doctor on a soapbox

from Just For Canadian Doctors Spring 2020

small talk

Dr. Chris Pengilly is Just For Canadian Doctors’ current affairs columnist. Please send your comments to him via his website at drpeng.ca.

History lesson

It has happened at last. I have finally terminated my provincial College licence. I orchestrated a soft landing from my original chaotic pace, but eventually had to quit taxiing along the runway and call it a day. This has inevitably made me look back over the 45 years since I first went into family practice in Canada in 1975.

Looking back, the changes are great and numerous. I’ll admit that in 1969 (year of my UK graduation) I had hoped that by the time I retired from family practice I could say “oh, it’s just a cancer, take these and see me in a month…” Nevertheless, there have been many changes enabling physicians to offer hitherto unimaginable treatments as a result of unforeseen diagnostic tests and pharmacotherapies. I’m sure that many of the younger readers could not imagine practising medicine without the ready availability of the CT scan (1979), let alone the MRI (early 1980s) or even the PET scan (1995). This enhanced medical imaging, besides being a great help to oncology, also enabled (or at least facilitated) the development of effective and enduring joint replacements. The hip was first (early 1970s), then the knee (1970s through 1980s) and the successful shoulder (1985). The 1970s seem to have been a busy decade, during which the rapid development of computer chip-based microcameras was a pivotal event in the rapid introduction of laparoscopy and facilitation of flexible endoscopies. It was also this decade that saw the useful utilization of diagnostic ultrasound. This provided a relatively inexpensive, safe and mostly effective diagnostic tool. It’s used, for example, in diagnosing gallbladder pathology or, probably most prominently, as the obstetrical ultrasound—undertaken productively about two or three times even in uncomplicated pregnancies. In 1981, there was the introduction of captopril, the first ACE inhibitor. Initially indicated for the treatment of refractory hypertension, it introduced the first welltolerated antihypertensive and was also more than useful in treating congestive cardiac failure. Though it is no longer available in Canada, it did blaze the trail for ramipril and a whole bunch of other ACEs. This was shortly followed by ARBs that have proven equally useful and better tolerated.

The development of PDE-5 inhibitors in 1981 has revolutionized the treatment of the distress in pulmonary hypertension, with the very useful side use for erectile dysfunctions. This was a difficult condition to treat in family practice, leading to my sense of helplessness and prescribing the useless placebo of yohimbine. In 1982 I had the first case of AIDS admitted to hospital; he was discharged with the diagnosis “viral infection NYD.” At that time this was a 100% fatal illness but now it’s another chronic disease with which to exist under medication. The result of these and many other changes means that physicians—all physicians—are able to offer patients many options and improved treatments. A few of these treatments will reduce the demands on the system; for example laparoscopy reduces hospital stays significantly. But this is more than offset by the needs of many patients—like the 59,000 hip replacements and 70,500 knee replacements last year in Canada. As I leave the profession it seems to be in a bit of a shambles. Wait times are becoming untenable again, and there is a chronic shortage of hospital beds and nursing home care. I am treading very carefully here because I want to avoid any misunderstanding. I am not suggesting an alternative private pay system. I am suggesting revisiting the politically unpalatable concept of a modest user fee for those that can afford it.

As an example, my wife is now on a seven-to-nine-month waiting list (along with hundreds of others) to have a second knee replacement. During this time, I’ve witnessed her becoming increasingly disabled (now able to walk about 200 metres on the level). I’m fortunate to be able to pay a reasonable user fee—with no expectation of queue jumping. And I’d like to be able to do so.

Can total medical care continue to be provided completely free? At the very least let us start a discussion… Reflecting on a long career that’s seen many big and broad changes in the medical field

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Sierra Leone is very, very poor. Their medical system is inadequate. International Vision Volunteers Canada (IVVC) has recently opened a new general hospital near Makeni, Sierra Leone, West Africa. The plan is that the hospital shall be managed and administered by Sierra Leonean staff and be funded by fees for service, and be financially self-sustaining within a few years. It can be done, but we are not there yet. The hospital is operational, it has the basic medical equipment for forty beds, it has a keen young Sierra Leonean staff. What it needs now is technical medical equipment and instruments, and western expertise to train surgeons, doctors, and nurses towards better medical standards and techniques. In fact, we need YOU. The catchment area of the hospital is about 1,000,000 people. Tens of thousands of people need your help. Whether you can transfer your skills in two days, ten weeks, or even by email, Sierra Leone needs YOU! If you have expertise in any medical or dental specialty you can help to develop the skills of the local staff. The top eight immediate needs for help are: The air-conditioned accommodation is good; food is western, with African options. - Vaginal-vesical fistula - X-ray interpretation - Ultrasound interpretation - ECG/EKG interpretation - Pregnancy management - Diabetic management - Cardiovascular management - Dentistry If you can help us, please respond to amd@ivvc.ca www.ivvc.ca