October

If people in influential positions say stupid things, I used to chuckle, shake my head, and make a mental note not to take them seriously in the future. Bit by bit, however, I’m chuckling less and feeling alarmed more. It used to be that when politicians intoned “no two-tier health care” I would assume that they were simply saying what they think people expected them to say, and that they actually knew, deep down, that mandating the same level of care for everybody flies in the face of human nature. Now I wonder—don’t these people get it?

In our present system, without including clinical prevention, front-line physicians have too much to do and too little time in which to do it. To add to the primary care workload the clinical preventive measures that have been proven effective is to invite their non-performance. Professionals in other disciplines such as dentistry and pharmacy have trained co-workers who complement and support the work done by the senior professionals. Family physicians generally do not have such support. They work under a model that began in the 19th century.

The standard test for latent tuberculous infection is the tuberculin skin test (TST) using purified protein derivative (PPD). It is among the oldest diagnostic tests in medicine, introduced in 1908 by Robert Koch, who erroneously thought tuberculin had therapeutic powers. Unfortunately, the TST has many limitations, including problems caused by errors related to administration and reading, false-positive reactions related to previous bacille Calmette-Guérin (BCG) vaccination, and cross-reactivity with environmental mycobacteria.

What we can learn from a more tactile approach to bedside medicine.

One evening after a pleasant dinner, a classmate and I were reminiscing as we leafed through our medical class yearbook.

“Remember him?”

“I wonder what became of her.”

“He was a terrible lecturer. My god, what a bore!”

Then we paused and, examining a certain photograph, looked up and said, “Now there was a real doctor. What a teacher and a real prince of a man. No one like him, before or after!”

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Background

In recent years the question of the appropriate use of human albumin has been of keen interest to clinicians and blood system funders. In British Columbia, no standardized guidelines exist for serum albumin use. There have been attempts in other jurisdictions to create such guidelines,[1-3] but controversy continues.[4,5]