Public Employees (CUPE), which represents hospital workers, has been campaigning this year for the preservation of medicare, in concert with such organizations as the Action Canada Network, seniors' groups, and the Canadian Health Coalition. One of the CUPE's demands is the public election of hospital boards, much as school boards are elected. There is no doubt that takeovers of hospital boards by antiabortion forces present an interesting problem to health care reformers. Dr. Mimi Divinsky, a Toronto family physician who speaks on the abortion issue for the 200-member Medical Reform Group of Ontario, says "hospitals must be accountable to the community they serve and election of hospital boards is an important part of democratization of the
health care system. However, the antiabortion forces don't express community values - they're just using the abortion question as a political football." She supports the CARAL position that abortions need not be performed in hospitals. Holland describes an argument that she used to good effect in her campaign to maintain access to abortion in Nanaimo. "What if a religious group, opposed to blood transfusions, started to obtain control of hospital boards and started banning transfusions?" She says much of the impetus for limiting access to abortion appears to be coming from Protestant fundamentalists. "Governments are curtailing a legal right of women when they allow access to abortions to be
limited by hospital boards," argues CARAL's Holmes. "Abortion is a necessary medical service. An unwanted pregnancy is not a healthful situation." Gavigan is unhappy with provincial governments' response to the abortion question. "There appears to be no political will by politicians and journalists to engage the antiabortion people about their discourse, as has been taking place recently in Ireland." In the future, financial restrictions on health care services, hospital closures and rationalization of local services might also contribute to the fragile access to abortion. It appears Canadians may be in for an endless debate about abortion, one that is making both Canadians and their doctors increasingly weary.m
Physician, tape thyself, communication expert advises Olga Lechky p ractising clinicians will notice a quick improvement in their clinical communication skills if they engage in a simple exercise, says a communications expert at the University of Western Ontario, London. Dr. Moira Stewart, a professor of family medicine and a member of the expert panel at the international Consensus Conference on Doctor-Patient Communication, held in Toronto late last year, suggests that doctors audiotape themselves during several Olga Lechky is a freelance writer living in North York, Ont. AUGUST 15,1992
patient interviews. "I think many physicians would be surprised at how they sound," she says. "It wouldn't be difficult for them to identify the things they could improve. The first thing to do is listen for interruptions -physicians frequently interrupt patients very early in their descriptions of why they've come and what they think is wrong." If frequent interruptions are a hallmark of their interviewing style, they should resist the urge to cut off patients and allow them to conclude their statements and present their concerns. The concerns should then be followed up
Stewart: taping helps CAN MED ASSOC J 1992; 147 (4)
499
with exploratory, open-ended questions that encourage the patient to elaborate. "Physicians should listen to see if they're using a lot of closedended questions - ones that require only a Yes or No response. If so, it would be easy enough to switch to using more open-ended questions. Also, physicians can listen for missed opportunities
where they could have clarified end of each segment of the interthings with patients. This ensures view. Basically, it's a safeguard that the doctor has understood that misunderstandings don't get what the patient has said and that worse as you go along." Ideally, however, physicians the patient has understood what the doctor has said. This involves should take a course in clinical the use of summary - summariz- communication, says Stewart. "A ing to the patient what you have good course goes beyond theory, heard [her] say and having the giving participants an opportunity patient summarize what you have to practise the skills they are being said. This should be done at the taught, either on a simulated pa-
Better communication may keep MDs out of courts' clutches About 75% of patient complaints about doctors involve misunderstandings that resulted from poor communication skills on the part of clinicians, says Dr. Robert Buckman. an authority on clinical communication and chairman of the first international Consensus Conference on Doctor-Patient Communication. It was held in Toronto late last year. Rarely are cliniCal-competency issues at the centre of doctor-patient disputes. says Buckman, clinical oncologist at the Sunnybrook Health Sciences Centre and associate professor of medicine at the tUniversity of Toronto. He argues that this fact highlights the recent overemphasis on the science of medicine at the expense of its art, and the urgent nieed to mend the growing rift between doctors and patients in today's world of impersonal. high-tech medicine. "Doctors have traditionally had a resistance to clinical communication issues, believing it to be a load of touchy-feely crap," says Buckman. "'But the day has come when it's no longer possible to pull the duvet over our ears and pretend a communication problem
500
CAN MED ASSOC J 1992; 147 (4)
with our patients doesn't exist. The conference put together 15 years of accumulated hard data that show beyond any argument that doctor-patient communication is a problem that affects patients' health. The positive side is that data presented at the conference showed that good clinical communication skills can be learned. and when used routinely in clinical practice, make a difference in what you get from vour patients in terms of their satisfaction and recovery.
A consensus statement issued by an international panel of experts at the end of the 3-day conference outlined some compelling reasons why medical training programs should starl putting clinical communication near the top of the teaching agenda. For example, about 50% of patient complaints and concerns are not elicited by physicians because their poor listening skills do not allow patients to fully air concerns. As a result, patients and doctors disagree on the nature of the presenting problem in about 50% of clinical encounters. Few patient visits involve patient education and feed-
back, and this results in a high proportion of patients who do not understand what their doctor has told them about their condition and treatment, or forget what was said. Given this backdrop, it's not surprising that most malpractice allegations stem from poor communication. Many physicians feel they do not have the time to improve the quality of communication with patients, but Buckman counters: "There are data suggesting that the time added is about 7 minutes per patient visit. Consider that in the context of how much time it would take to deal with a patient complaint. It all boils down to how physicians prefer to spend their time. Without good communication skills, you can spend an hour with a patient and achieve very little. On the other hand, by listening carefully to the patient's agenda, you can accomplish a tremendous amount in under 10 minutes." The consensus statement identified an area of critical concern to primary care practitioners - the urgent need to address psychosocial problems. "At least a third of visits to a primary care practitioner are
LE 15 AOUJT 1992
tient or a colleague who plays the role of a patient. This makes them feel more comfortable when they start using the new skills in their own practice. Viewing videotapes is a very powerful learning tool and would be an essential component of a good course, something physicians should look for in choosing a course." Physicians interested in tak-
not due to a physical illness," says Buckman. "But at least 50% of cases of depression are missed." Many clinicians would argue that a patient's depression and anxiety are the prov-
ince of psychiatrists, social workers and marriage counsellors. True, says Buckman, but they cannot do their jobs if primary care practitioners are not diagnosing problems and
referring patients. "If primary care practitioners adopt the at-
titude that psychosocial problems don't concern them, then they are failing to diagnose a treatable condition which has high morbidity and is potentially fatal. If any physician can tell me why he shouldn't be diagnosing a treatable condition which is potentially fatal, I would be very interested in hearing. "While it's not physicians' responsibility to find a depressed patient another job, they are required to deal with the secondary diagnosis. If a patient is so depressed because of his loss of income that his health or life is in danger, the doctor has to do something about it. Brief psychotherapy and antidepressant therapy
AUGUST 15, 1992
ing a course in clinical communication should contact the local continuing medical education (CME) department. "If no courses are being offered, make a case that they should be, and find other interested people," Stewart urges. "The resources to teach these courses are available at the medical schools. If enough interest is expressed, it's very likely
don't restore a person's salary what they do is restore a patient's ability to function socially and solve his own problems. It's a paper tiger for physicians to say, 'I can't fix the world.' No person alone can fix the world even coronary artery bypass surgery doesn't fix heart disease. It just stops the pain and improves a patient's quality of life. "In primary care physicians don't have any choice but to deal with psychosocial problems, so why not learn how to do it well?" And it is possible to learn to do it well in a short time. A study presented at the consensus conference by Debra Roter, PhD, associate professor of health policy and management at Johns Hopkins University in Baltimore, showed that it takes only two 4-hour continuing medical education sessions to improve primary care doctors' skills in diagnosing and treating psychosocial problems. In the study, physicians were trained either in emotion-handling skills or problem-handling skills. -
These physicians, who were compared with a con-
that a course will be offered." Interested physicians should also contact groups within organized medicine that are working to promote better education in this area, Stewart said. For example, the Ontario Medical Association's (OMA) Joint Practice Committee has a long-standing interest in clinical communication. Its chairman, Dr. Robert Heckadon
trol group that received no training, successfully translated their new skills into action in their practices. They increased their ability to spot psychosocial problems, such as anxiety, depression and psychosomatic illness, without significantly increasing the length of patient
visits. "We had a very positive response from the physicians," says Roter. "At 6-months' follow-up, the doctors were still using the skills they were taught. They thought the training was very worth while and said they would take a similar course again." [A March workshop in Toronto, sponsored by the Canadian Cancer Society, attempted to set national teaching standards and evaluation techniques for the teaching of clinical communication skills during undergraduate training. The workshop included participants from all 16 of the country's medical schools and most of its major medical organizations. A draft statement recommended that faculties of medicine collaborate in setting standards for faculty development and the teaching of students - Ed.]
CAN MED ASSOC J 1992; 147 (4)
501
Occasional, isolated, instances of elevated liver enzymes levels have been seen during clinical trials. No definite relationship to ketotifen fumarate therapy has been (ketotifen fumarate) established. DOSAGE AND ADMINISTRATION PRESCRIBING INFORMATION In children older than 3 years of age, Zaditen (ketotifen Therapeutic classification: Pediatric asthma prophylactic fumarate) should be given at a dose of 1 mg twice daily with and anti-allergic agent morning and evening meals. INDICATIONS AND CLINICAL USE There is no clear evidence of efficacy and safety in children Zaditen (ketotifen fumarate) is indicated as an add-on medi- under 3 years of age and the dose is not established in this cation in the chronic treatment of mild atopic asthmatic age group. children. To minimize the initial sedation with Zaditen, a progressive Zaditen is a prophylactic agent to be used on a continuous regimen is recommended during the first week of treatment basis and is not effective in the acute prevention or treat- commencing with one half the daily recommended dosage ment of acute asthma attacks. Continuous use of Zaditen given in 2 divided doses or in a single dose given in the may reduce the frequency, severity and duration of asth- evening, followed within 5 days, by an increase to the full matic symptoms or attacks, and lead to a reduction in daily therapeutic dose. requirements of concomitant anti-asthmatic medication, Concomitant Therapy: Existing asthma therapy should be like theophyllines and B2-agonists. maintained. A progressive reduction in dosage of other Several weeks of Zaditen therapy may be necessary before asthma drugs, where clinically indicated, should be the therapeutic effect becomes clinically evident. Full clini- attempted only after 6-12 weeks of Zaditen therapy. cal effectiveness is generally reached after 10 weeks of treatment. Zaditen may have an anti-inflammatory effect in Reduction of Cortlcosterolds: It is notfully established, but the lungs and the time of onset of clinical efficacy may some patients may be able to reduce corticosteroids. reflect the recovery period of the lungs from inflammation. The reduction in the daily maintenance dosage of steroids should be stepwise according to the recommended CONTRAINDICATIONS methods. The gradual reduction should be continued until There are no known contraindications. Patients sensitive to eitherthe patient cannot tolerate a further reduction, or it is benzoate compounds should not take Zaditen syrup. found possible to withdraw corticosteroids completely. PRECAUTIONS If troublesome symptoms recur during the period of reducGeneral: Anti-asthmatic drugs (xanthine derivatives, tion, the daily dose of corticosteroids should be raised B2-agonists, sodium cromoglycate, corticosteroids) immediately. A larger increase in the steroid dose may be already in use should not be reduced immediately when essential at times, as a temporary measure, to control a treatmentwithZaditen(ketotifenfumarate)is initiated. This severe relapse induced by antigen challenge, infection or applies especially to systemic corticosteroids and ACTH stress. (The increased physical or mental activity resulting injections because of the possible existence of adrenocorti- from subjective improvement can also constitute a stress). cal insufficiency in steroid-dependent patients; in such When symptoms are brought under control, a progressive cases recovery of a normal pituitary-adrenal response to reduction may be attempted as before. stress may take up to one year. Any reduction should be gradual while maintaining close Occupational: Since drowsiness may occur in the early surveillance and frequent examination of the patient. The stages of therapy, patients engaging in activities requiring ability of these patients to react to stress is usually rapid and precise responses should be cautioned. impaired. Acute adrenal insufficiency and severe asthma Drug interactions: A reversible fall in the trombocyte count can be precipitated by an increase in stress and/or reduction in patients receiving Zaditen concomitantly with oral anti- of either steroid or ACTH therapy. It is advisable to assess diabetic agents has been observed in rare cases. Throm- adrenal and pituitary function before reducing steroid dosbocyte counts should therefore be carried out in patients age in patients who have received long-term therapy. taking oral antidiabetic agents concomitantly. Method of Withdrawing ACTH: The same principles as Zaditen may potentiate the effects of sedatives, hypnotics, discussed above. antihistamines and alcohol. AVAILABILITY OF DOSAGE FORMS Use in Obstetrics: Although there is no evidence of ter- *Zaditen* (ketotifen fumarate) Tablets Each scored white atogenic effects, Zaditen should be given to pregnant tablet embossed with the name "ZADITEN " contains: 1 mg women only if the potential benefit justifies the potential ketotifen. Tablets are to be swallowed. Available in packs of risk to the fetus. 56 tablets containing 4 blister strips of 14 tablets each. Patients with Special Diseases and Conditions: Zaditen *Zaditen* (ketotifen fumarate) Syrup: 5 mL of syrup consyrup should not be administered to patients sensitive to tain 1 mg ketotifen. Available in 250 mL bottles. To be benzoate compounds. Zaditen tablets are benzoate-free and administered orally. can be administered alternatively to such patients. STABILITY AND STORAGE RECOMMENDATIONS ADVERSE EFFECTS Tablets: There was a relatively low incidence of adverse reactions place. Store attemperatures not exceeding 250C, in a dry reported. Sedation, weight gain, rash, respiratory infections, flu, headache, sleep disturbance, increased appetite, Syrup: Store at temperatures not exceeding 250C. abdominal pain, urticaria, ear infections, nose bleed and For further Information, please contact your Sandoz reprepuffy eyelids have been reported. These were similar in both sentative, or consult the product monograph, available on the Zaditen (ketotifen fumarate) and placebo treated groups request. of patients. The reports for CNS and G6 symptoms in the *Registered trademark placebo group are side effects known to be associated with xanthine administration, which was being used concomitantly by some patients during the study. Thrombocytopenia has been reported when Zaditen (ketoPME tifen fumarate) is combined with oral hypoglycemic agents ZAD-92-07-2027E (see PRECAUTIONS).
*ZADITEN'7Ig
A& SANDOZ
502
CAN MED ASSOC J 1992; 147 (4)
SANDOZ CANADA IC. Dorval, Quebec, H9R 4P5
of Windsor, Ont., says the committee is currently looking into the feasibility of publishing a book based on monthly articles about different aspects of the doctor-patient relationship that appear in the OMA's monthly journal, Ontario Medical Review. "We've spent a long time diagnosing that poor communication between doctors and their patients is a problem and we're only starting to look at some solutions," says Heckadon. "As awareness of the problem has grown, medical schools are providing more teaching of clinical communication at the undergraduate and graduate levels. But our main concern is with the practising clinician for whom there is very little in place at the moment in terms of CME programs." The OMA is also working with the CME department at the University of Toronto to establish a clinical communications program. "The emphasis would be on practical approaches to dealing with patients, how-to courses that deal with common situations that arise in practice, such as abusive or angry patients, compliance problems, problems in the family." Ideally, these courses would be incorporated as a half-day program into other clinical CME events in an effort to maximize exposure and overcome the traditional resistance of physicians to clinical communication issues, Heckadon says. "We're also exploring the idea of attaching CME communications courses to the regular meetings of medical societies throughout Ontario." The CMA Council on Medical Education is also taking an active interest in promoting the teaching of these skills. "As awareness of the issue grows, so does the recognition that good communication is a learnable skill," says Alexandra Harrison, the CMA's director of educational services. "It used to be thought LE 15 AOUJT 1992
that good communication was a skill you were born with - you either had it or you didn't. It's now recognized that it's a skill like any other - it's learnable." As a starting point, the council is planning to contact medical schools to find out what types of programs are being offered in training and CME programs. "If we find any big
gaps, we can make recommendations and work with educational authorities to improve the situation," says Harrison. Disciplinary bodies are also taking an active interest in communications education, but in a context most physicians would prefer to avoid. "The majority of the complaints received by the college about physicians
involve attitudinal problems," says Dr. Neal Sutton, associate registrar of public complaints investigation at the College of Physicians and Surgeons of Ontario. "We're currently exploring avenues for setting up ongoing programs in communications skills for physicians who come to our attention [through the complaints process]."u
Health care equity tackled from many angles at CHEPA conference Lynne Cohen
health impinges on my happiness. I care if someone else is ill and would prefer that [he was] not." So powerful is this element of human compassion, argued Mooney, that "there is almost universal agreement that equity in health care is important." He stressed that it is crucial for governments to have a clear definition of health care equity, even if it is difficult to reach agreement on what the principle means. Stephen Birch, associate coordinator of CHEPA and a professor in McMaster's Department of Clinical Epidemiology and Biostatistics, helped explain what equity is not. "It is not synonymous with equality, although the pursuit of equity might involve achieving equality in something. At the same time, inequality with respect to something else might be a prerequisite of equity [in health care]." Mooney named 13 countries, including Spain, Sweden, the United Kingdom and Canada, that had already found "reasonprinciple, manitarian-spillover" "the idea that someone else's ill ably clear statements on equity objectives." However, he said Canada's statement is least clear. The conference's opening Lynne Cohen is a freelance writer living in speaker, philosopher Daniel CallaOttawa.
F ew Canadians disagree with the notion of equity in health care. It is, after all, the powerful concept that forms the foundation of Canada's medicare system. The idea, which intrigues health policy experts around the world, also formed the foundation for the fifth annual conference of the Centre for Health Economics and Policy Analysis (CHEPA), the McMaster University-based research group that studies various aspects of health care policy. The 2-day spring conference in Hamilton, entitled Beyond Equitable Access: New Perspectives on Equity in Health Care Systems, attracted 150 delegates from universities and all levels of government. They came fr6m as far as Europe, Africa and India to hear from 20 experts. Gavin Mooney, director of the Health Economics Research Unit at the University of Aberdeen, Scotland, outlined the origins of the equity concept. He said it is based primarily on the "hu-
AUGUST 15,1992
han, PhD, director of New York's Hastings Center, a medical ethics research institute, denounced the American health care system. He described it as a highly inequitable system that is "chaotic, unfair, unjust and excessively expensive." In the same breath, he complimented the Canadian system: "Perhaps someday we will be able to adopt some of the solutions you have found here." The rest of his speech questioned how the high social value placed on scientific progress can be balanced with equitable access to health care services. For example, he said the artificial heart offers great possibilities for many patients because the technology could save from 30 000 to 50 000 lives per year and solve the problem raised by chronic shortages of transplantable hearts. "The other side of the debate says the artificial heart, which will only add between 3 and 5 years to life, is going to spell disaster in terms of access. The cost is going to be utterly astronomical, adding anywhere from $3 billion to $10 billion [a year] to health costs." At an individual cost of up to $250 000, he said, there is no way every American who needs an artificial heart is going to get one. CAN MED ASSOC J 1992; 147 (4)
503
health care system. However, the antiabortion forces don't express community values - they're just using the abortion question as a political football." She supports the CARAL position that abortions need not be performed in hospitals. Holland describes an argument that she used to good effect in her campaign to maintain access to abortion in Nanaimo. "What if a religious group, opposed to blood transfusions, started to obtain control of hospital boards and started banning transfusions?" She says much of the impetus for limiting access to abortion appears to be coming from Protestant fundamentalists. "Governments are curtailing a legal right of women when they allow access to abortions to be
limited by hospital boards," argues CARAL's Holmes. "Abortion is a necessary medical service. An unwanted pregnancy is not a healthful situation." Gavigan is unhappy with provincial governments' response to the abortion question. "There appears to be no political will by politicians and journalists to engage the antiabortion people about their discourse, as has been taking place recently in Ireland." In the future, financial restrictions on health care services, hospital closures and rationalization of local services might also contribute to the fragile access to abortion. It appears Canadians may be in for an endless debate about abortion, one that is making both Canadians and their doctors increasingly weary.m
Physician, tape thyself, communication expert advises Olga Lechky p ractising clinicians will notice a quick improvement in their clinical communication skills if they engage in a simple exercise, says a communications expert at the University of Western Ontario, London. Dr. Moira Stewart, a professor of family medicine and a member of the expert panel at the international Consensus Conference on Doctor-Patient Communication, held in Toronto late last year, suggests that doctors audiotape themselves during several Olga Lechky is a freelance writer living in North York, Ont. AUGUST 15,1992
patient interviews. "I think many physicians would be surprised at how they sound," she says. "It wouldn't be difficult for them to identify the things they could improve. The first thing to do is listen for interruptions -physicians frequently interrupt patients very early in their descriptions of why they've come and what they think is wrong." If frequent interruptions are a hallmark of their interviewing style, they should resist the urge to cut off patients and allow them to conclude their statements and present their concerns. The concerns should then be followed up
Stewart: taping helps CAN MED ASSOC J 1992; 147 (4)
499
with exploratory, open-ended questions that encourage the patient to elaborate. "Physicians should listen to see if they're using a lot of closedended questions - ones that require only a Yes or No response. If so, it would be easy enough to switch to using more open-ended questions. Also, physicians can listen for missed opportunities
where they could have clarified end of each segment of the interthings with patients. This ensures view. Basically, it's a safeguard that the doctor has understood that misunderstandings don't get what the patient has said and that worse as you go along." Ideally, however, physicians the patient has understood what the doctor has said. This involves should take a course in clinical the use of summary - summariz- communication, says Stewart. "A ing to the patient what you have good course goes beyond theory, heard [her] say and having the giving participants an opportunity patient summarize what you have to practise the skills they are being said. This should be done at the taught, either on a simulated pa-
Better communication may keep MDs out of courts' clutches About 75% of patient complaints about doctors involve misunderstandings that resulted from poor communication skills on the part of clinicians, says Dr. Robert Buckman. an authority on clinical communication and chairman of the first international Consensus Conference on Doctor-Patient Communication. It was held in Toronto late last year. Rarely are cliniCal-competency issues at the centre of doctor-patient disputes. says Buckman, clinical oncologist at the Sunnybrook Health Sciences Centre and associate professor of medicine at the tUniversity of Toronto. He argues that this fact highlights the recent overemphasis on the science of medicine at the expense of its art, and the urgent nieed to mend the growing rift between doctors and patients in today's world of impersonal. high-tech medicine. "Doctors have traditionally had a resistance to clinical communication issues, believing it to be a load of touchy-feely crap," says Buckman. "'But the day has come when it's no longer possible to pull the duvet over our ears and pretend a communication problem
500
CAN MED ASSOC J 1992; 147 (4)
with our patients doesn't exist. The conference put together 15 years of accumulated hard data that show beyond any argument that doctor-patient communication is a problem that affects patients' health. The positive side is that data presented at the conference showed that good clinical communication skills can be learned. and when used routinely in clinical practice, make a difference in what you get from vour patients in terms of their satisfaction and recovery.
A consensus statement issued by an international panel of experts at the end of the 3-day conference outlined some compelling reasons why medical training programs should starl putting clinical communication near the top of the teaching agenda. For example, about 50% of patient complaints and concerns are not elicited by physicians because their poor listening skills do not allow patients to fully air concerns. As a result, patients and doctors disagree on the nature of the presenting problem in about 50% of clinical encounters. Few patient visits involve patient education and feed-
back, and this results in a high proportion of patients who do not understand what their doctor has told them about their condition and treatment, or forget what was said. Given this backdrop, it's not surprising that most malpractice allegations stem from poor communication. Many physicians feel they do not have the time to improve the quality of communication with patients, but Buckman counters: "There are data suggesting that the time added is about 7 minutes per patient visit. Consider that in the context of how much time it would take to deal with a patient complaint. It all boils down to how physicians prefer to spend their time. Without good communication skills, you can spend an hour with a patient and achieve very little. On the other hand, by listening carefully to the patient's agenda, you can accomplish a tremendous amount in under 10 minutes." The consensus statement identified an area of critical concern to primary care practitioners - the urgent need to address psychosocial problems. "At least a third of visits to a primary care practitioner are
LE 15 AOUJT 1992
tient or a colleague who plays the role of a patient. This makes them feel more comfortable when they start using the new skills in their own practice. Viewing videotapes is a very powerful learning tool and would be an essential component of a good course, something physicians should look for in choosing a course." Physicians interested in tak-
not due to a physical illness," says Buckman. "But at least 50% of cases of depression are missed." Many clinicians would argue that a patient's depression and anxiety are the prov-
ince of psychiatrists, social workers and marriage counsellors. True, says Buckman, but they cannot do their jobs if primary care practitioners are not diagnosing problems and
referring patients. "If primary care practitioners adopt the at-
titude that psychosocial problems don't concern them, then they are failing to diagnose a treatable condition which has high morbidity and is potentially fatal. If any physician can tell me why he shouldn't be diagnosing a treatable condition which is potentially fatal, I would be very interested in hearing. "While it's not physicians' responsibility to find a depressed patient another job, they are required to deal with the secondary diagnosis. If a patient is so depressed because of his loss of income that his health or life is in danger, the doctor has to do something about it. Brief psychotherapy and antidepressant therapy
AUGUST 15, 1992
ing a course in clinical communication should contact the local continuing medical education (CME) department. "If no courses are being offered, make a case that they should be, and find other interested people," Stewart urges. "The resources to teach these courses are available at the medical schools. If enough interest is expressed, it's very likely
don't restore a person's salary what they do is restore a patient's ability to function socially and solve his own problems. It's a paper tiger for physicians to say, 'I can't fix the world.' No person alone can fix the world even coronary artery bypass surgery doesn't fix heart disease. It just stops the pain and improves a patient's quality of life. "In primary care physicians don't have any choice but to deal with psychosocial problems, so why not learn how to do it well?" And it is possible to learn to do it well in a short time. A study presented at the consensus conference by Debra Roter, PhD, associate professor of health policy and management at Johns Hopkins University in Baltimore, showed that it takes only two 4-hour continuing medical education sessions to improve primary care doctors' skills in diagnosing and treating psychosocial problems. In the study, physicians were trained either in emotion-handling skills or problem-handling skills. -
These physicians, who were compared with a con-
that a course will be offered." Interested physicians should also contact groups within organized medicine that are working to promote better education in this area, Stewart said. For example, the Ontario Medical Association's (OMA) Joint Practice Committee has a long-standing interest in clinical communication. Its chairman, Dr. Robert Heckadon
trol group that received no training, successfully translated their new skills into action in their practices. They increased their ability to spot psychosocial problems, such as anxiety, depression and psychosomatic illness, without significantly increasing the length of patient
visits. "We had a very positive response from the physicians," says Roter. "At 6-months' follow-up, the doctors were still using the skills they were taught. They thought the training was very worth while and said they would take a similar course again." [A March workshop in Toronto, sponsored by the Canadian Cancer Society, attempted to set national teaching standards and evaluation techniques for the teaching of clinical communication skills during undergraduate training. The workshop included participants from all 16 of the country's medical schools and most of its major medical organizations. A draft statement recommended that faculties of medicine collaborate in setting standards for faculty development and the teaching of students - Ed.]
CAN MED ASSOC J 1992; 147 (4)
501
Occasional, isolated, instances of elevated liver enzymes levels have been seen during clinical trials. No definite relationship to ketotifen fumarate therapy has been (ketotifen fumarate) established. DOSAGE AND ADMINISTRATION PRESCRIBING INFORMATION In children older than 3 years of age, Zaditen (ketotifen Therapeutic classification: Pediatric asthma prophylactic fumarate) should be given at a dose of 1 mg twice daily with and anti-allergic agent morning and evening meals. INDICATIONS AND CLINICAL USE There is no clear evidence of efficacy and safety in children Zaditen (ketotifen fumarate) is indicated as an add-on medi- under 3 years of age and the dose is not established in this cation in the chronic treatment of mild atopic asthmatic age group. children. To minimize the initial sedation with Zaditen, a progressive Zaditen is a prophylactic agent to be used on a continuous regimen is recommended during the first week of treatment basis and is not effective in the acute prevention or treat- commencing with one half the daily recommended dosage ment of acute asthma attacks. Continuous use of Zaditen given in 2 divided doses or in a single dose given in the may reduce the frequency, severity and duration of asth- evening, followed within 5 days, by an increase to the full matic symptoms or attacks, and lead to a reduction in daily therapeutic dose. requirements of concomitant anti-asthmatic medication, Concomitant Therapy: Existing asthma therapy should be like theophyllines and B2-agonists. maintained. A progressive reduction in dosage of other Several weeks of Zaditen therapy may be necessary before asthma drugs, where clinically indicated, should be the therapeutic effect becomes clinically evident. Full clini- attempted only after 6-12 weeks of Zaditen therapy. cal effectiveness is generally reached after 10 weeks of treatment. Zaditen may have an anti-inflammatory effect in Reduction of Cortlcosterolds: It is notfully established, but the lungs and the time of onset of clinical efficacy may some patients may be able to reduce corticosteroids. reflect the recovery period of the lungs from inflammation. The reduction in the daily maintenance dosage of steroids should be stepwise according to the recommended CONTRAINDICATIONS methods. The gradual reduction should be continued until There are no known contraindications. Patients sensitive to eitherthe patient cannot tolerate a further reduction, or it is benzoate compounds should not take Zaditen syrup. found possible to withdraw corticosteroids completely. PRECAUTIONS If troublesome symptoms recur during the period of reducGeneral: Anti-asthmatic drugs (xanthine derivatives, tion, the daily dose of corticosteroids should be raised B2-agonists, sodium cromoglycate, corticosteroids) immediately. A larger increase in the steroid dose may be already in use should not be reduced immediately when essential at times, as a temporary measure, to control a treatmentwithZaditen(ketotifenfumarate)is initiated. This severe relapse induced by antigen challenge, infection or applies especially to systemic corticosteroids and ACTH stress. (The increased physical or mental activity resulting injections because of the possible existence of adrenocorti- from subjective improvement can also constitute a stress). cal insufficiency in steroid-dependent patients; in such When symptoms are brought under control, a progressive cases recovery of a normal pituitary-adrenal response to reduction may be attempted as before. stress may take up to one year. Any reduction should be gradual while maintaining close Occupational: Since drowsiness may occur in the early surveillance and frequent examination of the patient. The stages of therapy, patients engaging in activities requiring ability of these patients to react to stress is usually rapid and precise responses should be cautioned. impaired. Acute adrenal insufficiency and severe asthma Drug interactions: A reversible fall in the trombocyte count can be precipitated by an increase in stress and/or reduction in patients receiving Zaditen concomitantly with oral anti- of either steroid or ACTH therapy. It is advisable to assess diabetic agents has been observed in rare cases. Throm- adrenal and pituitary function before reducing steroid dosbocyte counts should therefore be carried out in patients age in patients who have received long-term therapy. taking oral antidiabetic agents concomitantly. Method of Withdrawing ACTH: The same principles as Zaditen may potentiate the effects of sedatives, hypnotics, discussed above. antihistamines and alcohol. AVAILABILITY OF DOSAGE FORMS Use in Obstetrics: Although there is no evidence of ter- *Zaditen* (ketotifen fumarate) Tablets Each scored white atogenic effects, Zaditen should be given to pregnant tablet embossed with the name "ZADITEN " contains: 1 mg women only if the potential benefit justifies the potential ketotifen. Tablets are to be swallowed. Available in packs of risk to the fetus. 56 tablets containing 4 blister strips of 14 tablets each. Patients with Special Diseases and Conditions: Zaditen *Zaditen* (ketotifen fumarate) Syrup: 5 mL of syrup consyrup should not be administered to patients sensitive to tain 1 mg ketotifen. Available in 250 mL bottles. To be benzoate compounds. Zaditen tablets are benzoate-free and administered orally. can be administered alternatively to such patients. STABILITY AND STORAGE RECOMMENDATIONS ADVERSE EFFECTS Tablets: There was a relatively low incidence of adverse reactions place. Store attemperatures not exceeding 250C, in a dry reported. Sedation, weight gain, rash, respiratory infections, flu, headache, sleep disturbance, increased appetite, Syrup: Store at temperatures not exceeding 250C. abdominal pain, urticaria, ear infections, nose bleed and For further Information, please contact your Sandoz reprepuffy eyelids have been reported. These were similar in both sentative, or consult the product monograph, available on the Zaditen (ketotifen fumarate) and placebo treated groups request. of patients. The reports for CNS and G6 symptoms in the *Registered trademark placebo group are side effects known to be associated with xanthine administration, which was being used concomitantly by some patients during the study. Thrombocytopenia has been reported when Zaditen (ketoPME tifen fumarate) is combined with oral hypoglycemic agents ZAD-92-07-2027E (see PRECAUTIONS).
*ZADITEN'7Ig
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of Windsor, Ont., says the committee is currently looking into the feasibility of publishing a book based on monthly articles about different aspects of the doctor-patient relationship that appear in the OMA's monthly journal, Ontario Medical Review. "We've spent a long time diagnosing that poor communication between doctors and their patients is a problem and we're only starting to look at some solutions," says Heckadon. "As awareness of the problem has grown, medical schools are providing more teaching of clinical communication at the undergraduate and graduate levels. But our main concern is with the practising clinician for whom there is very little in place at the moment in terms of CME programs." The OMA is also working with the CME department at the University of Toronto to establish a clinical communications program. "The emphasis would be on practical approaches to dealing with patients, how-to courses that deal with common situations that arise in practice, such as abusive or angry patients, compliance problems, problems in the family." Ideally, these courses would be incorporated as a half-day program into other clinical CME events in an effort to maximize exposure and overcome the traditional resistance of physicians to clinical communication issues, Heckadon says. "We're also exploring the idea of attaching CME communications courses to the regular meetings of medical societies throughout Ontario." The CMA Council on Medical Education is also taking an active interest in promoting the teaching of these skills. "As awareness of the issue grows, so does the recognition that good communication is a learnable skill," says Alexandra Harrison, the CMA's director of educational services. "It used to be thought LE 15 AOUJT 1992
that good communication was a skill you were born with - you either had it or you didn't. It's now recognized that it's a skill like any other - it's learnable." As a starting point, the council is planning to contact medical schools to find out what types of programs are being offered in training and CME programs. "If we find any big
gaps, we can make recommendations and work with educational authorities to improve the situation," says Harrison. Disciplinary bodies are also taking an active interest in communications education, but in a context most physicians would prefer to avoid. "The majority of the complaints received by the college about physicians
involve attitudinal problems," says Dr. Neal Sutton, associate registrar of public complaints investigation at the College of Physicians and Surgeons of Ontario. "We're currently exploring avenues for setting up ongoing programs in communications skills for physicians who come to our attention [through the complaints process]."u
Health care equity tackled from many angles at CHEPA conference Lynne Cohen
health impinges on my happiness. I care if someone else is ill and would prefer that [he was] not." So powerful is this element of human compassion, argued Mooney, that "there is almost universal agreement that equity in health care is important." He stressed that it is crucial for governments to have a clear definition of health care equity, even if it is difficult to reach agreement on what the principle means. Stephen Birch, associate coordinator of CHEPA and a professor in McMaster's Department of Clinical Epidemiology and Biostatistics, helped explain what equity is not. "It is not synonymous with equality, although the pursuit of equity might involve achieving equality in something. At the same time, inequality with respect to something else might be a prerequisite of equity [in health care]." Mooney named 13 countries, including Spain, Sweden, the United Kingdom and Canada, that had already found "reasonprinciple, manitarian-spillover" "the idea that someone else's ill ably clear statements on equity objectives." However, he said Canada's statement is least clear. The conference's opening Lynne Cohen is a freelance writer living in speaker, philosopher Daniel CallaOttawa.
F ew Canadians disagree with the notion of equity in health care. It is, after all, the powerful concept that forms the foundation of Canada's medicare system. The idea, which intrigues health policy experts around the world, also formed the foundation for the fifth annual conference of the Centre for Health Economics and Policy Analysis (CHEPA), the McMaster University-based research group that studies various aspects of health care policy. The 2-day spring conference in Hamilton, entitled Beyond Equitable Access: New Perspectives on Equity in Health Care Systems, attracted 150 delegates from universities and all levels of government. They came fr6m as far as Europe, Africa and India to hear from 20 experts. Gavin Mooney, director of the Health Economics Research Unit at the University of Aberdeen, Scotland, outlined the origins of the equity concept. He said it is based primarily on the "hu-
AUGUST 15,1992
han, PhD, director of New York's Hastings Center, a medical ethics research institute, denounced the American health care system. He described it as a highly inequitable system that is "chaotic, unfair, unjust and excessively expensive." In the same breath, he complimented the Canadian system: "Perhaps someday we will be able to adopt some of the solutions you have found here." The rest of his speech questioned how the high social value placed on scientific progress can be balanced with equitable access to health care services. For example, he said the artificial heart offers great possibilities for many patients because the technology could save from 30 000 to 50 000 lives per year and solve the problem raised by chronic shortages of transplantable hearts. "The other side of the debate says the artificial heart, which will only add between 3 and 5 years to life, is going to spell disaster in terms of access. The cost is going to be utterly astronomical, adding anywhere from $3 billion to $10 billion [a year] to health costs." At an individual cost of up to $250 000, he said, there is no way every American who needs an artificial heart is going to get one. CAN MED ASSOC J 1992; 147 (4)
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