I rented a new Jeep in Ottawa. Great car and it came with Sirius Satellite radio. I had it on the comedy channel the whole time. I almost hit the meridian once I was laughing so hard I had tears in my eyes so couldn't see my turn. Other than that I was hooked.
My 2011 Mazda Miata came with Sirius Satellite and 6 months trial. After that it's $17 a month. Now I think it's worth it. That's the cost of not having advertisements. The Miata Bose Sound system comes with AM, FM1 and FM2 radio as well as 6 stack CD. The fact is I like Sirius Satellite because I don't like switching cd's or channels even though I'm really thankful the Miata has the radio controls on the steering wheel.
I've just been out here in the car at night like a kid putting in the the 18 Sirius channels I can program. I've got a couple of symphony and opera channels, a 60's rock, a modern rock, a couple of country channels, a folk and acoustic rock channel, three commedy channels. I've put in BBC world news and local weather. I almost put in CBC but I get CBC on AM and FM. 18 channels is a lot of channels. And I can switch channels from my steering wheel. Wow.
Okay I'm a Sirius Satellite fan. There's some 180 channels, 120 main ones and these others as well. Steady programming. And no commercials. Wow!
Wednesday, April 11, 2012
Gilbert - traveller
Since a puppy Gilbert has been travelling with me in whatever vehicle I've been using. He first came home in my truck. Then he travelled in Laura's car. After that he began riding on the back of my Harley. Since that he's ridden on the back of a Honda 230 and a Polaris 500 ATV. He's crossed Georgia Strait in my sailboat. This last winter he rode in the sidecar of my Ural Sidecar Motorcycle. He's flown east with me, a jet setter, though he prefers to be called a jet-cockapoo. I got a picture of him being loaded on the plane in his kennel. Now he's riding in my Mazda Miata and really enjoying being a sports car dog. There's no doubt Gilbert gets around and travels well. 
Medico Legal Opinion OBGYN
Journal of Obstetrics and Gyne 2002:24(7):590-2 published the committee opinion of the Council of the Society of Obstetricians and Gynecologists of Canada. This was excellent work by the committee , with principal authors, Titus Owolabi, MD FRCSC and Dan Farine, MD FRCSC both of Toronto.
First they note that providing expert opinion is a 'grave responsibility' and a 'civic responsibility". However they make a most important point that an 'expert physician is being as to conduct a peer review and educate those involved in the process of a judicial adversarial adjudication." The focus of the paper is more specific to OB GYN than generally speaking as it notes that "Tort or compensatory damage is sometimes demanded by the patient and her lawyer when there has been a bad clinical outcome, on the basis of allegations that appropriate care was not provided. The quality of the physician's care is often the key issue of the legal action, and consequently the physician is often the primary target of the lawsuit."
There are indeed other reason's for 'medical legal opinion' . This is perhaps the most onerous. The advise overall remains helpful in this specific sense and in other senses.
In the following discussion about qualifications included an interesting relevancy to training and time "physicians who obtained their relevant qualifications recently to provide opinion on an event that occurred many years ago without declaring this potential discrepancy and without learning the practice patterns and standards of care existing at the time of the event."
I'm of an age now that I really appreciated seeing this. Young colleagues apparently have no idea what the world was like, sometimes before they were born. They also don't realize that so much that is taken for 'granted' today wasn't 'taken for granted even as little as a decade past. Science is revolutionary and events like 'cell phone' communications are 'normal' today but I'm from an era of 'radio' and 'wall phone' and just the effect of those technologies on a physicians decisions can't be under estimated. There's tremendous arrogance in the youth and in those who've had the most limitted of practice experience and exposure. Having working in the wilderness, the north, and rural and urban areas I'm routinely aware of the utter ignorance of those in the centre of the reality outside the 'ivory tower'. The level of stupidity is so profound that it makes it very hard for one to take seriously their pronouncements on matters that because they're microscopic might have some actual relevance.
This paper dealt well with addressing the 'retroscopic perspective'. Armchair quarterbacks are always so very smug.
The paper gives a good overview of report writing and recommends the physician be clear and even set out what the 'issues' are and then provide an opinion regarding those 'issues'.
The paper further encourages that the physician provide reasons for the basis of the opinion with appropriate reference - "a standard textbook, specific review articles, professional society guidelines, widespread clinical practice in the physicians jurisdiction, or personal experience."
Finally the paper encourages experts to state "opinions that are credible and will stand the scrutiny of peers, leaving advocacy to the lawyers".
This is an excellent paper I would strongly recommend for any physician who has to be an expert in the courts.
First they note that providing expert opinion is a 'grave responsibility' and a 'civic responsibility". However they make a most important point that an 'expert physician is being as to conduct a peer review and educate those involved in the process of a judicial adversarial adjudication." The focus of the paper is more specific to OB GYN than generally speaking as it notes that "Tort or compensatory damage is sometimes demanded by the patient and her lawyer when there has been a bad clinical outcome, on the basis of allegations that appropriate care was not provided. The quality of the physician's care is often the key issue of the legal action, and consequently the physician is often the primary target of the lawsuit."
There are indeed other reason's for 'medical legal opinion' . This is perhaps the most onerous. The advise overall remains helpful in this specific sense and in other senses.
In the following discussion about qualifications included an interesting relevancy to training and time "physicians who obtained their relevant qualifications recently to provide opinion on an event that occurred many years ago without declaring this potential discrepancy and without learning the practice patterns and standards of care existing at the time of the event."
I'm of an age now that I really appreciated seeing this. Young colleagues apparently have no idea what the world was like, sometimes before they were born. They also don't realize that so much that is taken for 'granted' today wasn't 'taken for granted even as little as a decade past. Science is revolutionary and events like 'cell phone' communications are 'normal' today but I'm from an era of 'radio' and 'wall phone' and just the effect of those technologies on a physicians decisions can't be under estimated. There's tremendous arrogance in the youth and in those who've had the most limitted of practice experience and exposure. Having working in the wilderness, the north, and rural and urban areas I'm routinely aware of the utter ignorance of those in the centre of the reality outside the 'ivory tower'. The level of stupidity is so profound that it makes it very hard for one to take seriously their pronouncements on matters that because they're microscopic might have some actual relevance.
This paper dealt well with addressing the 'retroscopic perspective'. Armchair quarterbacks are always so very smug.
The paper gives a good overview of report writing and recommends the physician be clear and even set out what the 'issues' are and then provide an opinion regarding those 'issues'.
The paper further encourages that the physician provide reasons for the basis of the opinion with appropriate reference - "a standard textbook, specific review articles, professional society guidelines, widespread clinical practice in the physicians jurisdiction, or personal experience."
Finally the paper encourages experts to state "opinions that are credible and will stand the scrutiny of peers, leaving advocacy to the lawyers".
This is an excellent paper I would strongly recommend for any physician who has to be an expert in the courts.
Tuesday, April 10, 2012
Treating Psychiatrist as Expert Witness
"The Treating Psychiatrist Thrust into the Role of Expert Witness," by Thomas G. Gutheil, MD and James T. Hilliard, J.D, Psychaitric Services 2001, Vol. 52 No 11 is essential reading for any psychiatrist caught in the headlights of the court. I have just read this article and realized that I could have been saved serious suffering if I had read this 20 years ago. As it came out in 2001 it would not have saved me from the worst grief I experienced as an 'expert witness' in court. The example they begin with is truly 'every psychiatrist'. They further use a most useful term to describe treating psychiatrist activities, 'patient centred' compared to the court which is definitely not necessarily patient centered. In my personal case the judge was intent on beating me up as badly as they'd been throttling my patient from the get go with the help of the most horrendously biased opinion of a supposedly objective person. All my patient had told me about the discriminatory process was confirmed but in the process I was sucked into the nightmare.
Gutheill and Hilliard suggest "therapists sitting in their offices may legitimately venture informal opinions about third parties solely on the basis of what patients tell them, for supportive effect - for example...Such pronouncements pose no difficulty when the psychiatrist is operating empathically from within the patient's world view and from no other point of reference" However later they say "courts focus on more objective evidence, and in this context therapists should use extreme caution - or refuse entirely - when they are asked to give opinions about a patient or a third party, particularly when litigation is involved.'
Very usefully, Gutheill and Hillard remind us that 'Practitioners should be aware that the more helpful to their patients their letters or reports may be , the greater the likelihood that an opposing attorney will want to depose them and call them at trial."
Their recommendations are most useful and like their whole paper show great experience and insight.
1) "Patients have the right to know what use will be made of communications between their therapists and other parties."
Note here that years ago I have made my work transparent and shared what I have written with my patients. I have never changed the body of the work to alter my opinon but I have at the patients request excluded information that on reflection appeared extraneous and no way serving my opinion but potentially could harm my patient. This was challenged and I had to seek legal counsel who wholly supported my practice. However I was dealling with a reactionary and patriarchal organization that works in extremely secrecy and behind closed doors so they were attempting indeed politically opposed to such transparency. In the end it was not an issue but even something so obvious can cause a physician to encounter difficulties regarding records and record keeping. Increasingly the legal and administrative misuse and outright abuse of physicians clinical records will make clinician record keeping of no benefit for patients and clinicians and solely for the service of third parties. Already I have seen this trend and likelihood and watch my colleagues increasingly not recording pertinent or relevant clinical information out of dire fear of how it might be used by third parties. Given that we take an oath to 'do no harm' we must be aware that third parties are not similiarly constrained. Some third parties I've dealt with have the ethics of a snake and the dna of a cockroach where my patients health and welfare is concerned.
2) 'clinicians should develop the general habit of records sources of clinical data - for example - 'from the nurses notes....." This is a very good idea and one I have used occasionally and will use more often. It's clinically relevant and shows great insight.
3) The "roles of treating psychiatrist and expert witness should usually be separated' . I think this is a great idea and occurs often however I've been subpoened by the courts and as a result of my testimony lost a patient as the therapeutic relationships was destroyed by this process. Recently I told the police my patient shouldn't be allowed to have guns in response to his request only to have him come to see me belligerent and frankly frightening. I've not seen him since and believe that society would have benefitted from our continued relationship even though I suspect he's off finding some psychiatrist who approves of his gun ownership as a result of what I believe was a breach of confidentiality. However in fairness, the patient may well have figured he was denied gun ownership and figured it was because of me.
4) Gutheil and Hilliard recommend it as wise to seek advise from local counsell such as that which represents doctors when in doubt. Excellent thought. I've found this to be true and learned immensely useful information from the counsell that helps doctors in general. I've found that our CMPA has saved me even worse balderdashes than those I've been involved in because I've phoned and discussed my situations with their representatives learning alot in the process.
Gutheeil and Hilliard are to be celebrated for this excellent paper which I truly recommend to all psychiatrists.
Gutheill and Hilliard suggest "therapists sitting in their offices may legitimately venture informal opinions about third parties solely on the basis of what patients tell them, for supportive effect - for example...Such pronouncements pose no difficulty when the psychiatrist is operating empathically from within the patient's world view and from no other point of reference" However later they say "courts focus on more objective evidence, and in this context therapists should use extreme caution - or refuse entirely - when they are asked to give opinions about a patient or a third party, particularly when litigation is involved.'
Very usefully, Gutheill and Hillard remind us that 'Practitioners should be aware that the more helpful to their patients their letters or reports may be , the greater the likelihood that an opposing attorney will want to depose them and call them at trial."
Their recommendations are most useful and like their whole paper show great experience and insight.
1) "Patients have the right to know what use will be made of communications between their therapists and other parties."
Note here that years ago I have made my work transparent and shared what I have written with my patients. I have never changed the body of the work to alter my opinon but I have at the patients request excluded information that on reflection appeared extraneous and no way serving my opinion but potentially could harm my patient. This was challenged and I had to seek legal counsel who wholly supported my practice. However I was dealling with a reactionary and patriarchal organization that works in extremely secrecy and behind closed doors so they were attempting indeed politically opposed to such transparency. In the end it was not an issue but even something so obvious can cause a physician to encounter difficulties regarding records and record keeping. Increasingly the legal and administrative misuse and outright abuse of physicians clinical records will make clinician record keeping of no benefit for patients and clinicians and solely for the service of third parties. Already I have seen this trend and likelihood and watch my colleagues increasingly not recording pertinent or relevant clinical information out of dire fear of how it might be used by third parties. Given that we take an oath to 'do no harm' we must be aware that third parties are not similiarly constrained. Some third parties I've dealt with have the ethics of a snake and the dna of a cockroach where my patients health and welfare is concerned.
2) 'clinicians should develop the general habit of records sources of clinical data - for example - 'from the nurses notes....." This is a very good idea and one I have used occasionally and will use more often. It's clinically relevant and shows great insight.
3) The "roles of treating psychiatrist and expert witness should usually be separated' . I think this is a great idea and occurs often however I've been subpoened by the courts and as a result of my testimony lost a patient as the therapeutic relationships was destroyed by this process. Recently I told the police my patient shouldn't be allowed to have guns in response to his request only to have him come to see me belligerent and frankly frightening. I've not seen him since and believe that society would have benefitted from our continued relationship even though I suspect he's off finding some psychiatrist who approves of his gun ownership as a result of what I believe was a breach of confidentiality. However in fairness, the patient may well have figured he was denied gun ownership and figured it was because of me.
4) Gutheil and Hilliard recommend it as wise to seek advise from local counsell such as that which represents doctors when in doubt. Excellent thought. I've found this to be true and learned immensely useful information from the counsell that helps doctors in general. I've found that our CMPA has saved me even worse balderdashes than those I've been involved in because I've phoned and discussed my situations with their representatives learning alot in the process.
Gutheeil and Hilliard are to be celebrated for this excellent paper which I truly recommend to all psychiatrists.
Social Justice and Physicians
I have been reading again the Charter on Medical Professionalism put forth in the Annals of Internal Medicine, Feb 5, 2002 by Harold C. Cox, a project of ABIM Foundation, ACP-ASIM and European Federation of Internal Medicine. In it there are three principles, Principle of Primacy of Patient Welfare and Principle of Patient Autonomy and finally Principle of Social Justice. It's the last one that catches in the craw.
It says the medical profession must promote justice in the health care system, including fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion or "any other social category".
It "sounds" sweet and nice and sugar and spice but really is it 'reasonable' or 'emotionally sound'. Collectively it's a good thing for the profession to promote those things that make any 'brand' look good. However this all round 'anti discrimination' clause seems horribly reactionary and communist rather than socialist even but especially anti capitalist.
And really "any other social category". I immediately think should a serial murder in prison have same access to cataract surgery as the neonatal brain surgeon. What is most concerning is this 'any other social category'. What concerns me here is the 'entitlement' in society today where people who do not contribute to 'insurance' plans expect equal benefits from those insurance plans.
Further we specifically as physicians have 'rationed' health care resources on the basis of 'compliance' with treatment. I was early involved in the decision to give 'pig skin heart halves' to chronic alcoholics over mechanical heart valves because of the issue of 'blood thinners'. The chronic alcoholics would be at risk of not doing the appropriate after care and with the lesser beneficial 'natural' valve there was less after care. Given this clause I would think this reasonable medical decision making would be considered discriminatory towards an individual who is choosing excessive alcohol as a 'cultural imperative'.
I have spent alot of my career doing 'missionary' type work, choosing to work always in the areas of 'greatest needs' and not choosing the areas of greatest comfort, prestige or monetary reward in the profession. I could well have become a plastic surgeon but instead became a country northern physician and later a psychiatrist and addiction medicine specialist. I certainly would like more resources compared to my rich and richer brethren but somehow I don't want them if my plastic surgeon buddy with his multi millions is penalized for his attention to breasts and noses. I think this 'clause' is destructive of what was always thought of as key component of medical professionalism, that is 'physician autonomy'.
I read this charter and it reads like a government employment brochure. It's a great salaried position yet it overlooks the word 'freedom'. Professions have attracted the very best because of the potential for 'autonomy' and 'freedom'.
This charter by it's failure to address such central issues while focussing on matters such as "committment to just distribution of finite resources' and committment to professional responsibilities, seems highly weighted to governmental imperatives.
I personally was attracted to the profession of medicine because I was enterring a covenanted relationship with a patient in which I was to serve as a 'healer'. Clearly I would put the patient's interests first but how it was decided who would be my patient, the patient selection process itself, was never something I thought it was the responsibility of the 'profession'. In this way I'm arguing against myself in fact but that itself is 'professional'.
My first position was to go to a country hospital whereas the city positions carried more glamor, luxury, resources, pay and priviledge. I was a leading doctor and have always have tremendous choice something that perhaps those at the 'bottom of the class' didn't or didn't perceive. Many of my colleagues today choose the 'easy street' of 'administrative medicine' which carries power, priviledge, and 9-5 jobs and no patient contact with considerable capacity to be extraordinarily parental. Others choose 'forensic' medicine where there's a 'capitive' population. There is limitted considerations of 'social justice' in either of these spheres.
I was the only provincial doctor willing to work in Northern Manitoba on the Island Lake reserves the years I was there. The Northern Medical Unit had to bring in doctors from England to take positions which for 2 years could not be filled because of the low pay, high risk and general unattractiveness of the position. I got TB. I was in a plane crash. I was attacked. I was injured. I went through the ice in a snow mobile on a mercy run. I was without resources on many occasions. I had little back up. The greatest priviledge of the position was working with Dr. Jack Hildes.
After country medicine and northern medicine I did a community medicine, public health and psychiatry residency. There was no support in the psychiatry residency for 'social medicine' at the time. I wrote a paper on 'social responsibility' and it was belittled. The psychoanalytic model at the time favoured 'labour intensive' service for a few whereas despite my psychoanalytic training I went to work in the provincial asylum where no Canadian Psychiatrist was willing to work. The conditions for physicians were horrendous. Patients had it almost as bad. The administration was living the life of bliss.
As a psychiatrist I worked in the country and the north again and then moved to work in addiction psychiatry. My life has been threatened repeatedly. I have lost hundreds of thousands of dollars because my patients can't pay and the system penalizes doctors working with those who lack resources. I have found in general the stigma against psychiatric patients and those who care for them suffocating. I am now working in the Vancouver downtown east side with homeless drug addicts and street prostitutes part of my week. The hospitals and their services literally abuse my patients and myself because of the frustration within the 'system'.
I was a member of the International Society of Physicians against Nuclear War which got a Nobel Prize one day. I was never in favour of 'unilateral disarmament' during the cold war. I think it's a good thing to consider 'social justice' but given the present administrations in Canada, those managing health resources and their desire to increase their positions and their pay without having a similiar committment to 'patient's first' I'm concerned that we as physicians giving up 'autonomy' will play into the nefarious self interest of these groups who have to date not demonstrated their ability to have high ethical standards.
I see that my colleagues are willing to do 'service'. It's extremely common for missionary doctors to go to work in equally difficult place. The Evangelical Medical Association is forever having doctors volunteer to work in difficult situations yet most would not have worked in the situations that I have because of the government interference in health care, the over riding tendency of administration to use whips rather than rewards and all manner of concerns with health care in secular societies.
The greatest risk to patients is the 'company' doctor. The 'company' doctor or 'government doctor' was a doctor who to protect his own position of priviledge did as he was 'told' and 'told' the patients what the 'company' or 'government' propaganda or corporate stategy of the day was. He was a 'cog in the wheel' and his 'cowardice' in the medical community is legenday. He was described in detail by Dr. Jay Lifton in "Nazi Doctors". I personally don't want to be a 'nazi' doctor. I want my freedom and the patient's freedom enshrined. I want choice and I want the patient to have choice. Together we choose and together we stand. That's the nature of covenant. That's historically the nature of professionalism. This instead is something else and so watered down as to serve neither patients or doctor but likely to serve special interest groups and destroy the very trust that patients have historically had knowing their physicians are 'autonomous'. This emphasis on freedom and autonomy is not dealt with in the 'committment to conflict of interest'. I fear that the writers of this charter don't grasp or agree with what I and professionals before me meant by 'freedom" and 'autonomy". Alternatively they may have deliberately excluded this in preference for this 'brand' they are definitely promoting as a universal when truly I believe it falls far short of encompassing the purest conception of medical professionalism that has allowed it to spread world wide and served so many of us even as we are ostracized by those who have so many resources.
This charter of medical professionalism fails extremely because it in no way protects the autonomy of the physician. It doesn't address the need for a physician to ethically and morally refuse to participate in situations where it is obvious that 'systemic' abuse is taking place. It indeed appears to serve not the 'patient' but the very agencies that have so often ensured resources do not get to the patient or the physician providing direct care.
Professionalism requires 'autonomy' and 'freedom' for 'physician' and 'patient'.
It says the medical profession must promote justice in the health care system, including fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion or "any other social category".
It "sounds" sweet and nice and sugar and spice but really is it 'reasonable' or 'emotionally sound'. Collectively it's a good thing for the profession to promote those things that make any 'brand' look good. However this all round 'anti discrimination' clause seems horribly reactionary and communist rather than socialist even but especially anti capitalist.
And really "any other social category". I immediately think should a serial murder in prison have same access to cataract surgery as the neonatal brain surgeon. What is most concerning is this 'any other social category'. What concerns me here is the 'entitlement' in society today where people who do not contribute to 'insurance' plans expect equal benefits from those insurance plans.
Further we specifically as physicians have 'rationed' health care resources on the basis of 'compliance' with treatment. I was early involved in the decision to give 'pig skin heart halves' to chronic alcoholics over mechanical heart valves because of the issue of 'blood thinners'. The chronic alcoholics would be at risk of not doing the appropriate after care and with the lesser beneficial 'natural' valve there was less after care. Given this clause I would think this reasonable medical decision making would be considered discriminatory towards an individual who is choosing excessive alcohol as a 'cultural imperative'.
I have spent alot of my career doing 'missionary' type work, choosing to work always in the areas of 'greatest needs' and not choosing the areas of greatest comfort, prestige or monetary reward in the profession. I could well have become a plastic surgeon but instead became a country northern physician and later a psychiatrist and addiction medicine specialist. I certainly would like more resources compared to my rich and richer brethren but somehow I don't want them if my plastic surgeon buddy with his multi millions is penalized for his attention to breasts and noses. I think this 'clause' is destructive of what was always thought of as key component of medical professionalism, that is 'physician autonomy'.
I read this charter and it reads like a government employment brochure. It's a great salaried position yet it overlooks the word 'freedom'. Professions have attracted the very best because of the potential for 'autonomy' and 'freedom'.
This charter by it's failure to address such central issues while focussing on matters such as "committment to just distribution of finite resources' and committment to professional responsibilities, seems highly weighted to governmental imperatives.
I personally was attracted to the profession of medicine because I was enterring a covenanted relationship with a patient in which I was to serve as a 'healer'. Clearly I would put the patient's interests first but how it was decided who would be my patient, the patient selection process itself, was never something I thought it was the responsibility of the 'profession'. In this way I'm arguing against myself in fact but that itself is 'professional'.
My first position was to go to a country hospital whereas the city positions carried more glamor, luxury, resources, pay and priviledge. I was a leading doctor and have always have tremendous choice something that perhaps those at the 'bottom of the class' didn't or didn't perceive. Many of my colleagues today choose the 'easy street' of 'administrative medicine' which carries power, priviledge, and 9-5 jobs and no patient contact with considerable capacity to be extraordinarily parental. Others choose 'forensic' medicine where there's a 'capitive' population. There is limitted considerations of 'social justice' in either of these spheres.
I was the only provincial doctor willing to work in Northern Manitoba on the Island Lake reserves the years I was there. The Northern Medical Unit had to bring in doctors from England to take positions which for 2 years could not be filled because of the low pay, high risk and general unattractiveness of the position. I got TB. I was in a plane crash. I was attacked. I was injured. I went through the ice in a snow mobile on a mercy run. I was without resources on many occasions. I had little back up. The greatest priviledge of the position was working with Dr. Jack Hildes.
After country medicine and northern medicine I did a community medicine, public health and psychiatry residency. There was no support in the psychiatry residency for 'social medicine' at the time. I wrote a paper on 'social responsibility' and it was belittled. The psychoanalytic model at the time favoured 'labour intensive' service for a few whereas despite my psychoanalytic training I went to work in the provincial asylum where no Canadian Psychiatrist was willing to work. The conditions for physicians were horrendous. Patients had it almost as bad. The administration was living the life of bliss.
As a psychiatrist I worked in the country and the north again and then moved to work in addiction psychiatry. My life has been threatened repeatedly. I have lost hundreds of thousands of dollars because my patients can't pay and the system penalizes doctors working with those who lack resources. I have found in general the stigma against psychiatric patients and those who care for them suffocating. I am now working in the Vancouver downtown east side with homeless drug addicts and street prostitutes part of my week. The hospitals and their services literally abuse my patients and myself because of the frustration within the 'system'.
I was a member of the International Society of Physicians against Nuclear War which got a Nobel Prize one day. I was never in favour of 'unilateral disarmament' during the cold war. I think it's a good thing to consider 'social justice' but given the present administrations in Canada, those managing health resources and their desire to increase their positions and their pay without having a similiar committment to 'patient's first' I'm concerned that we as physicians giving up 'autonomy' will play into the nefarious self interest of these groups who have to date not demonstrated their ability to have high ethical standards.
I see that my colleagues are willing to do 'service'. It's extremely common for missionary doctors to go to work in equally difficult place. The Evangelical Medical Association is forever having doctors volunteer to work in difficult situations yet most would not have worked in the situations that I have because of the government interference in health care, the over riding tendency of administration to use whips rather than rewards and all manner of concerns with health care in secular societies.
The greatest risk to patients is the 'company' doctor. The 'company' doctor or 'government doctor' was a doctor who to protect his own position of priviledge did as he was 'told' and 'told' the patients what the 'company' or 'government' propaganda or corporate stategy of the day was. He was a 'cog in the wheel' and his 'cowardice' in the medical community is legenday. He was described in detail by Dr. Jay Lifton in "Nazi Doctors". I personally don't want to be a 'nazi' doctor. I want my freedom and the patient's freedom enshrined. I want choice and I want the patient to have choice. Together we choose and together we stand. That's the nature of covenant. That's historically the nature of professionalism. This instead is something else and so watered down as to serve neither patients or doctor but likely to serve special interest groups and destroy the very trust that patients have historically had knowing their physicians are 'autonomous'. This emphasis on freedom and autonomy is not dealt with in the 'committment to conflict of interest'. I fear that the writers of this charter don't grasp or agree with what I and professionals before me meant by 'freedom" and 'autonomy". Alternatively they may have deliberately excluded this in preference for this 'brand' they are definitely promoting as a universal when truly I believe it falls far short of encompassing the purest conception of medical professionalism that has allowed it to spread world wide and served so many of us even as we are ostracized by those who have so many resources.
This charter of medical professionalism fails extremely because it in no way protects the autonomy of the physician. It doesn't address the need for a physician to ethically and morally refuse to participate in situations where it is obvious that 'systemic' abuse is taking place. It indeed appears to serve not the 'patient' but the very agencies that have so often ensured resources do not get to the patient or the physician providing direct care.
Professionalism requires 'autonomy' and 'freedom' for 'physician' and 'patient'.
Monday, April 9, 2012
Cocaine Addicted Psychologists
If only for the reason that courts are relying more on psychologists and psychologists are becoming the de facto therapists recommended by various agencies given the shortages of psychiatrists I was interested in impairment studies among psychologists. I'd recently encountered a psychologist who considered 'recreational cocaine use'not a cause of serious concern. I remembered that this what we saw commonly when I began a country general practice 25 years ago. Then we joked, saying a "person didn't have an alcohol problem unless he drank more than his physician". Yet cocaine is much more concerning than alcohol.
A standing joke in 12 step programs where experience with drugs and alcohol and those who use them is highest is: an alcoholic will steal your wallet but a cocaine addict will steal your wallet and then help you look for it.
So I did a google search on impaired psychologists and found that there were articles, though few, and far less surveillance than doctors, nurses, or lawyers yet the problem is clearly increasing and the risks are far greater in future than in past where psychologists were more supervised than today.
Unfortunately all the references I found were not free to the public. In all cases I had to pay to access the material though I can find the incidence of addiction in lawyers per se without such an economic barrier. That alone concerns me. Hopefully concerned psychologists will address this issue.
A standing joke in 12 step programs where experience with drugs and alcohol and those who use them is highest is: an alcoholic will steal your wallet but a cocaine addict will steal your wallet and then help you look for it.
So I did a google search on impaired psychologists and found that there were articles, though few, and far less surveillance than doctors, nurses, or lawyers yet the problem is clearly increasing and the risks are far greater in future than in past where psychologists were more supervised than today.
Unfortunately all the references I found were not free to the public. In all cases I had to pay to access the material though I can find the incidence of addiction in lawyers per se without such an economic barrier. That alone concerns me. Hopefully concerned psychologists will address this issue.
-
Psychologist heal thyself: What is available for the impaired ...
psycnet.apa.org/journals/amp/40/1/84.htmlby DA Laliotis - 1985 - Cited by 85 - Related articles
A thorough search of the literature yielded little information on incidence of impairment in psychology. Thoreson et al. (1983) offered a conservative estimate of ...
Drug Addiction and Canadian Judges
It is estimated that the rate of drug and alcohol addiction among Canadian lawyers ranges 10 to 25%. (Alcoholism, Drug Abuse and Lawyers, Are we willing to address the denial? Rick Allen), As it is lawyers who become judges this is a very serious and indeed terrifying concern. It was surely bad enough when alcohol was the sole culprit but today lawyers and judges are like the general population of Canada turning to drugs like cocaine. Marijuania is being used more for supposedly 'medical reasons' yet there is ample evidence if only from driving studies that marijuana affects decision making. I like to refer to my simple test where not a single patient smoking marijuania asked if he or she wanted their neurosurgeon to be smoking marijuana agreed that this was a good idea. I certainly wouldn't want my neurosurgeon smoking a crack pipe.
Yet consider a Canadian judge who considers such an idea as 'recreational cocaine' isn't a cause for serious concern! To date there is no 'recreational cocaine use' in medical circles yet a judge believes that to suggest a ' chronic cocaine abuser' has a problem isn't evident to clinicians who see countless addicts but rather believes unscientifically that 'cocaine use' is like alcohol which the courts sadly, are decades behind in addressing among their ranks.
In the US 'safety sensitive jobs' require urine testing. I remember Reagan proudly holding up his drug free urine. Urine testing exposes cocaine abuse. It wouldn't necessarily pick up alcohol abuse but then alcohol is not an illegal substance. Marijunia like heroin is picked up on urine testing but there are today medical reasons for use of cannibis. To date there is no reason for 'self administration' of cocaine except addiction. We hear people say they are 'experimenting' with criminal drugs such as 'cocaine' but we don't consider people as normal who 'experiment with theft" for instance.
http://www.lawyersweekly.ca/index.php?section=article&articleid=1404
Only 10 years ago the Chief Justice of the Supreme Court justice had such a serious problem with alcoholism that he was approached by other judges. The Chief Justice of Quebec's drinking only came to an end when she was caught drinking and driving in 2004. That's alcohol but what judges are on cocaine? Worse given the effects of cocaine specifically and early regarding ethical and moral behaviour, what judges would even dare approach another judge with a cocaine problem? Imagine the arrogance and boundary violations of a judge high on cocaine and getting away with it. He would likely either over react to anyone who questioned cocaine abuse or himself over react to cocaine in an attempt to conceal his own complicity. What judges are smoking marijuani?
Finally given how high in the ranks this problem goes can any body in the legal system be safely entrusted with addressing judges addicted to cocaine..
Just as doctors have their own professional self help body which to date has had it's own difficulties dealing with drunkeness in senior doctors, whereas they're quite competent with dealing with drug and alcohol abuse among junior doctors, the same is likely true for the legal profession's self help group.
http://www.lapbc.com/images/Tips_on_Warning_Signs_of_Addiction_May_2007.pdf
Also consider the stigma of mental illness for a judge who actually views his and other's cocaine use as 'recreational'. forhttp://www.camh.net/news_events/key_camh_facts_for_media/addictionmentalhealthstatistics.html
I would think it would be as likely that Clinton as President would have voluntarily discussed his relationship with Monica with Congress.
That said, 80 to 90% of judges are not doing cocaine. The majority of judges are not smoking crack. So hopefully they will collectively address this ethical issue very soon. I personally don't want to hear after the fact that a supreme court judge was found with a crack pipe in his or her mouth. Chief Justice Beverly McLaughlin is fighting against tremendous resistance in the courts for transparency. Perhaps this could extend to urine drug testing. We expect as much from the Canucks and are especially concerned about olympic athletes. Should we accept far lesser standards from the Gods of Olympus?
We say that an alcoholic will steal your wallet but a drug addict will steal it then help you look for it.
Yet consider a Canadian judge who considers such an idea as 'recreational cocaine' isn't a cause for serious concern! To date there is no 'recreational cocaine use' in medical circles yet a judge believes that to suggest a ' chronic cocaine abuser' has a problem isn't evident to clinicians who see countless addicts but rather believes unscientifically that 'cocaine use' is like alcohol which the courts sadly, are decades behind in addressing among their ranks.
In the US 'safety sensitive jobs' require urine testing. I remember Reagan proudly holding up his drug free urine. Urine testing exposes cocaine abuse. It wouldn't necessarily pick up alcohol abuse but then alcohol is not an illegal substance. Marijunia like heroin is picked up on urine testing but there are today medical reasons for use of cannibis. To date there is no reason for 'self administration' of cocaine except addiction. We hear people say they are 'experimenting' with criminal drugs such as 'cocaine' but we don't consider people as normal who 'experiment with theft" for instance.
http://www.lawyersweekly.ca/index.php?section=article&articleid=1404
Only 10 years ago the Chief Justice of the Supreme Court justice had such a serious problem with alcoholism that he was approached by other judges. The Chief Justice of Quebec's drinking only came to an end when she was caught drinking and driving in 2004. That's alcohol but what judges are on cocaine? Worse given the effects of cocaine specifically and early regarding ethical and moral behaviour, what judges would even dare approach another judge with a cocaine problem? Imagine the arrogance and boundary violations of a judge high on cocaine and getting away with it. He would likely either over react to anyone who questioned cocaine abuse or himself over react to cocaine in an attempt to conceal his own complicity. What judges are smoking marijuani?
Finally given how high in the ranks this problem goes can any body in the legal system be safely entrusted with addressing judges addicted to cocaine..
Just as doctors have their own professional self help body which to date has had it's own difficulties dealing with drunkeness in senior doctors, whereas they're quite competent with dealing with drug and alcohol abuse among junior doctors, the same is likely true for the legal profession's self help group.
http://www.lapbc.com/images/Tips_on_Warning_Signs_of_Addiction_May_2007.pdf
Also consider the stigma of mental illness for a judge who actually views his and other's cocaine use as 'recreational'. forhttp://www.camh.net/news_events/key_camh_facts_for_media/addictionmentalhealthstatistics.html
I would think it would be as likely that Clinton as President would have voluntarily discussed his relationship with Monica with Congress.
That said, 80 to 90% of judges are not doing cocaine. The majority of judges are not smoking crack. So hopefully they will collectively address this ethical issue very soon. I personally don't want to hear after the fact that a supreme court judge was found with a crack pipe in his or her mouth. Chief Justice Beverly McLaughlin is fighting against tremendous resistance in the courts for transparency. Perhaps this could extend to urine drug testing. We expect as much from the Canucks and are especially concerned about olympic athletes. Should we accept far lesser standards from the Gods of Olympus?
We say that an alcoholic will steal your wallet but a drug addict will steal it then help you look for it.
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