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Docket: 1-5422 Initial: JN Customer: CMAJ 15422 January 27/98 CMAJ /Page 161

News and analysis appear optimistic that agreement will drigue, a spokesperson for the Feder- However, it said midwife-assisted be reached, the obstetricians have ation of GPs of Quebec, says it wants births should not take place more said that if a solution is not found by to encourage GPs to handle births. In than 30 minutes from a . — Feb. 1, all low-risk deliveries will the short term, however, “I think it © Janice Hamilton have to be handled by GPs. Obstetri- would be difficult for GPs to deal cians will be involved only in provid- with the situation” if obstetricians in- numbers ing essential and tertiary services for crease their pressure tactics. hold steady high-risk patients. Meanwhile, a government council Senikas says the insurance issue recently proposed that midwives be The number of in Canada brought the plight of her specialty allowed to practise in , dropped by 48 — or less than 0.1% into focus in Quebec, where obste- birthing centres and private homes. — in 1996. Figures released by the tricians make $252 per vaginal deliv- ery — less than in any province ex- cept Newfoundland. She says an Popularity of laser grows in BC obstetricians who handles an average of 120 deliveries a year has a take- Laser eye surgery is thriving to home pay of $20 per delivery. Many such an extent on the West Coast obstetricians outside the cities per- that a Vancouver ophthalmologist form even fewer deliveries, but their says British Columbia may be the insurance costs remain the same. busiest area for the procedure in Malpractice premiums are expected North America. Since the first to reach $40 000 by 2000. private opened here 7 years In recent years, many Quebec ob- ago, says Dr. Hugo Sutton, up to stetricians have become so angry about 30 000 have been treated in the situation that they left for the US Vancouver. Sutton, 1 of about 20 or other provinces; many others began BC ophthalmologists active in the deciding at a younger age to drop ob- field, says these numbers are “ap- stetrics and stick to gynecology. proached in Calgary and Windsor, “There’s no future for our young peo- but not in the US.” He attributes ple here, and they sense it,” Senikas ar- the popularity of gues. “We’re doing this for the future photorefractive surgery here to “a of the specialty, before it’s too late and recognition of Canadian refractive people have left or stopped. We’re not surgery for its careful due dili- asking for any increases except for gence as well as high volume and work related to the delivery room.” successful outcomes.” Dr. Michael Berman in the operating Obstetricians are seeking reim- Patients, who can refer them- room at his Vancouver bursement of their malpractice premi- selves, typically pay up to $5000 ums, so that they would pay $4900, for bilateral . volve cutting the , creating with the government paying the rest; Americans account for about 20% a tissue flap and then applying the this arrangement is already in place in of the caseload for Dr. Michael laser treatment, began just last Ontario. They also want the fee for a Berman, another ophthalmologist year; it now accounts for about vaginal delivery raised to $400, an in- with a laser-surgery clinic in Van- 80% of the work in Sutton’s clinic. crease in bonuses for evening and couver. He says Canada’s approval Why have these procedures be- night deliveries, and an agreement process for the second and third come so popular? Sutton says that that any money earned in the delivery generation of laser equipment has eliminating glasses or contact room will not be included in the an- been faster than in the US, and lenses is a “life-enhancing proce- nual salary ceiling of $257 000. this means that American patients dure for many people.” Berman Meanwhile, the general practition- may receive more advanced surgi- concludes that “people seem to ers who perform 42% of deliveries in cal techniques here. want to be free of glasses and con- Quebec think obstetricians have rea- Techniques have been improv- tact lenses,” and laser surgery has son to complain. The 600 GPs who ing. Laser in situ given him “another lease on oph- perform pay malpractice (LASIK) procedures, which in- thalmology.” — © Heather Kent fees of $4980 a year. Dr. Jean Ro-

CAN MED ASSOC J • JAN. 27, 1998; 158 (2) 161 Docket: 1-5422 Initial: JN Customer: CMAJ 15422 January 27/98 CMAJ /Page 162

Nouvelles et analyses

Canadian Institute for Health Infor- and retention. For instance, a new professionals in practice centres.” mation (CIHI) in December show program to assess and upgrade family She said pilot projects to establish that the number of physicians physicians was announced by the primary care service and teaching dropped to 54 958 in 1996 from province’s minister of health, and in units are being put in place in Twill- 55 006 in 1995. The decrease is con- the past year the province has in- ingate and Port aux Basques, and ser- sistent with declines that occurred in creased salaries for rural doctors by vices at the existing unit in Happy Val- 1994 and 1995. (The total includes 20% to 50%. Still, isolated areas con- ley-Goose Bay are being enhanced. only active civilian physicians. Med- tinue to face severe shortages. Although Forum ’97 ical students, residents and retired “While money is important, it’s allowed for discussion of problems and military physicians are not in- only part of the issue,” said Joan Marie and solutions in rural , the cluded.) Although the number of Aylward, Newfoundland’s minister of men and women who actually do the physicians dropped, there were 350 health. “We have grave difficulty at- job had issues of their own to discuss. more specialists in Canada in 1996 tracting sole practitioners and we have When the forum ended, rural family than in 1995; the 26 737 specialists to build models of care that cluster medicine preceptors spent a long practising in 1996 accounted for 49% of the total. The 51%-49% split with family physicians has remained rela- AMA reveals inflation’s bite tively constant for the last 20 years. CIHI also reported that the national The Alberta Medical Association recently produced a detailed list of physician–patient ratio moved from (AMA) says that not only are the the 100 services physicians provide 1:542 in 1995 to 1:548 in 1996; this province’s physicians being “deval- most frequently. It compares current compares with ratios of 1:395 in the US ued” by low fees for physician ser- fees with those of 10 years ago, and and 1:554 in the United Kingdom. vices but also inflation is eating away factors in annual adjustments for in- at their income. Fees in Alberta have flation. The fee information was re- Newfoundland’s unending fallen 5% since 1993–94 and the leased as part of the AMA’s Care to attempts to solve MD AMA claims that the “significant know how much doctors are paid? shortages gap” between fees and the cost of campaign to educate Albertans on living continues to grow. In prepar- how much physicians receive for Memorial University’s Faculty of ing for fee negotiations, the AMA each service provided. Medicine takes the problems of physi- Service Jan. ’87 fee Jan. ’97 fee ’97 fee if adjusted cian shortages in rural areas seriously, for inflation because it has sponsored annual rural health forums in each of the past 7 Office visit (family physician) $ 21.25 $ 21.54 $ 28.24 years in an attempt to find solutions. Chest x-ray $ 20.50 $ 21.64 $ 27.24 Many of the issues discussed at Major consultation () $ 98.40 $108.92 $130.76 Rural Health Forum ’97 this fall were Osteoporosis examination $154.00 $162.19 $204.64 removal with familiar, but some new initiatives insertion of $572.00 $505.13 $760.10 were unveiled to deal with the ongo- ing problem of physician recruitment

McMaster University student Christopher Andrews took this photo of skulls and femurs in Murambi, one of the many sites where genocide occurred in Rwanda in 1994. It is estimated to have claimed 500 000 to 1 million lives. Andrews, who described his chilling visit to Murambi in an Experience article in the Jan. 13, 1998, issue of CMAJ, had been completing an elective in nearby Uganda when he visited Rwanda. He says the bodies, bones and body parts that have been gathered in an unfinished school at Murambi offer mute testimony to mass murder.

162 CAN MED ASSOC J • 27 JANV. 1998; 158 (2)