  I delivered alot of babies, did surgery and examined countless bodies.  I worked in universities, hospitals,  my own  practices.  Another divorce.  The psychiatrist I was seeing for psychoanalytic training asked me in passing. 

“Do you think your marrying a female physician was ‘identification with the aggressor?” I’d told him about England. I’d  told him about my shame.  We’d talked for hours on end for several years about relationships, family,  love, lust,  work. He knew me better than I knew myself in some ways.  

There was no couch. Just comfortable chairs in a low lit room.  He was a soft spoken older man. I’d chose him for his brilliance and wisdom.  I’d admired his work with patients. His compassion. I wanted to be the kind of psychiatrist I knew him to be.

“Identification with the aggressor?” I asked.

“Yes, like in the Stockholm syndrome. You know.”

“I do. But I just never thought about it like that.  It was never that important.  Just a passing thing.  I told you my wives were brilliant and  beautiful.”

“I know. I don’t doubt it.” he went on.     “But there was the shame. The humiliation. You remember it . You talk about it. Not just once. It’s come up again. “ he said, looking at me, 

intently, caringly.

“I guess so.” I said.  There was silence then.

“It wasn’t that big a deal.” I said.

I tried not to think about it again.  I’d already told him my divorces were all my fault.  There were no extenuuating circumstances. I was a man. I was responsible.  I was always to blame.  That’s what being a man was. Being accountable.  Adults were accountable.  Life served lemons. Make lemonade. 

“Are we done for today,” I asked.

“If you wish,” he said.  I left then.  I took my jacket and the sweater I’d taken off  under my arm. I  didn’t put them on  until I  was out in the street.  I didn’t want to think about this anymore.  I didn’t like being reminded of it either.