The long and the short of it…

I remember the visit I had with the optometrist. He checked my vision and said
“Yup, your glasses look OK right now. No changes needed.”
When he asked if i used them for driving, I said “No”, and he looked at me kinda funny.
“You don’t wear your glasses when you are driving?” he said.
“No, I need them mainly for reading…… “and it struck me how stupid this sounded.

This is a story about short-sightedness. Not me. The healthcare system.
Recently I have been doing locum work in the office. My 3 internist colleagues have waiting lists that stretch out for a year. A year. What sort of practice allows that? You have either (a) died (b) have forgotten your symptoms (c) have been admitted to hospital for expedited care. But these people show up, and are thankful they are being assessed. I tell them the system is broken, and they nod and look forward to a full clinical review. Most times, something appears – poorly controlled blood pressure, the need for a stress test or echo, or updated lab work. Sometimes they leave with ample reassurance, which is therapeutic.​

But the ‘system is broken’ message is universally accepted. They understand that
politicians are elected on a 4-5-year ticket, so planning and responsiveness to change uses this measure. But to train a physician, then make a GP or specialist, then embed them in a healthcare team – takes 10 to 15 years. Who is it that has this LONG-TERM VISION, one that transcends politics and looks at the needs of Canadians?
Canadians – a population that is growing in numbers, and in age. And with these two facts, so too is their burden of degenerative disease and dependency on tests, drugs and surgical treatments. The extended family of yore is no more – the daughter moved to Ottawa, the son to Auckland – and they visit maybe once a year. Imprisoned in a condo unit with similar-fated souls, they exist in a delicate balance, until one falls and breaks her hip, or the other becomes demented and disabled. It is no surprise that this situation is unfolding: the surprise is that we haven’t made serious arrangements to deal with it.

On the contrary, with a fixed number of doctors being trained, and multiple hoops
for foreign trained doctors to jump even to enter Canada, we now have a ‘crisis’ in
manpower/womanpower. There isn’t a mad rush towards private healthcare (which has some issues) mainly because we have an archaic system that outlaws any such solution. It seems that, given the choice between extended debility and isolation and even premature death, the modest Canadian would rather throw his lot behind a dated system, and eschew any semblance of modernity. Today I read of a daughter who hired a caregiver to sit with her demented father IN HOSPITAL, such was the challenge to care posed by inadequate staffing levels.

​I wrote to Ms. Patti Hadji, the then Federal Health Minister, and was told it was not
her problems, healthcare is the responsibility of the Provinces. So, I wrote to Mr. Adrian Dix, Healthcare Minister for BC, whose deputy replied a few months later. “Primary care networks will fix everything” was the response, which surprised me. Since then, things have gotten a lot worse.

If healthcare is known as the most COMPLEX industry on earth, why is it run piece-
meal by provincial governments? Will we ever get a solution to isolation, drug-
dependency, frailty and poor accessibility without radical change? Radical reform is
needed, not now, but yesterday. Can you imagine the auto industry still investing in the future of the internal combustion engine, or an import business that doesn’t use shipping containers? Well, healthcare needs some serious overhaul, for sure.

I had suggested that we have a National Think-Tank. Around the table, there would
be representatives from 4 agencies – (a) patients (b) doctors and nurses (c) support staff, eg. pharmacists and community workers (d) administrators, economists, government. We identify problems, ask questions, and steal solutions (from anywhere in the world). Then we implement these potential solutions in various communities, and adopt those that work (this is called Quality Improvement). I would do this work for FREE. The most radical aspect of such a Think-Tank is the involvement of patients. You know, patients, the people who actually FUND healthcare - and who deserve to be heard loud and clear.

Let’s admit we have a list of work ahead – climate change, fossil fuels, opioid
epidemic, homelessness, mental health, etc. In the UK, they have come to realise their
sewage treatment capacity is inadequate, but – surprise, surprise - flushing out to sea is not a reasonable option. School buildings made of substandard concrete (RAAC) need replaced, who knew? This lack of foresight will bite us in the bum.

​Let’s not be myopic. If for no other reason than our grandkids and beyond.

Tonight, I watched television news.   Gloom and doom, anger, frustration and layers of judgement.   Where was the good news?  Where was laughter and joy?  The spring cherry blossom, a philanthropic donation, or a free art exhibit?  Downplayed for sure, nothing much to make me laugh.
 
It made me ask the question “is laughter the best medicine?” I looked into it.
 
Laughter is defined as the sound of mirthfulness, an expression of merriment or amusement.  It has several synonyms, including chuckle, giggle, snicker and guffaw.
 
Laughter as a drug is an interesting concept.   It doesn’t come as a liquid, pill, injection or vape.  It can originate from a circumstance, the written or spoken word.   Certain specialists prescribe laughter (comedians), and almost no one objects to it (maybe funeral parlour directors and high court judges).   It can be contagious, but nothing we vaccinate against.  It is usually free, and does not respect race/religious/sexual boundaries. In fact, these boundaries are often flash points from which laughter originates (stand-up comedy).
 
Robinson et al (1) highlight the benefits of laughter on the immune system, pain axis and stress response.  More commonly observed in children, it can have benefits long into adulthood. In addition to physical benefits, it can defuse conflict, enhance teamwork and promote group bonding. Creating opportunities to laugh include ‘seeking out funny people, share a joke, make time for fun activities and play with a pet’.  And don’t take yourself too seriously!
 
Now, when the Mayo Clinic weight in, you have to take it seriously. (2) “It’s just what the doctor ordered” (or didn’t).  Sure, it stimulates vascular health and releases endorphins, but do we actually prescribe it?   Maybe we need to rethink prescription pads: one for exercise, one for diet, one for pills, and one…  with a joke on it.

 
Seriously, given the epidemic levels of stress, isolation and anxiety we see in our elderly population, it may well be that a red nose and a funny hat could do more for our patients than the latest biologic agent, or heart failure drug.  A squawk from a rubber duck might dent my patient’s confidence, but I have yet to regret making a patient smile with a little humour now and then.  I am no Patch Adams.  But I usually tell them the main risk factor for heart disease is ‘age-over-60: that’s when the warranty runs out.’  It works both ways.  I used to look after a very elderly priest who treated episodic dyspnoea with a small cylinder of sports-oxygen (i.e. acute heart failure).   Eventually, he gave the device to me - citing avoidance-of-destiny, for him, might be a conflict of interest.  Ha, Ha!
 
Of course, I have to mention ‘laughing gas’, first popularised by Humphrey Davy in 1799: Laughing Gas Parties were all the rage in the UK and US.  In 1844, the American dentist Horace Wells noted that a participant (Samuel Cooley) was covered with bruises the next day (from falling over), without feeling any pain. Wells used nitrous oxide to good effect when extracting a tooth from John Riggs, but it was not very effective for surgical anaesthesia, especially in obese alcoholics. When a previous dental associate, Dr William Morton, tried ether instead - the practice of Anaesthesia was born (1846).(5) 
 
There are times when laughter may be inappropriate:
At the roadside.  “Well, officer, I thought a speed zone meant something altogether different…. Ha ha!”
At the graveside.  “Uncle Mario had a good life, he was a fair-and-honest cryptocurrency banker in Miami….. giggle, giggle, ha, ha!”
In the ER. “Yes, looks like acute renal failure to me!  Ha, ha!”
In court.  “So, your honor, just 4-months in prison for my break-and-enter?  Ha, ha!”
On the phone with the taxman.  “You’ll never find my retirement stash!  Ha, ha!”
 
David DiSalvo (3) emphasises the potent endorphin release properties of laughter (‘homegrown feel-good chemicals), mimicking the euphoria one sees with narcotics.  Social bonding, increased brain-region connectivity, strengthening of conjugal relationships, and short-term neurotransmitter release (c.f. antidepressants) add to the known cardiovascular and anti-inflammatory benefits.  
 
Let me ask the obvious question: “are humour and positivity taught in medical school, and has a randomised controlled study showing proven benefit?”  The answer is YES (4) - at least in China, where 87% of student and teacher respondents agreed with the use of humour in the didactic setting.  Presumably, the 13% who said ‘no’ became pathologists.  
 
I have to agree with one instruction, ‘don’t dwell on the negative.’ But how do I avoid negative interactions when everyday people bring me their problems and complaints?  Well, I sure do celebrate success, a balancing measure in any medical practice.
 
Some people might not have the gift – but we all have a ‘funny bone’ somewhere…  Funny and happy people are remembered, miserable and serious ones are not.  So, make someone smile today…. Ha, ha!
 
References:

Laughter is the best medicine
Robinson et al, HelpGuide.org 28Feb2023
https://www.helpguide.org/articles/mental-health/laughter-is-the-best-medicine.htm
 
Stress relief from laughter? Its no joke.
Mayo Clinic July 2021
https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth-stress-relief/art-20044456

Six Science-Based Reasons Why Laughter Is The Best Medicine
DiSalvo, D
Forbes June 2017 
https://www.forbes.com/sites/daviddisalvo/2017/06/05/six-science-based-reasons-why-laughter-is-the-best-medicine/?sh=4e61465d7f04

Use of humour in medical education: a survey of students and teachers at a medical school in China                                                                                                       
Yan-Ping Liu et al
BMJ Open. 2017; 7(11): e018853.
Published online 2017 Nov 28.
doi: 10.1136/bmjopen-2017-018853
 
Further reading:
The laughing gas parties of the 1700s – and how they sparked a medical breakthrough
ABC News 19Feb2019
https://www.abc.net.au/news/2019-02-20/laughing-gas-parties-discovery-of-anaesthesia/10811060

​Tonight, I was impressed by Jay.
 
Jay is a musician.   He plays in a jazz quartet.    He plays bass, but when he transitions over to the acoustic guitar, boy, can he make it sing.  Effortlessly.  I listened to his music for 3 hours, as he switched from double bass to double string guitar, quietly lifting the performance from the shadows.
 
Jay must be 72.   He is 6 ft tall, 230lb.   He has graying hair, and rounded jovial face.  He dresses well: nothing shabby about Jay.
 
So why am I writing about Jay?  As I observed his stance, his manner, his deportment, his skill with strings, the ease with which he gave accompaniment, I thought ‘What if Jay came to the ER of my hospital with an MI?’.
 
J Smith, 72, male.
90982929301
Bed C4
 
‘Chest pain in a lounge bar, came on suddenly.   Had been working hard all night, pressure came on about 10pm and affected the left arm.   Unable to continue playing guitar.   Sweaty and breathless, he attributed the latter to the smoky room.   Denies alcohol intake.   No cigarettes for 4 years.   Widowed.   On ASA and vitamins.   Diet controlled diabetes, poor control.  No known allergies.  Exam obese Caucasian male, pulse 58 irregular, BP 160/90, no JVD or edema, quiet heart sounds, chest clear.  EKG AF with slow ventricular rate, acute inferior MI.   Tn 40.   CXR nil acute.   BS 12.2  K3.1.  GFR48. 
IMP/Plan:  acute inferior MI, thrombolysis, admit telemetry, schedule cath.   Enoxaparin, ASA, nitrates, betablocker when HR allows.   Consult to IM/Cardiology, notify GP in am.’
 
What is missing here?   As I looked at Jay, I said, “Nothing in my exchange with this overweight man tells me he is a remarkable human being.   He is talented, personable and experienced.  He is a sought after, self-effacing, locally-famous bandsman”.   But the social history is what we gloss over first when time is at a premium.  
 
Jay has a first-class sense of rhythm.   But tonight, his rhythm is atrial fibrillation, and he is anxious.  He is not in his element.   He worries about his friends, Iris, Bennett and Lorraine, who have 2 more sets lined up at the end of the week.   Will he be better by then?   Will this illness mean a change in his life, a drop in his income, and in future – a stroke?   Will he be able to play again?  Will he be able to afford his drugs, will they take his driving licence away?
 
Jay lives in a small house in Park Royal, with a dog, Bonaparte.  His neighbours will see that Bonaparte is ok.  Jay’s name is on a dozen album releases: that he isn’t known to nurses and doctors in this venue is odd.   Jay lives for music, but there are no sounds in this emergency room cubicle.  Jay, like most of our patients, has become a number, a bed, a stay, a transfer, a procedure, and a disposition.   Jay the bass player, the Gibson’s wizard, the feted soloist and stellar team member – is facing his demons alone.   If only we knew.
 
Who hasn’t said ‘WOW’ when learning our patient (a) defused IEDs in Afghanistan (b) rebuilds antique cars for a hobby (c) is an accomplished portrait painter (d) travelled the world as a National Geographic photographer (e) was ski-ing in the Alps last winter at the age of 71 (f) has 20 grandchildren and great-grandchildren?
 
But this information trickles out later, when time allows us the opportunity to make that essential contact and healing touch with the simple question “What do you do, or did you do, for a living?”  It is one of the most interesting portals to understanding any patient.
 
To be honest, I don’t even like jazz.   But I know greatness when I see it:  it is in everyone.
 
 
 

It was a Tuesday morning, 10am.   Our group was reporting back to our staffman (Morley Lertzman) on the respirology consult service of St Boniface Hospital (Winnipeg).  I mentioned I had an interesting young lady was waiting to be reviewed.  Without any further discussion, we put down our teacups (yes, he was unique!) and went to her bedside.  Mandy was 29, indigenous, and unencumbered by medical paraphernalia.  Dr Lertzman took her pulse, thought for a moment, and said:
"I suspect she has mitral stenosis, mitral regurgitation and aortic incompetence".
Each of us in the group looked at one another, somewhat surprised.  
"How did you know?"
"Well, she is in atrial fibrillation, likely rheumatic at this age.   Most likely based on structural disease of the mitral valve - see, she has a malar flush. And if it's stenotic, it's likely regurgitant.   The AR is easy, she has a collapsing (Corrigan's) pulse.  If she was a hospitalised cardiomyopath, she might be on oxygen, have a heplock, or have dilated neck veins - not so."
The echo from the previous day was confirmatory.  I never forgot that lesson.  
 
In previous articles, I have referred to my career exemplar, John Dagg, who could help a group of novice medical students diagnose a patient's right-sided Pancoast Tumour with associated Horner’s syndrome - and an ipsilateral cerebellar metastasis - just from observation. Or put 2 and 2 together when a 30-year-old man - on the Hematology ward - presented with a swollen knee.  Hemophiliac hemarthrosis.
And Conan Doyle, who spied a mildly jaundiced, diaphoretic, tanned sailor in the waiting room, his hand over his upper abdomen.  Amoebic liver abscess.
Or my wife, out on a beach picnic, noting a hairy patch over a friend's lower back.  Spina bifida occulta.
 
Now that we are doing telemedicine, and examining actors in the fellowship exam, how much are we missing? I hear we cannot move forward with acute appendicitis until the CT is available.  Is observation a thing of the past?
 
I was an examiner at the Royal College exams one year, and a candidate (from a US school) was asked:
"Can you show us how you examine this man's knee?"
He looked at it, gave it a poke, and said "It looks OK to me."
My colleague and I were hoping for a bit more detail - inspection, range of movement, assessment of ligamentous laxity, balloting for effusion, etc.
"So, what did the MRI show?" he asks.
We gazed at the floor, and moved on.
Or the candidate who put everything together about the young diabetic we gave him. 
"And what do you think this red, blistering, dermatomal rash might be on his back?" we asked.
"Eczema?" 
 He exited stage left, the patient stage right (to see his family doctor ASAP).
The Royal College exams were a study-in-anxiety ('four years work depends on today's exam') - but nearly everyone who failed their Fellowship Oral had previously failed the Written exam.  We really bent over backwards to get their best performance ("get yourself a cup of tea and come back in an hour... ").   Good old tea.
 
Further reading:
For those interested in the power of observation (from a bowler hat), I can recommend the following short story:
‘The Adventure of the Blue Carbuncle’ by Sir Arthur Conan Doyle
https://ignisart.com/camdenhouse/canon/blue.htm

​I guess the first list of 10 were the 10 Commandments.
​
I remember David Hiebert’s list of 23 unsolved mathematical problems (1900), which kept 20th Century mathematicians busy for many years. Two are still unsolved (one of which is the Riemann Hypothesis, that the zeta function* has zeros only at negative even integers and complex numbers with real part ½). Prestigious medals are awarded to those who lead in mathematics, science and social advancement (eg. Fields, Copley, Nobel). It got me to thinking, what 10 questions would I like answered about medicine? After a long career dealing with medical quandaries, I thought I’d list 10:

i) Why is the hallux PIP the commonest joint to be affected by gout?
Is it because it is a ‘cool’ joint, distant from the heart, that allows uric acid
crystals to form?

ii) What is it that generates ‘clubbing’ in patients with chronic sepsis of cancer of
the lung?

iii) What do we understand about the initiating cause of multiple sclerosis?

iv) Why can half a liver regenerate, half a kidney does not?

v) If the appendix is ‘redundant’, what was its function originally?
Is it a storage site for bacteria – when we need to reboot our gut?

vi) Do we really lay down a protein for every memory – if so, why do some last,
some don’t?

vii) Why do some people with gluten sensitivity get sore joints?

viii) What is happening when a schizophrenic patient has an auditory or visual
hallucination?

ix) Cachexia of malignancy is caused by what, exactly?
​
x) What is going on in polymyalgia rheumatica, and what causes it?
Is it really an inflammatory response to a viral trigger?

Some readers will know the answers to some of these – do share. And if you have a list of 10 questions for the practicing clinician, add them.
In the realm of Global Public Health, you could tackle the Gates Foundation list, which lists the following grand challenges (GC) -
To improve childhood vaccines:
GC 1: Create effective single-dose vaccines that can be used soon after birth;
GC 2: Prepare vaccines that do not require refrigeration;
GC 3: Develop needle-free delivery systems for vaccines.
To create new vaccines:
GC 4: Devise reliable tests in model systems to evaluate live attenuated vaccines;
GC 5: Solve how to design antigens for effective, protective immunity;
GC 6: Learn which immunological responses provide protective immunity.
To control insects that transmit agents of disease:

GC 7: Develop a genetic strategy to deplete or incapacitate a disease-transmitting
insect population;
GC 8: Develop a chemical strategy to deplete or incapacitate a disease-transmitting
insect population.
To improve nutrition to promote health:
GC 9: Create a full range of optimal bioavailable nutrients in a single staple plant
species.
To improve drug treatment of infectious diseases:
GC 10: Discover drugs and delivery systems that minimize the likelihood of drug-
resistant microorganisms.
To cure latent and chronic infections:
GC 11: Create therapies that can cure latent infections.
GC 12: Create immunological methods that can cure chronic infections.
To measure disease and health status accurately and economically in poor countries:
GC 13: Develop technologies that permit quantitative assessment of population
health status.
GC 14: Develop technologies that allow assessment of individuals for multiple conditions or pathogens at point-of-care.

Interesting Reading:
a) 10 Greatest Discoveries in Medicine,
M Friedman and G Friedland (1998) ISBN 9780300075984
b) 10 Days in Physics that Shook the World
Brian Clegg (2021) ISBN 1785787489

*zeta function