I apologize for the extended hiatus. I have been busy with a “career transition”. I am in the process of moving from my research position back into clinical practice, an experience that has been interesting, challenging and, so far, fun. I’ll start with some deep background. It is basically the story of my career prior to my low-carb epiphany so you are forgiven if you decide it is too boring to bother with. For those of you with excess time on your hands, this is what has been happening.
After completing medical school, I trained in family medicine and did general practice for awhile before shifting into a public health role. I started working for the British Columbia Centre for Disease Control in 1988 as the Associate Director of Sexually Transmitted Disease at a time when the AIDS epidemic was the all-consuming public health concern. Vancouver was the Canadian epicentre of the epidemic and some of the early leading-edge research was being conducted here so it was an exciting time to be working in this area. I was tasked with developing HIV prevention programs targeting the Aboriginal population of the province. My efforts in this area attracted the attention of the federal government which needed to develop an Aboriginal component for their national AIDS strategy. This is how I came to be recruited to work for Health Canada in 1990.
While with the BCCDC, I had become interested in the intersection of public health and the mainstream media and came to appreciate the media’s incredibly powerful role in informing, and sometimes mis-informing, the public about health issues. In particular, during the early years of the AIDS epidemic, the media tended to fan the flames of hysteria about AIDS which complicated my job of getting accurate information to the public. I also knew that the media had the power to deliver a positive message which led me to develop the concept for a television series called “The Dr Peter AIDS Diary”. The Diary was the story of one of my colleagues, a young gay physician, who was dying of AIDS. Each week he did a brief segment on some aspect of AIDS. Our idea was to teach people the facts about AIDS with the subtext that it was something that can happen to anyone and that people with AIDS, and gay people, should not be feared or ostracized. The Diary was broadcast weekly on the evening news and was eventually turned into a documentary film that received an Academy Award nomination. The Diaries were an extraordinary success. Dr Peter became a local celebrity and when he died, after doing 111 consecutive episodes, there was a huge public outpouring of sympathy for him. Shortly before his death, at his request, a small group of us started a foundation to capitalize on the goodwill he had generated and were able to translate that into the establishment of a modern AIDS care facility in downtown Vancouver. The Dr Peter AIDS Centre has become a model for how to effectively serve people with a devastating disease in a compassionate and cost-effective way.
The Dr Peter series and the lasting legacy of the foundation were things that I worked at that were outside the duties of my civil service public health position. Back in those days it was not uncommon to be contacted directly by reporters whenever an issue related to AIDS was in the news. And there was generally no problem in responding. That, unfortunately, has changed over the years. Governments have become much more restrictive in terms of what individual civil servants are allowed to communicate via the media. This tightening of media access to public officials has been an ongoing process ever since I began working in government but had become increasingly constrictive with the arrival of the current federal administration. Ironically, they had campaigned on openness in government and then quickly instituted the tightest of controls once they were elected. Being constrained in what you can say to the public is a particularly difficult problem when you are working in public health. I recall an incident where we were dealing with a Listeria outbreak and the public was being warned about certain packaged meat products that had been contaminated. In small isolated northern communities, where the main vehicle for communication is via the local radio, our public health officers were not allowed to use that medium to get the warning out because of the complete clampdown on contact with the media.
In my case, since I was getting frequent requests for interviews related, initially to the documentary, and then whenever a diet story was in the news, I was a big problem for the communications staff. On the one hand, they preferred that I not respond to any requests at all but, on the other hand, they ran the risk of appearing to be keeping important information from the public. In fairness, some were quite sympathetic to what I was doing but were severely constrained by a rigid system that was run directly out of the Prime Minister’s office. As the media began to realize the extent of this policy change across government, there were actually news stories about scientists in the civil service who were being prohibited from discussing their work publicly because their findings were in conflict with government policy. Being caught on the horns of this dilemma was very stressful for communications staff. I recall one incident where a senior staffer had a screaming fit because I was scheduled to be interviewed about the documentary, even though it was clearly going to be a good-news story. In retrospect, it is remarkable that I was able to communicate via the media as much as I did, given the general “cone of silence” that had descended on the civil service with the current administration.
Where I worked, in the federal health department, there was a specific concern whenever I spoke to the media about the benefits of a low-carb diet because this is also the place where the Canada Food Guide is produced. Health Canada is particularly proud of the Food Guide as it is the most highly requested of any government communications product. Although I was always very careful not to embarrass the department by directly challenging the validity of the Food Guide, I also know there were many internal meetings of those bureaucrats to discuss how to minimize the damage I was doing to their highly valued brand. I am sure there was a big sigh of relief, maybe even a little celebration, in that office upon my departure.
When I first started working for the First Nations and Inuit Health Branch in Ottawa, I was able to continue to do part-time clinical practice in Vancouver. My Ottawa masters allowed me to continue to live in Vancouver on the understanding that I would have to travel the length and breadth of the country to do the necessary work. For several years I literally lived on airplanes and in hotels as I got Aboriginal AIDS programming underway across the country. During those years I really came to appreciate the value of continuing with clinical work while doing the other more bureaucratic stuff. It was almost a refuge from the pressure of functioning in the byzantine bureaucratic system and the rigours of the crazy travel schedule I was keeping. I loved returning to Vancouver to do clinic shifts and vacation locums. It was during that time that I came to realize what a tremendous gift my medical education was and that I was greatly privileged to be in a position to help others with their vital problems. I know this sounds kind of corny but I had reached some sort of state of grace with my practice of medicine which was particularly interesting since much of what I was doing at that time was in the STD/HIV clinic, a type of practice that was not highly sought after by my colleagues.
In 1996, I was offered a senior management position in Ottawa that required relocation and which didn’t allow me to continue clinical practice because of the demands of the job. I accepted these changes because I was intrigued with the challenge. I was to take control of the health benefits program that provided drugs, dental services, vision care and patient transportation to all the First Nations and Inuit people in Canada. The program represented a third of the entire Health Canada budget at the time and had been growing at double-digit rates. Because of the cost and growth rates, the program was in the cross-hairs of austerity-conscious senior bureaucrats and politicians. Over the course of three years, I worked with a staff of about 40 dedicated civil servants to bring some management control to the program to curtail unnecessary expense while preserving the essential services that were so important to the client population. We were constantly under attack by the drug companies and service providers whose incomes and profits derived from the program and also from the clients who were deeply suspicious that our mandate was to cut their benefits. Again, I found myself criss-crossing the country to communicate with providers and clients the true nature of our approach to re-designing the program. And, again, I learned how the media can be both your friend and your enemy when it comes to getting accurate health information to the public.
The pharmacy component of the program was the fifth largest drug plan in the country. After we established an electronic system to manage the pharmacy transactions, we also developed the capacity to systematically search for prescription drug abuse by clients, prescribers and dispensers. We were in the throes of figuring out how to translate that information into effective interventions to prevent prescription drug abuse when the Auditor General made our program the focus of his annual report to parliament. We had run into a significant roadblock from our legal colleagues in the Justice Department who were concerned with our use of the drug database for this purpose. They took the position that we could not use this newly available data to intervene, even in obvious cases of abuse, because it was deemed to be a confidential medical record. We were in the midst of grappling with this problem when the Auditor General used our new system to measure the extent of the abuse problem which they then described in lurid terms in their report while, at the same time, neglecting to tell the story of how we were also trying to address the problem. Of course, we got clobbered in the press and I was summoned to testify in front of hostile parliamentary committees about what was actually going on. It took years and enormous expense to get that issue sorted out to the point where the data could be used for the prevention of drug abuse.
Although I loved the challenge of the Ottawa job, and the progress we were making was considerable, I was in a working environment that was less than ideal. Over my three years there, we had reduced the budget growth to effectively zero through improved management and without cutting actual benefits. The overall savings we made during that period, based on projections of earlier growth rates, amounted to about $100 million. I had a wonderful staff and, during my tenure there, my shop became the most desirable place to work in the organization (I learned this from my future wife who was working in a different area at the time). I worked extremely hard and maintained an intense pace. In those days there was a sign-out book in the lobby of the office where you were required to make an entry if you left the building after 6:00 pm. It was a rare day that I didn’t sign that book. There was no monetary reward for working all those excess hours and, as I discovered, very little recognition for a job well done, either although the real reason for that was obscure at the time.
Even though I loved the job, I was finding it increasingly difficult to continue working there. I won’t get into the gritty details but, to give you some indication of the kind of workplace stress I was under, I will tell you that my immediate superior was charged with criminal behaviour and ended up sentenced to jail. It turned out that he had orchestrated a multi-million dollar fraud and was syphoning public funds into his multiple private bank accounts. Before this bombshell landed, I was finding it increasingly hard to work with him. In retrospect, my relationship problems may have intensified when I befriended and and became a golfing buddy with the departmental auditor. This would certainly have been a threat to my boss who needed to keep his crime well hidden from the internal system of checks and balances. Having somebody close to him hanging around with the person charged with preventing fiscal malfeasance, even though I was completely in the dark about my boss’s nefarious affairs at the time, was likely a big source of stress for him. In either case, the working relationship deteriorated to the point where I knew I had to escape.
When the Regional Director position opened up in Vancouver I grabbed it and moved back to the west coast to take on a job that was as far away from Ottawa as possible but was, in some ways, even more challenging. I was in charge of over 200 staff and had responsibility for a large budget that was constantly being strained by the health service delivery requirements of a diverse and needy First Nations population scattered across a huge geographic region. The legitimate health demands were always in excess of the available resources. I often said that one’s success as a Regional Director depended on how politely and skillfully one could say “no” and I don’t claim to have been particularly good at that. It was about six years after I became Regional Director that I developed type 2 diabetes. Job stress was certainly a factor although I also had a family history of diabetes and a not so good lifestyle at the time, too. In retrospect, my diet was probably the main contributor. I was vegetarian and thought nothing of eating pasta five nights a week and waffles with fruit, french vanilla yoghurt and maple syrup for breakfast every day (yikes!).
After my low-carb epiphany (described above in The Story So Far) I was fortunate in that I was given the opportunity to shift out of my executive job and pursue research into how low-carb dieting might be important for the prevention and treatment of type 2 diabetes. Since this disease was a big problem in the Aboriginal population and our other approaches were not delivering results, I was able to persuade the department to support my work in this area. I knew at the time, however, that by stepping outside the main business line of the First Nations and Inuit Health Branch, I would be vulnerable when the senior staff who were supporting me left or when the next budget crunch arrived. So, it came as no surprise that, a few months ago, when the Canadian government announced plans to chop 20,000 civil service jobs, mine would be one of them.
My years of employment as a civil servant entitled me to a pension, but since it represented a 60% drop in income and, since I am not independently wealthy, I was not ready, nor was I inclined, to actually retire. For the past six years, I have been focussed on using a LCHF diet to help people with their weight and metabolic problems. I have been involved in a number of research initiatives and have been working with First Nations communities to use this kind of approach for groups and individuals with some success. It seemed to me that my next career move should be the application of this kind of diet in a private practice medical setting. With this in mind, I had a look at the rules that the College of Physicians and Surgeons have developed for somebody like me who wants to return to clinical practice after some time away. I contacted them to explain my position and the fact that I had developed considerable expertise in this area, that I taught other physicians, lectured in the medical school, did research, etc, etc. My request was that I be given their blessing to embark on a practice limited to the use of this diet. I explained to them that I didn’t want to return to a general medical practice. Unfortunately for me, the rules don’t allow for that kind of focussed return to practice. I was told that I had to re-train in general practice and that it would take a year or more given the length of my time away. I was provided with some information on the re-training program that was available but was also advised that, given my age, my chances of getting a position there were effectively nil. It turns out that the existing positions that come with salaries, much like the medical residency positions one takes after graduating from medical school, were designated for immigrant doctors who need to qualify the Canadian exams. If I was to get re-trained, I would have to organize and fund my own program.
I relayed this information back to my “career transition” contact at Health Canada. I had been provided with a government policy document that laid out the process of negotiating the exit of senior executives in the civil service. The policy described a process where one’s particular circumstances were considered and an exit package would be uniquely designed to accommodate one’s transition needs. For most people this meant a lump-sum payment based on salary and some other potential benefits including career counselling, re-training and relocation costs. At first glance, it appeared to be quite generous and humane as I am sure it was intended to be when it was developed. The problem, as I soon found out, was that it was ill-suited to the current situation where the numbers of senior executives departing were unprecedented. It quickly became apparent that a one-size-fits-all approach was being applied. The problem for me was that, unlike other executives, who were able to start work in another position as soon as they departed, I was faced with a lengthy and expensive retraining program. I argued that this was a unique situation that warranted additional accommodation in the exit arrangement. I asked that I be allowed to embark on my retraining while still employed, something that is not uncommon for employees who are upgrading their education with plans to stay in the civil service. The difference in my case was that I would be leaving at the end of the educational period. Unfortunately, my arguments were not accepted, although, because of simple bureaucratic delay I was able to get a couple of months of the retraining done before the axe actually fell.
I am not at all bitter over my exit and continue to feel grateful that I had the support of the department to pursue the diet work for as long as I did. I did think that the fact that I had saved the department in excess of $100 million might have bolstered my argument for a bit more support on the way out but that was not to be the case. Even then, I don’t fault anyone in particular as I can appreciate how difficult a time it was for those senior executives who remained and who had to manage the decimation of the ranks that was occurring all around them as a result of the government’s decision to downsize. I relate this, not out of disgruntlement, but only as a backgrounder to the story of what I am doing now.
My immediate task is to meet the re-training requirements of the College of Physicians and Surgeons and to do this without the benefit of a funded position in an established program. So far, I have been able to cobble together some hospital rotations in internal medicine and emergency medicine and have found a family medicine group practice that has been willing to take me on in the capacity of a medical resident. I am four months into my ad hoc program now and am awaiting the results of a two-day comprehensive exam that I was required to write a couple of weeks ago. My exam performance will be used to determine how long I will be required to retrain before returning to unrestricted clinical practice. While this may seem like a burdensome process, and it is in some ways, I am actually really enjoying myself. The intensity of the hospital shifts was great for getting me back in the groove of dealing with a wide array of medical problems and, now, the day-to-day of a general practice clinic has been very edifying in terms of seeing first-hand how desperate is the problem of chronic disease. It is my impression that about half the people I am seeing don’t really need to see a doctor, their minor illnesses will get better on their own, while the other half, the truly ill ones, most often present with a multitude of the manifestations of carbohydrate intolerance. Even so, I am thoroughly enjoying my clinic time as I am back to where I started in terms of feeling privileged to be able to help others. I find this is especially true now that I have a much better understanding of diet and disease. I find patients are generally quite receptive to a discussion of diet but the time constraints of the typical office visit doesn’t allow for an effective intervention. The other doctors in the clinic are intrigued with my diet work and have encouraged me to start a diet group while I am working there. I have already recruited a number of the diabetic and metabolic syndrome patients from the practice and will start evening sessions for them in a couple of weeks. I am really looking forward to that.
I will continue to blog as time allows and I will still be doing as much lecturing as I can. I am scheduled to speak on the upcoming Low-Carb Cruise in May 2013, so I am looking forward to that, as well. Yesterday I spoke at an annual diabetes update meeting for physicians and was swarmed at the end of my talk by doctors wanting to learn more about low-carb and how to implement it in their practices. I am keenly interested in that question and am looking forward to developing an approach that can work within the resource constraints of a typical general practice and that can be made available to other interested doctors. When I finish my re-training, I hope to be able to work in a general practice that is focussed on diet while also helping the broader community of physicians find ways of applying LCHF in their practices. And, now that I am off the government communications leash, I am also looking forward to the opportunity to broadcast the message as widely as possible through the mainstream media. Stay tuned.