CONFERENCE * CONFERENCE
Assuine niantle of leadership and help save the planet, FPs at WONCA conference told
Eleanor LeBourdais
A t the United Nations-sponsored Earth Summit in Rio de Janeiro in June, leaders from some 150 nations converged to sign a declaration signalling their concerns about preservation of the earth. A month earlier, 4000 physicians had converged on Vancouver for the 13th world conference of the World Organization of Family Doctors (commonly known as WONCA), where they focused on the central role that family physicians have and should be playing in an attempt to alleviate global health problems. Dr. Helen Caldicott, an Australian pediatrician and worldrenowned antinuclear activist, offered an apocalyptic warning of the huge-scale medical problems that unchecked environmental degradation is already starting to cause: increased incidence of malignant melanoma, basal and squamous cell carcinomas, cataracts and vitamin D toxicity. Government policy is dominated by the monetary concerns of big business that benefit very few, she said. "What we have to do is Eleanor LeBourdais is a freelance writer in Port Moody, BC. JULY 1, 1992
Physicians probably don't realize how important their behaviour is in setting the public pace. Dr. Nyi Nyi, United Nations Children's Fund -
translate the advertisements com- urged political action. He said ing from corporations into medi- physicians have a duty "to speak cal data, so people understand out using the influence you have what is happening to this planet." as respected authorities to shape Caldicott said government of- public debate on what the emergficials and policymakers too often ing new world order should look lack the scientific background and like." knowledge needed to make enviNyi said physicians probably ronmentally responsible decisions. don't realize how important their As scientists, physicians have a behaviour is in setting the public vital contribution to make and she pace. "The tools you have develurged the 3000 doctors who heard oped and the experience gained her speak to return home, assume over the years must be sustained the mantle of leadership and run and extended to the places they for public office. The physicians have yet to reach." responded with a standing ovaDespite the pace of technotion. logic advance, Nyi said most Dr. Nyi Nyi, director of the health care problems and probprogram division of the United lems of living do not require highNations Children's Fund, also tech solutions. "Everybody knows CAN MED ASSOC J 1992; 147 (1)
105
the value of a coronary bypass, but most people don't need a bypass. They need advice on disease prevention and healthy living." Because of the spiralling costs of technology that benefits relatively few people, Nyi said the developing world must not try to follow the expensive path taken by more affluent countries. Emphasis on technology and specialization has helped give the United States the most expensive health care system in the world, to the apparent detriment of family practice there. Dr. Morris Mellon, president of the American Academy of Family Physicians in Omaha, Nebraska, reported that 18 US medical schools have no department or division of family practice and have resisted suggestions that they develop them. "Most say they're private schools and can do as they please. But they get more federal grants than almost all the public schools, and they should be responsible as public service corporations to train family physicians." Currently, family physicians account for only 13% of the US physician population; in Canada, they account for just over 50% of the total. Generalists have been the mainstay of rural and remote health care services in all parts of the world, but a seminar on the shortage of rural physicians revealed that there are similar problems in physician recruitment and retention in many countries. Regardless of location, the drawbacks of rural and small-town practice continue to provide persistent dilemmas: long work and on-call hours, a lack of specialists for referral purposes, shortages of hospital services and limited access to additional training and continuing medical education. Among the cultural and social problems related to rural practice, spousal dissatisfaction was cited as a major impediment - job opportunities for spouses are often lacking in rural areas. Single 106
CAN MED ASSOC J 1992; 147 (1)
physicians are also considered less Ont., family physician Dr. James likely to locate in areas where Rourke, "they're not likely to pursocial access to educational and sue it as a career." professional peers would be limitShorter hours are needed, ed. too. "We need to set some reasonBecause medical schools are able standards for how often you located in major cities, rural com- can expect a rural doctor to be on munities may have a hard time call before you wear him out," recruiting new doctors who are Rourke argued. As the size of the elderly and used to the bright city lights. Unless they have a chance to sample aging population increases over rural practice, argued Goderich, the next 25 years, so will the
WONCA meeting in Vancouver largest ever as 4000 MDs attend grown steadily to include 41 member organizations in 37 countries - there are about 150 000 members worldwide. While its most conspicuous activity has been the sponsoring of world conferences, such as the one held in Vancouver in May, WONCA's much broader purpose is to provide a forum for the exchange of knowledge and information among member organizations, to encourage and support the development of academic organizations of family practice, and to represent the educational and research activities of GPs and FPs before other world forums. WONCA world conferences have been held every 3 years since 1980; their location is determined through a competition between member nations. Canada's national representative body, the College of Family Physicians of Canada, and its British Columbia chapter were successful in their bid to host the 1992 meeting in Vancouver. Although previous world conferences have drawn 1000 to 1500 delegates, the 6 years of work leading up to the 1992 meeting in Vancouver appear decisions. Over the last 20 years, to have paid off: attendance hit WONCA's membership has an all-time high of about 4000.
Since 1964, family physicians from around the world have been gathering every few years to support and further the cause of family practice. The first highly successful meeting in Montreal led to additional conferences every 2 years until 1972, when the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians, or WONCA, was born during the fifth meeting in Melbourne, Australia. The organization is commonly known as the World Organization of Family Doctors. Before 1972, a loose association of colleges and academies of general practitioners and family physicians had been primarily concerned with sponsoring world conferences. The formal creation of WONCA led to the establishment of a permanent secretariat in Australia and to the formation of a world council comprising representatives of each member organization, which meets every 3 years at the world conferences. An executive committee also meets annually to implement council
LE I er JUILLET 1992
"The very elderly have a 1-in-3 some think a 1-in-2 chance of being demented, so as they get older your index of suspicion should rise." -Dr. Mark Clarfield number of older people who arrive in physicians' offices because they "just don't feel very well." Dr. Richard Waltman, a family physician who specializes in geriatric medicine in Tacoma, Washington, described his initial difficulty persuading medical journals to accept a paper outlining "failure to thrive" as a legitimate clinical geriatric entity. He said it was rejected because there was no other literature on the subject and he had been unable to provide a
bibliography. Waltman said psychologic and psychosocial deficits recognized as failure to thrive in children are equally applicable to the elderly and can be identified and resolved the same way. The keys are taking a comprehensive psychosocial inventory of the patient's life, and asking the right
questions. For instance, how much of the patient's condition is due to aging, and how much to disease? How does chronologic age compare with physical age? "Physiological age is what matters but we ask about chronological age," said Waltman. "Try asking the patient, 'how old would you be if you didn't know how old you are?'" If a diagnosis doesn't correlate with the patient's level of function, throw away the diagnosis. Can the level of function be improved? "With the right attitude, my answer is yes, 100% of the time," said Waltman. The right attitude has to include the belief that age itself is not pathology, and that if the JULY 1, 1992
older person doesn't feel well, there's something specifically wrong. "The number one complaint of older people is that doctors say their problems are caused by age. I think we insult our older patients when we blame anything on age before we do an evaluation." Although expensive, Waltman said a one-time comprehensive laboratory screening will often turn up abnormalities previously missed: metabolic derangements, low thyroid, low sodium and low potassium; over 11 years, he diagnosed five cases of pernicious anemia in patients who had been regularly seeing other doctors. Waltman said he is concerned when society writes off older people "and even more concerned when I see my colleagues do it. These people have given their lives to their families and communities and they deserve the best care we can give them." As the number of elderly Canadians grows, so will the incidence of dementia. Dr. Mark Clarfield, then a Montreal family physician and associate professor of family medicine at McGill University (he has since moved to Israel), cautioned doctors to consider the possibility of mental problems. "The very elderly have a l-in-3 - some think a 1-in-2 chance of being demented, so as they get older your index of suspicion should rise." He cautioned as well that the initial signs of dementia can sometimes be obscured by educa-
tion and polite behaviour. "There is some evidence that education may protect against the development of Alzheimer's disease and delay the onset of dementia. We also know that well-educated people who [have dementia] can fool the system for a long time, because they are smart and frequently have good social skills." The influx of immigrants into Canada presents assessment challenges and although there are testing criteria in languages other than English, poor education or illiteracy can confound results too much to provide an accurate picture. In the case of a woman with a Grade 3 education who can't read or write, Clarfield suggested it's better to dispense with testing entirely. "I throw away the [test] and talk to the patient and the family - I've even called shopkeepers. What can't she do now that she could do before? Here's where function is very important as opposed to these instruments that break down with language and education." Correctable causes of dementia, such as hypocalcemia, may be entirely asymptomatic and should always be ruled out by testing. Vitamin B,2 deficiency is another reversible cause of dementia that 95% of the time can be ruled out by a normal complete blood count (CBC). But, again, Clarfield urged caution: "There are cases where people have a normal CBC but an abnormal B12, and they get better if you treat it; so I always order a B12 ."" CAN MED ASSOC J 1992; 147 (1)
107
Assuine niantle of leadership and help save the planet, FPs at WONCA conference told
Eleanor LeBourdais
A t the United Nations-sponsored Earth Summit in Rio de Janeiro in June, leaders from some 150 nations converged to sign a declaration signalling their concerns about preservation of the earth. A month earlier, 4000 physicians had converged on Vancouver for the 13th world conference of the World Organization of Family Doctors (commonly known as WONCA), where they focused on the central role that family physicians have and should be playing in an attempt to alleviate global health problems. Dr. Helen Caldicott, an Australian pediatrician and worldrenowned antinuclear activist, offered an apocalyptic warning of the huge-scale medical problems that unchecked environmental degradation is already starting to cause: increased incidence of malignant melanoma, basal and squamous cell carcinomas, cataracts and vitamin D toxicity. Government policy is dominated by the monetary concerns of big business that benefit very few, she said. "What we have to do is Eleanor LeBourdais is a freelance writer in Port Moody, BC. JULY 1, 1992
Physicians probably don't realize how important their behaviour is in setting the public pace. Dr. Nyi Nyi, United Nations Children's Fund -
translate the advertisements com- urged political action. He said ing from corporations into medi- physicians have a duty "to speak cal data, so people understand out using the influence you have what is happening to this planet." as respected authorities to shape Caldicott said government of- public debate on what the emergficials and policymakers too often ing new world order should look lack the scientific background and like." knowledge needed to make enviNyi said physicians probably ronmentally responsible decisions. don't realize how important their As scientists, physicians have a behaviour is in setting the public vital contribution to make and she pace. "The tools you have develurged the 3000 doctors who heard oped and the experience gained her speak to return home, assume over the years must be sustained the mantle of leadership and run and extended to the places they for public office. The physicians have yet to reach." responded with a standing ovaDespite the pace of technotion. logic advance, Nyi said most Dr. Nyi Nyi, director of the health care problems and probprogram division of the United lems of living do not require highNations Children's Fund, also tech solutions. "Everybody knows CAN MED ASSOC J 1992; 147 (1)
105
the value of a coronary bypass, but most people don't need a bypass. They need advice on disease prevention and healthy living." Because of the spiralling costs of technology that benefits relatively few people, Nyi said the developing world must not try to follow the expensive path taken by more affluent countries. Emphasis on technology and specialization has helped give the United States the most expensive health care system in the world, to the apparent detriment of family practice there. Dr. Morris Mellon, president of the American Academy of Family Physicians in Omaha, Nebraska, reported that 18 US medical schools have no department or division of family practice and have resisted suggestions that they develop them. "Most say they're private schools and can do as they please. But they get more federal grants than almost all the public schools, and they should be responsible as public service corporations to train family physicians." Currently, family physicians account for only 13% of the US physician population; in Canada, they account for just over 50% of the total. Generalists have been the mainstay of rural and remote health care services in all parts of the world, but a seminar on the shortage of rural physicians revealed that there are similar problems in physician recruitment and retention in many countries. Regardless of location, the drawbacks of rural and small-town practice continue to provide persistent dilemmas: long work and on-call hours, a lack of specialists for referral purposes, shortages of hospital services and limited access to additional training and continuing medical education. Among the cultural and social problems related to rural practice, spousal dissatisfaction was cited as a major impediment - job opportunities for spouses are often lacking in rural areas. Single 106
CAN MED ASSOC J 1992; 147 (1)
physicians are also considered less Ont., family physician Dr. James likely to locate in areas where Rourke, "they're not likely to pursocial access to educational and sue it as a career." professional peers would be limitShorter hours are needed, ed. too. "We need to set some reasonBecause medical schools are able standards for how often you located in major cities, rural com- can expect a rural doctor to be on munities may have a hard time call before you wear him out," recruiting new doctors who are Rourke argued. As the size of the elderly and used to the bright city lights. Unless they have a chance to sample aging population increases over rural practice, argued Goderich, the next 25 years, so will the
WONCA meeting in Vancouver largest ever as 4000 MDs attend grown steadily to include 41 member organizations in 37 countries - there are about 150 000 members worldwide. While its most conspicuous activity has been the sponsoring of world conferences, such as the one held in Vancouver in May, WONCA's much broader purpose is to provide a forum for the exchange of knowledge and information among member organizations, to encourage and support the development of academic organizations of family practice, and to represent the educational and research activities of GPs and FPs before other world forums. WONCA world conferences have been held every 3 years since 1980; their location is determined through a competition between member nations. Canada's national representative body, the College of Family Physicians of Canada, and its British Columbia chapter were successful in their bid to host the 1992 meeting in Vancouver. Although previous world conferences have drawn 1000 to 1500 delegates, the 6 years of work leading up to the 1992 meeting in Vancouver appear decisions. Over the last 20 years, to have paid off: attendance hit WONCA's membership has an all-time high of about 4000.
Since 1964, family physicians from around the world have been gathering every few years to support and further the cause of family practice. The first highly successful meeting in Montreal led to additional conferences every 2 years until 1972, when the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians, or WONCA, was born during the fifth meeting in Melbourne, Australia. The organization is commonly known as the World Organization of Family Doctors. Before 1972, a loose association of colleges and academies of general practitioners and family physicians had been primarily concerned with sponsoring world conferences. The formal creation of WONCA led to the establishment of a permanent secretariat in Australia and to the formation of a world council comprising representatives of each member organization, which meets every 3 years at the world conferences. An executive committee also meets annually to implement council
LE I er JUILLET 1992
"The very elderly have a 1-in-3 some think a 1-in-2 chance of being demented, so as they get older your index of suspicion should rise." -Dr. Mark Clarfield number of older people who arrive in physicians' offices because they "just don't feel very well." Dr. Richard Waltman, a family physician who specializes in geriatric medicine in Tacoma, Washington, described his initial difficulty persuading medical journals to accept a paper outlining "failure to thrive" as a legitimate clinical geriatric entity. He said it was rejected because there was no other literature on the subject and he had been unable to provide a
bibliography. Waltman said psychologic and psychosocial deficits recognized as failure to thrive in children are equally applicable to the elderly and can be identified and resolved the same way. The keys are taking a comprehensive psychosocial inventory of the patient's life, and asking the right
questions. For instance, how much of the patient's condition is due to aging, and how much to disease? How does chronologic age compare with physical age? "Physiological age is what matters but we ask about chronological age," said Waltman. "Try asking the patient, 'how old would you be if you didn't know how old you are?'" If a diagnosis doesn't correlate with the patient's level of function, throw away the diagnosis. Can the level of function be improved? "With the right attitude, my answer is yes, 100% of the time," said Waltman. The right attitude has to include the belief that age itself is not pathology, and that if the JULY 1, 1992
older person doesn't feel well, there's something specifically wrong. "The number one complaint of older people is that doctors say their problems are caused by age. I think we insult our older patients when we blame anything on age before we do an evaluation." Although expensive, Waltman said a one-time comprehensive laboratory screening will often turn up abnormalities previously missed: metabolic derangements, low thyroid, low sodium and low potassium; over 11 years, he diagnosed five cases of pernicious anemia in patients who had been regularly seeing other doctors. Waltman said he is concerned when society writes off older people "and even more concerned when I see my colleagues do it. These people have given their lives to their families and communities and they deserve the best care we can give them." As the number of elderly Canadians grows, so will the incidence of dementia. Dr. Mark Clarfield, then a Montreal family physician and associate professor of family medicine at McGill University (he has since moved to Israel), cautioned doctors to consider the possibility of mental problems. "The very elderly have a l-in-3 - some think a 1-in-2 chance of being demented, so as they get older your index of suspicion should rise." He cautioned as well that the initial signs of dementia can sometimes be obscured by educa-
tion and polite behaviour. "There is some evidence that education may protect against the development of Alzheimer's disease and delay the onset of dementia. We also know that well-educated people who [have dementia] can fool the system for a long time, because they are smart and frequently have good social skills." The influx of immigrants into Canada presents assessment challenges and although there are testing criteria in languages other than English, poor education or illiteracy can confound results too much to provide an accurate picture. In the case of a woman with a Grade 3 education who can't read or write, Clarfield suggested it's better to dispense with testing entirely. "I throw away the [test] and talk to the patient and the family - I've even called shopkeepers. What can't she do now that she could do before? Here's where function is very important as opposed to these instruments that break down with language and education." Correctable causes of dementia, such as hypocalcemia, may be entirely asymptomatic and should always be ruled out by testing. Vitamin B,2 deficiency is another reversible cause of dementia that 95% of the time can be ruled out by a normal complete blood count (CBC). But, again, Clarfield urged caution: "There are cases where people have a normal CBC but an abnormal B12, and they get better if you treat it; so I always order a B12 ."" CAN MED ASSOC J 1992; 147 (1)
107
