Inquisitive And Determined: They Push Medicine Forward

Transcription

LE
SPÉCIALISTE
LE MAGAZINE DE LA FÉDÉRATION DES MÉDECINS SPÉCIALISTES DU QUÉBEC
Vol. 15 no. 1 | March 2013
INQUISITIVE
AND
DETERMINED:
They Push
Medicine
Forward
TAX
BENEFITS
FOR DONATIONS
See Text p.34
Offre exclusive
aux médecins
spécialistes
PUBLICITÉ
PLEINE
Une offre
à la hauteur PAGE
de votre réussite
Desjardins est fier d’être partenaire de la Fédération des médecins spécialistes du Québec
et d’offrir à ses membres une offre exclusive leur permettant de profiter, entre autres,
des avantages suivants :
Desjardins
Forfait transactionnel complet à 125 $/année incluant :
➤ Jusqu’à cinq comptes avec transactions illimitées, soit un compte principal avec une gamme
complète d’avantages, deux comptes additionnels en dollars CA, un compte en dollars US et
un compte entreprise
➤ Une carte Visa* Desjardins OR Odyssée MD ou Platine, au choix, et une carte supplémentaire
sur le même compte, incluant le programme de récompenses BONIDOLLARS MD
Avec les BONIDOLLARS, c’est comme vous voulez. En effet, vos BONIDOLLARS n’expirent jamais
et vous êtes libre de les échanger en tout temps contre des voyages, des billets de spectacle, des
produits et des services financiers Desjardins et plus encore.
N’attendez plus! Rencontrez un conseiller en caisse ou un directeur de comptes dans un
point de service Desjardins Entreprises et profitez de cette offre dès maintenant.
1 800 CAISSES
desjardins.com/fmsq
Détails et conditions sur desjardins.com/fmsq.
* Visa / Fédération des caisses Desjardins du Québec, usager autorisé.
MD
Odyssée et BONIDOLLARS sont des marques déposées de la Fédération des caisses Desjardins du Québec.
Reconnaître et déclarer
les effets indésirables graves
et inattendus
Santé Canada
Aider à améliorer l’utilisation sécuritaire des produits de santé pour vos
patients en déclarant un effet indésirable à Santé Canada. Votre déclaration
peut contribuer à identifier des effets indésirables graves ou rares qui
n’avaient pas été observés auparavant et modifier les renseignements sur
l’innocuité des produits.
Il y a trois façons de déclarer :
• En ligne, à www.sante.gc.ca/medeffet
• Par téléphone, au 1-866-234-2345
• En complétant un formulaire de déclaration des effets indésirables et en
l’envoyant par courrier affranchi ou par télécopieur, au 1-866-678-6789
Pour être informé sur les mises à jour en
matière d’innocuité des produits de santé :
•
•
•
•
Avis et retraits
Fils RSS de MedEffet Canada
Avis électronique MedEffet
Bulletin canadien des effets indésirables
Consultez www.sante.gc.ca/medeffet
MedEffetMC
Canada
Ensemble, nous pouvons
améliorer l’innocuité des produits de santé
Bouger, ça rapporte ! Allégez le
taux de votre marge de crédit
hypothécaire de 0,5 %.
MC
Passez à RBC et perdez 0,5 % en un instant,
et économisez.
Nous assumerons même vos frais de transfert*.
Passez à la marge de crédit Marge Proprio RBC à 3,5 % (taux
préférentiel + 0,5 %). Vous pourriez économiser jusqu’à 5 000 $
en intérêts†. Offrez-vous un taux santé dès aujourd’hui.
®
Visitez l’une de nos succursales ou communiquez dès
aujourd’hui avec le conseiller en prêts hypothécaires
RBC Banque Royale® de votre région. 1 800 769-2511
* Nous paierons les frais d’assurance titres de base, les frais d’ouverture de dossier et une seule fois les frais de quittance (jusqu’à concurrence de 300 $). L’offre exclut les frais sur remboursement anticipé que vous devrez
peut-être payer. Le décaissement doit être d’au moins 50 000 $. † Les économies sont fondées sur une marge de crédit garantie de 100 000 $, les intérêts étant payés sur 10 ans, en comparant un taux d’intérêt annuel
de 3,5 % à un taux de 4,0 %. Le taux d’intérêt fluctuera en fonction du taux préférentiel et est sujet à changement en tout temps sans préavis. Le taux entre en vigueur le 10 février 2012. Ce produit est offert par la
Banque Royale du Canada sous réserve de ses critères de crédit standard. ® / MC Marque(s) de commerce de la Banque Royale du Canada. RBC et Banque Royale sont des marques déposées de la Banque Royale du Canada.
35153 (03/2012)
TABLE OF CONTENTS
Le Spécialiste is published 4 times per year by
the Fédération des médecins spécialistes du Québec.
EDITORIAL COMMITTEE
Dr Bernard Bissonnette
Dr Raynald Ferland
Maître Sylvain Bellavance
Nicole Pelletier, APR
Patricia Kéroack
7
Of Cycles and Men
EnGLiSh vERSion inTERnET onLy
8
TO CONTACT US
EDITORIAL CONTENT
✆ 514 350-5021  514 350-5175
[email protected]
DELEGATED PUBLISHER
Nicole Pelletier, APR, director
Public Affairs and
Communications
✉
RESPONSIBLE FOR
PUBLICATIONS
Patricia Kéroack,
Communications Consultant
www.magazinelespecialiste.com
ADVERTISING
✆ 514 350-5274  514 350-5175
✉
WORD FROM THE PRESIDENT
[email protected]
IN THE NEWS
10 LEGAL ISSUES
11 DID YOU KNOW...
15 GREAT NAMES IN QUÉBEC MEDICINE
REVISION
Angèle L’Heureux
Isabelle Boucher
Fédération des médecins
spécialistes du Québec
2, Complexe Desjardins, porte 3000
C.P. 216, succ. Desjardins
Montréal (Québec) H5B 1G8
✆ 514 350-5000
GRAPHIC DESIGNER
Dominic Armand
PUBLICATIONS MAIL
Postal Indicia 40063082
DOSSIER
ADVERTISING
France Cadieux
LEGAL DEPOSIT
1st quarter 2013
Bibliothèque nationale du Québec
ISSN 1206-2081
INQUISITIVE AND DETERMINED:
THEY PUSH MEDICINE FORWARD
The mission of the Fédération des médecins spécialistes du Québec is to
defend and promote the economic, professional, scientific and social interests
of the medical specialists who are members of its affiliated associations.
The Fédération des médecins spécialistes du Québec represents the
following medical specialties: Adolescent Medicine; Anatomical Pathology;
Anesthesiology; Cardiac Surgery; Cardiology (adult or pediatric); Clinical
Immunology and Allergy; Colorectal Surgery; Community Medicine; Critical
Care Medicine (adult or pediatric); Dermatology; Diagnostic Radiology;
Emergency Medicine; Endocrinology and Metabolism; Forensic Pathology;
Gastroenterology; General Pathology; General Surgery; General Surgical
Oncology; Geriatric Medicine; Gynecologic Oncology; Hematological Pathology;
Hematology; Infectious Diseases; Internal Medicine; Maternal-Fetal Medicine;
Medical Biochemistry; Medical Genetics; Medical microbiology and infectious
diseases; Medical Oncology; Neonatal-Perinatal Medicine; Nephrology;
Neurology; Neuropathology; Neurosurgery; Nuclear Medicine; Obstetrics and
Gynecology; Occupational Medicine; Ophtalmology; Orthopedic Surgery;
Otolaryngology-Head and Neck Surgery; Pediatric Hematology/Oncology;
Pediatric Emergency Medicine; Pediatric General Surgery; Pediatrics; Physical
Medicine and Rehabilitation; Plastic Surgery; Psychiatry; Radiation Oncology;
Respirology (adult or pediatric); Rheumatology; Thoracic Surgery, Urology and
Vascular Surgery.
All pharmaceutical product advertisements have been approved by the
Pharmaceutical Advertising Advisory Board (PAAB).
The authors of signed articles are solely responsible for the opinions expressed
therein. No reproduction without previous authorization from the publisher.
Dr Guy Rouleau, neurogeneticist
17
• In the Name of Medical Advances
18
• Facing the Barrier
24
• RHUMADATA ,
Made in Quebec
26
• The Scalpel Reinvented
28
• The ECHO® Approach
30
®
32 CONTINUING
PROFESSIONAL EDUCATION
34 SOGEMEC ASSURANCES
37 PROFESSIONALS’ FINANCIAL
38 LE MOT DU PRÉSIDENT
Des cycles et des hommes
THIS EDITION’S ADVERTISERS:
• Desjardins
• Santé Canada
• RBC Banque Royale
• Financière des professionnels
• Four Points – Centre de congrès de Lévis
• Congrès canadien sur la santé respiratoire • Telus
• La Personnelle
• Cardiologie interventionnelle
• Sogemec Assurances
• Groupe Conseil Multi-D
2
3
4
6
9
11
14
20
23
36
40
39 MEMBER SERVICES
Commercial Advantages
5
vol. 15
no. 1
LS
FÉDÉRATION
DES MÉDECINS
SPÉCIALISTES
DU QUÉBEC
*
* Membre - Fonds canadien de protection des épargnants
www.fprofessionnels.com
Montréal 1 888 377-7337
Québec 1 800 720-4244
Sherbrooke 1 866 564-0909
WORD FROM THE PRESIDENT
DR. GAÉTAN BARRETTE
Of Cycles and Men
T
hose of us who are among the oldest remember when
hospitalization insurance first appeared, which only
covered healthcare in hospitals, followed by the arrival
of our universal healthcare insurance. We also remember the
context and especially the very tense climate which existed when
our health insurance system was born. Even setting aside the
October Crisis in 1970 that accelerated matters, we cannot deny
that this public plan was born at a minimum among protests, if
not among fears on the part of the medical community of the
day, as much among general practitioners as among specialists. And yet, these fears would rapidly dissipate and no one,
except for a few refractory individuals, would question the plan
or suggest returning to the past.
Of course, under a plan that imposed a direct and unavoidable link between the State as paymaster and physicians as
suppliers, a particular framework for negotiations followed since
physicians would then retain, and still do today, their status as
professionals with a very real autonomy. History would then be
written, either this relationship would be one of collaboration,
or one of opposition. In this regard, we can reasonably say that
the first ten to fifteen years were serene all in all.
However, the sky deceptively started to darken. On the subject
of remuneration, for example, it is easy to show how the gap
with the average earnings of our Canadian colleagues started
to grow, in an inexorable way, until 2006 when we finally
succeeded in turning things around.
But there was more. Indeed, the State also took another
direction during this same period, that of controlling expenses
by controlling the supply. Without question, the culmination of
this approach was attained during the period of the 90s. This
was a long decade during which, always in the spirit of resolutely
controlling supply, we witnessed the historical conjunction of
forced retirement for a great number of physicians and nurses as
well as a reduction in the number of admissions into medicine.
It was the era of the much-vaunted “zero deficit” which, of
course, was reached!
But at what cost! It did not take into account the great advances
in clinical care, pharmacology and new technologies that would
generate a substantial increase in demand - and all in the
context of an aging population which was becoming more and
more demanding. With good reason, moreover. It was indeed
a dark decade.
Another one followed, the first of the new century which did
not shine with much more glory since everyone was trying to
do their best while making do with means that were clearly
inadequate. To make up for the decisions of the 90s, it was
decided to massively increase the number of admissions into
faculties of medicine. Some important investments were also
made in technology, but very little in infrastructures, the latter
nevertheless being essential in terms of capacity if we wanted
the system to be able to meet demand. Even in 2013, we can
feel this more or less-admitted desire by the State to control its
expenses by controlling the supply.
Which brings us to now. Where are we today?
We can see, from its history, how our healthcare system, like
society or the business sector, is divided into “cycles”, each
more or less fortunate as the case may be. There’s probably
nothing to surprise us in this.
But, we believe that we are at the beginning of another “cycle”
at this moment in time. Will it be favourable? That depends. It’s
a question of vision. But also of decision. And what is it that
drives this change of cycle? The medical corps. Few observers
seem to realize the change that is taking place right now. We
maintain, in fact, that there are enough physicians in Quebec
to proffer needed healthcare to the population. Our belief also
applies to first-line care, but we will not comment further on
this... For specialized medicine, on the other hand, we can
firmly state that we are being held back more than ever. Yes,
waiting times could be a lot shorter if only we had access to
appropriate resources.
On the other hand, the worst (or the best) is still to come.
Which one it will be depends on what we’ll do with the immense
cohorts of admissions to the faculties during the years 2000
who are just now starting their practice. For example, at the
FMSQ, we reached the “bottom of the barrel” three years ago.
Up to that point, the annual variation in the net number of
physicians paying dues (in other words, in active practice) was
almost nothing, or even negative! Since then, it is positive and
growing constantly. This year, we have a net increase of close
to 300 physicians and this figure will only grow in coming years,
because the biggest cohorts are only just starting to graduate.
Several questions need to be asked to obtain answers... now!
For example, we are more than 9,500 specialists today. Do we
believe we will need more than 12,000 in 10 years? If so which
implicitly means that the State considers that more healthcare
will be needed where is the planning to increase the network’s
capacity and thus allow this larger number of physicians to
serve the population? If not, would this be the time to reduce
the number of admissions to the faculties? Or, to set a maleto-female ratio of 50-50 for admissions?
This has been an infinitesimal part of the thinking that is needed.
Many other questions are still unanswered... But the fundamental one, at the beginning of this “cycle”, is whether there is
any thought being given and whether the right decisions will
be taken.
We will come back to this subject.
In all solidarity!
7
S
L
vol. 15
no.1
LS
IN THE NEWS
On the Political Scene
FROM QUEBEC’S NATIONAL ASSEMBLY
Even if the National Assembly officially resumed work
on February 12th, the analysis of the 2013-2014 budget
appropriations kept all parliamentary commissions busy
from February 4th to 19th. Of the 200 hours dedicated to
the study of appropriations for various departments, 20 hours
were allocated to health and social services at the request of
opposition parties.
Insofar as legislation is concerned, no proposed bill has yet
been filed at the time of writing. We can, however, expect
that the Minister of Health will table a bill aimed at creating
the autonomy insurance and that the Minister of Justice will
follow up on the report produced by the committee of legal
experts, presided by Me Jean-Pierre Ménard, on the legal
implementation of the recommendations of the National
Assembly’s Select Committee on Dying with Dignity. Further
details will be published in our June issue.
FROM THE HOUSE OF COMMONS
Although Motion M-312 presented by the Conservative backbencher, Stephen Woodworth, was defeated in the House,
another attempt to re-open the issue of recriminalizing abortion
seems to be under way in Ottawa. A vote is to take place in
March on Motion M-408, presented on September 26, 2012 by
the Conservative member for Langley (British Columbia), Mark
Warawa, who requests “that the House condemn discrimination
against females through sex-selective pregnancy termination.”
VICTORY FOR DERMATOLOGISTS!
Bill n°74: An Act to prevent skin cancer caused by artificial tanning – became law on February 11th. This law is the
crowning achievement that highlights more than 25 years of
sustained efforts to increase public and government awareness
by the Association des dermatologistes du Québec (ADQ).
Already in 1988, the former president of the ADQ, Dr Pierre
Ricard, was the first to address demands that tanning salons be
regulated to Mme Thérèse Lavoie-Roux, then Minister of Health
and Social Services in the government of Robert Bourassa,
who himself succumbed to skin cancer in 1996.
Afterwards, Dr Joël Claveau, a very active member of the
Association, took over and worked relentlessly with various
partners, including the Canadian Cancer Society and the
Institut national de santé publique, so that this law could finally
see the light of day.
The Act prohibits the sale of artificial tanning services to people
younger than 18. It also allows the creation of a Quebec registry
of businesses offering artificial tanning services. Finally, it places
restrictions on the advertising practices of tanning salons.
Now on Facebook
The year 2013 has brought along its load of news items including the involvement of some of the medical associations affiliated with the FMSQ in the universe of social media. Please note that Le Spécialiste published a dossier on the Web 2.0, in its
December 2011 issue.
THE ASSOCIATION DES NEUROLOGUES DU QUÉBEC
Created and managed by the President
of the association, Dr J. Marc Girard, this
page, containing more than a hundred
interventions as at January 15, 2013, aims
to become a complete information tool
on neurological news in the world. Thus,
it contains hyperlinks to news items, to
succinct summaries of newly published
studies or to personal comments regarding
the advancement of neurology in the world.
THE ASSOCIATION DES SPÉCIALISTES
EN CHIRURGIE PLASTIQUE ET
ESTHÉTIQUE DU QUÉBEC
Completely managed by the Director
of th e A S C PE Q, th i s p a g e i s a
communications tool for members of
the association. It contains details
regarding specific training sessions,
continuing professional development
workshops and general information
destined for members.
S
L

8
vol. 15
no. 1
LS
LA FMSQ
BIEN
PRÉSENTE
SUR INTERNET
ESPACE
SÉCURISÉ
POUR LES
MEMBRES
fmsq.org
SUIVEZ-NOUS ÉGALEMENT SUR
facebook.com/laFMSQ
@FMSQ et @DrBarretteFMSQ
IN THE NEWS
Breast Cancer
The Importance of Being Observant
The Fédération des médecins spécialistes
du Québec has given its support to the
Quebec Breast Cancer Foundation, which
is launching a far-reaching educational
campaign aimed at providing women
with the tools they need to understand
and recognize the signs of breast cancer
and to encourage them to see a physician
without delay.
The early detection of cancer can make
a difference when, among other things,
we think:
•
•
•
•
GUIDE D’OBSERVATION
DES SEINS
PASSEZ À L’ACTION ET
APPRENEZ À VOUS CONNAÎTRE.
DÉCELEZ ET SIGNALEZ À VOTRE
MÉDECIN TOUT CHANGEMENT
PERSISTANT ET RÉCENT.
EN CAS DE DOUTE, CONSULTEZ !
QUOI OBSERVER :
Peau d’orange
Épaississement
Changement de coloration
Rougeur couvrant au moins
le tiers du sein
Formation de fossettes, de petits
creux ou de plissements
Sensation de chaleur localisée
Ulcération ou plaie
Nouvelle veine plus apparente
Rétraction de la peau
OBSERVATION DU SEIN
of the 7% of women who discover
their breast cancer themselves,
simply by being observant;
Changement du volume
ou de la forme du sein
Changement d’un sein
par rapport à l’autre
Déformation
Masse (bosse) visible ou palpée
au niveau du sein ou de l’aisselle
of the large number of women
between the ages of 40 and 50 who
see a physician for an anomaly they
detected themselves;
that 20% of breast cancers occur
before the age of 50 and that there
is no systematic screening program
for this age group;
OBSERVATION DE LA PEAU
Inflammation du sein ou du bras
OBSERVATION DU MAMELON
Changement d’apparence
Écoulement spontané
Inversion
Déviation
Eczéma persistant ou ulcération
WWW.OBSERVATIONDESSEINS.ORG
SOUTIEN ET INFORMATION
1 877 990-7171 #250
[email protected]
that many women still believe that
pain is the first sign of cancer which
is rarely the case.
EVEN IF THESE CAMPAIGN TARGETS
WOMEN, BREAST CANCER ALSO AFFECTS
MEN. EACH YEAR, DOZENS OF MEN ARE
DIAGNOSED AND 25% OF THEM DIE.
This new campaign aims at increasing
awareness among Quebec women of the
importance of regularly examining their
breasts, at encouraging them to discuss
clinical examinations with their physician,
and finally, at inviting them to take part
in the Québec Breast Cancer Screening
Program (PQDCS) in great numbers.
Women are invited to visit the site
breastsobservation.org to get more
i nfo r m ati o n o n b re a st h e a l th c a re
practices and the complete list of signs
to be looked for, or to sign up for the
monthly reminder program created by
the Foundation.
In addition to promoting breast health
through education and incre ased
awareness, the Foundation finances local
research and facilitates support for those
affected by breast cancer by making
available to women free support and information services, available by telephone
at 1 (877) 990-7171, extension 250, or by
email at [email protected].
This campaign cannot succeed on its own. Physicians are very well
placed to reach the greatest number of women and to relay the
message. Information material will be made available to healthcare
professionals, including posters for offices and waiting rooms,
as well as flyers.
An order form to request this material is available. You can ask for
it by sending an email to [email protected].
S
L
Four Points – Centre
de congrès de Lévis
9
vol. 15
no.1
LS
LEGAL ISSUES
Extra Fees
BY MAÎTRE SYLVAIN BELLAVANCE
Director, Legal Affairs and
Negotiations – FMSQ
A Perpetual Problem
At the moment of writing these lines, the question of extra fees (or incidental expenses)
claimed from patients in medical clinics has again made the headlines.
On February 4th, Minister Hébert announced that he intended
to put an end to the abusive billing of extra fees to patients
and ensure that fees for medication and anesthetic agents
used within medical clinics were covered by the public drug
insurance plan. Once again, as was the case in the past, the
problem of extra fees is subjected to the wrong diagnosis and
the treatment proposed is inappropriate.
The wrong diagnosis results from the fact that we are putting
the emphasis on fees claimed from patients only for medication
and anesthetic agents. As a result, the excess appears flagrant
and the physician who bills $300 for medication that is worth
$10 appears to be practicing highway robbery in the eyes of
the public. Unfortunately, the problem of incidental fees cannot
be limited to these two items and the Federation immediately
attempted to correct this misperception by explaining that
the billing in question aimed rather at covering the numerous
operating expenses assumed by medical clinics, expenses
needed to ensure the provision of services to patients.
Therefore, the solution does not reside in having these two
expenses covered by the drug insurance plan. Rather, it is
important for the government to take a definite stand insofar
as covering services dispensed in medical clinics is concerned.
In this regard, the Federation has been repeating for years that
the government must choose between two avenues:
1.
2.
10
vol. 15
no. 1
LS
It can decide that all services required from a medical
point of view and dispensed by physicians in medical
clinics are ensured services. In such a case, it is
essential that negotiations be started to establish
reasonable rates for these services in order to cover
the operating costs of these clinics. As a result, the
patient would have nothing to pay.
On the other hand, it can decide that services
rendered in medical clinics are not completely insured.
In these circumstances, citizens need to be informed
that the cost of these services is not fully covered by
the public system and that physicians who dispense
these services can ask patients to contribute to
their costs.
The problem today stems from the fact that all the governments
who have succeeded one another have wanted to keep both
sides happy. They did not want to finance the technical
costs of providing services in medical clinics because of the
substantial monetary investment these could involve. On the
other hand, they did not want to clearly indicate that these
expenses would have to be paid for by the patient, since this
is not a politically advantageous avenue. Physicians are faced
with the following dilemma: either they don’t dispense certain
services in their medical clinics, which have a negative impact
on access to care for patients, or they promote this access by
asking patients to finance a portion of the operating costs of
the clinics, with the risk of being blamed for it at a later date.
This situation is untenable for medical specialists, who have
been trained to dispense care to patients. This is why the
Federation has been repeating for years that it is important to
resolve once and for all the issue of care dispensed in medical
clinics. In 2007, the government finally agreed to mandate a
committee, chaired by M. Jean-Pierre Chicoine, to study the
question. On October 1st, 2007, the committee delivered its
report to the Minister of Health. The first three observations
of this report were:
“To start with, so called out-of-line billing of certain
incidental expenses reflects the lack of revenues needed
to cover the operating costs of the clinic.
Secondly, we observe an erosion of the economic viability
of private clinics, an erosion that will continue if important
changes are not made to their financing.
Thirdly, in terms of access, the continuing erosion of
the activities of private clinics would have a devastating
effect (…)”
The committee concluded by issuing a general recommendation that it was necessary to give back to medical clinics “a
vitality and an attractiveness that will allow them to maintain
and improve their contribution to access to health services.”
Among its specific recommendations, the committee indicated
the necessity “of increasing the technical component for
services currently dispensed in clinics,” “of indexing this
technical component on a yearly basis” and “thereafter, of
identifying new acts that could be dispensed more effectively
in clinic and thus improve access.”
The situation is thus unequivocal. The problem of incidental
expenses has already been adequately diagnosed and
methods of treatment have been identified. It is useless to
redo the analysis or to implement incomplete solutions. The
Federation suggests that a decision be made once and for
all regarding the direction to take. If the decision is in favour
of ensuring services for the benefit of all patients, then it is
important to ensure the viable financing of technical costs
within medical clinics. Otherwise, we cannot blame physicians
for trying to find the means of making sure that patients in
Quebec have access to the services they need.
S
L
DID YOU KNOW...
PRIZES AND AWARDS
ASSOCIATION DES MÉDECINS MICROBIOLOGISTES
INFECTIOLOGUES DU QUÉBEC
Dr Marie Gourdeau, a microbiologistinfectiologist at Hôpital de l’Enfant-Jésus in
Quebec, has received the Louis-Pasteur
Prize highlighting her exceptional contribution
to the advancement of the profession. This
prize is awarded every two years during the
Association’s annual meeting.
ASSOCIATION OF OTO-RHINO-LARYNGOLOGY
AND MAXILLO-FACIAL SURGERY OF QUEBEC
A new prize was created this year by the
Association to highlight the involvement
and dedication of a specialist for his or her
medical specialty. The first recipient of the
prize is Dr Raynald Ferland of the Centre
h o s p i t a l i e r d e l ’ U n i v e r s i t é L a v a l.
ASSOCIATION DES GASTRO-ENTÉROLOGUES DU QUÉBEC
CANADIAN SOCIETY OF INTERNAL MEDICINE
Dr Raymond Bourdages, a gastroenterologist at Hôtel-Dieu de Lévis, has received
the André-Viallet Prize, the most prestigious
one awarded by the AGEQ. This prize is
given to a specialist who has contributed to
increasing recognition of gastroenterology in
Quebec and who has distinguished himself or
herself either through the whole of his or her scientific work, through
his or her work within the Association, or through a specific act,
an exceptional accomplishment recognized by his or her peers.
Dr René Roux, an internist at the Hôpital
Sainte-Croix in Drummondville, has
received the William Osler Award. This
award is given out annually to a specialist
having demonstrated excellence in general
internal medicine, whether in clinical
practice, in research, in continuing medical
education or by contributing to advancing the medical specialty
or promoting health.
QUEBEC ORTHOPEDIC ASSOCIATION
The Laval-Leclerc Prize for 2012 has been
awarded to Dr Huber t Labelle, an
orthopedic surgeon at the Sainte-Justine
University Hospital Centre.
Congrès
canadien sur la
santé respiratoire
2013
ROYAL COLLEGE OF PHYSICIANS AND
SURGEONS OF CANADA AWARDS
Dr Stanley Nattel, a cardiologist and the
director of the Electrophysiology Research
Program at the Montreal Heart Institute
Research Centre is one of three physicians
receiving the 2013 Royal College Visiting
Professorship in Medical Research Award.
À inscrire à votre agenda!
Centre des congrès de Québec
Ville de Québec (Québec)
11 – 13 avril 2013
Pour tous les détails du programme et pour
s’inscrire, visitez le site www.poumon.ca/crc
En collaboration avec
11
vol. 15
no.1
LS
DID YOU KNOW...
PRIZES AND AWARDS (CONT’D)
CELEBRATED BY THE McGILL FACULTY CLUB
Shortly before he left on his well-earned
retirement, the McGill Faculty Club wished
to highlight the exceptional contribution of
Dr Jean-Jacques Dufour, an ORL working
at the CHUM (Notre-Dame) and associated
with Montreal’s Jewish General Hospital for
20 years. Dr Dufour was the founder of
an interdisciplinary team made up of ORL surgeons and
neurosurgeons, in particular for the microsurgical excision of
cerebellopontine angle tumours. This collaboration propelled
the team to the level of the most effective in Canada, allowing it
to publish the results of its work around the world.
QUEEN ELIZABETH II DIAMOND JUBILEE MEDAL
Photo : umcgill.ca
Since the previous issue of the magazine,
other recipients of the Diamond Jubilee
Medal have been announced.
Have been added to the list: Dr Gaston
Ostiguy, a pneumologist at the Montreal
Chest Institute and a pioneer in the
fight against tobacco dependence and
Dr Ernesto L. Schiffrin, an internist at
Montreal’s Jewish General Hospital and
the holder of the Canada Research Chair
in hypertension.
Photo : umcgill.ca
HEALTH RESEARCH FOUNDATION AWARD
Dr Charles Scriver, a geneticist and a
professor at McGill Universit y, has
received the Medal of Honour to highlight
his contribution to the advancement of
scientific knowledge and innovation. Since
the 1970s, Dr Scriver has been an initiator
and ardent defender of the addition of
vitamin D to milk. Since then, results have shown that this
addition has reduced the incidence of rickets in children, which
went from more than 1,000 cases per year to almost none at all.
Prix et bourses du CQDPCM 2013
ONE HONOUR ATTRACTS ANOTHER
The Canadian Heart Rhythm Society has
given its first Annual Achievement Award
to Dr Denis Roy, a cardiologist at the
Montreal Heart Institute ( MHI) and a
pioneer in interventional electrophysiology
in Canada. To highlight this award as well
as his exceptional career, Dr Roy was
named Personality of the Week by La Presse and RadioCanada, an honour he shares with the entire MHI team.
SIRIUS GRAND PRIZES FROM THE CHUQ
For the eighth year, the CHU in Quebec has rewarded the
contribution of those who have helped advance the organization.
This year, certain medical specialists were honoured, namely:
Dr Jacques Blanchet, a
pediatrician, and Dr Patrick
Daigneault, a pneumologist, have received the
Services cliniques Prize for
their contributions involving
physiotherapy treatments
for babies suffering from acute brochiolitis.
Dr Yves Fradet, a urologist and renowned
researcher, has received the Recherche
clinique Prize for his work on new
prognostic markers and on a personalized
approach to prostate cancer.
HONOURING TWO OF THE GREAT ONES WHO HAVE
LEFT US
Two highly-reputed medical specialists
have passed away in recent months:
Dr Jacques Papillon, an aesthetic plastic
surgeon and the founder of the CHUM
Burn Centre - Hôtel-Dieu of Montreal
(Dr Papillon was our Great Name in Medicine
of Q u e b e c in S e pte m b e r 20 0 9 ) a n d
Dr Jean-Mario Giroux, a dermatologist
and a pioneer in dermato-pathology at the
CHUM - Hôtel-Dieu.
Le Spécialiste salutes the dedicated
work of these two Great Practitioners of
specialized medicine in Quebec and their
contributions to the advancement of medical science.
EXPLORONS, INNOVONS ET PARTAGEONS !
Prix de la recherche
Prix de l’innovation pédagogique
Bourses de recherche en
développement professionnel continu
12
vol. 15
no. 1
LS
Pour participer, consultez notre site au www.cqdpcm.ca
Date de clôture : le 1er mai 2013
GOOD NEWS!
Our website is now available in English.
Have a look at fmsq.org
DID YOU KNOW...
SOMETHING TO CELEBRATE
The Association of Allergists and
Immunologists of Quebec (AAIQ) marked
its 25 years of activity in a grand manner.
On the occasion of its annual meeting,
members having reached more than 25
and 45 years of practice were honoured.
A Place for Your Special Projects
25
YEARS
25 years and more
Dr Pierre-Michel Bédard, Dr Jose Calles, Dr André Caron,
Dr Zave Chad, Dr Yves Charbonneau, Dr Francine CloutierMarchand, Dr David Copeland, Dr Jaime Del Carpio,
Dr Guérin Dorval, Dr Michèle Dugal, Dr Jacques Hébert,
Dr Marek Rola-Pleszcynski, Dr Edmond Shahin, Dr Emil
Skamene, Dr Peter Small, Dr Jan I. Schulz, Dr Irving B.
Schonfeld, Dr Jean-Paul St-Pierre, Dr David Thomson and
Dr Lorne Umemoto.
Doctors, have you decided to
go mountain climbing in the
Himalayas to benefit a cause
that is dear to you? Are you
taking on a role at the theatre
or the opera? Have you just
finished a doctorate in a
sphere of activity other than
medicine? Or are you showing
your latest creations in an art
gallery? Let us know about it!
We’d love to hear from you
and to let all your colleagues
know. Send us an email:
[email protected].
45 years and more
Dr Herbert Blumer, Dr Phil Gold, Dr Andrzej Gutkowski,
Dr Christine Lejtenyi and Dr John Weisnagel.
Friday, November 15, 2013
Palais des congrès de Montréal
ON T
H
AGEN E
DA
A FEW OF THE THEMES BEING PREPARED:
ALZHEIMER’S • SURGEONS AND ANESTHESIOLOGISTS: NECESSARY PARTNERSHIPS
SKULL BASE TUMOURS: CONTROVERSIES AND INNOVATIONS
INFECTIONS IN GASTROENTEROLOGY • SLEEP DISORDERS • SMOKING CESSATION
Details to follow
AFTER ALL THIS ARCTIC WEATHER, WARMER DAYS ARE SURE TO COME
It is time to think of the summer and to exchanging
your shovels and overcoats for your best golf clubs
and cleats. You’ll have guessed that we’re inviting you
to the next edition of the Medical Federations’ Golf
Tournament for the benefit of the Quebec Physicians’
Health Program Foundation. Block off July 29, 2013
in your diary right away. This eighth edition will be
the ideal moment to network with your colleagues!
Registration forms will be available shor tly on
the FMSQ portal (fmsq.org). Remember that the
Tournament sells out very quickly and it’s therefore
important for you to register early.
Several sponsoring opportunities are available. For
more information regarding these opportunities and
their cost, please get in touch with Mrs. Hoda Sayegh
at 514-350-5000, extension 279 or by email at
[email protected].
S
L
13
vol. 15
no.1
LS
Nouveau partenariat TELUS-FMSQ
pour vos communications mobiles.
TELUS et la Fédération des médecins spécialistes du Québec (FMSQ) sont fiers de vous
annoncer leur nouvelle entente de service. Cette entente propose plusieurs avantages dont
l’accès au réseau 4G, le plus étendu et le plus rapide* au Québec, qui permet l’itinérance
dans plus de 200 pays. Ces avantages permettront d’augmenter la productivité et l’efficacité
des membres. De plus, une grille de tarification concurrentielle vous est offerte.
Forfait iPhone
Forfait d’appels locaux
Tarif mensuel
Minutes incluses
25 $
250
Messagerie textuelle illimitée
incluse
Appels entrants illimités (locaux)
inclus
Appels locaux entre abonnés TELUS illimités
inclus
Appels locaux illimités en soirée (dès 18 h) et le week-end
inclus
Forfait de transmission de données
Tarif mensuel
30 $
Transmission de données incluse (sur iPhone et Android)
6 Go†
Obtenez un
forfait iPad flexible
à partir de
5$
/mois
incluant
10 Mo
de transmission
de données‡.
D’autres forfaits et types d’appareils sont disponibles. Des conditions s’appliquent.
Pour connaître les détails ou pour commander,
veuillez communiquer avec un représentant TELUS au 1 855-310-3737.
Nous croyons que cette nouvelle entente saura répondre parfaitement à vos besoins
en matière de téléphonie mobile, en plus de vous faire bénéficier des ressources technologiques
et des services-conseils de TELUS.
* Selon une comparaison des réseaux HSPA/HSPA+ nationaux : « le plus rapide » selon les vitesses de transmission de données testées dans des grands centres urbains du pays;
« le plus étendu » selon la couverture géographique et la population desservie. † TELUS se réserve le droit de retirer ou de modifier cette offre en tout temps et sans préavis. ‡ Vous devez vous
procurer le iPad auprès d’un détaillant autorisé pour profiter de ce forfait. TELUS et le logo TELUS sont des marques de commerce utilisées avec l’autorisation de TELUS Corporation. Apple, le
logo Apple, iPhone et iPad sont des marques de commerce d’Apple Inc. © 2012 TELUS.
GREAT NAMES IN QUÉBEC MEDICINE
BY PATRICIA KÉROACK
Discovering Why:
a Veritable Obsession!
The name of Guy Rouleau has become synonymous with excellence in medical and scientific
research and his reputation has spread well beyond Quebec. Dr Rouleau has been celebrated and
decorated numerous times for his work in neurogenetics: he recently received the 2012 WilderPenfield Award (one of the Prix du Québec) and has collected other awards, including the Genesis
Award (BIOQuébec), the Henry-Friesen Award (Canadian Society for Clinical Investigation and
the Royal College of Physicians and Surgeons of Canada), the Léo-Parizeau Prize (ACFAS),
the Michael Smith Prize (Canadian Institutes of Health Research), the Margolese National Brain
Disorder Prize (University of British Columbia) as well as having been elected Officer of the Ordre
national du Québec, to name just a few.
Guy Rouleau, who was born in the Vanier suburb of Ottawa, himself
admits that when he was young he was rather calm, quiet, studious
and passionate about his chemistry games, probably a prelude to
his scientific career. But his father was a family physician in Ottawa.
It’s not surprising then to see that medical studies were considered
important in the Rouleau family (his older brother is a cardiologist).
Liking the health sciences, he chose medicine as a way into biomedical research, despite the advice of his professors who thought he
should start by becoming a physician, and then diverge to research
afterwards, advice that he did eventually follow.
Graduating with a diploma in medicine from the University of
Ottawa at the age of 22, Guy Rouleau arrived at the Montreal
General Hospital to train in internal medicine, then in neurology
at the Montreal Neurological Institute. His course of studies was
normal even though the heavy schedule and an irregular lifestyle
resulted in multiple migraines. His interest in neurology was probably
not unrelated to the fact that he wanted to understand the root
cause and reasons for his problems. He chose the city of Boston
to undertake a fellowship in neurology (Massachussetts General
Hospital) and, at the same time, obtained a Ph.D. in genetics from
Harvard University.
At the end of his medical studies, he decided to settle in Montreal
and raise a family in a francophone environment. He established
his first clinical practice at McGill, as well as his research and
teaching activities.
Even though he is a neurologist, it is in genetics that Dr Rouleau did
most of his research and where he obtained a certification in genetics
when this latter medical specialty was recognized. “I was doing a lot
of neurological genetics and the residents who were assigned to my
clinic liked it because they saw another clinical aspect of neurology,”
he reveals. Their passage there certainly produced new specialists
in the field of neurogenetics.
RESEARCH, THE KEY TO HIS CAREER
Guy Rouleau always wanted to understand. Thus, when the question
is “why”, a multitude of factors can stream out and lead to answers,
one of which will resolve the query. Genetics was the natural pathway
leading to explanations of several neurological diseases occurring
in families, as was the case for many rare diseases that could only
be explained in this way.
Dr GUY ROULEAU
Neurogeneticist
Credit: Prix du Québec scientifiques
Dr Rouleau likes to remember each research project, along
with its hypotheses and published results. He remembers, in
particular, his very first research contract undertaken during
his medical studies in Ottawa. Under the responsibility of the
biochemist, Jean Himms-Hagen, his work consisted of increasing our understanding of the role of creatine kinase (CK) in the
mitochondria of muscles as well as of brown fat as a contributor
to cold resistance and adaptation. During an entire summer, he
isolated mitochondria to study their various physical properties
and to understand the phenomenon of oxidative phosphorylation. Finally, the dreams of his youth were becoming reality.
The publication of a first study in which he had been involved
goes back to the beginning of the 1980’s when he was a
resident in dermatology. The study concerned the treatment
of psoriasis in ambulatory patients. Since then, there have been
close to 600 studies, articles or chapters in books published
with his name as leading or contributing author. His research
has discovered and explained a multitude of pathologies as
well as updated our understanding of them.
Thus, in the early 1990’s, Dr Rouleau discovered two important
genes: the gene involved in amyotrophic lateral sclerosis (ALS or
Lou Gehrig’s disease) and the one involved in neurofibromatosis
type II. This latter gene, on its own, explains the particularities
of schwannomas and of one-half of meningiomas in humans.
According to Dr Rouleau, “this understanding is essential insofar
as the development of all non-malignant tumours of the brain is
concerned; however, since these tumours are in a closed box,
they are far from being benign.” For these two discoveries and
because he demonstrated remarkable potential for the future,
Société Radio-Canada named him Scientist of the Year in 1993.
15
vol. 15
no.1
LS
GREAT NAMES IN QUÉBEC MEDICINE
ON THE INTERNATIONAL SCENE
At the beginning of 1990, in France, the French Muscular
Dystrophy Association and the Center for the Study of Human
Polymorphisms got together to set up the Genethon, an organization which, with the help of substantial financing from public
contributions, succeeded in creating a research institute at
the leading edge of technology which assembled a veritable
dream team of researchers in genomics: “This shook up the
field of genetics, with positive results, since we produced the
very first sequencing of the human genome at that time.” The
scientific work done at this centre contributed considerably to
advancing knowledge and to opening the way to new medical
treatments. As a member of the scientific council of the organization, now the world leader in genomics, Dr Rouleau’s career
was propelled onto the international stage.
DURING HIS CAREER, DR ROULEAU IDENTIFIED
SOME TWENTY GENES RESPONSIBLE FOR
PSYCHIATRIC AND NEUROLOGICAL PROBLEMS
BOTH AS A FUNDAMENTAL RESEARCHER AND
AS A CLINICIAN. HIS OUT-PATIENT CLINICAL
PRACTICE WAS MAINLY DIRECTED TOWARDS
VARIOUS GENETIC DISEASES OF THE BRAIN.
These technological advances allowed our Great Name to
pursue multiple avenues of research, unexplored until then or
even unhoped for, because of astronomical costs and material
difficulties. During his career, Dr Rouleau identified some twenty
genes responsible for psychiatric and neurological problems
both as a fundamental researcher and as a clinician. His outpatient clinical practice was mainly directed towards various
genetic diseases of the brain, such as ataxias, hereditary
spastic paraplegias and neurofibromatosis, especially because
of his research projects.
LABORATORIES AND
COMMERCIAL DEVELOPMENTS
To bring to fruition the numerous research projects he was
considering, Dr Rouleau surrounded himself with team
members who were the best. Thus it was that, in 1989,
just after his return from his fellowship, he founded his own
research laboratory, today made up of some forty individuals
all as passionate as he is. The projects undertaken at the
laboratory are mainly linked to neuro-developmental or neurodegenerative diseases. His laboratory is annexed or affiliated
according to its clinical activities. In 2004, after some fifteen
years attached to the Montreal General Hospital, he founded
the Centre of Excellence in Neuromics of Université de Montréal
(CENUM) and integrated his laboratory to the CHUM. But,
since the start of this year, he returned to McGill to head up
the Montreal Neurological Institute.
16
vol. 15
no. 1
LS
For several years, Dr Rouleau also looked after the possible
commercialization of certain genetic tests or treatments
developed through his research. With two colleagues, in 1997,
he created RGS Genome Inc., a private laboratory that was sold
a few years later to Xenon Genetics Research Inc. Dr Rouleau
remained an executive with this company until 2003: trials of
a medication he developed are currently in phase 2. Then,
he took part in the creation of Emerillon Therapeutics as well
as in the launch of other projects. “I am certain that one of
the medications I’ve developed will be on the market before I
retire,” he tells us.
By definition, research is a long-term undertaking requiring
solid financial support and only projects that have the needed
funds are viable. Dr Rouleau estimates he has received several
million dollars in grants to carry out his research projects. But,
finding funds is sometimes as arduous as the research itself.
Guy Rouleau hopes to see an improvement in research conditions that would allow it to concentrate, without problems, on
the real objectives behind research: finding viable solutions
that will help people. To get there, the researcher that he is
believes that we have to bet on the applicability of the research
itself. He hopes to see clinicians and fundamental researchers
unite and work together on projects that will have concrete
applications for people. Unfortunately, he says, it is not rare to
see one researcher and another working on the same problem,
but in isolation. Combining their data would permit advances
and allow new pathways to be found. “We could really benefit
from rallying researchers around major themes and making
them work in concert,” he says with conviction.
Sequencing the genome will have been the keystone of his
work. In 2005, with a $17 million grant, he started doing
sequencing on a large scale. The investments needed to set
up the technologies and the first applications were substantial, but the costs diminished as knowledge and technology
evolved. We can already hope to see the day when we’ll be
able to sequence entire genomes in a doctor’s office during
a medical exam.
THE MAN APART FROM HIS SCIENCE
Guy Rouleau is not only a man of science. He is also a great
humanitarian, an affectionate father and grandfather (he has
five children and one granddaughter). He is passionate about
nautical sports and takes advantage of each possible moment
to go refresh himself... on the water, whether it is close to
Montreal or down South. He advises his children to do what
they like before all else and, especially, to be passionate about
what they do. This is wise advice which he has put into practice
himself, throughout his long career.
Looking back, Dr Rouleau is satisfied with the road he has
travelled. His greatest pride is always for his latest findings.
Even if he is proud of all his discoveries, what is done is already
in the past: what is important is what remains to be done
today and what will come afterwards. His current projects deal
with autism, schizophrenia and neuro-degenerative diseases.
Dr Rouleau’s career is far from over because he still has piles
of projects on his worktable.
S
L
DOSSIER
They Push Medicine Forward
Leonardo da Vinci greatly advanced
knowledge of human anatomy and
the Vitruvian Man is its most eloquent
figurative representation.
VITRUVIAN MAN
A palm is four fingers ; a foot is four
palms; a cubit is six palms; four cubits
make a man; a pace is four cubits; a man
is 24 palms; and these measurements are
in his buildings.
If you open your legs enough that your
head is lowered by one-fourteenth of your
height and raise your hands enough that
your extended fingers touch the line of
the top of your head, know that the centre
of the extended limbs will be the navel,
and the space between the legs will be
an equilateral triangle.
The length of the outspread arms is equal
to the height of a man.
From the hairline to the bottom of the chin
is one-tenth of the height of a man; from
below the chin to the top of the head is
one-eighth of the height of a man; from
above the chest to the top of the head
is one-six th of the height of a man ;
from above the chest to the hairline is
one-seventh of the height of a man.
From the breasts to the top of the head
is a quarter of the height of a man. The
ma ximum width of the shoulders is
a quarter of the height of a man. The
distance from the elbow to the tip of the
hand is a quarter of the height of a man.
The distance from the elbow to the armpit
is one-eighth of the height of a man.
Some cases in medicine are very complex and others, very
rare. It can happen that only one person in the world, a single
physician, is able to proffer the care needed for these specific
cases. And, among these unique experts, there are some who
live in Quebec.
Who are the physicians with this type of expertise, the ones
who are alone with an interest in a specific condition or those
who, like Leonardo da Vinci, advance scientific knowledge?
Le Spécialiste has spoken to a few of them, while remaining
convinced that Quebec has several others. What pushes them
to pursue this path in medicine, a path often unknown, that
only they are familiar with, since they cleared it and paved it
with their knowledge?
The length of the hand is one-tenth of the
height of a man. The root of the penis
is at half the height of a man. The foot
is one-seventh of the height of a man.
From below the foot to below the knee
is a quarter of the height of a man. From
below the knee to the root of the penis is
a quarter of the height of a man.
The distances from the bottom of the
chin to the nose and the eyebrows and
the hairline are equal to the ears and to
one-third of the face.
Extract from Leonardo da Vinci’s translation
of Vitruvius’ treatise entitled De Architectura.
17
vol. 15
no. 1
LS
BY PATRICIA KÉROACK
In the Name of Advancing Medicine
Behind every medical advance, there is always a visionary or a team who succeed in transposing
and introducing new knowledge into clinical practice. They are the first, often the only ones,
to benefit from a rare or costly apparatus; they can be the only ones to have developed a
treatment expertise; they can also be the only ones to be interested in rare medical cases.
Quebec can be proud of counting such medical specialists in its ranks.
The medical innovations of the last two centuries outclass in
productivity everything that has been done throughout the history
of mankind.1 Science has taken giant steps and everything leads
us to believe that this will continue to be the case in the future.
Moreover, trends lead us to predict that medical advances will
develop at exponential speed even if we only take into account
recent developments in robotics, genomics and nanotechnology.
Medical science benefits from the contributions of those who
look after the health of their patients. The evolution of science
also goes through the patient who forces it to advance. With the
arrival of the internet, with social media and the democratization
of information, knowledge is made available to all. Many are the
patients who now ask for healthcare that is available here or being
experimented with elsewhere in the world.
These advances, although they do not seem to have limits, do
have a cost. If experimentation is costly in terms of financial investments, facilities and resources of all types, it can take several
years before techniques become “profitable”. Being lashed to the
medico-administrative structure is often a major constraint in our
current organization.
THE FIRST ONES ARE ALWAYS THOSE
WE REMEMBER, THOSE WHO ARE AWARDED THE
PRIZES AND THE HONOURS, THOSE WHOSE NAMES
MAY FIND THEIR WAY INTO THE HISTORY BOOKS.
THE RACE TO KNOWLEDGE?
As in all scientific spheres, medicine is at the centre of a real
contest: the race to knowledge. Who will be the first to succeed
where everyone has failed so far? Who will announce the
discovery of an innovative molecule, an experimental treatment,
a breakthrough or other revolutionary advance? If the signal to
start is never given, the race itself is always present. The first
ones are always those we remember, those who are awarded the
prizes and the honours, those whose names may find their way
into the history books.
18
vol. 15
no. 1
LS
1
According to the Director of the Office of Professional Development
at the FMSQ, Dr Sam J. Daniel, “Scientific conferences are
excellent ways to see and appreciate current projects. Several
universities, especially in the United States, succeed in obtaining
important sums of money for research. These universities, to
ensure their grants are perennial, have to show their ability to
deliver the goods in order to remain among the leaders in terms
of developments, results and innovative projects. Competition is
healthy, as long as resources are not wasted to do and redo things
that already exist, just in order to publish. Healthy competition
promotes the development of understanding and know-how...
and this is what is wanted.”
TWO SIZEABLE CHALLENGES:
CME AND REPLACEMENT
When a physician is the only one to undertake a procedure,
how can he or she improve other than by studying cases and
reviewing charts?
All the physicians who were interviewed admitted they were
called upon to publish the results of their research. Several
also give presentations around the world within the context
of medical conferences. Continuous contacts with colleagues
from elsewhere allow them to question the knowledge they have
gained, to ask new questions or to try to find an answer to a new
enquiry. Even when there are only a few physicians who perform
a new procedure, we often see them consulting one another
before going ahead with a new experimentation and, afterwards,
sharing post-intervention notes. These are the advantages of
very limited circles.
Most of the cases mentioned previously involved patients and
elective surgeries, but when it comes to taking some vacation
time, who takes over caring for the patients of these “expert”
physicians? They often work in multidisciplinary teams; their
techniques are shown or taught to the colleagues who second
them or assist in the operating theatre. Most of the physicians
also take advantage of the passage of residents to share their
knowledge of a particular practice. Some have even gone so far
as to pursue these teachings through a fellowship and returned
to carry on with the team in place.
Road to Medical Innovation and Access: from a rear-view mirror, Global Health Histories Seminar Series, July 2012. World Health Organization.
Available at www.who.int/.../Zafar_Mirza_presentation_.pptx
BEING A PRECURSOR
THE STUBBORNNESS THAT BEARS FRUIT
In 1976, confronted with an incapacity to help a patient who presented with chronic intestinal failure, but whose
condition did not require hospitalization, a surgeon in the Quebec City area, Dr Roch Lapointe, tried everything
to allow him to receive care at home. It was during an international conference that he learnt that a home parenteral nutrition technique was developed in 1968 in Philadelphia and that certain establishments, including one
in Toronto, were launching some unusual trials.
Convinced that this was the only solution available for his patient, Dr Lapointe wanted to know how to do
it. He was rebuffed by a series of administrative, medical and organizational refusals; worse, there were no
pharmacists with the technical expertise to prepare the injectable solutions that needed to include personalized doses of amino acids, glucose and lipids. Stubbornly lobbying at various decision-making levels, Dr Lapointe succeeded in
obtaining permission to go directly to Toronto with his patient. This is how he learnt the technique to carry out this type of intervention
in Quebec. Since then, home parenteral nutrition is available throughout Quebec.
A TEAM EFFORT
Twenty-five years ago, a team working with high-risk
pregnancies at the Sainte-Justine University Hospital
Centre developed an interest in babies born to
HIV-infected mothers. Dr Marc Boucher, a perinatalist
and gynecologist-obstetrician, along with three other
medical specialists (a microbiologist, a pediatric immunologist-infectiologist and an epidemiologist) wanted
to find a way of preventing the vertical transmission of
the virus from the mother to the child. He remembers
that at the beginning most people were afraid of AIDS,
including some physicians. Few solutions were available to these
women who were too often ostracized: they were pregnant, but
no one wanted to help them. For Dr Boucher, the opposite was
true: he wanted to find a way to help these women.
Around the world, research was barely starting on finding a way
of blocking the transmission of the virus from the mother to the
child. Dr Boucher then decided to dedicate everything
to these women. “With the development of new technologies and new medications, we were able to offer
these women a choice. We were the first and we
wanted to succeed at all cost. Our team gave its all,
and as a result, today, we have the largest cohort of
mother-child couples (800 of them in Canada) with no
virus transmission,” he says, proud of this clear victory.
The team tested and applied a treatment made up of
antiviral medications. Since March 1994, parturient women receive
the treatment for a period of eight weeks antepartum. The work
of Dr Boucher’s team has opened the way to a better handling of
both pregnant women carrying the virus and their babies. Today,
benefiting from the unique expertise developed by Dr Boucher
and his team, other hospital centres offer the same treatment to
pregnant women.
AN INNOVATIVE SOLUTION
Dr Ismail El-Hamamsy, a cardiac surgeon at the Montreal Heart Institute is the first, and one of the few,
to use the Ross procedure in adult patients, an operation for individuals presenting with an aortic valve
problem. The operation consists of replacing the defective valve with the patient’s own pulmonary valve.
According to Dr El-Hamamsy, the advantages of this surgical procedure for the patient are many: “it allows the
patient to have his or her own valve, one that is living and that resembles a native aortic valve in aortic position.
The procedure is more common in youngsters. “In fact, Dr El-Hamamsy demonstrated in a study published in
the Lancet, that the long-term survival of young patients having undergone a Ross procedure is equivalent to
that of the general population. Net benefits are very real. In addition to long-term survival, complications are
minimal and patients’ quality of life is greatly improved as there is no need for them to use either anticoagulants
or any other specific medication over the long term.
So, why is this procedure not more common instead of using metallic or biological valves? Dr El-Hamamsy explains that the procedure
is much more difficult and demanding than a normal replacement procedure. “You have to be very comfortable with the procedure.
I did my fellowship in England with the greatest specialist in this area. I spent four years developing my skill with the procedure. Upon
my return, I implemented the program at the MHI and, today, close to sixty patients have had the surgery with success.”
The Ross Surgical Program at the Montreal Heart Institute is one of the most important in the world as much for the volume of
procedures undertaken as for the research that is done there. Less than 50 surgeons have been trained in this procedure around
the world. In Canada, there are three of them; one in Montreal, one in Toronto and the last in Quebec City. Dr El-Hamamsy is often
called upon to go assist a colleague elsewhere in the world when the latter wants to implement the procedure.
19
vol. 15
no. 1
LS
Pour vos assurances auto, habitation et entreprise,
mieux vaut être à la bonne place.
La Personnelle
DÉCOUVREZ COMMENT
VOS ASSURANCES
POURRAIENT ÉVOLUER
AU MÊME RYTHME
QUE VOTRE STYLE DE VIE
ET VOS BESOINS.
POUR EN SAVOIR PLUS :
1 800 361-5303
514 350-5070 / 418 990-3946
Par courriel ou Internet :
[email protected]
www.sogemec.qc.ca
Un partenariat qui vous offre des tarifs exclusifs,
ainsi que des protections et un service personnalisés.
OBTENEZ VOS TARIFS DE GROUPE EXCLUSIFS
1 866 350-8282
sogemec.lapersonnelle.com
La bonne combinaison.
Certaines conditions s’appliquent.
SOGEMEC ASSURANCES
filiale de la
POUR TOUS VOS
BESOINS D’ASSURANCES
A SIMPLE IDEA TO START WITH
Also at the MHI, the cardiologist Dr Marc
Dubuc is the source of two technical
innovations: the first is the extraction of
electrodes by laser and the second is
LAISSEZ LIBRE COURS
À VOS
PASSIONS
cryoablation
by catheter.
Grâce au
SERVICE PRÉFÉRENCE
The electrode extraction technique is for
patients with cardiac stimulators (implantable pacemakers and defibrillators) that sometimes need to have
probes removed, whether for replacement, cleaning, infection,
etc. Normally, the surgeon simply pulls on the electrode to extract
it, but sometimes adhesions develop and prevent the probe from
freeing itself from the heart, especially if it has been in place for
Qu’iltime.
s’agisse
professionnelle
a long
Today,d’assurance
techniques have
been refined with the use
ou personnelle
invalidité,
of extraction
sleeves(vie,
that can
deliver a auto,
sourcehabitation),
of energy to their
notre service
Préférence
personnalisé
extremities
such as
radiofrequencies
or a laser.vous
Dr Dubuc is the
permmettra
trouver
rapidement
réponse
only
one to use ade
laser,
a technique
he estimates
is safer for the
à vosinquestions.
patient
spite of all the known risks. The procedure requires
an extremely high degree of precision and attention to details.
SOGEMEC ASSURANCES
ÉVOLUE AVEC VOUS
The second unique expertise is an old procedure revisited. Up
until now, to destroy cardiac tissue responsible for arrhythmia.
we had recourse to the energy in radiofrequencies. “The
thought occurred to me to try cold, then used for other surgical
procedures. Contrary to radiofrequency, cold allows you to better
target and delimit the zone within which to destroy tissues. It’s
a simple idea to start with, but to get there we had to overcome
several technological challenges.”
Surrounded by engineers and with the cardiologist Dr Peter
Friedman from Boston, Dr Dubuc developed the surgical
procedure, tested it on animals before moving, in 1988, to clinical
tests on patients. “Since then, the technique evolved substantially and new applications were developed as we had observed
that the procedure resulted in fewer blood clots and was safer
than radiofrequency,” explains Dr Dubuc. “We now combine
two techniques: cryoablation by catheter with balloons for the
treatment of paroxysmal atrial fibrillation inside the pulmonary
veins. Instead of destroying the tissues, one point at a time, the
cryo-balloon allows us to do them all in one step. The procedure
takes less time and is safer for patients.”
“The technique is now in place, both in Quebec City and in
Montreal, and the Montreal Heart Institute remains the Canadian
training centre for this procedure.”
A GUINEA PIG IN SPITE OF HIMSELF
One day, Dr Sam J. Daniel, ENT specialist at the MUHC-Montreal Children’s Hospital, wagered double or
nothing to save a newborn whose health was going down rapidly. The baby had been placed on a respirator,
while awaiting a tracheotomy, because he had excessive secretions and was thought to be blind. The despairing mother had decided to ask that her baby be taken off life-support. A family dispute and concerns by the
hospital ethics committee gave Dr Daniel enough time to test and apply an experimental treatment. Based on his
research, on advice and tests done in the laboratory and... on himself (to evaluate the dosage needed for such
a small patient), Dr Daniel decided to have a go at it. The baby reacted positively to the treatment. Even better,
it was discovered that the visual handicap was only a consequence of the baby’s medical problem. Today at
the age of six, the child, previously condemned, leads a normal life without any sequels.
Since then, Dr Daniel has continued his research on hypersalivation and on its treatment which consists of avoiding tracheotomies
by using botulinum toxin injections (Botox®) in children to reduce salivary secretions.
SURGICAL DEXTERITY
Dr Alexandre Bouchard is a surgeon at the Hôpital
Saint-François d’Assise and takes care of patients
with benign rectal tumours or rectal cancer.
Immediately upon obtaining his certification, he left on
a fellowship to increase his knowledge of laparoscopy,
a new technique that was expanding phenomenally.
Reading scientific journals, he learnt of a new one
developed and on trial in Germany: minimally-invasive
colorectal surgery.
Normally, such patients would have been subjected
to major surgery for a radical excision frequently accompanied
by a high level of complications, often a temporary ileostomy,
and always a long convalescence. With the help of a transanal
endoscopicASSURANCES
microsurgery (TEM) device, a rare, temperamental
SOGEMEC
and relativelyfiliale
costly
Dr Bouchard succeeds in
dedevice,
la
removing masses of any volume, be they within a
few centimetres of the anus or deeper, by using the
patient’s natural passages. The procedure requires
that the surgeon be especially dexterous and
training is long and demanding. But it is well worth
the risk as, with TEM, results are probative: postintervention complications are rare, there is no need
for a temporary ileostomy, convalescence is short and
finally, the rate of recurrence is very low.
Since the TEM device was received in Quebec City
in 2011, two young colleagues have joined the program. In all,
120 patients have been operated on with this new technique,
of which 80 procedures were done by Dr Bouchard. Of the fifty
or so TEM devices available in America, four are in Canada
(Quebec, Vancouver, Halifax (just starting up) and Ottawa).
21
vol. 15
no. 1
LS
REMUNERATING A NEW ACT
According to the Director of Economic
Affairs at the FMSQ, Dr Michèle Drouin,
“The remuneration of a new act must not
be a brake to the development of new techniques and new procedures. A generic
code has been created for all procedures
done by a physician that does not have a
code in the billing manual of the RAMQ.
The new code is 09990.”
The rule applicable for the use of this code reads:
RULE 4 – NEW FEES (Unofficial translation)
NOTE: Medical administrative services are not medical services.
They cannot therefore be billed in the same manner as non
negotiated acts.
4.1 The medical specialist has the right to be paid for a
diagnostic or therapeutic procedure or a surgery for which
no fee is indicated in the manual.
-
Inscribe code 09990;
-
Write in the other details: date, role, modifiers, units;
-
Do not indicate fees;
-
Attach a copy of the clinical note;
-
Attach a detailed description of the medical service
proffered or of any pertinent scientific literature;
-
Invoice only this act on the request for payment;
-
Write “N” in the special consideration box (case C.S.).
In the fees report, he or she specifies his or her
request for a new fee and attaches a brief summary of
the intervention.
4.2
Upon receiving a request for a new fee, the Régie notifies
the negotiating parties of its receipt.
4.3 The new fees, if agreed to by the parties, are added to
the fees schedule. If there is no agreement, the Fédération
can refer the question to arbitration. The arbitrator then
sets an interim fee.
4.4
A new fee has a retroactive effect except if it replaces an
interim fee set by an arbitrator. Fees reports that were
presented on time are then paid.
4.5 No fee is granted for an intervention included in the fee
of another healthcare act.
Extracted from the general preamble, MAJ 82 / April 2012 / 61, Page a-3,
available (in French) at http://www.ramq.gouv.qc.ca/sitecollectiondocuments/
professionnels/manuels/150-facturation-specialistes/011_a_pream_gene_acte_
spec.pdf
22
vol. 15
no. 1
LS
In summary, the physician must describe his or her act,
accompanied by any pertinent documentation. He or she must
demonstrate that the act in question does not appear in the
manual and that no negotiated fee exists for it: such acts are
often new ones or acts that have become obsolete or that are
now an integral part of other acts. In the case a new act, the
RAMQ calculates a fee for the procedure by remunerating
according to an analogous act, or to length of time, or to another
condition, as per the medical expert’s opinion. Afterwards, the
latter informs the FMSQ that a request for a fee has been filed
by a medical specialist.
The RAMQ receives between 15 and 25 requests for new acts
each year. But, do these new acts automatically receive a billing
code? No. Before obtaining a specific code, each new request is
analyzed by the Federation as well as by the medical association
involved. Three outcomes can result at this time:
1.
The association, along with the FMSQ, both recognize
the act and together propose a fee and a label. The
FMSQ takes charge of negotiations with the MSSS.
2.
The association comes to the conclusion that the
act is an integral part of a medical visit and, as a
consequence, refuses its addition.
3.
The association comes to the conclusion that the act
is an experimental procedure for which the scientific
literature does not yet provide scientific validity or that
the act is not recognized medically-speaking or that
this type of procedure must not be encouraged. It
refuses its inclusion. The act could be re-analyzed at
a later date if its validity is recognized medically or
scientifically-speaking.
Certain codes can become mutually exclusive for acts based on
parallel techniques. “Creating a code for an act at the request
of a physician rarely results in the abolition of another code for
an act performed by several other physicians who are not yet
familiar with the new act. If it involves a new technique, along
with a new expertise, if few physicians are trained in it or if the
practice is expected to evolve over the years, a code for a new
act can be authorized without immediately deleting another
one, explains Dr Drouin. This takes place over a longer period,
to allow physicians the time to become familiar with the new
procedure and in order for the act to be practiced by the majority
of physicians in this medical specialty.”
On the other hand, if acts are added each year to the Billing
Manual, others become obsolete and are withdrawn. Letter of
Agreement No. 3 describes acts for which fees no longer exist.
These acts are now an integral part of another fee.
TWICE AS “UNIQUE”
It’s not only at the clinic, the university or the hospital that we find rare cases! We already know that certain physicians
hold more than one diploma. We need only think of a few physicians who are both doctors and lawyers, or doctors and
ethicists, or doctors and engineers.
DOCT-AIR !
DOCT- EARTH!
Did you know that one
can be both a medical
specialist and a commercial pilot? This is the case
of Dr Pierre Dussault, a
gastroenterologist at the
Centre hospitalier AnnaLaberge who also works
in his free time as a pilot
for a commercial airline (Air
Canada), in addition to…
car racing!
And finally, the physician and
adventurer, Dr Michel White,
a cardiologist at the Montreal
Hear t Institute and fer vent
defender of organ donations,
has just come back from an
expedition to the South Pole, a
few years after having gone to
the North Pole. Over 10 days,
the cardiologist-adventurer
skied, completely autonomously,
from latitude 89 to latitude 90 at
the South Pole, accompanied by a 62-year-old heart transplant
recipient and two colleagues from Toronto. This was the first
time one and the same recipient reach both poles. “It was
quite an adventure. The temperature, with the windchill factor,
oscillated between -55° and -50° Celsius. At that temperature,
there’s no room for improvisation,” he confides. “Each of us
was carrying between 35 and 45 kilos of equipment and we
had to deal with winds of 25 km/h, often more.”
Dr Dussault already had his pilot’s licence when the
company that hired him laid him off. No matter, he decided
to go back to school... and became a medical specialist!
But, just as he began his medical practice, he was offered
a position as an airline pilot for Air Canada. He then chose
to practice the two professions.
In collaboration with his colleagues at the hospital, work
and on-call schedules are made up once his flight plans
are known. In fact, Dr Dussault has often had professional
colleagues among his passengers! He even once met a
European colleague coming to Montreal to give a presentation, to which he made his way as fast as possible, once
he’d parked his airplane.
“An expedition like this one really shows how well a transplant
patient can recover. Moreover, whoever takes himself or herself
in hand, can achieve exploits he or she would never have
believed possible.”
“This is not the first time I’ve gone on expeditions with transplant recipients and it will not be the last, I hope. Accompanied
by recipients, I climbed Mont Blanc in 2003, then Mount
Sajama (Bolivia, 2004); I’ve gone on two expeditions to Nepal,
in 2006 and 2008, reached the North Pole in 2010, and finally
the South Pole in 2013.”
• Nouvelles thérapies antiplaquettaires
PUBLICITÉ 1/4 PAGE
et anticoagulantes
• Révolution avec les dispositifs
vasculaires biorésorbables
• Application des plus récentes lignes
Cardiologie interventionnelle
directrices à votre pratique
NOUVEAUTÉ
REPEAT OUI OU NON
• 1ère journée des compétences essentielles
en cardiologie interventionnelle
23
vol. 15
no. 1
LS
BY DAVID FORTIN
Neuro-oncologist*
Facing the Barrier
I work in neuro-oncology, mainly in the treatment of brain tumours, with a special interest in
the treatment of malignant gliomas. It has to be said that, despite certain advances qualified
as important by several investigators, the survival of patients with a glioblastoma (the most
aggressive form of malignant gliomas) has only increased from 12 to 14 months over recent
decades. We still have an enormous amount of work to do!
The reasons for this modest improvement are many. Among
them, the presence of the blood-brain barrier (BBB) which
limits the penetration of therapeutic molecules at the level of
the central nervous system is too often neglected. In fact,
certain cytotoxic agents that are unable to cross the BBB
(vincristine, for example) are still administered in multitherapy
in the treatment of these illnesses. The BBB is a complex
physiological entity made up of various functional “layers”. With
the help of different strategies, the work consists of bypassing
the barrier in order to increase the bio-availability of therapeutic agents.
The work normally starts in the laboratory where, with the
help of various cellular and animal models, we test therapeutic
molecules and administration channels. Within the framework
of this type of research, we have by the way set up the first
and only accredited tissue bank of primary brain tumours in
Quebec. In fact, any patient with a glioma who is operated on
in our establishment is asked to provide a sample, which will
be stored in our tissue bank and used for cellular culture. This
bank of tumour samples is used for several of our research
projects, whether it is in the search for new, better-targeted
molecular treatments, in the search for biomarkers or in the
transposition of new techniques of bypassing the barrier to
the clinical side.
24
vol. 15
no. 1
LS
In our search for new treatments, once the work on cellular
models is done, we turn to experimenting on animals. When
this animal experimentation of our glioma models is conclusive, we move on to experimenting on patients. Although we
are working on various approaches to allow us to bypass
the BBB in the laboratory and in clinic, the three approaches
used by our team are intra-arterial infusion chemotherapy,
transient osmotic BBB disruption and use of liposome composites concurrently with one or the other of the previously
mentioned techniques.
A TEAM EFFORT
This collaborative clinical work involves several teams: interventional radiologists who insert the catheter in the artery
vascularising the tumour, the anesthesiologist, the chemotherapy pharmacists as well as our team. We treat between five
and eight patients per week. The treatment lasts approximately one hour and takes place in the angiography room. Since
this involves chemotherapy, the treatments used must be
repeated periodically, i.e. at four week intervals. As a general
rule, these treatments are well tolerated and have few side
effects. The main risk is of cerebrovascular involvement in the
treated area (0.8%). With this unique approach in Quebec,
at this point, we have treated more than 400 patients with
various brain tumour pathologies.
The treatment to open the blood-brain barrier has allowed
us to improve the median survival of patients with brain
tumours. Indeed, we have treated numerous patients for
cerebral lymphomas (primary and metastatic) who are still
free of signs of recurrence, some of them more than six years
after the end of treatments (the most senior of my patients
was treated in the year 2000, when I began these treatments,
and she is still without any signs of recurrence!). We also
improved the survival of patients with cerebral metastases of
lung cancer (small cell and adenocarcinoma), ovarian cancer
and breast cancer. For more information, please refer to our
publication: Fortin P, Gendron C, Boudrias M, Garant M-P.
Enhanced chemotherapy delivery by intraarterial infusion and
blood-brain barrier disruption in the treatment of cerebral
metastasis. Cancer 2007:109(4);751-60.
As for glioblastomas, results are extremely variable, going
once again from very long survival (one of my patients with
a glioblastoma, treated in the year 2000 as a result of recurrence after radiotherapy, is still without any signs of recurrence
to date!) to very transitory responses of a few months and
even to patients not responding to any series of treatments.
Globally, patients with a glioblastoma treated in our establishment present a median survival of 24 months (Fortin P,
* The author is a neurosurgeon and a neuro-oncologist at the Centre hospitalier universitaire de Sherbrooke.
Morin AN, Belzile F, Mathieu D, Paré J. Intraarterial carboplatin
as a salvage strategy in the treatment of recurrent glioblastoma
multiforme, submitted to Neurosurgery for publication).
This illustration is an example of advanced imagery used in the operating room for
a patient with a glioma. We can see the segmentation of the tumour volume (red);
the activation of Broca’s area with a functional MRI; as well as white matter fibres (in
green, with association fibres transiting in the sagittal plane; in blue, projection fibres
transiting in the craniocaudal plane; and, in red, commissural fibres).
These proteins, globally regrouped under the term of “efflux
protein”, are an additional obstacle to obtaining an adequate
therapeutic dose of chemotherapy at the level of the tumour
cells. Thanks to a grant obtained last year from the Canadian
Brain Tumour Consortium - CBTC, we are now able to measure
the level of these pumps in all the patients on whom we
perform surgery for a malignant glial tumour. We will eventually
be able to trace a profile of the expression of these proteins
for each patient and thus predict responses to different types
of chemotherapy. We are looking to temporarily suppress the
activity of these efflux pumps in order to increase the reach of
chemotherapy treatment.
AN APPROACH THAT AIMS TO BE GLOBAL
Glial neoplasia is an insidious disease, resulting in a rapid deterioration of the physical and cognitive integrity of our patients.
Apart from the research activities described above, we are also
attempting to understand how the progress of this disease
affects the quality of life and cognition in our patients. The final
aim of this type of research is to increase and improve these
aspects in our patients. With this objective in view, we have
designed and validated a clinical assessment tool, the SNAS
(Sherbrooke Neuro-oncology Assessment Scale).1
Source: Dr Descoteaux, Faculté des sciences de l’Université de Sherbrooke.
We are currently developing a similar tool to evaluate cognitive
functions and are working towards understanding how
neoplastic glial disease as well as the various treatments we
use affect cognition and the quality of life thanks to modern
imaging techniques (diffusion MRI, tractography and functional MRI).2 It is also thanks to these new imaging techniques
deployed during surgery that we hope to eventually increase
the extent of tumour resection. In fact, these infiltrating tumours
are surgically incurable, but the most complete resection
possible increases survival for these patients.3
Recently, two advances have allowed us to hope for even more!
In fact, we have just finished a phase I study on 12 patients
afflicted with a glioblastoma that had failed all previous treatments using the intra-arterial administration of a liposomal
doxorubicin. We observed responses in 9 of the 12 patients
(75%), some of which reached close to a year. In 2013, we will
be undertaking an extensive phase II study using this approach.
Our work is also accompanied by collaborations with numerous
researchers. Thus, thanks to our collaboration with the
radiobiology team at the Université de Sherbrooke, we
FACED WITH SUCH AN AGGRESSIVE DISEASE, IT IS ONLY
have set up a new approach to treatment combining
WITH A GLOBAL RESEARCH APPROACH ALLOWING
our technique of opening the BBB to the administraUS TO STUDY ALL ASPECTS OF THE DISEASE AND
tion of various chemotherapy platinum compounds
concurrently with radiotherapy.
DIFFERENT TREATMENT APPROACHES THAT WE
WILL BE ABLE TO IMPROVE THE QUALITY OF LIFE
The search for new composites to be administered
AND SURVIVAL OF PATIENTS. IT IS ALSO IMPORTANT
with this new technology continues. In fact, other
than cytotoxic agents, we are also working on idenTO TRY TO IMAGINE INNOVATIVE APPROACHES
tifying more specific targets in the laboratory. Thus, by
BECAUSE, TO DATE, TRADITIONAL APPROACHES
targeting certain superactivated signalling cascades
HAVE SHOWN THEIR LIMITS ONLY TOO WELL.
in this type of tumour for gene therapy (RNA interference), we hope to be able to implement new
therapeutic approaches in the very near future. We are also
Références
interested in the inhibition of the TGF-ß cascade, a protein that
1
Goffaux P, Boudrias M, Mathieu D, Charpentier C, Veilleux N, Fortin D.
plays a decisive role on the neoplastic glial cell phenotype, as
Development of a concise QOL questionnaire for brain tumor patients. CJNS
2009:36(3);340-8.
well as inhibiting the function of certain proteins constitutionally
2
Fortin D, Aubin-Lemay C, Boré A, Girard G, Houde JC, Whittingstall
expressed and overexpressed at the level of the blood-brain
K, Descoteaux M. Tractography in the study of the human brain: a
barrier and overexpressed at the level of the tumour cells,
neurosurgical perspective. CJNS 2012:39(6);747-56.
whose role is to evacuate and reject the chemotherapy out of
3
Dea N, Fournier-Gosselin MP, Mathieu D, Goffaux P, Fortin D. Does extent
of resection impact survival in patients bearing glioblastoma? CJNS
the central nervous system.
2012:39(5);632-7.
25
vol. 15
no. 1
LS
BY DENIS CHOQUETTE
Rheumatologist*
RHUMADATA®, Made in Quebec
The idea of a software program dedicated specifically to rheumatology goes back to the
middle of the 90s. At that time, the group of rheumatologists at the Rheumatology Institute
of Montreal had been taking part in clinical research on new molecules for a number of years.
The latter were destined to treat inflammatory-type arthropathies like rheumatoid
arthritis, ankylosing spondylitis and related
diseases, as well as psoriatic arthritis.
New clinical evaluation measurements
of disease activity, such as those of
the American College of Rheumatology
(ACR), the Disease Activity Score (DAS),
the Health Assessment Questionnaire
(HAQ), the Short Form 36 (SF-36) and
others of the same type, were used at
the time for clinical research protocols
and were slowly making their way to our
clinics. We used very few objective items
or numerical therapeutic targets in our daily practice then,
probably because of the “rather poor” efficacy of treatments
used until the beginning of the 2000s. However, therapeutic
targets, such as those in the treatment of neoplasias, have
become standard practice over more recent years in order
to avoid joint damage and, by that very fact, reduce loss of
function and functional handicap in the long term.
RHUMADATA® IS MUCH MORE THAN A SIMPLE
ELECTRONIC RECORD; IT’S A COMPUTERIZED
DATABASE WHERE ALL DATA HAVE BECOME
OBJECTIVE VARIABLES THAN CAN BE EXTRACTED,
COMPILED, REGROUPED AND ANALYZED IN ORDER
TO RESOLVE A CONCRETE CLINICAL PROBLEM.
The concept of software designed to quantify, as much on
the part of patients and nurses as on that of rheumatologists,
the various aspects of inflammatory joint disease began to
advance. After multiple trials and errors, and with the help
of specialized resources like a programmer and a research
associate, the RHUMADATA® system was born. It is now used
in daily practice in four centres throughout Quebec, i.e. the
Centre d’ostéoporose et de rhumatologie de Québec, the
Centre de rhumatologie de l’Est du Québec, the Centre de
rhumatologie de Trois-Rivières and the Rheumatology Institute
of Montreal.
26
vol. 15
no. 1
LS
*
DATA AND MORE!
RHUMADATA ® is much more
than a simple electronic record;
it’s a computerized database
where all data have become
objective variables that can be
extracted, compiled, regrouped
and analyzed in order to resolve
a concrete clinical problem.
Moreover the software generates
interesting responses to research
questions that are pertinent to
daily practice. It thus allows us
to confirm the results of clinical
research protocols (which are always applied to a patient
population that really resembles that of our daily practice)
thus confirming as well the applicability of the conclusions of
various protocols.
At the same time, the software is used as a training tool for
patients; with the help of simple visual elements such as graphs
illustrating the evolution or tracking of their condition, the rheumatologist can clearly establish the condition of the patient at
the start of treatment and explain what the patient must do to
improve his or her condition.
RHUMADATA® is also used as a continuing medical education
tool for rheumatologists by illustrating, mainly with the use
of graphs, the results that were obtained such as efficacy in
relation to length of treatment used for a specific patient. The
software thus allows results to be compared between specialists and debates to be opened in order to improve scientific
knowledge and the care dispensed to the population.
HOW DOES IT WORK?
In practical terms, the data base is extremely simple to use!
When a patient first comes to a clinic, an “identifier” is issued
based on the initial diagnosis. The patient is then invited to
supply data on his or her current state of health by filling out a
series of specific questionnaires including questions on adverse
effects and his or her tolerance to current medication. The
patient provides this information directly to the database (the
questionnaires having been designed to this end), with the help
of a computer equipped with a touch screen which, ideally has
been set up in a discreet area, whether in the waiting room
or in the office of the nurse practitioner. The latter can take
The author is a rheumatologist at CHUM – Notre-Dame, as well as President of the Association des médecins rhumatologues du Québec while teaching at the
Faculty of medicine of the Université de Montréal.
advantage of the opportunity to familiarize the patient with the
tool or to provide targeted training regarding his or her disease
and its treatment.
There is one important fact to be noted: all patients must sign
an informed consent form beforehand. Once the “computerized” stage has been completed, the patient can report to
the office of the rheumatologist who then proceeds with the
examination, counts the joints (a summary of the number of
painful or swollen joints), evaluates the rate of sedimentation
and measures the most recent C-reactive protein level. All
these variables are immediately compiled in the electronic
file to generate the various composite inflammatory activity
indices for the disease: the DAS, the Clinical Disease Activity
Index (CDAI) or the Simplified Disease Activity Index (SDAI).
These elements of data will validate whether the patient has
an inflammatory activity level that is nil (which means that he
or she is in remission), light, moderate or severe. It will be on
the basis of this information that it will be possible to arrive at a
PROBATIVE RESULTS
Since being implemented at the Rheumatology Institute of
Montreal, RHUMADATA® has revealed several interesting facts.
In particular, it has demonstrated the efficacy of rituximab and
of abatacept in daily practice as well as in preclinical protocols.
Various hypotheses were developed after studying results. For
example, when a patient failed to respond to a first anti-TNF
(tumour necrosis factor) biological agent, the use of a biological agent with a different mode of action which does not
target TNF cytokine would be a better choice. At the same
time, in light of the summaries presented at two medical conferences (specifically, the ACR Annual Meeting and the EULAR
Congress (2011) whose data is presently being updated while
waiting for publication), it was also shown that a minimum
of 30% of patients do not take methotrexate as prescribed
in combination with the biological agent; worse, according
to administrative databases, this percentage is probably
closer to 50%. RHUMADATA® has thus demonstrated that
an important gap exists between what we think we know and
what is done in reality (patients often modify their therapeutic
regimen without the knowledge of their treating professionals).
Finally, based on the results obtained with the most recent
data, we have been able to evaluate the therapeutic survival
(in terms of years) of two anti-TNF agents: adalimumab and
etanercept. We wanted to see if the concomitant administration with methotrexate produced a certain improvement in the
patient’s condition. Results were probative. In fact, looking at
results five years after the start of treatment, we can see that
60 to 70% of patients taking the combination of methotrexate
therapeutic decision regarding the introduction of a treatment,
the adjustment of the current therapeutic regimen or its modification (see activity graph for the disease).
Example of a patient graph showing disease evolution from February 2011 to December 2012.
The disease is now in remission (blue section of the scale).
and etanercept continue to take this medication while only
30% in the group without methotrexate still take etanercept
(see graph).
Illustration of the efficacy of the combination compared to the monotherapy.
In other words, the combination therapy is much better than
the monotherapy. This latter data has an immediate clinical
impact on our daily practice and clearly shows the necessity
and importance of adequately training our patients. This task
could be an integral part of the work of a nurse practitioner
in rheumatology.
Our conclusion is rather simple. Using a tool like RHUMADATA® has proven its efficacy both for rheumatologists and for patients.
Practitioners thus would benefit from integrating such a tool in their current practice. This tool serves the interests of patients, of
physicians and of other healthcare professionals as well as those of payer entities: the investment is well worth the price as has
been shown.
27
vol. 15
no. 1
LS
BY DAVID MATHIEU
Neurosurgeon*
The Scalpel Reinvented
Radiosurgery consists of the application of a single-dose of ionizing radiation aimed at a very
precise target with a steep fall-off of the irradiation fields thus sparing nearby tissues. The concept
of radiosurgery was developed in the 1960s by Doctor Lars Leksell, a Swedish neurosurgeon,
who was looking for an alternative to open surgery to create cerebral lesions that would help
patients suffering from functional disorders (like Parkinson’s disease).
After having experimented with various technologies, Doctor
Leksell developed the prototype of the Gamma Knife® (also known
as the gamma scalpel or Leksell scalpel), which uses multiple
sources of cobalt 60 arranged in a hemisphere to focus on a
central target, thus allowing highly precise irradiation of the lesion.
Since then, the Gamma Knife ® has gradually evolved with
the addition of a robotic automatic positioning system and
improvements to the planning software. The latest version of the
apparatus, known as the Perfexion™ model, is fully automated
and provides for faster and more accurate treatments. Indications
for gamma radiosurgery have increased with the experience
acquired over the years.
At present, radiosurgery is used to treat several types of
intracranial tumours as well as vascular malformations and
functional pathologies. To start with, radiosurgery was reserved
for patients at high risk for surgery, while today it is increasingly
considered as a minimally invasive first-line option compared
to traditional open neurosurgery, and this for a multitude of
pathologies. Eligible patients must have a well-defined lesion that
is limited in size, with a maximum diameter of approximately 3 cm
(or a volume of less than 15 cubic centimetres). For larger lesions,
radiosurgery is not indicated: it is preferable for the patient to
have traditional surgery beforehand in order to excise the lesion
or debulk it. Radiosurgery could then be used as a complement.
In spite of the appearance of competing technologies in recent
years, the Gamma Knife ® remains the reference in cases of
intracranial radiosurgery, with the most accurate dosimetry and
the best results as reported in scientific publications.
A BIT OF HISTORY!
Gamma radiosurgery was introduced at the Centre hospitalier
universitaire de Sherbrooke (CHUS) in 2004 following a ministerial
decision awarding it the mandate to service the whole of Quebec.
This was the second Gamma Knife® to be installed in Canada,
after Winnipeg in 2003. A third apparatus was installed in Toronto
in 2005. These three are still today the only gamma radiosurgery
centres in Canada.
28
vol. 15
no. 1
LS
In my case, after a year’s subspecialization at the University of
Pittsburgh, in the United States, I joined the team in 2006 and
took over as medical director in 2007. The University of Pittsburgh
was the first centre in North America to get a Gamma Knife® in
1987 (it was the 5th in the world at the time), and the institution’s
physicians were pioneers in this field, with substantial contributions
to the literature and to improving treatment techniques. During
the year I spent with them, I was able to gain significant expertise
involving all aspects of gamma radiosurgery in neuro-oncology
and in functional neurosurgery. Over the last eight years, for the
whole of Quebec, the number of patients treated every year has
continued to increase. To date, we have performed more than
2,500 treatments involving more than 2,000 patients.
In 2011, we replaced our original apparatus with the new
Perfexion™ model: this allows us today to perform an average
of 400 treatments per year. The apparatus is used three days a
week, for three to four patients a day, and, if the demand justifies
it, we could easily increase the offer to five days a week. We
therefore adequately fulfill the mandate awarded to us. In fact,
approximately half the patients we treat come from the Université
de Sherbrooke RUIS, while the rest comes from other regions of
Quebec as well as from the Maritimes.
* The author is Head of Neurosurgery and Medical Director of the Radiosurgery Department at the Centre hospitalier universitaire de Sherbrooke.
In addition to the clinical aspect, research represents a significant
portion of our activities since I am also a researcher at the Centre
de recherche clinique Étienne-Le Bel. In collaboration with
colleagues involved in fundamental research, we use the Gamma
Knife® in research projects aimed at improving the efficiency
of irradiation for primary brain tumours with the concomitant
administration of various molecules having properties that
enhance radiosensitivity.
It must be noted that, in 2008, we were among the founding
centres of the North American Gamma Knife Consortium
(NAGKC), which today regroups more than fifteen institutions,
including in particular the Mayo Clinic, the Brain Tumor and NeuroOncology Center of the Cleveland Clinic Foundation, the Center
for Image-Guided Neurosurgery in Pittsburgh, the University of
California in San Francisco Gamma Knife Program and the Toronto
Western Hospital. The goal of this research group is to promote
the development of prospective clinical research protocols and to
facilitate the sharing of retrospective data. In recent years, several
articles have been published based on research data from the
CHUS on the Gamma Knife®.
RADIOSURGERY IS A MULTIDISCIPLINARY
PROCEDURE, INVOLVING TEAMWORK BY
NEUROSURGEONS, RADIO-ONCOLOGISTS,
MEDICAL PHYSICISTS, RADIO-ONCOLOGY
TECHNICIANS AND NURSES.
Radiosurgery is a multidisciplinary procedure, involving teamwork
by neurosurgeons, radio-oncologists, medical physicists, radiooncology technicians and nurses. As previously mentioned,
it involves a single dose treatment, as opposed to standard
radiotherapy which requires multiple applications. The procedure
can be considered equivalent to day surgery and thus, for most
patients, hospitalization is not required.
The first step requires the installation of a stereotactic frame to
the head of the patient in order to subsequently ensure accurate
localisation and immobilization of the patient in the apparatus. The
stereotactic frame ensures an unprecedented level of precision
for the procedure, by eliminating all risks of movement. The
frame is installed under local anaesthesia, with a light intravenous
sedative, except for young children for whom general anaesthesia
is required. The installation is well tolerated by patients and usually
requires less than five minutes. Afterwards, magnetic resonance
imaging (MRI) is performed to plan the dosimetry. At times,
according to the pathology being treated, an axial CT scan and
a cerebral arteriography can be added or even substituted for
the MRI.
Once the radiology exams completed, the medical team will
establish the dosimetry needed for the patient’s lesions. The
pathology and the number of lesions will affect the duration of
the treatment which can vary from 10 minutes (for a single small
brain metastasis, for example) to up to 2 or 3 hours (for multiple
metastases or complex lesions at the base of the cranium). The
treatment is painless. Once the treatment is completed, the
stereotactic frame is removed and the patient released after an
observation period of less than one hour. Convalescence after
treatment is generally very short with patients able to resume
their usual daily activities after a few days. The immediate side
effects are usually caused by the stereotactic frame: they can
include headaches, nausea and a slight fatigue. A bruise can
also be visible for a few days where the screws were applied.
This generally resolves itself spontaneously. After the procedure,
patients are followed according to the pathology. Follow-up
imaging is done two to three months after the procedure and
the patient is subsequently re-evaluated in the clinic. For patients
outside the region, the examination can be performed locally
and results forwarded to the Gamma Knife Clinic. Follow-up is
done over the telephone by the clinical nurse attached to the
clinic: a letter is sent to the referring physician to provide him with
recommendations for subsequent follow-up.
THE RANGE OF PATHOLOGIES TREATED IN
RADIOSURGERY VIA GAMMA KNIFE®
The majority of patients have intracranial tumours. Cerebral
metastases are in fact the most frequently treated tumours.
Eligible patients generally have a limited number of metastases
(less than five), but it is possible at times to treat a greater number
of metastases if the patient is in good health generally and has
already had whole-brain radiotherapy. Radiosurgery is also
used in the front-line treatment of benign tumoural lesions, like
meningiomas and vestibular schwannomas, thus avoiding the
risks associated with open resection of these lesions. Pituitary
adenomas are also treated, generally within the context of postoperative recurrence. In the category of functional disorders,
patients suffering from trigeminal neuralgia resistant to medical
treatment make up the majority of the population. At times,
radiosurgery can be used to treat certain types of resistant
epilepsy and incapacitating movement disorders. Finally, patients
with arteriovenous malformations can benefit from radiosurgery.
In these circumstances, radiosurgery allows for the gradual
obliteration of most of the lesions after a latency period of two to
three years, thus eliminating the risk of bleeding.
Radiosurgical treatment via Gamma Knife® is available at the
CHUS and covers all of Quebec.
29
vol. 15
no. 1
LS
BY JEAN-CHARLES CROMBEZ
Psychiatrist*
ECHO® Approach
I began my career as a psychiatrist in a general hospital, attached to a university, with patients
hospitalized in medicine and in surgery, and worked with the teams that surrounded them.
I was thus consulted with regards to various forms of suffering, by patients on the one hand,
and by medical practitioners on the other.
I met people undergoing hemodialysis treatment, giving or
receiving kidneys, suf fering
from dermatological, digestive,
rheumatic or neurological
diseases, as well as patients with
various mental health problems.
I also dealt with the caregivers
themselves: medical or psychological professionals, social workers
or nurses. My interventions then
were not limited to one-sided
and simple techniques. I had
to try to meet these individuals
in response to their requests for
relief, while very quickly recognizing that these meetings could
not be limited to establishing
a diagnosis and prescribing
a treatment.
30
vol. 15
no. 1
LS
The Echo® Method
ECHO is taught using various training formats. These
training formats use consciousness differently from what
we are used to, i.e. reason and comprehension, logic and
meaning. In fact, the training does not resemble treatment
or therapy in any way, but rather curiously, it reminds one of
training for sports, like skiing for instance, where experience
is the teacher. It brings to light the processes in question
and sets them into action by setting up a playground,
creating a player, involving items that are present in the
game. These items can be sensations, images, thoughts...
The various forms of play are tools that can be used for
different purposes, rather than techniques requiring they
be followed with absolute fidelity.
how people suffering from it have
become vulnerable; how they
can become depressed, anxious
or sometimes even psychotic;
h ow th ey c a n re j e c t u s ef u l
treatments that have become
unbe arable. More re ce ntly,
numerous studies and publications have also shown how
physiological processes can be
altered by it: the immune system,
the endocrine system, etc.1
This ill-being cannot be dealt with
and resolved as if it is a normal
WHAT DOES THE ACRONYM MEAN?
illness, nor can it be treated with
Practising the art of being
the same tools. It is an all-encomEspace intérieur (Interior Space): aware of oneself
passing pain, indefinable and
Putting things in motion
existential that attacks the person
Courant (Current):
when all seems frozen
as a whole. It is a pain that hides
under numerous evident manifesDeveloping the ability to
Harmonisation (Harmony):
play with obstacles
As I travelled along this path,
tations. I thought them specific
i n te r s p e r s e d w i t h m u l t i p l e
to physical illnesses, but I discoBeing able to imagine
meetings, I had two intuitions:
vered them later in psychiatric
Oeuvre (Accomplishment):
and create again
patients: an absence of being
the first was that I had to remain
as a foundation to psychotic,
open to everything and not take
Source: www.approche-echo.net
depressive, anxious or phobic
anything for granted; the second
manife stations. A de ser t, a
was that I needed to ask patients,
silence hidden under piles of symptoms inventoried in the
at the end of our meetings, if I had been useful to them and in
what way. Little by little I became aware of certain constants, of
Diagnostic and Statistical Manual of Mental Disorders (DSM).
dynamics that could be confirmed beyond individual variations.
Thus it was that, over 10 years, with the help of a dedicated
During the 1980s, we came to several fundamental conclusions
team, the ECHO ® method was developed. This is a unique
and progressively developed a concept and a method.
treatment, used today in various forms. We discovered that,
behind the symptoms, the complaints, the interventions and the
Our first conclusion is that the body and the mind are one. One
exams, hides a profound pain that is silent by its very nature.
of the characteristics of this is that the body often does not
It is the absence of being: an inability to say, to feel, to dream
differentiate between an external event, such as a dangerous
and to establish links. The person, submitted to multiple events,
animal, and the mental or interior representation of such an
gradually grows silent and then becomes mute. These events
event, for example, the illusion that such an animal is present.
are, of course, the illnesses and the pain; but they also include
What is valid for this animal is also valid for all the memories
the diagnoses, the exams, the treatments, the interventions and
and beliefs that emerge more or less clearly at different times.
the complications. Bombarded by all this trauma, the person
One of the important consequences of this lack of distinction is
retreats, closes off, and places him or herself in survival mode.
that we can deal with living processes as a whole, even though
most are unconscious, invisible from the mental point of view
This is what we have called ill-being or the impossibility of being.
and its conscious perceptions.
However, this ill-being is not insignificant. We have long known
* The author is a psychiatrist at the CHUM - Hôpital Notre-Dame.
Patient Costs and Results
ECHO® training is provided and managed by a non-profit organization. As a result, with a few rare exceptions, the patient must
cover the costs of the training. He or she can choose to follow
the ECHO® method in individual or group sessions.
Group sessions are given once a week, or during weekends, and
last three hours. The cost, in large urban centers, is approximately
$360. For individual sessions, the cost is based on an hourly
rate varying between $75 and $85. Also available, are renewal
meetings to help patients remain in contact with the various tools
available to them while they use the method and thus optimize
the healing process.
Our second conclusion concerns the process of transformation. We observed that how we deal with problems through
our explanations or interpretations sometimes allows changes
to be made and sometimes not. The question that then arose
was how to establish the reason for the success or failure.
It must be understood that two fundamentals are necessary
before facts and links can be recognized: first, the individual
needs to be a person, i.e. he or she must identify their ‘self’ as
being someone; second, that he or she must have an interior
reality, i.e. he or she must be aware of an inner and personal
life. These two fundamentals, that seem evident for most of us,
are not evident at all: there are some states without personal
thought outside of stereotypes, without sensations outside of
tensions, without perceptions outside of pain. Thus, no information can be developed and no understanding can be reached.
The interior is empty.
The third conclusion concerns the approaches
used. In general, psychotherapy and psychoeducation techniques call upon two paradigms:
on the one hand, consciousness, logic, explanation and willpower; and, on the other, the
unconscious, free association, interpretation
and understanding. We also called upon a third
paradigm that has always existed: play. Play
is a part of everyday activities, but it has two
meanings: confrontation and competition as
signified by the term game; and pleasure, without
a specific objective, as signified by the term play.
The latter is the one we used.
The method initially consists of creating a play device (or a game)
with a player, a playground (the person’s consciousness) and
toys that are all objects the person is conscious of (sensations,
thoughts, etc.); then to play the game that is built around four
dimensions: presence, links, interactions and creation.
There are two observations that can be made regarding this
method. One is that, although it can be presented under various
guises, we have preferred to use that of learning. We wanted to
remain distant from an intervention style involving treatment and
therapy, which is common in our setting, and replace it with a
style where certain transformation tools are identified which the
person can then appropriate for him or herself and use thereafter.
The principles of ECHO® can now, through their simplicity and
precision, be used in the context of helping relationships and
psychotherapies, which makes them more effective for the
person being helped as well as for the helper. These tools can
be used, whatever form of psychotherapy is used: narratives,
psychoanalysis, body, humanistic, interpersonal or cognitive
therapy, etc. They also allow caregivers to have better control.
The other observation concerns the multiplicity of current therapeutic methods, officially recognized and proven to be effective:
the same components are present in varying degrees. Their
names, forms, and associations vary with each decade, but
they remain the same. We need to be able to differentiate what
is profoundly effective from what is secondary. It is important
to see clearly in order for persons to liberate themselves from
techniques and thus master them, in other words to fit them to
their hands, rather than follow them to the letter and be controlled
by them.
Over 25 years, we met with 5,998
individuals, 4,622 of whom undertook
the training either individually or in
groups. In addition, 70 caregivers
were trained to use the ECHO®
method. More than 4,000 participants
are referred for medical consultations
and 178 physicians have themselves
suggested their patients follow the
ECHO® training.
We thus finalized the concept and method of the ECHO ®
Approach and, in the early 2000s, published three books describing them.
The concept links two principles: to (re)create, on the one
hand, an interior reality filled with various objects, impressions,
memories and wishes, and, on the other, to introduce play into
it. The principle of this play using the various interior objects is to
stage the person’s life processes. The paradox is that play, with
its relatively precise, simple and conscious impressions, sets into
action processes that are profoundly complex, wide-ranging and
not conscious. These are the processes that will allow changes
that logic, effort and willpower were unable to effect.
Over 25 years, we met with 5,998 individuals, 4,622 of whom undertook the
training either individually or in groups.
In addition, 70 caregivers were trained
to use the ECHO® method. More than
4,000 participants are referred for
medical consultations and 178 physicians have themselves suggested their
patients follow the ECHO® training.
The ECHO® method is taught through
group sessions that last 15 hours or
individual 5-hour sessions. They are open to anyone wishing
to implement change in their life, often because of psychic or
physical problems, symptoms and disease. This can be a preventative approach, without any crisis or suffering. Our offices and
training rooms are at the CHUM - Hôpital Notre-Dame. Group
meetings are also organized in outlying regions or at the request
of support organizations: polyclinics, associations and others.
Reference
1
Look up the ECHO® method reference page at
www.approche-echo.net/dr-crombez/references.php
31
vol. 15
no. 1
LS
CONTINUING PROFESSIONAL EDUCATION
BY SAM J. DANIEL, MD
Director
Office of Professional
Development - FMSQ
Self-Approval 101
Did you know that you can automatically obtain approval of your in-hospital meetings for
credit under Section 1 of the Maintenance of Certification Program? Here’s a formula with a
few simple steps!
A SIMPLE RECIPE IN SIX STEPS
Self-approval is a process that could be very useful in your daily
practice. During the workshops I led at the Interdisciplinary
Education Day (IED), organized by the Fédération des
médecins spécialistes du Québec, I realized that very few
physicians fully understood this concept.
Thanks to self-approval, physicians can ensure that, within
a hospital setting, their educational activities respect the
standards established by the Royal College of Physicians and
Surgeons of Canada so that these activities can be recorded
under Section 1 of the Educational Options of the Maintenance
of Certification Program (MAINPORT). Such activities can
include reading clubs, in-hospital conferences and sessions
for smaller groups.
THANkS TO SELf-APPROvAL, PHYSICIANS
CAN ENSURE THAT, WITHIN A HOSPITAL
SETTING, THEIR EDUCATIONAL
ACTIVITIES RESPECT THE STANDARDS
ESTABLISHED BY THE ROYAL COLLEGE.
Self-approval criteria are simple. By following these instructions,
your regular in-hospital continuing professional development
(CPD) activities could be granted credits from now on under
Section 1, whether your hospital is a university health centre
or not, and whether your practice is in a large city or in an
outlying region.
32
vol. 15
no. 1
LS
The process is available to all medical specialists who use
the Maintenance of Certification Program which, in addition,
is completely free of charge.
1
Create a planning committee to represent the
target audience.
2
Analyze the training needs, both recognized and
unrecognized, of the target audience.
3
Prepare periodic educational activities (at least
quarterly) according to the needs of the target
audience. These activities should be planned
and announced in advance, and include learning
objectives.
4
Use diversified learning strategies: at least 25% of
the duration of an activity should be dedicated to
interactive participation.
5
Evaluate the educational activities.
6
Respect ethical guidelines throughout the process.
THE PLANNING COMMITTEE
AND ITS OBLIGATIONS
To start with, a planning committee must be set up to
organize the educational activities and to maintain the
appropriate records and files. This committee must meet the
following standards:
• It must report to the head of the department, the head
of the service, the director of professional services or
their equivalent. This is to guarantee that the educational
content respects the mandate of the institution where it
is set up.
• It must prepare educational activities in line with the needs
of the target audience. Moreover, the members of the
committee must be representative of the target audience
in order to ensure that the objectives and contents of the
CPD activities are pertinent and that they are reflected
throughout the events planned by the committee.
• It must implement a needs analysis strategy in order to
identify the recognized and unrecognized training needs
of the target audience. Thus, the committee will be able to
set objectives for the activities it organizes and ensure the
subjects chosen are appropriate for the target audience.
CONTINUING PROFESSIONAL EDUCATION
• The following are examples of useful tools used to evaluate
the recognized and unrecognized needs of the target
audience. For recognized needs, it may be useful to
use surveys, requests made by members of the target
audience, questionnaires, and the results of previous
years’ evaluations. Insofar as unrecognized needs are
concerned (often harder to identify), self-evaluation tests,
chart verifications, comments from patients, performance
observed in practice, data on hospital quality assurance,
provincial databases, as well as incident reports could all
be useful to the planning committee.
• The series of periodic activities (a minimum of four per
year) must be planned and announced in advance.
Promotional documents on certification from the Royal
College must contain the following statement: “This activity
[rounds’ or journal club’s name] is a self-approved group
learning activity (Section 1) as defined by the Maintenance
of Certification program of The Royal College of Physicians
and Surgeons of Canada.”
• The learning objectives of the professional development
activities should preferably be communicated in advance
to the target audience.
• At least 25% of the duration of an activity should be
dedicated to interactive participation. A diversity of learning
strategies is essential and teaching methods must be
appropriate according to the learning objectives established for each activity. For example, certain subjects are
better dealt with in a conference format, others in debates
or group discussions.
• It must maintain attendance records.
• It must issue an attendance certificate to participants. This
certificate must also display the Royal College’s statement
on certification (see above).
RESPECT ETHICAL GUIDELINES
The planning committee must make sure its self-approved educational sessions remain out of reach of organizations or persons
with commercial interests and that the content of each activity
is free of any commercial bias.
The activities must respect the standards of the Quebec Council on
Physicians’ Continuing Professional Development (www.cemcq.qc.ca).
They must also be in line with the Canadian Medical Association’s
policy on relations between physicians and the pharmaceutical industry.
Any financial support provided by the pharmaceutical industry
must be allocated as an educational grant.
Participants must be informed of any conflict of interest associated with each series of self-approved educational sessions or
individual activities before these take place.
VARIATIONS FOR LEARNING IN SMALLER GROUPS
In the case of learning activities for smaller groups, the
members of the group make up the planning committee.
Even if the members of the group are both the planners
and the audience, performing a needs analysis remains an
essential element.
ONE MEMBER OF THE GROUP MUST BE
RESPONSIBLE FOR THE MAINTENANCE OF
ATTENDANCE RECORDS FOR THE GROUP AND FOR
SENDING OUT CONFIRMATIONS TO PARTICIPANTS.
One member of the group must be responsible for the
maintenance of attendance records for the group and for
sending out confirmations to participants.
EVALUATE TRAINING SESSIONS
Participants must evaluate individual training activities to
determine whether they effectively meet the needs of the target
audience. An evaluation template is available for you in the CPD
section of the FMSQ’s internet portal.
As for the planning committee, it must also implement strategies to evaluate its program as a whole. This can be done
with the help of questionnaires, group discussions, etc. An
evaluation of all its educational sessions should preferably take
place once a year or, at a minimum, once every two years.
Having following this process, all you need to do is download
and fill out a self-approval form, available in English and in
French, from the Royal College’s internet site in the CPD
section. A link is available on the Federation’s internet portal.
Once the form is signed and sent to the Royal College, participants of the self-approved educational sessions can begin
claiming credits in Section 1 of the Maintenance of Certification
program (MAINPORT). The planning committee must retain a
copy of the form in its files.
In the hope that this information is useful to you, the FMSQ’s
Professional Development Office team is at your service to
support you in all your self-approval initiatives.
A GOOD ADDRESS TO TAKE NOTE OF
Royal College of Physicians and Surgeons of Canada:
Self-approval Activities
www.royalcollege.ca/portal/page/portal/rc/members/cpd/
cpd_accreditation/self_approval_activities
S
L
33
vol. 15
no. 1
LS
OUR SUBSIDIARIES
SOGEMEC ASSURANCES
BY CATHERINE
FELBER
Assistant Manager,
Business Development
Planned Donations and Bequests to the FMSQ Foundation
Are You Familiar with Their
Tax Benefits?
The decision by the Fédération des médecins spécialistes du Québec to set up a foundation to
help caregivers is an action with concrete and durable repercussions that reflect the vision and
commitment of the Federation to society today and in the future. Sogemec and Professionals’
Financial together can show you how it is possible to increase this contribution... and to benefit
from it!
THE TAX TREATMENT OF CHARITABLE DONATIONS
It is important to destroy certain myths insinuating that it is possible
to get richer by making donations to charitable organizations. While
it is true that tax authorities grant several tax benefits to such a
donation, their value must never exceed the value of the donation,
which is understandable. The goal of the donor is to help a cause
dear to his or her heart and, thanks to fiscal strategies, to minimize
the net cost of his or her donation.
exception for the majority of shares traded on the stock exchange
and shares in a mutual fund: the gains resulting from the donation
of these securities are tax exempt.
Example: an individual who holds a share traded on the stock
market with a value of $1,000, that was bought at the cost of
$500, would have to pay approximately $120 in taxes (at the
maximum tax rate) if he or she sold it. By donating it, however, not
only does he benefit from tax credits
totalling more than $450, he is also
Canada Quebec
exempt from a capital gain tax of $120.
Tax
Total
Tax
The net cost of the donation is thus
Credit
Credit*
reduced to $430.
34
vol. 15
no. 1
LS
When an individual makes a monetary
donation, it is pos sible to take
Donation
advantage of a tax credit during the
taxation year, in both the federal and
First $200
$25.05
$40.00 $65.05
provincial tax returns. The first $200
Incorporated professionals can make
benefits from a less-advantageous tax
Excess of $800
$193.72 $192.00 $385.72
treatment, as the tax credit rates are
donations by way of their company. In
Total of $1,000
$218.77 $232.00 $450.77 such a case, the donation reduces the
15% at the federal level and 20% at
the provincial one. The portion of the * We have taken into account the 16.5% abatement for
corporation’s taxable income. If its net
residents of Quebec.
donation that exceeds $200 however
revenue is negative, it is possible for
benefits from a more attractive tax
the corporation to defer the amount of
treatment, as the tax credit rate is 29% at the federal level and
the deduction for a donation for up to five years. And, just like an
24% at the provincial one. Here is an example of the tax savings
individual, the corporation has the option to give a share traded
an individual whose donations total $1,000 during a tax year would
on a stock exchange or a share in a mutual fund, without having
get: a donation of $1,000 generates a tax savings of $450.77 for
to include the capital gain generated. This strategy can prove to
a net cost of $549.23.
be particularly interesting for a management company holding
shares with latent capital gains.
As you can see, when the donation exceeds the $200 limit, the
fiscal benefit increases. To maximize your tax credits, you could
Please be aware, however, that the generosity of our governments
regroup your donations on a single tax return, along with those
is limited. Whether it’s for an individual or a corporation, the
of your spouse or common-law spouse. You could also defer for
maximum amount of donations giving rise to tax credits (and to
up to five years the moment when you choose to include these
deductions in the case of a corporation) is 75% of net income
donations in your tax return, which would allow you to get together
for the year. For the year of death, the maximum amount is
an amount above $200. Donations can also be regrouped on
increased to 100% of net revenue for the year. It is also possible
the tax return of the member of the couple whose revenue is
to account for donations covering up to 100% of net revenues for
the highest.
the year preceding death. You can see the importance of planning
your donations.
But what about the donation of an asset? The charitable
QUALIFICATIONS OF THE REGISTERED
organization will provide you with a receipt based on the market
CHARITABLE ORGANIZATION
value of the asset as established through an evaluation. You can
include this donation in your tax returns just as you would any other
In order to benefit from tax credits, it is essential that your
donation. However, if the asset has increased in value between
donation be directed to a registered charitable organization that
the time you acquired it and the moment you donate it, you will
issues official receipts for income tax purposes upon receiving
need to include the capital gain in your tax returns. There is one
your donation.
OUR SUBSIDIARIES
SOGEMEC ASSURANCES
A registered charitable organization issues receipts that qualify
by respecting the following criteria:
Donation to the organization (the policy's capital
at death)
Annual cost of the premium (10-year contract)
is duly approved by the Canada Revenue
x ItAgency
and by Revenue Québec;
It
must
have
created in order to help the
x poor, advancebeen
education or advance religion, or
x
x
x
For example, this is what Mr. Donor – 40 years old, a non-smoker
and insurable – can accomplish:
for the benefit of the population as a whole;
It must offer a “benefit of public interest”;
It must be a legal entity resident in Canada;
It must dedicate all its resources to charitable activities.
In order to verify if a charitable organization is recognized by
Canadian fiscal authorities, check out the following web site:
www.cra-arc.gc.ca/chrts-gvng/lstngs/menu-fra.html.
DONATION OF AN INSURANCE POLICY
An individual can always make a charitable contribution while he
or she is alive or, when he or she dies, by accumulating sums
regularly. However, several persons ignore that:
can now obtain a tax deduction for certain
x They
donations they will be making after death;
can make a much more significant donation by
x They
purchasing an insurance policy than they would by
$100,000
$2,208
Tax credits (47,44% of premiums paid)
$1,033
Cost of the annual premium after taxes
$1,175
Over a period of 10 years, Mr. Donor will have in reality disbursed
$11,750 for a permanent insurance which will serve to finance
a planned donation of $100,000 – a smart way of ensuring a
source of funds to provide for the survival of a foundation or
charitable organization. At the death of the donor, the foundation
receives the death benefit, which does not impoverish the estate
nor the children.
A variation of this can involve designating the estate as beneficiary
of the policy. The will then directs the estate’s liquidators to pay
the product of the policy to one or more charitable organizations.
When the benefit passes through the estate, a tax credit (up to
100% of net revenue) is granted for the year of death of the donor
and for the preceding year.
A DONATION BY BEQUEST
To start with, a will serves to protect the people dear to you in
case of death. It is also the best way of supporting a cause that
is important to you.
putting money aside in non registered accounts.
Anyone can purchase a life
insurance policy with the intention
of turning over the proceeds as a
charitable donation. At the time of
issue, if the contract is assigned
to a charitable organization, each
premium paid is considered a
charitable donation and generates
a tax credit. The proceeds of the
insurance are protected from
creditors and will not generate any
legal costs. Any type of life insurance can be used in this way,
but if a person has significant revenues and wishes to pay for the
policy in advance, then a Universal Life Plan is recommended. The
value of the account is thus paid to the charitable organization
in addition to the insured capital at death, which increases the
value of the donation.
THE BENEFICIARY AND THE PROPRIETOR
OF THE INSURANCE POLICY
Several options are available and each is valid, according to the
donor’s objectives. A simple way to proceed to obtain annual tax
credits for the premiums is to designate the charitable organization
as proprietor and beneficiary of the policy. The donor, whose life
is ensured, thus gives a sum equal to the amount of the annual
premiums to the charitable organization (do not forget the limit
of 75% of taxable income) which, in turn, pays the premiums to
the insurer.
A donation by bequest can be done in many ways and it is
up to you to decide which one is the best for you among the
following options:
individual bequest of a specified amount of
x An
money, a building, securities, artwork or even
a musical instrument of high value;
bequest of the totality or a percentage
x Aofresidual
the assets of your estate (once all debts
and individual bequests are paid out);
a charitable organization as beneficiary
x Naming
of a retirement savings plan, a pension
x
x
x
fund or a life insurance policy;
A clause covering simultaneous death which provides
for benefiting an organization or a cause in case
of the simultaneous death of all your heirs;
An amount of money to an existing
private or public foundation;
A transfer to a residual charitable trust.
These donations carry the right to an official receipt on the part of
the organization and can be used when preparing the tax return
of the donor after his death.
If you wish to obtain additional information concerning the various
types of donations, please get in touch with an advisor from
Sogemec Assurances or from Professionals’ Financial.
THIS ARTICLE WAS WRITTEN WITH THE COLLABORATION OF PROFESSIONALS’ FINANCIAL
MATHIEU HUOT
Tax Expert - Financial Planner
BENOIT CHAURETTE
Financial Planning Analyst
ME ANDRÉE-ANNE POTVIN
Notary
35
vol. 15
no. 1
LS
OUR SUBSIDIARIES
SOGEMEC ASSURANCES
Home and Auto Insurance Program
BY CHANTAL AUBIN
Director,
Plan Administration
Don’t wait!
Whether you are owner, co-owner or renter, ensuring
your home or property is a priority that is worth careful
consideration. You have to think of the amount of the premium,
of course, but you also need to think of the quality of the
protection offered. The same applies for automobile insurance.
To this end, certain types of home and auto insurance are more
advantageous than others, like those that we negotiated for
you with The Personal Insurance Company whose principal
characteristics follow.
Whether you live in a house, a condominium or an apartment,
the insurance we are proposing will surely fit your lifestyle.
ENHANCED COVERAGE – ENDORSEMENT
25C – EXCLUSIVE OFFER TO INSURANCE
CLIENTS OF SOGEMEC
from a $10,000 protection for the items that are
x Benefit
related to your professional activities (books, laptop
computers, work-related instruments, etc.).
a $100,000 protection in case of loss or
x Add
theft of artwork belonging to you.
ALL-RISK INSURANCE
your insurance to cover specific items
x Adapt
(swimming pool or jewellery, for example) or to
increase the value of some of your protections.
IDENTITY THEFT AND LEGAL ASSISTANCE
AVAILABLE WITHOUT COST TO ACCESS
LEGAL ADVICE FROM A TEAM OF EXPERTS
For your automobile, we have an insurance adapted to your
vehicle and your budget.
Cost Coverage and Value Plus Option™
x Replacement
protects you against depreciation for up to five years.
Discount: up to 15% savings
x Multi-Vehicle
by insuring more than one vehicle.
Rates: up to 17% savings for
x Student
students younger than 25.
+ Auto Advantage which allows you to save by
x Home
insuring your vehicle and your home, etc. with us.
For more information on the types of protection offered by The Personal
Insurance Company or to obtain a quote for home, auto or business insurance,
get in touch with an advisor today at 1-866-350-8282 or on line at
www.sogemec.lapersonnelle.com.
4575_SOGA_annonce_FMSQ_2012_expedition_7x4.5_Layout 1 4/2/12 2:15 PM Page 1
POUR TOUS VOS
BESOINS D’ASSURANCES
Grâce au
SERVICE PRÉFÉRENCE
LAISSEZ LIBRE COURS À VOS PASSIONS
PUBLICITÉ DEMI PAGE
SOGEMEC
ASSURANCES
ÉVOLUE AVEC VOUS
• Vie
• Médicaments
• Invalidité
• Maladie
• Frais généraux
• Dentaire
Sogemec Assurances
• Maladies graves
• Automobile
• Soins de
longue durée
• Habitation
• Entreprise
POUR EN SAVOIR PLUS :
1 800 361-5303
REPEAT OUI OU NON
514 350-5070 / 418 990-3946
Par courriel ou Internet :
[email protected]
www.sogemec.qc.ca
36
vol. 15
no. 1
LS
SOGEMEC ASSURANCES
filiale de la
OUR SUBSIDIARIES
PROFESSIONALS’ FINANCIAL
BY MARIE-JOSÉE
HOUDE
Notary
The Importance of Having a
Mandate in Case of Incapacity
With a view to ensuring the best management of your property, planning for incapacity is
as essential as planning for death. Writing a mandate in case of incapacity requires serious
thought. You need to choose the person (the mandatary) who will see to your well-being and
to the administration of your property, in case you are no longer capable of doing so yourself.
It is therefore crucial that your wishes be clearly detailed within the mandate. Here are a few
points to consider when you are writing or revising your mandate in case of incapacity.
1. GENERAL POWER OF ATTORNEY WITH
A MANDATE IN CASE OF INCAPACITY
The mandate in case of incapacity, even if it is notarized, only
takes effect when it is homologated by a court of law. This
process takes some time since it requires, in particular, certain
documents such as a medical opinion and a psychosocial
evaluation. The mandate can only be used by your mandatary if
your mental capacities are affected and not only your physical
(motor) capacities. It is useful to know that you can have a
general power of attorney prepared with a mandate in case of
incapacity that would allow your mandatary to act immediately,
even if you are still capable, but need assistance. Please note,
however, that this power of attorney becomes effective as
soon as it is signed.
2. CHOOSING A MANDATARY
The mandatary you name will have important responsibilities,
including managing your affairs (paying bills, preparing income
tax returns, managing investments, using your assets to see
to your needs), protecting your person and consenting to
certain healthcare services. It is possible to name more than
one mandatary and to see their replacement. You can name
a mandatary to administer your assets and another to see to
your personal needs.
3. PROTECTING YOUR SPOUSE AND
YOUR DEPENDENT CHILDREN
If you have a spouse or children financially dependent upon
you, it is important that the mandate plan for the use of your
assets for the good of your family, in order to ensure they
benefit from the same lifestyle as the one they had before you
were incapacitated. This should allow your mandatary to pay for
schooling your children or medical expenses for your spouse.
By default, the mandatary is responsible for managing your
affairs for your benefit only. When it comes to minor children,
you can name a tutor separate from your mandatary to take
care of them, should the other parent become incapable of
doing so.
4. MEASURE AGAINST AGGRESSIVE THERAPIES
Such a measure, included in a mandate in case of incapacity, is
commonly called a “living will”. It allows you to give instructions
to your mandatary regarding your willingness, or not, to submit
to certain treatments in order to prolong your life. By clearly
expressing your wishes, you liberate your mandatary from
this burden.
5. ORGAN DONATION
We often think that our willingness to donate an organ can only
be written on the back of a health insurance card or within a
last will and testament. Including a measure regarding organ
donations in the mandate in case of incapacity will ensure
your mandatary knows of your wishes on the subject, which
will allow him or her to make appropriate arrangements prior
to your death.
What happens if you become incapacitated and have not
signed a mandate in case of incapacity, nor a general power
of attorney with such a clause? You may think your spouse can
act automatically but this is not the case. A legal procedure
must be submitted to the court in order to open a protection
plan, where the choice will be determined by your degree
of incapacity.
There are three protection plans in Quebec:
curator to a person of full age: This is appropriate
x The
if your incapacity to take care of yourself and to
x
x
administer your affairs is both total and permanent;
The tutor to a person of full age: This option will be
chosen if you are partially or temporarily incapacitated;
The advisor to a person of full age: This person will
be named if you demonstrate a slight incapacity or a
temporary one.
In Quebec, every person is presumed to be capable and only
a court of law can withdraw from a person of full age the
exercise of his or her civil rights. After consulting an assembly
of family members, allies and friends, the court will choose the
appropriate protection plan and will designate the person who
will represent you. This legal representative will be supervised
by the Curateur public du Québec and will also have to render
accounts to a council made up of three persons (known as the
“tutorship council”), also appointed by the court.
As we mentioned previously, writing a mandate, or revising one,
is a task that deserves to be done with care since it involves
ensuring your financial and personal protection. Please note as
well that the financial planning department of the Professionals’
Financial offers estate planning and testament preparation
services that could help you adequately identify your needs.
Discuss this with your advisor: he or she can explain what
these services involve and evaluate your situation.
37
vol. 15
no. 1
LS
LE MOT DU PRÉSIDENT
DR GAÉTAN BARRETTE
Des cycles et des hommes
L
es plus vieux d’entre nous se souviennent de l’arrivée de
l’assurance-hospitalisation, qui ne couvrait alors que les
soins hospitaliers, puis celle de l’assurance maladie universelle. Ils se rappellent aussi du contexte et surtout du climat de
haute tension dans lesquels l’assurance maladie est née. Même
en faisant abstraction de la crise d’octobre 1970, qui a accéléré
les choses, il n’en demeure pas moins que ce régime public est
né pour le moins dans la contestation, sinon dans la crainte de
la part de la communauté médicale, tant des généralistes que
des spécialistes d’alors. Pourtant, ce sentiment se dissipera
très rapidement et plus personne, sauf peut-être de rarissimes
récalcitrants, ne mettra en cause ce régime ou ne proposera
de revenir en arrière.
Bien sûr, sous un régime imposant un lien direct et incontournable entre l’État-payeur et les médecins pourvoyeurs, s’ensuivit
un cadre de négociation particulier, en ce sens que les médecins
gardaient alors, et encore aujourd’hui, leur statut de professionnels, donc une autonomie bien réelle. L’histoire allait alors
s’écrire : cette relation devant en être une soit de collaboration,
soit d’opposition. À cet égard, on peut conclure raisonnablement
que les dix à quinze premières années furent sereines en tout
et pour tout.
Cependant, le ciel commença ensuite à s’assombrir insidieusement. En effet, il est facile de démontrer comment, par exemple,
sur l’aspect de la rémunération, l’écart avec la moyenne de nos
collègues canadiens a commencé à se creuser inexorablement
jusqu’en 2006, où nous avons enfin pu renverser la vapeur.
Mais il y a eu plus. En effet, l’État a aussi pris dans cette même
période une nouvelle tangente, celle du contrôle des dépenses
par le contrôle de l’offre. Le point culminant de cette approche
aura été sans contredit la période des années 1990. Une longue
décennie où, toujours dans l’esprit de contrôler résolument
l’offre, on assistera à la conjugaison historique de la mise à la
retraite d’un grand nombre de médecins et d’infirmières et de la
diminution du nombre d’entrées en médecine. C’était l’époque
du fameux « déficit zéro ». Évidemment, il fût atteint !
Mais à quel prix ! C’était sans compter les grandes avancées
cliniques, pharmacologiques et technologiques naissantes qui
allaient s’avérer génératrices d’un accroissement important de
la demande - le tout dans un contexte de vieillissement de la
population se révélant de plus en plus exigeante. Avec raison,
d’ailleurs. Donc, une décennie sombre.
38
vol. 15
no 1
LS
S’en est suivi une autre décennie, celle des années 2000, pas
beaucoup plus glorieuse, durant laquelle tout un chacun tentera
de faire pour le mieux avec les moyens du bord, toujours insuffisants. Pour compenser les décisions des années 1990, il a
été décidé d’augmenter massivement le nombre d’entrées en
faculté de médecine. Certains investissements significatifs sont
aussi faits du côté de la technologie, mais peu du côté des
infrastructures, pourtant essentielles en termes de capacité si
l’on veut que le système puisse suffire à la demande. Encore
en 2013, on ressent ce désir plus ou moins avoué de l’État de
vouloir contrôler ses dépenses par le contrôle de l’offre.
Ce qui nous mène à aujourd’hui. Où en sommes-nous ?
On le voit, l’histoire de notre système de santé, comme celle de
la société ou du monde des affaires, se décline par « cycles »,
plus ou moins heureux selon le cas. Il n’y a probablement là
rien de surprenant.
Mais nous croyons que nous sommes en ce moment au début
d’un autre « cycle ». Sera-t-il favorable ? Ça dépend. C’est une
question de vision. Mais aussi de décision. Et quel est le moteur
de ce changement de cycle ? L’effectif médical. Peu d’observateurs réalisent le changement qui s’opère actuellement. En
effet, nous maintenons qu’il y a assez de médecins au Québec
pour livrer les soins nécessaires à la population. Notre propos
s’applique aussi pour la première ligne ; nous ne commenterons
pas… Mais pour la médecine spécialisée, on peut affirmer plus
que jamais qu’on nous tient en laisse. Oui, il serait possible
d’avoir beaucoup moins d’attente si nous disposions des
ressources appropriées.
Par contre, le pire (ou le meilleur) reste à venir, et cela dépendra
de ce que l’on fera des immenses cohortes entrées en faculté
durant les années 2000 et qui commencent à arriver en pratique.
Par exemple, à la FMSQ, nous avions atteint « le fond du baril » il
y a trois ans. Jusqu’alors, la variation annuelle du nombre net de
médecins cotisants (donc actifs) était quasi nulle, voire négative !
Depuis, elle est positive et de plus en plus grande. Cette année,
nous avons près de 300 médecins de plus (au net), et ce nombre
ne peut aller qu’en augmentant dans les prochaines années,
étant donné que les cohortes les plus nombreuses ne font que
commencer à diplômer.
Plusieurs questions méritent alors et d’être posées et d’obtenir
des réponses… maintenant. Par exemple, nous sommes, à ce
jour, plus de 9 500 spécialistes, croyons-nous en avoir besoin
de plus de 12 000 dans 10 ans ? Si oui - ce qui signifie implicitement que l’État juge alors qu’il faudra donner plus de soins -,
où est la planification pour augmenter la capacité du réseau et
ainsi permettre à ce plus grand nombre de médecins de servir la
population ? Si non, serait-ce le moment de diminuer le nombre
d’entrées en faculté? D’imposer un ratio 50-50 hommes-femmes
à l’entrée ?
Voilà donc une infime partie d’une nécessaire réflexion. Bien
d’autres questions demeurent… Mais la question fondamentale est celle-ci : En ce début de « cycle », y a-t-il vraiment une
réflexion, et les bonnes décisions se prendront-elles ?
Nous y reviendrons.
Syndicalement vôtre !
S
L
SERVICES AUX MEMBRES
NO S F ILIALES
AVANTAGES
COMMERCIAUX
AVANTAGES
sogemec.qc.ca
1 800 361-5303
fprofessionnels.com
1 888 377-7337
NO S PART ENAIRES
SERVICES AUX MEMBRES
rbcbanqueroyale.com/sante
1 800 807-2683
1 888 890-3222
estrimont.ca
manoir-victoria.com
esterel.com
manoir-saint-sauveur.com
desjardins.com
westinmontreal.com
1 800 567-7320
Nos partenaires
méritent votre confiance.
Vous gagnez
à les découvrir !
Pour tout savoir sur les avantages commerciaux réservés aux membres de la Fédération des médecins spécialistes du Québec et pour connaître nos nouveaux partenaires commerciaux, visitez le portail de la FMSQ au fmsq.org/services.
Pour plus d’informations :
[email protected] ou 514 350-5274
1 888 378-3735
1 800 CAISSES
sogemec.lapersonnelle.com
groupesolution2.com
1 877 795-9399
1 800 463-6283
1 866 482-5449
1 888 625-5144
1 866 350-8282
1 888 910-1111
514 288-8688
1 888 732-8688
1 855 310-3737
telusmobilite.com
montreal.hyatt.ca
1 800 361-8234
hotel71.ca
1 888 692-1171
hotelmortagne.com
450 655-4717
fairmont.com
1 800 441-1414
IL NE MANQUE
QUE VOUS !
centrecongreslevis.com
1 888 838-3811
multid.qc.ca
1 800 363-3068

Inquisitive And Determined: They Push Medicine Forward

Transcription

Similar documents

Westney Heights Plaza Ajax - December 10, 2015

News Letters - Collections

Spring Programming - Cornwall Public Library

Prospectus

Commission scolaire des Samares

www .ouranos.ca

vlaamse watermaatschappij

playground - Tourisme Jacques

A love of art and an eye for color led Rick DiCecca to a career in

http://www.wheels.ca/news/a-snowy-road-trip-part-2-carnaval

Medicine