Canadian Medicine

As Dr Joel Freeman drove his red two-door Porsche along Ottawa's St Laurent Blvd one day in September 2004, another car suddenly cut him off. Enraged, he tailgated the careless driver, gesticulating and swearing for the car to pull over.

When the two cars pulled in and stopped in a nearby parking lot, Dr Freeman leapt to the driver's side of the other car, reached in and repeatedly punched the driver in the face. The 26-year-old driver was left with a bruised jaw and bloody split lip.

Police alleged that Dr Freeman held a closed pocket knife in his hand as he bludgeoned the man and investigators later found a blade with the name 'Freeman' engraved on the handle in his Porsche.

The injured driver pressed assault charges, as . (The story has been removed from their website because of some inaccuracies later corrected in apology.) But when the case came before a judge in April 2006, the accusations of assault with a weapon and possession of a weapon for a dangerous purpose were withdrawn by the Crown after no evidence could be produced that Dr Freeman held the knife while striking the blows. In the end he pled guilty to one charge of assault and received an absolute discharge from the court.

Since the incident, Dr Freeman, a colorectal and gastric bypass specialist, has been publicly shamed. In 2005 he resigned his privileges at The Ottawa Hospital, and he's been removed from the University of Ottawa's medical faculty, where he taught in the past.

Now, his peers are taking him to task for his behaviour. At 9am this past Monday he had a disciplinary hearing at the College of Physicians and Surgeons of Ontario. "The committee found that he committed an act of misconduct unbecoming of a physician," says College spokeswoman Kathryn Clarke. "We've ordered a public reprimand and that the results of the proceeding be published." , to pay for half of the costs of the punishment proceedings. In an forthcoming release the committee plans to outline the reasons for their findings.


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An elderly Manitoba man’s last gasps of life are at the centre of a growing national controversy over end-of-life decision-making.

Yesterday, a judge extended an injunction barring physicians from withdrawing the ventilation and feeding tube that have been sustaining Samuel Golubchuk (pictured right) for about four months now. The judge's extension is in despite opposition to the positions of the attending doctors, the hospital and the provincial College of Physicians and Surgeons.

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Golubchuk’s son Percy and daughter, Miriam Geller, expressed relief after hearing the judge’s decision.

“God is with us,” Geller said. “This is for all the people in Canada and the world.”

“Doctors are not always right,” said Percy Golubchuk. “God is the main doctor.”

Here’s the background on Mr Golubchuk, from :

Samuel Golubchuk, aged 84, was admitted to Grace Hospital in Winnipeg in October with pneumonia and pulmonary hypertension. He had suffered a brain injury in 2003 from a fall, for which he had part of his brain removed. His condition deteriorated rapidly while in hospital and doctors told the family they wanted to take him off life support on November 30, 2007. The family refused, citing their Orthodox Jewish faith. An injunction over-ruling the doctors was granted while the court decides Mr Golubchuk's fate. On January 11, 2008, the judge heard that Mr Golobchuk had improved, regaining some neurological function and was classified on his chart as "awake."

Wednesday’s extension of the injunction runs contrary to the policy guidelines published last month by the College of Physicians and Surgeons of Manitoba, to fill the legal void created by the absence of any legislation that could serve as a guide on this case. You can read the news release (PDF) and the full guidelines (PDF). The guidelines say doctors have the authority to make independent do-not-resuscitate (DNR) decisions, though it also says families should be allowed sufficient time -- four days -- to appeal doctors’ decisions or seek an injunction.

That new policy hasn’t gone over terribly well.

"I think the College was irresponsible," Mr Golubchuk’s lawyer, Neil Kravetsky, told the Winnipeg Free Press. "They'd better smarten up before they issue directives that may border on criminal."

LifeNews.com, an American pro-life news website, has called the Golubchuk case “,” in reference to that ended in a judge deciding in favour of Ms Schiavo's husband, who wanted to withdraw life support, rather than the throngs of activists and politicians who piled on to push for continuing her care.


UPDATE, February 19: Terri Schiavo's brother has behind the Golubchuk family.

Photo: , a website set up by Mr Golubchuk’s family.

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Dave Hancock, Alberta's current Minister of Health and Wellness, may be in trouble.

Edmonton Journal political columnist Graham Thompson with Mr Hancock on the campaign trail. "I had to literally run to keep up with a fast-moving Conservative Dave Hancock who won by 900 votes in 2004 and who is seeking a fourth term as MLA for Edmonton-Whitemud."

The population of Mr Hancock's riding has risen sharply since the last election, from 15,000 households to 22,500, reports the Journal. Mr Thompson also points out that Mr Hancock may suffer from Premier Ed Stelmach's struggle to inspire voters of late.

But one of the most interesting suggestions about Mr Hancock's potential election loss pertains to a piece of legislation passed in December: the controversial Bill 41, which grants the Health Minister the power to take over aspects of independent health regulatory agencies.

Also adding to Hancock's woes is a potential local backlash by health-care professionals in his riding against Bill 41, the legislation which gave the government increased powers over the province's College of Physicians and Surgeons.

You can read more about doctors' significant opposition to the law in our previous coverage of the issue.

Besides Mr Hancock's situation, healthcare issues in general have moved nearer to centre-stage in the Alberta election campaign.

HEALTHCARE & THE ALBERTA ELECTION
Here are some of the recent healthcare issues at play in Alberta politics:

• As soon as the campaign kicked off, Premier Ed Stelmach quickly promised he'd increase the number of places in med schools to train an extra 225 physicians per year. Nice idea, says Dr Trevor Theman, the registrar of the College of Physicians and Surgeons of Alberta. But it's -- there are only two med schools in the province (U of Alberta and U of Calgary) and, combined, they account for just 250 spots as it is. Not long after the initial promise, the Tories revised the figure to "around 50 to 60." "Somewhere down the QE2 highway this week 175 doctors went missing," .
  

• Were Edmonton regional health authority officials pressured to permit Conservative politicians to , despite a history of barring other parties permission for similar uses?

• Emergency physician , a former federal Liberal, is in Edmonton-Meadowlark.

• Dr David Swann, a Liberal MLA and the party's environment critic, is on its latest climate change and emissions-reduction strategy, calling it "ridiculous."
  

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Dr Brian Goldman, an emergency physician at Toronto's busy Mount Sinai Hospital, somehow finds time in between ER shifts for a second job as a CBC radio host. His show, , airs Mondays at 11:30am and Fridays at 8pm on CBC Radio One. He also maintains a to accompany the show and appears on other CBC programs as the in-house medical columnist.

He took a few minutes out of his day, after already putting in a few hours in the Mount Sinai emergency department, to speak to us from the CBC's head office on Front Street in downtown Toronto, where he was revising some radio scripts.


First of all, how did the show get started?

I started to put together a proposal for a book called Medical BS. I sent it off to a bunch of publishers and they told me it was way too negative. Back to the drawing board. I had been a medical columnist for CBC for years, the health expert on afternoon shows. So I put together a proposal on the same idea -- what is true and what is BS. A producer, Quade Hermann, came back and said, “We’re not saying yes and we’re not saying no.” They said it needs work, it’s still too negative. We had meetings and one producer, Quade Hermann, kept asking, What is the black art of waiting rooms? What is the black art of waiting for surgery? Black art this, black art that. Doctors running around in white coats practising black art -- that’s how we got the title. Listeners want to understand why things work the way they do. They don’t want to complain anymore. As an emergency physician, they want to walk a mile in your shoes. What does it feel like? What is like to navigate through 10 patients, working in emerg, with nurses and everybody needing my attention at the same time? I pitched it two years ago and got funding, revised the proposal and made a pilot with Quade Hermann, which took about six months. That sat with the poobahs at CBC for six months and they came back and said, “Let’s make some episodes.” That was the happiest day of my life. It’s my show. It’s the most personal show I have ever done, and it’s the most fun for that reason. I get to do things and deliver commentary like I never have been able to do before. I’m lucky -- most hosts don't get to do what I’ve done. I feel incredibly fortunate to have this show on the air now. It comes at a perfect time in my career, at a quarter-century in broadcasting. I couldn't have done it ten years ago, but it’s perfect now.

Does your show have a lot of physician listeners?

We don't have exact surveys but we get a ton of physicians, family docs, specialists, nurses, pharmacists who listen -- all kinds of health professionals. And it’s not just individuals, but organized medicine too. We get emails from conferences, colleges of physicians nurses, schools, and universities.

What kind of feedback do you get?

Lots of suggestions for topics and lots of tips on how to fix the healthcare system. We have had [letters from] a number of people who have qualified to practise in other countries, like in the United States, who tried to get their licenses here but have gone back to the States and have opinions on what regulators should do. When we touch a raw nerve we hear about it. We did a show on physician competence, and we heard from them. We did a show on nurse competence, and we had a panel where nurses talked about newbies, new grads. And boy did we hear from the new grads. They said it’s a culture of eating their young. That really showed me people are listening.

Which subjects are the most popular?

Any story that gets inside the world of medicine and tells the story from the standpoint of the doctors and nurses. Any story that deconstructs for patients why they wait in the emergency department. We had an interview with a couple of triage nurses from the Peter Lougheed Centre in Calgary; they talked about the really incredibly difficult job triage nurses have, when they have 70 or 80 people or more waiting, eyeballing them. These nurses told some amazing stories of why they love it, what makes them frustrated -- the incredibly difficult job they do. We got a ton of people talking -- some good, some bad, some laudatory, some critical. What we are looking for on the show, as a colleague, a producer of a long running show on CBC Radio One, told me, is anger and understanding. That is the sweet spot. We want you to be a little peeved when you hear the inside story, but want you to understand what's going on.

Has anything else hit a nerve lately?

We did a show on queue jumping, how to be a successful queue jumper, and we opened with a Seinfeld episode -- the one where George and Jerry and Elaine are waiting at the Chinese restaurant and everybody is getting in ahead of them. This show gives me the license to pick from pop culture, music and Grey’s Anatomy and House. In fact, we devoted a half a show to whether a real-life House would be able to practise medicine in the real world.

What did you decide?

Probably 10 or 15 years ago he would have been able to, but now that doctor would be put out on his ass pretty quickly. I’ve heard of a surgeon who flung scalpels at OR nurses. You’re not allowed to do that anymore.

Do you try to target any of your content to physicians?

Of course, our primary audience is people who are health consumers, who are interested in understanding how the system works, not judging it but understanding how to get a little more out of the system, the code words to say to a doctor or a nurse to get more than they are getting now. But the amazing thing is the reaction from health professionals. When we hit the mark with consumers, we hit the mark with health professionals.

Do you listen to other radio programs for doctors?

One qualification: there are no similar shows to our show. There are none. What i have found -- with all due respect to health reporting and health commentary -- is that they tend to be advice. The only place you could get this kind of show is on CBC or on NPR in the US. There’s no other place to get documentary-style programs. I think the other shows serve a purpose -- you get questions you can ask your doctor, or whether you should be worried about something or not. I have been a health columnist on CBC radio for years and I hope that serves a purpose, but this venting, cathartic program is absolutely unique.


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Was it the vapours? Acute Darcyitis? A bilious attack?

What really killed Jane Austen?

In honour of Complete Jane Austen series, here's a little survey for all you medical detectives out there on what killed the beloved author of et al at just 41 years of age.

, first by Sir Zachary Cope in the British Medical Journal in 1964, is Jane Austen's most commonly accepted cause of death. , , , and , among others, have also been cited as possibilities. Hodgkin's disease is argued for in , published in the journal Medical Humanities in 2005 by English lit prof Annette Upfal of the University of Queensland.

There's precious little information for medical historians to go on, since the bulk of Jane Austen's correspondence was famously burned by her family. Here's what we know:

Fatal illness: In her last illness, thought to begin around a year before her death, Jane Austen exhibited the following symptoms: gastro-intestinal irritation (which she characterized as "bile" or "bilious attacks"), fever, weakness, languor, knee/leg pain (which she calls "rheumatism" in her letters), possible pruritis (skin itch), insomnia, pallor, syncope, skin discoloration ("black and white and every wrong colour" she wrote to her niece).

Medical history: Jane Austen was born four weeks post-date; she suffered "putrid fever" (typhus) as a child; as a young woman she had a bout of whooping cough accompanied by otitis externa.

Chronic conditions: Ms Austen also suffered throughout her life from chronic as well as severe (in her case, pain in the cheek and upper jaw).

The Valentine's Day edition of Grand Rounds, the "the weekly rotating carnival of the best of the medical blogosphere," at HealthBlawg, David Harlow's Health Care Law Blog.

Mr Harlow included Canadian Medicine's recent entry, "Doctors must kill the skunk, says bioethicist."

"One day, the phrase 'kill the skunk' will be synonymous with 'do the right thing,' and you'll be able to say you remember the day you read Sam Solomon's seminal medical ethics skunk post at Canadian Medicine."

Here are a few of the notable posts included in this week's Grand Rounds:

"How often do you see 'folie a deux' and 'Q-Tip' in the same post? Tip of the hat to Liana at for this tale of two strange birds. (Would someone kindly page Oliver Sacks?)"

"JC Jones ruminates on Heath Ledger's untimely demise at , and introduces us to a couple of 'wolves in white coats,' MDs peddling scrips for controlled substances."

You can read a with the host, health lawyer David Harlow, conducted by Nick Genes for Medscape.

will be hosting next week.

It looks as though we here at Canadian Medicine will be hosting Grand Rounds sometime next month. We'll be sure to let you know when we firm up the date.


Image: A neat image of a heart, the logo of the , seemed appropriate for a Valentine's Day-related entry.

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My name is Mario Meunier and I have quite a story to tell you...
So reads (below) placed on the eBay-style online auction site BidOfferBUY. Thirty-six year old Mr Meunier is offering his pancreas for sale to entice endocrine researchers to help him prove the connection between gastric bypass and nesidioblastosis, a pancreatic condition that leads to severe hypoglycemia. Mr Meunier suffers from the condition and is convinced his own gastric bypass operation eight years ago is responsible.

The asking price for the sick pancreas is $500,000 but Mr Meunier, who hails from the Rivière-du-Loup region, near Quebec's border with New Brunswick, insists his goals are academic not monetary.
On his (PDF), Mr Meunier recounts that when he was operated on in 2000 (he had a Roux-en-Y gastric bypass), he weighed around 200kg (440lbs). Two "magnificent years" passed and Mr Meunier reached his ideal weight of 64kg (142lbs), (not including the 14kg (30lbs) of excess skin he was carrying around). It was then his pancreatic troubles began.

Mr Meunier was due to undergo a partial ablation of the pancreas on February 21 to correct the problem, but he backed out when he found out St Luc Hospital in Montreal wouldn't allow him to keep any pancreatic tissue they removed. "We always have to send the organ to the pathology department for analysis," his surgeon Dr André Roy told La Presse. That's when Mr Meunier decided to take matters into his own hands.

The link between gastric bypass and hypoglycemia was thought to be rare, but a 2005 in the suggests the link may be stronger than previously believed. Nesidioblastosis is extremely rare in the general population, but the researchers found that gastric bypass patients "accounted for 40% of our patients with confirmed cases of nesidioblastosis" during the study period.

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