LETTERS * CORRESPONDANCE
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Has the CMA become "big business"9 W r ithin Doug Geekie's rex port on the May 29 and
30, 1989, CMA Board of Directors meeting (Can Med AssocJ 1989; 141: 150-151) was a sidebar entitled "Will there be a new CMA House?" (151). Geekie says in it that the board "has established a subcommittee to review future office requirements for the CMA and its subsidiaries - MD Investment Services, MD Management Limited and MD Realty Limited" and that- the "rapid staff growth in recent years, especially within the subsidiaries, has put a heavy strain on CMA House". It is foreseen that it -
For prescribing information see page 170
will be necessary to quadruple the available space in the next 5 to 7 years. My first reaction was to wonder if the CMA has become "big business", since it is stated that most of the space needed is required by the subsidiaries having to do with investment, management and realty. If so, what a change from the past! While we all recognize the great benefits of the national health system - free, universal and comprehensive - it must be recognized that the medical profession has been effectively and with great determination shoved aside from all key committees having to do with the establishment of the system, its policies, its orientation, its planning and its budgets. It is not surprising that the medical profession has therefore been placed in a defensive position. In line with the prevalent mercantilism of other professions and of our society it has directed its major interests and energies toward its financial remuneration and the management of personal funds. Is it also possible that this may be related to the fact that physicians are less active than in past generations in societal affairs and organizations? Is it not also a little astonishing that the CMA does not foresee much increase in space and staff for expansion of its facilities for postgraduate medical education, for transmission of scientific information to physicians, for medical ethics and for medicosocioeconomic aspects of medical care? For the older physician still attached to the ideals of medicine and the purposes of the medical
profession it is clear that times have changed. For the better? Jacques Genest, CC, MD Clinical Research Institute of Montreal Montreal, PQ
Boycotting pharmacies that sell tobacco products I object to the CMA's boycott of pharmacies that sell tobacco. I wrote last July "How would the CMA respond if the Canadian Pharmaceutical Association recommended a boycott of physicians who smoke?" (Can Med Assoc J 1989; 141: 96). Dr. Morton Rapp responded that my argument is not valid because I was "confusing the user of a drug with the dealer" and that "the law takes a much dimmer view of the latter" (ibid: 652). I believe that the main point of the issue is that tobacco is a legal product; hence, pharmacists are not criminal dealers. The effort to decrease smoking in society must be directed elsewhere than at pharmacists, who have a business to run. Norman Pinsky, MD 3635 Dutch Village Rd. Halifax, NS
Induced abortion he views expressed by Dr.
A.J. Cunningham (Can Med Assoc J 1989; 141: 869) are offensive and insulting to many members of our profession. Perhaps they are meant to be. CAN MED ASSOC J 1990; 142 (2)
Many of us who have served on therapeutic abortion committees and who have been part of the surgical teams carrying out therapeutic abortions would agree that abortion is not a joyful solution to a difficult dilemma. The fate of the young, unwed mother and her child is, likewise, hardly salubrious. For Cunningham to suggest that those who provide abortion services do so only for gain and that they are to be likened to Clifford Olsen is scandalous. Cunningham's righteousness does not grace the pages of CMAJ. David R. Amies, MB, BS 10109B 106th Ave. Grande Prairie, Alta.
Correlates of certification in family medicine in the billing patterns of Ontario general practitioners W re read with interest the x results of the analysis by Dr. Christel A. Woodward and colleagues (Can Med Assoc J 1989; 141: 897-904) that suggested differences between the billing patterns of Ontario physicians who were and were not certified in family practice. At first glance these data appear at odds with our recent finding of few, if any, differences in billing patterns between residencytrained and internship-trained practitioners (Can Med Assoc J 1989; 140: 913-918). On closer inspection, however, we believe that the results of the two studies are not incompatible; indeed, we argue that the work of Woodward and colleagues supports our recent
observations. We will leave aside the facts that theirs was a secondary analysis of a data set collected for other purposes that overrepresented one medical school (as acknowledged 98
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by the authors), that it pertained to only 1 year of billings and, most importantly, that the age and sex distributions of the patients appear not to have been taken directly into account. As well, the proportion of physicians submitting at least one billing in a given category does not appear to be a particularly illuminating variable. The most interesting finding, in our view, was that when on the basis of a billing criterion similar to ours Woodward and colleagues removed from their analysis the lower one-third of physicians their differences all but disappeared. This suggests that the overall certification effect that they reported must reside primarily in the physicians who were excluded. It is noteworthy that significantly more of their noncertificants than of their certificants were classified as working part-time (21% v. 14%; p = 0.028). Although the authors did adjust for binary part-time versus full-time status in their regressions, the question is raised whether such an adjustment is informative if, as their restricted analysis suggests, there might be an interaction between certification effect and active work status as we defined it. The fundamental difference between Woodward and colleagues' study and ours rests, therefore, on the inclusion in the analysis of physicians at the lowest end of the billing spectrum. Woodward and colleagues used a billing range extending as low as $5000 in total annual billings and only for the year 1986. It seems likely that they will have captured many of the physicians who spend several years after graduation doing various types of part-time and locum work or who moonlight at such work while still in postgraduate specialty training. In addition, over half of their sample had graduated during 1980-83 and, given 2 years of residency, could be in at most their fourth
and possibly only their first year of practice during the study year. On the other hand, we took pains to exclude such physicians by requiring 0.75 of the mean regional group billings for 3 consecutive years. Although our colleagues note that this reduced our sample by about 50% the bulk of the attrition was due to physicians who had simply graduated too recently to have established stable full-time practices and was similar in the two groups. In our view a significant proportion of physicians who are in their first few years after training and who bill as little as $5000 in a single year are likely to be in a very transient phase of their careers, and their practice patterns are neither stable nor particularly relevant to the question of longterm training effects, a key question for those investigating the effects of family practice certification. Martin T. Schechter, MD, MSc, PhD Associate professor Samuel B. Sheps, MD, MSc, FRCPC Associate professor and head Department of Health Care and Epidemiology University of British Columbia Vancouver, BC
Woodward and colleagues' study has failed to show any difference in the billing practices of certified versus noncertified physicians but, rather, has demonstrated a difference in the billing practices of female versus male physicians. Women were proportionately better represented in the group of certified physicians. I believe that if these groups had been matched on the basis of sex there would be no demonstrably significant difference based on certification. Lyle B. Mittelsteadt, MD #203, 9425 94 Ave. Fort Saskatchewan, Alta.
[Dr. Woodward responds.]
The results of our study and that