Ontario's family physicians entering winter of discontent DAVID WOODS
Ontario's family physicians are mad as hell, but haven't quite reached the point where they're not going to take it any more. What they're mad about, the incoming president of the Ontario chapter of the College of Family Physicians of Canada, Dr. Donald G. Workman, told some of the 843 registrants at the chapter's recent 16th annual scientific assembly in Toronto, is fragmentation of primary care, income erosion, income disparity between themselves and specialists and the question of who represents them - and how effectively - in tariff negotiations with the provincial government. Year of crisis The presidential year he's embarking on, said Workman, will be "one of crisis and decision . . (GPs) in Ontario have been slipping badly to inflation in comparison to our specialist colleagues and family physicians in almost every other province." Warm applause greeted Dr. Workman's reference to a recent questionnaire mailed to the chapter membership; the first 200 responses analysed showed 70% want the chapter to take a more active role in economic matters, and 35% showed interest in having the chapter begin gearing up to be the negotiating body for members. Earlier, retiring President Dr. Gary A. Gibson bad said that the central tariff committee of the Ontario Medical Association seemed almost totally out of touch with the goals and aspirations of GPs. But while his successor, Donald Workman, felt the chapteii should have some kind of contingency planning for producing a schedule of fees unique to family physicians, he said that in the critical 12 months ahead "the Ontario chapter and the (OMA) section of general practice can work together to make our position clear with our colleagues and our patients." This, he said, may require fundamental, democratic changes that would give more representation to family physicians within the OMA.
In an interview Dr. Workman said the OMA's section of general practice, while representing about half the association's membership, is still only one of 20 sections (there are, in fact, 45), "and doing it fairly for all is a problem." While fee schedules are difficult to weigh accurately, he said, GPs haven't received the benefits they should have. Because they work mainly from their offices, family doctors have been particularly hard hit by inflation; overheads have risen to at least 40% of gross income. In the coming year, Workman says he hopes to lead the chapter into closer liaison with the OMA section of general practice and establish regular communication with the association executive. While noting that he's not happy with the concept of what GPs are worth in relation to specialists, Workman said the OMA did strike a rate of 80% of specialist fees for GPs, but that this has slipped as low as 69%. The GP's present financial situation is affecting quality of care, he said, because the "easy out" is simply to refer to specialists. The chapter is going to be watchful and supportive - even strident - Workman concluded, but, for the present anyway, it will work through existing negotiating channels in trying to resolve its financial concerns. As for opting out of the Ontario Health Insurance Plan - as GPs were strongly urged, even challenged, to do at this meeting by OMA President Dr. William Vail - Workman said that's not the solution because if too many decided to do that, Ontario Minister of Health Dennis Timbrell "would likely opt us back in again." While Vail agreed in his speech to the chapter that family physicians had some cause to be mad as hell, he doubted that they had the collective fibre not to take it any more. In the past, he said, the OMA section of general practice's advocacy on behalf of family physicians has left something to be desired. But "the malaise of the section is now past history." Stating that the OMA reaffirms
1250 OMA JOURNAL/NOVEMBER 18, 1978/VOL. 119
its commitment to a net income ratio between general practitioners and specialists of 80%, Vail said that seven speciality groups were not granted any net income increase in the 1978 division of the provincial government's global budget to physicians so that the general practice section could move toward that objective. Vail, a general surgeon, made this challenge to Ontario GPs: "You say that fees for certain services are not adequate. Why don't you test the marketplace available to you through our fee schedule?" Noting that GPs' economic aspirations and satisfactions of practice "are unlikely to be reached by government generosity or its ability to pay", the OMA president said: "The only way that I can see that you can dramatically focus the public's and the government's attention on your serious problems in this area and to demonstrate thklt you are free, independent practitioners of medicine is by removing yourselves from the OHIP plan." Dr. Vail reiterated in an interview that GPs shouldn't take it any more, that they could regain pride and freedom by opting out, and that those who had the guts to do so would not lose by it. He said that, by December this year, Ontario family physicians will average 78% of specialist fees; that the OMA has gone to bat for GPs in negotiations with government, and that the Ontario chapter of the College of Family Physicians would be making a divisive move if it attempted to negotiate directly; not only that, but their constituency isn't broad enough, said Vail. The chapter has 2500-odd GP members; the OMA represents more than twice that number. Dr. Vail said he is committed to forging as strong a liaison as possible between the OMA section of general practice and the Ontario chapter of the college. At the well-attended scientific sessions (where delegates were not only forbidden to smoke, but were treated to a repeated series of filmslides
warning of the foolishness of the habit) it was learned that there's been a striking increase in incidence of lung cancer in Canada in the past 10 years; in fact, it's gone from 35 per 100 000 to 64 per 100 000. The number of new cases this year will be about 13 000. When you consider that the 5-year survival rate after diagnosis of the disease is only approximately 9%, the outlook is pretty bleak, said Dr. P.L. Landrigan, head of the division of respirology at Dalhousie University. But there does seem to be some levelling off in the incidence. In an interview Dr. Landrigan said he expects to see a cure for cancer within the next decade. If you look at the success we've had in treating one form of the disease - leukemia - it seem likely that some kind of agent will be developed to block proliferation of malignant growth. While early detection of lung or any other form of - cancer is desirable, Dr. Landrigan said that routine chest x-rays don't always work. They depend on the scrutiny of the radiologist, and in the earliest stages as many as 40% of them may be missed. As well, by the time x-rays are able to reveal tumours clearly the disease could well have progressed too far to do anything about. And, of course, there's the fact that large-scale, continuous monitoring of the population by this method is just too expensive. A better approach, Landrigan thinks, is for general practitioners to arrange for cytology testing - looking for malignant cells in the sputum of high-risk patients, that is, middleaged men who are heavy smokers, exposed to carcinogens such as asbestos or both. He also thinks the family physician is ideally suited to counsel patients at risk about smoking. Older but wiser Scientific meetings like this one are held, the chairman of the first day's sessions observed, because the family physician is "undereducated". With more than 30 formal presentations given in 3 days, and with several concurrent seminars, one can assume that GPs attending the assembly were wiser at the end of it all, but they were left in no doubt at all that they were older.
L..J 119 1251
Speaking one afternoon on "The ageing skin", dermatologist Dr. Marvin G. Lester was at pains to point out that his audience had aged since that morning. Ageing skin, he said, results from genetic, systemic and external forces, and these days the sun is playing a considerable role in the process. Looking at the problem as one of pluses and minuses - i.e., gain of growths and blemishes; loss of tissue and moisture - Lester said in older people the cell pattern in the five layers of the epidermis is disrupted, the capacity of sweat glands is reduced, everything is shrinking. Dr. Lester said that if what's inside it is in reasonably good order, the skin should be too; but the skin will reflect heart, liver or other internal problems . and possibly the drugs used in treating them. In older people, poorer nutrition or housing, psychological factors, newly acquired hobbies can all take their toll on the skin. Speaking on "The ageing brain", Dr. Melvyn J. Ball, an associate professor of neuropathology at the University of Western Ontario, said the major culprit in the tragic loss of memory in older people is not hardening of the arteries, as was previously believed, but Alzheimer's disease. About 65% of geriatric patients with memory loss, said Ball, suffer from Alzheimer's . "which may be the fourth or fifth commonest cause of death in Canada", claiming the lives of between 6000 and 9000 Canadians
over 65 every year. At Western, researchers, supported by the Canadian Geriatrics Research Society, are trying to shed new light on the disease - whose precise cause, said Dr. Ball, is still a mystery - by concentrating on the hippocampus, an area of the cerebral cortex that is a crucial centre for memory relay systems. The prevalence of Alzheimer's disease, said Ball, is 14 times that of multiple sclerosis. In a paper on the diagnosis and management of the latter (MS), neurologist Dr. Donald W. Paty, also of Western, referred to the continuing enigma surrounding the etiology and pathogenesis of this "most fascinating of the diseases affecting the nervous system". While the development of a specific treatment for MS won't be found until the cause is known, said Dr. Paty, earlier diagnosis is now possible, and even though physicians can't treat the patient, they can provide considerable support by maintaining interest and contact, educating the patient and his family and referring to local MS clinics and workshops and to the Multiple Sclerosis Society of Canada. Research is going on rapidly, said Paty, and "we hope that in 5 or 10 years there'll be more specific therapy." Dr. Richard Carlson, assistant professor of medicine at the University of Southern California School of Medicine, offered family physicians some caveats in the early management of acute myocardial infarction,
of which there are over 1 million a year in the US, he said. Referring to the harbingers - new pain, pain unrelieved by nitrates, rest pain, prolonged pain - Carison said don't delay in getting patients with these admitted for monitoring. There's a need to expedite the decision process both by patients and by doctors in these cases, he said, citing one study showing that patients delayed an average 307 minutes before seeking help; doctors an average 180 minutes between first contact and hospital admission. If the clinical educational aspects of this meeting were comprehensive and varied, there was evidence here not only of a growing interest by GPs in economic and political aspects of their craft but also of how intricate those aspects have become. A measure of that was retiring President Dr. Gary A. Gibson's review of his term of office: besides attending several regional meetings, he said, he had visited college headquarters 60 times, spent 37 days at college meetings, sent out a regular newsletter to members, given 20 talks on Global Television, had two meetings with the minister of health and suffered 18 migraines. For both philosophic and economic reasons, said Gibson, he believes most Ontario GPs will remain opted-in to Ontario's health insurance plan. But there's a need for rationalization and simplification of the fee schedule for family physicians.E
DiRECTORY
THE COLLEGE OF FAMILY PHYSICIANS OF CANADA Dr. M.A. Spooner, president Dr. D.I. Rice, executive director 4000 Leslie St. Willowdale, Ont., M2K 2R9
Research and Development G.D. Searle and Co. of Canada Ltd. 400 Iroquois Shore Rd. Oakville, Ont., L6H 1M5
continued from page 1226
Dr. W.R. Waters, secretary 240 - 444 St. Mary Ave. Winipeg, Man., R3C 3T1
CANADIAN THORACIC SOCIETY Dr. MR. Becklake, president Dr. E. Hershfield, medical director 75 Albert St., Suite 900 Ottawa, Ont., KiP 5E7 CANADIAN UROLOGICAL ASSOCIATION Dr. P.O. Crassweller, president Dr. G.A. Farrow, secretary Suite 407, 170 St. George St. Toronto, Ont., M5R 2M8
FEDERATION OF MEDICAL WOMEN OF CANADA Dr. F.M. Forrest-Richards, president Dr. Elizabeth Patriarche, honorary secretary, P.O. Box 9502, Ottawa, Ont., KiG 3V2
ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA Dr. D.G. Cameron, president Dr. J.H. Graham, secretary 74 Stanley Ave. Ottawa, Ont., KiM 1P4
SOCIETY OF OBSTETRICIANS AND GYNAECOLOGISTS OF CANADA Dr. S.C. Robinson, president PHARMACEUTICAL MANUFACTURERS Dr. J.C.G. Whetham, secretary ASSOC. OF CANADA (MEDICAL SECTION) Mrs. S.D. Marlatt, executive director Dr. R. Fynes, chairman Academy of Medicine Building Dr. R. White, secretary 288 Bloor St. W. Toronto, Ont. Medical Director and Director of M55 1V8 CMA JOURNAL/NOVEMBER 18, 1978/VOL. 119 1253
Ontario's family physicians are mad as hell, but haven't quite reached the point where they're not going to take it any more. What they're mad about, the incoming president of the Ontario chapter of the College of Family Physicians of Canada, Dr. Donald G. Workman, told some of the 843 registrants at the chapter's recent 16th annual scientific assembly in Toronto, is fragmentation of primary care, income erosion, income disparity between themselves and specialists and the question of who represents them - and how effectively - in tariff negotiations with the provincial government. Year of crisis The presidential year he's embarking on, said Workman, will be "one of crisis and decision . . (GPs) in Ontario have been slipping badly to inflation in comparison to our specialist colleagues and family physicians in almost every other province." Warm applause greeted Dr. Workman's reference to a recent questionnaire mailed to the chapter membership; the first 200 responses analysed showed 70% want the chapter to take a more active role in economic matters, and 35% showed interest in having the chapter begin gearing up to be the negotiating body for members. Earlier, retiring President Dr. Gary A. Gibson bad said that the central tariff committee of the Ontario Medical Association seemed almost totally out of touch with the goals and aspirations of GPs. But while his successor, Donald Workman, felt the chapteii should have some kind of contingency planning for producing a schedule of fees unique to family physicians, he said that in the critical 12 months ahead "the Ontario chapter and the (OMA) section of general practice can work together to make our position clear with our colleagues and our patients." This, he said, may require fundamental, democratic changes that would give more representation to family physicians within the OMA.
In an interview Dr. Workman said the OMA's section of general practice, while representing about half the association's membership, is still only one of 20 sections (there are, in fact, 45), "and doing it fairly for all is a problem." While fee schedules are difficult to weigh accurately, he said, GPs haven't received the benefits they should have. Because they work mainly from their offices, family doctors have been particularly hard hit by inflation; overheads have risen to at least 40% of gross income. In the coming year, Workman says he hopes to lead the chapter into closer liaison with the OMA section of general practice and establish regular communication with the association executive. While noting that he's not happy with the concept of what GPs are worth in relation to specialists, Workman said the OMA did strike a rate of 80% of specialist fees for GPs, but that this has slipped as low as 69%. The GP's present financial situation is affecting quality of care, he said, because the "easy out" is simply to refer to specialists. The chapter is going to be watchful and supportive - even strident - Workman concluded, but, for the present anyway, it will work through existing negotiating channels in trying to resolve its financial concerns. As for opting out of the Ontario Health Insurance Plan - as GPs were strongly urged, even challenged, to do at this meeting by OMA President Dr. William Vail - Workman said that's not the solution because if too many decided to do that, Ontario Minister of Health Dennis Timbrell "would likely opt us back in again." While Vail agreed in his speech to the chapter that family physicians had some cause to be mad as hell, he doubted that they had the collective fibre not to take it any more. In the past, he said, the OMA section of general practice's advocacy on behalf of family physicians has left something to be desired. But "the malaise of the section is now past history." Stating that the OMA reaffirms
1250 OMA JOURNAL/NOVEMBER 18, 1978/VOL. 119
its commitment to a net income ratio between general practitioners and specialists of 80%, Vail said that seven speciality groups were not granted any net income increase in the 1978 division of the provincial government's global budget to physicians so that the general practice section could move toward that objective. Vail, a general surgeon, made this challenge to Ontario GPs: "You say that fees for certain services are not adequate. Why don't you test the marketplace available to you through our fee schedule?" Noting that GPs' economic aspirations and satisfactions of practice "are unlikely to be reached by government generosity or its ability to pay", the OMA president said: "The only way that I can see that you can dramatically focus the public's and the government's attention on your serious problems in this area and to demonstrate thklt you are free, independent practitioners of medicine is by removing yourselves from the OHIP plan." Dr. Vail reiterated in an interview that GPs shouldn't take it any more, that they could regain pride and freedom by opting out, and that those who had the guts to do so would not lose by it. He said that, by December this year, Ontario family physicians will average 78% of specialist fees; that the OMA has gone to bat for GPs in negotiations with government, and that the Ontario chapter of the College of Family Physicians would be making a divisive move if it attempted to negotiate directly; not only that, but their constituency isn't broad enough, said Vail. The chapter has 2500-odd GP members; the OMA represents more than twice that number. Dr. Vail said he is committed to forging as strong a liaison as possible between the OMA section of general practice and the Ontario chapter of the college. At the well-attended scientific sessions (where delegates were not only forbidden to smoke, but were treated to a repeated series of filmslides
warning of the foolishness of the habit) it was learned that there's been a striking increase in incidence of lung cancer in Canada in the past 10 years; in fact, it's gone from 35 per 100 000 to 64 per 100 000. The number of new cases this year will be about 13 000. When you consider that the 5-year survival rate after diagnosis of the disease is only approximately 9%, the outlook is pretty bleak, said Dr. P.L. Landrigan, head of the division of respirology at Dalhousie University. But there does seem to be some levelling off in the incidence. In an interview Dr. Landrigan said he expects to see a cure for cancer within the next decade. If you look at the success we've had in treating one form of the disease - leukemia - it seem likely that some kind of agent will be developed to block proliferation of malignant growth. While early detection of lung or any other form of - cancer is desirable, Dr. Landrigan said that routine chest x-rays don't always work. They depend on the scrutiny of the radiologist, and in the earliest stages as many as 40% of them may be missed. As well, by the time x-rays are able to reveal tumours clearly the disease could well have progressed too far to do anything about. And, of course, there's the fact that large-scale, continuous monitoring of the population by this method is just too expensive. A better approach, Landrigan thinks, is for general practitioners to arrange for cytology testing - looking for malignant cells in the sputum of high-risk patients, that is, middleaged men who are heavy smokers, exposed to carcinogens such as asbestos or both. He also thinks the family physician is ideally suited to counsel patients at risk about smoking. Older but wiser Scientific meetings like this one are held, the chairman of the first day's sessions observed, because the family physician is "undereducated". With more than 30 formal presentations given in 3 days, and with several concurrent seminars, one can assume that GPs attending the assembly were wiser at the end of it all, but they were left in no doubt at all that they were older.
L..J 119 1251
Speaking one afternoon on "The ageing skin", dermatologist Dr. Marvin G. Lester was at pains to point out that his audience had aged since that morning. Ageing skin, he said, results from genetic, systemic and external forces, and these days the sun is playing a considerable role in the process. Looking at the problem as one of pluses and minuses - i.e., gain of growths and blemishes; loss of tissue and moisture - Lester said in older people the cell pattern in the five layers of the epidermis is disrupted, the capacity of sweat glands is reduced, everything is shrinking. Dr. Lester said that if what's inside it is in reasonably good order, the skin should be too; but the skin will reflect heart, liver or other internal problems . and possibly the drugs used in treating them. In older people, poorer nutrition or housing, psychological factors, newly acquired hobbies can all take their toll on the skin. Speaking on "The ageing brain", Dr. Melvyn J. Ball, an associate professor of neuropathology at the University of Western Ontario, said the major culprit in the tragic loss of memory in older people is not hardening of the arteries, as was previously believed, but Alzheimer's disease. About 65% of geriatric patients with memory loss, said Ball, suffer from Alzheimer's . "which may be the fourth or fifth commonest cause of death in Canada", claiming the lives of between 6000 and 9000 Canadians
over 65 every year. At Western, researchers, supported by the Canadian Geriatrics Research Society, are trying to shed new light on the disease - whose precise cause, said Dr. Ball, is still a mystery - by concentrating on the hippocampus, an area of the cerebral cortex that is a crucial centre for memory relay systems. The prevalence of Alzheimer's disease, said Ball, is 14 times that of multiple sclerosis. In a paper on the diagnosis and management of the latter (MS), neurologist Dr. Donald W. Paty, also of Western, referred to the continuing enigma surrounding the etiology and pathogenesis of this "most fascinating of the diseases affecting the nervous system". While the development of a specific treatment for MS won't be found until the cause is known, said Dr. Paty, earlier diagnosis is now possible, and even though physicians can't treat the patient, they can provide considerable support by maintaining interest and contact, educating the patient and his family and referring to local MS clinics and workshops and to the Multiple Sclerosis Society of Canada. Research is going on rapidly, said Paty, and "we hope that in 5 or 10 years there'll be more specific therapy." Dr. Richard Carlson, assistant professor of medicine at the University of Southern California School of Medicine, offered family physicians some caveats in the early management of acute myocardial infarction,
of which there are over 1 million a year in the US, he said. Referring to the harbingers - new pain, pain unrelieved by nitrates, rest pain, prolonged pain - Carison said don't delay in getting patients with these admitted for monitoring. There's a need to expedite the decision process both by patients and by doctors in these cases, he said, citing one study showing that patients delayed an average 307 minutes before seeking help; doctors an average 180 minutes between first contact and hospital admission. If the clinical educational aspects of this meeting were comprehensive and varied, there was evidence here not only of a growing interest by GPs in economic and political aspects of their craft but also of how intricate those aspects have become. A measure of that was retiring President Dr. Gary A. Gibson's review of his term of office: besides attending several regional meetings, he said, he had visited college headquarters 60 times, spent 37 days at college meetings, sent out a regular newsletter to members, given 20 talks on Global Television, had two meetings with the minister of health and suffered 18 migraines. For both philosophic and economic reasons, said Gibson, he believes most Ontario GPs will remain opted-in to Ontario's health insurance plan. But there's a need for rationalization and simplification of the fee schedule for family physicians.E
DiRECTORY
THE COLLEGE OF FAMILY PHYSICIANS OF CANADA Dr. M.A. Spooner, president Dr. D.I. Rice, executive director 4000 Leslie St. Willowdale, Ont., M2K 2R9
Research and Development G.D. Searle and Co. of Canada Ltd. 400 Iroquois Shore Rd. Oakville, Ont., L6H 1M5
continued from page 1226
Dr. W.R. Waters, secretary 240 - 444 St. Mary Ave. Winipeg, Man., R3C 3T1
CANADIAN THORACIC SOCIETY Dr. MR. Becklake, president Dr. E. Hershfield, medical director 75 Albert St., Suite 900 Ottawa, Ont., KiP 5E7 CANADIAN UROLOGICAL ASSOCIATION Dr. P.O. Crassweller, president Dr. G.A. Farrow, secretary Suite 407, 170 St. George St. Toronto, Ont., M5R 2M8
FEDERATION OF MEDICAL WOMEN OF CANADA Dr. F.M. Forrest-Richards, president Dr. Elizabeth Patriarche, honorary secretary, P.O. Box 9502, Ottawa, Ont., KiG 3V2
ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA Dr. D.G. Cameron, president Dr. J.H. Graham, secretary 74 Stanley Ave. Ottawa, Ont., KiM 1P4
SOCIETY OF OBSTETRICIANS AND GYNAECOLOGISTS OF CANADA Dr. S.C. Robinson, president PHARMACEUTICAL MANUFACTURERS Dr. J.C.G. Whetham, secretary ASSOC. OF CANADA (MEDICAL SECTION) Mrs. S.D. Marlatt, executive director Dr. R. Fynes, chairman Academy of Medicine Building Dr. R. White, secretary 288 Bloor St. W. Toronto, Ont. Medical Director and Director of M55 1V8 CMA JOURNAL/NOVEMBER 18, 1978/VOL. 119 1253
