Canadian Medicine

A UN-associated agency is -- once again -- publicly criticizing Canada for providing harm reduction for drug addicts, including initiatives such as the Vancouver safe-injection site, needle exchange programs and the distribution of safe crack pipe kits. And despite widespread disdain for the agency's opinion among Canadian public health officials, federal Health Minister Tony Clement "this is additional information that we will have regard for when a decision is rendered." Read more for an explanation of the agency's complaints against Canada and to listen to my interview with Stephen Lewis (pictured above) about the controversy.

THE REPORT
On Wednesday, the (INCB), which calls itself "the independent and quasi-judicial control organ monitoring the implementation of the United Nations drug control conventions," released its (PDF). The report includes a section titled "Evaluation of overall treaty compliance by selected Governments," under which Canada appears first. Here are the highlights:

• the INCB applauds Canada's abandonment of its erstwhile plan to decriminalize marijuana (proposed legislation never made it out of committees in 2004);
• approves of the new federal Anti-Drug Strategy, the same one that has been by many public health experts;
• and reminds us that it considers Vancouver's safe-injection site in violation of the (PDF), an issue I blogged about in November.

CANADIAN CRITICS
Scathing opinions of the INCB's report from a number of influential Canadian addiction policy experts have been :

• Senator Larry Campbell, former Vancouver mayor: "I will stand at the doorway if necessary when they try to close it. What are they going to charge me with? I'm not supplying drugs. I'm supplying health."
• Dr Thomas Kerr, British Columbia Centre for Excellence in HIV/AIDS: "I wouldn't be surprised if the federal Conservative government uses it as an excuse to try and continue to stop harm reduction interventions from operating and to further justify its completely non-evidenced anti-drug strategy approach... [the INCB's] position is totally disingenuous."
• Richard Pearshouse, lawyer and policy analyst with the Canadian HIV/AIDS Legal Network: "The INCB report is driven more by ideology and a war on drugs ideology than the research and the scientific evidence that supports these as a public health intervention."
  

The Ontario government has also voiced its opposition to the INCB report, , on the grounds that the INCB opinion contradicts research and recommendations from the World Health Organization.

STEPHEN LEWIS
I recently spoke with Stephen Lewis -- the former UN Special Envoy for AIDS in Africa and former Canadian ambassador to the UN, who's now teaching global health policy at McMaster University -- about the INCB's pronouncements on Canada. (This conversation took place last month, before the new Annual Report was released.)

His first words on the subject? "Complete poppycock!"

Listen to the rest of what he had to say here:


A full-length version of my Q&A with Stephen Lewis will appear in the in the coming months.


Photo: Nick Wiebe, courtesy of the

Check out our website:

We're hosting Grand Rounds next Tuesday. For those of you who aren't familiar with it, Grand Rounds is a weekly anthology of the best writing on medical blogs.

The deadline is approaching fast; submissions are due by the end of the day on Sunday, March 8. Please send your submissions to with "Grand Rounds" in the subject line.

For more details on submitting, to read previous editions of Grand Rounds, and to read about our suggested themes, please click here or email us with any questions.

Check out our website:

I recently wrote an article about the , which proposed ideas such as a modified form of user fees, a tax hike, allowing doctors to work in the public and private systems at once -- all of which were promptly dismissed by provincial Health Minister Philippe Couillard. But gradually, as the over the more radical aspects of the report died down, Dr Couillard began to speak of some of the ideas -- mixed public-private practices, and some of the other ideas in the report -- in more favourable terms.

(My article will be published online tomorrow. I'll update this post with the link. UPDATE: .)

I spoke to the chair of the commission that created the report, Claude Castonguay, the man responsible for designing Quebec's public health insurance system. Here's an abbreviated version of our conversation:


Were you frustrated to hear Dr Couillard’s initial, dismissive reaction to your commission’s report?

Well, I was disappointed, that’s for sure. You don’t work for eight months like we did... after all, the government was asking us to identify and propose new sources of financing. That was part of our mandate. We didn’t have the opportunity to say whether there should be additional sources of financing or not, we were told to identify new sources of financing. There was some surprise and disappointment, obviously.

Will it still be possible to implement some of the reforms that Dr Couillard has accepted, without the new sources of financing that he’s rejected?

If they say no to the sales tax and the deductible, they will have to find some other way of funding the expenditures, either by moving taxes or reducing the funding of other departments. That doesn't prevent all the other proposals to improve productivity and the quality of care of taking place. They are two separate questions, really -- sources of revenue on one hand and sources of expenditure on the other hand.

Do you think the government is at risk of losing the trust of the medical community by rejecting sections of your report, which the medical associations have largely accepted?

I have noticed that since Wednesday morning when Dr Couillard reacted first, the tone has changed considerably and he is a lot more open to our other proposals and that's a good sign.

Do you mean the mixed public-private practices idea, which Dr Couillard has admitted may be desirable at some point?

All the other proposals, financing of services, evaluation of performance, et cetera.

Do you think his change of heart is due to pressure from doctors?

Not necessarily doctors. There are lots of other people involved, and responses are positive in lots of quarters. People at large feel something has to be done and expect change.

Are you pleased that most doctors seem to support your conclusions?

Yes, certainly. As you know, we had a lot of meetings in the fall with a lot of groups, we listened to what they were saying and looked at Europe. What we are proposing has been tried and proven elsewhere.

Which European countries do you think the Canadian system should be modeling itself after?

The Canadian system, or the Quebec system, was patterned initially after the National Health Service, the British system, but [the British] have moved quite a distance in the last few years. What comes out of all these studies is there is no ideal system. Each system has to evolve in accordance with its own situation. But there are some ideas that you find that seem to be working well in all systems.

Why bother proposing the modified user fee, which you call a “franchise” in French, when it’s very likely illegal under , which states “In order that a province may qualify for a full cash contribution referred to in section 5 for a fiscal year, user charges must not be permitted by the province for that fiscal year under the health care insurance plan of the province”?

I don't think its a violation of the Canada Health Act. The Canada Health Act says there should be no obstacle to the access of care. A fee is an obstacle because before you see the doctor you pay a fee, but we are proposing a charge to be made after the year’s end, after the service has been rendered. It’s payable much later, and not to the doctor. It’s not a fixed amount for everybody; it’s based on the income of the individual. It’s a kind of user fee payable afterward. I don't believe it goes against the Canada Health Act.

So you believe your plans don’t contravene the law, yet you’ve insisted the Canada Health Act should nevertheless be changed.

It should be adapted to leave a little more room for provinces to change.


Photo:

Check out our website:

Happy Belated Family Day! If you don’t know what I’m talking about, your February probably passed as usual: nasty, brutish, short -- and undisturbed by a civic holiday.

But last month two lucky provinces, Ontario and Manitoba, joined Alberta and Saskatchewan in adding a new February holiday, called and , respectively, to help break up the winter blahs. To gauge the situation out there, we devised the quiz below. So, how family-friendly are you, doctor?

Check out our website:

Here's a new take on the reason for the spread of the second wave of SARS in Toronto in 2003: blame those party-loving nurses.

A by the Public Health Agency of Canada found that North York General Hospital nurses who attended a nursing appreciation breakfast in mid-May 2003 were more than five times more likely to have later contracted SARS than nurses who didn't show up to nosh.

The Canadian Press :

It is a bitter irony: A staff appreciation breakfast staged to thank health-care workers for their valiant efforts during Toronto's SARS outbreak helped spread the disease in a devastating second wave of illness in May and June of 2003. [...]

Nurses who worked on the floor where the orthopedic ward was located ate together in a small common room. And a staff appreciation breakfast, timed so that it could be attended by staff from both the night and day shifts, was held. The report said these interactions amplified the spread that was taking hold in the hospital.

"How ironic," [Dr Donald Low, head of microbiology at Mt Sinai Hospital and a co-author of the report] said.

But before you place all the blame on the nurses, don't forget to read the limitations of the study:

Limitations of our report include the focus only on nursing staff and not physicians, porters, cleaners and other hospital staff. While other hospital staff did become ill with SARS and may have contributed to spread of the outbreak, sufficient detailed and comprehensive records on movements in the hospital, shifts worked and patients cared for were only available for nursing staff.

Dr Low told the Canadian Press: "I think everyone had a role to play. It's just that the record keeping was that much more meticulous for the nurses."

Unfortunately, that quote was buried deep in the Canadian Press wire copy, and the Toronto Sun's edit of the Canadian Press article ("") omitted it, meaning nurses were portrayed as the only group that played a role in the transmission.

So doctors and other hospital staffers get off with no blame here because they didn't keep their records in order? That doesn't seem fair.

Lesson #1: the hospital should have enforced better infection-control standards, even for a period of time after they felt the threat had subsided.

Lesson #2, for nurses: don't keep such excellent records during emergencies or else you'll catch all the flak in the newspapers five years later.


Check out our website:

Grand Rounds will be hosted here at Canadian Medicine next week.

Despite our Canuck-centric name, we are actually interested in stuff beyond hockey and maple syrup.* We've selected a few themes for next week's Grand Rounds, but please feel free to submit a post on any subject. Here are the suggested themes:

• Doctors on doctors (or anyone else writing about doctors, real or fictional)
  

• Medical slang (we've written about this a few times before: here, and )
  

• Jane Austen's last illness and other medical mysteries (for more on the Jane Austen mystery, check out from last month)

The deadline for submissions is the end of the day on Sunday, March 8. Please send submissions to [email protected] with "Grand Rounds" in the subject line.

If you're not familiar with Grand Rounds, it's a weekly anthology of the best in medical blog writing. You can read a few previous editions at , and . For a schedule of upcoming Grand Rounds editions, consult Dr Nick Genes at .

*Hockey and maple syrup-themed submissions are, however, most welcome

Check out our website:

The latest edition of Grand Rounds -- an anthology of the week's best medical blog writing -- is , hosted by Jenni Prokopy at chronicbabe.com, "a site for young women with chronic illness who strive to live well in spite of health-related limitations... to be babes!"

Canadian Medicine is included, with our post "For Canadian doctors, refugee care presents huge challenges." I figured that was appropriate to the theme of new beginnings, though the subject seems to have been defined quite broadly. Other notable entries:

• How to read underexposed X-rays if you're in a poorly equipped Guatemalan hospital and all you have at hand is a cardboard tube, from Dr Paul Auerbach at .
• Jennifer Lopez's fancy obstetrical gown, and ideas for a gown of the future, from David Williams at .
• How to ruin children's parties: eliminate junk food, or eliminate food altogether. Actually, Jolie Bookspan from says that will improve children's parties but I think we all know that's not true.
• "Dr Clairebear," a self-described young Filipina doctor in quarter-life crisis, explains why she likes working as a resort doctor, at .
  

Canadian Medicine will be hosting Grand Rounds next week. Check out our announcement in the next post above, or in the right-hand sidebar, for details on how to submit.


Image:

Check out our website:

That's the new Canadian Medical Association ad that's running on the websites of some newspapers. A nearly identical ad ran in the print editions of the newspapers, as well.

It's certainly an arresting image, I'll grant them that. But is the coherent? Not really, says Saskatchewan urologist Kishore Visvanathan.

Many medical procedures (including some suturing) can be performed by professionals other than doctors, like nurses, nurse practitioners or physician assistants. And some of the current access problems in Canada can be solved with office-based reforms, :

The "More doctors. More care." slogan suggests that we're doing a great job already; we just need to more of it. There's remarkably little nuance to this argument.

What if we're not operating at maximum efficacy? If we crank up the number of practitioners, we'll multiply waste and poor quality. [...]

How much waste could be trimmed if the CMA put some of its "Help wanted" budget into quality improvement training, mentoring and support for physicians? How much physician time would this free up for additional patient care?

Dr. Day, show me some creativity beyond the sledgehammer approach of expanding the physician workforce.

Uh oh. Dr Visvanathan has raised the spectre of the controversial 1991 , which recommended limiting the number of doctors allowed to practise in Canada in an effort to control rising costs in the healthcare sector. That report is now more commonly referred to as the Barer-Stoddart "fiasco" or the Barer-Stoddart "disaster," though it's not so clear that Morris Barer and Greg Stoddart were entirely wrong -- and it's even less clear that they are to blame for the current physician shortage.

That idea has recently come under further attack, from UBC health economist Robert Evans and public health researcher Kimberlyn McGrail in a new paper published in the March issue of Healthcare Policy, titled "." The essay lends credence to Dr Visvanathan's assessment, rather than CMA president Dr Brian Day's "" credo. Here's the abstract:

"Truth is the daughter of Time," said mystery writer Josephine Tey. This point, illustrated in her rehabilitation of the "villainous" King Richard III, is equally apt for a reconsideration of the 1991 Barer-Stoddart report on medical personnel. Canadian physicians have reviled these authors for "creating" a physician shortage by encouraging provincial cuts to medical school enrolment. Yet, data pre- and post-1991 are quite clear: their report did not and could not have had this effect. The physician-to-population ratio has been stable since 1989. Average physician hours of work have fallen, but per capita expenditures on physicians' services (inflation-adjusted) are rising rapidly. A flood of physicians from the major expansion of enrolments now in place threatens serious fiscal trouble over the next two decades, and is likely to pre-empt any significant system reform.

Bob Evans -- who seems genuinely pleased to quote a description of Barer and Stoddart that places them behind him in terms of Canadian health economics iconoclasm -- concludes:

Any suggestion that physicians, while fully employed, are in oversupply thus raises potentially embarrassing questions. The view acceptable to the profession is that if services are being provided by well-trained physicians, then they must, by definition, be needed - res ipse loquitur - no matter how large the supply. If more doctors correlate with more servicing - and increased expenditures - so be it. Patients are benefiting. To suggest otherwise would be outrageous.

Barer and Stoddart provided a convenient lightning rod for discharging this sense of outrage. The fact that, whether or not there was or is a physician shortage, their report did not and could not have had anything to do with it, was irrelevant.

Perhaps Dr Day would do well to heed Dr Visvanathan's advice: tone down the "more doctors" rhetoric and start working on real, efficacious solutions to our healthcare system's problems -- like multidisciplinary, collaborative care models including other healthcare professionals, who would be more than happy to help that poor man sew up that gash in his arm in the new CMA advertisement.


TRUTH IN ADVERTISING
Here's about a new CMA ad, from the National Review of Medicine's February issue:

Have kidney, will travel
OTTAWA — There must have been some red faces at the CMA when they checked their ad on the National Post website recently. Adjacent to it was an article about Indian surgeon Amit Kumar, dubbed "Dr Horror" by the Indian press. Dr Kumar ran a surgery out of the basement of his home in a New Delhi suburb that sold kidneys extracted at gunpoint from India labourers to wealthy foreigners. Dr Kumar has relatives in Canada, visits regularly and is now suspected of hiding out here. [He's since been apprehended in Nepal.] That unfortunately placed CMA ad? It read: "CANADA NEEDS MORE DOCTORS."

And how much is all this questionably efficacious advertising costing the CMA? "Something north of $1 million," .


Update, March 6: The involves sending stethoscopes to Members of Parliament and journalists in Ottawa, to emphasize that you can't "do it yourself" and we need more doctors to man all those lonely stethoscopes. Dr Keith Martin, a British Columbia MP and retired physician, is trying to salvage some of these expensive devices to prevent them from going to waste in desk drawers on Parlimant Hill. Dr Martin is planning to send the stethoscopes to Africa. Brilliant lobbying or wastefulness? You decide.


Image: Canadian Medical Association advertisement

Check out our website:

Ontario Health Minister George Smitherman (right) may have meant well when he announced last Wednesday that he was thinking of trying out the incontinence diapers to see if they were sufficient for Ontario longterm care residents, but his remarks immediately sparked criticism from far and wide. He was called insensitive and arrogant, and rival politicians called for his resignation. He's since apologized for the PR gaffe, but that didn't stop the National Post's Scott Stinson from in an imaginary Smitherman diary over the weekend:

TUESDAY

Major confession, diary. I tried out an incontinence diaper today. It was so ... freeing. I had three large coffees from Tims -- but no winners :(-and then I sat through a three-hour meeting with a bunch of bureaucrats.

No pee breaks! It was so much more efficient. Made a bit of a stumble at lunch, though, by having the side dish of asparagus. Won't make that mistake again! I think this will really help in my discussion with the nurses' union. Five hours seems to be the limit before things get a little soggy. I think I'll publicly float the idea tomorrow. Right after I shoot up an eight-ball of smack to get a better feel for drug addiction.

Ouch. The matter of drug addiction is a touchy subject for Mr Smitherman, who admitted a few years ago to have been a "party-drug" addict. I asked him about the admission last year when I interviewed him for a . "Some [fellow Liberals] appreciated my candour, and some sure as hell don't want to hear another word about it," he told me.

L'Affaire Diaper isn't the first time Furious George has gotten himself in deep you-know-what for running his mouth.

Speaking about new building plans suggested by some hospital boards in Ontario, Mr Smitherman dismissively referred to the expensive proposed upgraded facilities as "Taj Ma-hospitals."

His most famous outburst was featured on Stephen Colbert's American parody politics talk show in 2005. Talking to none other than an assemblage of the Ontario Association of Optometrists, Mr Smitherman called optometrists "a bunch of terrorists, and I don't negotiate with terrorists." "Bravo, sir," . "Optometrists are a menace. You have to be careful with a group that gets their kicks blowing air into our eyeballs."

Call me crazy, but I'm willing to bet -- despite his contrition -- this won't be the last time an offhand remark from Mr Smitherman causes a province-wide uproar. Though it probably will be the last time he brings up his own urination habits in Parliament.


Update, March 5: Mr Smitherman is "" wearing a diaper. Oh well.


Photo:

Check out our website:

Although the Progressive Conservatives are in Alberta's provincial election, held today, the opposition Alberta Liberals recently picked up some much-needed support from the province's physicians.

The Alberta Medical Association asked each party 10 questions on their health platforms and asked about 150 doctors to , from A through F. Here's how they rated:

Liberal Party: B
New Democratic Party: C+
Progressive Conservative Party: C
Green Party: D
Wildrose Alliance: (did not respond)

"If I brought some of these grades home to my mother, certainly there would be some discussion around priorities and doing homework," AMA president Dr Darryl LaBuick told the Canadian Press late last week.

You can read the party's full responses to each question (PDF). And you can also read the (PDF).

The Liberals scored high partly for their opposition to recent legislation, called Bill 41, that gave the government powers to take over functions of professional regulatory agencies, including the College of Physicians and Surgeons of Alberta, in emergencies. An AMA members' meeting was unanimously opposed to the law, which the Tories pushed through the legislature in December without Liberal and NDP support. You can read more about Bill 41 in our previous coverage.

To read more about healthcare issues in the Alberta election, check out our post from last month about Health Minister Dave Hancock's vulnerability and the government's muddled health human resources promise.

Election results should be announced this evening.

Check out our website: