Tuition Fees up 27% at U of T Physicians Must Close the Gap In

Return to June 27, 2000 News and analysis Table of Contents Nouvelles et analyses

Tuition fees up 27% at U of T

The bad news for students entering med- funding formula for universities in- ical students are “gravely concerned” ical school at the University of Toronto cludes only partial allowances for differ- about tuition fee trends. “Although the this year is that their tuition fees are ris- ences in program costs. This means University of Toronto is the most re- ing by 27%. The good news, says Dean that, compared with a large lecture- cent increase, similar decisions are be- David Naylor, is that further large in- based course in the humanities or social ing made from Dalhousie to UBC,” creases are “extremely unlikely.” The U sciences, small professional programs she said. “The most recent increase in of T now has the highest fees in Canada, have high per-student costs.” Toronto has come in complete igno- although this may change as other Naylor added that, paradoxically, rance of an outcry for a need to evalu- schools announce increases this summer. universities that are successful in win- ate the effect that rising tuition has on New medical students at the U of T ning research awards — as the U of T the demographics of the physician will pay $14 000 in tuition fees this is — face a further funding squeeze be- population. For many young Canadi- year, up from $11 000 in 1999; students cause overhead costs are not included ans, it is impossible to even contem- already registered in the program will in the awards. “This is a further indirect plate an education that would incur face a 5% increase. funding pressure,” he added. “All such high debts, and as a result the Naylor says the rea- of these forces had an impact on pool of talented students who would be sons for the increases our tuition decision.” physicians is getting shallower.” are simple. “Ontario’s In 1999, tuition fees at Naylor acknowledges that the U of provincial govern- Canada’s 16 medical T is concerned about rising fees, but ment has been schools ranged says data about their impact are con- balancing its from a low of flicting and inclusive. “On the preven- budget, and it $2452 at the tive front, we are continuing to increase has taken a very University of the number and level of our bursaries tough line on Montreal to and interest-free loans. Our faculty’s university fund- a high of commitment is simple: once accepted, ing. This means $12 600 at McMaster no students should ever have to leave that more of the University. Tara Mas- any of our programs as a result of per- costs of professional programs must be tracci, president of the Canadian Fed- sonal financial problems.” — Patrick borne by students. As well, the block- eration of Medical Students, says med- Sullivan, CMAJ

Physicians must close the gap in asthma care

More than 1 million Canadians with that asthma care is falling far short of are out of the acute state. Now we’ve asthma required urgent medical care last the national standards set in the 1999 raised the bar. People with asthma need year, according to a recent national sur- Canadian Asthma Consensus Guide- routine chronic care follow-up.” vey. Not surprisingly, the Asthma in lines (CMAJ 1999;161[11 Suppl]). Follow-up includes asking how often Canada survey report also revealed that Those guidelines state there should patients use their short-acting bron- 57% of Canadians with asthma do not be minimal need for urgent medical chodilators, watching them take their have the disease under adequate control. care, yet 51% of respondents required it medications, asking about peak flows and The survey of 1001 adults with at some time. The guidelines also say following up with environmental-control asthma or parents of children with there should be no sleep disruption, but measures, such as dust-proof bedding. asthma and 266 physicians was con- 35% of respondents said they awaken “GPs, who treat most asthma sufferers, ducted by the Angus Reid Group and with breathing problems at least once a need a mindset shift from acute to endorsed by the Asthma Society of week. Finally, 37% of respondents ex- chronic disease,” says Greenwald. Canada (ASC), the Lung Association ceed the recommended weekly use The ASC has created a Web site and the Canadian Thoracic Society. (maximum 3 doses) of “rescue” drugs. with educational information, the Asthma affects 2 million Canadians, in- “There is a gap in care,” explains Dr. guidelines, pamphlets and the opportu- cluding 10% to 15% of children, and Mark Greenwald, a Toronto asthma nity to “talk” to a certified specialist in claims the lives of 10 Canadians a week. specialist and vice-president of the ASC. asthma education (www.asthma.ca). — In a related survey, the ASC found “To patients, ‘control’ means that they Barbara Sibbald, CMAJ

CMAJ • JUNE 27, 2000; 162 (13) 1861

NWT report urges recognition for aboriginal healers

Recognition for traditional aboriginal wanted today.” The report says that the encouraged to hire competent tradi- healers and increased involvement of territorial government should retain re- tional healers in situations where their nongovernmental organizations are sponsibility for legislation, standards and expertise and knowledge may be bene- among the recommendations from a enforcement, but responsibility for pro- ficial in treating a patient.” government-appointed committee that gram delivery should be transferred from According to the report, nongovern- investigated health care issues mental organizations and other across the Northwest Territories. agencies are now prevented from Our Communities, Our Deci- working harmoniously with sions: Let’s Get On With It!, the fi- health care providers by “obso- nal report of the Minister’s Fo- lete territorial and federal fund- rum on Health and Social ing arrangements and inappro- Services, also calls on the territor- priate lines of authority.” These ial government to remove itself include groups devoted to mental from delivery of health services health, the aged, disabled, and a unless specifically asked for help wide range of conditions and dis- by health boards. abilities, which should be sup- The suggested changes consti- ported by multiyear funding tute a complete restructuring of a through regional boards. system that, in just 10 years, has Substance abuse remains the been transferred from the federal gov- regional boards to local communities NWT’s most serious health concern, ernment to the territorial government over the next 5 years. Territorial funding the authors said. “Communities, boards and then to 9 health and social services should not be program specific, and and front-line workers talk of alcohol, boards. boards should be free to negotiate among drugs, inhalants, gambling, food, The report points out that the terri- themselves for shared services. The fo- promiscuous sexual activity and nicotine torial government has produced 4 ma- rum visited 12 communities across the as addictions. Substance-abuse problems jor reviews of its health care system NWT and received input from more in our communities are deeply rooted during the past 5 years, resulting in than 800 individuals and organizations. and of long standing. People are beset about 200 recommendations, many of Repeating a recommendation from a with feelings of hopelessness, despair which have yet to be acted upon. “No 1998 consultant’s report commissioned and impotent rage. From this comes more reviews, studies or reports are by the territorial government, the new violence, suicide and sexual abuse.” — needed,” the authors stated. “Action is report suggests that health boards “be David Helwig, London, Ont.

Beware of all types of bat exposure, BC MDs warned British Columbia has joined some RPEP should be offered even if a bite or Experts aren’t other provinces in recommending ra- scratch is not obvious. “All bat contact certain why the bies postexposure prophylaxis (RPEP) should be assessed very cautiously,” says contact has been so when direct patient contact with a bat Skowronski says. “We’re beginning to hard to pin down, cannot be ruled out. The US Centers recognize that cases we couldn’t specify but there are sev- for Disease Control and Prevention previously were actually bat rabies.” eral possibilities. (CDC) recommends the same action. A check with some other provinces Bat teeth are thin Dr. Danuta Skowronski, physician showed that CDC guidelines are also and needle-like and epidemiologist at the BC Centre for being followed in Alberta and Ontario, it’s possible individu- Disease Control, says that such action but not in New Brunswick. als are bitten without should be taken when people awaken to Although the last rabies death in realizing it. Bats are also inclined to lick find a bat in the room, or when unat- Canada occurred in 1985, there have their claws and wings, and may deposit tended children and mentally handi- been 36 such deaths in the US since infected saliva there that can be trans- capped or impaired persons are found in 1980, and 21 were due to bat-variant ferred through a scratch or by touching the presence of a bat (see CMAJ rabies. More troubling is that “a bite an existing wound rather than by bit- 1997;157[1]:55). In such cases, she says, was identified in only 1 or 2 of them.” ing. (Aerosol transmission is not a con-

1862 JAMC • 27 JUIN 2000; 162 (13) News and analysis

Fourth-year medical student takes Donner Prize

When the winner of the Donner Prize for the best book on public policy was announced prematurely last month, many people couldn’t believe who had won — including the author himself. It took a call from a Toronto reporter to convince 25-year-old David Gratzer, who graduated from the University of Manitoba’s medical school this spring, that he had won the $25 000 first prize. His competition included 6 professors, 1 of them a federal cabinet minister. Gratzer’s book, Code Blue: Reviving Canada’s Health Care System, takes an insider’s look at problems besetting that system: hallway medicine, long waiting lists for cancer treatment, a shortage of high-tech equipment, the movement of Canadian doctors to the US. Gratzer’s brother, a psychiatrist, has already relo- David Square cated to the US. Dr. David Gratzer: patients overconsume, doctors overprovide Gratzer said family discussions about the poor state of medicine in Canada and To resuscitate this "very bureau- Gratzer said there would then be in- his own rotations in medical departments cratic, very expensive system,” he sug- centive to spend the money wisely: at the prompted him to write the book. His ar- gests a system of individual medical sav- end of the year, money left in the ac- ticles on health care in Canada have al- ings accounts that is already in use in count might be rolled over into a retire- ready appeared in several newspapers. parts of China, Singapore, parts of the ment savings plan that would continue to A major theme in his book is the US, and South Africa. "In Canada, in- grow. People would also be required to need to improve health care in Canada stead of spending $700 per year on purchase catastrophic health insurance to by improving the doctor–patient rela- health services for a young, healthy cover extraordinary medical expenses. tionship. "The way we've structured male, the Canadian government would Gratzer plans to spend part of his medicare has corrupted this relationship give me that money to put into a sav- $25 000 prize on gifts and birthday par- by allowing patients to overconsume ings account. Out of this account I ties for his niece and nephew; the rest will health services, doctors to overprovide would pay for minor day-to-day ex- go toward covering costs during his psy- services and health administrators to be penses such as seeing my family doctor chiatry residency at Mount Sinai Hospital accountable to no one,” Gratzer says. or getting an x-ray.” in Toronto. — David Square, Winnipeg

cern, except for individuals who receive foxes and, more recently, raccoons in the lip by a bat when it flew in her extended or severe exposure, perhaps Ontario are all vectors for the disease bedroom via an open skylight. Two by spending time in a cave filled with — their ability to get into homes and hospitals failed to advise the girl’s par- bats.) cottages makes them a special concern. ents that she should receive immediate But while the method of transmis- Although the prevalence of rabies in RPEP. Fortunately, the parents con- sion may be up for debate, the response bats is less than 1% in random surveys, tacted their local health unit and the is clear. Once exposure has been veri- it is somewhere between 5% and 10% girl received prophylaxis. The bat fied, patients should be offered the in bats submitted for testing, probably tested positive for rabies. standard prophylaxis even if it is many because sick bats are more likely to “We clearly need to get the informa- days after the exposure, because the income into human contact. tion out to more health care workers,” cubation period for rabies varies. Still, the message is not always get- Skowronski says of the case. “Rabies is Although bats are not the only car- ting through to physicians. Last year, not a disease you take chances with.” — riers of rabies in Canada — skunks, an 11-year-old BC girl was bitten on Daphne Gray-Grant, Vancouver

CMAJ • JUNE 27, 2000; 162 (13) 1863 Nouvelles et analyses

On the Net Raving on the Internet

Few groups are as aware of the potential Ravesafe group (www.freezingman DanceSafe’s site reflects its mission of the World Wide Web as Canada’s .com/ravesafe/) to the Ottawa Associa- of educating ravers to the dangers of computer-literate rave community (see tion for Teaching Safety (www.oats drug use. It provides information on pages 1843-8). The Internet’s most pre- .xvi.com), there are sites providing con- specific drugs, their ingredients, their dominant rave sites have grown out of tacts for those wishing to help ensure the effects and the potential dangers they the tight-knit communities within cities safety of ravers. pose, including contraindications and possessing a large rave subculture. These precautions to take before choosing to sites, which provide an important voice drive home. DanceSafe maintains an for individual ravers, often include dis- open mind and tries to make the act of cussion groups, party reviews that allow attending a rave as safe as possible. members to decide which rave promot- RaveSafe’s site is less thorough than ers to avoid, and a strong sense of com- DanceSafe’s in providing information munity. In Ottawa, Techno XVI about ecstasy and other drugs, but it does (www.techno.xvi.com) is the dominant have extensive testimonials from drug site, with more than 4000 members users that provide a revealing look at why from across North America. In Toronto, people use (and continue to use) ecstasy. Purerave (www.purerave.com) pro- RaveSafe also provides an extensive and vides an immense contact list of ravers to There are also several international useful list of harm-reduction links supplement its discussion groups. harm-reduction sites, the most vocal of (www.ravesafe.org/linx-harmreduction The online rave community is well which are DanceSafe (www.dancesafe .htm), mainly articles in medical journals aware of the drug use that exists at raves, .org), an international site, and RaveSafe and documents provided by groups and as evidenced by harm-reduction groups (www.ravesafe.org/home.htm), by a associations with an interest in harm re- based across the country. From Alberta’s harm-reduction group in South Africa. duction. — Greg Sullivan, Ottawa

Raves worry Edmonton MDs, police

Like other Canadian cities, Edmon- the drug ecstasy ended up in the in- “Without ecstasy,” says Abbott, ton is trying to deal with the fallout tensive care unit with cerebral “there is no rave.” from the increasingly popular all- edema. Following a rave in March, The drug problem is compounded night parties known as raves. The city several people had seizures and one because of an upper middle class de- has 4 rave clubs and the events attract became hyperthermic and developed mographic, aged 13 and up, “that thousands of people every month. rhabdomyolysis. The main challenge, normally, probably wouldn’t be Nine people were taken to a hospital he says, is that the drugs produce dif- found using hard drugs.” emergency room during the city’s last ferent symptoms in different people. He says idealistic ravers don’t un- big rave, and Constable Rick Abbott He is trying to educate other emer- derstand the increasing presence of of the Edmonton police predicts that gency physicians through rounds at drug dealers jockeying to control the the city’s first rave-related death may the hospital. flow of drugs at raves, and the grow- occur this year. The rave ideal is PLUR — peace, ing potential for gang violence. “It’s Dr. Gregg Scheirer, an emer- love, unity and respect — and ravers expensive to be a raver,” says Abbott, gency physician at the Royal Alexan- are quick to point to the lack of alco- with one tablet of ecstasy costing dra Hospital in downtown Edmon- hol and violence at most events. about $25. Abbott estimates that at ton, agrees. Scheirer saw his first rave However, ravers frequently use drugs least 50% of people attending raves patients this January, when 4 young such as ecstasy to achieve the height- take drugs; many smoke marijuana people arrived in his ER within 3 ened sensitivity needed to “see the and do not take ecstasy. hours. One person who had taken music and hear the light.” The rave clubs are presenting police

1864 JAMC • 27 JUIN 2000; 162 (13) News and analysis

Pulse Where do medicine’s job opportunities lie?

More than 80% of graduating medical students matched to a program within Percentage of graduates matched, 1993/2000 their top 3 choices in this year’s Cana- dian Resident Matching Service (CaRMS) match. The overall success 100 rate of the service (94%) has remained 90 relatively stable in recent years. Excluding applicants whose schools 80 do not participate in the match (Laval, 70 Sherbrooke, Montreal), 58% of graduates matched to a postgraduate training 60 program at a faculty that wasn’t the same 50 as the one they graduated from. There was a significant increase in the number % Matched 40 of couples (35) that entered the match, 30 up 40% from last year. By contrast, the 20 number of applicants sponsored by Na- tional Defence fell from 25 to 30 gradu- 10 ates in the early 1990s to 6 this year, a re- 0 flection on the military’s recruiting woes. 1993 1994 1995 1996 1997 1998 1999 2000 Of those who matched this year, Year 88% received their first-choice discipline, although perhaps not in the loca- To first choice of Overall To first choice of discipline tion they wanted. The percentage of discipline and program graduates choosing family medicine is down from 35% of the total in 1997 to 29% in 2000, even though the percentage of positions available for family tors thought that opportunities would ment, followed by grades in mandatory medicine has remained relatively con- either remain constant or deteriorate clerkship rotations. stant at around 38% of the total. were occupational medicine (100%), When asked to select the most im- All program directors surveyed by neurosurgery (77%), pediatrics (54%) portant qualities of the ideal candidate, CaRMS said that job opportunities in and community medicine (50%). the qualities mentioned most often by radiology, medical genetics, general In selecting students for their pro- program directors were a sense of re- surgery and thoracic surgery will im- grams, a student’s grades in electives in sponsibility (70%), integrity (54%) and prove in the next 5 years. Specialties in the program director’s specialty rated as communication skills (50%). — Lynda which the majority of program direc- the most important academic achieve- Buske, [email protected]

with the major challenges, because age limits and legislate hours of opera- clubs and talking to teenagers about they require only a business licence to tion. The police recently met with city the differences between hard and soft operate. Since they are not licensed to officials, who are looking at creating drugs. Abbott is frustrated with harm serve alcohol, they are exempt from such bylaws. Mayor Bill Smith has reduction groups such as RaveSafe, gaming and liquor act bylaws. How- been “overwhelmingly supportive” and which simply hand out literature ever, Abbott says that because the clubs has visited raves to see the problems about rave drugs. “Kids don’t under- often open after licensed premises have first-hand, says Abbott. stand how dangerous [the drugs] are. closed, many patrons arrive inebriated. Meanwhile, without bylaws to en- They just see a cute little pill that you Police would like the clubs to be regu- force, the police are limited to parking can swallow and you’re high.” — lated by bylaws, such as those that set a mobile command unit near the rave Heather Kent, Vancouver

CMAJ • JUNE 27, 2000; 162 (13) 1865 Nouvelles et analyses

Research Update Is cloning the fountain of youth?

Scientists from the British Columbia found that the telomeres in cloned cows mechanism, if the telomeres are too Cancer Agency have discovered that are elongated compared with newborn short in the fertilized egg.” cloned calves are younger, on the cellu- and age-matched normal animals, Lansdorp noted that “the increase in lar level, than normal calves the same meaning that the clones are more telomere length in the cloned cells age (Science 2000;288:665-9). The find- youthful than their normal counter- from cattle corresponds precisely to an ing contradicts a previous discovery parts. “Previously, it was thought that increased ability of the cells to divide in that Dolly, the sheep cloned in Scot- only the cells that produce sperm and Petri dishes. This research suggests that land 3 years ago, was biologically older eggs, as well as cancer cells, could elon- cloned cows might actually live longer than a normal lamb. gate or maintain telomeres. But our than cows conceived naturally.” The startling discovery centres findings clearly show that telomeres can There is growing medical research around telomeres, DNA threads that be elongated by cloning as well,” says on telomeres, because telomeres do not “tie up” the ends of chromosomes to Dr. Peter Lansdorp, senior scientist at shorten in cancer cells, making them protect the genetic coding information the Terry Fox Laboratory. immortal. A promising approach to of the DNA. Telomeres generally be- Lansdorp proposes 2 possible expla- eventual cancer treatment in humans come shorter with each cell division: nations for the longer telomere length may be to inhibit telomerase, which ap- the older the cell, the shorter the in the cows. “It may be that our notions pears to maintain telomeres, in order to telomeres. When scientists examined about telomere maintenance in normal reverse the immortality of tumour cells. the telomeres of Dolly, they discov- biology were wrong. We have evidence Meanwhile, in the burgeoning field ered that the clone’s cells were the that telomeres are maintained in the of therapeutic cloning, scientists are same age as those of the 6-year-old male germ line, but in the female germ trying to create embryonic stem cells sheep from which Dolly was cloned, line, we actually never looked. It’s pos- that can be differentiated to grow re- meaning that Dolly was prematurely sible that there is a need to restore placement tissues or organs in the labo- “old” and would probably not enjoy a telomere length because the female ratory. Such differentiated cells already normal lifespan. chromosomes have short telomeres. . . . exist in laboratory mice, says Lansdorp. However, the BC researchers have Alternatively, there may be a safety — Heather Kent, Vancouver

Death and tax brackets: link between income inequality and mortality holds true in US, but not in Canada The income gap between the haves and Wolfson’s study compared 50 US states says Wolfson. “There appears to be have-nots is not strongly linked to and 10 provinces, as well as 282 US and something going on in Canada that has death rates in Canada, unlike in the 53 Canadian metropolitan areas. allowed us to grow more ‘sharing’ US, according to recently published in- “We were quite surprised by the cities, which seem to have quite positive ternational research (BMJ 2000;320: findings,” said Michael Wolfson, direc- health effects.” While Canada’s health 898-902). tor general of the analysis and develop- care system likely plays a significant When Michael Wolfson and col- ment branch at Statistics Canada. “We role in dampening the effects of income leagues compared income inequality had hypothesized that we would find disparity, Wolfson believes it is not the and all-cause mortality at the state or the same association here as in the sole reason for the marked difference provincial and at the metropolitan level, United States, just not as steep a slope.” between the 2 countries. they found no association in Canada. Although the team’s findings show In looking at the combined figures There was a strong relation, on the that the strong association between in- for North America, the researchers es- other hand, in the US data — confirm- come inequality and mortality in the timate that if the relationship between ing results from previous studies. US is absent here, Wolfson is quick to income disparity and mortality were The research team defined income point out that the research provides no causal, a 1% increase in the share of to- inequality as the proportion of total evidence why this is so. Possible expla- tal income for the bottom half of family income received by the less well- nations include the more equitable dis- households would prevent 21 deaths off 50% of households. Mortality data tribution of wealth and the greater het- per 100 000 population. — Greg Basky, were grouped and adjusted by age. erogeneity of communities in Canada, Saskatoon

1866 JAMC • 27 JUIN 2000; 162 (13) News and analysis

Public Health

Drowning in Canada

Epidemiology fect, leading to hypervolemia and dilu- rologic sequelae.4 Children who present tional hyponatremia. It later became to the emergency department with a There were 566 deaths from drowning clear that volumes far greater than what Glasgow coma scale ≥13, undergo a nor- in Canada in 1997. Most of these were is normally aspirated in drowning are mal physical exam and have normal res- related to boating activities (176, 40%), required to create these proposed blood piratory effort and an oxygen saturation swimming (103, 23%) and unintended volume changes. of at least 95% on room air 4–6 hours af- falls into water (104, 23%). Populations Both fresh and sea water wash out ter arrival in the emergency department that appear to be at particularly high surfactant and create the potential for can be safely discharged home.5 risk of drowning include toddlers aged noncardiogenic pulmonary edema.2 1–4 years (1.85 drownings/100 000), Near drowning in icy water results in a Prevention youth aged 15–19 years (1.28/100 000), higher chance of survival, perhaps be- people with seizure disorders (8– cause of the diving reflex that preferen- Generally, children are not develop- 20/100 000), recreational fishermen tially shunts blood to the brain.3 Conta- mentally ready for swimming lessons aged 65–74 (0.72/100 000) and aborigi- minants in the water, such as chlorine until after their fourth birthday.6 nal men aged 25–34 (25.6/100 000).1 and bacteria, contribute to the common Aquatic programs for infants and tod- “Drowning” is death by suffocation complications of acute respiratory dis- dlers have not been shown to decrease after submersion in a liquid medium. tress syndrome and pneumonia.2 the risk of drowning, and parents “Near drowning” occurs when a patient Cardiopulmonary resuscitation should not feel that their child is safe recovers, at least temporarily, from a (CPR) should be instituted as soon as after participating in such programs.6 drowning episode. Patients who ini- possible. In the hypothermic patient, si- Parental supervision and appropriate tially recover but then die within 24 nus bradycardia or atrial fibrillation application of barriers around pools, in- hours are classified as drowning may be present, making the pulse diffi- cluding four-sided fencing with self- victims.2 “Secondary drowning” refers cult to palpate, so rescuers should take a closing and self-latching gates and to death from complications of submer- full minute to assess vital signs. The pa- doors, and pool safety covers, may pre- sion at least 24 hours after the episode.3 tient should be extricated rapidly from vent some accidents involving toddlers.2 “Immersion injury” is a generic term the water, with spinal cord precautions In 71% of boating fatalities, the vic- that refers to all patients who have ex- being observed. The Heimlich ma- tim was not properly wearing a flota- perienced submersion,2 while “immer- noeuvre is of unproven benefit.2 tion device; in 46% of these fatalities, sion syndrome” refers to sudden death As soon as possible, supplemental alcohol was known to be involved.1 The after contact with cold water.3 Immer- oxygen and bag and mask ventilation alarmingly high rate of drowning sion injuries have a high case-fatality with proper positioning of the jaw and among aboriginal groups signals the rate.4 tongue should be administered; pre- need for culturally appropriate and hospital tracheal intubation and the ad- community-endorsed interventions to Clinical management ministration of drugs (i.e., epinephrine) reduce harm. — Erica Weir, CMAJ should be carried out when indicated. References Cerebral hypoxia is the common fi- Resuscitative efforts in the emer- 1. Canadian Red Cross Drowning Report 2000. Avail- nal pathway in drowning victims. gency department may involve the ap- able www.redcross.ca/english/watersafety/water- Whereas approximately 15% of victims plication of positive end expiratory safety.html (accessed 2000 May 30). 2. DeNicola L, Falk J, Swanson M, Kissoon N. have acute laryngospasm, resulting in pressure and the correction of acidosis, Submersion injuries in children and adults. Crit “dry drowning” from profound ob- hypovolemia and hypothermia.3 Since Care Clin 1997;13:477-502. 3. Sachdeva R. Near drowning. Crit Care Clin structive asphyxia, most drowning vic- drowning victims often experience mul- 1999;15:281-96. tims aspirate.2 tiple organ failure, admission to the in- 4. Rivara F. Pediatric injury control in 1999: Where do we go from here? Pediatrics 1999; Aspiration of even small amounts of tensive care unit is usually indicated. 103:883-8. fluid (1–3 mL/kg body weight) can lead Patients who are conscious on arrival 5. Causey A, Tilelli J, Swanson M. Predicting dis- charge in uncomplicated near-drowning. Am J to severe abnormalities in gas exchange. at the hospital after successful resuscita- Emerg Med 2000;18:9-11. In the 1970s it was believed that hyper- tion have an excellent chance of recovery, 6. Committee on Sports Medicine and Fitness and Committee on Injury and Poison Prevention, tonic sea water would draw plasma vol- but a child who requires CPR in the American Academy of Pediatrics. Swimming ume into the interstitial space while emergency department will almost cer- programs for infants and toddlers. Pediatrics fresh water would have the opposite ef- tainly die or experience significant neu- 2000;105(4pt1):868-70.

CMAJ • JUNE 27, 2000; 162 (13) 1867 Nouvelles et analyses

Alberta launches country’s first peer-support network for MDs in legal trouble

Barbara Sibbald

n the face of a civil suit or a college disciplinary hearing, help and personal support when facing a lawsuit or similar dif- I many physicians simply don’t know what to do. “Some be- ficulties. “Physicians report that when they could speak to a come devastated,” says Dr. Stanley Kolber. trusted colleague or family member, it was helpful,” she said. He ought to know. Not only is Kolber a lawyer and a The CMPA has documented the stressful effects of disci- physician, he’s also in charge of Alberta’s new Medical-Legal plinary actions and civil suits. A 1995/96 survey of 73 CMPA Peer Support Network, the first of its type in Canada. And members looked at the effects of stress on doctors after a he’s seen it all. complaint was launched against them at a provincial college.2 “Those who don’t know what to do — their practices fall Pressure was most intense immediately following notification apart, their families fall apart, their lives fall apart,” says Kol- of the complaint, with 75% of respondents experiencing sig- ber. “This [support network] allows them to put it back to- nificant levels of stress. The intensity lessened as the physi- gether.” It also helps those who are merely overwhelmed by cians prepared to respond and awaited the college decision, the stress created by the legal process. but more than 40% of respondents still experienced signifi- The network, a new effort by the Alberta Medical Associ- cant stress throughout the entire process. After the complaint ation’s Physicians’ Assistance Committee, was launched Mar. was resolved, only 25% of the respondents felt that their 1 by 10 volunteers who have themselves been through legal stress had been eliminated. or disciplinary proceedings. “They have a feel for what’s in- These physicians reported that reviewing records, talking volved, for why you need a support group,” says Kolber, a to trusted colleagues and being reassured by peers helped family physician in Sherwood Park. them deal with the stress. The most helpful strategies were The network’s one-on-one approach may be unique in discussing the issues with their family, making contact with North America. Some US states offer group sessions to pro- the CMPA and receiving CMPA assistance. vide support, but Kolber thought the individual approach Dr. Arlene Rosenbloom, an Ottawa physician who, along would better suit Canadians. “They don’t want others to know with her practice partner, faced a wrongful-birth malpractice or they don’t want to show their weakness,” he says. “Nobody suit, says she would have welcomed a peer-support service.3 wants to admit [that he or she] allegedly made a mistake.” “It would have been nice to have had some support.” She The Alberta peer-support volunteers pay house calls to says she would have liked some reassurance about procedures provide an “arm around the shoulder” but they also help the and likely outcomes. “The whole secrecy surrounding a law- physician answer a crucial question: Why me? Using the suit contributes to the anxiety you feel. It was a private “culture-of-error concept,” which is common in the aviation trauma you carried.” industry, the volunteers are trained to look at the total event Since her case ended in 1996, with a $3-million award for and its possible causes.1 the family involved, Rosenbloom has helped 3 other physicians The culture-of-error concept focuses on what can be done cope with civil suits. “There is a need for a formal network be- to eliminate errors rather than focusing on individual physi- cause of the increase in frequency and severity [of lawsuits],” cians’ problems. “The physician is just the end result of a she says. “Having a service in place helps and validates the whole mess of problems: education, budgetary constraints problem. Doctors tend to suffer on their own. . . . It’s a control and the like,” says Kolber. issue. If you ask for help, it means you aren’t coping well.” At the end of the process, there will likely be evidence of Kolber, who would welcome new volunteers or sugges- turmoil in the system, evidence that “you can’t practise with- tions, can be reached by fax, 780 449-3110. out relief, without money, without staff.” The volunteers “try to reassure, educate and put it all in perspective.” Barbara Sibbald is CMAJ’s Associate Editor, News and Features. However, they do not go into the details of the case because a plaintiff’s lawyer could then subpoena them to testify. References Instead, they give examples of similar cases so that physicians 1. Leval MR. Human factors and surgical outcomes: a Cartesian dream. Lancet have something to relate to their own case. 1997;349:723-5. The Canadian Medical Protective Association says this 2. Gambhir IB. Stress and the college complaint. CMPA Information Letter 1999;June. type of service is needed. Dr. Indu Gambhir, assistant secre- 3. Cohen L. Code of silence hardest part of being sued, FPs say. CMAJ tary-treasurer at the CMPA, says physicians need both legal 1999;160(1):97-8

1868 JAMC • 27 JUIN 2000; 162 (13)

Cheap prescription drugs creating new brand of US tourist in Canada, Mexico

Milan Korcok

y the busload, thousands of American seniors are cross- product in foreign countries at a lower price than in the US. Bing over into Canada and Mexico to stock up on the one Passage of the act would be bad news for Canadians, who will valuable commodity they can’t seem to find at home — af- face higher prices, but Americans would enjoy lower prices. fordable prescription drugs. The Pharmaceutical Research and Manufacturers of Amer- Armed with sturdy American greenbacks and lured by ica, a trade group representing the industry, doesn’t buy his price differentials that save some of them thousands of dol- reasoning, but it also opposes the price controls that exist in lars a year, the list of treks being made by these day trippers Canada and many other countries on grounds that they is growing: from Maine to Quebec and New Brunswick, dampen innovation, research and development. from the state of Washington to Calgary or Vancouver, from Meredith Arp, an association spokesperson, told CMAJ Arizona, Texas and California to Mexico. that it takes 12 to 15 years for an experimental drug to go According to US Senator Slade Gorton of Washington, from lab to patient, at an average cost of US$500 million; the stomach acid medication omeprazole costs US$129 for a only a small proportion of these drugs actually make it to 30-pill order in his state, but only US$53 in Canada. The an- market. “We do oppose the Gorton bill,” she said. “It is dra- tihyperglycemic agent metformin costs $52 in the US, but conian. It is a price-control bill, and all patients would suf- only $12 in Canada, while conjugated estrogens cost $26 in fer.” She said the bill would place control of American drug Washington and $7 in Calgary. Overall, the survey found pricing in the hands of foreign government bureaucrats and that for the 10 most commonly prescribed drugs, average would set prices below those of foreign countries that ration prices were 64% lower in Canada than in Washington state. health care and limit access to medicines. (All prices provided are in US dollars and are based on the “It is not my intent to harm the research going on in the lowest dosage available for each drug.) To American seniors, US,” says Gorton. “Drug companies should be able to re- many of whom have health plans (including Medicare) that coup the research and development of both unsuccessful and do not cover prescription drugs, these savings could make a successful new drugs. But my constituents in Washington huge difference. and other Americans should not be forced to pay all of those The plight of these pharmaceutical nomads has clearly in- costs for the rest of the world.” Gorton’s bill is scheduled for flamed the passions of federal and state politicians during this committee hearings during the summer. election season, particularly because the issue of expanding But perhaps more significant than Gorton’s initiative is prescription drug benefits to 38 million Medicare beneficia- the recent passage of the nation’s first drug price control law ries and 44 million uninsured Americans has zoomed to the in Maine. It is designed to bring drug prescription prices top of the political agenda. Everybody, it seems, is looking more in line with those being paid in Canada by thousands of for a solution to the high cost of prescription drugs. But forc- Maine seniors, who regularly trek across the border to Que- ing seniors to hop the border to Canada or Mexico to fill bec and New Brunswick to make their purchases. The spon- shopping bags with drugs, many of which were manufactured sor of that measure, Maine’s Senate Majority Leader Chellie in the US, is not a politically appealing one. Pingree, told CMAJ that drug manufacturers will have until Industry representatives generally attribute lower drug 2003 to bring wholesale prices down to the levels they charge prices in foreign countries to consumer drug price controls, Canadian or European wholesalers, or other bulk buyers like such as those provided by Canada’s Patented Medicines Prices HMOs and the US federal government. If they don’t, state- Review Board. Drug manufacturers and their US wholesalers mandated price controls will kick in. Initially, Mainers who have to sell at a great discount if they want to make their prod- lack prescription insurance coverage will be given a prescrip- ucts available abroad. Even in the US, large bulk buyers of tion card that will entitle them to 12% to 15% drug dis- drugs like HMOs, insurance companies and the Veterans Ad- counts. These will be increased annually until prices are ministration get huge discounts for their volume purchases. roughly comparable with Canadian ones. “What we’re saying However, the folks who buy retail are out of luck. to manufacturers is ‘give us the same prices you give to all the To level out this playing field, Gorton has introduced the others,’ ” she said. Pingree also noted that a similar legislative Prescription Drug Fairness Act, which is designed to spread measure is being considered in Vermont, where 50% of the out the costs of research and development internationally. state’s population is within a 90-minute drive of Quebec. His bill would prohibit drug companies from selling any Legislators from Pennsylvania and New York State are also

CMAJ • JUNE 27, 2000; 162 (13) 1869

showing interest. Drug manufacturers have vowed to fight admitted, that they do their homework and they usually get the new law in the courts. what they want. Pingree said that Maine seniors’ groups regularly organize Ditto on America’s southern border. The Arizona Republic drug-shopping bus trips to Quebec for their members. But notes that in the Mexican border town of Algodones, 28 far- should pharmacists here serve them? macias are clustered in a 3-block area well known to thou- Reneé Couturier, communications and issues manager for sands of Americans who venture in regularly for their med- the Canadian Pharmacists Association, said that according to the ications. Many claim they save US$500 to $600 per trip. One association’s standards and practices, pharmacists can only dis- bus company from the Lake Havasu City-Kingman area now pense a drug if they have a script written or cosigned by a doctor takes up to 200 seniors weekly on the “Colorado river run.” licensed to practise in Canada. But it’s clear, she said, that “there Other companies claim greater numbers. Near each farmacia probably are pharmacists who are choosing to avoid the law. there are doctors’ offices where, for US$15 to $25, shoppers We’ve even seen cases where pharmacists have openly admitted can get all the scripts they need. And quite often even that filling scripts [for Americans] during television interviews.” need is overlooked by a farmacia clerk who might charge an She said the association gets many calls from American se- extra $20 to make an unscripted sale. niors asking how they might buy drugs in Canada. They ask Where there’s a will when it comes to buying cut-rate which pharmacies they can go to or which doctors might drugs, there seems to be a way. write prescriptions. “We tell them what the rules are and that they will have to do their own homework.” But it’s clear, she Milan Korcok is a Canadian journalist based in Florida.

HOLIDAY REVIEW 2000 CALL FOR PAPERS

Holiday reviews have become an annual tradition at CMAJ. Underneath their heavy parkas or layers of mosquito repellent, Canadian physicians have shown that they have a thoughtful soul and a quirky sense of fun. MEDICINE IN CANADA. We encourage you to submit reflective essays on difficult decisions you’ve had to make as a physician, adventures (big or small) in your professional life and defining moments in your career. We’re also looking for descriptions of medical events that could only happen in Canada. CANADA IN MEDICINE. This year we hope to hear from Canadians who have practised medicine abroad. Tell us about the unforeseen challenges and the unexpected joys of working far from home. How did your experiences change your perception of what it means to be a Canadian physician? YOU’VE GOT TO BE KIDDING. As in the past 2 years (click on Back Issues at www.cma.ca/cmaj and go to the December issues for 1998 and 1999) we plan to leaven the mix with some humour. Show us your inner child — or better yet, the collective inner child of your clinic or hospital department. We’re looking for papers that take a playful poke at sober scientific thought by postulating the preposterous and proving the unprovable. Articles should be no more than 1200 words, preferably accompanied by illustrations. Submissions received by Oct. 1, 2000, are more likely to be published. Send submissions to: Dr. John Hoey CMAJ 1867 Alta Vista Dr. Ottawa ON K1G 3Y6

1870 JAMC • 27 JUIN 2000; 162 (13)