Barry J. Goldlist's blog

Most year end reviews come at the end of December. At that time I was working full speed as an attending physician on our hospital’s general medical service and never saw the light of day. Immediately afterwards, I took over an extremely busy geriatric consult service. However, I am now back from two weeks of rest and recuperation in the sun and once again capable of stringing words together.

This past year was a momentous one for several of my colleagues who became members of the Order of Canada or Ontario. They are all exceptional physicians and scientists who are more than worthy of the honours they received. What about the rest of us, who work hard and feel successful, but labour in relative obscurity? What about our recognition?

In fact, I believe that most of us know that we are recognized by that most important group, our patients. I have been practicing medicine as a specialist since 1979, and I still feel that we are part of a noble profession. I still feel that if I go home after a ‘good’ day, it is truly a win-win experience, for me and my patients. We have the opportunity to work in a field that allows us on a daily basis to help other human beings, and unlike others in the helping/caring professions (e.g. social workers, teachers), we are among the highest paid professionals in society (although more would be even better!). Not only are we helping people, but the work itself is intellectually demanding and satisfying. I am hoping the daily intellectual demands of medicine will protect me against dementia in the future (although some of my colleagues feel it is already too late for that).

For me, the most surprising part of practicing medicine is the tremendous amount of respect we get, from our patients and society at large. This contributes to the ‘psychic’ pay (as opposed to money pay) that we receive for our jobs. Sometimes, however, we take this respect for granted, and in hospital at least, expect our patients to agree with everything we say or do. In effect, we expect sick hospital patients to grant us respect even if we do not earn it. I am starting to enjoy the ‘difficult patients’ who demand explanations and reasons for my actions. They remind me that in most person to person interactions trust is earned, not granted just because of a position and title. I am trying more and more to explain my thought processes and reasons to all my patients, especially in those areas where evidence is sketchy and treatment may not be beneficial.

Enjoy this new year, and I hope some of you become members of the Order of Canada!
Regards,
Barry Goldlist

November 6, 2011

Last week I had the opportunity to attend the 6^th Canadian Conference on Dementia (CCD) in Montreal.  Like its predecessors it was a fabulous meeting.  The two co-chairs, Ron Keren and Sandra Black, did a phenomenal job, and attracted many of the top people in the field as participants.  I am very interested in dementia, and in fact work in a Memory Clinic in Toronto on a weekly basis.  However, I was clearly several levels below many of the participants in my knowledge and expertise in the field of dementia.  This is in fact not surprising, as I subspecialized in Geriatric Medicine because I wanted to focus on all of a person’s problems, rather than those caused as a result of dysfunction in a single organ system.  However, that more diffuse focus comes at a price.  My hospital just attracted a new behavioural neurologist just out of her research fellowship.  This is in fact her first full time job, and yet she is far ahead of me in the dementia field.  This made me a bit uncomfortable at first, but I have reconciled myself to my place in the field.

However, knowing my own inferior level is one thing.  What would really upset me is the thought that I am providing second rate care for my patients at the memory clinic.  However, I do not think that I am, and my experience is possibly generalizable to other fields.  First, there is evidence going back to the 1980’s from Seattle that general medical optimization of patients (most of whom are elderly) with dementia improves cognitive function, often for a prolonged period.  This is what I bring to the clinic, however, I think I provide good assessments of patients with dementia as their only active issue as well.  How am I able to accomplish this?  By working closely with the experts.  As a group we have decided on a standardized way to approach both the history and cognitive testing.  I am constantly cued to ask the right questions by a template created by a more expert colleague (thank you David Tang-Wai).  But the real power comes from the interprofessional conference after the clinic has ended.  Detailed case discussions with a neurologist, geriatric psychiatrist, and allied health, means that all aspects of the case are reviewed before a diagnosis and plan of action are put in place.  The learning opportunities for the non-expert such as myself are enormous, and are particularly valuable because of their clinical relevance.  I have learned more at these conferences than reading journals or even attending the CCD.

Is this model generalizable?  I think so.  Just considering two of the major issues facing our older patients, diabetes mellitus and congestive heart failure, leads to obvious areas where geriatricians, general internists, and family physicians could work side by side with specialists and make an important contribution, and on occasion even improve the quality of care.  An example of the latter effect would be the work of George Heckman showing the high prevalence of cognitive impairment in a heart failure clinic.  Often treatment failure in such a setting requires alternate means of ensuring medication adherence (dosettes, blister packs, supervision), rather than increasing medication dosage.  The ability to learn from each other can also improve care in other settings as well. 

Still, I had better learn a bit more to avoid embarrassing myself in front of junior colleagues!

Regards,

Barry Goldlist

As I write this we are already half way through the summer, and I have spent a fair amount of the time on vacation.  The other night, I woke up at about 2 a.m., and for some unknown reason started thinking about my first clinical rotation as a medical student during the summer of 1973 (in those days clinical work at U of Toronto started in fourth year with virtually no break after third year finished).  It was in obstetrics and gynaecology at the Toronto General Hospital and I had an incredible time.  I was able to do 8 deliveries all by myself, and the majority of the delivery in another 25, numbers that I suspect few medical students could match today.  It was also my first introduction to the power of communication (or more accurately miscommunication) and how it affects patient care.  I met one young Chinese couple who were furious because of their poor care.  The wife spoke no English and her husband spoke only minimal English.  They had sought advice about birth control at the hospital’s gynaecology clinic, but despite that the young woman was pregnant.  The husband was particularly indignant, as he had taken the birth control pills as directed without missing even once!  Another young woman had received a years supply of a sequential BCP with placebos for the last 7 days of the cycle.  These pills thus came in three colours.  She put all the pills in a large glass dish, and selected each morning the colour pill that matched her mood most appropriately.  She too was indignant that medical science had not been able to prevent an unwanted pregnancy.  I also had a great privilege on that rotation.  In the previous 2000 years of recorded history only one immaculate conception had been recorded.  I was privileged to see two in just two weeks in clinic.

Still unable to sleep, my morbid memory then moved to the suicides I saw while in training.  That same year I was a fourth year clinical clerk, one intern killed himself, and one patient snuck out of her medical ward and cut her wrists in a closet on the radiology floor (to be discovered by a radiologist hanging up his coat the next morning).  The most frightening episode was a double suicide that occurred in January of my PGY2 year.  I had been in Florida for a conference followed by a vacation, and one of the residents on neurosurgery had been in Florida at the same time.  The week after returning to work, I bumped into that resident and asked him how he was doing.  He replied, I am depressed and without much thought I replied, yeah me too it’s tough getting back to work after a great vacation.  Two days later a young woman was admitted to psychiatry after an overdose.  Unfortunately, she conned the staff physician into giving her a four hour pass the next morning.  She immediately went to the rooftop bar at the Park Plaza Hotel and jumped off, hitting the Avenue Road bus head first.  The bus driver fainted (he was fine) and the girl (obviously dead) and he were brought to the ER.  Despite the futility of the intervention, neurosurgery was paged stat to assess the woman.  Unknown to all of us, the resident on call (the one I mentioned above) had just hung himself that same morning and his body was discovered by his three year old son.  We did not know till later that in fact we were paging a dead man to minister to a dead woman.  I still get the shakes to this day when I think of it.  Enough of this morbid thinking, enjoy the rest of the summer.

Regards,

Barry Goldlist

When you work at a teaching hospital, there is often a layer between you and hospitalized patients.  That layer of course is composed of residents.  They insulate us from many of the day to day tasks of caring for sick patients, but they also insulate us from the pleasure we get from interacting with (and sometimes actually helping) patients. For much of this week I have had no residents on my service, so have been seeing in patients on my own.  This morning after rounds I left Mount Sinai to follow up on a consult I had seen yesterday at Toronto Western Hospital.  This woman is the wife of  a prominent physician, and had become delirious on medications.  It was wonderful to see that she had almost recovered, and particularly impressive to see how fabulous her children were in staying at her side throughout the 48 hours of delirium to ensure that a familiar voice and face was always available during her period of confusion.  I followed this up with a family conference at Toronto General Hospital.  Once again meeting the daughter of a severely demented woman whom I had consulted on two days earlier, I was overwhelmed by how dedicated some caregivers are.  The daughter (herself a grandmother) knows that her mother never wanted to enter a nursing home, and has spared no physical effort or expense to help her mother stay in her own home (which is a few houses away from hers). I then returned to Mount Sinai, where I met a 91 year old retired nurse who lives by herself and still drives.  Unfortunately she tripped over a kitchen stool and had a fracture adjacent to her previous knee replacement.  She intended to return to her apartment and to continue driving after rehab.  I then met an indomitable 83 year old woman who had survived bladder cancer (ileal conduit in place), lung cancer (second hand smoke exposure from her husband), two hip replacements, and unstable angina.  She had tried to put something on a high shelf and instead of getting a step ladder, she stood on a rickety chair, and fell and broke her shoulder.  Her embarrassment was greater than her pain!  My sojourn on the orthopaedic ward ended with a delightful consult on a retired psychiatrist who tripped getting out of the shower (diabetic peripheral neuropathy) and broke his tibia.  He was an absolute delight to chat with. These type of direct interactions with patients are always special.  Community physicians have these types of interactions every day, and on days like today I envy them.  I see patients on my own in clinic all the time, but it is a different type of interaction (although still satisfying).  They are not in crisis when I see them in clinic, so the interaction is not as intense.  So for those of you who are thinking ‘If I only had residents’, think again.  Something is lost by having them around.  Enjoy the weekend, Barry Goldlist

I have been in practice so long, that I sometimes get the illusion that I actually know what I am doing.  Big mistake!  Despite my long experience in geriatric medicine, one family this month has outwitted me continuously in keeping their mother in hospital.  The number of family meetings to discuss disposition seems to have hit double figures.  Each ends with a decisive and reasonable plan that the family is able to sabotage the next day.  Perhaps this week’s meeting will produce some results! I had the unfortunate experience of admitting a lovely young police officer with recurrent, and untreatable, osteosarcoma.  I learned from my oncology colleagues that there has been a mini epidemic of osteosarcoma in police officers in Ontario.  The connecting link is radar guns that are kept on and cradled in the officers’ lap between possible speeders.  If you think you are the one who suffered the most from a speeding ticket, think again. We admitted a 91 year old man with an ischemic leg who developed complication after complication post amputation.  There was obviously no reasonable hope for his survival despite his family’s optimism.  He has bounced back and is now doing very well while awaiting rehab to master independent transfers before going home.  So much for my erudite prognostications. I am also continuously astounded by the grace and courage that many patients exhibit despite their grim outlooks.  The police officer mentioned above was a particular example of grace under fire.  She seemed to spend more time comforting the hospital care-givers about her prognosis than we did comforting her.  Another 80 year old man who was diagnosed with metastatic colon cancer (including liver metastases) explained to us that he understood his impending death, but just needed to regain enough strength to be able to die at home. Heading back to the wards now, where I undoubtedly will learn even more. Regards, Barry