By the time this diary is published
I pray the winter cold will have eased up and the only
lingering memory will be the heating bill. Today, however,
is cold. The St Lawrence River is frozen over and the
wind that whistles across the ice chills the bones.
As I get in the car and head up the highway towards
the hospital the news is all glum. My son has made me
a few CDs and I head up the road to the sounds of Otis
Redding singing "Sitting on the Dock of the Bay."
When you do a lot of driving along
familiar routes it's easy to enter a fugue state and
you can find yourself up the road not remembering the
drive you just did. This morning my mind's on diabetes
care.
It's one of the sad realities of
our healthcare system that patients who depend upon
a provincial drug benefit program sometimes end up with
sub-optimal care. When I try to add another agent I
find that (according to the provincial drug plan) I
need to wait until my patient's A1C has worsened way
beyond an acceptable level before it will be covered.
Why? Because a committee decided their budget cannot
afford much use of the newer, more expensive medications.
The process actually encourages poor quality care.
The Canadian Guidelines are clear
about when to initiate or add agents according to A1C
levels — and the arbitrary level of 10% chosen
by our province's drug program is not it!
As a family doctor I'm trying to
change my practice habits to be more aggressive in managing
my diabetic patients: don't hesitate to add a second
or third oral agent to get tight control; think insulin
if targets are still not met; be aggressive in managing
BP and lipids. Instead I find myself dealing with government
red tape. Otis Redding didn't die from diabetes but
he did express my frustration when he sang "Looks like
nothing's gonna change/Everything still remains the
same/I can't do what ten people tell me to do/So I guess
I'll remain the same"
GASTRO
ALLEY
When I arrive the hospital is awash in diarrhea. One
of my patients, who's confused and wanders the corridors,
has had the problem for a few days and is now being
unsuccessfully isolated. C difficile has hospitals
extra paranoid. I try to get through my rounds quickly
but I am washing and gloving and gowning ad nausea.
The only victims here are the staff having to clean
up the mess. All the cultures to date have been negative
so we just need a couple of "formed" days before my
patient can wander freely once more.
I gather my coat and medical bag
and head for the car. Just hanging around the hospital
is giving me gas. It's been a busy week, I think, heading
to clinic. On Monday evening a colleague and I attended
an evening CME on stroke management given by Drs Michael
Sharma and Steve Lehay. It was an excellent review of
secondary prevention and risk factor treatment in primary
prevention.
Wednesday evening there was a meeting
of our Family Health Network (FHN), an association which
changes our pay structure from fee-for-service to roster-based.
There are a myriad of administrative tortures to this
transition and, like Dante, we move slowly through each
level of hell.
Thursday evening I drive into Ottawa
to a talk on the genetics of Apolipoprotein E and its
implications for diagnosis and treatment of dementia,
given by an expert from McGill. Friday evening we have
a party for two staff members who are retiring after
a combined 50-some years of service at our clinic. The
evening is full of fun and tears as people reminisce
about the times we've spent together in work and play.
They'll both be missed.
Dr Paul Coolican is a family physician
from Morrisburg, ON
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