Canadian Medicine

It's that time of year again: the NHL all-star game, the Super Bowl, and the Canadian Medical Association presidential election.

There's no "skills competition" and victory is celebrated more frequently by sincere congratulations than by synchronized end-zone gyrations, but the CMA presidency has nevertheless become a major annual event of late, thanks in part to the high-profile work done by recent reformist presidents Dr Brian Day (2007-08) and Dr Robert Ouellet (current).

Three candidates are on the ballot this year in Ontario:

Dr John Tracey, family physician, Brampton
This isn't the first time Dr Tracey has run for the OMA's nomination to become CMA president. He ran last time Ontario was preparing to hold the rotating CMA presidency, in 2003, and won. However, he never became president. As I wrote a few months ago in an article on the conflict between the OMA and the dissident Coalition of Family Physicians of Ontario, "Dr Tracey, who was then the Chair of the COFP’s Political Action Committee, won the [2003] election to become Ontario’s nominee as Canadian Medical Association president, beating out five former OMA presidents. But a surprise “nomination from the floor” during the CMA’s subsequent vote several months later -- which is usually nothing more than a rubber stamp -- resulted in a dramatic victory by defeated OMA past-president Dr Albert Schumacher." (That was the last time a "challenge from the floor" was successful, though one was attempted in 2006 when Dr Jack Burak ran against Dr Day after losing to him in the British Columbia Medical Association's nomination election.) Dr Tracey represents, to a certain extent, the same school of thought on the role of the private sector in Canadian healthcare as Drs Day and Ouellet; in his position statement (see below) he calls for a reevaluation and modernization of the Canada Health Act. More information is supposed to be available at but the site is down at the moment.

Dr Jeffrey Turnbull, internist, Ottawa
Dr Turnbull, who was named to the Order of Canada in 2007, has emerged as the left-wing candidate in this election. The Ottawa Citizen that he was convinced to run by a group of Ontario physicians who believe, like he does, that the "publicly-funded system can be more efficient and do a better job." In his position statement, he writes, "Through new partnerships, a clear vision, dedicated advocacy and wisdom we can preserve the rich traditions of medicine within a publicly-funded health care system that serves our patients the way it is supposed to." The former president of the College of Physicians and Surgeons of Ontario and the medical director of the Ottawa-based Inner City Health Project, Dr Turnbull was recently appointed chief of staff of the Ottawa Hospital. Dr Turnbull's experience in medical education is extensive. He holds a Master's degree in education, and besides continuing to teach at the University of Ottawa, he served as president of the Medical Council of Canada. Dr Turnbull is one of the very few candidates for CMA president over the years who has never served on the board of directors of the CMA or a provincial medical association. Details about Dr Turbull are available in his position statement (see below) or online at .

Dr Deborah Hellyer, internist/respirologist/occupational medicine, Windsor
In addition to sitting on the boards of directors of the OMA and the CMA, Dr Hellyer teaches at the University of Windsor and is director of the Windsor Regional Hospital's Pulmonary Rehabilitation Program. Her main interest in running for CMA president, she says in her position statement (see below), is in improving the prognosis for Canada's health human resources. Her goal is to see Canada become "self-sufficient" in its production of doctors, and she was instrumental in making the idea of implementing physician assistants in Ontario a reality. She doesn't address the public/private debate directly in her position statement, instead simply closing with the vague line: "The CMA direction and goals resonate strongly with my personal philosophy." Out of all three candidates, Dr Hellyer was the only one to add a personal note to her position statement: "I have two adult children and English Bulldogs," she wrote.

Voting began yesterday and ends February 26. OMA members can vote by mail using the ballot mailed to them or online at .

This month's election is, technically speaking, not the CMA presidential election but rather the Ontario Medical Association's vote to nominate a candidate for the CMA presidency, which rotates between provinces every year.

The election winner will -- if he or she doesn't meet the same fate as Dr Tracey did in 2003 -- become CMA president in 2010. The 2009-2010 president, Saskatchewan family physician Anne Doig, was elected last year and takes office after her inauguration at the CMA's annual meeting in Saskatoon in August. (Read my Q&A with Dr Doig .) Ontario Medical Association members are now voting on whom they want to nominate for the job of president for the 2010-11 term. The 2011-12 term will go to Newfoundland and Labrador, with their medical association's election to come next year.


POSITION STATEMENTS AND CVs

Dr John Tracey

Colleagues:

I am respectfully seeking your support for the nomination for President-Elect of the Canadian Medical Association. We are all proud members of our profession and value the contribution that it brings every day to the healthcare of Canadians, our patients.

Overwhelmingly, patients and physicians agree that we must work hard to preserve and enhance our current publicly-funded, universal healthcare system.

However, we face an ever-growing catalogue of system stresses; indeed, the literature states that by many comparative measures, Canada is not performing well. We know it and our patients feel it.

Major change is required if we are to become a world leader again. However, the recent federal election failed to provide any clear policy initiatives from any of the parties. We seem to have entered into a time of political instability and ‘healthcare agenda fatigue’ with no clear direction.

It would be remiss not to address the fiscal realities that our healthcare system is currently facing- none more so than the recent severe economic recession. The Canadian government will likely introduce a series of Federal deficit-financing infrastructure projects. There are few better investments for Canadians than to build out and upgrade the infrastructure for information technology, hospitals and medical schools. The cost is approximately $1 billion a year over a 10-year period to implement an EHR infrastructure for every patient in Canada. Along with the benefits to patient health outcomes, recent Canadian studies suggest that the return on investment would result in an estimated savings of $6 billion annually.

Intense pressures are also likely to occur on our physician resources as the US healthcare reform agenda seeks to attract 80,000 physicians to meet its current shortfall and projected targets. To ensure system sustainability, Canada needs to pay serious attention and introduce innovative solutions for retaining our current physician workforce.

The average age of Canadian physicians is 51.2 years. A defined benefit pension plan is regarded as an excellent retention initiative. Changes to the federal pension law that would allow independent- contractor physicians the opportunity to participate in alternative pension plans are revenue neutral for the federal government. There is member interest in this proposal and I intend to pursue this initiative.

The CMA is conducting a review of healthcare systems in selected OECD countries, notably in the UK. This is part of a major strategy to introduce transformational change to bring about patient- focused care in Canada. Proven to significantly reduce wait times, a patient-focused approach aims to align the healthcare system with the needs and expectations of patients in order to improve their access to treatment and information, and help ensure choice and participation in decision-making. Competition and improved service within a publicly-funded system, based on quality and efficiency, is promoted by using such strategies as changing hospital funding from block funding (global budgets) to a ‘service-based funding’ system. Furthermore, current CMA policy seeks to: eliminate or reduce waiting lists; develop a Canadian national strategy to ensure an adequate workforce of doc- tors and other healthcare professionals; and, establish a prescription drug insurance plan across the country - all of which I endorse.

In 2002, Hon. Monique Begin at The Institute for Research and Public Policy Conference spoke on the Canada Health Act, an act originally tabled to enforce the federal health financing formula. She believed that the CHA could be reopened and modernized, asking, ‘When do we start?’ I would say that right now would be fine.

There is a great deal of concern and frustration about the increasing demands for patient health information and the significant increase in time dedicated to the related administrative work. I have been consulting with the insurance industry and others about simplifying the process and reducing the increasing demands for medical information and reports. Doing so would allow physicians more time to see patients and increase access to care. Research shows that if we lessened the burden by 30% in Ontario, it would free up the equivalent of about 1150 FTE physicians-almost as many physicians as graduate in Ontario every year.

You and I know that experience means a great deal to CMA Council. Five years ago, I made the commitment to work hard on your behalf. Having spent over four years on the OMA board, three years on the CMA board, and contributing to many other committees and task forces, I feel I have acquired the necessary experience-at both the provincial and national levels-to gain the confidence of the CMA Council and my colleagues. With your support, I look forward to serving you and our patients.

Selected Experience:
-Emergency Medicine at Peel Memorial Hospital Brampton from 1973-1983
-Former Occupational Health Physician for Nortel Networks
-Medical Director of Peel Manor Home for the Aged from 1978-1990
-Past member of The Board of Medical Directors of Homes for the Aged for the
Province of Ontario
-Government of Canada Occupational Health and Safety Agency Designated Physician
-Former professional representative on the Peel-Halton District Health Council
-Ontario Medical Association Board Director (District 5 West) (2004 -)
• Past Member of the Physician Services Committee
• Chair of OMA Political Action Committee
• Co-Chair WSIB Steering Committee
• Chair Timely Return to Work Task Force
• Member of OMA Communications Advisory Committee
• Member of Urgent Care Centres Task Force
• Past Member of Local Health Integration Networks Task Force
• Past Board representative on Ontario MD IT Project negotiating team
• Past Co-Chair bilateral Task Force on Third Party Services
• Member of Negotiating Committee for Master Agreement Reassessment (2007)
-Canadian Medical Association Board Director (2004 - )
• Member of the Political Action Committee
• Chair of Task Force on GST Review
• Chair of Task Force on Member Communications
• Member of CFPC/CMA Primary Care Wait Times Initiative
-Former Executive Director of the Coalition of Family Physicians of Ontario

Dr Jeffrey Turnbull

It’s an honour to be considered for the presidency of the Canadian Medical Association. I do not take this responsibility lightly.

As former Chair of Medicine and now Chief of Staff at one of Canada’s largest hospitals, I see first hand the enormous challenges every physician faces in delivering quality health care within a system that is under resourced, poorly coordinated and over capacity. I believe our health care system works as well as it does only because of the extraordinary dedication of the professionals working within it.

The presidency of our national association is an opportunity to represent all doctors in accelerating the much need- ed reforms that we know must happen if we are to restore public and physician confidence in our health care sys- tem. Like you, I am disheartened by stories of patients who have had to wait too long for care when we have proven solutions that are just waiting to be implemented. As a practicing general internist, I am also aware of the many ways in which physicians and our colleagues in other professions are working hard to improve access to high quality care, and I am heartened by the many examples of success across Ontario and the country.

We are at a critical juncture in health care in Canada. Our needs are many, our economy is uncertain and Canadians will be looking to physicians to provide effective leadership to make our system better. We must advocate effectively to make sure our patients can obtain the care they need.

As a former President of the Medical Council of Canada I have already had the privilege to work in a leadership role at the national level. During my presidency of the College of Physicians and Surgeons of Ontario, I worked col- laboratively with the Ontario Medical Association to improve physician well-being for the benefit of our profession and our patients. I am particularly proud of the roles I have played in making medical education more responsive to community needs, in increasing opportunities for new physicians trained in Canada and abroad, and in fostering positive relationships between various medical organizations and government.

We need every physician to be involved in the fight for renewed investment and safer, higher-quality care. We need to strengthen our research infrastructure. We need to ensure that an educated public assumes greater responsibility for their health and their health care, while continuing to provide the professional care they depend on.

Importantly we need to depoliticize health care decisions. One of my goals as CMA president would be to ensure that policymakers consider the best available evidence when developing health care policy. This is a time of enormous change, but also a time of great opportunity. Through new partnerships, a clear vision, dedicated advocacy and wisdom we can preserve the rich traditions of medicine within a publicly-funded health care system that serves our patients the way it is supposed to.

Should you decide to give me your vote, I promise to work with all physicians to put our system back on track— family doctors and other specialists, urban and rural physicians, solo practitioners and those who work in groups or hospitals, as well as the medical students and residents who are entering medicine at this exciting and challenging time. I thank you for considering my candidacy.

Experience:
Member, Order of Canada
Past President, College of Physicians and Surgeons of Ontario
Past President, Medical Council of Canada

Current Appointments
Chief of Staff, The Ottawa Hospital, 2008-present
Medical Director, Inner City Health Project, Ottawa, 1998-present
Professor of Medicine, University of Ottawa, 1997-present

EXPERIENCED MEDICAL LEADERSHIP
As Vice-Dean and then Chair of Medicine at the University of Ottawa, and as President of the College of Physicians and Surgeons of Ontario, I worked at the local, provincial and national levels to promote excellence in education, research and clinical care. I have fostered productive and constructive working relationships with multiple partners, including the CMA, OMA and provincial and federal Ministries of Health. I am Chair of the CPSO’s Physician Human Resources Task Force and was Chair of the CMA future of Medicine Project.

COMMITMENT TO MEDICAL EDUCATION
I have had the privilege of being President of the Medical Council of Canada, a leader in the Educating Future Physicians for Ontario project, Chair of the American Association of Medical Colleges’ Group on Education Affairs and Chair of the Internal Medicine Specialty Committee of the Royal College of Physicians and Surgeons of Canada. I have helped make medical education more responsive to the needs of Canadians, and I have also led several curriculum development initiatives as Vice-Dean of Education in the Faculty of Medicine at the University of Ottawa.

POVERTY AND HEALTH
For 10 years I have provided services to chronically homeless people within the shelters of Ottawa as the Medical Director of the Inner City Health Project. This unique model of care has been proven cost-effective and gained national and international recognition. I have also helped develop health services in resource-poor settings in Bangladesh, Kenya and Nigeria.

Dr Deborah Hellyer

We do live in interesting times. In the present economic upheaval, healthcare has taken a back seat to the oppressing financial uncertainty, increasing unemployment, and threats of large corporation bankruptcy. It is just as crucial to continue to advocate for a sustainable healthcare system. Physicians, with their commitment to patient care are pivotal knowledge brokers. We advocate on our patients behalf for timely, quality access to healthcare. This has become increasingly difficult with inadequate physician resources, fragmented information technology, increased administrative burden, hospital deficits and regionalization. Stronger physician input into solution development is required. Physicians need to be heard. Through strong local grassroots district, provincial (OMA) and national organizations, changes will occur. A coordinated approach is required. Physicians must drive and direct the needed systemic changes needed to sustain Canadian healthcare.

The practice of medicine is rapidly changing to meet the demands of patient involvement in their care, physician demographics, recognition of the benefits of collaborative multidisciplinary care and the importance of balance in professional and personal lives. In this milieu, the role of physician as leader, coordinator of care and medical record keeper needs to be supported. Physician organizations need to aggressively promote the unique and vital role of physicians as the most trusted healthcare provider and strengthen awareness and support of the medical profession among key audiences.

Physician shortages in Ontario exceed 2400 physicians. A recent Institute for Clinical Evaluative Sciences (ICES) report revealed the impact of not having a primary care physician among people with chronic conditions. This report further emphasized the need for physician human resources as a top health system priority. A multifaceted, balanced, coordinated and creative approach is required in addressing recruitment and retention needs. Canada should strive to be self sufficient. As a Board member of the OMA and CMA, addressing physician shortages have been my priority. I chaired the OHRC and was CoChair of the Physician Human Resources Committee. In those capacities, I called for an independent and permanent Office for Physicians Workforce Policy and Planning in Ontario to coordinate system planning. I have championed the introduction of Physician Assistants provincially and nationally, promoting interprofessional solutions to the physician shortage, that do not compromise patient safety. I will not support extending the roles of other health care professionals in clinical situations where the physician is not the leader of the team. My experience and background demonstrate my commitment in this regard.

Another area that needs to be immediately addressed is the financial debt faced by medical students and residents. This exorbitant educational cost needs to be eliminated as a motivator for practice style choice and restrictor for medical school applicants. There is much that can be instituted to improve physician human resource needs. As an OMA and CMA Board member I have supported these measures and will continue this important work if I become Ontario’s CMA President.

During my tenure as Essex County Medical Society president, OMA and CMA Board member, I have been an advocate for physicians through the elimination of the Medical Audit Review (MRC), advancing physician human resources, medical and resident debt relief and through the implementation of the Physician Assistants project both provincially and nationally.

The Canadian Medical Association is at a crossroads. It is committed to renewal, having completed a five year strategic plan, implementation of the 2008 governance review and entering a search for a new CEO. The strategic plan addressed the need for a strong and effective CMA as the foundation for the goals of a healthy population, healthy patients, healthy profession and healthy physicians. The implementation of the governance review will improve efficiency of the organization and outreach to the membership. The CMA direction and goals resonate strongly with my personal philosophy.

Current Appointments
-Ontario Medical Association Board of Directors
Since 2002, I have: implemented the 2004 agreement; improved physician human resources; changed the Ontario
Medical Audit and Review process (MRC); promoted Interprofessional Care with physicians as leaders, advocated
for medical students and resident debt relief and improved member engagement. Committee involvement:
• Physician Human Resources Committee - co chair - bilateral committee with MOHLTC, to coordinate
physician human resources for Ontario
• Physician Services Committee (PSC) - implementation of the 2004 agreement and negotiation of the
reassessment
• Chair Implementation of the Physician Assistants project
• Health Policy Committee - development of policies
• Chair Medical Review Committee - input into Cory report and successful changes to the medical audit
system, monitoring implementation of Cory recommendations
• Supporter OMA Student Bursary Fund
-Canadian Medical Association Board of Directors
• Promoted improved communication between the OMA and CMA
• Chair of Appointments and Review Committee, member strategic planning
• Chair of 2nd National Symposium on Physician Assistants
• Strategic Planning Task Force
• CEO Selection Committee

Photos: Ontario Medical Association

The adoption of the incredibly simple World Health Organization Surgical Safety Checklist reduced the number of deaths by nearly half and cut medical errors by 43%, reported researchers from Toronto and seven other cities around the world in a published online yesterday in the New England Journal of Medicine. Though prior studies have shown similar results, albeit on smaller scales, researchers hope their findings can spur uptake of similar checklists.

"I would not undergo surgery unless I knew the checklist was being done," Dr Bryce Taylor, the University Health Network's chief surgeon and one of the NEJM study's coauthors, . The Canadian portion of the research was conducted at the UHN's Toronto General Hospital.

Just last year, Canadian reporter Graham Lanktree wrote about the absence of checklists in most Canadian hospitals, in an . Sunnybrook, in Toronto, uses a checklist, but research-ethics requirements have proven a barrier to their widespread use. "There's a long way to go before checklists will be routinely used," Dr Roy Ilan, who was responsible for implementing the idea at Sunnybrook, told Mr Lanktree. "Much of that has to do with medical culture. This new study may prove instrumental in changing the scenario in Canada. The UHN -- the country's largest teaching and research hospital institution -- has the checklist at Toronto General, Toronto Western and Princess Margaret hospitals.

The NEJM study was led by Dr Atul Gawande, a Harvard surgeon and New Yorker magazine staff writer. In 2007, he wrote about , inspired by Johns Hopkins researcher Peter Pronovost's groundbreaking and (until recently) woefully underappreciated work on checklists in critical care medicine.

The influential Institute for Healthcare Improvement, which is leading an initiative to get checklists into more US hospitals, heralded the study's results. "I cannot recall a clinical care innovation in the past 30 years that has shown results of the magnitude demonstrated by the surgical checklist," said IHI President Donald Berwick in . "This is a change ready right now for adoption by every hospital that performs surgery."

Illustration:

Botox injections can lead to the potential fatal condition "distant toxin spread," warned Health Canada. [] Details for health professionals are available .

This year's flu shots don't protect against most influenza B viruses. US government scientists are now studying the idea of including multiple strains of the influenza B virus in the vaccine, rather than trying to guess at which one will be most prevalent every year.

The University of Western Ontario recently celebrated the 40th anniversary of the establishment of the first family medicine teaching centre in Canada. []

The Ontario government broke -- or perhaps "bent" -- its promise to pay for prostate-specific antigen (PSA) prostate cancer screening for men, accused Ottawa Citizen columnist Richard Bercuson, the author of Assume the Position: One Guy's Journey Through Prostate Cancer. "The Ministry's Dec. 16, 2008, bulletin states the test will be covered under OHIP 'when it's ordered by a primary care provider for men who meet the test's clinical guidelines.'" wrote Mr Bercuson. "But if you don't have a primary care provider or meet those ominous 'clinical guidelines,' you pay."

An Ontario resident called for Health Minister David Caplan's resignation. "It is one thing to appoint a supervisor for a specific hospital that has been poorly run and, as such, poses unnecessary risks to patients therein. However, it is quite another to appoint supervisors to replace publicly elected boards such as has happened in Midland-Penetanguishene, Alliston and Scarborough," wrote Alan Bangay of Bracebridge in a letter to Mr Caplan.

The Alberta College of Physicians and Surgeons has written a new edition of its policy on how to deal with complaints against physicians, including a "code of conduct" for doctors. "Rude or even abusive behaviour from doctors toward other health providers isn't rampant, but the body that regulates physicians in the province says it's time to clamp down with a new code of conduct," reported the Canadian Press.

In 2008, Quebec surpassed its record for organ donations made in a one-year period, with 513 organs retrieved and transplanted. []

The Canadian Medical Association published a wish list for the 2009 federal budget, including requests for government investment in infrastructure and electronic medical records. The Canadian Health Coalition, which doesn't often agree with the CMA, agreed in this case -- with the proviso that the "stimulus must be directed to the public system, not to privatized, for-profit care. This means that all health infrastructure funding must be tied to public, non-profit ownership, with public control, management and operation of the facilities, equipment and services." []

To remedy the problem of Calgary-area physicians shutting down their practices because of rising overhead costs, Calgary Mayor Dave Bronconnier suggested that the provincial government build clinics next to community recreation centres and either give the space for free or lease it at a reduced rate to doctors. "I welcome that kind of creative proposal," said Alberta Health Services chairperson Ken Hughes. I wrote about the problem of rapidly rising overhead costs in Calgary in an article in 2007. "If you have a good secretary, they can literally walk across the street to any oil patch and see a substantive increase in pay," Dr Gerry Kiefer, then president of the Alberta Medical Association, told me.

Migraines are significantly associated with anxiety and mood disorders, reported researchers from the University of Manitoba and German in a new study.

Canadian scientists have become the first in the world to learn how to induce the growth of new blood vessels in damaged muscle. "Blood vessel regeneration suggests that the body's own cells might one day be used to repair heart damage and restore function," announced the University of Ottawa Heart Institute in a statement to accompany the publication of the new study in the Federation of American Societies for Experimental Biology Journal. [] "The Heart Institute team has created an injectable material that forms a 'smart scaffold' inside the body, which sends out signals to particular cells in the blood," reported the Canadian Press. "Those cells, called progenitors, can give rise to the type of cells that make up the lining of blood vessel walls." []

A new study in Blood showed that people whose blood has an excess of the Pk antigen are more susceptible to HIV. The study was conducted by researchers from Canadian Blood Services, Toronto's Hospital for Sick Children and Swedish scientists. "This study is not suggesting that your blood type alone determines if you will get HIV," said lead author Dr Don Branch in a release. "However, it does suggest that individuals who are exposed to the virus, may be helped or hindered by their blood status in fighting the infection." SickKids scientist Dr Cliff Lingwood said, "The conclusions of this study pave the way for novel therapeutic approaches to induce HIV resistance and promote further understanding of the pandemic as a whole." []

Montreal researcher Dr Martin Guimond announced the discovery of the method by which CD4+ T lymphocytes are stopped from regenerating. "[T]his study by Dr. Martin Guimond is likely to have a major positive impact on patients who undergo intensive chemotherapy, receive bone marrow transplants, or become infected with HIV," said the Maisonneuve-Rosemont Hospital in a release. [] [Canadian Press] La Presse profiled Dr Guimond, who returned to Montreal recently after a stint at the US National Institute for Health. [La Presse]

An endogenous protein previously believed to be harmless has been pegged as having a role in the spread of breast cancer, Canadian researchers found. "Until now, ARF1 has been associated with harmless albeit important housekeeping duties of cells," said University of Montreal pharmacology professor Audrey Claing in a release. "The Université de Montréal and the University of Alberta team is the first to characterize the role of ARF1 in breast cancer... Taken together our findings reveal an unsuspected role for ARF1 and indicate that this small protein may be a potential therapeutic target for the treatment of invasive breast cancers."

Among patients on methadone treatment for opioid addictions, depressed patients had significantly more physical problems than did patients without depression, reported a group of pharmacy researchers from Toronto's Centre for Addiction and Mental Health in February's Journal of Clinical Psychopharmacology.

In a November article in the British Columbia Medical Journal, Dr Romayne Gallagher blamed doctors for the health literacy problem that is so prevalent across Canada. "Doctors often don't explain things simply or properly, yet it's our obligation to communicate well," she told the Vancouver Sun's Pamela Fayerman. When I wrote about this subject, in 2007, the health literacy researchers I interviewed placed much more emphasis on the role of patients and the role of government in educating patients sufficiently; they pointed at public policy decisions as the culprit, to some degree.

Saskatoon urological surgeon Kishore Visvanathan loves waiting in line. "Being stuck in traffic, waiting at the grocery store checkout - they're all golden learning experiences if you're a student of queues. But nothing beats air travel..." []

The US Congress passed a bill to expand the State Children’s Health Insurance Program (SCHIP) that, if it becomes law by passing the Senate and being signed by soon-to-be-President Obama, would provide coverage for families who earn up to 300% of the poverty line -- a change projected to translate into insuring 4.1 million more children. The cost of the expansion is around $8 billion USD per year, and it will be funded by a new $0.61 hike in federal taxes on packs of cigarettes. Congress passed similar legisation, twice, in 2007, but both times President George W Bush vetoed the laws and supporters of the bills couldn’t rally enough support to override his vetoes. President Bush later agreed to sign a scaled-back version of the SCHIP extension to provide funding through March 31 of this year. President-elect Obama has already pledged to make the new SCHIP expansion “one of the first measures I sign into law” when he takes office next week. Some physicians are unhappy about one aspect of the new law, which will make it illegal for physicians to “self-refer” patients for treatment at hospitals they own a share of.

The New Republic's Jason Zengerle on the high rate of drug addiction among anesthesiologists: "It was understandable, perhaps, that Cambron was curious to experience these sensations himself, to feel what his patients felt once the drugs began coursing through their bodies. It could even be considered a clinical experiment of sorts."

"Bacteria on doctor uniforms can kill you," warned Committee to Reduce Infection Deaths chairperson Betsy McCoughey in an op/ed in the Wall Street Journal. For a light-hearted take on a deadly serious problem, check out this .

As one would expect about such an emotional issue, Canadian physicians are deeply divided about the current war between Israel and Hamas. Take, for example, the recent experiences of two Canadian MDs, Mark Clarfield and Miriam Garfinkle.

Dr Mark Clarfield, a Canadian geriatrician who now lives and works in Israel, has been documenting his experience of working within range of Hamas rockets. In the National Post earlier this week, he wrote about being forced out of his department's offices, which were deemed unsafe by the Home Front Command, and the hospital staff's urgent rush to move patients into the hallways when a rocket siren sounds. "For example just yesterday the alarm went off and I ran into the hall, crouching in the 'safe' area which would have done me no good in the case of a direct hit. Several seconds later I heard and felt a tremendous crash as the Grad rocket landed less than 100m from the hospital. I was lucky this time." [ and ] In his first entry on the British Medical Journal's website last week, he described his attempt to comfort a frightened woman in a bomb shelter at a Honda car dealership as the sirens wailed. "... I explained in my best evidence-based mode, while the chance of a rocket hitting someone was real, the chance of that particular projectile hitting us was very low. I used the lottery as an analogy, and the fact that I had never won, as proof. (As in most clinical situations, while one must never lie, one does not always tell the whole truth). I could see that my words were having some effect, and in order to keep calming her down, I just kept talking, going over my 'certainty' that nothing would happen to us. Fortunately, nothing did."

Dr Miriam Garfinkle was among the Jewish women arrested last week for occupying the Israeli consulate in Toronto to demand an end to attacks on Gaza, alongside Judy Rebick and others. [] [] Rick Salutin wrote about their protest. [] Dr Garfinkle is a member of the organization Health Professionals Against the Siege of Gaza, which in November called for the Canadian government to publicly oppose Israel's blockade of Gaza. In 2007 she wrote an article for the Canadian website Connexions about the medical disaster faced by Gazan children, blaming Canada for a share of the disaster. "After the 2006 election in Gaza, Canada was one of the first countries to withhold world funds from the Gazan authorities. This has left the population in a terrible situation."

Medical and law enforcement officials warned that the drug benzylpiperazine, or BZP, -- which is being used recreationally by Canadian partygoers, who buy it legally in the form of mass-marketed stimulants made by a Canadian company named Purepillz -- is potentially dangerous and may have been linked to several recent deaths. Adam Wookey, a Purepillz director, defended the product when confronted by the Canadian Press, saying that the company's drugs should be classified as harm reduction. "With this substance, as with every other substance, there is a risk... All it is is the risk is significantly reduced from anything you would be taking in place of it that would be its illicit counterpart," he said. "At the end of the day, if there is a risk to this product being taken off the market, that's an issue too." RCMP officer Scott Rintoul, a specialist in the rave scene, told the Canadian Press, "That's an irresponsible statement to say that BZP is a harm reduction drug. To wean people off of what? To take them away from ecstasy? I don't understand that." []

Police arrested Dr Uwe Schwarz, an anesthesiologist and researcher at the Children's Hospital of Eastern Ontario, in Ottawa. Dr Schwarz, who allegedly said he would kill his wife and co-workers, has been charged with uttering death threats.

In 2007, Ontario judge Jon-Jo Douglas refused to handle documents touched by an HIV-positive witness in his courtroom, and moved a case to a larger courtroom so he didn't have to sit near the HIV-positive witness. But since that incident and the subsequent backlash, the Toronto Star reported, he has made an effort to educate himself about the virus and visited a Toronto hospice for HIV/AIDS and shook hands with patients. We wrote about Justice Douglas's phobia last year. [Canadian Medicine]

It took 24 years, but finally researchers in Dr David Rosenblatt's McGill genetics lab have figured out the cause of a rare condition called cblF-Hcy-MMA that prevents the uptake of vitamin B12. Dr Rosenblatt first identified the disease in 1985. []

Eli Lilly reportedly will settle criminal and civil charges in the United States for unlawfully marketing its drug olanzapine, an antitypical antipsychotic sold under the name Zyprexa, to doctors for use in children and elderly patients, for whom the drug was not approved. The settlement will be as much as $1.4 billion, reported the New York Times -- a record amount for a whistleblower case. The drug allegedly caused serious side effects, particularly for many children who developed diabetes as a result of taking Zyprexa. The settlement may not augur well for Eli Lilly, which last July lost an appeal to have an Ontario judge limit potential damages in a $900-million Canadian class-action lawsuit.

Jailing intravenous drug users actually makes them less likely to stop injecting, a study in the January of the issue journal Addiction reported. The study, by the world-renowned research team at the BC Centre for Excellence in HIV/AIDS (including International AIDS Society President Dr Julio Montaner), found that being incarcerated within the last six months made addicts 57% less likely to quit injecting. They also found that getting methadone treatment made users 38% more likely to quit. Besides discouraging drug users from quitting, imprisonment also raises their risks of contracting HIV, Dr Montaner and two of the study's coauthors -- Evan Wood and Thomas Kerr -- wrote in a commentary published in The Lancet in 2005.

18% fewer aboriginal Canadians in northern Alberta had access to HIV care within one month as compared to non-aboriginal Canadians, according to a new government-funded study published online in the journal AIDS Patient Care and STDs. Patients over 45 years old and rural patients were also less likely to receive timely HIV care after diagnosis, wrote the group of federal, provincial and academic authors. [ (PDF)]

Karen Casey has been appointed to replace Chris D'Entremont as Nova Scotia's minister of health. [] A school principal before she became a Progressive Conservative legislator and rose to minister of education, Ms Casey (left) also has experience as the chairperson of the Colchester East Hants district health authority. "It’s a huge department," Ms Casey remarked to the Truro Daily News in a rather unenlightening interview. "With something that large it certainly brings challenges."

Quebec Health Minister Dr Yves Bolduc plans to study why 11 emergency rooms across the province regularly top an occupancy rate of 200% and have 24-hour wait times. [La Presse]

Dr Martina Scholtens, a Vancouver physician who sees plenty of immigrant and refugee patients, describes two recent unique cases in "That would hurt" and "Pain in his... what do you call it?"

The Toronto Star's Stuart Laidlaw blogged about a New York surgeon who, in his divorce proceedings, is asking for the kidney he donated to his wife to be returned to him, or for $1.5 million in compensation.

An update to what I wrote yesterday about Zimbabwe: the World Health Organization now estimates the death toll of the ongoing cholera outbreak to have surpassed 2,000. []

When the Supreme Court of Canada ordered Air Canada and WestJet to give obese passengers an extra seat for free if they are "functionally disabled by obesity" it opened a can of worms for physicians that it might not have anticipated. The two airlines announced their policies last week: passengers will be deemed eligible for a free extra seat only if they provide "a doctor's certificate of their disability or need for an attendant when travelling, as well as medical approval for travel," in Air Canada's wording. Now, the Canadian Medical Association -- which has long been waging a war against businesses requiring any form of a doctor's note -- is upset at the idea of having fill out even more paperwork that doctors feel should not fall to them. "The question of whether or not someone can fit into a specific seat on a specific plane is not a medical decision," said CMA President Dr Robert Ouellet in a release. "As much as we support the rights of these travellers, we do not feel that airlines should try and pass the buck to physicians over what is essentially a business matter.. We will be writing directly to Air Canada and WestJet asking that they immediately revisit their requirements for doctors' certificates." [CMA News] The airlines' policies show "a disregard for the use of scarce medical resources," Dr Ouellet said.

Alzheimer's patients treated with antipsychotics are twice as likely to die within three years as those who are not given antipsychotics, a new study in The Lancet Neurology reported.

Obnoxious teenagers are much more likely to develop mental health problems as adults, showed a new study in the British Medical Journal by a team of British researchers, led by psychiatric epidemiologist Ian Colman, a University of Alberta professor of public health. The study showed that teenagers with what are called "externalizing," or antisocial, behaviour are twice as likely as adults to suffer from severe symptoms of depression or anxiety, and 1.5 times as likely to report a history of "nervous trouble" or to abuse alcohol. They were also twice as likely as adults who had had non-aggressive youths to become parents before the age of 20, and marital and interpersonal difficulties were much more common, as were educational, employment and financial problems. Many of those connections have been made before, but Dr Colman's study -- a 40-year follow-up of over 3,600 residents of Great Britain -- has cemented the correlation, even after the researchers accounted for differences socioeconomic backgrounds, cognitive ability and adolescent mental health conditions.

Specially tinted glasses designed by a group of Toronto medical researchers may help reduce the health risks of nighttime shift work, such as an elevated incidence of breast cancer and heart disease. The yellowish lenses block a certain wavelength of light that appears to be responsible for hormonal changes in the workers. The glasses must still undergo further testing, including a trial involving night-shift nurses at Toronto Western Hospital.

Dr Ellen Warner, an oncologist at Sunnybrook Health Sciences Centre, in Toronto, has launched PYNK, a guidance and counselling program for girls and young women diagnosed with breast cancer. PYNK is the first Canadian breast cancer initiative targeted at young women. "On an emotional level, younger women face their breast cancer diagnosis while coping with intimate early relationships, fertility uncertainty, younger families, emerging careers, social isolation, body image issues, and need for personal time," said Dr Warner. []

In a new study, Toronto and Sherbrooke surgeons reported the rate of complications from the fairly new high-tech Gamma Knife surgical procedure. A very small percentage of patients who underwent Gamma Knife surgery had serious problems either during or afterwards, the authors reported. "Treatment is not risk free, and some patients will develop complications; these are likely to decrease as institutional experience matures. Expanding availability and indications necessitate discussion of these risks with patients considering treatment."

Should dentists and dental hygienists learn to recognize undiagnosed cases of diabetes based on their examinations of periodontal conditions? "There is sufficient evidence of a bidirectional relationship between diabetes and periodontal disease to formulate guidelines for screening for undiagnosed diabetes and the co-management of patients with diabetes in the clinical practice of dentistry and dental hygiene," wrote University of Manitoba periodontics professor Casey Hein. "For those dental and nondental practitioners who embrace the opportunity to become more actively involved in this important arena of healthcare, this new and exciting level of clinical practice is certain to benefit patients and be professionally rewarding."

The ratio of physical therapists to the general population increased much, much faster in the United States throughout the last two decades than it did in Canada, reported a new study published online by researchers University of Toronto and University of North Carolina at Chapel Hill. []

Physician for Human Rights, an advocacy organization based in Massachusetts, will release a report tomorrow calling for Zimbabwe President Robert Mugabe to be charged with crimes against humanity, reported GlobalPost. Charges should be brought against him for "presiding over the destruction of a health system and an economy. It is not mismanagement, it is calculated. It is criminal," Physicians for Human Rights CEO Frank Donaghue said. "The Mugabe government created the grounds for the cholera epidemic by allowing the water supply system to break down, by not repairing broken sewer pipes and allowing public water to become contaminated, by closing hospitals and allowing the entire health system to collapse... Cholera is not just a disease, it's a crime." More than 1,800 Zimbabweans have died of cholera since the disease began to spread last year.

"Can Playing the Computer Game 'Tetris' Reduce the Build-Up of Flashbacks for Trauma?" asked a new study. The answer, believe it or not: "Playing 'Tetris' after viewing traumatic material reduces unwanted, involuntary memory flashbacks to that traumatic film, leaving deliberate memory recall of the event intact. Pathological aspects of human memory in the aftermath of trauma may be malleable using non-invasive, cognitive interventions. This has implications for a novel avenue of preventative treatment development, much-needed as a crisis intervention for the aftermath of traumatic events... Further research is required but potential clinical applications of our paradigm include use by emergency services in the early post-trauma period, e.g. to victims of rape or delivering such tasks to populations subject to regular trauma exposure e.g. firefighters or those involved in armed combat."

What patients lie to their doctors about, and why.

The latest edition of the Health Wonk Review, the anthology of the best health policy writing by bloggers, is online.

Voting is open until this weekend for the Medical Weblog Awards 2008, hosted by Medgadget. Nominees for the best medical blog of the year are Clinical Cases and Images, Clinical Correlations, The Health Care Blog, Kevin, M.D., and the Wall Street Journal Health Blog. The only Canadian medical blog to turn up in any of the awards' categories this year is the Toronto Star's , by reporter Stuart Laidlaw.