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?"     

Internet access

A 65-year-old man undergoes a routine checkup before retiring. His wife has urged him to have his prostate examined, because she has read about testing for prostate cancer and a friend has just died of this disease. During the rectal examination, the man''s physician discovers some firmness in the right lobe of the prostate gland. The patient has had no urinary symptoms and is in excellent general health. Sexual function is normal. There is no history of prostate cancer; his father died of a stroke at age 86 years. Testing shows that the patient''s prostate-specific antigen level is 9.3 ng/mL, and he is referred to a urologist. Transrectal ultrasound-guided needle biopsy reveals adenocarcinoma with a Gleason score of 7 (intermediate grade). At a follow-up meeting with his physician, the patient says, "I have been doing some research, and it appears that I should have treatment. However, what is less clear to me is what form of therapy is best--surgery or radiation treatment. Please tell me what you can about the state of the art with respect to surgery."     

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.     

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.     

Let's make Golgi

Does the Golgi self-organize or does it form around an instructive template? Evidence on both sides is piling up, but a definitive conclusion is proving elusive.In the battle to define the Golgi, discussions easily spiral into what can appear like nitpicking. In a contentious poster session, an entire worldview rests on whether you think a particular mutant is arrested with vesicles that are close to but distinct from the ER or almost budded from but still attached to the ER.Sometimes obscured by these details are the larger issues. This debate “gets to the fundamental issue of how you think of the Golgi,” says Ben Glick of the University of Chicago (Chicago, IL). “The dogma has been that you need a template to build an organelle. But in the secretory system it''s possible in principle that you could get de novo organization of structure. That''s the issue that stirs people emotionally and intellectually.”Then there are the collateral issues. There is an ongoing controversy about the nature of forward transport through the Golgi—it may occur via forward movement of small vesicles, or by gradual maturation of one cisterna to form the next. The cisternal maturation model “argues for a Golgi that can be made and consumed,” says Graham Warren (Yale University, New Haven, CT)—a situation that is more difficult to reconcile with Warren''s template-determined universe.Even more confusing is the situation in mitosis. Accounts vary wildly on how much of the Golgi disappears into the ER during mitosis. The answer would determine to what extent the cell has to rebuild the Golgi after mitosis, and what method it might use to do so.Several laboratories have made major contributions to address these issues. But none define them so clearly as those of Warren and Jennifer Lippincott-Schwartz (National Institutes of Health, Bethesda, MD). At almost every turn, on almost every issue, it seems that Warren and Lippincott-Schwartz reach opposite conclusions, sometimes based on similar or identical data.And yet, at least in public, there is a remarkable lack of rancor. “These are not easy experiments for us to do,” says Warren. “It''s all cutting-edge research and we are pushing the technology to the limit. Part of that is that you push your own interpretation.” For her part, Lippincott-Schwartz approaches a lengthy poster-session debate with Warren with something approaching glee. This is not triumphal glee, however. Rather, Lippincott-Schwartz seems to relish the opportunity to exchange ideas, and on this point Warren agrees. “Complacency is the worst thing to have in a field,” he says. The debate “has made all of us think a lot harder.”     

NHS waiting list have been a boon for private medicine in the UK.

Health care: public, private or both? In Great Britain, about 13% of the population is covered by private health insurance, and everyone else is served by the public health care system known as the National Health Service, or NHS. Caroline Richmond, who examined the impact of private medical practice in Britain, says people become private patients for one compelling reason: to avoid the NHS''s notoriously long waiting lists for surgery. According to Professor Alan Maynard, a health care researcher, the mainstays of the private sector are the "three h''s" --hips, hernias and hemorrhoids-- along with some elective surgery, particularly in gynecology and opthalmology. Another small sector focuses on fertility regulation and cosmetic surgery. Although the levels are not monitored closely, physician consultants are not permitted to earn more than 10% of their income from private practice.     

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.     

Women's health. The childbearing years and after.

Health and development planners have tended to see women primarily in context of their reproductive role. As a result, solutions to women''s health needs have been restricted to expanding and improving maternal and child health systems. There has recently been a major shift in direction, largely because of the influence of the world conference on population and development held in Cairo in 1994. Dr Guiseppe Benagiano, director of the special programme of research, development and research training in human reproduction based at the WHO, says, "We need to remind ourselves constantly that reproductive health is not simply a biomedical issue but one with serious implications for our general health and by extension, for all our efforts in human social and economic development." The 1993 world development report on health identified the lack of a clear strategy for engaging women in health care and suggested that child health services, prenatal care, treatment of sexually transmitted diseases, and family planning services should be provided jointly at convenient times. In an example of this, the Chilean Institute of Reproductive Medicine now offers integrated family planning services at the same time as child health services, and Thailand is experimenting with mobile health clinics to reach women in their homes. As the proportion of elderly women increases, old age is increasingly being seen as a female issue. With the impact of urbanisation and industrialisation, more of these women are living isolated lives, often suffering from chronic debilitating diseases. In his opening statement to the global commission on women''s health in April 1995 which focused on health conditions of women in old age, Dr Hiroshi Nakajima, the WHO''s director general, said: "Our goal should not be solely to extend lives in the physical sense, but to ensure that the added years are worth living."     

Private health care dominates meeting as general council calls for national debate on issue.

The CMA''s General Council has decided to withhold its stamp of approval for a "private parallel" health care system by voting against a motion to remove legislative barriers to private insurance. However, General Council did call on the CMA to take the issue directly to Canadians and conduct a national debate. General Council did pass a "Blueprint for Action"--16 resolutions spelling out the CMA''s views on ways to protect Canada''s medicare system.     

WHO in retreat: is it losing its influence?

WHO says it has three main functions: to set normative standards; to provide technical advice and assistance on medical matters; and to advocate changes in health policy. During its 46 year history the first two functions have been a constant and uncontroversial backbone through which WHO has earned its reputation for scientific excellence. The third function, advocacy, came to the fore with the launch of Health for All in 1977, after which WHO took a key role in influencing international health policy. WHO''s friends and critics alike now say that the organisation is losing its influence and retreating into its technical and biomedical shell. This article maps the changes in WHO''s approach over the past 46 years and considers whether fears about its loss of influence are justified.     

The New Health Practitioner — The Past as Prologue

The training and utilization of New Health Practitioners (NHP''s) has moved within a decade from a small tentative beginning in the mid-1960''s to a major health manpower policy issue. Its discussion transcends a number of important and emotionally charged areas including the role of various professions in providing health care services, the renaissance of primary care, the geographic and economic maldistribution of medical services, and the cost of care. It is valuable to highlight what is known, what is professed and what needs to be studied further about this issue.     

Public versus private care: philosophy,not economics,is shaping the debate

A debate is brewing on the future of private health care within Canada''s medicare system, and even though the federal government professes its intention to defend the existing public system, the growing rightward trend of Canadian voters may mean they are willing to consider more private care. Citizens may continue to express undying support for medicare as an “untouchable” public good, says Charlotte Gray, but they are less and less willing to pay for it through taxes.     

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.     

Prison became second home for psychiatrist (George Scott).

Retired prison psychiatrist George Scott recalls his career working in Canada''s penal system, including his peacemaking role in a hostage-taking incident and his work with Steven Truscott. Life "inside" is dangerous for guards, inmates, staff and psychiatrists, he says, but he never regretted his decision to devote his career to studying criminal behaviour.     

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.”     

Hospital and community health service costs: England and Scotland compared.

In publications which have compared the health expenditure in the component parts of the United Kingdom by applying the Resource Allocation Working Party (RAWP) formula to the health budget of England, Scotland, Wales, and Northern Ireland it has been previously concluded that Scotland''s hospital and community health services expenditure is more than 19% above what would be a fair distribution. It has also been implied that Scotland''s allocation should be cut substantially to improve services in England. On the assumption that the purpose of examining the distribution of the health and community health service budget is to ensure "equal opportunity of access to health care for people at equal risk" it is concluded that simple RAWPing of the United Kingdom budget is flawed and a conclusion based on this is therefore untenable.     

CMA-cosponsored conference raises many questions about future of regionalized health care.

Is regionalization better because it''s cheaper? Or because it provides better outcomes? Or simply because it''s different from whatever went before? Those were some of the questions asked during a recent conference cosponsored by the CMA and Queen''s University. With each successive speaker, says Charlotte Gray, the message became clearer: there are more muddled theories behind the trend and more pitfalls ahead than planners ever expected when they embarked on the exercise to decentralize health care in Canada and elsewhere.     

Toronto centre hopes to cash in on growing demand for private health services

When the CMA held its 1996 annual meeting, part of the debate on the future of health care involved the "appropriate balance of the roles of the public and private sectors" in delivering health care. The King''s Health Centre in Toronto is now doing its own balancing act: providing publicly funded care to Canadians, and private care to non-Canadians and Canadians who can afford it. This article discusses some of the niche markets King''s is attempting to develop.     

Is Private Health Care the Answer to the Health Problems of the World's Poor?

Background to the debate: The global burden of disease falls disproportionately upon the world''s low-income countries, which are often struggling with weak health systems. Both the public and private sector deliver health care in these countries, but the appropriate role for each of these sectors in health system strengthening remains controversial. This debate examines whether the private sector should step up its involvement in the health systems of low-income countries.     

Past presidents join forces to refurbish gravesite of Sir Charles Tupper,first CMA president.

The CMA''s past presidents have donated a plaque and refurbished the headstone and plot at the Halifax gravesite of Sir Charles Tupper, the association''s first president. "Sir Charles Tupper was a very significant personality in the conception of a national medical association and the past presidents wanted that fact to be remembered," Dr. Athol Roberts says of the endeavour.