A reason to book your elective procedure for November

Oct. 15 | Joe McAllister, senior editor

A Swiss study has proven right what many doctors have long suspected—when new trainees arrive in hospitals they make more errors during their first few months.

The study by Dr. Guy Haller of the division of clinical epidemiology at Geneva University Hospital looked at 19,560 patients having an anesthetic procedure carried out by first- to fifth-year trainees starting work for the first time at the hospital over the period 1995 to 2000.

The rate of undesirable events was 28% higher at the beginning of the academic year compared with the rest of the year (137 versus 107 per 1,000 patient hours. The overall adjusted rate ratio for undesirable events was 1.40).

This excess risk was seen for all residents, regardless of their level of seniority but decreased progressively after the first month and disappeared completely after the fourth month of the academic year.

An editorial in the British Medical Journal details some steps that could be taken to alleviate this problem, but if you are thinking of booking your elective procedure, better wait until November.

British doctors face pay freeze
Oct. 13 | Joe Mcallister, senior editor

British GPs have done pretty well for themselves over the last few years. The Labour government there has poured millions of pounds into surgeries to promote more preventive care and faster service. But the good days may well be over.

Chancellor Alistair Darling has called for a pay freeze for 40,000 senior public servants in 2010-11. Doctors with government contracts should get no more than 1%, he said.

The British Medical Association and similar doctor groups have reacted with the usual dismay and outrage. BMA Chairman Dr. Hamish Meldrum said: “Penalizing all doctors, and in particular singling out GPs for a total pay freeze, is completely the wrong move and is likely to prove counterproductive.”

As in Canada, it’s difficult to know exactly how much doctors earn, since office overhead and other expenses make it difficult to determine exactly how much doctors take home. Probably the best statistics come from the National Health Service’s GP Earnings and Expenses 2007/08 Provisional Report which came out Sept. 16.

It indicates the average income before taxes is £106,072 ($175,914) for those GPs working under a general medical services or primary medical services contract. This is after expenses, which are estimated at about 55% of gross earnings.

Overall since 2004, when GPs’ earnings were tied to bonuses and incentives for performing preventive care and reaching benchmarks in treating those with chronic conditions, U.K. GPs’ average gross payments have increased about 5% a year, with expenses rising about 4% a year.

How well have the incentives worked is another question. Here’s one study that looked at diabetes care.

Does study contradict Canadian vaccination schedules?
October 7 | Joe McAllister, senior editor

Throw another puzzle piece into the flu vaccination question. Now the British Medical Journal has published online a study which suggests the trivalent inactivated flu vaccine from 2008/09 provided some protection against the pandemic influenza H1N1. See the study here.

That would seem to go against Canadian researchers, who are suggesting somewhat the opposite in an as-yet-unpublished or released study. See the entry below for more details and the story.

The case-controlled study from a Mexico City specialty hospital has limitations. It involves only 60 H1N1 cases and 160 controls. The researchers at the Instituto Nacional de Salud Pública, noted the H1N1 cases “were more likely than controls to be admitted to hospital, undergo invasive mechanical ventilation and die.” Mexico was ground zero during the first months of the pandemic scare—particularly noteworthy because so many Mexicans diagnosed with that strain got severely ill, required ventilation and died. Reports since, particularly from other First World nations, have suggested H1N1’s symptoms in most populations are far less severe.

The Canadian study, done by two well-respected researchers and, we think, with a far larger population base, may be more definitive. The trouble is we don’t know. The study is awaiting publication despite the fact it has been cited as the reason for turning our flu vaccination program topsy-turvy. In most provinces, we are now waiting until after giving the H1N1 vaccine to give the seasonal flu vaccine.

I can only sympathize with the poor GP who is left wondering what to tell patients, particularly those who are most at risk during flu season. Confusion doubt and fear are growing. A U.S. web publication here reports “the U.S. Food & Drug Administration, the World Health Organization and the pharmaceutical industry are bracing for an onslaught of fake and substandard drugs, with a special eye out for unauthorized versions of Tamiflu.”

Hopefully Canadians won’t suffer quite as much from “flu madness” but the season is shaping up to be chaotic.

We haven’t seen the Canadian research that has thrown smart scheduling aside. It should be noted the BMJ online publication of the Mexican paper is freely available to everyone—subscriber or not.

The Mexican submission to the BMJ was accepted on Sept. 18, peer reviewed, prepared for publication, press releases written for pre-release of the study to the press and finally released to everybody on Tues., Oct. 6. That’s the speed information needs to be disseminated in our global world of SARS and swine flu.

Sept. 29 | Joe McAllister, senior editor

Here's hoping doctors aren't having the same difficulties keeping up with the various H1N1 and seasonal flu vaccination announcements as I am having.

Which vaccine will be given first? And to whom--seniors first with seasonal flu vaccination followed by H1N1 vaccine for all, followed by the seasonal flu vaccine for all? That seems to be the direction the provinces are going in, but it sure is puzzling. (Information about B.C.'s campaign can be found here, information about Ontario here, Nova Scotia information is here.) I haven't been able to find information from Alberta, Manitoba, Saskatchewan and other provinces, but press reports say only New Brunswick is currently going to give the seasonal flu vaccine before the H1N1 vaccine.

What's puzzling in all of this is that these changes were made after reports started leaking out about a study saying those getting the regular flu vaccine have an increased chance of contracting H1N1. The unpublished report from two Canadian researchers seems to have influenced decisions on the timing of vaccine delivery this winter.

Dr. Danuta Skowronski of the British Columbia Centre for Disease Control and Dr. Gaston De Serres of Laval University reportedly have submitted their findings to an unnamed scientific journal. Again, from sketchy press reports, they found that recipients of the seasonal flu vaccine were at a moderate 1.5 to 2-fold increased risk of medically attended H1N1 illness during the spring and summer of 2009.

Let me be a skeptic here for a minute. Doesn't it make sense that those concerned enough to get a flu vaccination last year would also be most likely to report flu like symptoms and be tested for H1N1? There would be a natural association between those who received the seasonal flu vaccine in 2008 and those who were diagnosed with H1N1 this past spring and summer. It is not a causal link.

Our clinical editor, Terry Murray, has a series of reports on H1N1 that will appear in the Medical Post issue of Oct. 6.

Murray is no stranger to all things contagious. Twenty-five years ago she brought Canadian doctors some of the first scientific reports about a strange disease affecting gay men--which we now know is AIDS and HIV. She's followed the SARS outbreak and the Walkerton tragedy.

But even Murray is confused by the reasoning behind delaying the use of the seasonal flu vaccine, and even more confused why this report isn't public.

Why haven't we seen this study? What are the numbers? Researchers in theU.S. report they haven't found similar findings. Why not? What is the biological mechanism for this counter-intuitive increased risk? After all, many other vaccines for one contagious agent have actually been shown to increase the chances of an immune reaction to other, similar contagious agents.

Murray has tried to get some answers from the researchers and health officials that have seen the study, but so far she has had no luck. It would seem that the researchers are waiting to first publish their findings.

Excuse me, but we are in a pandemic alert. It would seem most appropriate to publish this study immediately so doctors, and the public, can judge if pandemic vaccine delivery is being done in the correct and most efficacious way.

A curious choice of examples for free-market advocate
September 16 | Joe McAllister, Senior Editor

The Fraser Institute has taken a look at Canada's regulation of natural health products and decided the government agency in charge‹the Natural Health Products Directorate (NHPD, whose regulatory authority was established 2004)—doesn't do a very good job and should be "abolished and the monitoring of NHP safety and effectiveness be left to various nongovernmental organizations."

Further, the report's author, the indomitable Cynthia Ramsay, who writes regularly on health issues, suggests "all current health practitioner licences, including physician licences, be replaced with certification, with the opportunity for various organizations to become certifying agencies."

Has the Fraser Institute ever met a government agency it likes? And Ramsay makes some good points concerning the slowness and cost of getting alternative medicines or herbal remedies approved. The report, "Unnatural Regulation: Complementary and Alternative Medicine Policy in Canada" is here. She
writes: "Some have conservatively estimated the NHP market numbered at least 70,000 products at one point, but the NHPD has reduced that total to fewer than 40,000 products available for Canadians to purchase domestically in 2009.

"Sales of natural health products in Canada," according to the report, "were an estimated $2.5 billion in 2005, in addition to more than $2.7 billion spent on functional foods," conventional food that has physiological benefits and/or reduces the risk of chronic disease. Further on in the report, it's noted in the year ending in June 2006: "Canadians spent more than $5.6 billion out-of-pocket on visits to providers of alternative medicine."

However, if you delve into the report, Ramsay uses a couple of interesting examples. One is her discussion of acupuncture regulation that ends with the suggestion that certifying agencies replace licensing agencies such as colleges.

But I have a long memory. Back in 2004, the Medical Post featured a story about Quebec public health authorities warning that 1,200 patients should be tested for HIV and hepatitis B and C after a Montreal acupuncturist, who had been practising illegally for 25 years, pleaded guilty to using unsterilized needles. This is a perfect example of where strong and vigilant regulation of alternative therapies was needed.

The other example that intrigued me was Ramsay's use of an Alberta distributor of "natural" products who said one Utah-based company, Nutraceutical Corporation, makers of the Solaray brand, pulled out of this country after Health Canada denied its site licence renewal four years after the application was submitted. According to Ramsay, Nutraceutical's website says the company "offers over 3,000 quality vitamin, herb and specialty products."

Where have I heard the name Nutraceutical Corp. before? It was involved in a long and drawn out court battle over the sale of ephedra. The Food and Drug Administration in the U.S. banned ephedra in 2004, and Nutraceutical took the feds to court. The company lost and ephedra was banned in the U.S. (Apparently, this year a Utah judge allowed it back on the market. It was long available on a black market basis and is often used for weight loss.)

As a Mayo Clinic website on CAMs says: "Major safety concerns have been associated with ephedra or ephedrine use, including hypertension, tachycardia, CNS excitation, arrhythmia, myocardial infarction and stroke."

Less regulation? How about more regulation of CAMs? How about banning herbal and alternative medicines unless they meet the high standard of proving their safety and efficacy with exactly the same type of rigorous clinical, peer-reviewed trials we force prescription drugs to go through before they are allowed on the market?

Can you help with our upcoming finance coverage?
September 14 | Colin Leslie, editor

Our November 3 issue is going to have a special report on physician finances. So here’s a great opportunity to share your financial lessons learned, whether you are 28 or 63. Our coverage is going to offer finance tips every doctor should know—but broken up by age. So tips for your 20s, tips for your 30s, etc.

If you have some financial tips you’d like to pass along to other doctors, we’d like to hear them!

Send your tips to Medical News Editor Matthew Sylvain to matthew.sylvain@medicalpost.rogers.com.

We all know about the financial advice services offered by MD Management, an arm of the Canadian Medical Association,  but we’re also looking to interview some of the nation’s other leading financial advisors who understand the unique financial planning needs of physicians. If you’ve come across a financial advisor or finance expert who really impressed you, also send their name along to Matthew Sylvain too.

One Brit loudmouth takes on Quebec health care
September 11 | By Joe McAllister, Senior Editor

After reading my blog entry on the National Health Service "Market reforms in Britain work" a friendly reader from New Brunswick sent me a link to London Times columnist's Jeremy Clarkson's funny rant "What's the Canadian Word for Lousy Care?"

It would seem Clarkson earlier this summer had a run in with Quebec's health-care system and didn't come away very impressed. He didn't seem to be unhappy so much with the care his friend's son received after a boating accident but rather with the waiting time and the fact he was dealing with a French speaking staff in a regional hospital . . . oh . . . and that there weren't enough waiting room chairs.

Clarkson's column is interesting and as my New Brunswick reader explains: "This column received a good deal of media attention but mainly in Quebec and, therefore, in French media. We Canadian doctors are too close to look at our medicare with an objective eye but when a foreigner does, we should pay attention."

All true, we should pay attention to the viewpoint of those not familiar with our system, but I wonder if Clarkson, whose biography in the Times refers to him as an "equal opportunities loudmouth" isn't just expressing a typical British chauvinism toward anything French.

He writes at one point in his Quebec column that after not receiving an answer in English to a question he resisted "the temptation to explain that the Marquis de Montcalm lost and that it's time to get over it". And in another column
that had nothing to do with language differences he wrote "Have you ever tried to move a donkey when it wants to remain stationary? It'd be easier to move France."

Join the FMWC’s Pap campaign
September 11, 2009 | Joe McAllister, Senior Editor

The Federation of Medical Women of Canada is sponsoring its second walk-in Pap smear days between October 26 and 30. The event is intended to promote cervical cancer screening across Canada and I think it’s a great idea we should all get behind.

The federation is interested in getting doctors across Canada to open up their offices to women, even for quick no-appointment-necessary Pap smears. It takes place during the annual Cervical Cancer Awareness Week. (Of course it’s recommended that patients make an appointment.)

Last year was the first year of the program. Susan Dallin-O’Grady, executive co-ordinator of the FMWC told me that in 2008, there were 15 clinics participating, representing 11 cities. Almost 500 women attended and while not all of them were orphan patients (without a family doctor), most had not gotten around to having a Pap test for far too long—15 years in one instance. One clinic reported 10% abnormal test results, while another reported 13%.

That ties in with a recent, alarming, report from Ontario’s Institute of Clinical and Evaluative Sciences, (the Medical Post story can be found here) which found fewer than half of women in Ontario with a low-grade abnormal Pap smear receive appropriate followup care.

Further about 30% of Canadian women don’t get a Pap smear in the recommended time frame.

So it’s great the FMWC and its partners—the Society and Obstetricians and Gynaecologists of Canada, the Society of Canadian Colposcopists and financial supporter GlaxoSmithKline—are doing this. And this year it is a fully bilingual campaign.

Doctors who want their office or clinics to participate can contact the federation through their website at: http://www.fmwc.ca/ and follow the links on the left to the Pap test campaign.

Dem bones, dem bones
September 4, 2009 | Joe Mcallister, Senior Editor

There's been some interest in the media about a study published in the Journal of Neurology, Neurosurgey and Psychiatry that showed patients given a positive example of the success of their back surgery had better outcomes.

The study from the Academic Neurosurgery Unit of St George's University in London, randomly assigned 38 patients to an experimental group who were presented with their removed disc fragments after a lumbar microdiscectomy while 36 patients in a control group received normal care.

According to the abstract of the paper: "The two groups were matched for age, sex and preoperative symptoms. More patients in the experimental compared with the control group reported improvements in leg pain (91.5 vs 80.4%; p<0.05), back pain (86.1 vs 75.0%; p<0.05), limb weakness (90.5 vs 56.3%; p<0.02), paraesthesia (88 vs 61.9%; p<0.05) and reduced analgesic use (92.1 vs 69.4%; p<0.02) than preoperatively."

The abstract can be found here (a log in is required to view the entire study).

Market reforms in Britain work
September 4, 2009 | Joe Mcallister, Senior Editor

A study published in the British Medical Journal by researchers from the London School of Economics shows that market reforms in the National Health Service did not adversely affect care for lower socio-economic patients. Indeed they may have improved the care.

The study looked at close to a million patients who had elective knee or hip replacement, and 2.5 million who had elective cataract repair in England during the period 1997 to 2007. Although initially patients waited longer for treatment, waiting times fell by the end of the study and there was no difference in the treatment received when patients' socio-economic or other statuses were considered. Indeed in some instances patients with a lower socio-economic status seemed to get treated faster than others.

This is important because in the same period Britain moved toward market reforms giving patients more choice and ramping up competition between institutions offering care. It should be noted that during the same period Britain spent considerable money trying to reduce waiting times and improving service.

The concern in Britain was that the market changes would result in worse care for those of a lower status. This appears not to have been the case and maybe market reforms similar to Britain should be considered by those in charge of reform in Canada.

Fun with numbers
Aug. 31, 2009 | Joe Mcallister, Senior Editor

Want to idle away a few minutes between patients? Have a look at the internet site Death Risk Rankings from the Carnegie Mellon Institute. The online tool will allow you to compare the rates of mortality for diseases in various regions of the U.S. or in the U.S. against Europe.

The tool shows, for example, that a person has twice the chance of dying from a homicide in the U.S. compared to Europe. No surprise there, but who knew you were about 25% more likely to die from cancer in Europe compared to the U.S. Unfortunately, Canadian statistics don't appear to be available.

On a similar note a study appearing exclusively on the website of the publication Health Affairs, compares innovation in drug discoveries in the U.S. and Europe. It finds that over the last 20 years European drug companies were better innovators in drug development than the U.S. This, despite constant claims that U.S. consumers pay more for drugs because more research and innovation is done in the U.S.

There's much to debate about this finding, including the fact it can be hard to tease out the results of innovation and research in Europe compared to the U.S. given that the same multi-national drug companies prosper on both continents. What isn't at doubt is that consumers in the U.S. pay more for their prescription drugs than do Europeans.

Heroin, gambling and governments, oh my!
August 26 | Joe McAllister, Senior Editor

Sometimes it takes the printed page to reveal the surreal nature of our political process and how inter-connected we are in this global age. In many editions of the Globe and Mail (Tuesday, Aug. 25, 2009) some smart editor put together two stories on the same page that nicely illustrate the power of an old-style newspaper.

One report was about the Quebec government withdrawing a grant of $600,000 that was to go for a study that compared a treatment regimen where health-care providers gave heroin instead of methadone to addicts. Despite a favourable pilot project, results of which were recently published by no less than the New England Journal of Medicine, Quebec's Health and Social Services Ministry withdrew funding, saying it was re-directing funding to other needs.

The other item of interest was a column by the Globe's western columnist Gary Mason on a decision by the B.C. government to start up an online provincial poker game. Gambling money—lotteries—are manna from heaven for cash-strapped governments, so B.C. is getting in on the action; despite the fact Rich Coleman, the provincial minister in charge of B.C. Lottery was once fiercely anti-gambling; despite some questions about if B.C.'s online poker game will assist—you guessed it—money laundering of drug money.

An "on the money" quote from Mason's column says it all: "Gambling is like booze. Governments tried to prohibit it, and when that didn't work, they decided to make money by regulating the industry. That's what's going on with gambling now."

"The fact is, billions are being generated through gambling. A recent report by Merrill Lynch predicts online gambling will bring in $528-billion worldwide by 2015. Governments everywhere are struggling with the temptation that pool of money presents."

The NEJM article (log-in required) is a study by Drs. Suzanne Brissette and Eugenia Oviedo-Joekes (PhD), of Montreal's Saint Luc Hospital and UBC, respectively. They and colleagues showed in this open-label, phase III study (The North American Opiate Medication Initiative‹NAOMI) of 226 individuals that patients using the active ingredient in heroin are 62% more likely to remain in addiction treatment and 40% less likely to take street drugs and commit crimes to support their habit than those given methadone. But the numbers are small; only 226 patients among the two treatment groups, so a larger study is certainly needed.

So let me see if I've got this correct. One government cuts off funding to a harm reduction project that, it appears, might reduce crime, improve the lives of addicts and save money in treatment, policing, and social services. That savings would reduce the pressure on governments overall to run online poker games that create gambling addicts and offer an opportunity for money-laundering by drug dealers.

A bonus global inter-connectivity: The next time you watch TV footage of another ramp ceremony in Afghanistan, remember that the international trade in raw opium is based in Afghanistan. And that trade funds the Taliban, who kill brave men and women serving in our armed forces. A newspaper page can so easily relate two seemingly unconnected articles which are actually closely related in this interrelated world.

Delegates showed red state, blue state colours at CMA annual meeting
August 25 | Colin Leslie, editor

Ruled over by the rapier-like wit of speaker Dr. Margaret Kirwan, the Canadian Medical Association’s General Council—the parliament of the profession—in Saskatoon this year was a smoothly operating motion-passing machine.

Under Dr. Kirwan, the usual practices of endless wordsmithing of motions and having numerous speakers standing at microphones reiterating their position on widely supported motions have been much reduced. This left more time to debate the contentious motions.

Indeed, it is clear CMA delegates are divided along American-style red state, blue state lines on motions that examine anything that even smells supportive of private care.

One group questions any motion it fears could undermine medicare. The other group, including former CMA president Dr. Brian Day, also supports medicare but is more willing to examine internal markets or other devices to improve medicare’s efficiency.

The divide was seen most clearly this year in the discussions over a motion from Dr. Andrew Kotaska of the Northwest Territories calling on the CMA to oppose fee differentials between the public and private system.

The usual members of the first group were quick to the mics in support, while the usual members of the latter group were up speaking in opposition. (The motion was defeated and full coverage on the motion will appear in the Sept. 8 issue of the Medical Post.)

But aside from this divide, CMA delegates are mostly in accord on the issues of the day.

Motion after motion generally passed with more than 95% support, and many with 99% support. This year, oddly, almost all motions had one dissenter, which annoyed a number of delegates—especially when it was hard to imagine how any sane doctor could be opposed to some of the motherhood motions. In fact, when one motion finally passed with 100% support, Dr. Kirwan quipped: “Oh, I guess that delegate has gone to get a coffee!”

Notes on a pandemic foretold
August 19 | Joe McAllister, senior editor

Dr. Robert Dickson, a friend of the Medical Post in Hamilton, was deep into his escapist summer reading—“I like ‘fun,’ gentle adventures for summer reading,” he wrote in an email—when he discovered the below quotes in the frontispiece of Clive Cussler’s thriller Medusa, which is about a pandemic.

Dr. Dickson continued: “With the H1N1 pandemic threat predicted to recur this fall, I thought you might be interested in these quotes regarding the 1918 influenza epidemic.”

Here are the two quotes:

“If the epidemic continues its mathematical rate of acceleration, civilization could easily disappear from the earth”.
Dr. Victor Vaughn in The American Experience, “Influenza  1918”

“Wash inside of nose with soap and water each night and morning; force yourself to sneeze night and morning, then breathe deeply; do not wear a muffler; take sharp walks regularly and walk home from work; eat plenty of porridge.”
Influenza prevention advice in the News of the World newspaper,  1918

“Eat plenty of porridge” might be the best advice we’ll get, if recent reports about delays in production and bottling of the H1N1 vaccine are accurate.

To U.S. debaters, socialized medicine leads to ‘death panels’
August 13 | Joe McAllister, senior editor

Watching the debate in the U.S. about health-care reform is, if nothing else, interesting. The debate is often not informative and sometimes is downright crazy, as this example indicates. But every now and then a few interesting and little-known facts pop up among the demagogy and insults. Take for example these little gems from a recent article in the Atlantic Monthly magazine: “For every two doctors in the U.S., there is now one health-insurance employee—more than 470,000 in total. In 2006, it cost almost $500 per person just to administer health insurance.”

Or how about this article in Slate, the online magazine. The article documents a marked decline in the number of U.S. residents who have personal or company-paid health insurance. The article suggests that development of a universal healthcare system in the U.S. would actually help the bottom line of the health insurance industry. (Slate, by the way, has run numerous good articles on the ongoing U.S. debate, including a few pieces that, correctly, pilloried the insurance industry.)

Then there’s this article from the American Press on the bartering that goes on between health care providers and patients looking for non-monetary ways to pay their medical bills. Finally there is this piece from the New York Times on the massive public response to a free health clinic offered in the Los Angeles Forum, home of the LA Kings pro-hockey team.

Canada is so boring by comparison. All we do is debate ways of reducing our waiting lists … nobody seems much concerned, as they are in the U.S., about how socialized medicine everywhere results in “death panels” which order the plug pulled on ailing grandmothers who end up in hospital. The Fraser Institute just doesn’t match the rhetorical bombast of a Sarah Palin.

Here we are now, eatertain us
July 14,  2009 | Matthew Sylvain, staff writer

The current New Yorker features a diverting article that attempts to pin down why Americans (and of course, Canadians) are getting collectively fatter.

The article—in fact a mass book review—includes this gem of industry speak that should and probably will become part of the everyday lexicon: Eatertainment. It's apparently the term used in the food industry for making fast and junk food more fun to eat (so we'll eat more and more of it).

The review also includes a quick summary of the ways the fast-food industry manipulates portions and perceptions of portions (again, so we'll eat more and more of it).

Recently I had a mildly surreal brush with this fast-food chicanery, at a Wendy's restaurant near the McMaster University Medical Centre. After placing a by-the-number combo order, the cashier asked me what size I wanted. I asked what were the options. Small, medium and large, she replied. Twisting up my face, I wondered what happened to the standby "regular" option. So I asked what size was the regular. Even as I said it I was struck by the illogic of the question. The cashier, to my surprise, didn't blink, and replied that it was the small. I ordered the "small"—and was handed the familiar "regular" proportion that is enough food to eatertain my 5'10, 170 lb frame.

UK MD incentive mess highlights shortcomings here
July 2, 2009 | Joe McAllister, senior editor

Think you get the short-end of the stick with arcane provincial fee schedules and government pressure to join group practices and provide 24/7 care for your patients?

Think again.

British doctors are up in arms over incentives they receive for getting high marks on annual patient experience surveys, according to the Daily Mail newspaperand the British Medical Association (BMA).

In a press release, the BMA says the 2009 survey found that overall 91% of patients were satisfied with the care they received at their doctor’s clinic, 84% could get an appointment within 48 hours, and 76% were able to book an advanced appointment.

The BMA noted that year-over-year comparisons weren’t possible, as the wording of questions had changed.

The problem is, on the basis of results for individual practices, some doctors and group practices could loose significant incentive money because they did not meet certain benchmarks for service, including those from survey results.

As an example, the BMA mentions that one practice in rural Lacashire stands to lose out on approximately $19,000 in incentive pay. It turns out less than 1% of its 14,000 patients had answered the questions about 48-hour and advanced access, drastically skewing its practice-specific results. (Meanwhile 93% of their patients were happy with the practice's 48-hour access and 61% with their advanced access, but no matter).

How many Canadian patients would be just thrilled to be among a 90% cohort happy with their treatment and able to get a doctor's appointment within 48 hours? Indeed, how many doctors would be just as thrilled if that were the situation?

Did British doctors threaten to strike if doctors weren't insured during flu outbreak?
June 21 | Joe McAllister, Senior Editor

The British Medical Association is denying reports that GPs in the U.K. might strike if they are not adequately insured against dying from swine flu.

The whole issue came up because of the comments of a negotiator who was concerned that some doctors are not properly insured against death while performing their duties.

It is a tempest in a teapot, but Pulse, a U.K. magazine for doctors, gives a fairly concise overview of the problem.

What's really interesting for Canadian doctors who want to see our doctors gain a pension plan, is that this whole episode seems to have gotten its start over concerns that locums who have worked for less than two years continuously are not covered by the insurance provisions of the National Health Service Pension Scheme. Not only do U.K. doctors have a pension plan, they have insurance against death or disability while on the job.

It would seem that not only do doctors in the U.K. have a pension, but they are also covered for death and disability which occurs in the course of performing their duties.

Canadian chapter of Doctors Without Borders elects new head
June 25 | Joe McAllister, Senior Editor

The general assembly of of Médecins Sans Frontières/Doctors Without Borders Canada has elected Dr. Joni Guptill, a family physician in New Brunswick as its new president. The Halifax native replaces Dr. Joanne Liu, a Montreal pediatrician, who served as president for five years.

A founding member of the Canadian chapter, which was organized in 1991, Dr. Guptill has served in a number of world hot-spots, including Somalia, Iraq, Turkey and China.

Her last field mission was in 2006 to southern Sudan where MSF was treating patients during a meningitis outbreak.

Defending Canada as Americans debate health care
June 24 | Joe McAllister, senior editor

Bill Mann, a journalist and now blogger for the popular Huffinginton Post has started a cross-border experiment. After hearing some of the things said about Canadian health care he wrote:

"There's another, factual view—by those of us Americans who've lived in Canada and used their system. My wife and I did for years, and we've been incensed by the lies we've heard back here in the U.S. about Canada's supposedly broken system."

He goes on to specifically site Dr. David Gratzer writing in the Wall Street Journal for "a hit piece" about the Canadian system. It should be noted that Dr. Gratzer is a Canadian and his opinions have graced the pages of the Medical Post.

The response has been interesting. There are 22 pages of comments, from the general public, but also a few from doctors with intimate knowledge of the Canadian system. Mostly its partisan blather, but a number of Canadians have taken up Mann's challenge and defended the Canadian system, as have a number of Americans.

That's all, folks!
June 23 | Terry Murray, clinical editor

Who decided that saying, "Thank you for your attention" was a good way to end a talk?

You have to say something to let the audience know you've finished so they're not murmuring among themselves, "Oh, is it over?" Ideally it should be something that doesn't take energy away from the conclusion of your research and the call to action implicit in your findings.

But after sitting through two major clinical conferences in the last month and hearing 98% of talks end with, "Thank you for your attention," I have decided it's a pathetic closing line. Think about it—you may as well say, "Thank you for not falling asleep," or "That's my time" or "That's all."

Few clinicians or researchers have the chutzpah to raise their arms in the air and shout, "You've been a great audience! I'm here all week!"

What about, "Thank you for your interest"? Or, better, "Again, I'd like to thank the organizers for the opportunity to present our work"?

Anything but, "I'm done now—thanks for staying awake."

Pun a decade in the making
June 18 | Terry Murray, clinical editor

I've been writing about influenza pandemic potential and the need for pandemic preparedness for more than 10 years, so I came to think the pandemic would come when pigs fly.

Well, swine flu.

Inside—and after—MD Pension Action Day: June 15
June 16 | Colin Leslie, editor

The Medical Post's June 15 MD Pension Action Day got off to an early start: 4 a.m. EST.

That is when Medicalpost.com sent out a preprogrammed news alert reminding Canada's doctors this was the day we wanted as many of you as possible to e-mail federal health minister Leona Aglukkaq about physician pensions.

Not much later, longtime pension advocate and Ottawa GP Dr. Mary Fernando appeared on Canada AM.

If you've never sat in a darkened studio facing a camera and very bright lights while trying to respond to tough questions coming via your earpiece on live television, well, it ain't easy.

But Dr. Fernando, though she admitted she was a bit nervous, handled herself well and outlined the reasons why Canadian doctors being allowed to negotiate for pensions—just like their European colleagues already have—would be a good physician retention device. (As editor of the Medical Post, I had the much simpler task of being interviewed on the Gary Doyle Show on 570 News radio in Waterloo, Ont.—an afternoon gig.)

Canada AM viewers have been posting comments about Dr. Fernando's appearance here. Although comments run the gamut, some make for eye-opening reading regarding Canadians' attitudes toward doctors. For example: "Boo hoo, sell one of your BMWs. What a joke."

Others were more supportive: "You shouldn't be jealous of a doctor's salary. If you want to make that much, get off your butt and go to university for 10 to 15 years and earn that right. As for having access to pensions, it only makes sense. They don't just want to collect but the right to contribute, as well."

We don't know how many doctors e-mailed Health Minister Aglukkaq on June 15. I contacted Tim Vail, her director of communications, at the end of MD Pension Action Day, but at the time of this posting, have had no response. Look for more feedback in the July 7 issue of the Medical Post.

Despite the early silence from the health minister's office, we've definitely been heartened by the shouts of support we've had for this campaign.

One Newfoundland doctor told us she e-mailed "more than 500" colleagues and "had positive responses from a number of them back to me."

We asked the Canadian Medical Association if they could do anything to help get the word out. In response, cma.ca hosted a story on June 15 about the e-mail campaign.

As well, in his May 28 column, the Globe and Mail's public health reporter, André Picard, threw his support behind the idea of pensions for Canada's doctors: "To give credit where it's due, the Medical Post, a feisty bimonthly . . . has launched an old-style media crusade to promote the notion," he wrote.

By the way, in case you didn't get a chance to e-mail the health minister on MD Pension Action Day, I'm sure she'd still love to hear from you: E-mail aglukkaq.l@parl.gc.ca.

U.S. healthcare debate mirrors Canadian birth of medicare
June 15 | Joe McAllister, senior editor

Hey, haven't we seen this movie before...way back in 1960?
 
Canadians watching with interest, as the U.S. once again attempts to implement some form of universal health care coverage, can't help but notice the parallels between what is happening now south of the border and what happened here in Canada 50 years ago.
 
The American Medical Association (AMA), although it supports better or universal coverage, in recent days has come out in opposition to government-sponsored health coverage. In an attempt to woo doctors, President Obama spoke June 15th at the AMA's annual general meeting.
 
Cutting to the heart of the matter in fiscal terms, Obama was quoted by the New York Times as saying: "‘I understand that you are concerned that today's Medicare rates will be applied broadly in a way that means our cost savings are coming off your backs.'" He also talked about, but did not promise, tort- or medical-malpractice reform and a way to allow Americans to choose their own doctor.
 
Flashback: It was back in 1960 that the Canadian Medical Association came out in opposition against publicly funded health care. In 1962 Saskatchewan's NDP government introduced the first public health care program. Doctors there went out on a strike that collapsed in less than a month. In 1965 Emmett Hall's Royal Commission called for a universal health insurance and in 1966 Parliament passed a bill creating a national medicare program with Ottawa paying 50% of provincial health costs.
 
It should be noted that even back in 1960, large numbers of Canadian doctors supported some form of medicare. It's the same in the U.S. today. Doctors for America, a pro-reform movement, came out with a survey, albeit one that is probably unscientific, that suggested 97% of physicians supported a well-crafted public insurance option.

Awards for Alzheimer's research
June 15 | Joe McAllister, senior editor
 
The Alzheimer Society has launched a new awards program that recognizes "outstanding contributions in the areas of research, care, volunteerism and philanthropic leadership."
 
Two of the recipients are probably known to the medical community:
 
Dr. Ron Keren is an assistant professor at the University of Toronto and the clinical director of both Toronto's University Health Network and the memory clinics at Whitby, Ont.'s Mental Health Centre (Renamed at the start of June: Ontario Shores Centre for Mental Health Sciences). Through his work on Alzheimer's disease and related dementias, and as the founder and president of the Canadian Colloquium on Dementia, he has advaced knowledge about the disease.
 
Dr. Sherry Dupuis (PhD) is the Director of the Kenneth G. Murray Alzheimer Research and Education Program (MAREP) and an associate professor in the Department of Recreation and Leisure Studies at the University of Waterloo. Dr. Dupuis has focused on identifying ways to improve the quality of the lives of persons living with dementia and their families. She has worked to get patients and their families directly involved in the plans needed to deal with Alzheimer's and has worked at translating research into practice.

Consumer drug 'reminder' ads on rise
June 9 | Joe McAllister, senior editor

Direct to consumer advertising of prescription does take place in Canada and it is increasing if a University of British Columbia study is correct.

The study by UBC's Centre or Health Services and Policy Research looked at what is called reminder advertising. Although direct to consumer prescription drug advertising is not allowed in Canada, as it is in the U.S., Health Canada made a policy change in 2000 that allowed what are called "reminder ads." These are basically ads that mention the brand name of the drug without additional information or health claims.

The B.C. researchers, using constant 2006 dollars, estimate that spending rose from less than $2 million in 1999 to $22 million in 2006.

The UBC study, released at the end of last month, further found that of the eight drugs most heavily advertised in 2005/2006, four had "black box" warnings of contraindications in the U.S. and five had been subject to Health Canada safety advisories.

The top five drugs advertised in Canada were Viagra, Botox, Alesse, Lipitor and Cialis and they made up over two-thirds of the total dollars spent, according to the study, which obtained information on the media buys from TNS Media Inc. In 2006, 85% of the ad spending was for TV.

In a press release about the study, Dr. Steve Morgan, one of the study authors and an associate professor at the UBC School of Population and Public Health said: "Research has shown that the greater exposure to these ads, the greater the effect on medicine use and costs. And there is conspicuously little evidence to suggest this is a net benefit to the population's health or to the health care system."

Who are you gonna cal-Mythbusters
June 9 | Joe McAllister, senior editor

Congrats to André Maddison, a master's student in Community Health and Epidemiology at Dalhousie University and Kathleen Decker, of CancerCare Manitoba and the University of Manitoba, the two winners of the Canadian Health Services Research Foundation's 2009 Mythbusters Award.

Mythbusters is a series run by the CHSRF which uses plain language that everyone can understand‹not medical jargon‹to explode widely held beliefs about our health care system that can be disproved by careful research. Various Mythbusters articles from the recent past include the myth that Canadian doctors are leaving for the U.S. in droves and that generic drugs are lower quality and less safe than brand-name drugs.

Decker's contribution was called: Whole-body screening is an effective cancer screening test while Maddison's was: Patients with primary care needs are causing emergency department overcrowding. Both winners are working with the CHSRF to prepare their submissions for publication. Part of the award was $1,500 given to each of the winners by the CHSRF.

Why Canadian nurses move to the U.S.
June 7 | Joe McAllister, senior editor

Why do Canadian nurses move to the U.S. and stay there? Because the American health care system treats them better than does the Canadian system. That's one of the conclusions of a study released last month from the University of Toronto Bloomberg Faculty of Nursing's Dr. Linda McGillis Hall, the associate dean of research.

The study abstract is here, but you need to register on the site to get the full text.

In a press release that said "the grass is greener" for Canadian nurses in America, it was revealed that Canadian-educated RNs working south of the border found opportunities for continuing their education, including formal support for graduate education, ease of licensure and, of course, full-time employment, were reasons Canadian nurses emigrated to the U.S.

Probably the most interesting fact that came out of the study was that more Canadian RNs working in the U.S. were employed full-time than their American counterparts, or their Canadian counterparts in Canada.

No wonder we've got problems keeping our well-educated nursing professionals in our own hospitals.

McAllen, Texas typifies problem with U.S. health care
June 1 | Joe McAllister, senior editor

An article in a recent issue of the New Yorker, "The Cost Conundrum: What a Texas town can teach us about health care," by Dr. Atul Gawande, is interesting reading for any Canadian doctor watching the health-care debate ramp up in the U.S. The piece, thankfully, doesn't compare the American system to the underfunded, technology-lacking, wait list-wracked system we have here, but rather looks at why one Texas town, McAllen, has vastly higher costs of providing health care when compared to other similar towns in the U.S., yet the quality of care is lower.

Why? Because McAllen is in the thrall of doctors who act like entrepreneurial businessmen when compared with communities where the doctors are part of a team that strives for quality of care.

As Dr. Gawande writes: "Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some Œskin in the game,' and then they'll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no difference.

"The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen."

World of Warcraft makes for good ob/gyns?
May 6 | Joe McAllister, senior editor

Mothers concerned that their sons are spending too much time playing the World of Warcraft video games should take heart. It might one day help them become better obstetricians and gynecologists.

In a tongue-in-cheek poster presented at the annual American College of Obstetricians and Gynecologists meeting in Chicago May 5, Dr. James Fanning of the Summa Health Systems in Akron, Ohio recounted taking 15 expert teenage video gamers and putting them up against 15 first-year ob/gyn residents in a challenge involving three laparoscopic simulator assessment procedures.

Computer simulations of laparoscopic and other procedures are all the rage among doctors these days. They are being touted as one of the best ways to train not only for laparoscopic procedures, but also for many other procedures where practising on real humans just can't be done.

The teens proved just as adept, if not more adept, than the residents, although mothers will probably be glad to know the laparoscopic simulator assessment procedures did not involve exact or graphic simulation of gynecological procedures. "This may favourably impact future residents' laproscopic skills if they have prior teenage gaming procedures," the poster noted dryly.

169 years of the BMJ now free online
May 5 | David Hodges, staff writer

Every British Medical Journal article published since the first issue in October 1840 can now be viewed at www.bmj.com free of charge. By all means, check out the latest research findings, but also allow yourself the pleasure of reading some of the original study articles that paved the way for some of the biggest medical discoveries of the 19th and 20th centuries. For
instance:

- In 1847, Dr. James Simpson publicized his work on chloroform, paving the way for modern anesthetic techniques. And in 1867, an article by Dr. Joseph Lister introduced the concept of antiseptic to promote wound healing.

- At the turn of the 20th century, a study by Drs. Patrick Manson and Ronald Ross established the theory that mosquitoes transmit malaria.

- In the 1950s, landmark research included work by Dr. Richard Doll and statistician Austin Bradford Hill confirming the link between smoking and lung cancer, and a study by Dr. Alice Stewart showing a link between low-level radiation and childhood leukemia.

Other famous names from the archive include Dr. David Livingstone, Sir Arthur Conan Doyle and Florence Nightingale.

For an introduction to the digital archive (a 10-year endeavour involving 824,000 scans, often from thin, friable paper), a series of specially commissioned videos focusing on some of the important issues and individuals that have appeared in the journal's pages are now available here.

Three quarters of American doctors accept freebies
May 1| Joe McAllister, senior editor

America seems intent on bringing more transparency to relations between doctors and drug and medical device companies. The Institute of Medicine, part of the National Academy of Sciences, has just released a report saying doctors should stop taking money, gifts and free drug samples from drug and device manufacturers.

There is a bill in the U.S. Congress that would require drug and device companies to report all payments to doctors. The bill or something similar may well have enough bipartisan support to pass.

But in a recent report in a New York Times article, the most interesting aspect was a report on a 2007 survey which found: "A 2007 survey found that more than three-quarters of doctors accept free drug samples and free food, more than a third get financial help for medical refresher courses and more than a quarter get paid for giving marketing lectures and enrolling patients in clinical trials."

Update: $25 million for Stanfields?
May 1 | Joe McAllister, senior editor

(This is an update to a previous entry).I finally had a chance to talk to Dr. Vivian Mushahwar (PhD) from the University of Alberta. We have been playing telephone tag—she's been busy in the lab.

Dr. Mushahwar basically confirmed the suspicions I had about the reporting on an Alberta Heritage Foundation grant given to her team. It was not a $25 million grant given to her team as reported in the National Post. The $25 million in grants was given to five different interdisciplinary teams in Alberta. And the $5 million given to her team, as reported in the Edmonton Journal, is a grant spread over five years. And not all of it will be spent on the development of "smart" underwear to prevent pressure ulcers in paraplegics or others confined to wheelchairs or beds. The "smart" underwear is the first project being developed and the first to undergo testing.

"I was disappointed with the National Post," she said, "Maybe we should have done something active about it." She is considering writing to the two newspapers involved to make sure their online reports are more accurate.

The final word on active smoking, second-hand smoke and breast cancer causality?
April 29 | David Hodges, staff writer

Perhaps a day will come when common sense will prevail throughout the world and we won't require any more valuable research time dedicated to proving the absolutely deleterious effects of cigarettes. (I can't even begin to describe how maddening I find it when I have to listen to some self-righteous nicotine junkie tell me there's no conclusive evidence that smoking is harmful.)

But for any of you doctors out there trying to persuade a patient that their smoking is hurting themselves and those around them, here's some great ammunition courtesy of the Ontario Tobacco Research Unit, an affiliate of the Dalla Lana School of Public Health at the University of Toronto.

With the assistance of the Public Health Agency of Canada, the panel group analyzed all available research up to 2008 that examined the link between breast cancer and tobacco smoke, and found enough evidence to link active smoking to both pre- and postmenopasual breast cancer.

Historically, the epidemiological evidence concerning breast cancer and smoking was conflicting, according to the panel, with some studies showing increase in risk and others not. But recent cohort studies now suggest that early age of smoking commencement is associated with an increase in breast cancer risk of 20%. As well, these studies have added to the evidence suggesting that higher pack-years of smoking and longer duration of smoking may increase risk by 10% to 30%.

However, the strongest evidence for an active smoking risk and breast cancer causality resulted from studies examining smoking and genetics. Three recent meta-analyses and a pooled analysis have found 35% to 50% increases in breast cancer risk for long-term smokers with one of several N-acetyltransferase 2 (NAT2) slow acetylation genotypes. (NAT2 is an enzyme that functions to both activate and deactivate carcinogens in the body, and about half of North American women have a NAT2 slow acetylation genotype, depending on ethnicity.)

Second-hand smoke was also linked to breast cancer causality in younger women. For example, both the California Environmental Protection Agency in 2005 and the U.S. Surgeon General in 2006 published meta-analyses that suggested a 60% to 70% increase in breast cancer risk among younger, primarily premenopausal women who had never smoked, associated with regular long-term exposure to second hand smoke.

Evidence, however, was considered insufficient to pass judgement on second-hand smoke and postmenopausal breast cancer.

"An estimated 80% to 90% of women have been exposed to tobacco smoke in adolescence and adulthood," said Neil Collishaw, panel chairman of the Canadian study.

For detailed findings of the research go to www.otru.org.

$25 million for Stanfields?
April 27 | Joe McAllister, senior editor

A little item in the National Post last week caught my eye. It reported on a University of Alberta cell biology professor, Dr. Vivan Mushahwar who is to lead a team to develop "smart" underwear that will help prevent pressure ulcers or sores in bedridden or wheelchair-bound patients.

What really stopped me in my tracks was the sentence in the story that said: "The professor will work with nurses, scientists, engineers, doctors and rehabilitation specialists to develop the underwear with $25-million from the Alberta Heritage Foundation for medical research."

Twenty-five million dollars to develop underwear? Boy, that amount would surely pay for a complete line of Victoria Secret's underwear for the paraplegic and bed-ridden. Following up I phoned Dr. Mushahwar a few times to talk to her about her research. We are still playing telephone tag, so I'll update this item when I hear more.

But, looking a little further I found an Edmonton Journal article that was probably the basis for the National Post story (The National Post and the Edmonton Journal are both owned by Canwest and they probably share stories). But the Journal article only mentions a $5 million grant to Dr. Mushahwar's team, which is a little better.

Going a little further—to Dr. Mushahwar's homepage the University of Alberta's website ‹we get an idea that her team is involved in more than creating Stanfield's with electrical impulses to stimulate blood flow. And we learn that Dr. Mushahwar has a PhD in bioengineering, which makes more sense than calling him a "cell biology professor."

We shouldn't complain about spending lots of research money on finding ways to prevent pressure ulcers and I'm pretty sure the $5 million will be spent on more than just developing underwear, but what this little tale does show is how wrong news reports can be.

More unbelievable news
April 27 | Joe McAllister, senior editor

Speaking of unbelievable news reports, how about these two reports, one from the Montreal Gazette and the other from the Globe and Mail. Is there any wonder privatized health care is a hard sell in Canada? We will be doing a further report from Mark Cardwell in the May 5 issue of the Medical Post.

Congratulations are in order
April 27 | Joe McAllister, senior editor

Dr. Gabor Maté, of Vancouver, has won the 2009 B.C. Book Prize in the non-fiction category for his book In the Realm of Hungry Ghosts: Close Encounters with Addiction.

Dr. Maté was profiled in the Medical Post last year where he talks about the book, but also his life serving down-and-our residents of Vancouver's East Side.

Asthmatics think they've got it 'under control'
April 17 | Amber Lepage-Monette, staff writer

You know that sinking feeling you have that your patients aren't taking their medication properly? It's probably true.

A recent survey of 1,001 asthma patients and 300 physicians carried out by the Asthma and Allergy Foundation of America and funded by AstraZeneca found patients often stop taking medication once they start feeling better and don't have a clear understanding of what asthma control means.

Overall patients weren't as clueless as you might expect: 79% said they understand there are risks associated with not taking their medication as instructed and 70% say they know their could be risks associated with stopping medication when they don't have any symptoms.

And yet, only 62% of patients said they were using controller medication at the time of the survey. Among those not using their controller medication, 71% said they only take it when they have symptoms and nearly the same number of patients said they stopped medication because their asthma was under control without it. And how did they interpret "under control?" Well, an equal number of patients said it means only two urgent doctor visits a year, or one emergency room visit a year, or that your asthma bothers you less than half the time you exercise or that you only need to use your relief inhaler three times a week.

But this didn't come as a surprise to physicians. Half of those surveyed said they though only 40% to 60% of patients took their medication as instructed—almost exactly the number the survey found.

So are patients just being difficult? Probably not. Seventy-eight per cent of the physicians surveyed said it was hard to explain inflammation to patients because it is something that isn't obvious to the patient until they experience acute symptoms. The results also brought to mind a recent article in the New York Times that suggested patients have low health literacy and just don't understand what they are being told.

Whatever the case may be, I think it's good to see physicians are realists when it comes to patients and should never take anything for granted when discussing medication use.

So much e-health spending, so little to e-show for it
April 13 | Joe McAllister, senior editor

I see the Ontario government is under fire for $647 million it has spent to digitize medical records. A Toronto Star headline referred to a "boondoggle" in the closing of the Smart Systems for Health Agency (SSHA), which was leading the way to e-records until the agency was abruptly dissolved in 2008 and responsibility to get Ontario's health system into the 21st Century electronically was turned over to a new agency, e-Health Ontario. The opposition in the Ontario legislature wants to know what the province got for the $647 million spent by the SSHA in the five years of its existence.

It's an interesting question. Indeed, how many provinces is it that have had made big investments in electronic medical records without a lot to show; what would the number be? Would it be close to 10? Let's see: Alberta, Quebec, N.S., N.B.–wait, wasn't N.B.'s e-health involved with IBM, hardly an organization prone to fail? And shouldn't B.C., Saskatchewan and Manitoba also be included in that total?

Reading the online comments beneath the Star article leads one to blame typical government incompetence and the usual featherbedding. But I'm frankly not so sure. Anyone in the business world who has had to deal with an "enterprise computing system" knows the steep learning curve and sheer quirkiness of systems intended to deal with records from one single company. Never mind the difficulty of interoperability across a myriad of systems, hospitals, clinics, labs and doctors offices.

It should be pointed out that Canada is hardly alone in having trouble instituting e-health records. The Obama regime in the U.S. recently earmarked $19 billion to enhance interoperability in health records, but a New York Times article questions the slow growth of computerization in U.S. healthcare. And some of the comments at the bottom of that article seem to be written by doctors who are none too happy with the way things are going electronically there.

So what is it about electronic health records, beyond the obvious complexity, that makes implementation of such systems so difficult? Send me an e-mail if you have any ideas and we'll post some of the more interesting ideas.

What Month Is This?
April 13 | Amber Lepage-Monette, staff writer

Did you know that April is National Safe Handling Awareness Month? Me neither. That may be because this April is the first and a press release that landed in my inbox just brought it to my attention today.

Or, it could be that I'm just so overwhelmed now with the sheer number of events and causes that each and every month is a spokes-month for. Don't get me wrong, drug handling can be a hazard to those in the health-care community and I don't have a problem with promoting a good cause. But April is already Daffodil Month for the Canadian Cancer Society, National Oral Health Month for the Canadian Dental Association, Irritable Bowel Syndrome Month for the Canadian Society of Intestinal Research, Parkinson's Awareness Month for the Canadian Parkinson's Society. As well, April 2 was World Autism Day, April 7 was World Health Day, April 17 is International Hemophilia Day, April 19-26 is National Organ Donor Awareness Week...and these are just the issues related to health!

Obviously it's important for these groups to promote consciousness and encourage funding and research for these issues. And that was exactly the point of having these spokes-months when they first started–to draw attention to these worthy causes. I'm starting to wonder, though, with so many events simultaneously clamouring for your attention, are the messages getting lost in the noise?

Self-esteem for neonates
April 7 | Terry Murray, clinical editor

Apparently it's never too early to start building a child's self-esteem, or so marketers would have us believe.

We've recently become aware of a new product that will end the soul-destroying gender confusion that is so humiliating for bald baby girls and their parents.

It's Baby Bangs!, a headband made up of a hair ribbon bedecked with floral appliqués, to which— and let me quote from the company's material here—"silky strands of Monofiber Kanekalon" are attached and "arranged in the cutest most adorable elfish coiffure." (See www.babybangshairband.com.)

Speaking for your baby daughter, Baby Bangs! announce to the world, "I'm not a boy!"

It reminded us of a similar product for boys, advertised on Saturday Night Live a few years ago—Nelson's Baby Toupees, designed to help bald baby boys avoid the "shame and disgrace" of "male infantile baldness." What took the Baby Bangs! people so long to come up with a product for girls?

ER closure a boon for medicine
April 7 | Terry Murray, clinical editor

It's a good thing that the fictional "County General" Hospital in Chicago has an orthopedics department, because last week's final episode of "ER" was so lame.

After 15 seasons of subjecting the leading characters to tortures such as dismemberment by helicopter, sex in a poison ivy patch and murder by a delusional patient, as well as the constant threat that the hospital would be closed, the staff of County General are just carrying on, off-screen, and it's we, the viewers, who have gone away.

However, a recent study by two Canadian physicians suggests the demise of "ER" may be good for medicine. Drs. Peter Brindley, a critical-care specialist at the University of Alberta Hospital, and Craig Needham of the department of anesthesiology and pain medicine found "common recurrent deficiencies" in the pulmonary resuscitation skills of Canadian trainees in anesthesiology, surgery and emergency medicine.

In a letter to the journal Resuscitation, they noted inadequate positioning of the head and neck was especially prevalent prior to intubation attempts.

When Drs. Brindley and Needham explored the causes for this, the trainees said they'd had limited supervision or hands-on training, and had learned first by trial and error, and second by watching intubation on TV dramas, with "ER" being the most often cited program.

Sure enough, although "ER" had several medical advisers, a review of 22 intubation attempts that could be adequately seen by a TV viewer in the latest two seasons showed that none achieved optimal airway positioning, the Alberta doctors said.

"Few would suggest that medical dramas can be held responsible for physician performance," Drs. Brindley and Needham said, but they cautioned against leaving pulmonary resuscitation for the inexperienced or unsupervised.

What's the hold up on smoking bans?
April 3 | Carol Hilton, associate editor

This week the New Brunswick provincial government introduced legislation banning smoking in cars with children under the age of 16, joining several other provinces and a territory that already have bans. That's great, but my question is: What's taking so long in the rest of the country?

These bans already exist in Nova Scotia, Ontario, British Columbia and the Yukon. Manitoba is introducing similar legislation and the P.E.I. government has announced it plans to do the same.

Don't get me wrong; it's great to see the effects of secondhand smoke being taken seriously. But it's not like it's based on new information. In fact, with what is known about smoking you'd think a ban wouldn't be necessary today, but apparently it is.

I just thought that once one province figured it would be worth making an official statement on protecting children from secondhand smoke, everyone else would follow suit immediately.

I suppose we could be doing worse. This week North Dakota voted down a bill seeking to ban smoking in cars when children are present, with one House representative stating it is not the government's responsibility.

So, kudos to New Brunswick for making a statement about protecting those who can't protect themselves. For those provinces lagging behind, can you not see through the smoke?

Not just a tempest in an academic teapot?
April 3 | Joe McAllister, senior editor

A curious little academic dispute has been going on between a professor of neuroanatomy at Lincoln Memorial University in Tennessee and the august Journal of the American Medical Association.

JAMA has long been a proponent of disclosure in medical research and, through its tough standards and peer review, a bastion of high-quality research reporting.

Last year Dr. Jonathan Leo (PhD), an associate professor of neuroanatomy at Lincoln complained about a study published in JAMA by University of Iowa psychiatry professor Dr. Robert Robinson about the use of antidepressants in stroke patients. According to Dr. Leo, Dr. Robinson did not disclose a financial relationship with the maker of the drug being studied.

Dr. Leo contacted JAMA last October. Late last month the British Medical Journal published a letter from Dr. Leo saying he has received no reply from JAMA. A week later JAMA published a correction and a letter from Dr. Robinson admitting he had been paid by the drug company and failed to report that fact.

All this may seem to be a tempest in an academic teapot, but in the same issue of JAMA the editors, maybe miffed that Dr. Leo had gone to a competing learned journal, wrote that anyone wanting to file a similar complaint about a conflict should contact JAMA and not go to other press contacts until JAMA had dealt with an issue. JAMA said it could be trusted to handle the affair correctly.

All of which lead to charges that JAMA was trying to shut down a whistle blower and questions about how JAMA might try to punish anyone who contradicts this new "policy."

Researchers are a touchy lot when it comes to publishing in the major journals. The last thing they want is anything that might prevent their research being published in a publication as important as JAMA. It has something to do with the incestuous relationship between citations by other researchers and departmental tenure.

But still, this all seems a little far-fetched. I know it takes months and sometimes years before the final publication of an accepted piece in the New England Journal of Medicine, JAMA or the BMJ, but couldn't JAMA have responded more quickly to Dr. Leo . . . maybe using that newfangled thing called e-mail? And couldn't they have published Dr. Robinson's letter online rather than waiting for print?

No wonder PLoS online and others like it are threatening the stranglehold the major journals have on scientific and medical publishing.

BMJ awards honour hand-washing proponent
April 3 | Joe McAllister, senior editor

And speaking of the British Medical Journal, the BMJ Group has just made its first ever set of awards. Held in association with the Health Foundation of Great Britain, the awards "recognize and celebrate excellence in health-care across the globe (including) awards for corporate global responsibility, clinical research, health-care communication and medical education."

We particularly like the fact that Dr. Valerie Curtis (PhD), director of the Hygiene Centre at the London School of Hygiene and Tropical Medicine, was named Health Communicator of the Year for getting a simple message out across the world: Hand washing can save your life.

Among other sponsors, she got the world's largest retailers of soap, Procter & Gamble, Colgate-Palmolive and Unilever, to help promote hand washing to reduce diarrhea in developing countries, which kills 2 million children a year. Her work led to the first ever Global Handwashing Day last October 15, and 20 countries now have national hand washing programs.

It's such a simple idea with the potential for a huge health benefit.

CAPE lauds Ontario's pesticide progress
April 3 | Joe McAllister, senior editor

The Canadian Association of Physicians for the Environment (CAPE) is happy because, they say, Ontario's Cosmetic Pesticide Ban Act makes the province a leader in banning pesticides and herbicides that contain potentially toxic ingredients.

"Up to now Quebec has had the best legislation, but it only bans 20 pesticides. Ontario is banning five times that number. And the U.S. can't even agree on a ban on 2,4-D, while Ontario is protecting us from 2,4-D and 95 other toxic chemicals!" wrote Gideon Forman, executive director of CAPE, about the list of banned chemicals that the province released in March.

Now it's on to other provinces and other environmental battles for this successful organization—successful because through smart PR and using the fact that the public trusts doctors' opinions on such matters, CAPE has made its voice heard loud and clear in corridors of power.

Health Canada warns against e-cigarettes
April 1 | Amber Lepage-Monette, staff writer

It is the digital age, after all, so maybe it shouldn't come as a surprise that electronic cigarettes exist. Nor is it a surprise that Health Canada doesn't seem to think the high-tech version is any better than the original.

On March 27, Health Canada issued a warning against the use of electronic smoking products (including cigarettes, cigarillos, cigars and pipes), which are not authorized for sale in Canada.

According to the press release, e-cigarettes are often marketed as safer alternatives to traditional cigarettes, likely due to the lack of tobacco. But, according to Health Canada, they can still be addictive and/or cause nicotine poisoning. E-cigarettes work by vapourizing liquid chemicals, including nicotine.

Seeing as they're dressed up to look like real cigarettes—e-cigarettes produce a smoke-like vapour and even have a glowing tip—I'm not sure why anyone would think they're that different than traditional cigarettes. I mean, if it walks like a duck and quacks like a duck. . . .

I suppose it's the lack of tobacco that appeals, but e-cigarettes come with hassles, too: You need to plug them in to charge the battery. Seeing as I can't even remember to charge my cellphone on a regular basis, it's probably a good thing that I'm a non-smoker.

Lancet calls for Pope's repentance on HIV comments
March 30 | Carol Hilton, associate editor

The medical journal the Lancet has added its authoritative voice to the widespread condemnation of Pope Benedict XVI's recent comments regarding condom use and HIV/AIDS in Africa.

Aboard the papal plane on March 17 on his way to Africa for his first visit to the continent as pope, the head of the Catholic Church made a statement encouraging sexual abstinence to fight the spread of HIV. "You can't resolve it with the distribution of condoms," the pontiff told reporters on the plane. "On the contrary, it increases the problem."

His statements sparked criticism around the globe, with health workers battling the epidemic on the front lines saying the Pope values religious dogma above the lives of African people.

In the Lancet editorial dated March 28 but posted online in advance, the writers called on the Pope to retract his statements:

"When any influential person, be it a religious or political leader, makes a false scientific statement that could be devastating to the health of millions of people, they should retract or correct the public record. Anything less from Pope Benedict would be an immense disservice to the public and health advocates, including many thousands of Catholics, who work tirelessly to try and prevent the spread of HIV/AIDS worldwide."

Amen to that.

Alberta health minister shirks proposed trans fat legislation
March 30 | David Hodges, staff writer

Under pressure from the food industry, Alberta Health and Wellness Minister Ron Liepert, once a public darling for pursuing a province-wide ban on trans fats, recently made the abrupt decision to do a complete about-face on his once highly progressive stance against the deleterious effects associated with the use of these partially hydrogenated vegetable oils.

Just one year ago, Calgary led the country with the first policy to regulate trans fats in eateries, with Liepert promising to extend the policy throughout the province to restaurants and grocery stores alike. Now, the health minister has hung his hat on the foolish hope that all food purveyors will voluntarily decrease their use of the cheap oils derived from trans fats that give foods a longer shelf life and instead opt to use more expensive, healthier natural oils. Yeah, right.

In reality, the health minister has simply chosen to walk away from his once ambitious plans to overhaul Alberta's health-care system. Apparently, Liepert would rather wait and see if the federal government will step into the fray and impose a country-wide ban on trans fats, thereby removing him from any responsibility in the matter. Of course, anybody who has been following this issue on a national level will tell you the feds have given no indication that they plan to do this any time soon.

Leading the media charge against Liepert has been the Calgary Herald, which blasted Liepert as being "backwards and reckless," suggesting that his consultations with the food industry motivated him to completely disregard the advice of scientists, physicians and Albertans concerned with the well-known risk of heart attacks and other diseases linked to the consumption of trans fats.

This suggests the short-term financial gains of providing cheap, greasy fast food or cookies that can sit in your cupboard for half a year are more important than the long-term sustainability of Alberta's health-care system.

Dying WITH prostate cancer, not OF prostate cancer
March 30 | Joe McAllister, senior editor

It was maybe 10 or even 15 years ago that I attended an American Urology Association annual meeting and first heard heated debate about using a new test—PSA —to screen for prostate cancer. Yet just weeks ago, the New England Journal of Medicine released online the results of two studies on PSA screening http://content.nejm.org/, of which neither answered the questions asked so long ago: Does screening reduce death rates, and is screening a valid way to reduce prostate cancer?

The U.S. National Cancer Institute study of 76,693 men randomly assigned to screening or usual care found "after seven to 10 years of followup, the rate of death from prostate cancer was very low and did not differ significantly between the two study groups."

The European Randomized Study of Screening for Prostate Cancer study of 182,000 men in seven European countries, which started in the early 1990s, concluded: "PSA-based screening reduced the rate of death from prostate cancer by 20% but was associated with a high risk of over-diagnosis."

In other words, PSA or other forms of screening didn't make much difference. Prostate cancer is so slow moving that even if screening identifies prostate cancer, there's a good chance men will die of other causes before prostate cancer kills them.

The online magazine Slate, in an article trying to make sense of the studies, recalled a 1992 Hawaiian study reported in Cancer Epidemiology and Prevention. That study found on autopsy "prostate cancer in 80 of 293 (27%) autopsied Hawaii Japanese men who died after 50 years of age, reaching a frequency of 63% (10 of 16) among men over 80 years of age." None of the autopsies were in men who had died of prostate cancer.

So there's good reason most experts don't advise screening men older than 75 years of age. Even if they have the cancer, they will probably die from another cause.

And there is good reason to avoid the known treatments for prostate cancer; treatment often leads to incontinence, erectile dysfunction, osteoporosis, nerve damage or other complications.

Maybe in another 10 or 15 years, given the snail-like speed of prostate cancer, I'll be able to sit down and report that researchers have finally quantified how, who and when men should be screened. Until then I'll probably have my PSA tested and submit to the hated DRE during my annual physical … but I'm not sure what to do if I'm diagnosed.

American Psychiatric Association ends sponsored seminars
March 27 | David Hodges, staff writer

Despite these lean economic times, the American Psychiatric Association (APA) has made the bold decision to end industry-financed medical seminars at its annual meeting. It's no small gesture, given that the total income from symposia sponsored by drug or device makers account for about 10% of the group's $50-million annual budget.

Drug advertisements in its journals, commercial exhibits at meetings and industry-sponsored fellowships are here to stay, but growing criticism concerning potential bias in favour of a sponsors' products at continuing medical education events prompted the APA to put the kibosh on the funded symposia. The group said it would also phase out meals at the meeting paid for with industry money.

The APA was not aware of any other medical organization that has made this type of decision.

Generics take the lead in prescription sales
March 27 | Joe McAllister, senior editor

IMS Health Canada, which tracks prescription drug sales here, just released details of retail prescription sales in 2008. According to the report, retail prescriptions filled by Canadians grew 7.1% in 2008 and cost $21.4 billion, up from $20.2 billion in 2007. Canadians filled 453 million prescriptions in 2008, an average of nearly 14 prescriptions per Canadian.

The Canadian Generic Pharmaceutical Association crowing because, for the first time, more prescriptions for generic medications (51.6%) were dispensed than brand-name drugs (48.4%). While the number of prescriptions for generic drugs grew by 15%, the volume of brand-name prescriptions declined by 0.3%.

IMS data are often fascinating, and it is worthwhile having a look at the charts that come with the report. Lipitor is the top-selling drug, with close to 15 million prescriptions written in 2008, and cardiovascular medications are the top therapeutic class, with $3.1 billion in sales. But who knew that Quebec leads the category of prescriptions per capita with 23, compared with the average of 14 per capita across the country? However, IMS helpfully notes that the number is so high in Quebec because prescriptions in that province are generally written for a shorter duration than in others, so the number of prescriptions dispensed is higher; it's not that the total amount of prescriptions drugs taken in Quebec is higher.

Canadian trial is one of the hottest in medicine
March 26 | Andrew Skelly, writer-editor

A Canadian-led study of perioperative beta-blocker therapy is one of the hottest papers in clinical medicine, according to citation research service Essential Science Indicators.

The paper by Dr. P.J. Devereaux of McMaster University in Hamilton and colleagues was published in the Lancet last May, but in recent months had one of the largest percentage increases in citations, the service said. That suggests the paper's call to reconsider guidelines recommending these drugs for noncardiac surgery is being heard by the medical community.

Dr. Devereaux and colleagues in 23 countries noted beta-blockers had been recommended for perioperative cardiac protection despite shaky evidence. Their PeriOperative ISchemic Evaluation (POISE) trial involved 8,351 patients—more than four times as many as all previous such trials combined. Patients were randomized to extended-release metoprolol succinate or placebo starting two to four hours before surgery and continuing for 30 days.

The results suggested the drug did more harm that good: For every 1,000 patients undergoing noncardiac surgery, a beta-blocker would prevent 15 heart attacks, but at the cost of an extra eight deaths and five strokes.

In a recent interview with ScienceWatch.com, Dr. Devereaux estimated perioperative beta-blocker use for noncardiac surgery has led to 800,000 premature deaths and 500,000 strokes worldwide during the past decade that guidelines have recommended the practice—and that's assuming only 10% of physicians followed the guidelines.

He said the negative effects of metoprolol seem to have been related to hypotension, and the researchers are now investigating whether the alpha-2 agonist clonidine can beneficially lower patients' heart rate but reduce blood pressure to a lesser extent. Stay tuned for the sequel: POISE-2.

BC EMR survey suggests reasons for pessimism
March 24 | Matthew Sylvain

A study published online by the B.C. Medical Journal today found electronic medical record (EMR) systems remain underused, even among the Canadian physicians who were most keen to get them—the so-called early adopters.

The study was spearheaded by Dr. James Lai, a UBC clinical associate professor, and supported by an unrestricted research grant from B.C.'s Physician Information Technology Office (PITO). According to the study, "analysis of EMR functions used by early adopters in patient care showed the level of use was low. Therefore, although the majority of users described a successful EMR implementation, optimal use of EMR functions that would be expected to produce evidence-based benefits and practice quality improvement were not seen in this study. There was no correlation of increasing optimal EMR use with the length of time since implementation."

It's a crucial insight. It is also bad news for the future of the rollout of EMRs. As Dr. Lai points out in the discussion, there is ample evidence showing meaningful returns on investment for doctors once they, as the saying goes, take it to the next level. And if early adopters aren't taking it to the next level, who will?

The study, undertaken in fall 2007, included the feedback of 928 B.C. doctors, both EMR users (418) and non-users (510). Results will also appear in the journal's April print edition.

Does our minister for science and technology understand what science means?
March 18 | Joe McAllister, Senior Editor

Is anyone else concerned about the beliefs of the Minister of State for Science and Technology Gary Goodyear? No, no . . . I'm not thinking of whether or not he believes in evolution, although one would think that disputing evolution, a basic tenant upon which our medical and biological sciences rest, would automatically disqualify someone from holding that ministry.

What should be of greater concern is the revelation that he is a chiropractor.

Now as someone who has spent the last 20 years in awe of the doctors and medical researchers who have advanced medical care through careful and scientifically valid studies, I'm not a big fan of chiropractic therapy. Before I start believing that adjusting the spine can solve back problems, cure asthma or solve any other type of medical problem, I want to see some good, double-blind, peer reviewed studies that can be replicated.

Worse, according to a report in the Globe and Mail,Goodyear says his interest in science goes back to his early years tinkering with engines in a high-school shop class and his invention of black-box chiropractic devices he has used successfully in his medical "practice."

If this is what Goodyear considers scientific research, it's no wonder the basic-science community is up in arms with the minister about funding and a lack of understanding about basic research.

Medical terms make bafflegab list
March 18 | Matthew Sylvain, Staff Writer

The Local Government Association, a group that represents small municipalities in the U.K., today released a list of 200 words it recommends people in "public bodies" refrain from using, and a surprising number of the 200 are common medical lingo. The list includes: baseline, benchmarking, best practice, collaboration, evidence base, framework, guidelines, interdepartmental, multidisciplinary, and practitioner (practitioner, really?).

Now admittedly, many of these words have very precise meanings in medicine (i.e.: practitioner), but the point‹when it comes to writing, or speaking for that matter, keeping it simple, stupid‹is always a good reminder. And too, the association can itself be seen falling into the trap of lazy communication. For example, it says in a press release these terms should not be used if communicating "effectively with local people" is the goal. In this context, and to borrow from the millstone the association hangs around the neck of many terms (where it doesn't otherwise offer a more efficient suggestion, like "reform" in place of "reconfigured"), "why use it at all?"‹why say "local" and not just say "people"?

Research by prominent pain specialist called into question
March 17 | Joe McAllister, Senior Editor

The anesthesiology community has been shocked by reports that one of it's most prominent researchers, Dr. Scott Reuben, of the Baystate Medical Center in Springfield, Massachusetts, fabricated results in at least 21 articles on pain relief dating back to 1996. Press reports in a Wall Street Journal blog, a Scientific American article and, more importantly, in Anesthesiology News have more details on the controversy.

Dr. Rueben published in many top-flight anesthesiology journals such as: Anesthesiology, Anesthesia and Analgesia and the Journal of Clinical Anesthesia.

Many of them have retracted papers they have published by Dr. Rueben. Anesthesiology News has a list of the papers that have been, or are expected to be, withdrawn.

It should be noted that none of his co-authors in these studies have been implicated in wrongdoing.

Dr. Reuben was a pioneer in the development of multimodal pain relief after surgery such as the use of nonsteroidal anti-inflammatory drugs and neuropathic agents instead of using opiates and giving analgesia automatically.

Immunization Committee caught up in HPV frenzy
February 25 | Joe McAllister, senior editor

Terry Murray's article in the Feb. 20 edition of Medical Post on the state of Canada's National Immunization Strategy is a little tale for our times—small successes, some failure and some big dangers ahead. (To read Murray's article, click here.)

The success was the work of the agencies in promoting a uniform use of a number of vaccines across Canada. In 2004, the federal government allocated $300 million for universal immunization programs for four recommended vaccines: pneumococcal conjugate, meningococcal C, varicella and acellular pertussis for adolescents.

Studies of the programs show a dramatic reduction in invasive pneumococcal disease due to vaccine serotypes between 2000 and 2007, and a sevenfold reduction in meningococcal disease between 2002 and 2006.

But one of the cautions Murray raised in her story was the complaint about the speed with which the National Advisory Committee on Immunization and the Canadian Immunization Committee respond to the introduction of new vaccines. The example she cited was the HPV vaccine.

Not that we should be surprised that any science-based agency should be slow to deal with the HPV vaccine. It's not that the vaccine doesn't work. It does protect exactly as promoted against certain strains of HPV, many of which cause cervical cancer. What causes a brain freeze for any agency trying to validate the usefulness of the vaccine is that it protects against the relatively innocuous HPV, not cervical cancer, which some strains of HPV cause in some women—"some" being the key here.

We know, through a lot of good research, that cervical cancer can be detected through Pap smear screening, and treated. We've become so good at it that the incidence of cervical cancer has declined by 20% since 1995, according to the Canadian Cancer Society.

But in evaluating the cost-effectiveness of this vaccine in Canada, researchers are looking at a very different endpoint than for most vaccines: not just protection against human papillomavirus types, but against cancer. Further, the vaccine doesn't cover all the oncogenic HPV types and not all cervical cancer is caused by HPV.

So, is it worthwhile to pay $300-plus for a three-dose course to protect a 15-year-old girl against a relatively slow-moving cancer that we've learned to detect through a simple and cheap screening process? Will any vaccine that protects against 70% or 80% of HPV strains that cause cervical cancer result in an actual reduction in cervical-cancer deaths?

Good questions, taken out of the hands of the two agencies by events. Whether it was from grassroots or Astroturf support, federal and provincial governments in Canada decided to pony up the money for HPV vaccination. ("Astroturf" being the name given to organizations that appear to be grassroots groups but are actually supported and/or directed by corporate or government sponsors.)

Similar decisions to buy HPV vaccine were made by various U.S. states, including Texas. Who knew religiously fundamentalist and conservative Texans were supportive of funding a vaccine to protect women who were having sex? Still, it's nice to think our politicians finally realize a women's reproductive health is a no-brainer, a vote-getter that should be supported.

The whole debate has left Canada's federal agency charged with validating and costing HPV vaccine use. To stay in the game, evidence-based medicine will have to find a way to make its voice heard early and clearly in the expected debates on the cost and efficacy of various vaccines and treatments.

Finally, some bad news about green tea
February 25 | David Hodges, staff writer

Green tea has been hailed as a panacea for everything—cancer, obesity, heart disease, a bad muffler, you name it. Okay, I made that last part up, but you get where I'm going with this. This has been the health supplement that can do no wrong. That is, until now it seems.

A prepublished February online study in Blood (the official journal of the American Society of Hematology) suggests that some components of green tea may counteract the anticancer effects of the cancer drug bortezomib (Velcade).

In previous animal studies, the green tea antioxidant compound epigallocatechin gallate (EGCG) polyphenol has been shown to be a potent anticancer agent; among other properties, it binds to a common protein in tumors called GRP78 (which is responsible for preventing cell death) and inhibits its function. But Dr. Axel Schönthal (PhD), an associate professor at the University of Southern California Keck School of Medicine in Los Angeles, wanted to better understand how green tea compounds interact with cytotoxic cancer drugs and how that may affect patient outcomes in those who look to green tea to complement their therapeutic regimens.

He and his colleagues evaluated whether the combination of green tea and bortezomib would improve outcomes against multiple myeloma and glioblastoma in both in vitro and in vivo mouse experiments. The team was surprised to find that the EGCG compound seemed to prevent bortezomib from fighting the disease by blocking its proteasome inhibitory function—the two compounds effectively contradicted one another in the cell, leaving nearly 100% of the tumor cells intact.

The study findings may have several important implications in the clinical setting. The EGCG blocked bortezomib's antitumour effects at levels that are commonly achieved with the use of available concentrated green tea supplements, suggesting the impact is very real for patients supplementing their therapy.

"The current evidence is sufficient enough to strongly urge patients undergoing bortezomib therapy to abstain from consuming green tea products, in particular the widely available, highly concentrated green tea and EGCG products that are sold in liquid or capsule form," Dr. Schönthal said in a statement. However, he also stressed that his study has only exposed detrimental effects of green tea in specific combination with bortezomib and not any other cancer drugs.

"(T)his should not minimize the previously reported potentially beneficial effect of this herb. Related studies with other types of cancer therapies are promising and green tea extract may actually improve the anticancer effects of other drugs."

Yet even more bad news about one's health during an economic downturn
February 16 | David Hodges, staff writer

These days, there's no shortage of news releases cooking up some angle involving the global financial crisis as a way to get a message across. The latest to land on my desk fitting this bill came from Astellas Pharma Canada, Inc. (the only Japanese pharmaceutical company in Canada).

The group was promoting its Eczema Awareness, Support and Education (EASE) program, which warns people that our troubled economy may worsen eczema symptoms by causing stress triggers in three out of four Canadians with this medical condition. They based this information on a voluntary online survey of 450 Canadians in their EASE database who reported having eczema, of whom 75% said emotional factors—including stress—were one of the most common causes of their flareups.

Dr. Marlene Dytoc, an associate clinical professor of medicine at the University of Alberta in Edmonton who was involved in the development of the small study, recommends exercising regularly, practising relaxation techniques (like yoga or meditation) and taking part in enjoyable activities as ways to help manage stress.

A quick jaunt over to the EASE program's website at http://www.eczemacanada.ca also provides information about how massage can ease eczema sufferers' stress flareups.

Given the financial stress we're all currently experiencing, this reporter recommends everyone get a relaxing massage—regardless of whether or not you have eczema.

Voluntary trans fat regulations aren't working
February 13 | David Hodges, staff writer

"Canada's Trans Fat Scorecard: Few brownie points in latest survey"—this was the introductory zinger attached to one of the latest news releases from the Heart and Stroke Foundation of Canada.

With so much emphasis now being placed on preventive health care, the organization is pressuring the federal government to step up its game with the food industry and regulate the amount of trans fats in prepared foods.

In June 2007, the feds accepted recommendations that the total trans fat content of cooking oils and soft margarines be no more than 2% of total fat content, and that trans fat totals in all other foods be no more than 5%.

However, Sally Brown, CEO of the Heart and Stroke Foundation, says self-regulation has simply failed. Although some companies and sectors have stepped up to the plate and done well, many brands of cookies, processed popcorn and brownies remain the worst offenders for harbouring the heart-clogging fat molecules. Consider also that children are major consumers of such processed food items.

"What is disturbing is that while some producers of the products have long ago complied with the recommendations, others continue to ignore them entirely," Brown said. "We know that trans fats can be relatively easily removed from these products but some companies it appears just can't be bothered, despite the known health risks to the consumers. And it seems, without regulation these companies will likely never bother."

Failing any new regulations, be sure to tell patients that trans fats may extend the shelf-life of their favourite processed foods, but will likely shorten theirs.

Fed's Canada example not worth emulating
February 11 | Matthew Sylvain, staff writer

A press release of earlier today, where Health Canada re-announced (that is, announced news it'd already announced) $500 million in spending for Canada Health Infoway, reads: "many other countries are following Canada's adoption of electronic medical records."

Excuse me? Many other countries are following our (inferred) leadership in the uptake of EMRs? While technically true, that's a great massage of reality: it's like saying that my finish in the 2008 Toronto half-marathon‹the 497th runner to do so‹was an inspiration to the runners who came after me (all 4,000 of them), ignoring the performance of the 496 who crossed the tape head of me‹including, of course, the winner.

To keep with the sports analogy, Canada's EMR performance is simply abysmal by the standards of the big league countries we ordinarily compare ourselves to socio-economically. For example, in an often cited 2006 study of more than 6,000 primary care by the Commonwealth Fund, Canada, at 23%, had the lowest percentage of doctors using EMRs. Netherlands was the race leader (98%), followed by New Zealand (92%), the U.K. (89%), Australia (79%), Germany (42%), the U.S. (28%).

While three years has past, it's safe to say Canada has not caught up to any of these countries. Credit the federal government this: The $500 million is indeed needed by Infoway.

SOGLAD still moribund but gay med student group rolling
February 11 | Michelle Cinelli, Medical Post intern

If you've been checking, SOGLAD (Southern Ontario Gay and Lesbian Association of Doctors), is currently not operating because the group is in need of a leader.

But GLBTMeds (Gay, Lesbian, Bisexual and Transgendered Medical Students of Canada) can be an alternative for anyone looking for support or information.

GLBTMeds was originally started slowly in the mid-1990s at the University of Toronto as a support system for GLBT medical students. Picking up steam from 2003 to 2005, the group grew nationally and not only has links to other groups on the website
(http://www.utoronto.ca/diversity_in_medicine/glbtmeds/) but also has a email list that any doctor, student or university faculty member can join for networking, support, and information on events nationwide.

The group was outraged after reading that close to 20% of medical students still thought homosexuality was "immoral" in 2004 (The Medical Post, May 11), and have been working ever since to eradicate prejudice from coast to coast.

Medical Post looking for viral emailed medical humour
February 11 | Colin Leslie, editor

For an unusual Last Laugh item in an upcoming issue of the Medical Post we're hoping to look at viral email humour (you know, the kinds of things a doctor friend of yours thought was funny and forwarded to you by email). Here's a sample of one such involving sentences supposedly typed up by National Health Service secretaries in Glasgow:

- "The patient has no previous history of suicides."

- "Patient has left her white blood cells at another hospital."

- "The skin was moist and dry."

- "Examination of genitalia reveals that he is circus sized."

So . . . if you have examples like this of emailed medical humour (could be just text or could be YouTube or forwarded videos or even forwarded still pictures), please send them to me for the next few weeks (colin.leslie@medicalpost.rogers.com). We'll going to try and confirm the veracity of some and then run samples as mentioned on the Last Laugh page of an upcoming Medical Post!

Waiting for the doctor
February 10 | Joe McAllister, senior editor

Take a look at your waiting room, with its desolate patients flipping through your collection of People magazines circa 1996. Think of the cost of keeping your patients waiting. Alan Krueger, an economics professor at Princeton, took a look and calculated that Americans age 15 and older collectively spent 847 million hours waiting for medical services to be provided in 2007.

Writing in the Economix blog on the New York Times website, (February 9/09) Krueger used average hourly wages paid to Americans to suggest that time spent in waiting rooms cost Americans $240 billion in 2007, an uncounted cost that would add about 11% to total health care expenditures.

The equivalent would be about $24 billion for Canadians, presuming we spend about the same time in our waiting rooms.

Maybe wait times in Canada are longer, given our doctor shortages, but when you hear about problems in health care south of the border, they all sound depressingly familiar to Canuck ears.

The Wall Street Journal's Health blog reported last summer on a U.S. government report that found there 119 million emergency room visits in 2006, an increase of 36% in the decade from 1996. Yet the number of emergency rooms actually fell, from 4,019 to 3,833. The rate of ER visits per 100 people rose from 34.2 to 40.5 in that same decade.

And its not the uninsured who are driving ER visits. They accounted for between 17% and 18% of ER traffic in both 1996 and 2006. The rise is due to the inability of the insured to get prompt care at the doctor's office.

So stop reading online blogs and get back to moving patients out of the waiting room. Or at least update your magazine subscriptions.