Wednesday, December 30, 2015

Peggy's Cove & Gawande: Complications & Being Mortal!

In August I read Gawande when in Peggy's Cove and posted about his book Complications! Honestly, I did not know Gawande was giving the Reith Lectures. 

Peggy's Cove: Charm & Complications!

What a charming place: Peggy's Cove of Halifax.

The Cockroach Catcher was finishing reading the book Complications and such charming old landscape reminds him of the old traditional medical training he received and how some doctors still do. Like the author of this book.

The book reads more like a collection of blog posts and in fact it was. Yet it was real and touching. Sometimes it was brunt and brutal. and after all doctors are as human as anyone. Complications includes those doctors themselves may suffer: mental illness and alcoholism as well as the serious cardiac condition of the author's young son.

We, doctors make mistakes and please we must be allowed to sort them out without affecting career or worst, future medical behaviour.

A great book for doctors in particular and when on holiday in a charming place.

 (Metropolitan Books, 288 pages, $24), a collection of 14 pieces, some of which were originally published in The New Yorker and Slate magazines, Gawande uses real-life scenarios – a burned-out doctor who refuses to quit; a terminal patient who opts for risky surgery, with fatal results – to explore the larger ethical issues that underlie medicine. He asks: How much input should a patient have? How can young doctors gain hands-on experience without endangering lives? And how responsible are these doctors for their mistakes?
While “Complications” is full of tragic errors and near misses, the book is not intended to be an expose. Rather, Gawande asserts, it is meant to deepen our understanding of the intricacies of medicine. “In most medical writing, the doctor is either a hero or a villain,” he says, with an edge in his voice. “What I am trying to do is push beyond that and show how ordinary doctors are – and at the same time show that what they can do is extraordinary.”
John Freeman, Copyright (c) 2002 The Denver Post.

Quotes

- ‘There have now been many studies of elite performers – international violinists, chess grand masters, professional ice-skaters, mathematicians, and so forth – and the biggest difference… is the cumulative amount of deliberate practice they’ve had.’

- ‘We have long faced a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. Residencies attempt to mitigate potential harm through supervision and graduated responsibility. And there is reason to think patients actually benefit from teaching. Studies generally find teaching hospitals have better outcomes than non-teaching hospitals. Residents may be amateurs, but having them around checking on patients, asking questions, and keeping faculty on their toes seem to help. But there is still getting around those first few unsteady times a young physician tries to put in a central line, remove a breast cancer, or sew together two segments of a colon… the ward services and clinics where residents have the most responsibility are populated by the poor, the uninsured, the drunk, and the demented… By traditional ethics and public insistence (not to mention court rulings), a patient’s right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden behind drapes and anesthesia and the elisions of language.’ 

- ‘There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference – or, more simply, M+M – and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges.’ 
Latest Gawande Book:



In one of the most moving passages in the book, Gawande’s father, in hospice, rises from his wheelchair to hear his son lecture at their hometown university. “I was almost overcome just witnessing it,” Gawande writes.

........Gawande offers no manifesto, no checklist, for a better end of life. Rather, he profiles professionals who have challenged the status quo, including Bill Thomas and other geriatricians, palliative-care specialists, and hospice workers. Particularly inspiring are the stories of patients who made hard decisions about balancing their desire to live longer with their desire to live better. These include Gawande’s daughter’s piano teacher, who gave lessons until the last month of her life, and Gawande’s father, also a surgeon, who continued work on a school he founded in India while dying of a spinal tumor.
He’s awed not only by his father’s strength, but by the hospice care that helped the dying man articulate what mattered most to him, and to do it. Gawande thinks, as he watches his proud father climb the bleachers, “Here is what a different kind of care — a different kind of medicine — makes possible.”

What would lawyers say about M + M:

- ‘There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference – or, more simply, M+M – and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges.’ 

            >>>See also Dr No: We Have No Black Boxes
                                               Abetternhs's Blog  What are we afraid of?

August 27 2014:

What a charming place: Peggy's Cove of Halifax.

The Cockroach Catcher was finishing reading the book Complications and such charming old landscape reminds him of the old traditional medical training he received and how some doctors still do. Like the author of this book.

The book reads more like a collection of blog posts and in fact it was. Yet it was real and touching. Sometimes it was brunt and brutal. and after all doctors are as human as anyone. Complications includes those doctors themselves may suffer: mental illness and alcoholism as well as the serious cardiac condition of the author's young son.

We, doctors make mistakes and please we must be allowed to sort them out without affecting career or worst, future medical behaviour.

A great book for doctors in particular and when on holiday in a charming place.










All photos©2014 Am Ang Zhang  

 (Metropolitan Books, 288 pages, $24), a collection of 14 pieces, some of which were originally published in The New Yorker and Slate magazines, Gawande uses real-life scenarios – a burned-out doctor who refuses to quit; a terminal patient who opts for risky surgery, with fatal results – to explore the larger ethical issues that underlie medicine. He asks: How much input should a patient have? How can young doctors gain hands-on experience without endangering lives? And how responsible are these doctors for their mistakes?
While “Complications” is full of tragic errors and near misses, the book is not intended to be an expose. Rather, Gawande asserts, it is meant to deepen our understanding of the intricacies of medicine. “In most medical writing, the doctor is either a hero or a villain,” he says, with an edge in his voice. “What I am trying to do is push beyond that and show how ordinary doctors are – and at the same time show that what they can do is extraordinary.”
John Freeman, Copyright (c) 2002 The Denver Post.

Quotes

- ‘There have now been many studies of elite performers – international violinists, chess grand masters, professional ice-skaters, mathematicians, and so forth – and the biggest difference… is the cumulative amount of deliberate practice they’ve had.’

- ‘We have long faced a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. Residencies attempt to mitigate potential harm through supervision and graduated responsibility. And there is reason to think patients actually benefit from teaching. Studies generally find teaching hospitals have better outcomes than non-teaching hospitals. Residents may be amateurs, but having them around checking on patients, asking questions, and keeping faculty on their toes seem to help. But there is still getting around those first few unsteady times a young physician tries to put in a central line, remove a breast cancer, or sew together two segments of a colon… the ward services and clinics where residents have the most responsibility are populated by the poor, the uninsured, the drunk, and the demented… By traditional ethics and public insistence (not to mention court rulings), a patient’s right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden behind drapes and anesthesia and the elisions of language.’ 

- ‘There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference – or, more simply, M+M – and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges.’ 

Peggy's Cove: Charm & Complications!


Thursday, December 24, 2015

Crab & Goose: Xmas alternatives?

The Cockroach Catcher loves his home reared turkey when he was young and to date he is having trouble finding anything close. So he chose Goose instead. Watch the wine alternative to Claret!


What about the seafood starter?

It has to be England's best kept secret, Brown Crabs that we nicked named as Dumb Crabs as they are slow and sluggish unlike some fast and aggressive ones. Unfortunately the secret is not such a secret as China is now importing most of the top quality ones.  Try some before they disappear. 




The crabs are served cold: delightfully fresh and sweet tasting.  Any seasoning? None required.

This time of the year the female ones have a good bit of roe.  We often pan fry the crab roe by beating a couple of eggs in with the roe and frying the mixture with olive oil and chopped fresh garlic.  




The paired wine: Puligny Montrachet 1er Les Referts (2004).  This has a delightful apricot and almond nose, and in taste a herbal fruitiness and subtle buttery character typical of Puligny Montrachet.  A good match for the freshest seafood simply prepared.

Billingsgate: The Cockroach Catcher’s Guide
Goose could perhaps be done in my home style:

The goose is more difficult to pair with wine. If you are lucky to get a fatty one, you can pick a top Champagne such as Krug that will go extremely well.  But the Cockroach Catcher is going to surprise you with a wine he discovered when he went to Chile: where Cabernet Sauvignon still grows from original root stock:
Don Melchor: rated as top 10 wine of 2015 by Forbes, it is certainly a good value wine for special occasions considering what you would be paying for the top Bordeaux wines.


Well, what can I say, goose has stronger flavour than turkey and Don Melchor is as good as any French Top Growth and its herbal hint suits the Cilantro used in cooking the Goose.   

Happy Xmas !

An earlier post





Food Posts:


Tuesday, December 22, 2015

Norway & Hong Kong: Drunk Or Art Nouveau!

Democracy Or Alcohol?



Ålesund ©2012 Am Ang Zhang

In 1904 fire destroyed most of Ålesund.

It was rebuilt in Art Nouveau style and is arguably the most beautiful city in Norway without the City Hall.

Democracy: Voted against joining EU in 1972 and 1994.


Norway is one of the richest and most contented nations on earth, with a GDP per capita of £40,000 – compared to £23,000 in the UK, and an EU average of £21,150.
Unemployment is at 3.25 per cent, while GDP is growing at 2.75 per cent per year – as it has on average over the last 40 years.

It also regularly tops the UN's survey of quality of life, with a generous welfare system – women receive 46 weeks maternity leave at full salary, compared to Britain's six weeks on 90 per cent – and free education (incl. universities) is provided for all.

The country funds this through its huge reserves of oil, timber and fish which it manages prudently, stashing away large percentages of its oil revenues to fund the future healthcare needs of an ageing population.

Alcohol:


Do we ever learn that prohibition never did anything to alcohol consumption nor would price control? 


With the millions spent on Cocaine in Wall Street and The City, when will we wake up to the fact that these are Tax Free perks?




©2013 Am Ang Zhang

By Wendy Leung - February 27, 2008 05:37 EST
In a place without democracy!

Feb. 27 (Bloomberg) -- Hong Kong's government abolished taxes on wine and beer after posting a record surplus, boosting efforts to turn the city into a wine-trading hub.

The tariffs will be abolished immediately, costing the city government HK$560 million ($72 million) in annual tax revenue.
Tax was 80% before 2007 then 40%


The rest of Hong Kong Tax:
No sales tax
No capital gains tax
No VAT
Maximum salary tax of 20%
Profit tax maximum of 16%
Inheritance tax or estate duty has been abolished since             11February 2006. 

Yet, my doctor friends told me that there is no binge drinking problem like they have in Norway where there is high taxation and much difficulty in buying alcohol.

Strange: A drink too many!

Ålesund Norway©2012 Am Ang Zhang





Solveig Torvik 
December 16, 2010 

Weekend binge drinking is a perplexing feature of Norwegian cultural life to many visitors.

The role of alcohol in Norway often appears to be to consume it until you’re senseless, and alcohol commonly is accepted as an excuse for indulging in antisocial behavior. Binge drinking seemingly isn’t regarded as aberrant behavior in Norway, even by sober citizens who, generally speaking, uncomplainingly tolerate the ensuing brawls and other unpleasant results.

But why do so many people who do live in the “world’s best place” drink until they’re comatose? And why are many of them prone to violence and aggression when drunk? No one knows.

Dr Ole Johan Hoyberg, formerly a hospital-based psychiatrist in Ålesund, told newspaper Sunnmørsposten: “There’s a great deal more drunkenness in the communities that I got an insight about as a hospital doctor. Alcohol abuse is on the point of becoming a national sickness.”

Which seems an odd state of affairs indeed for a nation that’s billed as the world’s best place to live.

Perhaps no tax on alcohol beats democracy!


Cuba 2: Charm & Elegance!














Old and beautiful.

Monday, December 21, 2015

Flat Earth & Miracles: Duping & Human Kindness!




It is reassuring that there are still people that were kind enough to risk everything in order to help others in desperate need. It became more upsetting when you realised that the kind-hearted person has been duped. But then even government has been duped into paying millions of our money to so called charitable organizations we can hardly blame any individual except of course the individual is not losing other people’s money but their own.

Photoshop Miracle:

Black Currant Miracles © 2012 Am Ang Zhang


        It is not my intention, either as an individual or as a scientist, to express an opinion on religious visions and miracles. Science has generally failed to understand these phenomena and many religions on the whole have tended to ignore scientific explanations.
        For the religious amongst us, a close study of the history of religion would have seen deliberate attempts a couple of millennia ago to trick people into believing certain things supernatural. In a recent visit to Ephesus, we heard tales of how early “Christians” were duped and “cured”.
        When the Western World was in the tight grip of the Catholic Church, the Jesuits were generally regarded as the greatest scholars. They brought Western culture and religion to the East. They must have had a glimpse of the Chinese understanding of the universe and the world. Yet for so long the religious view of Flat Earth held true. Did the Jesuit scholars know the truth or did they pretend not to in order to avoid persecution and possible death? We shall never know.
        Many “visions” have proved to be the work of errant brain waves due either to epilepsy or brain tumours. Yet the Church continued to celebrate these phenomena.
The first picture is the original: the rest miracles!

From my book The Cockroach Catcher,  Chapter 15: Miracles:

Third Miracle
        The third miracle is closer to home. I did not perform it either, but it happened to the mother of one of my patients.
        Over the years, I was blessed in my work at different clinics with interesting secretaries. They had always managed to fill me in with the latest gossip, teenage trends ranging from fashion to music to leisure pursuits, and local news, all of which was so important in my work.  In thirty years I have been to the local pub no more than five times. Without my secretaries I would probably have very little understanding of the main group of families that I dealt with most of the time.  I cannot, by any stretch of imagination, claim to be able to move amongst that circle.  Only rarely did I come across a family that shared my interests in art, music and culture in general.
        I have certainly come across a child psychiatrist who could hold his own in any pub and was able to switch into Cockney at will and who became a professor at a very young age.   But, that was not me and I have no hope of changing that.
        This particular clinic was in a “new town” which was established after the war to take in south London inhabitants as part of the great Social Engineering endeavour of the post war government. Having worked in three totally different localities in the same county, I can safely report that the morbidity rate in the new town far exceeded that of the other two locations, one of which has recently been classed as amongst the five most liveable towns in the whole of England.  Off the top of my head, the rate of disturbance is between two to two and half times of that in the other two localities.
        As far as I am concerned, the only slim chance of success of  Social Engineering  would be in a totalitarian state.
        It was therefore a bit of a shock for me to hear about this miracle in the “new town”.
        This particular morning my secretary showed me a copy of the local paper. I never bought the local papers.  I used to find them so intellectually de-stimulating that I had an unspoken fear of reading them. The clinic though had an extremely long tradition of ordering not one but both papers and that tradition continued. I often wondered when, in the new world of NHS management, someone would take that away to boost the manager’s performance related pay.
        On the front page was a big picture of the mother of one of my patients. 
        “Miracle Cure” was the headline.
        One could not miss her as she was amongst the most obese patients I had ever met.
        I was half expecting to see a seven stone wonder on the inside page.  Instead it was a picture of her church complete with members holding a candlelight vigil.
        ‘After a 49-night vigil, she was cleared of all cancer,’ it was reported. 
        It could not be.   My trusting parents normally told me these things. She never looked like she was ill and if anything, she seemed to have continued to put on weight in the six months I had known her. I always remembered her as being overweight by any standard.
        “Doctors could not find any cancer cell!”  The report continued.
        She was apparently given only three months to live and had been on morphine for some weeks before she joined the church. Now her specialist told her that there was no longer a single cancer cell in her.
        As she was due to attend our clinic, my social worker said she would make some phone calls to the Family doctor and gently enquire about it. She had in the past mentioned something about painkillers but never cancer.
        My social worker’s enquiries drew a blank. They had read the same paper and were equally puzzled. She was certainly not receiving any treatment for cancer and definitely not on painkillers.
        During the session she told my social worker that she had private health insurance and produced a card to prove it. She was told that she only had three months to live. In desperation she joined the local church and the rest we knew. Also, her son’s soiling had stopped as well.
        There was no further need to attend our clinic.

        We were all amazed.

Sunday, December 20, 2015