Ottawa Citizen journalist Dan Gardner castigates, and rightly so, how Olympic athletes sell out to corporations for oodles of cash without any consideration for the potential harm to public health outcomes. His column can be read here.

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I am not a fan of how newspapers use headlines to misrepresent stories to provke unwarranted fear, and heightened risk perception. Today, the Ottawa Citizen published two stories about seasonal and H1N1 vaccine. The first story, For Guillain-Barre survivors, flu shot stirs up unwelcome memories, emblazoned on the front page has all the elements of what is regrettably become the norm in newspaper headlines. Headlines are not under control of the journalist. The article was written by Sharon Kirkey.

Ottawa Citizen journalist Dan Gardner’s book, Risk: The Science and Politics of Fear discusses this journalistic approach to sensationalizing news called the Example Rule.

This rule is used to present rare occurrences as if they are common or lurking among us, misrepresenting true risk. Therefore, it was no great surprise to read the front-page headline of today’s Ottawa Citizen continuing this tradition. It outlines the history of a woman who develops a rare neurodegenerative disease called Guillain Barre Syndrome (GBS) and implies a link to the flu vaccine.

The medical content of the story accurately presented the risks of developing GBS, about 1-2 per 100, 000 people. There is some evidence that indicates that the flu vaccine may add an extra 1 per 1 million people. However, the headline clearly did not reflect this. It cites one Ontario study that the seasonal flu vaccine increases the relative risk of contracting GBS by 45 percent.

The absolute risk change of the 1 in a million increase was mentioned immediately following the 45 per cent claim. This former should have been the only statistic cited.

Relative risk is presented to emphasize dramatic change. It is used by media, pharmaceutical companies, food manufacturers, and the Natural Health industry among others to bolster their health claims.

Relative risk does not provide context for the change in risk and should not be included in health reporting. However, it is the number that will be cited by the reader when they discuss this issue with others, hence the problem of skewed risk perception.

The story ends with the woman who had GBS stating, “I made a promise to myself, that if I ever walk again, I will do whatever it takes to keep whatever doesn’t belong in my body out of it.” Although it is understood that traumatic experiences can influence one’s sense of risk, the statement is used to conjure up the idea that unnatural substances are implicated in the disease process and are to be avoided.

If that were the case, one could argue that we should avoid touching any manufactured product, walking down the street and being exposed to car exhaust’s polyaromatic hydrocarbons, and using chemical cleanser’s and agents among others. Exposure to some of these potentially harmful compounds is likely in the parts per million or billion as well. We do not routinely think about this because our sense of risk from these everyday products and activities is low.

News reporting should present information with context. The public should be treated with respect, which includes removing the fear mongering for the sake of selling newspapers, TV and radio shows and magazines. Globe and Mail health reporter Andre Picard has commented on this issue as well as Dr. Noni MacDoanald in an article written for the Canadian Medical Association Journal.

The second story written by Pauline Tam, Our best shot against swine flu?, deserves kudos to the reporter for excellent evidenced-based content and science writing.

Ms. Tam accurately represented the uncertainty that is inherent in medical research yet clearly emphasized the strength of evidence against many misperceptions about the flu vaccine.

She covered the issue about adjuvants or immune system boosters and reviewed how the adjuvant improves efficacy of the vaccine. The adjuvant, squalene, is produced by our liver and is found in many foods as natural oil.

One wonders why, given the focus by some groups on how natural products are better than synthetic, there is such controversy. It would make sense that the logic should remain consistent.

Ms. Tam also reviews the preservative thimerosal found in some multidose vaccines and cites evidence from numerous reputable sources regarding its safety profile.

What Ms. Tam accomplished it to foster critical analysis of health information and present it in context allowing the reader to make an informed decision and risk assessment. She shows medical research is always evolving and is not perfect (nor should it ever be if we are to continue to learn) and how it is a jigsaw puzzle of information pieces that are brought together to create the best picture to date about flu vaccine efficacy and indication for use.

Background:

The evidence-based website Up to Date cites this data:

Vaccination — Guillain-Barré syndrome has followed vaccinations, but this danger may be overstated.

Influenza vaccination — In the United States, an increased risk of GBS was associated with the swine influenza vaccine in 1976, although the severity of the risk has been controversial. Subsequently, no increased risk was observed up to 1991.

Individuals who received either the 1992-1993 or 1993-1994 influenza vaccinations were not at significantly increased risk for GBS, but combining the two seasons suggested that influenza vaccination resulted in approximately one additional case of GBS per million patients inoculated. This risk appears to be substantially less than the overall health risk posed by naturally occurring influenza.

The annual reporting rate of GBS following influenza vaccination in adults declined significantly from 1996-1997 through 2002-2003 in the US. Nevertheless, the long onset interval for post vaccination GBS compared with other post vaccination adverse events (median 13 days versus one day, respectively) is consistent with a possible causal association between GBS and influenza vaccine.

Other data are conflicting, but suggest that influenza vaccination is associated with a low or negligible risk of GBS. In a self-matched case control series from Ontario, Canada that identified 269 hospital admissions for GBS diagnosed within 42 weeks of receiving influenza vaccination, the estimated relative incidence of GBS during the primary risk interval (weeks two through seven after vaccination) compared with the control interval (weeks 20 through 43) was 1.45 (95% CI 1.05-1.99). However, a separate time-series analysis of 2173 hospitalized cases of GBS showed no statistically significant increase in hospitalizations for GBS after institution of the universal influenza vaccination program in 2000.

References:

Guillain-Barre syndrome following influenza vaccination.
Haber P; DeStefano F; Angulo FJ; Iskander J; Shadomy SV; Weintraub E; Chen RT
JAMA 2004 Nov 24;292(20):2478-81.

The Guillain-Barre syndrome.
Ropper AH
N Engl J Med 1992 Apr 23;326(17):1130-6

Guillain-Barre syndrome after influenza vaccination in adults: a population-based study.
Juurlink DN; Stukel TA; Kwong J; Kopp A; McGeer A; Upshur RE; Manuel DG; Moineddin R; Wilson K
Arch Intern Med. 2006 Nov 13;166(20):2217-21.

The Guillain-Barre syndrome and the 1992-1993 and 1993-1994 influenza vaccines.
Lasky T; Terracciano GJ; Magder L; Koski CL; Ballesteros M; Nash D; Clark S; Haber P; Stolley PD; Schonberger LB; Chen RT
N Engl J Med 1998 Dec 17;339(25):1797-802.

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Originally published in The Ottawa Citizen December 19, 2003
Original Title: Cycling the virtual highway

WARNING: Before you read any further, I have to confess that I am a cycle nut. Forgive my indulgence in sharing my love of this world with you in one column.

The exercise, scenery, skill and exhilaration one experiences while on their road or mountain bike is one of the joys of life. Some of them are works of art and a testament to the beauty of engineering. However, with the arrival of winter, save for a few diehards, we bring our machines into the house. Some will hang them up for the season; others will mount their bike onto a stand in front of the TV turning it into a stationary bike.

I tried the TV thing but it just did not provide the same workout experience. One of the frustrations of many cyclists is the potential to lose some if not all their training and fitness gained throughout the summer months. Indeed, there are gyms that offer various aerobic machines including bikes but it remains a second cousin to the real deal.

My Christmas gift suggestion for this year will appeal to the cyclist on many levels. If you love technology, computers and music in addition to your bike, these gifts are the cure for cycling withdrawal syndrome (I have no financial stake in these company’s products nor have I been asked to review them).

Tacx (www.tacx.nl), a Netherlands company, has created the T1900 I-Magic Virtual Reality Trainer that transports you into a fully functional 3-D world. The I-Magic comes with a mounting stand that accommodates any road bike or mountain bike with a front fork. It has a steering attachment that allows you to go off-road in the virtual world before you.

The rear wheel abuts against a silver electronic roller that responds to the virtual terrain. Climb a hill and the resistance increases, catch a draft from a cyclist in front of you and the resistance decreases. A small sensor unit attached to the front handlebars records your heart rate data, cadence and speed. The sensor unit attaches via a USB connection to your computer.

The Analyzer software provides a second-by-second review of your cadence, power, speed and heart rate. The Tacx website’s BikeNet page allows you to share your time trials and courses with others by uploading your data. Conversely, you can download another cyclist’s course and time into your program. Once downloaded, your competitor will appear on the screen; the race is on!

You can change your camera angle from a first-person perspective to an overhead helicopter view to just behind your rider. A collision option adds to the realism. Obstacles and other riders can knock you off your bike.

A virtual reality cycling league (www.i-magicleague.com) now has 100 members competing in nine rounds of courses ranging from a cycling oval to mountainous terrain. Ambient sounds of the country including the mooing cows pipe through as you ride.

Fitcentric (www.fitcentric.com) sells NetAthlon, a software package that includes both real and imaginary world bike terrains. These terrains are also available for runners. If you ever wanted to cycle the 2000 Olympic Sydney triathlon cycle course, the 112 mile Hawaiian Iron Man Kailua Pier Kona, the Colorado Springs Olympic Velodrome, the banks of the Charles River in Boston, the Boston Marathon course, BMX courses, eco-adventures and alpine trails, now is your chance. Pop in your MP3′s, point your summer fan at your face and you have an indoor cycling experience that cannot be beat.

You can create other virtual cyclists to join you as a pacer for your workout.

Fitcentric offers an online site where cyclists can meet and compete in real time against one another. The software accommodates a headset allowing you to talk to your virtual cycling partner as you ride. The GameSpy website (www.gamespy.com) also offers the means to compete against others if you both share the same courses.

Fitcentric also offers courses for treadmills and the latest versions of the Concept rowing machines.

The I-magic’s list price was $999 this summer. Rebec and Kroes on Bank Street sells the unit. The Fitcentric software sells for about $80 US for three courses. Additional courses run between $10 to $25 US each.

The minimum computer specifications are a 500 MHz Pentium 3 with 128 MB of RAM and USB and a 32MB Nvidia GeForce or ATI Radeon graphics card.

After buying it and using it for over three months, I can unequivocally state that it will provide even the most experienced cyclist with as much of a challenge and workout as they desire.

Cycling through Hawaii or Sydney, Australia in the dead of winter has a certain appeal and you maintain your fitness to boot! All the best on this holiday season and a Happy New Year.

© Dr. Barry Dworkin 2003

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Originally published in The Ottawa Citizen May 13, 2003
Original Title: It’s a skewed, skewed, risk perception world

We are in the midst of a large-scale data collection and evaluation process of West Nile virus infection and outbreak in North America. Although West Nile virus affects other areas of the world like Europe, the Middle East, Russia, Tunisia, Morocco and South Africa among others, it is difficult to extrapolate their experience to the North American arena. The North American West Nile virus is genetically distinct and seemingly more virulent than strains from other parts of the world.

Most people want to know the risk of contracting the virus this summer. Unfortunately, the three years of experience since the virus’ arrival in New York City has yet to provide a clear picture of risk. Indeed, the virus continues to spread east to west in the United States and eastward and westward from central Canada.

We do know that past infections arose at the end of August and early September in the temperate regions of North America. Mosquitoes emerge in the spring. They start the process of viral amplification in the bird-mosquito-bird cycle that peaks in the early fall. Thereafter the risk of infection decreases in humans when female mosquitoes begin semi-hibernation (diapause) and infrequently bite.

The problem is that dead crows have already turned up in Ontario. This suggests the bird either migrated from southern climes or was bitten by mosquitoes surviving the winter. We do know through reports out of New York City and Windsor, Ontario, the virus survives in diapausal mosquitoes residing in the sewer systems.

The latest 2002 Statistics Canada data indicates 307 confirmed cases and 83 probable cases of West Nile Virus in Ontario and 18 deaths. The United States Centers for Disease Control data notes 4,156 laboratory-positive cases and 284 deaths.

The death rates do not tell the entire picture. The numbers of confirmed infection are small relative to our population. However, this is a disease on the move. In other countries, the outbreaks were sporadic and did not recur every year. More Canadians and Americans will be exposed to the virus this year. How many will remain unaffected, suffer nerve and muscle damage or succumb to their illness?

To date, most people infected with the West Nile virus will not have any type of illness. Twenty per cent of people infected with West Nile virus develop West Nile fever; a mild form of the disease. The symptoms last about six days, recovery is rapid and the illness poses no long-term health risk.

The severe form of the disease, West Nile encephalitis/meningoencephalitis occurs in one in 150 infected people (especially those over 50 years old) according to past data. New reports suggest that this risk may not reflect the North American experience. Small studies suggest the risk of prolonged or permanent severe and long-lasting nervous system damage and muscle weakness is greater than one in 150. Forty per cent of people with the severe form of the disease had muscle weakness in reports out of New York.

To date, the risk of contracting the illness remains low according to the Institute for Clinical and Evaluative Sciences (www.ices.on.ca). In regions where the virus resides, few mosquitoes are infected. The risk of severe infection from one mosquito is small occurring in less than one per cent of bitten people. It is unclear why some people develop severe disease. Advanced age is the most important predictor of death and patients older than 70 years are at particularly high risk.

Person-to-person transmission does not occur with West Nile virus. Kissing or touching another person will not place you at risk of disease. Indeed, there is no evidence that you can directly contract the disease from birds, horses or other mammals.

Prevention is the only means of protecting the population at large. Liberal use of mosquito repellents on clothing or skin (depending upon the concentration of the solution), patio screens, mesh-covered tents, protective clothing and avoidance of mosquito-infested areas and draining stagnant water sources are about all we can do for now.

If we do not give a second thought about getting into our car, we should not let the West Nile “threat” alter our day-to-day lives. Death and injury from car crashes far exceeds the damage from West Nile virus. Indeed, our behaviour regarding health prevention is less than optimal. Last week, a report revealed the reticence of most Canadians to implement lifestyle changes to prevent and reduce the risk of heart disease. A woman’s lifetime risk of dying from heart disease is one in two.

Every new West Nile infection will be front-page news and mercilessly skew the perception of true risk. It will require a few seasons to determine North American risk and the behaviour of West Nile virus. As unpalatable as this may be, this is RealTV.

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Originally published in The Ottawa Citizen April 22, 2003
Original Title: The Death of Tony Hsu

Dr. Tony Hsu, a Welland pediatrician in practice for 30 years died last week, his body recovered from Lake Ontario. Humiliated and abused by the Medical Review Committee (MRC), his plight, profiled by CTV’s Avis Favro last November, showed us a caring and dedicated physician destroyed by the committee. Dr. Hsu worked on-call one every two nights, provided free service to the Children’s Aid Society and was respected and admired by his patients and colleagues alike.

Last December I wrote about the draconian MRC. The MRC has a mandate from the Minister of Health to “go after” physicians who do not fit a particular computer program billing practice profile. This program will digest and average out the number of specific fee codes a family doctor or specialist should bill in a year. It flags any significant deviation from the “specialty average”. These deviations can occur because of different patient demographics, location of practice (rural North versus Urban setting), the physician’s area of interest or fraud.

The MRC is not a judiciary body. They do not have to listen to evidence, legal arguments or expert opinion. The physicians under investigation have provided the service to their patients. There are no fraudulent acts. Indeed, fraudulent actions are the domain of the Anti-Rackets Squad of the Ontario Provincial Police, not the MRC.

Whatever the reason for the computer flag, the General Manager of OHIP may decide to send a letter to the physician stating he believes the physician has been overbilling for several years. The letter will sometimes state that for a large sum of upfront settlement money, they will drop the file. Should you not agree to make an offer they cannot refuse, the general manager refers the matter to the MRC.

If the physician wishes to mount a defence and submit to a full review, he/she must bear the costs of the entire proceeding.

The physician must prove their innocence instead of the onus on the MRC to prove guilt. Even if only one of the hundreds of reviewed billings is deemed in error, the physician will have to pay all legal costs including the $1000 per day cost of the auditor(s).

Once proclaimed “guilty” the physician must pay back OHIP within one year all overbilling with interest including the MRC and OHIP legal costs (about $15,000 to $25,000) irrespective of an appeal. Exoneration is a rare event.

Should the physician not have sufficient funds to pay the penalty, the government will seize their assets. Further, the MRC can re-audit the physician for a different billing period for the same perceived infraction.

These physicians, aptly described by Dr. Doug Mark, president of the Coalition of Family Physicians, are the “Living Dead”.

The computer flagged Dr. Hsu because he allegedly billed more annual check-ups than the average. What the computer did not reveal was that he billed one-third less consultation fees. In other words, he billed less than his counterparts.

He had to pay back $108,000; close to his yearly net income. He had to cash in part of his RRSP lest the government garnish his entire yearly salary or seize his RRSPs. Dr Hsu was not a criminal, did not commit any fraudulent acts, honestly provided the medical services and diligently served his community. His crime according to the MRC was that did not write enough chart notes to justify billing for an annual check-up although he did perform the check-up. The MRC did not consider the letters of support from his patients and colleagues.

In a prophetic statement last November, Dr, Hsu wrote about the effect the MRC has had on physicians.

“The targeted physicians were by majority hardworking, accountable community pillars with over 15 years in practice. The allegations of wrongdoing were devastating to the unsuspecting physicians.

Initial reactions of disgrace, shame and humiliation were followed by self-doubt as to lifelong misinterpretation of acceptable billing methodology. All experienced overwhelming stress, questioned on what defined fraud, and considered the event an attack of personal integrity. These led to decreased professional work, family disruption, major clinical depression, constant anxiety and post-traumatic stress disorder akin to being subjected to repeated rape. Some practitioners opted for early retirement or gave up hospital privilege. Medical-legal intimidation paranoia was common.”

This trampling of basic human rights and unconstitutional actions destroys the careers and now the lives of Ontario doctors. Canadians are fair-minded people and should be outraged that Soviet-style justice or the English witch-hunting trials of 1650 exist in our country.

Rest in peace Dr. Hsu. Your death will not be in vain.

© Dr. Barry Dworkin 2003

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Originally published in The Ottawa Citizen January 7, 2003
Original Title: Millions for Prevention: Is anyone listening?

The only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you would rather not. – Mark Twain (1835-1910)

As soon as a question of will or decision or reason or choice of action arise, human science is at a loss. – Noam Chomsky (1928- )

A recent front-page story in the Citizen remarked how a Health Canada anti-tobacco campaign using Olympic skaters Elvis Stojko and Josée Chouinard did not have much influence on reducing or quitting cigarette use. Indeed, how effective are health promotion campaigns?

A National Post article (Death: What are the odds?, December 31, 2002, page B3) reviewed the ten most common causes of death by disease in 1989 and 1999 for men and women (see inset). Some diseases are on the decline yet others such as lung cancer in women have surpassed breast cancer. Flu and pneumonia are on the rise partly due to an aging population, smoking, other chronic disease states and an aversion to flu vaccine.

Certainly, there are educational health advisory programs to combat disease. Societies and organizations do their best to inform the public about treating and preventing injuries and disease. They do an admirable job.

Yet as a physician, I continue to see many people who do not heed the sage advice of health care professionals and organizations. Perhaps it is the overwhelming nature of the health information. The mind has a tendency to turn itself off when overloaded. Ask any patient with type 2 diabetes about the plethora of diabetes health information, diets, medical tests and procedures following their diagnoses. Further, the health arena is replete with differing views and advice.

There are limits in our ability to digest (pardon the pun) the latest news about the foods and nutrients in our diet, medical studies, prevention programs and general health advice.

To wit, this is a partial list of diseases and conditions amenable to prevention, eradication or reduction of damage with early diagnosis and screening:

• Diabetes, heart disease, hypertension, congestive heart failure, stroke, kidney failure
• Emphysema, chronic obstructive lung disease, asthma
• Colon, breast, prostate, skin, cervical and lung cancer
• Depression, panic disorder, obsessive compulsive disorder, suicide, bipolar disorder, schizophrenia, eating disorders
• Liver failure, hepatitis A, B and C
• Chlamydia, gonorrhea, human immunodeficiency virus (HIV), herpes simplex, human papilloma virus (HPV)
• Tetanus, diphtheria, polio, mumps, measles, rubella, meningitis, whooping cough, influenza A and B, typhoid, chicken pox
• malaria, water-borne parasitic and bacterial diseases
• peptic ulcer disease,
• fractures, head injuries
• motor vehicle injuries

Family doctors advise their patients about all these relevant topics at the appropriate time. We have to prioritize prevention advice and screening based upon the individual’s age, lifestyle, past medical history, family history and screening tests.

“Prevention” is the buzzword heard in discussions about primary care reform (PCR). The hypothesis is that preventing these diseases would reduce human suffering and health care system expenditures. The implication of this statement is all people will cooperate and follow the recommendations of their doctor or other allied health professional. To quote Hamlet, “Ay, there’s the rub.”

What do you do when a patient refuses a treatment despite your best efforts to persuade them that it will prevent future illness? Cigarette smoking is a good example. I know a charming diabetic asthmatic father of a four-year-old girl. She asked him if he loved her. “Of course I do”, he responded. “Then stop smoking because I don’t want you to die”.

Yet he continues to smoke. He feels guilt and shame and knows very well what will befall him if he remains on his present path.

Many people know of someone in the same predicament. Despite all the education and effort to prevent disease, human nature does not fit into a predictable neat package. Throwing more money into primary prevention will not change this crucial component of health care. The very nature of human responses to disease (fear, denial, anger, and concerns about loss of independence among others) can disrupt any prevention program. Indeed, patient non-compliance to therapy is a leading cause of deteriorating medical conditions and hospitalizations in Canada.

Even with the advent of computerized records to recall patients for specific blood tests, cancer screening programs and disease-specific follow-up appointments, it remains with the patient to assume the responsibility for their own health care. Health care professionals cannot track every iota of their patients’ lives micromanaging each of their potential risk factors for disease.

The Canadian Task Force on the Periodic Health Exam provides age-specific guidelines to help physicians prioritize the relevant tests and procedures for their patient. Each person requires an individualized approach to prevention and treatment. This approach includes the person’s willingness to participate in his or her own health care.

PCR states that the present system does not encourage doctors to provide preventive care services. In fact, many physicians do provide this service. Indeed, it is a family doctor’s responsibility to prevent as well as treat disease. We can offer the appropriate tests and procedures to screen for cancer and prevent disease but rarely does any program or system ever achieve 100 per cent success.

There will always be people that require treatment despite illness prevention campaigns. Although sometimes it leads to better health, other times not, people must be free to choose for themselves.

LEADING CAUSES OF DEATH BY DISEASE AMONG MALES IN 1989 (PER 100,000)

1. Heart disease — 200.3
2. Lung cancer — 73.2
3. Stroke — 47.4
4. Chronic airway obstruction (asthma, emphysema, etc.) — 27.8
5. Flu and Pneumonia — 24.8
6. Colorectal cancer — 23.6
7. Suicide — 20.8
8. Diabetes– 14.1
9. Hereditary and degenerative nerve disease (Parkinson’s, etc.) — 12
10. Cirrhosis and liver disease — 11.7

LEADING CAUSES OF DEATH BY DISEASE AMONG MALES IN 1999 (PER 100,000)

1. Heart disease — 156.4
2. Lung cancer — 68
3. Stroke — 42.2
4. Chronic airway obstruction — 30.7
5. Flu and Pneumonia — 27.9
6. Prostate cancer — 23.8
7. Suicide — 21.3
8. Diabetes — 20.3
9. Cirrhosis and liver disease — 9.2
10. Alzheimer’s disease — 6.1

LEADING CAUSES OF DEATH BY DISEASE AMONG FEMALES IN 1989 (PER 100,000)

1. Heart disease — 147.4
2. Stroke — 62.1
3. Breast cancer — 34.5
4. Lung cancer — 29.9
5. Flu and Pneumonia — 25.9
6. Diabetes — 15.5
7. Hereditary and degenerative nerve disease — 13.5
8. Chronic airway obstruction — 13.2
9. Kidney disease — 7.4
10. Cirrhosis and liver disease — 5.4

LEADING CAUSES OF DEATH BY DISEASE AMONG FEMALES IN 1999 (PER 100,000)

1. Heart disease — 123.4
2. Stroke — 58.7
3. Lung cancer — 41.8
4. Flu and Pneumonia — 31.2
5. Breast cancer — 30.9
6. Chronic airway obstruction — 21.6
7. Diabetes — 20
8. Senile and presenile dementia — 12.9
9. Alzheimer’s disease — 12.6
10. Cirrhosis and liver disease — 4.5

Source: Statistics Canada

© Dr. Barry Dworkin 2003

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Originally published in The Ottawa Citizen September 24, 2002
Original Title: Copy Capers

A recent Dave Brown column touched upon the thorny issue of patient chart transfer requests. He cited the case of one individual who expressed his irritation with transfer fees that he felt should be free of charge. Copyright law analogy provides the basis for his assertion. His claim is that patient chart notes are paid by the patient through taxation and as such did not belong to the physician. The physician writing the notes does so for the patient who subsequently owns the record.

The crux of the issue is not who owns the charts. It is the expectation that all medical and administrative services should be free. OHIP pays for medical, not extra-administrative services. In some instances considerable secretarial time is spent collating the documents. Odd-sized lab report paper cannot be automatically fed through the photocopier feeder and require manual single sheet copying. The chart notes and lab results are sorted chronologically and if necessary a covering note from the physician is placed at the front. Then it is mailed to the new physician.

This is not about copyright law. The medical records are not being published. The information contained within the chart belongs to the patient. They are entitled to a copy of their records. The physician requires their own original copy to best provide patient care and for medicolegal purposes. Records must be kept for ten years beginning from the date of the last patient visit.

It has been my experience that patients sometimes lose original documentation. Heck, they misplace prescriptions and ask for another an hour after I prescribed it for them! Mistakes happen. If the originals are lost, copied records are a poor substitute for purposes of legibility (multiple copies of copies degrade resolution) and original evidence.

The OMA provides guidelines for third party billing purposes where OHIP fees do not cover these services. It states in the OMA Physicians Guide to Third Party and Other Uninsured Services, Section 1, Para. (e): “Preparation and transfer of an insured person’s health records when this is done because the care of the person is being transferred at the request of the person or person’s representative. In addition to the office overhead, the physician may charge for his or her time in preparing the information for transfer.”

Where I part company with the guideline’s fee is thus: their recommended rate is $27.96 for pages 1-5 and $1.12 for each page thereafter. I know that the physician writes the notes but it is hardly worth the price of a thick novel. In our practice we charge $15 for pages 1-5 and ten cents per page thereafter. The average cost is about $20. For whole families, the $15 is waived for each additional family member. I believe this is a reasonable compromise.

There has to be a reasonable accounting for services and value provided for the fee. Our health care system has influenced the public’s expectation that all requests for services are free and therefore have no inherent value. This is especially true for sick notes or for telephone or fax prescription renewal requests. I do not agree that I or any physician should work for nothing. You would not expect the same from any other professional service that provides reports and information requested by an individual. If I request a transfer of my business accounting records from my accountant, I would receive a bill for the service.

OHIP pays the physician for the services outlined in the General Preamble of The Schedule of Benefits (physician billing code book), not the patient. The purpose of OHIP is to remove the barriers between doctor and patient by having a third party pay for the medical services. The physician does not have to worry about payment and the patient need not be hindered by lack of funds in seeking medical care. The doctor-patient relationship is protected by this arrangement.

The notion that the public pays my salary is not quite correct. OHIP is an insurance organization. Other insurance companies collect premiums from their clients. If the client has an accident or requires medical attention, the insurance company will pay the professional fees. Would one say then that all the clients pay the salary of that professional? Or is it the insurance company that oversees these funds and negotiates the best value for their dollar? Where does the circle of funding end?

Let us look at government contracting out service requests from independent businesses or third party individuals. Do we assume that these people are beholden to the taxpayer? Are they not independent businesses on contract to government? Is it not the government who is responsible for how the money is spent in-trust for the taxpayer? Where is the public outrage about the recent disclosures of misappropriation of federal monies?

The circuitous logic of where the money trail begins and ends and who owns the money is flawed. Frankly the basis for the whole issue centres once again on the insinuation that doctors are greedy and are looking for any angle to justify the extra fees. It is an issue that is demeaning to me and my profession.

I do not condone exorbitant fees for chart transfers. I do not withhold the chart if the patient does not pay. I rely on good faith and reputation as the carrot. There is no stick. I do not subscribe to the notion that because I am paid through OHIP, I am beholden to the whims and rages of the taxpayer. At some point the refrain “I pay your salary”, denoting control, loses its charm.

© Dr. Barry Dworkin 2002

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Originally published in The Ottawa Citizen September 10, 2002
Original Title: Live Long and Prosper: Longevity is for Vulcans

Man would die, though he were neither valiant, nor miserable, only upon a weariness to do the same thing oft, over and over.

- Francis Bacon (1561 – 1626, English essayist, philosopher)

If life were eternal all interest and anticipation would vanish. It is uncertainty which lends it satisfaction.

- Kenko Hoshi (14th century A.D., Japanese Buddhist)

Recent and projected health technology and treatment advances pose interesting dilemmas regarding the human lifespan. Nanotechnology, stem cell research, gene therapy, new drug therapies, cancer vaccines and electromechanical life support devices are just a few of the lines of research and development in our quest to cure disease and maintain our health. These are indeed exciting times.

Medical advances to date have increased the average life span to about 81 in women and 76 years in men respectively (StatsCan). Let us assume that these technological advancements over the next 50 to 100 years will increase the human lifespan to 90 to 105 years of age. Will we attain a long and healthy life?

One hundred years ago no one thought the elimination of Tuberculosis, pneumonia, diarrhea and enteritis (bowel infection and inflammation) and other infectious diseases would lead to unimagined new diseases. Modern day scourges such as breast, lung and colon cancer, heart disease, Type 2 Diabetes and Alzheimer’s require time to develop. As life span increases, so too does the incidence of these diseases. Although women live longer than men in Canada, some of those extra years are spent in disability.

What will happen when we cure them? Can we presume we will live longer still? Living longer does not necessarily mean people will be happier or have a better quality of life. The benchmark for happiness is not entirely based upon how long we will live. Consider the social, economic and health impact of these changes.

From a social standpoint there will be a greater proportion of elderly people living past 100 years of age. Assuming they are in good health, will they continue to contribute to society for a longer interval of time? Younger people may find that the job market becomes tighter as the older folk wish to continue their endeavours. Pension plans would have to compensate for this longer-living population. The mandatory retirement laws (age 65) would have to be reexamined. Would people want to retire with 30 to 40 years left in their lives? They would be just past middle age if compared to present day.

If we achieve long life but now contract an as yet unknown disease at age 90 or 100, how would this affect quality of life? How will families adapt to this rapid change? Our experience to date concludes prolonged life will not be synonymous with complete health and independence. Will 70 year old children have to support their 100 year old parents? If they are unable to do so, will it fall upon their 40 to 50 year old children to support both parents and grandparents alike? If the burden becomes too great, the onus will fall upon the state to provide the care. Yet the state cannot handle today’s demands for long-term care. Already in some small rural villages in Japan, because the young have moved away for jobs, 70 year-olds are looking after 90 year-olds.

In 1900 only half of the population could expect to live to 21 and still have both parents living. In 2002 only half of the population when they are 21 live in a family in which both their parents are still married to each other. How many step-parents and step-grandparents will children have if the older generation live to 100 and divorce as frequently as they do now?

Talk to people who have lived long and full lives. Many remark that they are not afraid of death but of how they will die. They do not wish to live an additional 20 years if it means prolonged suffering. They want to remain healthy and not be a burden their families.

Is the quest for longevity more a desire of younger individuals when life is full of new and exciting opportunities? The idea of a hundred years of excitement and experience is compelling.

Will we see “life fatigue” if we live too long? The idealism of youthful desires may create a self-inflicted purgatory in their future. You cannot go back in time to reduce life expectancy. Rather than living with 20 years of disability after one organ system failed, would the ideal situation be if all organ systems failed simultaneously at 95?

Technological advances would be restricted at first to those who have the ability to pay. Our present health care system does not have the capability to provide these expensive new therapies. Nor does it have provision or adaptability to accommodate rapid technological advances in the forthcoming decades. If we are unable to reduce hospital backlogs with people lying on the floor for lack of beds, a problem that grows worse with time how will the system incorporate state-of-the-art medical care and therapy?

A change in one life variable does not necessarily equate with concomitant improvement in other life variables. For example, how will it affect our criminal justice system’s sentencing decisions? What about RRSPs, life insurance, disability and social assistance programs? How will they change?

In a stochastic system there are many possible outcomes. Isaac Asimov and Arthur C. Clarke among others wrote stories examining the consequences of long life. They caution us about life for life’s sake. What makes us human is our mortality. Our present lives should be as healthy, productive and free of unnecessary hardship, suffering and pain as possible. We have to be careful not to wish for more than we can handle.

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Originally published in The Ottawa Citizen July 30, 2002
Original Title: Count, Pour, Lick and Stick

Many patients express their disdain over medication dispensing fees. All Canadian pharmacies charge this fee. I too had some misgivings about the fees but did not have the necessary background to draw any firm conclusions. Further enquiry to determine their origin and their original purpose was needed. Do people get value for their money? Why do dispensing fees vary? A spokesman for the Ontario Pharmacists’ Association (OPA) addressed these issues in an interview several weeks ago.

In the 1960′s the price of a medication consisted of a combination of a price mark-up and the dispensing fee. Pharmacists were under no obligation to reveal the dispensing fee amount to the customer. The Government of Ontario enacted legislation mandating that both the prescription medication cost and the dispensing fee appear on every receipt. The original fee was initially three to four dollars.

Quebec pharmacists do not have to post or reveal their dispensing fees. This leads to the misconception that Quebec pharmacists do not charge a fee. Naturally people conclude that if pharmacies across the river can remain financially viable without extra fees, why not those in Ontario? Contrary to popular belief, all Canadian pharmacies charge dispensing fees but not all provinces have a law similar to Ontario’s.

The fees, set by the individual pharmacist, must be registered with the College of Pharmacists and posted in the pharmacy. It is based on the cost of a maximum of 100 days of prescribed medication. For greater quantities there is a concomitant fee increase.

The Ministry of Health and Long Term Care (MOHLTC) determines the maximum price of prescription medications. These prices appear on the Ontario Drug Benefit (ODB) formulary that lists all the medications covered under social assistance and elderly benefit plans. The pharmacist cannot charge more than a 10% mark-up on the ODB mandated cost for all patients regardless of coverage eligibility.

Pharmaceutical companies submit their list price to the MOHLTC for inclusion in the formulary. The MOHLTC decides whether it will accept this price. It can impose its own value well below cost. The pharmacist has no choice. They have to use this fee.

There are 150 prescription medications that exceed the formulary list price. Pharmacists have to subsidize these increased costs out-of-pocket. They are forbidden to mark-up the cost of the medication. In 2000, pharmacists lost about $22.5 million subsidizing the cost of these medications.

An audit of dispensing fees done by Cunningham and Associates, Chartered Accountants indicated that the cost incurred for the pharmacists time, overhead and cost of doing business was $5.85 in 1987 and $9.31 in 1999. Over the past ten years, the average cost of pharmacy practice increased by 31%. In 2000-2001 prescription volume increased by 8% to 46 million placing an increased strain on human resources.

The MOHLTC caps a maximum dispensing fee of $6.47 for people on social assistance or over 65 years of age. This fee cap has not changed in 12 years. Both the cost of the medication and the dispensing fees for this large group of people is governed by the MOHLTC; another example of health care central planning. Of the $1.9 billion dollars spent by the Ontario government on drug benefits, dispensing fees accounted for 3.2% of the total.

In effect, the fee has not kept pace with the real cost of doing business. It falls upon those outside of the government assistance plans to compensate for the capped fee.

The fee generally is a small percentage of the overall price of the medication. It is a means for the business to recoup lost revenue due to the government’s fixed retail pricing.

Are patients getting value for their dollar? According to the OPA indeed they are. The fee covers the business expenses of the dispensary and all the extra services each pharmacist offers to their patients.

Pharmacists not only “count, pour, lick and stick” but oversee potential medication and food interactions, allergies and potential interactions with herbal preparations. The College of Pharmacists mandates patient counseling for each new prescription. This include a full disclosure of potential side-effects, complete dosing instructions, ensure an understanding of why it is being used and how to know if it is working as intended. Much unpaid time is spent on the telephone discussing therapeutic options and prescription clarification with physicians. They deal with third party insurance payment plan paperwork.

The pharmacist should answer every question posed by the customer. Inevitably, the customer develops a personal/professional relationship with their pharmacist establishing a contract for trust. The pharmacist learns about their client’s medical history. Over time they are able to determine whether a particular off the shelf or new prescription medication has the potential to interact with their present regimen.

People tend to think that price comparison-shopping for medications is akin to buying a car. This can be a difficult process because an accurate price requires a precise description of the medication and its dosage. Pharmacists are forbidden to advertise the cost of prescription medications. Most do not mind providing the price over the phone. People have the right to ask about the cost of their prescription before dispensing. No one should be blindsided.

The OPA has to better communicate the concept of dispensing fees. It has to explain to people why some medications that cost pennies (penicillin, prednisone, tetracycline among others) have dispensing fees of four to 12 dollars added onto the final price. It is understandable that the consumer becomes jaded and suspicious.

Do you think your pharmacist provides a valuable service? What is your take on dispensing fees? Your comments to the Citizen are always appreciated.

© Dr. Barry Dworkin 2002

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Originally published in The Ottawa Citizen July 2, 2002
Original Title: Apocalypse Now

Parents are forever vigilant protecting their young children from some of life’s harsher realities. It is indeed frustrating and indeed infuriating when parents encounter unexpected situations that expose their children to potentially deleterious actions and images. Their child-rearing timetable explodes. They have to now enter damage-control mode.

What control do parents have regarding the protection of their young children of horrific images or pictures in a public setting? I ask this because my seven year-old son told me the other day he saw “a picture of a baby with its head cut off.” The head in question lay next to the body.

This graphic image among a gamut of others was paraded to unsuspecting families and individuals at the Bank Street and Hunt Club Road intersection on Monday afternoon, June 24th. They were on large five foot high placards. The aim of this protest was to encourage support for the anti-abortion movement. My intent here is not to address the pros and cons of abortion, an issue that remains as unresolved as ever.

At what point does debate of an issue exceed societal norms? The focus is the effect these images have on unsuspecting individuals especially children. Let me repeat this: unsuspecting individuals.

I am now faced with a discussing an issue with my son that he is ill prepared to understand. It upsets my parental timetable. He witnessed images that I would not allow him to see on TV or in movies. Yet it seems it is perfectly acceptable for someone else to make this decision for me. TV programs and movies come with a rating system. There are warnings of graphic images and violence so parents can decide its appropriateness for their children’s viewing.

One mother recounts her encounter with this group. Most distressing to her was the effect it had on her children. “One year ago, I was driving down Merivale Road taking my kids to Toys R Us when we came upon a three block-long protest group. The people were each holding large posters depicting various stages of aborted fetus. Some held anti-abortion messages.

The fact that I was unable to even turn off of Merivale to take an alternate route made me feel like I was trapped in a fire. It was there that I was forced to answer the questions that came from my nine year-old son and 11 year-old daughter about why they were holding pictures of ‘broken babies’ and what was abortion. This was a discussion I had hoped to have when they were in their teens.”

The right to free speech does not imply that you can show children decapitated fetuses any time you would like. If this were a purely adult audience, I would have less of a problem with this. The assertion that the shock value of these demonstrations will provoke discussion is spurious. People are able to debate issues of conscience and morality without graphics.

Free speech does not mean you should stress and shock small children. Parents have the right to introduce difficult issues and morals to their children at times that they consider to be appropriate. Granted, they cannot be protected from all the world’s ills, but certainly deliberate actions such as these are not to be included in this set of life situations. My son still does not understand why these people showed those pictures.

If the aim of the demonstration was to convince people not to abort their pregnancies for the sake of the children, why is it acceptable to potentially harm those children who witnessed this event?

By all means take the time to prepare your case and present it to the public in a forum that is acceptable to all parties. This is not a new issue. It does not require the same immediacy for protest as with some political or civic events.

It would have been a completely different matter if this group had forewarned the public about their protest. Further due to the nature of the images, it would have been appropriate to hold it in a location away from children with notice that the presentation would be graphic in nature. At least it would have provided some measure of respect for the public by giving them a choice.

The anti-abortionist message is that life begins at conception: respect life. Why then are dead mutilated fetuses used as props? What ever happened to respecting human dignity? Some would claim that these photos demonstrate how human dignity is disrespected. This is an end-justifies-the-means argument and is rife with hypocrisy. Taking the high road is preferable.

Intruding on the parent’s ability to protect their children is a great way to provoke a most forceful defensive response. Deflector shields up! The debate is over.

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