Wednesday Night #1200

Recognition of recent deaths
There was a brief recognition of two recent deaths: Hunter Thompson, the inventor of “Gonzo” journalism, who even in death provoked a number of reactions, and a less flamboyant, but much more important figure, Jef Raskin , who created the Macintosh computer at Apple in the early 1980s, revolutionizing computer interface design. He also invented “click and drag” and other methods that we now take for granted.

News from the oil patch
The morning’s papers carried the announcement of Petrocan’s partnership with “upstart” UTS Energy Corporation in the Fort Hills tar sands project near Fort McMurray. Bruce Kippen expanded on the published news as he has been close to UTS for some time, working with management; UTS is the most junior company with the richest property in the tar sands, which has been producing for over 50 years with absolutely no decline. Petrocan has become a 60% partner, putting up $1 billion. Athabaska has reserves equalled only by Saudi Arabia, but for years it has been deemed uneconomic. This is no longer the case. China is still trying to get into the tar sands, but without success so far.

While the Annual Meeting of the AAAS (American Academy for the Advancement of Science) always offers a panoply of scientific topics, there were five or six symposia related to climate change and new energy policies more than ever before, reflecting the interest of the science community.
The current warming trend is expected to cause extinctions. Numerous plant and animal species, already weakened by pollution and loss of habitat, are not expected to survive the next 100 years. Human beings, while not threatened in this way, are likely to face mounting difficulties. Recent severe storms, floods and droughts, for example, appear to show that computer models predicting more frequent extreme weather events are on target.
The sea level rose on average by 10 to 20 cm during the 20th century, and an additional increase of 9 to 88 cm is expected by the year 2100, as higher temperatures cause ocean volume to expand, and melting glaciers and ice caps add more water. If the higher end of that scale is reached, the sea could overflow the heavily populated coastlines of such countries as Bangladesh, cause the disappearance of some nations entirely (such as the island state of the Maldives), foul fresh water supplies for billions of people, and spur mass migrations.
Agricultural yields are expected to drop in most tropical and sub-tropical regions — and in temperate regions, too, if the temperature increase is more than a few degrees C. Drying of continental interiors, such as central Asia, the African Sahel, and the Great Plains of the United States, is also forecast. These changes could cause, at a minimum, disruptions in land use and food supply. And the range of diseases such as malaria may expand.
While we have been hearing about overall global warming, a disquieting note is sounded closer to home: the snowmelt in the Rockies is coming much earlier and the streams are flooding about 9 days earlier, leading to much more drought because snow runs off too early in the spring. There was an interesting session on probability analysis applied to the global system, response rates of the system to climate change i.e. bird migrations come earlier, but at certain thresholds, the system becomes more sensitive and responses are irreversible at least in the medium-term i.e. in the boreal forests of western Canada and Siberia where there is much greater insect infestation.
For more information, the Pew centre is currently publishing a paper looking at different energy scenarios and their impacts on the environment.
There was solid representation from abroad, and active recruitment of American scientists by the UK, the EU, and the Germans.
Politics inevitably play a part in the development of any and all solutions (see California restrictions on oil emissions). There is little hope that the U.S. federal government will take any action as it continues its mantra that any such action “would be bad for the economy”.
This month’s Scientific American has a lead article on climate change which puts forward the hypothesis that our ancestors’ farming practices started warming the earth thousands of years before industrial society started burning coal and driving cars.
One guest suggested that implementation of the Kyoto agreement will not accomplish anything like a worldwide effort, tax credits and a number of other incentives, by governments to make it attractive and profitable for the number one cause of air pollution to disappear. If 15% of our cars were replaced by hybrid fuel-driven cars, that would do more in 2 years than Kyoto in 100. But this in turn would create another level of pollution. As usual, there are no easy solutions to a problem of global concern.

The medical crisis in Quebec
There is no doubt that there is a crisis in healthcare in Quebec. While Dr. Mark Roper confirmed the content of several news clips and reiterated some points that have been raised on previous Wednesday Nights, his guest, Dr. Sharon Johnston, Chief Resident at the Jewish General in the family medicine residency programme, lawyer and bio-ethicist [also founder of the Westmount Girls hockey team], addressed the areas of concern to the younger doctors who are being forced to leave Québec.
Montreal now has a shortfall of 300 family doctors. Patients cannot find a family doctor and 60% of family doctors are not taking new patients, with consequences for everyone who uses the health system. At the Royal Victoria Hospital there are 6,000 patients are now without family practitioners.
Many of the problems were precipitated a decade ago (when Paul Martin was Finance Minister) by reduction of about $9 billion in ’94-’95 of federal transfer payments (a cut of almost 45%), resulting in frantic cutting of provincial budgets.
Dr. Roper maintains that the theory of supply-side control was introduced into healthcare, with decreases in access to physicians, in beds, in OR time, in nurses, and in medical school numbers, limits on recruitment of physicians, and perhaps most damaging, the early retirement programme for physicians over 55 (’96-’98), whereby they could retire with the equivalent of three years gross billings or almost $500,000. No impact analysis was done on patient care.
Today, most politicians (Romanow, Bouchard, etc.) have publicly apologized for the effects of these policies, and are attempting to reverse the consequences but Québec under Minister Legault took a different stance, treating medical practitioners as employees, forcing them to work a given number of hours, take on emergency room duties and, finally, to live and practice in designated areas of the province.
While some disagree with the supply-side control theory, there is general agreement with Dr. Roper’s analysis with additional questions raised. We hear about waiting times and we hear about difficulties in obtaining doctors, but what are we trying to achieve? What are our health statistics? What is the rate of morbidity? What is the outcome? What is the impact on the health of the population?
There are rising costs. People are living longer; treatments, pharmaceuticals, hospital equipment, laboratories,- all are more sophisticated and more expensive;
Funding problems are easier to fix than the cultural ones [young mothers and the elderly with minor if any problems taking up emergency rooms]. As Beryl Wajsman pointed out in his piece In Critical Condition of September 13, 2004: “The $40 billion dollars spent on health care by Ottawa each year is exceeded in the Federal budget year after year by what has now grown to over $60 billion being spent on corporate welfare and politically correct pork-barrel vote grabs in social and cultural programming. … Health care may be a provincial responsibility under our constitution but it is no violation of that jurisdiction for the Federal government to put directives on the use of new funding.”
Is the UK official two-tiered system better than ours? The Canadian waiting list is 5 times that of the UK. UK experience is illustrated by the doctor who says: “I can do this procedure on a private basis within two weeks and it will cost you xxxx, or I can do it under the public health system and you will wait two to six months, but it is free”.
How do we get new – or any – physicians to practice in the remote areas? Quebec is doing it the wrong way and it’s going to cost the northern regions as well as the southern communities their physicians. It will hurt all patients.
Why don’t we do as Ontario has done save certain places in medical schools for people who come from different regions, and pay their tuition and a modest living expense and they in turn agree to return to practice in the remote areas for a number of years?
There are some success stories among new doctors who go to remote communities, but largely they go, serve their 4-5 years and leave, and this hurts the far communities that need us the most. However, shortages exist across the province. Two areas that have been touted by Minister Couillard as success stories under the provincial programme are the Mauricie and Lanaudière. According to the Index of access to GPs, the Mauricie had 84% of the Quebec average; the figure for the West Island of Montreal is 64% and DDO has the worst access of all areas of Quebec.
The system treats physicians as though they were pieces in a production line; there is absolutely no flexibility. Young physicians in Quebec are facing a situation whereby the have to apply for a secondary license that allows them each to practice in a certain region and bill at 100%; without that, they can practice wherever they choose, but only bill at 70% of gross income (with expenses of 50%) and the numbers have been restricted so that the medical schools will send their doctors to the more remote areas. McGill has 40 new residents finishing this year. Not one received a license to practise in Montreal. The McGill residents were informed that they had to apply one month after the licenses were no longer available. The francophone universities all were advised of the requirement to apply a month before the deadline. Many of the residents are married to someone in Montreal, Dr. Johnston has been given a license to practice in the Outtawais, 2½ hours away from home; her husband is a physician at the Montreal Children’s. Bureaucrats are apparently unable to understand why she would not work three weeks a month away from home and one week in a private office in Montreal.
The biggest losers are the patients; the 300,00 in Montreal without a GP. But no patients have come forward to demand a family doctor.

Canada’s refusal to participate in the US. Ballistic Missile Defence System is seen by almost all Wednesday Nighters as a major mistake and an unnecessary rebuff to the United States, given that the issue goes back to the 1980’s; participation in the current programme costs Canada nothing, Canadian industry would benefit from contracts; Canada would have a “seat at the table”, etc. At the very least, Paul Martin should have told George Bush when they were in Belgium together that he couldn’t deliver on his promises because of political reasons at home. Furthermore, the PM’s undercutting of his new handpicked ambassador to Washington, Frank McKenna, is disgraceful. Whether or not one agrees with the programme, all agree that the PM has totally mishandled the affair and that this presages some very unpleasant retaliation over the next months.

Some Quotes from the Evening
— If Quebecers stopped smoking tomorrow, the individual living in a major city (Montreal, Quebec, Sherbrooke), simply by being outside for 20 minutes a day, is breathing in the equivalent of a pack and a half of cigarettes because of the emissions of buses alone
— Every individual in this country has a right to medical care
— We need to do more to educate people to look after their health at a basic level (good nutrition, exercise)
— I have learned most of what really counts on the hockey rink: you don’t back down when the game is on the line
— We have a shortage of physicians and we have a shortage of physicians in some crucial areas
— The reality is that they (qualified students from remote areas) come to medical school, they meet friends, establish themselves in the community, they all become neurologists and stay in the big city
— We don’t have politicians who say to our society that the teachers and the healers are (at least) as important as entertainers and sports stars
— We also don’t have federal politicians with the guts to tell the provincial politicians that there will be strings attached to federal monies
— While it does cost a billion dollars to develop and bring a new pharmaceutical product to the marketplace, what the public doesn’t realize is that 80% of those costs are subsidized by the government in Ottawa or in Washington

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The Prologue

All are reminded that there is an exhibition of recent works by Wednesday Night’s OWN Herbert Bercovitz at the Gallery at Victoria Hall, with a vernissage at 6 pm on Thursday (March 3) and running until March 31. Pictures of the opening night of this stunning exhibition, by Robert Galbraith and David T. Nicholson

In the company of Wednesday Night’s OWN Dr. Mark Roper and at least one special guest, we will concentrate this Week on medical issues, especially those that have been making headlines (again) recently, and in particular the looming dearth of young family medicine practitioners who are being driven out of the province by policies of the Quebec government. Quebec has been losing nearly one-third of its new general practitioners to other provinces after a policy came into effect requiring them to start their careers outside of Montreal. The province is estimated to have an overall shortage of 800 GPs. Consider the forgoing in combination with findings from the College of Physicians that there were also 600 fewer doctors under 35 in 2003 compared with 1994, and among specialists, more than a third were more than 55, and more than 1,000 of them were older than 65. There is cause to worry.
We also expect Frank Kinnelly who has just returned from the annual American Association for the Advancement of Science (AAAS) annual meeting. He comments: “There were indeed a number of interesting sessions [including those on] new energy technologies and recent analysis of climate change impacts, … and I picked up quite a few links that should be of interest. … There’s not been much in the press, but the 5-year NPT review conference is coming up in May, and it very much looks like there could be a set-to between the Bush Administration and the rest of the world.”
Other topics that will certainly come up are the recent news of China’s proposed currency reform
The PM’s flubbing of the BMD issue Who read L. Ian Macdonald‘s scathing comments in Monday’s Gazette “Paul Martin’s duplicitous and craven handling of the missile-defence issue will permanently damage U.S.-Canada relations – all because the prime minister couldn’t make a decision”?
The Liberal Policy Convention – an oxymoron?
The evolving situation in the Middle East with the fall of the government of Lebanon and the recent announcement by Egypt that multi-party presidential elections are contemplated – is this, as the White House says, “a further sign of democratisation in the Middle East”? We think that Paul Wolfowitz was reaching when he compared events in Lebanon to the peaceful change that took place in Ukraine last year and in the Philippines in 1987, but possibly that’s just our bias speaking.
[Let’s not forget the prediction of #1198: Syria is going to be whacked within two weeks]
How time flies when you are having fun!
“Sometime in the early hours of Sunday morning Martha Stewart will walk out of the Alderson correctional facility in West Virginia, be whisked to her estate in Bedford, New York, and become the latest public figure to disprove F. Scott Fitzgerald’s famous truism that there are no second acts in American lives. Ms Stewart appears poised to equal if not surpass her pre-incarceration career.

Links for WN #1200
Quebec losing its new family doctors: report
The Quebec government’s attempt to direct new family doctors to more remote areas of the province has backfired.
Quebec has been losing nearly one-third of its new general practitioners to other provinces after a policy came into effect requiring them to start their careers outside of Montreal. Dr. Mark Roper works as a doctor recruiter for the McGill University Health Centre in Montreal. He says physicians outside Quebec won’t even consider moving there anymore.
Docs leaving Quebec despite shortage
Montreal doctor Mark Roper says a government rule that favours sending new doctors to rural regions is making the situation worse.
“What type of system prevents us from hiring doctors when the need is so great?” He’s part of an advisory committee that suggests to the province how many doctors need to be hired each year. “We needed 342 physicians in Montreal and in 2004 we were allotted a net gain of five,” Dr. Roper says.
Quebec’s 90 opt-outs
MONTREAL The Gazette, Feb. 15, 2005 — The number of Quebec doctors who have opted out of the public medicare system in the past five years has soared by 60 per cent, a Gazette study has found. Ninety doctors no longer bill the Regie de l’assurance-maladie du Quebec, and instead, charge patients for medically necessary services.
[See also Gazette Five-part series on private healthcare]
New GPs fleeing Quebec
The province had expected to recruit 216 GPs last year, but only 145 stayed on to practise in Quebec. This means that 71 doctors who were trained in Quebec – many at McGill University – decided to start their careers elsewhere. Those doctors who choose to stay in Montreal are docked 30 per cent of their pay. Before they can regain their full salary, they must first work for three years in an outlying region. “The thought was to redistribute doctors in the province of Quebec. It has really redistributed doctors into other provinces,” said Dr. Mark Roper, director of the division of primary care at the McGill University Health Centre. “The law of unexpected consequences is taking place here.”
Fewer Quebec doctors going into family practice: report
The shortage of family physicians showed no sign of abating, and a recent rise in the number of people studying medicine is unlikely to translate into greater number of doctors before 10 to 15 years’ time, according to the province’s College of Physicians. In the meantime, the College was calling for measures to soften the public impact of the shortage. These included, among others, a wider sharing of resources through the expansion of group practices, university health networks and integrated electronic access to patient records.
The College also argued it should be easier for foreign-trained doctors to practice medicine in Quebec, and that pay for family practitioners should be increased in order to attract greater numbers of newcomers. That 653 skilled medical professionals should leave Quebec in 5 years is scandalous. Medical practice in Quebec has to be made more attractive. Coercive measures concerning physician employment must be eliminated. We have to take a fresh look at how our system is managed and find new ways to fund it, while still maintaining the principles embedded in the Canada Health Act. Health care and the biomedical sciences have to aim for excellence. If we do that, then perhaps we will be able to offer our physicians a more attractive environment.
Jean-Sébastien Delisle Président Fédération des médecins résidents du Québec
See also CBC Healthcare In depth and NATIONAL PHYSICIAN SURVEY