FreshMD

View from my kitchen window

What I love about Vancouver is that the snow comes close enough that you can look at it, admire it, and take a short drive to touch it if you so choose. But it keeps a respectful distance.

Diana Smith's "Melamine Heaven Triptych"

Every year for our anniversary, Pete and I purchase a piece of art.

I loved the photography of Diana Smith, Vancouver artist, the second I laid eyes on it at Arts off Main at Main and 28th Avenue in Vancouver.

I learned recently where Diana Smith lives, and it's a towering old house that we walked past hundreds of times in our old neighbourhood. I like to think of her rummaging through her cupboards for the perfect melamine cup for her afternoon tea.

I noticed recently that my thrifted hodgepodge of dishes that I've begun to collect for the kids bears a striking resemblance to those cupboard contents. I wonder what would be sitting in the driveway if we had purchased her Old Car Triptych instead?

Recommended toys

Children bring clutter. Toys accumulate over the years, and kids seem to take particular pleasure in spreading their treasures across as great a surface area as possible. I'm a minimalist, and I dislike waste, and buckets of unnecessary toys bring out the editor in me.

Some toys are better than others. Toys ought to be safe, well-made, suited to a range of ages, fun, and able to be played with in endless ways. I prefer a handful of great toys over buckets of cheap plastic playthings. We've pared our collection down to ten categories of our favourite, most hardworking toys.

I'll be posting the list in installments, and as one complete post at the end.

1. Food toys

Child-size appliances have the added benefit of providing storage space. I wish I had invested in one of these years ago. Above, left is A Simple Hearth from Palumba, made in the USA. Above, right is Lucy's Kitchen from Nova Natural Toys and Crafts. (Photos from corresponding websites.)

Edibles can be wooden, plastic, plush or knit. Above, from left to right: Good Eggs from Palumba, plush cake from My Paper Crane and wool felt cookies from Natural Pod. (Photos from corresponding websites.)

Dishes and utensils round out the collection. I've scored some great little pans, tins and bowls at thrift stores.

Plan Toys, Brio, Willow Tree Toys, Casey's Wood Products, Quiet Hours Toys and The Wooden Wagon also supply quality food toys.

Some of the links above are to the more mouth-watering finds out there, but there are plenty of less expensive stores that supply food-related toys as well. Our own collection is quite humble. The assortment doesn't need to be of one style or brand - kids don't mind mix and match.

I'd love to hear your own recommendations, for food toys and playthings in general.

Must have made for greasy bedsheets

Me: How long have you had that cough?

Patient: A week. What I really need is this treatment my mom used to give me when I was a kid. She'd collect the fat drippings from a roasted chicken.

Me: And she made you drink that?

Patient: No, no. She rubbed it all over my chest, like Vicks VapoRub.

Bezoars

I received an email last week entitled "Please blog on this . . . . eeeewwwww!" with this link to a story on a 10-pound hairball in an eighteen-year-old woman.

I'm happy to oblige.

I did find two items in the article somewhat unsettling: the photo of the hairball, and the description of it as a "mass of black, curly hair."

A bezoar is a mass of indigestible material found in the stomach or intestines. A trichobezoar is composed of hair (a hairball), and a phytobezoar consists of vegetable fibres.

Trichobezoars are caused by the ingestion of hair, either one's own (from the scalp, eyebrows, eyelashes or elsewhere) or from others. Most cases involve young children who chew hair out of habit, or young women with trichotillomania and trichophagia, psychiatric conditions where anxiety is relieved by pulling and swallowing hair.

There are 24 cases in the medical literature of Rapunzel syndrome, where the body of the trichobezoar lies in the stomach, but a long extension of it trails further down the gastrointestinal tract to as far as the colon. Sorry to ruin that fairytale for you.

Phytobezoars are caused by the concretion of indigestible vegetable fibres, usually in postgastrectomy (stomach removal) or diabetic patients. Orange segments are a common culprit. Improper chewing of food, often due to poorly-fitting dentures, can also be a contributing factor. Persimmons predispose to this condition, and there have been epidemics of persimmon bezoars in regions where the fruit is common.

Bezoars are treated in a variety of ways. Some are removed endoscopically, others are dissolved with enzymes (one case in the literature used Adolph's Meat Tenderizer with success), and others require surgery.

This is a condition where an ounce of prevention is worth a pound - or ten - of cure.

Pearl

Some of the more interesting things I learned in medical school didn't come from textbooks, but were handed down in the oral tradition. I'd give credit to the source of this succinct summary of specialties, if I had any idea who it was:

Internists know everything and do nothing.

Surgeons know nothing and do everything.

Psychiatrists know nothing and do nothing.

Pathologists know everything and do everything, but a day too late.

Berkshire pullover

I finished last year's Christmas present for Pete this week.

It's the Berkshire pullover from Melanie Falick's book Weekend Knitting: 50 Unique Projects and Ideas. I'm guessing the "weekend" in the title refers to pre-children weekends, the ones where you can sleep until ten, meet friends for brunch at Sophie's Cosmic Cafe, spend the afternoon reading the paper, and then do dinner and a show. You could use one of those weekends of leisure to be productive and make turtleneck egg cozies or a lap blanket. If you have children, disregard the "weekend" part of the title.

The wool is Morehouse merino, bulky weight. It's undyed, from black sheep grazing in the Hudson River Valley of New York state, faded to a chocolate brown by the sun. There are bits of straw stuck to the fibres, and it smells like farm country in all the right ways.

I usually knit for my kids, who are very forgiving of imperfect fit. Unfortunately, an ill-fitting hand knitted garment on a grown man does not look charming, it looks pathetic. So I had to custom size this sweater, and ended up rewriting the entire pattern.

I'm pleased with the end result. And equally pleased to be done with it.

HIV Plush Toy

I know for a fact that Dr. Montaner does not have one of these on his desk, and I'm wondering why, as president-elect of the International AIDS Society, he does not.

* photo from Giant Microbes website

Giant Microbes classifies HIV as a "professional" plushie, along with hepatitis, tuberculosis and polio. Laypeople can purchase E. coli and the clap.

The HIV plushie is marketed as an educational toy. Maybe my boss suspects that producing a five-inch black doll with widely spaced eyes and a red ribbon over its heart while describing a life-threatening retrovirus would prove confusing.

Is he frustrated that despite prevention efforts, HIV is presented as a cuddly bedtime companion? Does the thought of children playing with it repulse him?

Maybe it's the inaccuracy of the design that irritates his scientific sensibilities.

Perhaps he realizes that the urge to employ universal precautions every time he handled the toy would be tiring.

Or maybe he's not even aware of the existence of these creatures. Perhaps the marketers missed the opportunity of a lifetime when they neglected to send him a sample.

In which case, my Christmas shopping just got a little easier.

The end

My children, three robust little beings, have made death much more real to me.

I can't remember my own beginnings; my earliest memories are spotty dreams. So I feel as if I'll end in the same vague way.

But Saskia had a definite, dramatic starting point. I can give concrete details - the day of the week, the room number, the precise time - of her birth. And it suddenly became clear to me that she will have as explicit an end.

Maybe that is partly what drives the fierceness of mother love: the desperate realization that all living things die.

Hierarchy

Medicine is hierarchical. When any two health professionals meet, be it medical student and pharmacist, nurse and resident, or psychiatrist and family physician, there is a silent and rapid assessment of the other's ranking.

Now that I'm out in practice, this caste system means little, save for when a new member (resident, nurse practitioner, medical director) joins the team and there is some subtle jostling of positions while boundaries are marked or defended.

In medical training, however, there was a very clear pecking order. Medical students answered to interns, who answered to junior residents, who answered to senior residents, who answered to the attending physician. Where things got tricky was the relationship to other team members, particularly nurses.

As third-year medical students we wrote orders for the nurses, but it wasn't uncommon to ask them first what their preference was. But by fourth year and internship, the turf wars could be fierce. Without a doubt, the nastiest people I've ever personally encountered were nurses during my medical training. Of course there were lovely nurses, nurses who made you afternoon tea while you delivered babies, but the memorable ones were the ones who changed your orders and fudged your signature, or waited until you were finally asleep at 3AM to call about a Tylenol order, or made sure not to page you when the labouring patient you'd been tending to all day began to push.

I attributed this to a vicious cycle: nurse resents attending physician's attitude; nurse focuses this displeasure on medical student; student grows up to become attending physician; fledgling physician has no inclination to treat previously abusive nurses kindly; next generation of medical students are tormented. A colleague recently reminded me that the female medical students were mistreated far more often than the boys, so clearly my theory doesn't offer a full explanation. Was it jealousy? Sadism? Commitment to providing a rite of passage? Were we just unbearably annoying, with short white coats and notebooks, too eager and green?

That was a long time ago. I'm pleased to say that the clinic nurses with whom I currently work are wonderful. We have parties, baby showers, we're even friends on Facebook.

But I will say that each of the three times I was admitted to St. Paul's obstetrics ward, I warned Pete that if a particular nurse was on duty and assigned to me, I would sooner deliver my own child than have that woman in the labour suite with me.

But I'm not bitter.

Sunday Walk at Hastings-Sunrise

I've posted previously about our tradition of going for a Sunday afternoon walk or drive. Since today was sunny, we opted for a late afternoon walk.

Pete's proposals for destinations usually involve a natural setting, such as Mount Seymour or Ambleside. My suggestions almost always involve cityscapes. I love neighbourhoods, houses, gardens, sidewalks, sheds and back alleys. Today I won.

We headed to Vancouver's Hastings-Sunrise area, south of McGill and east of Nanaimo. There are some lovely residential streets in there, lined with massive trees. Saskia and Leif brought bags to fill with chestnuts, damp leaves and acorns. As they gathered their treasures, I had my own gems to admire: rows of circa 1910 heritage homes.

For the Flickr show, click here.

Government-assisted refugee statistics in British Columbia

Information is from January 1, 2003 - December 31, 2006 and obtained from the Immigrant Services Society of British Columbia. These statistics include government-assisted refugees (GARs) but not refugee claimants or group-sponsored refugees.

Top 5 source countries: Afghanistan (26%), Sudan (14%), Iran (12%), Colombia (7%) and Myanmar (6%)

39 total source countries

7500 GARs arrive in Canada annually

11% (800) settle in BC

11% under the age of 5

58% age 19-64

1% over 65

33% settle in Burnaby; 20% in Surrey; 19% in Vancouver; 12% in Tri-Cities

5000 Sudanese currently living in the Lower Mainland

Over 95% of Iranians come to Canada via Turkey, where they spend an average of 1-2 years

140,000 Myanmar refugees have been living in Thai refugee camps for the past 20 years

Individuals receive $400/month maximum for shelter, and $235/month for food from Citizenship and Immigration Canada for one year or until (s)he becomes self-sufficient

1 refugee medical clinic, in Vancouver, screens every GAR arriving in BC.

Beards

I was browsing at a Vancouver thrift store last week when I overheard an old Sikh man, with a long grey beard and turban, trying to ask a question of an employee. He held up a small electronics item and asked with a thick accent, "What? For what?"

The employee, an older Jewish man with a white beard, black yarmulke, and standard Value Village red vest, inspected the gadget. "It's a shaver," he explained. "To cut hair on the face." He clapped a friendly hand onto the customer's shoulder. "But people of our faiths," he said cheerfully, "we don't need these!"

Daily folic acid recommended for most women

Most of my patients make their first appointment to discuss pregnancy once they've become pregnant, not in the planning stages. Unfortunately, most women are unaware of some very important preconception medical recommendations.

Folic acid, or folate, is a vitamin recommended for all women of reproductive age who are sexually active.

Folic acid reduces the incidence of neural tube defects (NTDs). NTDs are deformities of the brain and spine, the most common of which is spina bifida. The neural tube is formed in the first few weeks of pregnancy, before most women realize they're pregnant. Folic acid should be taken for at least three months prior to conception, and through the first trimester.

The incidence of NTD in Canada is roughly 1/1000 births, or 400 cases each year. British Columbia has an average of 22 NTD births annually. (This does not reflect the spontaneous and induced abortions of affected fetuses.) It is estimated that at least half of these cases could have been prevented by adequate folate intake.

It is very difficult to absorb enough folate by diet alone. I have seen several cases of spina bifida in children born to well women with healthy diets in their thirties.

Women usually require 0.4 mg of folate per day. A woman with diabetes, epilepsy, or a family history of NTD may require 4.0 mg/day. Women should discuss their recommended dose with their physician.

As half of Canadian pregnancies are unplanned, women should take folate supplements even if they are using contraception.

Despite this recommendation being in effect for years, and a folic acid awareness campaign launched by Health Canada in 2002, very few of my patients are aware of it. This is one of many reasons to visit your physician before you attempt pregnancy.

Garden

I've discovered a secret garden, and it's an exquisitely beautiful mess.

Walking through Mt. Pleasant neighbourhoods on my way to work today, in the slanting morning light, I came across a community garden. It was fenced but the gate was ajar.

It was full, full of purple stalks of swiss chard, painted birdhouses, compost, rotting lettuce, rusted tomato cages, sparrows, lengths of rope, fat purple globes of allium, wind chimes, smashed bricks, yellow asters, discarded metal gates, and branches snagging my briefcase.

It was in gorgeous disarray, and there was no one admiring it but me.

Uniform

My daughter's school requires uniforms, and I appreciate the tidy, focused academic atmosphere it fosters. I also find a six-year-old in a plaid jumper, navy cardigan and matching headband utterly charming, but that's secondary.

I was fascinated to learn recently (through this blog) that Ray and Charles Eames, American mid-century designers, fashioned uniforms for themselves to work in every day: a black pocketed tunic-style dress for Ray, and a button-up shirt, cardigan and bowtie for Charles.

I've been wondering lately about a uniform for myself, considering wearing the white coat I haven't touched since residency. Dr. M. Ross, in this BCMJ article, makes some interesting observations about physicians' dress:

"Another way in which physicians and nurses may have diminished their comforting authority in society is the casualness of their dress. There is an inherent respect for work-related uniforms—from the bus driver to the shaman. We have good historical records of the very precise dress of physicians in ancient Persia and until recently professionals dressed professionally. This is important as a placebo. A policeman blowing his whistle does not stop traffic if out of uniform."

I wonder if I could convince the clinic nurse to wear nylons and a white cap?

Saturday morning coffee at Opa and Oma's

Flickr slideshow here. Note Oma feeding Ariana Cheezies from a silver bowl. That pretty much sums up the delightfulness of our visits.

Did not confirm this with the patient

Me: "That swab from his ear canal grew E. coli! How do you explain that?"

Nurse: "He shit in the bath?"

My dad will drive you home

When I was growing up in the eighties, birthday parties were pleasant, casual affairs. Each girl would hand out invitations to the other seven girls in the class. After school, the mom would bring us to her home in the station wagon. We'd eat cake, open gifts, play in the rec room, and have lasagna. Then the dad would drive everyone home. We'd all be trying to see what was in our treat bags by the light of the street lamps, and hoping to be the last to be dropped off.

For my kids, invitations can't be handed out at school unless every child in the class is invited. Most parties are held on the weekend, at community centres, Science World or Go Bananas. Some parents hire planners; I suppose this becomes necessary when, as was the case with a party we attended this summer, over sixty children are in attendance. Parents of the partygoers can't drop their children off because they're required to help supervise.

It's very organized and inclusive.

I miss the old days.

Horns

When I was a resident doing a rotation at a pediatric orthopedics clinic, one of our patients was a day-old boy. His mother, wrapped in a blue hospital gown, was wheeled over from the adjoining maternity hospital with the bundled newborn on her lap.

The medical students summoned me fifteen minutes into their assessment, stymied. The mother retold her story: "They sent me over because he has two bumps on his forehead." The babe did indeed have two subtle protrusions above his eyes. On palpation they were smooth, bony and even in size. I was stumped. The junior and then senior orthopedic residents were consulted, and were similarly mystified.

Finally the orthopedic surgeon himself swept into the room. He made a swift diagnosis. "Anterior horns," he announced. The students and residents were impressed.

"Horns?" repeated the child's mother incredulously.

"Yes. Horns. These are bony growths that will likely continue to grow throughout childhood," explained the doctor cheerfully. He went on to reassure her, "When he's a teenager, he could consider having them surgically removed. But as a fifteen-year-old boy, he might very well be quite pleased to have them."

Blabla

Could there be an occupation more delightful than being the artist behind a line of children's stuffed toys? Florence Wetterwald, a French-born designer, has created a menagerie of dolls for Blabla. Check out the photography on their website:

I first noticed these charming characters, handknit in 100% cotton in Peru, at Room6 in Deep Cove. You don't want to know how long it took me to select just the right one for each of my kids last year. But I think I got it right: Bubbles for Saskia, Lemonade for Leif, and Lollie for Ariana.

 

Magic in medicine

This article in October's BC Medical Journal makes several points that I find particularly relevant to today's practice of family medicine.

Dr. Michael Ross states, "7000 years ago, healing was performed by the partnership of the priest and the potion. Then the priest was the more effective of these partners. Now, with the privilege of science, the potion has become the power and the priest has withered to the writer of prescriptions or the performer of a process . . . Human nature, however, has not changed, and the need for that priestly power persists."

I agree wholeheartedly that patients today seek priests, magic and spiritual healing. I believe that this is a key reason that so many people visit naturopaths and other alternative medicine providers. The problem is that while the family physician is in the best position of all to provide comprehensive care of the patient, he is not compensated for it. The Medical Services Plan fee schedule makes care of the whole patient unfeasible.

Some of the best medical care (resulting in the most satisfied patients) is, in my experience, provided at clinics where physicians are paid sessionally rather than fee-for-service. If a patient is in crisis (medical, social, emotional or spiritual), the physician can take the time necessary to provide full care, because she is fairly paid for it. That luxury does not exist in private practice.

I am in the very early stages of planning my eventual return to private practice, which I intend to include a healthy dose of priesthood. Unfortunately, it seems it's going to take an awful lot of creativity and cleverness to make it work.

Weekly photos on Flickr

I plan to post a set of photos on Flickr every weekend. This week's batch is a little heavy on Ariana, sorry.

HIV statistics - 2006 (unless otherwise stated)

39.5 million people worldwide living with HIV

4.3 million new HIV infections

18,000 AIDS-related deaths in North America

2.1 million AIDS-related deaths in Sub-Saharan Africa

47% of new HIV diagnoses in Canada were in MSM (men who have sex with men)

34% in heterosexuals

10% in IDU (injection drug users)

1/300-400 needlesticks from an infected source will transmit HIV

1/3 of latex gloves allow HIV-size microbes to pass through

61,423 Canadians diagnosed with HIV from 1985-2006

27,271 of those in Ontario

348 in New Brunswick

1 AIDS case reported in Canada in 1979

3 in 1980

1,828 in 1993

318 in 2005

4,023 patients receiving anti-HIV medications at the St. Paul's Hospital Drug Treatment Centre in Vancouver (June 2007)

$241,000 US lifetime treatment cost of one HIV+ person (2001)

Thank goodness we're compatible

Saskia's top five:

My top five: