Practice Issues

Antibiotic resistance

Two Angus Reid surveys suggested that most physicians and patients have adjusted their habits over the last three years and now are more judicious in prescribing and using antibiotics. Researchers tracking isolates of antibiotic-resistant bacteria have also found a corresponding decrease in certain "antibiotic" resistance rates in Canada during the same period. The National Information Program on Antibiotics (NIPA), a coalition of eight health organizations (including the CMA), is concerned about the appropriate use of antibiotics in Canada. "Since the introduction of several patient, pharmacist and physician education initiatives in 1996, prescriptions for penicillin and other oral antibiotics have decreased by four%," said Dr. Ronald Grossman, the NIPA chair. CMA News 2000;10(4):3

Clearing the air: discussing resuscitation orders in hospitals

Although most people want their physicians to discuss resuscitation or "code status" with them, these discussions are often fraught with difficulty and delay in the hospital setting.

BC researchers conducted in-depth interviews with five family physicians and five family practices residents admitting patients to a family practice teaching ward in a university-affiliated urban hospital. The authors report that physicians identified personal discomfort with confronting mortality, fear of damaging the doctor–patient relationship and other factors as barriers to discussing code status with patients. The authors suggest that family physicians are "ideally situated" to facilitate code status discussion because of their existing relationship with the patient. However, they add that recognizing barriers to communication is necessary so physicians can become more self-aware of their own feelings concerning end-of-life issues. CMAJ 2000;163(10):1255-9.

Close the gap in asthma care

More than one million Canadians with asthma required urgent medical care in 1998. Not surprisingly, 57% of Canadian with asthma do not have the disease under adequate control. The Asthma in Canada survey, conducted by the Angus Reid Group, found that the disease affects two million Canadian, including 10% to 15% of children and claims the lives of 10 Canadians a week. In a related survey, the Asthma society of Canada found that asthma care is falling far short of the national standards set in the 1999 Canadian Asthma Consensus Guidelines (CMAJ 1999;161[11 Suppl]). CMAJ 2000;162(13):1861.

CME in Mexico

The Mexican Institute of Social Security comprises 1,450 family medicine clinics, 240 secondary care hospitals and 10 tertiary care centres. Seven Mexico City authors describe the development and initial implementation of a continuing medical education program for the Institute’s primary care physicians. The program involved developing clinical practice guidelines for acute respiratory infections and type 2 diabetes, training of clinical instructors, an educational intervention and evaluations of physicians’ performance and patients’ health status. The likelihood of physicians using appropriate strategies to manage the target illnesses increased with the intervention. CMAJ 2000;163(10):1295-9.

A commentary highlights the strengths of this approach, particularly the integration of the education component into the practice setting, the emphasis on action and the study of performance measure of outcome. CMAJ 2000;163(10):1278-9.

Doctors can’t give their practice away

Two rural Nova Scotia physicians couldn’t give away their practice this summer. Dr. Susan Hergett and her husband, Dr. Brian Burke, had to close their practice in Canning, a two-hour drive from Halifax, leaving 2,000 patients without a family doctor. The Medical Society of Nova Scotia receives more than 400 phone calls a month from people looking for a family physician. CMAJ 2000; 163(5):581.

Fee-for-service not dead yet

The declining popularity of fee-for-service payments in Canada may have levelled off, according to the CMA’s 2000 Physician Resource Questionnaire. In 2000, 62% of respondents reported receiving 90% or more of their professional earnings from fee-for-service (FFS) payments, the same level as in 1999. This follows steady declines in the popularity of FFS payments since 1990, when the level stood at 68%. The questionnaire also looked at net income, workload levels and more. CMAJ 2000;163(5):601.

Medical malpractice insurance hikes

As the Canadian Medical Protective Association prepared to hold its annual meeting in August, some doctors wondered if it was about to face competition from a new Ontario medical protective association. That possibility was driven by the CMPA’s decision to pursue regional rating, which saw Ontario physicians paying Canada’s highest malpractice protection charges. The CMPA now pays about $46 million more to provide malpractice protection for Ontario doctors every year than it collects in fees ($130 million vs. $84 million). Meanwhile, in Quebec revenues total almost $60 million, while the CMPA’s costs only total about $20 million. CMAJ 2000;163(2):201.

Ontario and the CMPA managed to hammer out a three-year agreement in July that ensures Ontario doctors remain under the CMPA umbrella. Although CMPA fees increased in Ontario, the 45% rise introduced by regional rating will now be spread over three years. The increase could be less than that because of savings brought about by the agreement, which calls on the government to consider introducing tort-reform legislation. CMAJ 2000;163(4):433.

The CMPA announced at its annual meeting in August that Ontario doctors fees would rise by only 13.6% in 2001. Ontario physicians took money out of their share of the CMPA’s legal settlement reserves to prevent an increase of 45% or more. Meanwhile, fees for Quebec doctors will drop by 50% and physicians in the rest of the country will see a decrease of nearly nine%. CMAJ 2000;163(5):595.

When the CMPA set its 2001 rates in October, Ontario obstetricians learned that their fees will double next year, rising from $31,404 to $60,372. (Under an agreement with the province, taxpayers, not doctors, cover the cost of the increase. Obstetricians will pay only their 1986 rate — $4,900 — with the province paying the remaining $55,472.) Ontario obstetricians are being hit hard because Ontario courts are by far the most generous in awarding patients following medical misadventures. CMAJ 2000;163(11):1491.

Rational restraint

A retrospective review of the use of physical and chemical restraints, found that out of 156 patients admitted to a medical teaching units in an acute care hospital, 18 patients (11.5%) were either physically or chemically restrained, or both. The authors found that the reasons for using restrains were not well documented, and no orders had any time limits. While physicians usually ordered their use, it generally became a nursing decision as to whether or not they were applied. The authors state that guidelines on the rational use of restraints are needed. CMAJ 2000;162(3):339-40.

Revised fitness-to-drive guide available

The CMA’s new Determining Medical Fitness to Drive: A Guide for Physicians, which took two years to revise and is three times longer than the previous version, was launched in July. This new version reflects changes in medicine, the transportation industry and the legal system over the past 10 years. There is a new section on airbags, more supplementary information and an expanded appendix with evaluative tools. The guide also provides the latest information about elderly drivers and driving and medical conditions such as epilepsy, sleep apnea and cardiovascular disease. CMAJ 2000;163(2):198.

The limitations of evidence-based medicine

The term "evidence-based medicine" is less than 10 years old, although the underlying concept predates it. It is a subject of increasing interest and some controversy. Two authors reviewed the published criticisms of evidence-based medicine. Some problems are intrinsic to the practice of medicine, such as the variable quality of evidence and the difficulty in applying the results of a trial to the care of an individual patient. Others, such as the need for busy clinicians to acquire new skills and to spend time seeking information, should be addressed through established educational forums and new technologies. Many criticisms result from misperceptions, which may be addressed by careful attention to the definition and intent of evidence-based medicine. CMAJ 2000;163(7):837-41.

Vague child protection law puts onus on physician to report

Ontario physicians and other health professionals now have a large but ambiguous responsibility to report not only children who "suffer abuse" but also cases in which a child is "in need of protection." New child protection legislation aims to prevent children from falling through the cracks of the child protection system. But the new legislation puts physicians in a vulnerable legal positions. They are now legally liable for failing to report cases, and penalties include fines of up to $1,000 and imprisonment for up to a year. CMAJ 2000:162(10):1464.

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