Increase in numbers and pay of salaried physicians associated with increase in status within profession MILAN KORCOK In North America the salaried physician has not exactly been looked upon as an heroic figure by all his fellows. He has often been seen as of the profession, but not in it: a sort of second-class citizen shunted aside by his fee-for-service colleagues because he placed a greater value on security than on professional independence and because he lacked the greatest of all possible virtues - entrepreneurial initiative. Without that, he couldn't be expected to wield much clout in the affairs of organized medicine. But a certain amount of persistence has paid off. While fee-for-service physician-economists and government negotiators have been hammering at each other over an ever-diminishing medical services budget - usually in full view of a voyeuristic press - salaried physicians have been quietly and determinedly making strides of their own, often on their own. Not poor cousins Their numbers have grown, their incomes have grown and their status has benefited by that growth. They are not poor cousins any more. In a speech last year to the British Columbia Medical Association - one of the first groups to try effectively to represent the salaried - former CMA President Dr. Gustave Gingras had this to say about the new d6tente: "I am delighted to see the (BC) association showing much more interest in the salaried physician. I have been a salaried physician for a considerable number of years and look, I don't have any horns. I am a physician; I am a member of the association." "There is nothing unholy or dirty or unethical about salaried physicians. We are not lepers, nor do we have any intention to serve as the avant garde in a socialist war against the fee-for-service method of payment." Then came Gingras's best shot: "Neither are we such a distinct minority within the profession that organized medicine can or should ignore us." In fact, salaried physicians are becoming potent in Canadian medicine, and though statistics on their numbers and activities are not as well compiled as those on fee-for-service physicians, there is sound evidence that close to one of each four Canadian physicians is salaried. And if one considers physicians working in group medical prac-
tice, where remuneration is really a sophisticated form of salary, that proportion could be bumped up to 30 or 35% of all physicians. Physicians who work wholly or partly for salary range broadly across the profession. They are employed by federal, provincial and municipal governments and by hospitals, universities, privately-run clinics and industrial organizations. But it is the physicians employed by various governments (especially those in mental health institutions) who make up the single largest component within the ranks of the salaried. Given these growing numbers and their greater visibility, it seems only rational that most provincial medical associations, as well as the CMA, see a new priority in the concerns of salaried physicians. As Gingras noted in his BC speech, "It was nothing short of astonishing that (last year) close to 80% of Manitoba's medical profession discontinued practice for a day in support of salaried members." (The strike was in sympathy for psychiatrists employed by provincial mental institutions, who were deadlocked with government over salaries as well as over which physicians would be excluded from the collective agreement.) In 1974 the MMA was certified by the provincial labour board as a bargaining agent for physicians employed by the provincial government. The MMA fought hard to get this bargaining power. Significantly, the MMA is far from the only provincial medical association to negotiate on behalf of salaried members. In 1975 the British Columbia Medical Association fought hard to retain bargaining rights on behalf of government employed salaried physicians who, by edict of the Public Service Labour Relations Act, were about to be absorbed by a professional employees' association representing engineers, foresters, dentists and other professionals. The stake was the professional status of 125 physicians employed by government - a significant proportion of the 275 members of BCMA's section of salaried physicians. The BCMA did not intend to be overly subtle in suggesting to government that, if this "compulsory unionization" of physicians was irrevocably implemented, the province
162 CMA JOURNAL/JULY 17, 1976/VOL. 115
might wake up one morning to find itself without a mental health service. It worked. The BCMA grasped firm control of the bargaining rights and at the same time clinched a respectable salary settlement for this group of professionals - one that ranges from a minimum of $29 212 for a medical officer II (less than 2 years of experience since completion of internship) to $47097 and up for a medical specialist III. New ranges were to be negotiated for implementation as of Apr. 1, 1976. In Newfoundland, where the cottage hospital system still flourishes (26% of total physicians registered in the province are on salary), the NMA has clearly defined powers to bargain for salaried physicians. The new medical act makes it mandatory for all physicians to become members of the NMA, and this eliminates any problem about speaking on behalf of nonmembers - there just aren't any. The government also has stated that it wants to negotiate salary items only with the association. Haphazard dealing Before this system was established, salary payment was haphazard, depending on what deal an individual struck with the administration of the cottage hospital division. The range just prior to the advent in 1969 of medicare was around $11 000 to $25 000. The most recent salary scale (effective April 1977) will bring salaries to about $25 000 minimum for an assistant medical officer and $47 000 for a senior medical officer. This is supplemented by a fringe benefit and rent subsidies. In Saskatchewan, where between 15 and 20% of physicians are salaried, the SMA has asked the government for powers under the Trades Union Act to represent physicians in government service. This right to representation is being strongly challenged, in a struggle for turf, by the Canadian Union of Public Employees. Lack of collective bargaining has led to some striking anomalies. For example, until quite recently, psychiatrists at provincial hospitals have had to work 22 years before getting a 4th week of holidays. Nurses and all tradesmen got this privilege after 15 years. Many SMA members are wary of the trade union initiatives. They believe
identification with these forces will ultimately degrade the profession. Proponents of this course may not like it either, but they see it as the only way. In Nova Scotia, the medical society is moving toward legislation that would allow it to represent salaried physicians. Approximately 75% of the salaried physicians in the province are government employees. The society at present negotiates with paying agents on behalf of interns and residents. As for other groups, what negotiations there are are carried out between representatives of the specific physicians' groups and the medical services pay plan, Department of Health, NS Health Services and Insurance Commission (NSHSIC) and Civil Service Commission. The society would prefer to deal with but one representative agent, the NSHSIC, which is the true source for medical funds. In New Brunswick, approximately 95 physicians (about 20% of the total) are on salary. A section of salaried physicians has existed within the NB Medical Society for 8 years, and this section elects a liaison representative to attend all meetings of the society executive. None the less it has become the practice in recent years for individuals to negotiate on their own. In 1975 salaried physicians were polled to find whether they wanted the society to represent them in salary negotiations. The poll seemed affirmative, but there was considerable emphasis on obtaining the services of a professional negotiator or adviser to develop the salary packages - similar to the work done on fee schedules. In Prince Edward Island, approximately 16% of physicians are salaried, but to date there has been no agitation of any kind to develop a bargaining mechanism for this group. Essentially, pathologists, radiologists, civil servants and psychiatrists in mental institutions negotiate individually with the hospitals, health insurance commission or appropriate government agency. A salary range for certain groups is normally published in the annual fee schedule, but it is intended only as a guide. La difference Fragmentation seems to impede the development of bargaining processes in Quebec that would consolidate salaried physicians' powers. In this province 20% of physicians are salaried - most of these are provincial or municipal government employees. Many of the salaried physicians at hospital or university centres negotiate their salaries individually. The question of representation continues to be thorny in Quebec. As la Federation des medecins omnipraticiens
perceives for itself
a somewhat similar function. The OMA has sections for clinical teachers, occupational health, psychiatric hospitals and hospital schools - all of which impact on the concerns of salaried physicians. The OMA has also been publishing a suggested scale for various grades of salaried physicians as part of its annual fee schedule. The scale is intended as a guide, not a hard and fast bargaining
position.
At the national level, the CMA tends retiring posture when the words "bargaining" and "negotiation" are uttered ("those are the provinces' functions, not ours"). Yet the national organization has gradually moved - or been pushed - into assuming an identifiable presence on behalf of salaried physicians. In early 1975 a meeting was called at CMA House to consider policy on salaried physicians and how their interests should be represented nationally. A recommendation urged the Council on Economics to consider creation of a subcommittee on salaried physicians. When the council brought this idea to the CMA board in December 1975, the directors quashed it in favour of a broader based subcommittee on physician remuneration. The interests of salaried physicians would be carried on within this broader context. The first meeting of this subcommittee, in February 1976, spent much time sorting out its own terms of reference. But in the course of that debate the CMA's research and development department was also charged to pull together whatever relevant data there were across the country in respect to salary scales and fringe benefits. The subcommittee also supported the concept that provincial medical associations "may be recognized as official bargaining agents for salaried physicians paid from provincial funds when requested by a group of salaried physicians." No uniformity Finding some interprovincial denominators for salary scales is going to be exceedingly difficult because no two provinces have the same nomenclature or the same categorization of job descriptions. A medical officer IV in British Columbia has (up to April, 1976) a salary range of $36 962 to $40 539. In Ontario the closest equivalent salary range - $34700 to $40 300 - is paid a grade II salaried physician not in clinical practice. But it would take a genie to determine whether or not the terms of reference or the qualifications for these two jobs could really be equated. In this respect, the activities of the federally employed salaried physicians, to a
Gingras:
a
salaried
physician without
horns
du Quebec notes, the Ministry of Social Affairs has officially recognized the federation as representing any GP wherever he practises and whatever the method of remuneration. Despite that, government has not held back from entering into individual agreements with physicians. In Alberta and Ontario, salaried physicians' advisory groups have been established to gather data, define appropriate salary scales and assist salaried physicians in their own negotiations. But in neither province are the associations legally empowered as bargaining agents. The Alberta Medical Association has emphasized that the goal of its section on salaried physicians is "that of an adviser, resource centre and, if requested, a mediator". It has not yet been asked to serve in these functions. The AMA sees its principal role "as a professional association, not, at this time, as a union." At least 271 of the the total of 2098 association members are salaried (virtually full-time). If one added in those who earn at least half their income from salary, the number could go as high as 625. A recent survey of Alberta's salaried physicians showed that 64% of those on full-time salary earn more than $30 000 and 24% earn more than $40 000. Fringe benefit packages for these include pension plans, paid statutory holidays, sabbatical leave, paid vacations, illness at full pay, employersubsidized life and health insurance, payment of professional dues by employers and allowance for such professional expenses as educational leave. The Ontario Medical Association
164 CMA JOURNAL/JULY 17, 1976/VOL. 115
members of the medical group of the Professional Institute of the Public Service of Canada (PIPS), take on added significance. This group, which in 1973 covered 340 MDs, represents physicians in federal service. Negotiations are conducted directly with the Treasury Board. And though the Treasury Board could never be accused of overt generosity, the PIPS medical group contracts are clearly the soundest in the country for incomes and benefits. They could well serve as models for provincial associations looking for guidance in the bargaining process. They not only have a handsome range of fringe benefits (in the neighbourhood of 30% of their basic wage) but they have such wrinkles as pensions indexed to the cost of living. In effect, they benefit by inflation. Dr. Maurice Chr.tien, medical advisory branch, Canada Pension Commission, who took part in the CMA subcommittee meeting in February, candidly states that the salary levels enjoyed by this group are the highest in the country - higher than those in any province. He says the provinces could do well "to use the federal scales as models for their own provinces." About the only groups who do better than the federally employed physicians generally are those working in the larger corporations of the country, where fringe benefits have been known to amount to 40% of salary. Industry well paid A recent report on salaries and fringe benefits for practising physicians, commissioned by the OMA and prepared by Health Program Consultants Ltd. (headed by Dr. Edmond A.D. Boyd) shows that some parts of private industry can be lucrative for the physician. In a survey of 12 large corporations employing physicians, the consultants' report shows wide variations in salary range: $35 000 to $50 000 for regional physicians, $40 000 to $60 000 for assistant medical directors and $45 000 to $77 000 for medical directors. It also shows that a normal work week for physicians covered in this survey is 35 to 37½ hours a week though it does note that those in upper administrative roles work up to 65 hours a week. A survey of Canadian industry, now being prepared by CMA's R&D department, tends to support Boyd's figures. It notes that fringe benefits account for between 25 and 30% of total payrolls, and it shows that the average salary of physicians working in industry is about $38 000. For part-time physicians, the aver-
age hourly rate is around $28. Because corporations often have difficulty hiring physicians for full-time positions (and only the largest can really afford that) they are willing to be generous with fringe benefits. Often these packages include all or most of these: 4 weeks' paid vacation, short- and long-term disability insurance, I to 2 weeks' study leave with pay, 2 to 3 paid conventions a year, pension plans paid by the company, savings plans (up to 6% of salary, Lisually matched by the company), deferred profit sharing, extensive health insurance and disability package, professional association dues paid by the company, one or two club memberships, car allowance to I 1.25./km, often a 10 to 25% discount on purchase of company products and services. This kind of package would range well upwards of 25% and would be closer to 40% of the basic salary. Dr. Boyd also noted that among the companies surveyed, the support services given physicians would be the stuff of dreams for privately practising physicians. The average costs of the surveyed medical departments' activities were equivalent to $145 per employee. The average overall annual cost per clinical physician including his support staff was, to these companies, $250 000. The 1975 budget for one industrial medical department showed 5½ physicians (with an aggregate of $200 000 in salaries) to have a support staff of 34 people accounting for an additional $340 000 worth of salaries. Boyd teases with an interesting speculation: if the $145 per employee reflects the cost of preventive medical care "coLild we afford it on a national scale?" The equivalents Developing fiscal equations between salaried and fee-for-service physicians is an elusive science. Even those who make their living at such science retreat from any unqualified statements about the "worth" of fringe benefit packages or about comparisons between gross and net earnings of fee practitioners and salaried physicians. Usually, approximations such as 30 to 35% are used to reflect fee practitioners' practice-related overhead. By deducting this, we have net before taxes. But once we have this figure, is it fair to compare it to the basic wage of the salaried physician? Or is it more appropriate to compare this before-taxes net to the basic wage only after the value of the fringe package has been added on? These questions will have to be sorted out by economists.
But A.V. Hall, research officer of the Professional Institute of the Public Service of Canada (PIPS) shows that there are far too many variables involved. "It is not possible to say that a cost to the employer of a certain package is reflected as a benefit of the same percentage to an employee. Some fringe benefits are salary-dependent, some are salary-independent. For some, the cost of the benefit is related to salary level (pension, disability insurance). Other benefits are at a standard premium rate." The monetary value placed on fringe benefits in the public service can only be highly subjective, says Hall. "If one were, nevertheless, to attempt to provide some overall figure to express their value, it would have to be of the same order as is expressed for employer gross payroll costs, even though individual public servants might give very different answers as expressions of their worth or value." Variables aside Such variables aside, Hall agrees that the salaried physician is riding a trend in which his disposable income, his "standard of living", his quality of life, is accelerating more swiftly than is that of his fee-for-service counterpart. Within the past 3 years, increases given out by the Treasury Board to federally employed physicians have been quite substantial. From 1973 to 1975, for example, PIPS medical group salaries jumped 20%. In New Brunswick and Nova Scotia, increases have averaged 8 to 9% annually over 3 years. The Ontario consultants' (Boyd) report indicates that from 1969 to 1975, salary levels for physicians in the lower categories increased more than 80%. Grade 1 maximum in 1969 was $17 500; in 1975 this was $31 360. In the higher categories, salaries have increased more slowly but still dramatically - by 50% (from $30 250 in 1969 for grade 5 to $45 920 minimum in 1975). At the federal level, a medical officer III in 1961 had a minimum of $11600; in 1965 he was at $14099 minimum, in 1970 at $20 105 and in 1975 at $34 343. At the same time, fringe benefits would have increased from 15% of the basic wage package to more like 30%, says PIPS research officer Hall, although he adds there are no real statistics on the value of the fringe benefits and his estimate is somewhat "intuitive". By comparison, average net professional earnings of active fee-for-service practising physicians stood at $24 486 in 1962 and at $41 342 in 1973.
CMA JOURNAL/JULY 17, 1976/VOL. 115
167
Canestw¶ Antifungal and clotrimazole trichomonacidal agent
PRESCRIBING INFORMATION INDICATIONS Canesten Cream and Solution: Topical treatment of the following dermal infections: tinea pedis, tinea cruris and tinea corporis due to T. rubrum, T. mentagrophytes and Epidermophyton floccosum; candidiasis due to C. albicans; tinea versicolor due to Malassezia furfur. Canesten Vaginal Tablets: Treatment of vaginal candidiasis and trichomoniasis. Canesten Vaginal Tablets may be used in both pregnant and non-pregnant women, as well as in women taking oral contraceptives. (See Precautions) DOSAGE AND ADMINISTRATION Cream and Solution: Thinly apply and gently massage sufficient cream or solution into the affected and surrounding skin areas twice daily, in the morning and evening. For vulvitis, Canesten Cream should be applied to the vulva and as far as the anal region. For balanitis and prevention of vaginal infection or reinfection by the partner. Canesten Cream should be applied to the glans penis. Vaginal Tablets: One tablet a day for six consecutive days. Using the applicator, insert one tablet deep intravaginally, preferably at bedtime. In order to avoid treatment during menstruation, it is suggested that treatment be started at least 6 days prior to the anticipated menstrual period. DURATION OF TREATMENT Cream and Solution: The duration of therapy varies and depends on the extent and localization of the disease. Generally, clinical improvement with relief of pruritus usually occurs within the first week of treatment. Tinea infections require approximately 3-4 weeks of therapy while in candidiasis, 1 -2 weeks treatment is often adequate. If no clinical improvement is observed after 4 weeks, the diagnosis should be reviewed. If a cure is not mycologically confirmed or in order that relapses may be prevented (particularly in mycoses of the foot), treatment should, as a rule, be continued for 2 weeks after all clinical symptoms have disappeared. Vaginal Tablets: The six-day therapy may be repeated if necessary. SPECIAL REMARKS Cream and Solution: Added hygienic measures are of special importance in the management of the often refractory fungal diseases of the foot. To avoid trapped moisture, the feet - particularly between the toes - should be dried thoroughly after washing. Onychomycoses, owing to their location and physiological factors, generally respond poorly to topical antimycotic therapy alone due to poor penetration into horny substance. Treatment with Canesten may be considered in cases of paronychia and as adjunctive therapy in onychomycoses following extraction or ablation of the nail. Vaginal Tablets: Added hygienic measures such as twice daily tub baths and avoidance of tight underclothing is highly recommended. In the case of clinically significant trichomonal infection, additional therapy with a systemic trichornon acidal agent should be considered. Such therapy is essential for the treatment of vaginal infections which may also involve Bartholins glands and the urethra. CONTRAINDICATIONS Except for possible hypersensitivity, Canesten Solution, Cream and Vaginal Tablets have no known contraindications. PRECAUTIONS As with all topical agents, skin sensitization may result. Use of Canesten topical preparations should be discontinued should such reactions occur, and appropriate therapy instituted. Canesten Solution and Cream are not for ophthalmic use. Canesten Vaginal Tablets are not for oral use. Use in Pregnancy: Although intravaginal application of clotrimazole has shown negligible absorption from both normal and inflamed human vaginal mucosa, Canesten Vaginal Tablets should not be used in the first trimester of pregnancy unless the physician considers it essential to the welfare of the patient. The use of the supplied applicator may be undesirable in some pregnant patients, and digital insertion of the tablets is an alternative which should be considered. SIDE EFFECTS Large scale clinical trials have shown that Canesten is very well tolerated after topical and vaginal application. Cream and Solution: Erythema, stinging, blistering, peeling, edema, pruritus, urticaria, and general irritation of the skin have been reported infrequently. Vaginal Tablets: Skin rash, lower abdominal cramps, slight urinary frequency, and burning or irritation in the sexual partner, have occurred rarely. In no case was it necessary to discontinue treatment with Canesten Vaginal Tablets. AVAILABILITY Canesten Solution 1 % is supplied in 20 ml plastic bottles, in carton. Each ml contains 10 mg of clotrimazole in a non-aqueous vehicle.
Canesten Cream 1 % is supplied in 20 g tubes, in carton. Each g contains 10 mg of clotrimazole in vanishing cream base. Canesten Vaginal Tablets 100 mg are supplied in boxes containing one strip of six tablets with plastic applicator and patient leaflet of instructions.
REFERENCES 1. Lohmeyer, H., Postgrad. Med. J., 50 Suopl. 78, 1974. / 2. Schnell, iD., Ibid., p. 79. / 3. Legal, H.P., Ibid., p.81. /4. Widholm, 0 Ibid p 85 / 5. Couchman, J.M. Ibid., p. 93 /6 Higton,BK,lbid,p.95./7.
Oates, J.K., Ibid., p.99 /8 !-Aasterton, MB et al., Curr. Med. Res. 0.in., 3, 83, 1975 / 9 Sawyer, P.R., et al.,
Drugs, 9:42 1975. / 10. Postgrad. Med. J., 50 Suppl., 54-76, 1975. For further prescribing information please consult the
Canesten Product Monograph or your Boehringer Ingelheim representative.
* I.) PRA
FBA Pharmaceuticals Ltd. Distributed by Boehringer Ingeiheim (Canada) Ltd. 2121 Trans Canada Highway Dorval, P.Q. H9P 1J3 FBA-65-76
One piece of data coming out of the CMA research department shows that in actual buying power (after-tax income corrected for inflation and indexed to constant 1961 dollars) physician s incomes have dropped sharply since 1971 -more than 15%. In fact, the average physician could buy less in 1973 than he could in 1964. If, for example, buying power had remained at 1961 levels, in 1964 he would have had $18 293 dollars to spend, in 1971, $21 268, and in 1973, $28 015. The Boyd consultants' report concludes that if fee-for-service physicians had worked no harder in 1974 and '75 than they did in 1973 and had relied on fee changes alone, their advances would have been negligible. Salaried physicians have, on the other hand, been able to tally up their financial advances without necessarily working harder. If there is any general equation to be drawn, it is that the average practising fee-for-service doctor is still keeping abreast of the most highly paid salaried doctor in 1975. But in 1973 he was far ahead. At a time when the free enterprise system is coming under such close scrutiny by various governments, the fee-for-service method of paying physicians has come under much attack. Because fee for service is somewhat open-ended, several federal and provincial paymasters have urged placing all physicians on salary, thus curbing any inherent "extravagances" within the system. It seems to be part of the conventional wisdom that control equals frugality. Well, the consultants' report commissioned by the OMA put the salaryequals-control-equals-frugality equation to the test - and found it seriously wanting. Salary costs more In fact, if all Ontario physicians now earning fees for service were to be put on salary and given the normal range of emoluments given to their confreres in other professions, Ontario's medical services bill would be dramatically higher than it is now. The report makes its projections on the basis of a $28 000 base salary for any licensed physician for a 40-hour week, plus paid vacations. It adds in a bonus of $5000 for a 2-year family practice residency, $10 000 for a 4-year specialist qualification, overtime pay (at normal industrial rates), a 2.6% annual increment for each year in the salaried service, additional salary increases indexed to the wage and salary index for Ontario, a prestige bonus for
170 CMA JOURNAL/JULY 17, 1976/VOL. 115
specialists to Whom most patients are referred (a specialist seeing 100% referred patients would be paid 25% more than a similarly classified specialist with no referred work), an overhead expense allowance of $22 000 a year (line by line or global budget method) and a $5 per hour retainer for doctors on call in institutions. If all this was put together in one package, the way it is in normal salaried circumstances, the average, actively practising GP working 55 hours a week would gross $101 000. This is already 44% higher than the current gross of the same practitioner doing essentially the same work now on fee for service. Under the same formula, the average specialist would gross $142 000. Under such circumstances, the total cost of medical care in Ontario in 1976 would be $962 million (counting 4000 general physicians and 4000 specialists). For medical services between Apr. 1, 1974 and Mar. 31, 1975, OHIP paid out $617 million. To this would also have to be added various costs involved in administering a totally salaried service such as regional supervision of doctors' practices. This would easily bump the cost up in excess of $1 billion, says the consultants' report. By comparison, the Ontario Ministry of Health has estimated that medical care under OHIP will have cost $700 million in 1975. More than money As salaried physicians increase their numbers, it is inevitable that comparisons between the workstyles (salary and fee for service) will be promulgated. But these comparisons should reflect more than just salary levels and the size of fringe benefit packages, says Dr. Edward Napke, first vice-president of the Professional Institute of the Public Service of Canada, who heads the federal adverse reaction and poison control division. Napke emphasizes that most comparisons between salaried and fee-forservice medical practices don't mean very much, because they are comparisons of totally different entities. "There are frustrations I, as a professional man, have that no man in fee for service has," he says. "When I want to do something I have to deal with a structure around me. When you get into an organization you have a system, and dealing with that system can be nerve-wracking. "It takes a certain kind of temperament to be able to do that. And as an individual you must decide what kinds of problems you are willing to face continued on page 178
been more involved in the mainstream of national activities and thought dealing with public health and the delivery of health care. His successor is Dr. Kenneth I.G. Benson of Vancouver, and next year's CPHA meeting will be held in that city. The Moncton meeting concluded
with the approval of resolutions on compulsory seat-belt legislation in provinces where there is none, on field trials for swine 'flu vaccines, on opposition to financial cutbacks in such areas as home care and community geriatric programs, and on recruitment of native peoples into the public health field and the CPHA.E
APPOINTMENT SYSTEM continued from page 161 Remember, people do not mind waiting if they know beforehand how much time may be involved. Another basic rule is that the doctor should be prepared to modify his system. One of the advantages of the front-end load system is that it lends itself to modification. When problems arise, the doctor or receptionist should note the time when the delay occurs. By this means, the pattern of the difficulty can be established and the system changed accordingly. In one case where the system was used, the mornings ran smoothly; however, the doctor fell behind every day in the afternoon. During discussions with the doctor and his staff it was mentioned that he tended to slow down after lunch each day. His activity curve dropped for the first hour and a half after lunch and then picked up to surpass his morning rate. The solution was to schedule two fewer patients during the first part of the afternoon and one more per hour for the remainder of the afternoon. The fifth basic rule in establishing an appointment system is that the scheduler should have autonomy. One of a medical secretary's duties is to schedule appointments, and providing the ground rules are explicit (for instance, complete physical examinations on
Wednesdays, Thursday afternoons off) only this person should keep the appointment record. This means that the physician should not book appointments. It is always interesting to look objectively at any communications transaction. It quite often happens that what the speaker said, what he meant, and what was interpreted are three different things. For example, when a doctor after examining a patient decides that a follow-up visit is required, he should not say "Mrs. Jones, I would like to see you again in about 2 days' time" because the patient may assume that she has a fixed appointment 48 hours later. If a doctor wishes a patient to return, the patient should be advised to arrange an appointment with the secretary, who is then able to fit the patient into the time frame without disrupting the schedule. Finally, a doctor should be prepared for the unforeseen. Every practice has a number of unscheduled patients. These may be drop-ins or people with urgent problems. A doctor who finds that in his practice there are one, two or three such patients each day should leave one, two or three blanks in the appointment schedule. Then, when one of these patients shows up, it is almost as if he were scheduled and the blank period in the timetable will allow the doctor to avoid falling behind.E
SALARIED PHYSiCIANS continued from page 170 and what kind of successes you want to achieve." Dr. Napke believes there is a more critical endpoint to the bargaining process than achieving dollar parity between salaried and fee-for-service physicians - however one defines parity. That endpoint is the recognition of professionalism. "There is a certain mystique that goes along with professionalism," says THE UPJOHN COMPANY OF CANADA Napke. "You have to give up certain DON MILLS, ONTARIO things because you enjoy the job. You can't bargain for overtime or call-back. 178 CMA JOURNAL/JULY 17, 1976/VOL. 115
If the job is there, as a professional you handle it. If you don't like the job, get out of it. "The real question is, who are we? Are we still the people responsible for making decisions? What makes a professional a professional?" The answers to such questions may remain elusive, but Dr. Napke believes that an improvement in the general level and status of any one segment of the medical profession benefits all physicians. The corollary is straightforward: when the professional status and role of salaried physicians are fully recognized, the entire profession is strengthened.E
M.trin (ibuprofen)
Indications and Clinical Uses: Ibuprofen is indicated for the treatment of osteoarthritis and rheumatoid arthritia. Contraindicationa: Ibuprofen should notbe uaed during pregnancy or in pmdiatric patienta becauae ita aafety under these conditiona haa not been establiahed. Ibuprofen ahoutd not be uaed in patienta with a history of acetylsalicylic acidinduced bronchospasm. Precautions: Ibuprofen should be used with caution in patients with a history of gastrointestinal ulceration. ibuprofen has been reported to be associated with toxic amblyopia. Therefore precautions should be taken to ensure that patients on ibuprofen therapy report to their physicians for full ophthalmological examination if they experience any visual difficulty. Medication should be discontinued if there is any evidence of toxic amblyopia. Adverse Reactions: The following adverse reactions have been noted in patients treated with ibuprofen. Gastrointestinal: Nausea, vomiting, diarrhma, constipation, dyspepsia, epigastric pain and gusiac positive stools have been noted. A few cases of gastric or duodenal ulceration, Including some complicated by bleeding or perforation have occurred. Central Nervous System: Dizziness, light-headedness, headache, anxiety, mental confusion and depression were noted in some patients treated with ibuprofen. Ophthalmologlcal: Blurred vision was noted in some patients and rarely a sensation of moving lights was observed following administration of ibuprofen. in addition there are three published cases of toxic amblyopia associated with the use of ibuprofen. Although a definite cause and effect relationship was not established, the attending physicians considered them to be drug related. The condition was characterized by reduced visual acuity and difficulty in colour discrimination. Defects (usually centrocucsl) were observed on visual field examination. Symptoms were reversible on discontinuation of treatment. Skin: Maculopapular rashes, urticaria, and generalized pruritus have been reported with ibuprofen therapy. Occasional cases of .dema have also been reported. Laboratory Teats: Sporadic abnormalities of liver function tests have occurred in patients on ibuprofen therapy (SGOT, serum bilirubin and alkaline phosphatase) but no definite trend was seen indicating toxicity. Similar abnormalities of white blood count and blood urea determinations were noted. A slight fall in hamoglobin and hmmatocrit has been noted in some patients.
Symptoms and Treatment of Overdosage: One
case of overdosage has been reported. A oneyear-old child ingested 1200 mg ibuprofen and suffered no Ill effects other than being drowsy the next day. Blood levels of ibuprofen reached 711 mcg/ml, which is considerably above the 90 mcg/ml previously recorded as the highest level seen In adults after a single oral dose of 800 mg. The SGPT level, nine days post-Ingestion, was 72. No specific antidote is known. Standard measures to stop further absorption and maintain urine output should be Implemented at once. The drug is excreted rapidly and excretion is almost complete in six hours.
Dosage and Administration: To obtain rapid re-
sponse at the start of treatment, particularly when transferring from other anti-inflammatory therapy, Motrinshould be given at a dose of 1200 mg per day In 4 divided doses. Depending on the therapeutic response, the dose may be adjusted downward or upward keeping the 4 times a day dosage schedule. The daily dose should not exceed 2400 mg. Maintenance therapy, once maximum response is obtained, will range from 800 to 1200 mg per day. Due to lack of clinical experience, ibuprofen is not indicated for use in children under 12 years of age. Supplied: 200 mg yellow coated tablets and 300 mg white coated tablets in bottles of 100 and 1000.
E.D
tice, where remuneration is really a sophisticated form of salary, that proportion could be bumped up to 30 or 35% of all physicians. Physicians who work wholly or partly for salary range broadly across the profession. They are employed by federal, provincial and municipal governments and by hospitals, universities, privately-run clinics and industrial organizations. But it is the physicians employed by various governments (especially those in mental health institutions) who make up the single largest component within the ranks of the salaried. Given these growing numbers and their greater visibility, it seems only rational that most provincial medical associations, as well as the CMA, see a new priority in the concerns of salaried physicians. As Gingras noted in his BC speech, "It was nothing short of astonishing that (last year) close to 80% of Manitoba's medical profession discontinued practice for a day in support of salaried members." (The strike was in sympathy for psychiatrists employed by provincial mental institutions, who were deadlocked with government over salaries as well as over which physicians would be excluded from the collective agreement.) In 1974 the MMA was certified by the provincial labour board as a bargaining agent for physicians employed by the provincial government. The MMA fought hard to get this bargaining power. Significantly, the MMA is far from the only provincial medical association to negotiate on behalf of salaried members. In 1975 the British Columbia Medical Association fought hard to retain bargaining rights on behalf of government employed salaried physicians who, by edict of the Public Service Labour Relations Act, were about to be absorbed by a professional employees' association representing engineers, foresters, dentists and other professionals. The stake was the professional status of 125 physicians employed by government - a significant proportion of the 275 members of BCMA's section of salaried physicians. The BCMA did not intend to be overly subtle in suggesting to government that, if this "compulsory unionization" of physicians was irrevocably implemented, the province
162 CMA JOURNAL/JULY 17, 1976/VOL. 115
might wake up one morning to find itself without a mental health service. It worked. The BCMA grasped firm control of the bargaining rights and at the same time clinched a respectable salary settlement for this group of professionals - one that ranges from a minimum of $29 212 for a medical officer II (less than 2 years of experience since completion of internship) to $47097 and up for a medical specialist III. New ranges were to be negotiated for implementation as of Apr. 1, 1976. In Newfoundland, where the cottage hospital system still flourishes (26% of total physicians registered in the province are on salary), the NMA has clearly defined powers to bargain for salaried physicians. The new medical act makes it mandatory for all physicians to become members of the NMA, and this eliminates any problem about speaking on behalf of nonmembers - there just aren't any. The government also has stated that it wants to negotiate salary items only with the association. Haphazard dealing Before this system was established, salary payment was haphazard, depending on what deal an individual struck with the administration of the cottage hospital division. The range just prior to the advent in 1969 of medicare was around $11 000 to $25 000. The most recent salary scale (effective April 1977) will bring salaries to about $25 000 minimum for an assistant medical officer and $47 000 for a senior medical officer. This is supplemented by a fringe benefit and rent subsidies. In Saskatchewan, where between 15 and 20% of physicians are salaried, the SMA has asked the government for powers under the Trades Union Act to represent physicians in government service. This right to representation is being strongly challenged, in a struggle for turf, by the Canadian Union of Public Employees. Lack of collective bargaining has led to some striking anomalies. For example, until quite recently, psychiatrists at provincial hospitals have had to work 22 years before getting a 4th week of holidays. Nurses and all tradesmen got this privilege after 15 years. Many SMA members are wary of the trade union initiatives. They believe
identification with these forces will ultimately degrade the profession. Proponents of this course may not like it either, but they see it as the only way. In Nova Scotia, the medical society is moving toward legislation that would allow it to represent salaried physicians. Approximately 75% of the salaried physicians in the province are government employees. The society at present negotiates with paying agents on behalf of interns and residents. As for other groups, what negotiations there are are carried out between representatives of the specific physicians' groups and the medical services pay plan, Department of Health, NS Health Services and Insurance Commission (NSHSIC) and Civil Service Commission. The society would prefer to deal with but one representative agent, the NSHSIC, which is the true source for medical funds. In New Brunswick, approximately 95 physicians (about 20% of the total) are on salary. A section of salaried physicians has existed within the NB Medical Society for 8 years, and this section elects a liaison representative to attend all meetings of the society executive. None the less it has become the practice in recent years for individuals to negotiate on their own. In 1975 salaried physicians were polled to find whether they wanted the society to represent them in salary negotiations. The poll seemed affirmative, but there was considerable emphasis on obtaining the services of a professional negotiator or adviser to develop the salary packages - similar to the work done on fee schedules. In Prince Edward Island, approximately 16% of physicians are salaried, but to date there has been no agitation of any kind to develop a bargaining mechanism for this group. Essentially, pathologists, radiologists, civil servants and psychiatrists in mental institutions negotiate individually with the hospitals, health insurance commission or appropriate government agency. A salary range for certain groups is normally published in the annual fee schedule, but it is intended only as a guide. La difference Fragmentation seems to impede the development of bargaining processes in Quebec that would consolidate salaried physicians' powers. In this province 20% of physicians are salaried - most of these are provincial or municipal government employees. Many of the salaried physicians at hospital or university centres negotiate their salaries individually. The question of representation continues to be thorny in Quebec. As la Federation des medecins omnipraticiens
perceives for itself
a somewhat similar function. The OMA has sections for clinical teachers, occupational health, psychiatric hospitals and hospital schools - all of which impact on the concerns of salaried physicians. The OMA has also been publishing a suggested scale for various grades of salaried physicians as part of its annual fee schedule. The scale is intended as a guide, not a hard and fast bargaining
position.
At the national level, the CMA tends retiring posture when the words "bargaining" and "negotiation" are uttered ("those are the provinces' functions, not ours"). Yet the national organization has gradually moved - or been pushed - into assuming an identifiable presence on behalf of salaried physicians. In early 1975 a meeting was called at CMA House to consider policy on salaried physicians and how their interests should be represented nationally. A recommendation urged the Council on Economics to consider creation of a subcommittee on salaried physicians. When the council brought this idea to the CMA board in December 1975, the directors quashed it in favour of a broader based subcommittee on physician remuneration. The interests of salaried physicians would be carried on within this broader context. The first meeting of this subcommittee, in February 1976, spent much time sorting out its own terms of reference. But in the course of that debate the CMA's research and development department was also charged to pull together whatever relevant data there were across the country in respect to salary scales and fringe benefits. The subcommittee also supported the concept that provincial medical associations "may be recognized as official bargaining agents for salaried physicians paid from provincial funds when requested by a group of salaried physicians." No uniformity Finding some interprovincial denominators for salary scales is going to be exceedingly difficult because no two provinces have the same nomenclature or the same categorization of job descriptions. A medical officer IV in British Columbia has (up to April, 1976) a salary range of $36 962 to $40 539. In Ontario the closest equivalent salary range - $34700 to $40 300 - is paid a grade II salaried physician not in clinical practice. But it would take a genie to determine whether or not the terms of reference or the qualifications for these two jobs could really be equated. In this respect, the activities of the federally employed salaried physicians, to a
Gingras:
a
salaried
physician without
horns
du Quebec notes, the Ministry of Social Affairs has officially recognized the federation as representing any GP wherever he practises and whatever the method of remuneration. Despite that, government has not held back from entering into individual agreements with physicians. In Alberta and Ontario, salaried physicians' advisory groups have been established to gather data, define appropriate salary scales and assist salaried physicians in their own negotiations. But in neither province are the associations legally empowered as bargaining agents. The Alberta Medical Association has emphasized that the goal of its section on salaried physicians is "that of an adviser, resource centre and, if requested, a mediator". It has not yet been asked to serve in these functions. The AMA sees its principal role "as a professional association, not, at this time, as a union." At least 271 of the the total of 2098 association members are salaried (virtually full-time). If one added in those who earn at least half their income from salary, the number could go as high as 625. A recent survey of Alberta's salaried physicians showed that 64% of those on full-time salary earn more than $30 000 and 24% earn more than $40 000. Fringe benefit packages for these include pension plans, paid statutory holidays, sabbatical leave, paid vacations, illness at full pay, employersubsidized life and health insurance, payment of professional dues by employers and allowance for such professional expenses as educational leave. The Ontario Medical Association
164 CMA JOURNAL/JULY 17, 1976/VOL. 115
members of the medical group of the Professional Institute of the Public Service of Canada (PIPS), take on added significance. This group, which in 1973 covered 340 MDs, represents physicians in federal service. Negotiations are conducted directly with the Treasury Board. And though the Treasury Board could never be accused of overt generosity, the PIPS medical group contracts are clearly the soundest in the country for incomes and benefits. They could well serve as models for provincial associations looking for guidance in the bargaining process. They not only have a handsome range of fringe benefits (in the neighbourhood of 30% of their basic wage) but they have such wrinkles as pensions indexed to the cost of living. In effect, they benefit by inflation. Dr. Maurice Chr.tien, medical advisory branch, Canada Pension Commission, who took part in the CMA subcommittee meeting in February, candidly states that the salary levels enjoyed by this group are the highest in the country - higher than those in any province. He says the provinces could do well "to use the federal scales as models for their own provinces." About the only groups who do better than the federally employed physicians generally are those working in the larger corporations of the country, where fringe benefits have been known to amount to 40% of salary. Industry well paid A recent report on salaries and fringe benefits for practising physicians, commissioned by the OMA and prepared by Health Program Consultants Ltd. (headed by Dr. Edmond A.D. Boyd) shows that some parts of private industry can be lucrative for the physician. In a survey of 12 large corporations employing physicians, the consultants' report shows wide variations in salary range: $35 000 to $50 000 for regional physicians, $40 000 to $60 000 for assistant medical directors and $45 000 to $77 000 for medical directors. It also shows that a normal work week for physicians covered in this survey is 35 to 37½ hours a week though it does note that those in upper administrative roles work up to 65 hours a week. A survey of Canadian industry, now being prepared by CMA's R&D department, tends to support Boyd's figures. It notes that fringe benefits account for between 25 and 30% of total payrolls, and it shows that the average salary of physicians working in industry is about $38 000. For part-time physicians, the aver-
age hourly rate is around $28. Because corporations often have difficulty hiring physicians for full-time positions (and only the largest can really afford that) they are willing to be generous with fringe benefits. Often these packages include all or most of these: 4 weeks' paid vacation, short- and long-term disability insurance, I to 2 weeks' study leave with pay, 2 to 3 paid conventions a year, pension plans paid by the company, savings plans (up to 6% of salary, Lisually matched by the company), deferred profit sharing, extensive health insurance and disability package, professional association dues paid by the company, one or two club memberships, car allowance to I 1.25./km, often a 10 to 25% discount on purchase of company products and services. This kind of package would range well upwards of 25% and would be closer to 40% of the basic salary. Dr. Boyd also noted that among the companies surveyed, the support services given physicians would be the stuff of dreams for privately practising physicians. The average costs of the surveyed medical departments' activities were equivalent to $145 per employee. The average overall annual cost per clinical physician including his support staff was, to these companies, $250 000. The 1975 budget for one industrial medical department showed 5½ physicians (with an aggregate of $200 000 in salaries) to have a support staff of 34 people accounting for an additional $340 000 worth of salaries. Boyd teases with an interesting speculation: if the $145 per employee reflects the cost of preventive medical care "coLild we afford it on a national scale?" The equivalents Developing fiscal equations between salaried and fee-for-service physicians is an elusive science. Even those who make their living at such science retreat from any unqualified statements about the "worth" of fringe benefit packages or about comparisons between gross and net earnings of fee practitioners and salaried physicians. Usually, approximations such as 30 to 35% are used to reflect fee practitioners' practice-related overhead. By deducting this, we have net before taxes. But once we have this figure, is it fair to compare it to the basic wage of the salaried physician? Or is it more appropriate to compare this before-taxes net to the basic wage only after the value of the fringe package has been added on? These questions will have to be sorted out by economists.
But A.V. Hall, research officer of the Professional Institute of the Public Service of Canada (PIPS) shows that there are far too many variables involved. "It is not possible to say that a cost to the employer of a certain package is reflected as a benefit of the same percentage to an employee. Some fringe benefits are salary-dependent, some are salary-independent. For some, the cost of the benefit is related to salary level (pension, disability insurance). Other benefits are at a standard premium rate." The monetary value placed on fringe benefits in the public service can only be highly subjective, says Hall. "If one were, nevertheless, to attempt to provide some overall figure to express their value, it would have to be of the same order as is expressed for employer gross payroll costs, even though individual public servants might give very different answers as expressions of their worth or value." Variables aside Such variables aside, Hall agrees that the salaried physician is riding a trend in which his disposable income, his "standard of living", his quality of life, is accelerating more swiftly than is that of his fee-for-service counterpart. Within the past 3 years, increases given out by the Treasury Board to federally employed physicians have been quite substantial. From 1973 to 1975, for example, PIPS medical group salaries jumped 20%. In New Brunswick and Nova Scotia, increases have averaged 8 to 9% annually over 3 years. The Ontario consultants' (Boyd) report indicates that from 1969 to 1975, salary levels for physicians in the lower categories increased more than 80%. Grade 1 maximum in 1969 was $17 500; in 1975 this was $31 360. In the higher categories, salaries have increased more slowly but still dramatically - by 50% (from $30 250 in 1969 for grade 5 to $45 920 minimum in 1975). At the federal level, a medical officer III in 1961 had a minimum of $11600; in 1965 he was at $14099 minimum, in 1970 at $20 105 and in 1975 at $34 343. At the same time, fringe benefits would have increased from 15% of the basic wage package to more like 30%, says PIPS research officer Hall, although he adds there are no real statistics on the value of the fringe benefits and his estimate is somewhat "intuitive". By comparison, average net professional earnings of active fee-for-service practising physicians stood at $24 486 in 1962 and at $41 342 in 1973.
CMA JOURNAL/JULY 17, 1976/VOL. 115
167
Canestw¶ Antifungal and clotrimazole trichomonacidal agent
PRESCRIBING INFORMATION INDICATIONS Canesten Cream and Solution: Topical treatment of the following dermal infections: tinea pedis, tinea cruris and tinea corporis due to T. rubrum, T. mentagrophytes and Epidermophyton floccosum; candidiasis due to C. albicans; tinea versicolor due to Malassezia furfur. Canesten Vaginal Tablets: Treatment of vaginal candidiasis and trichomoniasis. Canesten Vaginal Tablets may be used in both pregnant and non-pregnant women, as well as in women taking oral contraceptives. (See Precautions) DOSAGE AND ADMINISTRATION Cream and Solution: Thinly apply and gently massage sufficient cream or solution into the affected and surrounding skin areas twice daily, in the morning and evening. For vulvitis, Canesten Cream should be applied to the vulva and as far as the anal region. For balanitis and prevention of vaginal infection or reinfection by the partner. Canesten Cream should be applied to the glans penis. Vaginal Tablets: One tablet a day for six consecutive days. Using the applicator, insert one tablet deep intravaginally, preferably at bedtime. In order to avoid treatment during menstruation, it is suggested that treatment be started at least 6 days prior to the anticipated menstrual period. DURATION OF TREATMENT Cream and Solution: The duration of therapy varies and depends on the extent and localization of the disease. Generally, clinical improvement with relief of pruritus usually occurs within the first week of treatment. Tinea infections require approximately 3-4 weeks of therapy while in candidiasis, 1 -2 weeks treatment is often adequate. If no clinical improvement is observed after 4 weeks, the diagnosis should be reviewed. If a cure is not mycologically confirmed or in order that relapses may be prevented (particularly in mycoses of the foot), treatment should, as a rule, be continued for 2 weeks after all clinical symptoms have disappeared. Vaginal Tablets: The six-day therapy may be repeated if necessary. SPECIAL REMARKS Cream and Solution: Added hygienic measures are of special importance in the management of the often refractory fungal diseases of the foot. To avoid trapped moisture, the feet - particularly between the toes - should be dried thoroughly after washing. Onychomycoses, owing to their location and physiological factors, generally respond poorly to topical antimycotic therapy alone due to poor penetration into horny substance. Treatment with Canesten may be considered in cases of paronychia and as adjunctive therapy in onychomycoses following extraction or ablation of the nail. Vaginal Tablets: Added hygienic measures such as twice daily tub baths and avoidance of tight underclothing is highly recommended. In the case of clinically significant trichomonal infection, additional therapy with a systemic trichornon acidal agent should be considered. Such therapy is essential for the treatment of vaginal infections which may also involve Bartholins glands and the urethra. CONTRAINDICATIONS Except for possible hypersensitivity, Canesten Solution, Cream and Vaginal Tablets have no known contraindications. PRECAUTIONS As with all topical agents, skin sensitization may result. Use of Canesten topical preparations should be discontinued should such reactions occur, and appropriate therapy instituted. Canesten Solution and Cream are not for ophthalmic use. Canesten Vaginal Tablets are not for oral use. Use in Pregnancy: Although intravaginal application of clotrimazole has shown negligible absorption from both normal and inflamed human vaginal mucosa, Canesten Vaginal Tablets should not be used in the first trimester of pregnancy unless the physician considers it essential to the welfare of the patient. The use of the supplied applicator may be undesirable in some pregnant patients, and digital insertion of the tablets is an alternative which should be considered. SIDE EFFECTS Large scale clinical trials have shown that Canesten is very well tolerated after topical and vaginal application. Cream and Solution: Erythema, stinging, blistering, peeling, edema, pruritus, urticaria, and general irritation of the skin have been reported infrequently. Vaginal Tablets: Skin rash, lower abdominal cramps, slight urinary frequency, and burning or irritation in the sexual partner, have occurred rarely. In no case was it necessary to discontinue treatment with Canesten Vaginal Tablets. AVAILABILITY Canesten Solution 1 % is supplied in 20 ml plastic bottles, in carton. Each ml contains 10 mg of clotrimazole in a non-aqueous vehicle.
Canesten Cream 1 % is supplied in 20 g tubes, in carton. Each g contains 10 mg of clotrimazole in vanishing cream base. Canesten Vaginal Tablets 100 mg are supplied in boxes containing one strip of six tablets with plastic applicator and patient leaflet of instructions.
REFERENCES 1. Lohmeyer, H., Postgrad. Med. J., 50 Suopl. 78, 1974. / 2. Schnell, iD., Ibid., p. 79. / 3. Legal, H.P., Ibid., p.81. /4. Widholm, 0 Ibid p 85 / 5. Couchman, J.M. Ibid., p. 93 /6 Higton,BK,lbid,p.95./7.
Oates, J.K., Ibid., p.99 /8 !-Aasterton, MB et al., Curr. Med. Res. 0.in., 3, 83, 1975 / 9 Sawyer, P.R., et al.,
Drugs, 9:42 1975. / 10. Postgrad. Med. J., 50 Suppl., 54-76, 1975. For further prescribing information please consult the
Canesten Product Monograph or your Boehringer Ingelheim representative.
* I.) PRA
FBA Pharmaceuticals Ltd. Distributed by Boehringer Ingeiheim (Canada) Ltd. 2121 Trans Canada Highway Dorval, P.Q. H9P 1J3 FBA-65-76
One piece of data coming out of the CMA research department shows that in actual buying power (after-tax income corrected for inflation and indexed to constant 1961 dollars) physician s incomes have dropped sharply since 1971 -more than 15%. In fact, the average physician could buy less in 1973 than he could in 1964. If, for example, buying power had remained at 1961 levels, in 1964 he would have had $18 293 dollars to spend, in 1971, $21 268, and in 1973, $28 015. The Boyd consultants' report concludes that if fee-for-service physicians had worked no harder in 1974 and '75 than they did in 1973 and had relied on fee changes alone, their advances would have been negligible. Salaried physicians have, on the other hand, been able to tally up their financial advances without necessarily working harder. If there is any general equation to be drawn, it is that the average practising fee-for-service doctor is still keeping abreast of the most highly paid salaried doctor in 1975. But in 1973 he was far ahead. At a time when the free enterprise system is coming under such close scrutiny by various governments, the fee-for-service method of paying physicians has come under much attack. Because fee for service is somewhat open-ended, several federal and provincial paymasters have urged placing all physicians on salary, thus curbing any inherent "extravagances" within the system. It seems to be part of the conventional wisdom that control equals frugality. Well, the consultants' report commissioned by the OMA put the salaryequals-control-equals-frugality equation to the test - and found it seriously wanting. Salary costs more In fact, if all Ontario physicians now earning fees for service were to be put on salary and given the normal range of emoluments given to their confreres in other professions, Ontario's medical services bill would be dramatically higher than it is now. The report makes its projections on the basis of a $28 000 base salary for any licensed physician for a 40-hour week, plus paid vacations. It adds in a bonus of $5000 for a 2-year family practice residency, $10 000 for a 4-year specialist qualification, overtime pay (at normal industrial rates), a 2.6% annual increment for each year in the salaried service, additional salary increases indexed to the wage and salary index for Ontario, a prestige bonus for
170 CMA JOURNAL/JULY 17, 1976/VOL. 115
specialists to Whom most patients are referred (a specialist seeing 100% referred patients would be paid 25% more than a similarly classified specialist with no referred work), an overhead expense allowance of $22 000 a year (line by line or global budget method) and a $5 per hour retainer for doctors on call in institutions. If all this was put together in one package, the way it is in normal salaried circumstances, the average, actively practising GP working 55 hours a week would gross $101 000. This is already 44% higher than the current gross of the same practitioner doing essentially the same work now on fee for service. Under the same formula, the average specialist would gross $142 000. Under such circumstances, the total cost of medical care in Ontario in 1976 would be $962 million (counting 4000 general physicians and 4000 specialists). For medical services between Apr. 1, 1974 and Mar. 31, 1975, OHIP paid out $617 million. To this would also have to be added various costs involved in administering a totally salaried service such as regional supervision of doctors' practices. This would easily bump the cost up in excess of $1 billion, says the consultants' report. By comparison, the Ontario Ministry of Health has estimated that medical care under OHIP will have cost $700 million in 1975. More than money As salaried physicians increase their numbers, it is inevitable that comparisons between the workstyles (salary and fee for service) will be promulgated. But these comparisons should reflect more than just salary levels and the size of fringe benefit packages, says Dr. Edward Napke, first vice-president of the Professional Institute of the Public Service of Canada, who heads the federal adverse reaction and poison control division. Napke emphasizes that most comparisons between salaried and fee-forservice medical practices don't mean very much, because they are comparisons of totally different entities. "There are frustrations I, as a professional man, have that no man in fee for service has," he says. "When I want to do something I have to deal with a structure around me. When you get into an organization you have a system, and dealing with that system can be nerve-wracking. "It takes a certain kind of temperament to be able to do that. And as an individual you must decide what kinds of problems you are willing to face continued on page 178
been more involved in the mainstream of national activities and thought dealing with public health and the delivery of health care. His successor is Dr. Kenneth I.G. Benson of Vancouver, and next year's CPHA meeting will be held in that city. The Moncton meeting concluded
with the approval of resolutions on compulsory seat-belt legislation in provinces where there is none, on field trials for swine 'flu vaccines, on opposition to financial cutbacks in such areas as home care and community geriatric programs, and on recruitment of native peoples into the public health field and the CPHA.E
APPOINTMENT SYSTEM continued from page 161 Remember, people do not mind waiting if they know beforehand how much time may be involved. Another basic rule is that the doctor should be prepared to modify his system. One of the advantages of the front-end load system is that it lends itself to modification. When problems arise, the doctor or receptionist should note the time when the delay occurs. By this means, the pattern of the difficulty can be established and the system changed accordingly. In one case where the system was used, the mornings ran smoothly; however, the doctor fell behind every day in the afternoon. During discussions with the doctor and his staff it was mentioned that he tended to slow down after lunch each day. His activity curve dropped for the first hour and a half after lunch and then picked up to surpass his morning rate. The solution was to schedule two fewer patients during the first part of the afternoon and one more per hour for the remainder of the afternoon. The fifth basic rule in establishing an appointment system is that the scheduler should have autonomy. One of a medical secretary's duties is to schedule appointments, and providing the ground rules are explicit (for instance, complete physical examinations on
Wednesdays, Thursday afternoons off) only this person should keep the appointment record. This means that the physician should not book appointments. It is always interesting to look objectively at any communications transaction. It quite often happens that what the speaker said, what he meant, and what was interpreted are three different things. For example, when a doctor after examining a patient decides that a follow-up visit is required, he should not say "Mrs. Jones, I would like to see you again in about 2 days' time" because the patient may assume that she has a fixed appointment 48 hours later. If a doctor wishes a patient to return, the patient should be advised to arrange an appointment with the secretary, who is then able to fit the patient into the time frame without disrupting the schedule. Finally, a doctor should be prepared for the unforeseen. Every practice has a number of unscheduled patients. These may be drop-ins or people with urgent problems. A doctor who finds that in his practice there are one, two or three such patients each day should leave one, two or three blanks in the appointment schedule. Then, when one of these patients shows up, it is almost as if he were scheduled and the blank period in the timetable will allow the doctor to avoid falling behind.E
SALARIED PHYSiCIANS continued from page 170 and what kind of successes you want to achieve." Dr. Napke believes there is a more critical endpoint to the bargaining process than achieving dollar parity between salaried and fee-for-service physicians - however one defines parity. That endpoint is the recognition of professionalism. "There is a certain mystique that goes along with professionalism," says THE UPJOHN COMPANY OF CANADA Napke. "You have to give up certain DON MILLS, ONTARIO things because you enjoy the job. You can't bargain for overtime or call-back. 178 CMA JOURNAL/JULY 17, 1976/VOL. 115
If the job is there, as a professional you handle it. If you don't like the job, get out of it. "The real question is, who are we? Are we still the people responsible for making decisions? What makes a professional a professional?" The answers to such questions may remain elusive, but Dr. Napke believes that an improvement in the general level and status of any one segment of the medical profession benefits all physicians. The corollary is straightforward: when the professional status and role of salaried physicians are fully recognized, the entire profession is strengthened.E
M.trin (ibuprofen)
Indications and Clinical Uses: Ibuprofen is indicated for the treatment of osteoarthritis and rheumatoid arthritia. Contraindicationa: Ibuprofen should notbe uaed during pregnancy or in pmdiatric patienta becauae ita aafety under these conditiona haa not been establiahed. Ibuprofen ahoutd not be uaed in patienta with a history of acetylsalicylic acidinduced bronchospasm. Precautions: Ibuprofen should be used with caution in patients with a history of gastrointestinal ulceration. ibuprofen has been reported to be associated with toxic amblyopia. Therefore precautions should be taken to ensure that patients on ibuprofen therapy report to their physicians for full ophthalmological examination if they experience any visual difficulty. Medication should be discontinued if there is any evidence of toxic amblyopia. Adverse Reactions: The following adverse reactions have been noted in patients treated with ibuprofen. Gastrointestinal: Nausea, vomiting, diarrhma, constipation, dyspepsia, epigastric pain and gusiac positive stools have been noted. A few cases of gastric or duodenal ulceration, Including some complicated by bleeding or perforation have occurred. Central Nervous System: Dizziness, light-headedness, headache, anxiety, mental confusion and depression were noted in some patients treated with ibuprofen. Ophthalmologlcal: Blurred vision was noted in some patients and rarely a sensation of moving lights was observed following administration of ibuprofen. in addition there are three published cases of toxic amblyopia associated with the use of ibuprofen. Although a definite cause and effect relationship was not established, the attending physicians considered them to be drug related. The condition was characterized by reduced visual acuity and difficulty in colour discrimination. Defects (usually centrocucsl) were observed on visual field examination. Symptoms were reversible on discontinuation of treatment. Skin: Maculopapular rashes, urticaria, and generalized pruritus have been reported with ibuprofen therapy. Occasional cases of .dema have also been reported. Laboratory Teats: Sporadic abnormalities of liver function tests have occurred in patients on ibuprofen therapy (SGOT, serum bilirubin and alkaline phosphatase) but no definite trend was seen indicating toxicity. Similar abnormalities of white blood count and blood urea determinations were noted. A slight fall in hamoglobin and hmmatocrit has been noted in some patients.
Symptoms and Treatment of Overdosage: One
case of overdosage has been reported. A oneyear-old child ingested 1200 mg ibuprofen and suffered no Ill effects other than being drowsy the next day. Blood levels of ibuprofen reached 711 mcg/ml, which is considerably above the 90 mcg/ml previously recorded as the highest level seen In adults after a single oral dose of 800 mg. The SGPT level, nine days post-Ingestion, was 72. No specific antidote is known. Standard measures to stop further absorption and maintain urine output should be Implemented at once. The drug is excreted rapidly and excretion is almost complete in six hours.
Dosage and Administration: To obtain rapid re-
sponse at the start of treatment, particularly when transferring from other anti-inflammatory therapy, Motrinshould be given at a dose of 1200 mg per day In 4 divided doses. Depending on the therapeutic response, the dose may be adjusted downward or upward keeping the 4 times a day dosage schedule. The daily dose should not exceed 2400 mg. Maintenance therapy, once maximum response is obtained, will range from 800 to 1200 mg per day. Due to lack of clinical experience, ibuprofen is not indicated for use in children under 12 years of age. Supplied: 200 mg yellow coated tablets and 300 mg white coated tablets in bottles of 100 and 1000.
E.D
