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Friday, November 9, 2007

Jacques Chaoulli, hero of the proletariat

Dr Jacques Chaoulli's Supreme Court win struck a blow for the common man, according to economist Larry MacDonald's rather unusual reading of the matter, published yesterday in Canadian Business Online under the title "Lawyers: Another conspiracy against the laity?"

The title comes from a George Bernard Shaw quotation: "All professions are conspiracies against the laity." (Keep in mind that he also said, "Every doctor will allow a colleague to decimate a whole countryside sooner than violate the bond of professional etiquette by giving him away," and, "At present, intelligent people do not have their children vaccinated, nor does the law now compel them to. The result is not, as the Jennerians prophesied, the extermination of the human race by smallpox; on the contrary more people are now killed by vaccination than by smallpox." The US National Library of Medicine has a nice overview of vaccine hysteria, including George Bernard Shaw's role.)

Expand this post for an excerpt from Mr Macdonald's article.

Montreal doctor Jacques Chaoulli spent eight years representing himself all the way up to the Supreme Court where in 2005 he successfully persuaded the top court to strike down Quebec's ban on private medical insurance. One of his suggestions for improving the legal system: Canadian lawyers should provide consulting services for people who want to represent themselves, just like lawyers in the U.S. do (which is a lower cost alternative to direct representation).

Deborah Rhode, a Stanford law professor and leading scholar on legal ethics, argues in her book, Pro Bono in Principle and in Practice (2005), that lawyers bear an ethical duty to ameliorate "their monopoly's deleterious effects" by doing more pro bono work for those who are disenfranchised. After all, "the state-sanctioned scarcity of legal services" is the reason for their affluence, she writes.

To be fair, the problem lies not entirely with the law societies. The complexity of court procedures also contributes to delay and high costs (the Supreme Court of Canada's Web site has a section on self representation that advises: " … it is a good idea that you get a lawyer as the procedure is complicated"). It thus follows that another part of the solution would be to simplify the tangled web of court procedures.

Until fees come down, litigants can save themselves a fortune and register a vote against a cartel-like arrangement by joining the do-it-yourself trend running through other industries such as investing and real estate services. The great enabler, of course, is the Internet, which yields easy access to any Canadian statute, regulation, or case. If you have the time and dedication to do it right, success is possible, as Chaoulli demonstrated.

Photo: National Review of Medicine

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Audit exposes Quebec Health Ministry woes

Quebec Auditor General Renaud Lachance (right) released his latest annual report last week, on November 1. In it, he provides a scathing critique of the way that the province's Ministry of Health and Social Services is governed. His biggest complaint is the lack of accountability of health organizations' boards of directors, he explains in a press release (PDF):

In Québec’s health and social services network, some 3,500 members who make up the boards of directors are responsible for the governance of health and social service agencies as well as public institutions. In 2006-2007, these authorities were entrusted with the management of budgets totaling close to $13 billion.

One is forced to admit that good practices in the governance field are not applied sufficiently by the boards of directors. This situation concerns, among other things, their collective skill profiles, their independence, the training of their members and their participation in the strategic exercises of the entity. It follows that the boards of directors do not fully occupy their rightful place, which detracts from their effectiveness.

Moreover, the Ministère de la Santé et des Services sociaux must clarify its expectations, notably those related to the accountability of boards and those pertaining to reporting obligations. It is important to dissipate the confusion that reigns concerning the roles and responsibilities entrusted to the stakeholders. In addition, the Department should do more when it comes to the electoral process pertaining to the appointment of directors of institutions. Indeed, public participation in the last elections was below the 1 percent mark.
You can read the full report online, or expand this post to read the chapter on health governance.


The following is the full text of Chapter 4 of the Auditor General's report:
Governance in the agencies and public institutions of the health and social services network

Audited Entities:
• Ministère de la Santé et des Services sociaux
• health and social services agencies
• public institutions of the health and social services network

4.1 As a general rule, the concept of governance refers to the processes whereby
organizations are directed, controlled and have to report on their activities.
Based on the principles of transparency, integrity and accountability, governance
deals with the structures and processes related to decision-making,
accountability, control and conduct at the top of organizations.
4.2 In Québec’s health and social services network, some 3,500 members who
make up the boards of directors are responsible for the governance of the
health and social services agencies as well as public institutions. For the
2006-2007 fiscal year, these authorities were entrusted with the management
of budgets totaling close to $13 billion.
4.3 Our objective was to verify that the current structures and processes allow
the boards of directors to ensure good governance. We carried out our work
with the Ministère de la Santé et des Services sociaux (MSSS) and boards
of directors chosen from among the regional authorities and institutions.
Several members, including presidents and executive directors or executive
directors, were interviewed, while other directors were asked to complete
a questionnaire. Our audit, which took place from July 2006 to July 2007,
covers the activities of the 2005-2006 year, but some comments concern
situations before or after that period.
4.4 One is forced to admit that good practices in the governance field are not
applied sufficiently. What is more, the boards of directors do not fully
occupy their rightful place, which detracts from their effectiveness. Similarly,
the MSSS must perfect some of its approaches while making sure that it
clearly makes known its expectations, notably those related to the accountability
of boards and those concerning reporting obligations.
4.5 Here are the main conclusions drawn from our work:
• In the case of both agencies and institutions, the roles and responsibilities
of the board of directors and its committees, as well as of top management
are already defined in relation to one another and in relation to
the upper levels and the minister. Despite this fact, a certain confusion
reigns in reality and it tends to be more pronounced in the case of agencies.
Efforts must be made to ensure that the roles and responsibilities
assigned to stakeholders are well understood and that the actions taken
comply with the Act.
Boards of directors should give themselves the means so that each one
collectively possesses the skill profile, independence and commitment
required to accomplish its duties. As for the MSSS, it should take additional
measures to make better known the electoral process pertaining
to the appointment of directors of institutions by aiming notably to
increase the tangible involvement of the public. Indeed, public participation
in the last elections was below the 1 percent mark.
• The members of boards of directors receive training to variable degrees.
However, since no policy has been adopted to structure the activities
offered, some needs go unmet. Among the subjects warranting special
attention, mention may be made of the roles and responsibilities and the
principles inherent to sound governance.
• Ordinarily, the boards of directors – be it in the case of agencies or
institutions – proceed with the approvals submitted to them. However,
their actions should be reinforced. The effect of this would be to increase
their influence on the performance of organizations. For example, their
contribution in strategic exercises is not optimal. Furthermore, no mechanism
is provided to systematically assess the effectiveness of boards of
directors and that of their committees. It should also be pointed out that
there is little to no reporting on their activities.
• As for the documentation produced at all levels (MSSS, agencies and
institutions) to reflect the objectives aimed for and the results obtained,
there is a lack of integration between the strategic plans, the management
and accountability agreements and the annual management reports.
Furthermore, our work reveals that the upper levels provide very little
feedback on the strategic plans and annual management reports of agencies
and institutions. Moreover, since these documents often have shortcomings,
the interpretation of the overall performance of the health and
social services network and each of its parts often proves difficult.
Recommendations
4.6 This section brings together the recommendations made in our report. It
should be noted that for information purposes, the number of the paragraphs
in question is indicated in parentheses.
(4.37) We recommended to the department that it clearly establish its expectations
regarding the roles and responsibilities of the boards of directors
and the top management of agencies and institutions, notably with
respect to their accountability and their reporting obligations, by considering
what is stipulated in the Act.
(4.64) We recommended to the department that it:
• make the necessary efforts to increase public participation in elections;
• rule on the question of those members who in addition to being on
the boards of directors of agencies sit on the board of directors of
an institution of the same region.
(4.65) We recommended to the boards of directors of the audited agencies
and institutions that they see to it that sound governance practices are
applied, notably:
• devise a strategy in order to be able to benefit from the appropriate
skill profile to fulfill their mandate;
• take steps to ensure that their members represent the entity first
and foremost and that they see to it that the entity’s mission and
objectives are achieved at an optimal level.
(4.73) We recommended to the department that it offer adapted training for
the boards of directors of agencies.
(4.74) We recommended to the boards of directors of the audited agencies
and institutions that they establish a policy in the training field for all
of their members, in particular for newcomers in order to meet their
needs.
(4.94) We recommended to the boards of directors of the audited agencies and
institutions that they reinforce their actions to increase their influence
on the performance of their organization, namely:
• get more involved in the strategic exercises, notably the strategic
plan, the management and accountability agreement, the annual
management report, internal control activities, value for money and
risk management;
• regularly update their internal management by-law;
• rule on the management information that they wish to obtain: form,
frequency and timeframe;
• make an annual assessment of the effectiveness of their board, its
committees as well as each of the members;
• include in the annual management report the reporting of the board
of directors and its committees.
(4.113) We recommended to the department that it:
• make sure that the strategic plans of agencies and institutions are
submitted to the upper levels;
• make sure that the documents pertaining to its performance as well
as to that of agencies and institutions are integrated and coherent;
• make sure that the upper levels offer systematic feedback on the
annual management reports of agencies and institutions;
• make sure that the chosen indicators provide information on the final
purpose of the health care system, namely to improve the health
and well-being of Québec’s population as well as the accessibility,
continuity, quality and safety of care and services;
• make sure that the strategic plans, management and accountability
agreements and annual management reports of agencies and institutions
respect the legal obligations;
• see to it that the management and accountability agreements are
signed in a timely manner.
(4.114) We recommended to the boards of directors and to the top management
of the audited agencies and institutions that they:
• periodically carry out together a strategic planning exercise which
will include the setting of objectives, targets and indicators;
• jointly report on the results according to the objectives of their strategic
plan and their management and accountability agreement in
accordance with the legislation and good practices in this field.
Image: Office of the Auditor General of Quebec

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Thursday, November 8, 2007

Our most popular subjects

The following are the 11 most commonly used subject headings (Blogger calls them 'labels') on this blog:

1. private healthcare (21 posts)
2. Ontario (18)
3. law (15)
4. British Columbia (13)
5. journalism (8)
5. economics (8)
6. Alberta (7)
6. public health (7)
7. Dr Brian Day (6)
7. oncology (6)
7. Michael Moore (6)

(By the way, in case you didn't know, you can read our blog by subject heading instead of chronologically, if you like, by clicking on a label. I've provided links for the ones listed above.)

The five most widely read entries are listed in the sidebar, on the right-hand side of the page. The list is updated occasionally. I updated it today, and the top five are:

1. Public health boss blasts Maclean's for HPV 'guinea pig' hysteria
2. Medicare defenders roll out Trojan Horse
3. Canadian docs stage private care putsch
4. How to beat RateMDs, Round 2
5. The best way to die

Keep in mind that you can subscribe to receive updates from this blog by email, via Really Simple Syndication (RSS), or through Technorati by using the links provided in the sidebar.

Also, if you have a blog that you think we should include in our list of "More Health Blogs" in the sidebar, please let us know in the comments to this post.

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For vascular health, South Beach trumps Atkins

Not all fad diets are created equal, according to researchers at the University of Maryland. The Atkins, South Beach and Ornish diets all lead to weight loss but what happens when the weight plateaus, as it inevitably will? That's what one new study explored, presented this month at the American Heart Association's annual scientific meeting in Orlando, Florida -- with disappointing results for Atkins fans.

"It really is the Atkins diet that is the worst," cardiologist and lead author Dr Michael Miller, told the Montreal Gazette. "The Atkins diet caused the LDL (bad cholesterol) levels to go up by about 7 percent, whereas in the Ornish and South Beach diets ... they went down 7 to 10 percent."

The high-fat Atkins diet caused damage to blood vessels, increased bad cholesterol levels and showed higher inflammation markers than the low-fat South Beach or Cornish diets -- and that's after the diet was stopped.

Dr Miller asked, "Why not start out with a diet that will be healthier for you in the long run after weight loss?"

The University of Maryland has made available an MP3 recording of Dr Miller speaking about his research comparing the three diets:


(Alternatively, you can download the audio file on the school's website.)

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The latest from the CMA

The CMA, now under the leadership of Dr Brian Day, is turning its attention to hospital funding reform and medical school tuition assistance.

A CMA conference discussed hospital funding in late October. Dr Day said that patient-focused funding should replace our current block funding model:

We need some significant changes in the way we pay for health care delivery, especially in the institutional setting. We need to make hospitals more efficient and service oriented and treat patients, physicians and hospitals as value centres, not cost centres.
One interesting piece of news from that CMA update is the mention of a "special working group" recently established "to investigate patient-focused funding as it relates to both hospitals and physicians." The group will submit a proposal to the board of directors of the CMA next year, so it appears patient-focused funding won't soon be forgotten. It will be interesting to find out whether any federal political parties take up the cause. (I wrote about Dr Day's patient-focused funding proposal in February.)

The CMA is also taking a look at governments' role in keeping medical residents' expenses down. In late September, Dr Day wrote to federal Health Minister Tony Clement:
Many Canadians might not recognize that increasingly onerous medical student debt levels are an important health human resource issue. Concern about medical student debt limits the accessibility of a medical education and may also affect diversity within the medical profession. [...]

A recent survey of residents found that their average accumulated debt has reached $158,000, almost four times the average debt of British medical graduates. Moreover, this level of debt is growing since resident trainees are required to start repaying interest and principal on government student loans immediately following medical school even though 2 to 7 more years of training remain. Residents do receive a relatively modest salary during postgraduate training, but they also have expenses such as mandatory fees. When combined with student loan repayment, this leaves little money for basics or raising a family. [...]

The federal government should allow medical residents to postpone [loan repayments] and allow new graduates to make career decisions based on where they can best contribute, and not on their accumulating debt.

Of course, the issue of med students' rising levels of debt isn't a new one. The results of the last National Physician Survey in 2005 pointed to the same problem. (See also the recent announcement from the Association of Faculties of Medicine of Canada that first-year medical school fees have passed $12,000 this year.)

Dr Day is the only person to be featured in an NRM Q&A twice; he first appeared in a Q&A last year, after he was elected CMA president, and then again this September, when he finally took office.

Photo: Dr Brian Day

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Killer traffic poisons Toronto residents

Toronto traffic jams can be murder... literally.

Car emissions kill some 440 Torontonians every year, according to a new study from Toronto Public Health (TPH) -- and they cost $2.2 billion in traffic-related pollution deaths and illness. (You can read the full report on their website, in PDF format.)

A mere 10% cut in traffic pollutants would save 63 people every year, the report said.

But not everyone is buying the TPH's 'alarmist' stats. Dr Ross McKitrick, environmental economics professor at the University of Guelph, told the National Post:

"I'm a bit worried when you have a report that looks like a set of policy conclusions in search of a rationale... There's all these policy changes they'd like to advocate for and the beginning sections were kind of filler to motivate that."
The study raises the possibility of road tolls and congestions charges to persuade people to use public transit.

Photo: Brent Foster, National Post

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Taser used on 68-year-old BC man

Yet another Taser incident in BC sparks yet another police review:

[68-year-old Kelowna man] John Peters double-parked his vehicle while picking up his wife Monday morning. As Anne Peters approached, a police car pulled up and one of the officers got out. [...]

The officer told Mr. Peters he was giving him a ticket for double-parking. Once Mrs. Peters got into the vehicle, Mr. Peters suddenly drove off. The officers drove after him and he pulled over in a parking lot.

“He should not have taken off. I convinced him to pull over, which he would have done anyway. I always try to get him to please be polite to the police officers, but he is who he is,” Mrs. Peters said.

Officers tried to arrest Mr. Peters but he raised his arm, refusing to co-operate. One of them grabbed him by the shirt, and Mrs. Peters told them her husband had suffered a stroke and has a neurological disorder that compromises his ability to understand language.

“Police zapped him twice with the taser,” she said. Mr. Peters also claims one of the officers punched him.

(CBC coverage of the incident is online here.)

Check out NRM's latest issue for more on recent Canadian Taser incidents and doctors' concerns about the danger of the guns causing ventricular fibrillation and the controversial invented diagnosis of "excited delirium."

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Wednesday, November 7, 2007

What's in the news: November

Here are some of the interesting items NRM wasn't able to include in our latest print edition (November 15-30, Vol 4, No 19).

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Once-yearly osteo med approved

Health Canada has approved zoledronic acid (Aclasta), the first ever once-yearly treatment for postmenopausal osteoporosis sufferers, Novartis Pharmaceuticals announced in a press release.

NRM
brought you the news of the drug's efficacy back in May, when the New England Journal of Medicine published the results of a three-year trial of more than 7,700 women. A single 15-minute infusion of zoledronic acid reduced the risk of spine fractures by 70% and hip fractures by 41%.

"The approval of a new medication is welcome news for the millions of Canadians who have osteoporosis," said Julie Foley, President of Osteoporosis Canada in the press release. Nearly 60% of patients on daily bisphosphonate treatments and 50% of those on weekly bisphosphonate meds don't stick to their drug regimen, and it's hoped the once-a-year dosage will offer those patients a treatment option they can more easily follow.

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Chinese toy beads contain date-rape drug GHB

Chinese toys aren't just tainted with lead, apparently. One toy, a kind of beads called Bindeez, also contains a chemical that metabolizes into the date-rape drug gammahydroxybutyrate (GHB), announced the Australian government today.

After three Australian children who swallowed the beads were hospitalized for seizures over the last two weeks, it was discovered that instead of the nontoxic chemical 1,5-pentanediol, the manufacturers had used 1,4-butanediol.

The drug information website Lycaeum has quite an extensive article about the dangers of 1,4-butanediol, but you should generally take their writing with several grains of salt. Although the conclusion of their article is that people shouldn't use the drug, some of the writing may be suspect. The piece was written by someone who goes only as "Murple," after all. This 2001 NEJM article, "Adverse Events, Including Death, Associated with the Use of 1,4-Butanediol," is a better source. The authors wrote:

We identified nine episodes of toxic effects in eight patients who had ingested 1,4-butanediol recreationally, to enhance bodybuilding, or to treat depression or insomnia. One patient presented twice with toxic effects and had withdrawal symptoms after her second presentation. Clinical findings and adverse events included vomiting, urinary and fecal incontinence, agitation, combativeness, a labile level of consciousness, respiratory depression, and death. No additional intoxicants were identified in six patients, including the two who died. The doses of 1,4-butanediol ingested ranged from 5.4 to 20 g in the patients who died and ranged from 1 to 14 g in the nonfatal cases. In some cases there was evidence of addiction and withdrawal. [...]

The health risks of 1,4-butanediol are similar to those of its counterparts, -hydroxybutyrate and -butyrolactone. These include acute toxic effects, which may be fatal, and addiction and withdrawal.
Yet another imported product for parents to worry about. But Moose Enterprise, the Australian company responsible for importing the toxic beads, says it has a solution: coat the beads with Bitrex, "the most bitter substance yet discovered," to make the beads "unpalatable." (The photo apparently depicts a child who's just tasted some Bitrex. Yuck.)

Update, November 8: Canada, too, has pulled similarly dangerous products, called Aqua Dots, from the market over GHB concerns.


Photo: Bitrex

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King Tut revealed in all his bucktoothed glory

King Tutankhamun is looking pretty good -- for a 3,000-year-old. The boy king's mummified face was shown to the public on November 5 for the first time since the discovery of his tomb in 1922 by archaeologist Howard Carter.

"With his beautiful buck teeth, the tourists will see a little bit of the smile from the face of the golden boy," said overjoyed Tutankhamunologist Zahi Hawass, who unveiled the remains.

Dr Hawass was instrumental in debunking the King Tut murder theory two years ago. CT scans, done in 2005, provided a complete health report on the 19-year old pharaoh. King Tut was apparently healthy, well fed and had the pronounced overbite of Egypt's 18th dynasty. The only jarring detail was a break in his leg, just above the knee.

"He was not murdered as many people thought. He had an accident when he was hunting in the desert. Falling from a chariot made this fracture in his left leg," Dr Hawass told reporters. The wound became infected and led to the king's death.

Photo: Discovery News

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Tuesday, November 6, 2007

Europe approves first advanced liver CA drug

Sorafenib, the oral anti-cancer drug commonly used for kidney cancer, earned the European Commission's (EC) seal of approval for advanced liver cancer treatment, on October 30. The manufacturer, Bayer Pharmaceuticals, is now waiting for decisions from Health Canada and the FDA.

In a press release, Bayer spokesperson Arthur Higgins said,

"The approval of Nexavar (sorafenib), a novel multi-kinase inhibitor, represents an unprecedented advance for patients with hepatocellular carcinoma (HCC) who, until now, had no approved systemic treatment options."
The drug -- already on the Canadian market for renal carcinoma treatment -- boosts HCC patients' survival by 44%, adding up to three months to their lives. NRM reported on sorafenib's dramatic results in June, when the research was presented at the American Society of Clinical Oncologists meeting in Chicago.

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