Resource allocation and physician liability

Lawyer Karen Capen says funding cutbacks that have affected the services physicians can provide may cause legal problems for Canada''s doctors. If cutbacks affect the care that is being provided, they should be discussed with the patient and noted on the chart. She says physicians have "good reason to be concerned" about increasing pressures that create an imbalance between health care resources and the demand and need for services. For some doctors, these have resulted in court cases.     

"Don't let others design your future", new CMA president tells physicians. Interview by Nancy Robb.

Dr. Judith Kazimirski of Nova Scotia becomes the CMA''s 126th president during the association''s annual meeting in Sydney, NS, this month. She says her priority for the next year is to help the CMA play a lead role as the debate intensifies about the future of health and health care in Canada. "The time is right for a very public debate about what people want their system to be, what problems they''re having, and how reform is moving ahead," she says, "and physicians have a critical leadership role to play."     

Jehovah's Witnesses leading education drive as hospitals adjust to no blood requests.

Jehovah''s Witness representatives have visited more than 10 Canadian medical schools and 200 hospitals in an attempt to educate future and practising physicians about nonblood medicine. The trend is becoming more popular since the advent of HIV, and there are now about 100 bloodless medicine and surgery centres around the world, including 52 in the US. However, a Jehovah''s Witness spokesman says Canada is "conspicuously absent" from the list of countries that offer bloodless-medicine programs.     

Pretrial preparations can improve a physician's value as an expert witness.

Many physicians appear in court as expert witnesses, but the quality of their testimony varies considerably, says a Nova Scotia judge. Pretrial preparation will improve the quality of a physician''s testimony, reduce stress and save time, says Judge Timothy Daley, who provides some suggestions about how to prepare to be an expert witness and what to expect in the courtroom.     

Requests approaching 50,000 annually for emergency drug release program.

Health Canada''s Emergency Drug Release Program, which allows physicians to acquire nonmarketed drugs to treat people with HIV infection, AIDS and other illnesses, handles about 44 000 requests annually. The executive director of the Drugs Directorate says the program''s name is a misnomer, since few of the requests involve medical emergencies. Dr. Philip Berger, who uses the program for his AIDS patients, complains that the amount of paperwork required is oppressive. A government spokesperson says changes may be made to make the program less labour intensive.     

Towards a more rapid diagnosis of rapidly progressive glomerulonephritis.

An attempt was made to provide simple practical guidelines to alert general practitioners to the diagnosis of rapidly progressive glomerulonephritis and lead to early referral to hospital. The duration of illness before referral to this hospital and its effect on outcome in patients with crescentic nephritis were assessed retrospectively from the case notes of 24 patients referred over two years. Four patients had Goodpasture''s syndrome, 11 Wegener''s granulomatosis, seven microscopic polyarteritis, and two idiopathic progressive glomerulonephritis. The duration of symptoms before referral to the local hospital was similar in the four groups of patients and varied from one week to 28 months (mean 10 months). The duration of stay in the local hospital was two, nine, 11, and 180 days in the patients with Goodpasture''s syndrome and a mean of four days (range one to eight) in those with Wegener''s granulomatosis and 10 days (one to 18 days) in those with microscopic polyarteritis. In the local hospital the diagnosis was based on the results of renal biopsy and detection of antibodies to glomerular basement membrane in two patients with Goodpasture''s syndrome and on the results of renal biopsy in seven of the other patients aided by the detection of antibodies to the cytoplasm of neutrophils (ANCA) in 10. Three of the 24 patients died and four required maintenance haemodialysis. Patients who present to their general practitioners with persistent non-specific symptoms should have a urine dipstick test and then blood tests and emergency referral to hospital if necessary. Hospital physicians should be aware of the speed and accuracy with which current assays can confirm a diagnosis of rapidly progressive glomerulonephritis.     

Dr. Balfour Mount and the cruel irony of our care for the dying.

Dr. Balfour Mount of Montreal thinks that the health care system, because of its fixation on disease processes, may have forgotten that it also has a mandate to alleviate suffering. "We need to recapture that vision," says Mount, who describes palliative medicine as a "rich combination" of clinical pharmacology, rehabilitation medicine and internal medicine. Mount says there is a cruel irony in our care of the dying. "Although these are the sickest people in our health care system, when medical technology doesn''t know what to do, the quality and quantity of care falls away. How can we justify that?"     

Concern mounts as transfusion medicine loses its lustre

Transfusion medicine is in trouble. Several factors, ranging from the tainted-blood scandal to changes in the way the system operates, mean that young physicians are avoiding the specialty. Dr. Antonio Giulivi of the Red Cross says the issue is serious because these specialists act as the system''s overseers, and this fact won''t change when the Red Cross gets out of the blood business in September.     

"I won't do surgery if you don't try to do my job," head of new blood agency tells MDs

Ken Fyke is known as a tough administrator, and he is going to need all of his administrative tricks as first chair of Canadian Blood Services, the new national organization that is taking over responsibility for the nation''s blood supply from the Red Cross come September. Fyke says he hopes to work closely with physicians, but they will have to realize where their responsibilities end and his begin.     

Volunteers,doctors take palliative care into the community.

The face of palliative care is changing. In Ontario''s St. Catharines region there has been a concerted effort to make it more of a community-based procedure. A local college even teaches a 2-year course in palliative care. The trend is expected to continue because Canadians are living longer, and more frail elderly people will be dying at home. Dr. Sandra Hartman, a palliative-care consultant, says physicians interested in palliative care must remember that there is more to it than providing medical assistance. She considers bereavement counseling for the patient''s family a necessary part of follow-up preventive care.     

Reference-based pricing: Will other provinces follow the BC lead?

REFERENCE-BASED PRICING has had a major impact on medical practice in British Columbia. Anne Mullens discusses the new system''s first 2 years. She says physicians outside BC should pay attention, because RBP may be heading their way. It is set to land in Australia next month.     

Dubin calls on CMPA to eliminate fee differentials,adopt flat fee for all physicians

Charles Dubin''s massive review of the Canadian Medical Protective Association supports the CMPA''s policy of maintaining a large reserve for malpractice coverage, but calls for a major overhaul of the association''s fee structure. Regardless of the risks their practices pose, says Dubin, all doctors should pay the same fee in order to keep physicians practising in high-risk specialties such as obstetrics and orthopedic surgery. The alternative, said CMPA president Dr. Bill Thomas, is an exodus from certain specialties because of massive bills for malpractice insurance.     

His own private hospital

Dr. Brian Day had a simple solution when it became increasingly difficult to book operating room time in Vancouver. He built his own hospital. The Cambie Surgical Centre, which treats patients from BC and around the world, has 2 main operating rooms, 10 recovery beds and 5 private rooms for extended stays. "What I''ve done," says Day, "is say that if there are no operating rooms at UBC, I''ll build my own."     

Interest in physician-buyout packages grows as more doctors contemplate retirement

Provincial governments are turning to voluntary retirement programs, buyouts and phase-outs to help manage physician supply. Demographic data show that in 1996 nearly 27% of Canada''s active physicians were aged 55 or older and that the average age of retiring physicians was 68. Although 1 goal of such programs is to give willing older physicians the financial ability to retire, provinces also hope to do away with some billing numbers.     

US ad uses lure of prompt treatment to entice Canadians needing joint replacement.

A Virginia hospital has used newspaper advertisements to solicit Ontario patients who are waiting for hip- or knee-replacement surgery. The ads promote the medical services of US orthopedic surgeons and call attention to exasperatingly long waiting lists for the same surgery in Canada. "Pain doesn''t wait," they state. "Neither should you." The hospital says it has been receiving more than 100 calls a week inquiring about the procedure, which costs $15000 (US).     

Are MDs more intent on maintaining their elite status than in promoting public good?

The message that philosopher John Ralston Saul delivered during a recent CMA policy conference may have been unpopular with many physicians, but it wasn''t intended to win their support. Instead, organizers wanted him to provide food for thought. Charlotte Gray reports that he did just that.     

Doctor,you're in tobacco sales!

The director of British Columbia''s Doctors'' Stop-Smoking Project says that, whether they recognize it or not, doctors have the best and most competitive position within the tobacco industry because they have the best product line. Dr. Frederic Bass says physicians'' products—health and freedom from addiction—will win against the competition, which can offer only smoke, addiction to nicotine and ill health. “We offer the better deal,” he says, “but are we selling like we could? That''s the issue.”     

Nova Scotia health minister issues plea for more MD participation in politics.

Dr. Ronald Stewart admits that there are negative aspects to becoming a politician, but when he addressed a recent national meeting of Canada''s emergency physicians he pleaded for more physician involvement in the political process. Stewart, an emergency physician who serves as Nova Scotia''s health minister, thinks work as a politician can be both frustrating and fulfilling.     

Evidence-based medicine designed to save physicians time,energy, FPs told

Although not all physicians welcome the current move toward evidence-based medicine, Dr. Warren McIsaac, a member of the Institute for Clinical Evaluative Sciences in Ontario, says it is designed to save them time and energy. He made the comments during a meeting of family physicians in Ontario.     

Activists decry physician disinterest in Lyme disease during Vancouver conference.

Although it was well advertised, few Canadian physicians attended a recent conference on Lyme disease in Vancouver. The apparent lack of interest upsets the president of the Lyme Borreliosis Society, who says many patients have been misdiagnosed, mistreated or untreated and "are now chronically disabled." Interestingly, the disease seems to be much more common in the US than Canada. In New York State, for instance, more than 26,000 cases have been diagnosed, but in nearby Ontario the total is only 200.