Fraud worries insurance companies but should concern physicians too,industry says

The amount of insurance fraud is increasing in Canada. This should worry physicians, because all personal-injury claims must be substantiated by a medical certificate. The vast majority of physicians are honest and ethical, fraud investigators say, but some are being duped as patients scheme to cheat the insurance industry. In one sensational auto-insurance-fraud case, some Ontario physicians are being investigated about possible involvement in a self-referral scheme. Nicole Baer looks at insurance fraud and the challenges it poses for doctors.     

Medical examiners' seminar looked at mysteries surrounding sudden death

Medical examiners in Nova Scotia recently attended their first-ever seminar concerning the skills, challenges and techniques their jobs require. It was welcomed by the physicians, most of whom are family physicians with little training in the investigation of sudden death.     

Factors influencing family physicians to continue providing obstetric care.

To determine the reasons some family physicians continue to practice obstetrics when most of their colleagues do not, we surveyed family physicians in 26 counties of northern California whose practices include obstetrics and those who have recently discontinued it. In all, 70% of family physicians practicing obstetrics cited enjoying it as a reason for continuing this practice. Over a third of family physicians practicing obstetrics thought that obstetric practice was a responsibility to the community. Only 1 in 6 reported obstetrics to be important in terms of financial implications. Despite this, family physicians practicing obstetrics had a mean gross income derived from obstetric practice of $30,000 above the cost of their total malpractice premium. In contrast, a comparison group of family physicians who had recently discontinued obstetrics cited malpractice insurance costs most frequently as the reason for discontinuing it. Nearly 40% of these physicians indicated that they would be willing to return to obstetrics if circumstances were to change substantially. The most frequently cited change necessary for these physicians to return to obstetrics was a reduction in malpractice insurance rates.     

Taking care of patients--does it matter whether the physician is a woman?

Researchers have recently begun to compare male and female physicians'' attitudes toward patients, medical knowledge, and practice styles. Although women start medical school with more "humanistic views," the conservative effect of medical socialization on both male and female students attenuates these differences. While some studies suggested that men are more scientifically knowledgeable, recent studies showed no significant differences in physicians'' medical knowledge. Male and female physicians also had comparable diagnostic and therapeutic behavior. In the intimate world of physicians and patients, however, there were notable differences. Women physicians seemed better able to communicate sensitivity and caring to patients, which may account for the common perception that women are more caring and empathic physicians. Medical educators may wish to study more closely female physicians'' communication styles to identify these behaviors and inculcate them into all physicians.     

US not the only country luring Canadian MDs

The recruitment of Canadian physicians to work in other countries has become a booming business, and some international recruitment firms were in Ottawa recently in search of physicians seeking a change.     

Castration Anxiety Physicians, “Do No Harm,” and Chemical Sterilization Laws

Chemical castration laws, such as one recently adopted in the U.S. State of Louisiana, raise challenging ethical concerns for physicians. Even if such interventions were to prove efficacious, which is far from certain, they would still raise troubling concerns regarding the degree of medical risk that may be imposed upon prisoners in the name of public safety as well as the appropriate role for physicians and other health care professionals in the administration of pharmaceuticals to competent prisoners over the inmates’ unequivocal objections. This paper argues that the concerns raised by chemical castration are grave enough that, until they are adequately addressed by policymakers, physicians ought not to participate in the process.     

The young physician: types of practice.

An inquiry was conducted into the type of practice (whether solo, group or salaried) entered by young physicians graduating from Canadian medical schools in 1970. Twenty-one percent entered solo practice, 57% joined a group practice or partnership, and 22% became salaried physicians in a number of different categories. Surgeons and psychiatrists, more than other types of specialist, were inclined to select solo practice. Group practice was more popular in the western provinces and in rural than in urban areas. More than half of the physicians recently established in urban solo practice complained of having too few patients. Lack of patients was a lesser problem in smaller towns and rural areas.     

MDs remain sceptical as chelation therapy goes mainstream in Saskatchewan

The College of Physicians and Surgeons of Saskatchewan recently agreed to allow physicians to administer chelation therapy. Supporters, relying on anecdotal evidence, say it works wonders in overcoming heart disease, but many physicians remain profoundly sceptical. In Saskatchewan, the college decision has proved popular with patients but has drawn an angry reaction from doctors.     

CHANGING CONCEPTS IN MEDICAL TREATMENT

In a community—even a small one—where physicians established in practice have intensity of purpose, continuing curiosity, healthy skepticism and the spirit of research, the medical atmosphere is one to attract and welcome young physicians who are recently graduated and eager to apply the knowledge gained from the specialists who taught them in medical schools.As the modern laboratory and other facilities and equipment now in use in teaching institutions become available in more and more small communities, general practice remote from the medical centers probably will have increasing allure for neophyte physicians upon whom great influence is being brought to bear to induce them to practice medicine where the need is greatest.Knowledge of the changes in concepts of medical treatment that have taken place in the life-span of the physicians already established in a community will help the young physician fit himself congenially and effectively into the methods of practice of his elder colleagues, with mutual benefit.     

Physicians debate Internet-related marital problems on CMA's online service

The Internet itself has been the topic recently on the CMA''s Internet-based discussion group for physicians, Clinical Q&A. A recent discussion involved physicians from around the country who have dealt with patients with marital problems related to the Internet. They concluded that the Internet may have made problems manifest, but the underlying issue--marital disharmony--already existed.     

Cell-Mediated Immunity and Its Role in Resistance to Infection

The recently acquired knowledge of the importance of cell-mediated immunity in many illnesses and the discovery of a variety of substances that can restore certain cell-mediated immune functions has served to focus the attention of physicians on this area of immunity. It is important for practicing physicians to have a clear understanding of current knowledge of the role of cell-mediated immunity in resistance to infection and how this arm of the immune system relates to the diagnosis and therapy of infectious diseases.     

Modes of Admission to Hospital: A Survey of Emergency Admissions to a General Medical Unit

In a survey of the modes of referral and disposal of “acute patients” to a general medical unit during the period 1 February 1968 to 31 July 1970 only 1,432 out of 3,455 were referred by general practitioners. There was a high incidence of self-referral to hospital, and this trend was on the increase. A large percentage of self-referred patients came from their homes, and 65-77% of these arrived by ambulance ordered by themselves.     

Patterns of practice among older physicians in Ontario

BACKGROUND: Policy-makers interested in the supply of doctors in Canada have recently begun focusing attention on older physicians. This study informs the policy debate by analysing the practice patterns of Ontario physicians aged 65 years and over. METHODS: A cross-sectional and longitudinal analysis of physician claims data for fiscal years 1989/90 through 1995/96 was conducted. The number of full-time equivalent (FTE) physicians by age category, urban or rural status, and specialty was calculated by means of an established method, and differences between older physicians, established physicians and recent graduates (in practice for 5 years or less), in terms of the types of services provided and patients seen, were examined. RESULTS: The proportion of FTE physicians aged 65 or more increased from 5.3% to 7.0% during the study period, whereas the proportion of recent graduates decreased from 19.6% to 16.3%. Of the older physicians, 61.4% practised part time (less than 1 FTE). Half of the physicians aged 75 in 1989/90 were still in practice 6 years later. Older physicians were less likely than those under age 65 to practice obstetrics (4.6% v. 16.9%), provide emergency department services (1.1% v. 14.8%) or house calls (38.7% v. 60.4%), or perform many minor procedures (38.7% v. 62.3%) (p < or = 0.001 for all comparisons). Older physicians tended to be male and had older patients in their practices than did younger physicians. Rural regions had higher proportions of older specialists. INTERPRETATION: Ontario''s physician corps is aging. This may result in decreasing availability of obstetrics and emergency department coverage in the future. Encouraging retirement may create more openings for recent graduates, but if such policies are enacted, special attention should be paid to ensure that rural communities and older patients continue to be served.     

Hepatitis C

Canada now has an institute to study alternative medicine and seek evidence concerning it. The founder, endocrinologist Wah Jun Tze, says most physicians appreciate that the institute will seek to find evidence for unproven therapies. It recently named a research director, and expects to have protocols for randomized, controlled studies in place by the new year. Herbal remedies are one likely candidate for study.     

Obstetric care,Medicaid, and family physicians. How policy changes affect physicians' attitudes.

Recent expansion of Medicaid eligibility for pregnant women and increased reimbursement to physicians who provide perinatal services were designed to improve access to care. Family physicians provide a relatively high proportion of care to pregnant women on Medicaid, especially in rural areas. We surveyed all family physicians who provide obstetric services in 26 northern California counties regarding these changes and perceived barriers to providing obstetric care to women on Medicaid. Of surveyed physicians who limited the number of their Medicaid obstetric patients, 58% stated that recent Medicaid policy changes had increased their willingness to accept new Medicaid obstetric patients. Despite these policy changes, administrative issues and poor reimbursement were cited as the two most notable barriers to providing obstetric care to women on Medicaid. Fear of being sued by Medicaid patients is still seen as a barrier by physicians who have recently discontinued practicing obstetrics and by those who continue to care for a large number of Medicaid obstetric patients.     

Continuous deep sedation and the doctrine of double effect: Do physicians not intend to make the patient unconscious until death if they gradually increase the sedatives?

Continuous deep sedation (CDS) has the effect of making the patient unconscious until death, and that it has this effect is clearly an undesirable aspect of CDS. However, some authors have recently maintained that many physicians do not intend this effect when practicing CDS. According to these authors, CDS is differentiated into two types; in what is called “gradual” CDS (or CDS as a result of proportionate palliative sedation), physicians start with low doses of sedatives and increase them only gradually, whereas in “rapid” CDS (or palliative sedation to unconsciousness), physicians rapidly administer a heavy dose that clearly induces unconsciousness from the beginning. The claim is that the physicians intend permanent unconsciousness only if they rapidly administer a heavy dose, but they do not intend it when the unconsciousness is the result of a gradual increase of sedatives. This paper attempts to refute these claims based on a close examination of the protocol of gradual CDS. If my argument is valid, the doctrine of double effect would not be useful in justifying most, if not all, cases of CDS.     

Taking responsibility for the early assessment and treatment of patients with musculoskeletal pain: a review and critical analysis

Musculoskeletal pain is common across all populations and costly in terms of impact on the individual and, more generally, on society. In most health-care systems, the first person to see the patient with a musculoskeletal problem such as back pain is the general practitioner, and access to other professionals such as physiotherapists, chiropractors, or osteopaths is still either largely controlled by a traditional medical model of referral or left to self-referral by the patient. In this paper, we examine the arguments for the general practitioner-led model and consider the arguments, and underpinning evidence, for reconsidering who should take responsibility for the early assessment and treatment of patients with musculoskeletal problems.     

Pathology: Tumor Necrosis Factor in Human Disease

The Scientific Board of the California Medical Association presents the following inventory of items of progress in pathology. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, or scholars to stay abreast of these items of progress in pathology that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on Pathology of the California Medical Association, and the summaries were prepared under its direction.     

Aspects of Medical Care of Soviet Jewish Emigrés

Soviet Jewish emigrés are a recently arrived refugee group in San Francisco and in other cities in the United States. They have frequently been perceived as a demanding and complaining population, particularly the elderly, often chronically ill members. These behaviors can also be seen as positive survival mechanisms that have evolved in response to the Soviet health care system and cultural background. An understanding of that background and system, together with time, greatly improves the interaction between Soviet Jewish patients and American physicians.     

Neurology: botulinum toxin therapy for torticollis

The Scientific Board of the California Medical Association presents the following inventory of items of progress in neurology. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, research workers, or scholars to stay abreast of these items of progress in neurology that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on Neurology of the California Medical Association and the summaries were prepared under its direction.