Methadone not good enough?

One of two Calgary methadone treatment centres that services about 500 patients is scheduled to close at the end of this month. The reasons include not meeting city standards for zoning and not adequately consulting with community associations before it opened in late 2008. 

How it managed to open despite these claims is anyone's guess, but is it justifiable that the community associations are legitimately worried? On one hand, they can be blamed for adopting a "not in my backyard" policy and fueling the stigma of those living with substance addictions. But if you put yourself in the shoes of a community resident, having addicts freely and frequently roam your streets may be a good enough reason to complain. 

Let's take a step back and look at the big picture for a second. Closing the treatment centre will leave a few hundred of people without the appropriate care and support needed to wean off their drug addictions. This will be particularly devastating to those who are already committed to their regimens, but that need convenience and habituation to carry themselves through. The risk of relapse will be high, potentially undoing years of hard work on the part of both patients and health care workers. 

Although immediate closure seems like a worst-case scenario, relocation is not that much better. As mentioned, treatment for substance abuse can be long and arduous. If people with addictions rely on routines to maintain compliance, any disruption in this pattern can be detrimental. How big of an impact will moving a clinic cause? I guess it depends on how far away it will be from the greatest locus of clients, how many health care personnel will continue to work in it, and if the services will be delivered at the same level of efficiency. It doesn't help that a 3-month wait time exists at the other methadone clinic, which cannot realistically take on more patients. 

What bothers me is this. Even though science (and perhaps some heart-warming testimonies) can show compelling evidence of the effectiveness of methadone treatment, the needs of substance abusers often come second to none. Are they less deserving of treatment because of who they are or what they do? You would be surprised if I told you that those with drug addictions come from all walks of life. 

Even then, a doctor would say no to this question because dealing with health and health care issues is what unifies all human beings. As Perri Klass puts it nicely, "doctors are engaged with individual humans at the level that makes everyone human." 

On the other hand, a policy-maker (as this is a career path I'm still considering) has to weigh several other opinions, ranging from those of city counsellors to community members to anyone else with a public interest on this matter. Policy-makers sorting through this dilemma would be hard-pressed to take sides between those that are healthy versus those that are unhealthy. Doctors, as advocates for their patients, have a clear position. 

How can someone reconcile being both a doctor and a policy-maker?

WC

Big'ups

Big'ups to the movie Up!

I finally had the chance to see it, and after much anticipation, it still managed to exceed my expectations. Just based on the preview alone, one would think that the lead character, Carl, is just a grumpy old man with nothing better to do than concoct wild ideas of flying a house. Who would have thought that he lived a life that many people only wish they had, of growing old with the person you love the most?

There was an obvious climax to the movie. This was when Carl finally reached Paradise Falls and looked over his sentimental "Adventure Book" for the last time. Up until then, Carl had been living on a unfulfilled promise to his late wife, Ellie. When he flipped through the book, little did he realize that Ellie's adventure began when they got married. It was a heartfelt reminder of cherishing the past and moving on. 

Sometimes we need a wake-up call to remind us of appreciating, rather than, regretting life's journey. Sometimes it takes the most unlikely of characters, such as a chubby Wilderness Explorer, a talking dog, and even an overgrown pelican, to change our frame of mind. Sometimes, embarking on a new adventure happens when we least expect it.

WC

Dental Discoveries #2

My tooth aches. It's the same tooth that had a cavity and then a filling. I'm seeing the dentist this Wednesday to get it checked up. I suspect that either the filling came loose or the cavity wasn't completely removed. Either way, the dentist should fix it up without charging extra on top of a regular appointment. I will be quite surprised if I have to pay additional costs for what very well may have been her mistake. 

During my last appointment, the dentist recommended a wisdom teeth extraction. She stressed the importance of preventative action: taking out your wisdom teeth at a younger age will lower your risk of getting infections in the future. In her opinion, removing the teeth before their roots fully mature would be a less invasive and less painful procedure (no bone drilling required!). Although she presented these reasons convincingly, I was suspicious about her vested interest in doing the extraction. I asked her about the fee for removing one wisdom tooth - a whopping $300! For three teeth, my dental insurance would not only max out, but over 2/3s of the funds would have to come from my pocket. Tooth be told, I needed to talk to other people and do my own research before making a final decision. 

So far, I have shared my concerns with three of my colleagues at UofT dentistry. They have all provided me with some sound advice, despite the controversy surrounding wisdom teeth removal. One friend encouraged me to consider whether my teeth will induce pain and discomfort by putting pressure on adjacent ones. When I reviewed my X-ray images with the dentist, she pointed out that one of my teeth was growing in sideways. I admit that I was worried about this at the time and almost bought in to the procedure right away. 

My other friend told me, in more detail, about how impacted wisdom teeth can cause many problems down the road. There are several ways. If they grow sideways, they can crowd the rest of your teeth and mess up your beautiful row of pearly whites. Although this may be true, tooth alignment does depend to some degree on the size of your jaw. 

He also discussed the possibility of having the wisdom teeth erupt into the oral cavity, allowing bacteria to accumulate and cause decay on adjacent teeth. Although infrequent, these infections can spread to the head and neck regions, potentially damaging surrounding nerves. In a worst case scenario, the brain and heart can be infected through fascial spaces. 

On the other hand, he mentioned about the cons of going forward with wisdom teeth extraction. With any medical procedure, risk is involved and mouth surgery is no different. For example, the lingual nerve, which is fairly close to the third molars, can be damaged if the surgeon is not careful. I wonder how often this happens as I have yet to look at studies that investigate dental errors. 

My last friend talked about the risk of having caries on partially erupted and fully impacted wisdom teeth. This can potentially lead to damage to the surrounding bone structure if decay progresses toward the root of the tooth. When he mentioned this, I couldn't help but wonder whether good oral hygiene would save any of this from happening. He did say that brushing wisdom teeth is more difficult than brushing regular teeth. In addition, there is no accessibility to those that are impacted.

He did leave me with some positive considerations for keeping the "wise" ones. First, they can be used to treat damaged teeth - I guess in a similar way as grafting skin for burned areas on the body. Apparently, they can also prevent bone resorption of the jaw during old age. As to how this happens, I have no clue. I'm sure the dental literature holds the answer. All these considerations come with keeping immaculate oral hygiene. 

At the moment, I am leaning towards having my wisdom teeth removed, but only when my dental insurance coverage gets renewed in the fall. I have three impacted wisdom teeth with one growing sideways into an adjacent tooth. Although none of them bother me at the moment, they are in a prime position for extraction because their roots are not fully grown. This means that the surgery will be less intense and post-operative recovery will be smoother if I do not delay.

I'm anxious to see what the literature has to say about my colleagues' advice. 

WC

Losing Momentum...

Teaching is something I used to enjoy. Now, it feels like a chore that I just don't want to do. 

When I'm giving a lecture, I often wonder what my students are thinking about me. Are they confused about my explanations? Do they think my jokes are too corny? Am I a boring lecturer? I can sometimes read their minds through their facial expressions and body movements. Not everyone is going to be wide awake and interested about what I have to say, yet I am quick to assume fault for this. Irrational, no? 

Today, I got the sense that my students were getting fed up with my teaching style. I covered a particularly unexciting section of organic chemistry, which involved writing out reaction upon reaction on the board. I admit that I wasn't fully prepared for this class - my boardwork was sloppy, my explanations unclear, and I made mistakes. As the class carried on, I felt that I was losing the confidence of my students, leading to doubts about my ability to teach. I was quickly reminded of my struggles during the training session for this job. 

Why am I having these reservations? Maybe there are things that I don't like about this teaching position. Firstly, organic chemistry is not my passion. I don't get excited about electrons moving around, but I'm sure that there are some people who do. Secondly, teaching that requires intense board work for 2.5 hours is physically laborious. I feel like I have to bring a change of clothes, a towel, and a water bottle even though I'm not headed to the gym. Finally, my learning philosophy is fundamentally different from what the Princeton Review practices. Being in the shoes of a student, I know that there is limited value to lecture-based learning. It takes a lot of skill and practice to be an excellent lecturer, but if I could have it any other way, I wouldn't be teaching the material in this style. 

Teaching does have its perks. It's always nice to interact with the students and help them reach the "Aha!" moment when they finally understand a concept. Questions that are asked during class encourage me to be quick on my feet. Finally, teaching is an opportunity to develop communication skills - you have to be clear and concise when conveying your knowledge to other people. 

I suppose that I just had a bad day and things will pick up in the next class. I wish there was an opportunity to get more consistent feedback from my students so I could see where to make improvements. I'm not satisfied with being just an average teacher...I want to be a good one. 

WC

What a patient can teach a doctor?

Dressed in a gown and wearing only shorts, I felt cold in the doctor's room. This was going to be a long night, I reminded myself, and popped a piece of cinnamon-flavoured gum in my mouth to freshen my breath. I quickly reviewed my clinical case so that I knew all the facts of my "fake" condition. The OSCE examination was supposed to commence 15 minutes ago, and I had no idea why things were starting so late. Oh well, I thought to myself, time for me to sneak in a power nap. Afterall, I needed all the rest I could get before blitzing for 6 hours straight.

As I was just about to close my eyes, the clinical evaluator for my station came in. She looked a bit flustered, and I gathered that she too was unhappy about the lack of punctuality. We had a quick introduction before she started shuffling through her papers and getting organized. When she was finished preparing, we discussed about possible reasons why the examination was running behind schedule - could it be that some preceptors or standardized patients didn't show up, was there a mix-up in the organization, did some first-year medical students loose their way? We did not know, but clearly she was becoming more impatient with each passing moment. 

Alas, we heard shuffling noises behind the door - the students were lining up and reading the triggers! A gentle knock on the door soon followed. The first medical student was ready to enter the room and perform their required duties. I was nervous for them. 

A young man in his late twenties walked in. Upon entering the room, he washed his hands right away, introduced himself, asked me how I should be addressed, and asked permission to examine me - all standard procedures of a short clinical exchange. Did he forget the confidentiality spiel? I made a mental note of it. I could tell that he was anxious - it showed in his trembling hands and stuttering voice. He asked me to describe my symptoms and I gingerly recalled the information relevant to my clinical case. For some responses, I deliberately spoke in vague terms so as to prompt him to follow up with more focussed questions. There was nothing interesting or outstanding about my clinical presentation, but I noticed that the medical student was trying hard to study every response I made. Simultaneously, he was trying to work through a standard set of history-taking questions - past medical history, family history, taking any medications, drinking/smoking/recreational drug use, diet, etc. There were moments where he paused to recall a series of questions. This impacted the flow of the conversation. Who would have thought that communication could be so challenging in a clinical setting? 

After the history-taking, he performed an abdominal examination on me. I had to lie across the bed in the room with my gown rolled up to my chest and drapes across my lower extremities. I felt vulnerable, self-conscious, and not surprisingly afraid. This random stranger was about to put his hands on my stomach and perform tests that would induce discomfort and pain. I could tell his hands were cold and I cringed at the prospect of having sweaty hands kneading at my skin. I was not prepared for this kind of up-front and physical interaction with a person entrusted to care for me. I had a rare glimpse of what it feels like to be a patient.

During this one-night stint, what did I learn about being a doctor? Sure, it is important to know how to take a proper history and physical examination. As you build a differential diagnosis about what the patient has, you have to be quick on your feet to process new information. It is important to ask the right questions that will guide your clinical judgment but not restrict the flow of the conversation. For example, when you ask a patient if they have experienced "fevers, chills, or nightsweats", you might get a response along the lines of "no." Does that mean that the patient is experiencing none of these symptoms or just a few of them? It doesn't hurt to clarify, summarize, or paraphrase in these circumstances. But these competencies alone do not separate average doctors from good ones. 

Of all the medical students that I met that evening, who did I prefer to be my doctor? Those that showed empathy immediately caught my attention. One of my rehearsed opening statements consisted of telling the students that I was worried about my condition. Only a handful of students picked up on the opportunity to say, "I could imagine that going through this must be hard for you." A seemingly insignificant statement made a significant difference in my mood. Realistically, it's difficult to remember to be empathetic when your mind is juggling what you're trying to say, what you are seeing and hearing, and how everything fits together to paint a clinical picture. But showing empathy is crucial because it demonstrates that you genuinely care about the patient's plight and take interest in understanding their situation more deeply. 

Of course, there are other things that a physician can do to show concern for the patient. For example, asking permission to perform certain procedures, explaining in lay terms what they are doing during an examination, warming their hands before touching the patient, and reassuring them that they made the right decision of coming in. These are all small actions that demonstrate respect and professionalism, the sum of which can have a huge impact on the patient's disposition. If we know that these displays of politeness and dignity are effective in building patient rapport, why do I still suspect that they are not emphasized enough in real life situations? No doubt there are competing objectives. In a brief 10 minute appointment, how do you know that you are showing enough empathy while balancing your duties of taking a thorough history and physical examination? Ten minutes is arguably not enough time to perform all these tasks, yet there is a point to be made about being efficient in the way you communicate. Of greater concern, how do you show that you are genuinely empathetic about your patient's plight when you have nothing in your past experiences to relate to what they're going through? For example, if a young pregnant female comes to see me about aborting her fetus, am I really in a position to understand what she is enduring? And finally, when does being genuine cross the emotional threshold in a way that biases your clinical judgment and renders your thought process irrational? 

In that brief encounter between the physician and the patient, I almost find the weight of the physician's responsibilities overbearing. 

WC

New Hairstyle...

Let me begin by saying that I think my head is awkwardly shaped. It is round yet asymmetrical, with the misfortune of having hair grow longer at the sides than on the top. In addition, my hair is dry and coarse in texture - two qualities that would make you cry if you were my personal stylist. Did I also mention that in bright, reflective light you might mistake my black hair for being gray? 

When I was young, I used to hate going to the barbershop because I almost always expected to be disappointed. My barber would ask me what I want, to which I would reply, "go crazy." I was never impressed by a single design. 

Recently, I've grown accustomed to my current hairstyle - the quasi fo-hawk. Its a clean cut, a bit funky, and has encouraged me to care more about personal grooming. However, maintaining this bad boy requires me to drop a bill almost every two weeks. Frankly, its time for a change. 

I know that my new hairstyle will be longer than the current one, with proportionally more length than width. I might push for a messy or a clean look, the former requiring less styling product and the latter requiring more. I'll also give the hair stylists a second chance. When I grow my hair, at least they'll have more confidence working with something long enough to hide their mistakes...

Here are some photos of old hairstyles. Should I return to them or try something new?  

The Paper Tear...4 Years Later

The dean of my program is known for his "paper tear" talk. I've heard him give the speech several times over the past four years, but I only decided recently to give it critical thought.

Here is what the "paper tear" is about: every audience member starts with a blank sheet of paper. Del, the dean of my program, delivers a simple set of instructions that requires folding the sheet of paper several times over and ripping it at specific corners. The catch to this straightforward exercise is that no one can talk and everyone has to keep their eyes shut at all times.

Although everyone followed the same set of instructions to complete the relatively easy task, each individual's final product was inevitably different.

What can be gathered from this demonstration?

Del believes that too often than not we aim for conformity and fail to acknowledge individual differences. For example, in a formal education environment, lecture-based teaching promotes a one-size fits all model for learning. Everyone gets the same dose of information, but it is obvious that the interpretations of such information will differ. Yet, when it comes time to evaluate our learning progress, we are expected to share similar interpretations in order to arrive at the same answers. The "paper tear" reminds us that while learning in this idealistic way is necessary for cognitive development, it has its limitations in the real world where complexity can shatter our overly naive thinking.

This brings me back to my program. BHSc. is rooted in the philosophy that a more personalized approach to learning allows its students to acquire knowledge at their own pace, using various mediums, and with the support of facilitators and peers. The "paper tear" exercise demonstrated that everyone arrived at a different final product because they weren't able to communicate with each other. It's no surprise then that collaboration is at the heart of the program. Were we able to work together, I have no doubt that our paper products would look similar if not the same.

In addition, we should understand how we arrived at the final product rather than if we had the same design. Focusing on process promotes the identification of strengths and weaknesses that is necessary for growth in learning. Exclusive orientation to outcome, on the other hand, can be maladaptive should it detract from understanding one's learning process. Unfortunately, most systems, especially those pertaining to education, are rested on measuring and standardizing outcomes. For example, good marks and grades are necessary for getting into professional school even though they are debatable indicators of your competency to learn.

It bothers me that I can't seem to remember my interpretation of the "paper tear" demonstration back in first year. Being young and reckless at the time, I suspect that I didn't have enough experiences to appreciate and internalize the value of the underlying message. Moving to a new school next year with a somewhat different pedagogical paradigm, I wonder how my interpretation of the "paper tear" will change. Will I still be a strong believer of problem-based learning? Only time, in the length of 4 years, will tell...

WC

Biking for a Cause?

Before this summer, I kept telling myself that my post-graduation vacation trip would consist of a luxurious and lengthy stay in a posh European city. I had other options laid out too: a trip to the motherland, an Indiana Jones' like escapade to Machu Picchu, and...a bike trip across Ontario.

So it seems that reality has set in and I just don't have enough dough to travel by air. I tell myself that I would rather travel by bike because I can get regular physical activity, leave less of a carbon footprint, and have the luxury of creating my own adventure. Economical considerations aside, it seems that a bike trip is growing more and more enticing.

Having the willingness to go on a bike trip assumes that one enjoys biking. I do enjoy biking, although I wouldn't say that I'm a hardcore marathon cyclist or an adrenaline-seeking mountain biker. Ever since I started the Duke of Edinburgh Awards program back in Grade 9, my first real exposure to the outdoors was with a biking troupe. On my very first excursion (from Toronto's Harbourfront to Mississauga's Indian Line campgrounds), I learned how to be safe while sharing the road with other vehicles, how to refrain from eating all of the other cyclists' food (anyone who knows my appetite can speak to this), and how not to roll over people in a communal tent. It was the beginning of my appreciation of the Canadian outdoors, although I would hardly consider a trip from Toronto to Mississauga "roughing it out".

The biking trips that followed were more physically strenuous, longer in duration, and wrought with challenges that required the problem-solving efforts of an entire team. On one trip, for example, my fellow cyclists and I could not find our campsite because it was late at night and we were caught in a torrential downpour. At one point, we found ourselves in the middle of nowhere...even our map was of no help. A few members of the group became frustrated at the realization of being lost. After everyone was reassured that we were not in an emergency situation, we calmly retraced our steps and found our original path. No sooner than later, we were at the campsite and everyone was relieved to have a good night's rest. As much as this experience was a mental whirlwind for me, I miss it because it was exhilirating. Being lost can be an excuse for finding adventure - something I look forward to on my next, highly anticipated bike journey.

More about this next big trip. It will likely happen in August. I finish work on the 14th and start school on the 24th - a perfect window of opportunity. I'm hoping to have some of my close friends come along if they're up for the challenge: Dave, Tom, Mike, Justin, Reena, Gabe, and Katrina. I also think there needs to be a greater purpose attached to this trip beyond self gratification. I've recently been inspired about the Ride for World Health project, which is a 2-month, cross-country biking tour that aims to address global health disparities by focusing on education, advocacy, and fundraising. The education stream is quite interesting. Participants deliver lecture series at community centres and schools along the way with the goal of facilitating discussion on global health problems and empowering audiences to become informed and active global citizens. Unfortunately, this project is only based in the United States. Fortunately, there may be a chance of starting something like this in Canada, perhaps with slight differences in design (as suggested by my friend Dave).

Rather than focussing on global health issues, why not pick health/health care issues that directly affect Canadian communities, such as rural medicine, Aboriginal health, ecological health, sexual health, healthy living & exercise, etc. Of course, doing adequate research on these topics and being culturally sensitive to our audiences would be requirements before delivering any kind of presentation. I think high school students would be most receptive to our message, as biking long distances is a feat worthy of inspiring this population. Gauging the interest of fellow cyclists with a passion for biking as well as health(care) issues would be a good start of getting together a group of like-minded individuals. Who knows where the planning process might take us...

For my upcoming one week bike trip, I'm anxious to see if I can not only overcome the physical and mental duress of an outdoor adventure, but also the inertia of developing an idea and not seeing it come to fruition. On that note, what are ways to sustain one's motivation for a fleeting thought? Perhaps committment of the thought to a written form...

WC