My first peer-reviewed publication is out, and I’m proud to say the case study made the cover of the British Columbia Medical Journal (BCMJ).
If you are wondering how I can possibly justify diagnosing weird fungal infections with my “less is more” approach to medicine, read this post on my Less is More blog.
If you want to check out the article, read it on the BCMJ’s site.
I haven’t written in a while, but I thought it was time for an update. This blog is taking/has taken more of a personal direction while most of my professional stuff, on the subject of “right care,” is posted on the Less is More blog.
For what it’s worth, I still read a ridiculous number of medical articles, some of which get a reflection or précis treatment on that blog, and the rest of which might appear on my DrOttematic or Less is More Med twitter feeds.
Our kittens are now a year old, they really like going outside and have learned how to jump out of second story windows; perhaps I’ll learn some veterinary medicine :(. Ian’s flying a different plane now. The work is more rewarding for him and he has a better schedule which makes it easier for us to travel and plan fun things. The weather in Vancouver has been wonderful and I now have a used folding/electric bike to toodle around on as well as a stationary bike for rainy days. This week I had enough time off to get together some Emergency Preparedness supplies; it has been on my “to do” list for a long time, but the tips I got at a Wilderness Medicine course, Ian’s recent reading about the Cascadia Fault, and having a few days off at home prompted me to get organized. There are still a few gaps; I’m certainly not a “panicked prepper,” but it feels good to know that if the power goes out or we don’t have running water for a few days, we’ll be self-sufficient.
This year has been a bit subdued (aka less exotic) compared to previous ones, but we did enjoy a week chasing lava on Big Island, Hawaii in January, a nice quick trip to Quebec City during Carnaval de Québec in February, a week in Toronto in March (while Ian was training to fly a new airplane), a visit to Sidney BC including a day trip to Botanical Beach at low tide in April, and a trip to New Mexico at the end of May, where we explored national parks and monuments before I began a wilderness medical conference in Santa Fe. The conference was fantastic and highly practical both for my northern work and for personal safety/health while enjoying the wilderness. Our next big trip will be this fall – we are aiming for Iceland.
Things were going okayish, then I had a little relapse (?) of my Transverse Myelitis in March while I was in Yellowknife. Saw the MS clinic (see prev post). Saw them again in early May. Things were pretty good actually; I even had a day where I didn’t think about my condition at all since I had no symptoms that day. At the clinic, for the first time, my physician said “well, maybe it isn’t MS.” Things were continuing to improve and I was so very close to ‘normal’ until during our trip to New Mexico I woke up with numb arms. Numb like I had slept funny on them. And honestly, that is what I told myself for a few days. “Oh I just slept funny. Hotel beds, who knows.” I was obviously in denial that it was anything significant. Home from the trip, I discussed it with my dad (a nurse) who is very good at telling me like it is. He told me I should call the MS clinic. So I’ve done that, and they will eventually (“soon”) scan my head and neck, since it’s likely I have a brain or cervical spine plaque, and that my diagnosis is MS after all. Technically my neuro issues have to be disseminated in time and space to be diagnosed as MS. We have time (multiple different events at different times) but not space (there was only one lesion on my MRI at T10). I would be surprised if there is nothing on my head/neck scans, and per previous discussion, it sounds like my specialist will suggest aggressive, early treatment to prevent more MS plaques from building up, thus reducing further weird neuro symptoms. Now I just twiddle my thumbs and do the impossible dance of not stressing with uncertainty, aka keep busy and try to ignore it.
Given my health stuff and because we have a lovely place in Vancouver to live (and that’s where my fella is most of the time), I’ve been going up north a little less. This year, I just have a few trips to Nunavut and the Northwest Territories. Next week, I’m off to Yellowknife for some clinic and then hospitalist work. I quite like hospitalist work. I really enjoy the older patients, working in a team, and the ability to divide up my time as I see fit. I can devote lots of time to the sick patients or those with new diagnoses, and I can spend little time with the stable, well patients. It’s not as “cowboy”/adrenaline-heavy/glamorous as emergency medicine, but it’s also less stressful, and I think I make more of a positive impact in people’s lives. Also, my regular commute in Vancouver is a 20 minute walk; can’t beat that for health or sanity!
Stemming from a previous interesting case at work, next month should see the publication of me and colleague Dr B’s case report in the BC Medical Journal. It’s my first peer-reviewed article and so you can bet I’ll be posting a link here to showcase the great case and our hard work!
Health Policy Stuff:
Speaking of attempts at positive impacts, I’ve been devoting a lot of my “free” time to health care policy work. I’m on medical policy committees at the local, provincial, and national scale but I’m still learning the ropes and wanted to do something a little more hands-on. I started up the Less is More Medicine website this spring and have been following it up with other related endeavours trying to spread the word about this approach:
- interviews (in Santé, & soon The Medical Post)
- a research project (something around Choosing Wisely pioneered by a hospitalist colleague)
- talks (at UBC for the Medical Students in DPAS with Dr James McCormack of The Best Science (BS) Medicine Podcast, a solo one at Family Medicine Forum in November 2014 in Quebec, and tentatively at two other conferences in the spring)
- papers (ok ok all in draft form, but I’m constantly writing things..)
It’s rewarding to be able to sink my teeth into something I really believe in. “Less is More” is certainly not my only interest but it is a pretty exciting time to be involved. Many before me have done incredible work in the area and I see my role as spreading the message as well as supporting and encouraging physicians or patients to experiment with thinking this way.
Words cannot fully express my enthusiasm and gratitude for an opportunity that I have next week. I’ll write about it here or at the Less is More blog soon.
Today I officially join the ranks of the chronic, autoimmune, neurological patients.
I saw the experts at the MS clinic. A Fellow from the US, the head of the clinic, a remarkably efficient nurse, the quick and able lab tech at the hospital, and finally the medical daycare nurses.
Short story: no official diagnosis yet, and may never have one. Have had 2 or three events proving dissemination over time, not sure about dissemination over space. Both are required to say “YES, MS! We factor in my previous Bell’s palsy, my first episode in December, the emergence of l’hermitte’s sign (bending neck forward sends a zappy/tingle down my legs) in January, and what seems to count a relapse in early March. The only radiological lesion is at T10 on my spinal cord. Head normal so far. So I don’t have dissemination over space, technically, not yet anyway.
We discussed the differential diagnosis and were able to rule out a few things with the tests done so far: HIV, Hep C, neurosyphilis, HSV, cryptococcus, lyme disease, TB; with history and the pattern of things and statistics, we concluded that brucellosis (exposed), cat scratch fever (scratched), scistosomiasis (swam in amazon), lymphoma are all quite unlikely. Basically it’s inflammation, not infection or cancer, using the information we have so far. What kind of inflammation is less clear, but it’s acting like MS.
The summary/plan is:
- some lab tests today to rule out NMO (my clinical picture and MRI don’t fit this, so I won’t explain it more), neurosarcoidosis (pretty rare, but the Fellow said that if a follow up MRI of a lesion is still enhancing aka lights up with MRI dye a few months after the original symptoms (and mind did, though it was less lit up), this is more characteristic of sarcoid than MS; one test related to sarcoid can also rule out lupus
- might have “recurrent Transverse Myelitis” – pretty rare; treated slightly differently than MS, more general immunosuppressants
- statistically, MS is most likely though it’s not easy to label me with that, yet
- boss doctor recommended IV steroids “as soon as possible” so, I had a dose this afternoon
- originally, I understood that while they might help me feel better sooner, they don’t change the degree to which I recover nor the outcomes with MS
- however, if I have recurrent Transverse Myelitis, there is anecdotal evidence (per boss neurologist) that it might change outcomes.
- risks of pulse steroids are not so bad as a prolonged course; I’m trying to be a good patient, trust the process, express my goals/values, so I’ll give it a go; if it helps me get back to tolerating exercise sooner, it would be worth it
- getting my IV steroids was fun! the nurses were lovely, the building sunny, the company (other patients) nice to chat with; one of the nurses seemed to take a motherly shine to me, I even got a hug and kiss and her best wishes. That sure made me feel cared for!
- tomorrow, I’m working. I’ll take a brief break from work to pop-over to medical daycare, get my massive dose of IV solumedrol, and finish up the work day. Not ideal, might raise some eyebrows, but I don’t want to leave my colleagues high and dry, and frankly, I really enjoy my work and would rather be doing that than worrying or stewing on the subject of my health. I’ve done enough of that already.
- originally, I understood that while they might help me feel better sooner, they don’t change the degree to which I recover nor the outcomes with MS
- follow up 1 month to see where I’m at
- repeat head MRI to rule out new plaques; apparently MS people get about 4 new plaques a year, so in 6 months from my previous scan, we should see something if it is MS
- repeat cervical-spine MRI to assess the l’hermitte’s; it’s usually related to a c-spine lesion but there was nothing on my original scan (and thoracic lesions can produce this, though less commonly). However, this odd symptom developed almost 2 months after my original symptoms so maybe it represents a new lesion.
- I probably need to be on some fairly serious treatment but I’m not sure when/what, what’s covered by my health plan, etc
- immunosuppressants can be toxic and dangerous; not safe to be pregnant, could stop for a while if I want to have a baby
- pretty big decision; my MS neurologist’s bias is towards aggressive care: “hit it hard, fast, early and quiet down the immune system”, mine is to “less is more” but that includes “right care.” In this case, there’s little evidence so it’s going to be a question of balancing risks and benefits into the unknown
What I learned:
- I should take a lot of vitamin D (4000units/day).
- There is a pill that might help with my migraines as well as with the neurological symptoms that I currently have (nortriptyline) but we will hold off for a bit on that. (I thought they might suggest gabapentin but I would have less confidence in that)
- the weird feeling in my legs (vibrating/jangling/buzzing) is not necessarily a result of activity per se more one of heat intolerance. Apparently whenever the core temperature raises, as with exercise, the nerves that are damaged (MS/TM means the myelin or coating on the nerves has been destroyed by an autoimmune response) have trouble conducting. So, “cool off and resume” is the recommendation. Interesting!
- vaccines might trigger flares/relapses; next elective one is the flu shot in November so at least we have until then to consider it
And that’s as much as I know. I was delighted to see a team who have had encounters with other patients with similar findings. Their experience is the best evidence that exists so far. This makes me glad that I incidentally used to fundraise for the MS Society (after a dear friend was diagnosed). I also laugh now at the fact that I used to use “Dre Moelle Épinière” to fill out BS forms for online subscriptions etc. when I didn’t want to put my real name in the medical-spammer-verse. That is french for (Dr) Spinal Cord.
I must also mention how great the Fellow was. She heard me. She answered my silly little questions that meant a lot to me (like “why do I get this horrible feeling in my legs when I’m active?”. She had happened to have some serious health issues herself, and understood what it was like to be an MD and a patient. I hope that I’ve absorbed even more from today to make me the most compassionate, realistic, and thoughtful partner and expert in care I can be.
Also, I hope I figure out how to take care of myself.
In medicine, as in many things, more is not always better.
Some of what we do, with our best intentions, may be harmful. An unnecessary test or treatment can have a very real impact on a person’s health, and often it’s not for the better. There are also other patients who need a certain service, but may have trouble accessing it because the system is too burdened with overtesting and overtreating others. It’s time to talk more about this.
To that end, over the past few months, I’ve been working on a project about “the right amount” of healthcare. I would love for you to take a look:
Your thoughts and questions are very much invited. I’ve been a little quiet here on DrOttematic as my passions have steered me elsewhere for now, but I’m still keeping afloat.
I was flattered lately to get a few emails and tweets from people who are used to seeing updates from this blog. They said they missed my writing, my ideas! What a lovely thing to pass along. For a while, I suspended this blog since I was busy doing other things and couldn’t contribute to it with any regularity. Work, travel, chasing kittens, sitting on committees.
I also managed to be hospitalized with something called Transverse Myelitis. I got sick in the middle of a work rotation up north in Yellowknife (which was wonderful! the patients and staff there were a treat), a few weeks before Christmas.
I went numb and tingly from the waist-down one day. I thought it was related to my migraine or my migraine medication (known to cause tingling aka parasthesias). Maybe I was in denial, as I kept thinking it would just get better on its own. But it lasted, and after two and a half days, I finally talked to one of my colleagues and he invited me to the ER to get checked out. I left on the next plane and went to one of the hospitals I work at in Vancouver because Yellowknife didn’t have MRIs, neurology, or the support I needed. I was examined a few times, MRI’d, and admitted. There was something on my spinal cord. Long story short, I got a lumbar puncture (spinal tap), high dose IV steroids for 3 days, more MRIs, some blood tests, and got out in time for my birthday. I told just a few friends who were good at expressing care at a distance; I didn’t really want visitors or to tell too many people because I didn’t actually know what to tell them – I didn’t know what I had or whether to worry or not. I was very lucky to have my fella looking after me. I was allowed to be scared and he was calm beside me. He brought the comforts of home to the hospital and even obliged trying to put my hair in a pony tail (when I couldn’t do it myself because my IV wouldn’t allow me to bend my arm). That hairdo was terrible.
There are still tests ongoing and we don’t know what caused it. Right now I guess it is called “idiopathic transverse myelitis,” meaning an inflammation across my spinal cord which developed for unknown reasons. Hopefully it was a one-off, triggered by an infection perhaps, but given the results of some of my tests, there’s a high chance I’ll develop Multiple Sclerosis (MS) in the future. I’d never taken a ‘sick day’ since starting practice, and here I was away on disability for 6 weeks. It was pretty uncomfortable at first and emotionally it was challenging; not knowing what I had, and even having a label for it, not really understanding it was very hard. Also, probably TMI but when you can’t feel your genitals, going to the bathroom is super creepy! At least I didn’t have any weakness/paralysis. My case certainly could have been worse and I’m grateful that I can walk and talk and think and smile.
There are between 1 to 8 cases of transverse myelitis per million people , so there isn’t a lot written about it. Also, some of the tests didn’t really provide answers and other tests that were ordered were never completed. Uncertainty is a challenging thing and I’m glad I had the time off because I don’t think I would have been able to be completely devoted or empathetic towards my patients while I was trying to come to terms with my own illness. I was lucky to be able to travel and be with my fella and my family – good distractions from the racing thoughts. I’m 29 and I did not expect at this age to be considering picturing adding a wheelchair ramp to the home that we dream of building. I am far from that now, and it may never happen, but this has been a wake-up call to realize that health can change at any instant. I also realized how powerless one can feel in that time. And how bad hospital food really is.
It’s been a very good experience to be a patient. I’ve been admitted before for 5 or 6 days with tonsillitis but it was a feverish, drooling blur. I had Bell’s Palsy in 2010 and while it was scary, I was very lucky to have almost complete resolution. Now, 8 weeks from when it began, my legs are much better and I’m back to work. When I have interrupted activity – walk, sit for a while, walk again – my legs get “jangley.” They feel like they are buzzing and vibrating and there is an apprehension feeling that they will collapse, but this is gradually lessening. Soon, I hope I’ll be back to hockey.
None of this was a secret, it just kept me busy and has probably changed me as a person and as a physician, I hope for the better. I still don’t fully “get” what is going on and probably will never get all the answers. I’ll get used to it, whatever happens next. Plus, I’ve got more important things to think about! In my six weeks off, I couldn’t quite sit still. In addition to lots of time with family, I submitted a paper to a journal, read a few books, and started a big project.
I don’t know how much I’ll be writing on this blog, but when it’s ready, I’ll post an update on my not-so-secret secret project, Less is More in Medicine.
(I share this not to seek sympathy, but because writing and sharing and hearing the stories of others will help me extract whatever meaning and learning I can from this experience)
Partly as an extension of my work with the Canadian Medical Association’s Healthcare Transformation Working Group, I was invited to give a brief presentation on The Unique Value Proposition of Physicians at an eduction session that was part of the CMA’s General Council.
It’s probably shameful to admit it, but I need to say it: I am still a relative new-comer to the world of medical leadership and policy, so it was a complete honor that I was invited to speak, if briefly, about a controversial topic in front of a room full of very engaged physicians, healthcare advocates, and policy makers.
To have my input valued to the point where a room full of brilliant people sat and listened to me, it’s a dream. It felt incredible as I looked out and saw people in the crowd nodding their heads in agreement, or when they came up to me afterwards or the next day and passionately agreed or disagreed or were bursting with their own perspective. In hallways and elevators, with wine or coffee in hand, everything from “that was fantastic, yes, patient care comes first” to “you young people, you’re what’s ruining our profession and making doctors inaccessible to patients with your work-hour restrictions and ‘work life balance’ ” was passed by my ears. I certainly didn’t have a snappy response for everything – the unique role and value of a physician can be quite nebulous – but we all agreed that we, as a group, need to work better at defining what we do now and what we want to do in future.
Being around smart people who really care about the future of medicine is such a reassuring thing. There are many people in our daily lives who are dispassionate. Who don’t seem interested in what’s happening around them or in affecting change. But at this event, there are hundreds of physicians (and some affiliates) who are – for lack of better description – “fired up.”
There were some extremely controversial subjects up for discussion including end-of-life care, scope of practice, physician wellness, and so on. I’m quite sad to be missing the Appropriateness and Accountability session as it has been emerging for the last few years as a real area of interest for me, however, I will be able to watch it online. I think I’ll be waving my arms at the screen and saying “yes! exactly! I know!” a lot.
One huge bonus of the GC was meeting and reuniting with some pretty interesting people, some of whom certainly had a hand in where I am today. One of my first PBL tutours, a leadership guru with an incredible memory, a blogger that I’ve followed off-and-on for years, some fellow young docs who are leading their peers in tricky times, an intensivist who tells it like it is, a rural doc who has all the characteristics that an awesome rural doc should, a big city innovator with rural roots, and the list goes on!
I hope that other early-career physicians like me will find that the CMA does have a lot to offer. Even if you don’t agree with what the CMA is doing on an issue, you should still get involved. In fact, that’s a great reason to join the CMA. We have the privilege of being a self-regulating profession and every view point needs to be included in that. It still floors me to think that the future of healthcare in Canada can really be shaped by physician voices, including mine.
There are some well-known reasons to date a doctor and some oft-repeated warnings about the process. There have been a few things that I would say my mate never expected. Maybe there are some perks but there are also plenty of quirks. Be warned! Any mystique the MD once had will definitely fade with this post.
You know you’ve got the hang of dating a doctor if it doesn’t phase you when:
- you wake up next to your significant other who is holding a measuring tape around her calves and has the Well’s criteria for DVT Calculator open on her iPhone. “What? I might have a DVT! Well I probably don’t, but I’m on that birth control pill which has an increased rate of DVT, I’ve had calf-pain for 3 days, and I just don’t want to be one of those fools who doesn’t go to the doctor until they are dead.”
- your counterpart sizes up any lump or boil that you have, offering to incise and drain it or to cut it out of you, and is frankly a little let down when you won’t invite them to do so
- there are several drawers in the bathroom that if you open too quickly, various medications and medical implements (ciprofloxacin, metoclopromide, sutures, gloves, etc.) fall out. “Well, you never know when you might need them,” she says, and you are starting to agree.
- she learns that your work has benefits like a dental plan, she seems a little too excited about the prospects of sharing yours and expresses how excited she is to be able to see her dentist who she misses dearly [No, doctors don't get any extended health benefits, including no drug coverage, dental care, etc. and most of us think it's ridiculous or are cheap so we can't wait to be on your benefit plan ;) ]
- with friends, your doctor partner cannot resist talking about work, and it usually degrades to gore stories about messy deliveries (the taste of amniotic fluid), breaking ribs during CPR, or that one time the guy’s abscess burst all over her shoes – and you can listen to any conversation, even while eating raw sea creatures for dinner
- she has to ask for your guidance or expertise in order to know how to spend unplanned time off; “how do you… like… what will we DO with that time? Maybe I should just take more shifts?”
- it’s hard to have a meal out without her commenting on the artery-hardening or diabetes-producing qualities of the food, yet she eats every last bite of it; you are beginning to question why there is EDTA in your salad dressing [since we are being honest, my fellow calls it "ESPN" with a laugh]
- after first meeting your new doctor girlfriend, within a day, your dad asks for her to apply her surgical skills and remove a sliver from his foot; your mom is embarrassed, your doctor girlfriend is delighted, and dad hands her the paint thinner (“sterilizing solution”), a blunt needle, and puts his foot up on a chair
Doctors, what has your partner put up with? Partners, got any hard-to-come-to-terms-with ‘gems’ to tell about being with a doctor?