Merry Christmas Everyone!

I hope that all of you hard working family physicians out there are going to get some time off over the holidays. Have a safe and enjoyable season with your family and friends!

Zithromax drug interaction with Coumadin

Zithromax (Azithromycin) is a very popular antibiotic in primary care. It is widely used for a variety of indications such as community aquired respiratory tract infections and tonsillitis. I find it especially useful because of it's easy once daily dosing and short five day course. Patient compliance is improved. When Zithromax was first introduced and I educated myself on the drug, I noted that there was a possibility of Zithromax increasing the effect of Coumadin and elevating a patient's INR. For a few years, every patient I had on Coumadin had their INR's checked a couple of extra times during therapy with Zithromax. Not once did I find any significant changes in their INR. Because of cost and time, I stopped doing the extra lab work. I recently treated a male patient in his mid sixties with Zithromax for community aquired bronchitis. He is on Coumadin for anticoagulation for a mechanical aortic valve. For months, his INR had been steady with no changes in dosing of his Coumadin. Two weeks after starting his Zithromax, his respiratory symptoms had improved. He came in to the office however, for severe left flank and anterior thigh pain. He required urgent evaluation and eventual hospitalization for a severe anemia. His hemoglobin had dropped to 79. Abdominal CT scan revealed a large left sided retroperitoneal hematoma. His INR on admission was 15. He responded to transfusions and reversal of his anticoagulation with vitamin K. On final review, the Zithromax would appear to be the culprit for the significant change in this patient's INR and the substantial bleed he developed. I have reviewed other antibiotics commonly used to treat community aquired respiratory tract infections. Many drug monographs state that no significant effects on INR have been noted clinically, but then they give a disclaimer that patients should have their INR's followed during therapy. From now on in my practice, every patient on Coumadin who requires antibiotic therapy will have to put up with repeated INR checks. I'm not going to risk the type of reaction I saw in this described patient again.

The Ontario Medical Association

I have included a link to the Ontario Medical Association's website. The member's section is a source for current information on government initiatives such as Family Health Networks, Family Health Groups and the latest proposals of Family Health Teams and Local Health Integration Networks.

Additional $300 "negotiation fee"

Well what an unpleasant surprise when I opened my mail from the OMA yesterday. My annual legislated membership fees are due. In addition, I am told that the executive have decided to pick my pocket for another $300 to support further negotiations with the Ministry of Health. I'm not sure I really got anything from the first round and the proposed agreement that the profession voted down. Besides, I don't think the Ministry will be open to further negotiation anyway. They will decide what the final agreement will be and legislate it in. So what will the OMA do with another $300 of mine? I would happily agree to pay the money if it was used to hire professional negotiators. I have great respect for the amount of work that our physician representatives put in trying to get a good agreement but physicians are trained for skills other than negotiation with government. We should pay for professionals to assist us. I think at this point I will send in my basic dues and let them chase me down for the additional $300. At some point I'm sure the MOH will just withhold it from my billings. It seems like a feeble protest but if all Ontario physicians did it...the impact would be significant.

Midazolam infusion in palliative care

I had a challenging palliative care case recently. The patient was a 42 year old woman with terminal metastatic breast cancer. Her family was providing excellent care for her in her home. Agitation became a significant symptom in her final stages. She had excellent pain control with a morphine infusion via CADD pump. I used Haldol i.m. initially and switched to Nozinan i.m. I was still not satisfied due to a persistent, low level of restlessness. I called a palliative care consultant at the Kingston General Hospital. She suggested I add in Midazolam. It can be given as a s.c. infusion. We set up another CADD pump. The starting dose was 1 mg/hour. It could be titrated up in increments of 1 mg. This was a very helpful treatment. I will probably consider this type of sedation more quickly in the future as it was very effective and eliminated the need for the family to be administering i.m. medication when nursing was not available.

Palm Treo

I have been using a Palm Pilot handheld device for several years now. I have found it to be an invaluable reference tool during a busy office day. A couple of months ago, I needed to replace my cell phone. I checked out the new Palm Treo. It is a "smartphone". This means you get both a full featured cell phone and a full featured palm pilot. To date I've found it small enough to be inobtrusive (although not as small as some cell phones) and easy to use. I don't have the need to make use of all the web based phone features such as text messaging but it has all of those latest features available. It also has picture capturing capability. This is also a feature I don't think I'll be using often. I've tried a variety of medical software for the palm pilot over the years. To date,
I've found the products available from Skyscape to be the most complete. I am currently using Griffith's 5 Minute Clinical Consult and Dr. Drugs. Many other titles are available and many come as bundled packages to save money. The programs can be downloaded directly from the website and are easy to install and use. Computing in all of it's various forms is becoming a ubiquitous part of family practice.

Quackwatch

I've posted a link to this website today. Probably more than any other medical providers, family physicians are faced with patients bringing in information on the latest "miracle cure", fad diet, nutritional supplements, homeopathy etc. They may just be looking for our opinion or they may be advocating their use. I have found that this website provides me with independent, well researched information with which to educate both myself and the patient. I usually send them home with the website address.

Family medicine in Canada is in a state of crisis. Here in Ontario, it seems our provincial government is intent on coming up with as many new ways to juggle the provision of medical care as possible. We currently have solo practices, group practices, Comprehensive Care pracitces, Family Health Networks and Family Health Groups. The latest initiative being discussed is a Family Health Team. The Ontario Medical Association and the Ministry of Health and Long Term Care recently negotiated a proposed agreement between the government and the physicians of our province. When it was voted on by the general membership of the OMA, it was turned down by 60% of the profession. This agreement offered new financial incentives only to family physicians willing to involve themselves in one of the groups previously noted. It is an effort to herd doctors into structures that have no proven benefits for either cost savings or more efficient delivery of medical care. The discrepancy in income between family doctors and our specialist colleagues has progressively widened over the last many years. New physicians are not choosing family medicine as a career when for two more years of training, they can markedly improve their long term earning potential by going into a specialty. The proposed agreement between the province and Ontario physicians did not address this issue in any substantial way. Prime Minister Paul Martin promised to cut wait times for medical care in this country when he ran for re-election. I would suggest that the fastest way for him to accomplish this goal is to quickly deal with our shortage of family doctors. Family doctors have always provided the most comprehensive care to the most number of patient. Patients receiving good primary care stay out of emergency departments and have problems evaluated in a timely fashion. This care provides the best triage possible for guiding patients through the medical system and being efficient with health care dollars and limited resources.