U of Manitoba program delivers care to natives, hope to aboriginal students.

In northern Manitoba and the Northwest Territories, aboriginal communities receive their medical care via a network of nursing stations run by the J.A. Hildes Northern Medical Unit at the University of Manitoba. Most care is provided by nurse practitioners and local health care staff, supported by weekly visits from Winnipeg-based physicians and weekend telephone consultations. It is hoped that more aboriginal students will eventually choose medicine as a career and return to live and work in their communities. The CMA helps support this goal through a bursary program for native students.     

Physicians and the pharmaceutical industry (update 1994). Canadian Medical Association.

The history of health care delivery in Canada has been marked by close collaboration between physicians and the pharmaceutical and health supply industries, this collaboration extending to research as well as to education. Since medicine is a self-governing profession physicians have a responsibility to ensure that their participation in such collaborative efforts is in keeping with their duties toward their patients and society. The following guidelines have been developed by the CMA to assist physicians in determining when a relationship with industry is appropriate. Although directed primarily to individual physicians, including residents and interns as well as medical students, the guidelines also govern the relationships between industry and medical associations. These guidelines focus on the pharmaceutical companies; however, the CMA considers that the same principles apply to the relationship between its members and manufacturers of medical devices, infant formulas and similar products, and health care products and service suppliers in general. These guidelines reflect a national consensus and are meant to serve as an educational resource for physicians throughout Canada.     

Medical publishing on the Internet: The CMA goes online

The CMA's Publications Department has created an interactive information service on the Internet, CMA Online (http://hpb1.hwc.ca:8400/), to provide physicians with rapid access to up-to-date clinical information and health care news, as well as to facilitate electronic discussion among health care professionals throughout the world and to provide information to patients. The CMA is the first national medical association in the world to do this. The service, part of the Internet's multimedia system known as the World Wide Web, is the first totally electronic product from the CMA. Because anyone with access to the Web can use the service, CMA Online will be an important vehicle for raising the profile of the medical profession in Canada and for disseminating health care information to the computer-literate public. It is tangible evidence of the CMA's commitment to provide strong leadership in the health care field.     

Experience with a Diabetic Service in an “Open” Hospital

A survey of the management of diabetes mellitus in an “open” hospital, Calgary General Hospital, was conducted in 1954 by reviewing the records of 100 consecutive diabetic admissions and by interviewing medical, nursing and dietetic staff members. The diabetic state was controlled satisfactorily by diet and insulin, but early diabetic complications and patient education tended to be overlooked by physicians. Diabetic management from the nursing, administrative and dietetic standpoints was considered to be inefficient, unpredictable and incomplete.

In 1955 a comprehensive diabetic service was instituted which co-ordinated the activities of medical, nursing and dietetic staffs and provided for patient education. A repeat survey conducted in 1961, in which the records of 87 consecutive diabetic admissions were reviewed, showed marked improvement in all areas of diabetic patient care.

Objections to voluntary conformity by staff members were surprisingly absent. The institution of a diabetic service is recommended for all hospitals as a means of improving diabetic care.

     

Federal health financing

The CMA believes that financial support from the federal government for health care should provide for the following. [List: see text]

The CMA is committed to preserving the right of reasonable access to high-quality health care regardless of ability to pay. It is also committed to maintaining the national health care standards (accessibility, universality, portability, comprehensiveness and public administration) and developing health goals to ensure that all Canadians receive the best possible care when required. The CMA supports the goal of maintaining the national integrity of the health care system. It encourages the federal government to be sensitive to the concerns of equity and to ensure that provinces and territories that have not attained a level of health care services and facilities equivalent to those of other provinces and territories, because of fiscal incapacities, have access to additional funding requirements to reduce the gap. The CMA views stability in funding as essential to effective health care planning and believes that unplanned and unilateral federal reductions may compromise accessibility and quality of patient care.

     

Future of health care has top priority at CMA's 1995 annual meeting

The CMA Board of Directors has taken the unprecedented step of organizing a series of strategic-issue sessions focusing on the future of health and health care. They will be held during the annual meeting Aug. 13-16. The objective is to establish a set of principles that will guide the board in developing short- and midterm policies and give direction for a CMA action plan dealing with the future Canadian health care system.     

Confidentiality, ownership and transfer of medical records

The Canadian Medical Association (CMA) regards medical records as confidential documents, owned by the physician/institution/clinic that compiled them or had them compiled. Patients have a right to information contained in their records but not to the documents themselves. The first consideration of the physician is the well-being of the patient, and discretion must be used when conveying information contained in a medical record to a patient. This medical information often requires interpretation by a physician or other health care professional. Other disclosures of information contained in medical records to third parties (eg. physician-to-physician transfer, lawyer, insurance adjuster) require written patient consent or a court order. The CMA is opposed to legislation at any level which threatens the confidentiality of medical records.     

Integrated delivery systems: has their time come in Canada?

In the 1990s every Canadian province is struggling to reduce health care expenditures without jeopardizing access to health care or quality of care. The authors propose a new model for health care delivery: the Canadian Integrated Delivery System (CIDS). A CIDS is a network of health care organizations; it would provide, or arrange to provide, a coordinated continuum of services to a defined population and would be held clinically and fiscally accountable for the outcomes in and health status of that population. A CIDS would serve 100,000 to 2 million people; the care it would provide would be funded on a capitation basis. For providers, there would be explicit financial incentives to minimize costs. At the same time, service quality and consumer choice of primary care practitioner would be maintained. Primary care physicians and specialists would work with other health care service providers to offer a full spectrum of care. CIDS providers would form strategic alliances with community agencies, hospitals, the private sector and other health care services not managed by the CIDS, as needed. For physicians, affiliation with a CIDS that provided strong clinical leadership could be beneficial to their income stability and autonomy. Pilot projects of this model in several communities would determine whether this concept is feasible in the Canadian health care context.     

The Role of a Medical Faculty in Reorganizing Family Practice to Meet Current Community Needs

There exists a crisis in the delivery of medical services, particularly by family doctors of whom there is an apparent shortage.

A study of family practice in Kingston, Ontario, and in the nearby countryside indicates three critical needs in family practice: professional assistants for the family doctors, efficient office facilities and new methods of delivering family medical care in rural areas. The Faculty of Medicine at Queen's University has involved itself in a study of these matters and is developing a program to help solve them, by research into the nature of the problems and into methods for alleviating them, by keeping practising physicians informed through research reports and the continuing education program of the Medical School, by the development of pilot projects, and by the evaluation of new services aimed at these problems, independently launched by physicians in the community. Pilot projects to date include two designed to study the use of registered nurses as doctor assistants and another which involves the organization and operation of a university-sponsored community health centre. Last, but by no mean least, the Provincial Government is continually briefed on all these activities.

     

Confidentiality, ownership and transfer of medical records (update)

The Canadian Medical Association (CMA) regards medical records as confidential documents, owned by the physician/institution/clinic that compiled them or had them compiled. Patients have a right to medical information contained in their records but not to the documents themselves. The first consideration of the physician is the well-being of the patient, and discretion must be used when conveying information contained in a medical record to a patient. This medical information often requires interpretation by a physician or other health care professional. Other disclosures of information contained in medical records to third parties (eg. physician-to-physician transfer for administrative purposes, lawyer, insurance adjuster) require written patient consent or a court order. CMA is opposed to legislation at any level which threatens the confidentiality of medical records.     

Focus groups confirm that MDs, public differ on role of private health care

Polls conducted by the CMA in 1995 indicated that most physicians favour more private funding for Canadian health care. However, new information gathered in a series of CMA-sponsored focus groups confirms earlier findings that the public does not yet share these views. In March, a polling expert told the Board of Directors that physicians must be cautious in advocating a position on the issue.     

Physician need. An alternative projection from a study of large, prepaid group practices

To model a base level of physician demand in a managed health care system, we examined in 1983 the ratios by specialty of full-time equivalent physicians to health maintenance organization members in seven large, closed-panel health maintenance organizations, each with more than 100,000 members. The medical director of each plan was surveyed by mailed questionnaire and telephone interview to determine the plan's number of full-time equivalent physicians by specialty and members served. Out-of-plan physicians contracted by the group were included within the specialty distribution wherever possible. We compared our findings (4779.4 full-time equivalent physicians serving 4,297,790 members) with Graduate Medical Education National Advisory Committee and others' projections of physician need and supply. Based on this model and unknowns that might affect utilization, our study suggests that at least 111 physicians per 100,000 population would be necessary in a system that emphasized reduced utilization of services and that more primary care physicians would be needed than the Graduate Medical Education National Advisory Committee predicted would be available.     

Takeover of Ontario Blue Cross may be sign MDs will soon face US-style managed care.

The privatization of health care is becoming a major issue on the Canadian health care agenda, with even the prime minister musing that the Canada's medicare system may no longer be able to cover all medical needs. This would appear to indicate that there will soon be a growing market for private health care in Canada, and the recent takeover of Ontario Blue Cross by an American company, the Liberty Mutual Group, is a sign this market is being recognized. Milan Korcok says the privatization trend holds major implications for Canadian physicians, who soon may witness firsthand US-style managed care.     

Polls point to growing gap between MDs, patients over financing of health care

An unprecedented round of CMA polling points to some startling differences in the way physicians and patients perceive the financial problems facing Canada's health care system. One poll indicates that doctors consider recent federal budget cuts a sign that the private sector will soon have a major role to play in health care financing. However, a poll of nonphysicians shows that Canadians oppose any move toward “out-of-pocket” payments for health care services, including payments for private insurance. The CMA board has responded by turning much of the 1995 annual meeting over to the topic of the future of health care in Canada, including financing, and the medical profession's response.     

General Council insists on retaining role as CMA's key policy-making body

General Council has reaffirmed its role as the CMA's primary policymaking body. Rejecting key elements of a report from the Committee on Structure that would have made General Council advisory to the Board of Directors, delegates at the 129th annual meeting said the current structure serves members well and does not need to be changed. However, there was considerable support for measures that would provide increased representation for young physicians and medical students. Delegates discussed how to make the annual meeting more representative of CMA members, then referred the report to the Board of Directors.     

Joint statement on resuscitative interventions

This joint statement includes: guiding principles for health care facilities when developing cardiopulmonary-resuscitation (CPR) policy; CPR as a treatment option; competence; the treatment decision, its communication, implementation and review; and palliative care and other treatment. This joint statement was approved by the Canadian Hospital Association, the CMA and the Catholic Health Association of Canada and was developed in cooperation with the Canadian Bar Association.¹     

Population-health concept challenges dominance of clinical medicine.

As the emerging policy concept of population health challenges the dominance of clinical medicine in health care, many question how it will affect "grass-roots" physicians. Although primarily a planning tool for policymakers that provides a framework to study the determinants of health, health outcomes and health interventions, population health can also be applied to medical practice. The CMA identified population health as a priority issue in March 1994, and has sponsored several presentations and workshops on the issue. On Jan. 23 three CMA Councils will meet jointly to discuss the implications this new policy holds for physicians.     

The legal assault on physician—patient privilege

Can there be appropriate and just disclosure of medical and therapeutic records, given that such records are defined and acted upon quite differently in the arenas of law and health? Medical and therapeutic records are kept for healing purposes, not as findings of fact for a court. However, Canadian courts increasingly are being asked to disregard privilege between doctor and patient when that patient has reported a sexual assault. The Supreme Court will soon rule in two cases that may change policies and laws and affect Canadian physicians, other health care professionals and hospitals.     

Heart-Alert: emergency resuscitation training in the community

One approach to reducing avoidable mortality from coronary artery disease is to provide resuscitation capability in the community. In Manitoba this is the function of the Heart-Alert program, sponsored by the Manitoba Heart Foundation. The program is based on public and professional education dealing with the recognition and immediate care of cardiac emergencies, including cardiopulmonary resuscitation (CPR). The three components to the program are (a) training in basic CPR for all health care and community rescue groups; (b) training in definitive CPR for physicians, critical care nurses and advanced emergency medical technicians; and (c) education of the public to recognize the signs of impending or actual cardiac emergencies and to take appropriate action to summon quickly an emergency rescue team.

The initial emphasis of the program has been on developing an organizational structure and a training network for basic CPR. A corps of instructor-trainers and instructors has been certified to implement CPR training in the medical and community target groups. Developmental problems include problems of quality control, of providing for self-sustaining and continued expansion, and of evaluation of the overall results.

It is suggested that widespread implementation of CPR training is facilitated by the incorporation of CPR into existing training activities, particularly those of the medical, nursing and other health care disciplines, those of community protection agencies such as police, fire and ambulance departments, and those of volunteer groups concerned with rescue work and first-aid. If the impetus, organizational structure and instructor training are provided by a strategic agency, wide dissemination of CPR training is then possible at relatively modest cost.

     

Bioethics for clinicians: 28. Protestant bioethics

“PROTESTANT” IS A TERM APPLIED TO MANY DIFFERENT Christian denominations, with a wide range of beliefs, who trace their common origin to the Reformation of the 16th century. Protestant ideas have profoundly influenced modern bioethics, and most Protestants would see mainstream bioethics as compatible with their personal beliefs. This makes it difficult to define a uniquely Protestant approach to bioethics. In this article we provide an overview of common Protestant beliefs and highlight concepts that have emerged from Protestant denominations that are particularly relevant to bioethics. These include the sovereignty of God, the value of autonomy and the idea of medicine as a calling as well as a profession. Most Canadian physicians will find that they share certain values and beliefs with the majority of their Protestant patients. Physicians should be particularly sensitive to their Protestant patients' beliefs when dealing with end-of-life issues, concerns about consent and refusal of care, and beginning-of-life issues such as abortion, genetic testing and the use of assisted reproductive technologies. Physicians should also recognize that members of certain Protestant groups and denominations may have unique wishes concerning treatment. Understanding how to elicit these wishes and respond appropriately will allow physicians to enhance patient care and minimize conflict.