Operation of the abortion law To the editor: The report of the committee on the operation of the abortion law was submitted to the minister of justice of Canada in January 1977 (Can Med Assoc 1 116: 553, 1977). It immediately received reviews of indignant disappointment by the Globe and Mail and the Medical Post (Mar. 1, 1977). The fault lay not in the report, which answered its term of reference, "Were therapeutic abortions obtainable equitably across Canada?", with a resounding Nay, but in the disappointment and frustration of the press that no major step had been taken in the apparently insoluble problem of therapeutic abortion. The report was assessed as an unnecessary expense ($680 000), a waste of time and a political sop to the controversies generated by such a contentious issue. To one who works in the field of therapeutic abortion, if not by choice, at least by necessity, the report makes fascinating reading and provides a wealth of information - a bonanza bargain at the cost. It is comparable to the 1974 Lane report from Great Britain. Chapter 2 of the report presents a most commendable summary of the therapeutic abortion situation in Canada. This is the underlying basis of the report from which the conclusions may be drawn for further recommendations with respect to therapeutic abortion. The Society of Obstetricians and Gynaecologists of Canada has precious little to say on the topic, and the proposal by the Canadian Medical Association, that the issue is one between the patient and her doctor, is totally inadequate. What then are the conclusions that can be drawn when the findings documented in the report are combined with almost 8 years' experience under the present law? Many of the present activities are carried out by contentious minority groups dissipating their efforts in emotionally charged causes in a milieu of political trepidation. There has been enough time in passage, combined with sufficient experience and the present documentation, to face the issue. Indeed, there is present experience to show that the time may be ripe for all levels of government to approach other current political issues that are equally contentious. It is therefore proposed that the appropriate professional medical organizations, following due consideration, approach the related government agencies with the following recommendations: 1. That the problem of therapeutic abortion be assigned to the provincial governments for implementation by a program developed by the department
of health of each province and the appropriate professional medical associations of that province. 2. That such a program be developed within the present law or such changes made within the law to provide that "an abortion is designated as therapeutic when performed within an approved provincial health care program". 3. That greatly extended efforts be made to deal with the long-term problem of the unwanted pregnancy by an ongoing comprehensive birth control program coordinated by the federal government in conjunction with related agencies. If these principles were obtainable, effective long- and short-term policies could conceivably be developed to deal with the unwanted pregnancy. This might negate the present futility of conflict, which submerges any advancement of policy. Q.A. SCHMIDT, MD, FRC5[C] President, Society of Obstetricians and Gynsecologists of Canada 367 Lytton Blvd. Toronto, Ont.
The family practice nurse To the editor: In his editorial entitled "The family practice nurse" (Can Med Assoc 1 116: 829, 1977) Dr. Keith Hodgkin clearly sets forth the basic criteria for determining the validity of the concept of the "family practice nurse". He indicates that the basic criteria are twofold: first, the nurse must be medically effective and, second, the nurse must be cost-effective. He adduces abundant evidence to support the concept of medical effectiveness; my personal experience indicates that this objective is clearly achievable. Dr. Hodgkin does not dwell upon the cost-effective principle with the same intensity that he does the medically effective principle; this is understandable because we are primarily medically oriented. He does, however, conclude that cost-effectiveness is present by indulging briefly in business management principles with the quotation "Never do a job yourself if it can be done as well or better by someone who is paid less." The assumption is that the physician is paid more than the family practice nurse. The validity of this observation is shown when the net annual incomes of these two groups are compared. However, this is an inappropriate comparison for purposes of cost-accounting. To obtain an accurate comparison one must determine the hourly wage of the two groups and divide this by the number of services per hour. It would then be possible to determine if there is a cost advantage in this kind of work delegation. If a physician's net annual income was $40 766 and his work week
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was somewhat less than average, his rate of payment would be $12 per hour. If, on the average, he rendered four services per hour, his net income from each service - or the converse, the cost to the patient for each of the physician's services - would be $3. If a family practice nurse received a net annual income of $12 000, had the usual work week for employees and received the usual fringe benefits, her cost per hour would be $6.73. Thus, if he or she worked at the same speed as the physician, there would be a cost reduction in excess of 40%. However, this has not been demonstrated. In view of the shorter training period, lesser experience and lesser knowledge, it is unlikely that the nurse's speed of work could become more than 50% of that of the physician, and under these conditions it is clearly more expensive to have the medical service rendered by the family practice nurse than by the physician. Dr. Hodgkin is correct in principle when he says, "Never do a job yourself if it can be done as well or better by someone who is paid less", but it remains to be demonstrated that the family practice nurse is paid less than the physician. M.A. BALTZAN, MD Professor and bead Department of medicine University of Saskatchewan Saskatoon, Sask.
To the editor: I have two comments to make about Dr. Baltzan's strictly financial arguments on the use of the family practice nurse. In his example he is attempting to compare apples and oranges. His figures suggest that a physician works about 68 hours per week for 50 weeks in the year to make $40 766 (12 x 68 x 50 = 40800); the time is possibly underestimated, as he suggests. His computation does not take into account that it is vital to good medicine that a good proportion of this 68 hours is not devoted to face-to-face consultation with patients. Before accurate comparisons of time and other factors can be made between a doctor paid fee-forservice and a nurse on salary the extent of this hidden input and actual numbers of patients seen by each must be taken into account. Thus, if the physician sees patients for 34 hours each week, the cost of his service per patient must be doubled. Many other factors, such as cost of training a nurse and a doctor, and definitions of "competent job" and "cost-effective", must be specified before strict comparisons can be made. All this does not affect my main argument, that the medical profession is not developing the sound principle of delegation. Dr. Baltzan's financial argument
of health of each province and the appropriate professional medical associations of that province. 2. That such a program be developed within the present law or such changes made within the law to provide that "an abortion is designated as therapeutic when performed within an approved provincial health care program". 3. That greatly extended efforts be made to deal with the long-term problem of the unwanted pregnancy by an ongoing comprehensive birth control program coordinated by the federal government in conjunction with related agencies. If these principles were obtainable, effective long- and short-term policies could conceivably be developed to deal with the unwanted pregnancy. This might negate the present futility of conflict, which submerges any advancement of policy. Q.A. SCHMIDT, MD, FRC5[C] President, Society of Obstetricians and Gynsecologists of Canada 367 Lytton Blvd. Toronto, Ont.
The family practice nurse To the editor: In his editorial entitled "The family practice nurse" (Can Med Assoc 1 116: 829, 1977) Dr. Keith Hodgkin clearly sets forth the basic criteria for determining the validity of the concept of the "family practice nurse". He indicates that the basic criteria are twofold: first, the nurse must be medically effective and, second, the nurse must be cost-effective. He adduces abundant evidence to support the concept of medical effectiveness; my personal experience indicates that this objective is clearly achievable. Dr. Hodgkin does not dwell upon the cost-effective principle with the same intensity that he does the medically effective principle; this is understandable because we are primarily medically oriented. He does, however, conclude that cost-effectiveness is present by indulging briefly in business management principles with the quotation "Never do a job yourself if it can be done as well or better by someone who is paid less." The assumption is that the physician is paid more than the family practice nurse. The validity of this observation is shown when the net annual incomes of these two groups are compared. However, this is an inappropriate comparison for purposes of cost-accounting. To obtain an accurate comparison one must determine the hourly wage of the two groups and divide this by the number of services per hour. It would then be possible to determine if there is a cost advantage in this kind of work delegation. If a physician's net annual income was $40 766 and his work week
214 CMA JOURNAL/AUGUST 6, 1977/VOL. 117
was somewhat less than average, his rate of payment would be $12 per hour. If, on the average, he rendered four services per hour, his net income from each service - or the converse, the cost to the patient for each of the physician's services - would be $3. If a family practice nurse received a net annual income of $12 000, had the usual work week for employees and received the usual fringe benefits, her cost per hour would be $6.73. Thus, if he or she worked at the same speed as the physician, there would be a cost reduction in excess of 40%. However, this has not been demonstrated. In view of the shorter training period, lesser experience and lesser knowledge, it is unlikely that the nurse's speed of work could become more than 50% of that of the physician, and under these conditions it is clearly more expensive to have the medical service rendered by the family practice nurse than by the physician. Dr. Hodgkin is correct in principle when he says, "Never do a job yourself if it can be done as well or better by someone who is paid less", but it remains to be demonstrated that the family practice nurse is paid less than the physician. M.A. BALTZAN, MD Professor and bead Department of medicine University of Saskatchewan Saskatoon, Sask.
To the editor: I have two comments to make about Dr. Baltzan's strictly financial arguments on the use of the family practice nurse. In his example he is attempting to compare apples and oranges. His figures suggest that a physician works about 68 hours per week for 50 weeks in the year to make $40 766 (12 x 68 x 50 = 40800); the time is possibly underestimated, as he suggests. His computation does not take into account that it is vital to good medicine that a good proportion of this 68 hours is not devoted to face-to-face consultation with patients. Before accurate comparisons of time and other factors can be made between a doctor paid fee-forservice and a nurse on salary the extent of this hidden input and actual numbers of patients seen by each must be taken into account. Thus, if the physician sees patients for 34 hours each week, the cost of his service per patient must be doubled. Many other factors, such as cost of training a nurse and a doctor, and definitions of "competent job" and "cost-effective", must be specified before strict comparisons can be made. All this does not affect my main argument, that the medical profession is not developing the sound principle of delegation. Dr. Baltzan's financial argument
