Here comes the sun

Transcription

Here comes the sun

Vol. 17 no. 2 – June 2015
HERE COMES
THE SUN
THE PRESIDENT’S EDITORIAL
ARE YOU BILLING BY ANALOGY?
Dr René Blais
page 7
page 17
Page 33
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MD
TELUS se réserve le droit de retirer ou de modifier cette offre en tout temps et sans préavis. Certaines conditions s’appliquent. Sur présentation d’une
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marques de commerce utilisées avec l’autorisation de TELUS Corporation. © 2015 TELUS.
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TABLE OF
CONTENT
LE SPÉCIALISTE IS PUBLISHED 4 TIMES PER YEAR BY
THE FÉDÉRATION DES MÉDECINS SPÉCIALISTES DU QUÉBEC.
EDITORIAL COMMITTEE
Dr Harold Bernatchez
Dr J. Marc Girard
Dr Karine Tousignant
Maître Sylvain Bellavance
Nicole Pelletier, APR
Patricia Kéroack, c. w.
7THE PRESIDENT’S
EDITORIAL
TO CONTACT US
EDITORIAL CONTENT
✆ 514 350-5021
 514 350-5175
✉ [email protected]
Social Accountability
20
DOSSIER
HERE COMES THE SUN
21
SKIN CANCER
24
INVISIBLE LIGHT
25
SUN ALLERGIES
27
VITAMIN D
28
LIGHT THERAPY
29
LAW AGAINST
ARTIFICIAL TANNING
ADVERTISING
✆ 514 350-5274
DELEGATED PUBLISHER
Nicole Pelletier, APR
Director, Public Affairs
and Communications
 514 350-5175
✉ [email protected]
magazinelespecialiste.org
RESPONSIBLE FOR
PUBLICATIONS
Patricia Kéroack, c. w.
Communications consultant
REVISION
Annie Dallaire
Angèle L’Heureux
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
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PUBLICATIONS MAIL
Postal Indicia 40063082
ADVERTISING
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LEGAL DEPOSIT
2th quarter 2015
Bibliothèque nationale du Québec
ISSN 1206-2081
ENGLISH VERSION
INTERNET ONLY
8FEDERATION AFFAIRS
9IN THE NEWS
11 DID YOU KNOW...
14LEGAL ISSUES
17 ABOUT BILLING
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); Child and Adolescent Psychiatry; Clinical Immunology and Allergy; Colorectal
Surgery; Community Medicine; Critical Care Medicine (adult or pediatric); Dermatology;
Developmental Pediatrics; Diagnostic Radiology; Emergency Medicine; Endocrinology
and Metabolism; Forensic Pathology; Forensic Psychiatry; Gastroenterology; General
Internal Medicine; General Pathology; General Surgery; General Surgical Oncology;
Geriatric Medicine; Geriatric Psychiatry; Gynecologic Oncology; Gynecologic
Reproductive Endocrinology and Infertility; 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.
18CONTINUING
PROFESSIONAL
EDUCATION
32PREVIOUSLY IN
THE NEWS
33GREAT NAMES IN
QUÉBEC MEDICINE
Dr René Blais
All pharmaceutical product advertisements are previously 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.
35PROFESSIONNALS’
FINANCIAL
2
• Telus
3
• RBC Banque Royale
4
• Financière des professionnels
6
• La Personnelle
10
• Evenko
12
• Collège des médecins du Québec
13
• ims health I brogan
16
• Sogemec Assurances
• MultiD
36
40
37 SOGEMEC ASSURANCES
38L’ÉDITORIAL DE
LA PRÉSIDENTE
L’imputabilité sociale
39 MEMBERS SERVICES
Commercial Benefits
C’EST LA LOI !
30Il est interdit
CLIMATE
CHANGE
à toute personne mineure d’utiliser les services
de bronzage artificiel par rayons ultraviolets de cet établissement.
Une pièce d’identité avec photo pourra être exigée.
Renseignements et plaintes :
1 855-RAYON UV
31
HEAT STROKE
729-6688
12-269-11FA_bronzage_interdiction18+_Colleverso.indd 1
www.sante.gouv.qc.ca
13-01-21 10:52
LE SPÉCIALISTE I VOLUME 17 • NO. 2
• Desjardins
12-269-11FA © Gouvernement du Québec, 2013
THIS EDITION’S ADVERTISERS
5
VOS VALEURS
SONT D’UN
PUBLICITÉ
INTÉRÊT
CAPITAL.
PLEINE PAGE
DES CHANGEMENTS S’OPÈRENT
À LA FINANCIÈRE.
Financière
des professionnels
Nos valeurs, nos services et notre image de marque évoluent, mais
notre mission demeure la même : aider les professionnels à mieux gérer
leurs finances.
Nous avons bonifié notre offre de service et notre Gestion privée est plus
accessible qu’auparavant, pour vous permettre de mieux tirer profit de
nos solutions de placement variées.
Nos experts sont vos partenaires de confiance pour vous guider à toutes
les étapes de votre vie. Ils font plus que de la gestion de patrimoine.
Ils prennent soin des valeurs qui vous sont chères.
PROFITEZ D’UN CONSEILLER À VOS CÔTÉS.
FÉDÉRATION
DES MÉDECINS
SPÉCIALISTES
DU QUÉBEC
Actionnaire de Financière des professionnels depuis 1978
fprofessionnels.com
Financière des professionnels inc. détient la propriété exclusive de Financière des professionnels – Fonds d’investissement inc. et de Financière des professionnels – Gestion privée inc. Financière des professionnels – Fonds d’investissement inc. est un gestionnaire de portefeuille
et un gestionnaire de fonds d’investissement qui gère les fonds de sa gamme de fonds et offre des services-conseils en planification financière. Financière des professionnels – Gestion privée inc. est un courtier en placement membre de l’Organisme canadien de réglementation du
commerce des valeurs mobilières (OCRCVM) et du Fonds canadien de protection des épargnants (FCPE) qui offre des services de gestion de portefeuille.
Dre Diane Francœur
W
hether it’s wilfully
or through ignorance,
there’s no mention of the
fact that the future physician not
only studies throughout his training,
he’s working during his residency!
But, what is the real accountability
of medical specialists towards their
patients in a system where budgetary
austerity comes ahead of social
responsibility? How can the physician
remain liable for the best possible
use of the system and its resources
when, behind closed doors, the
administration cuts into patient care?
Our Minister of Health and his leader
can continue repeating that they
will not cut services to patients and
to the population, but the facts speak
for themselves: a single bath a week
is enough... using a washcloth is good
enough the rest of the time!
Not replacing staff members who are
sick, inadequately planning external
clinics, cutting back on operating
rooms during the summer: no, no,
there aren’t any cuts in services to
patients! By the way, where is the
Minister’s social accountability? In this
period of austerity, a balanced budget
forgives everything. It erases all traces
of promises not kept.
IN THIS PERIOD OF AUSTERITY, A BALANCED
BUDGET FORGIVES EVERYTHING. IT ERASES
ALL TRACES OF PROMISES NOT KEPT.
This being said, we, medical specialists,
are duty-bound to the population and
we discharge our duty. We all have
hospital obligations and, under the
supervision of the board of directors,
it’s the role of department heads and
the CMDP to define them, just as it’s
the role of the DPS to make sure we
respect them. When all of us respect
our promises, we meet our obligations
and deliver quality. When an orchestra
is well-rehearsed, everyone does his or
her part at the right moment.
In this era of changes for the healthcare network that are as
rapid as they are disruptive, it becomes easy for politicians and
reporters to launch a new attack, this time on the professionalism
of physicians and on their obligations towards the population.
Some ask THE question ”Since training a physician costs so much
to taxpayers... shouldn’t physicians have to sign up for public
service, like joining the army, in order to pay back their (so-called)
debt to society?“
The quality of specialized medicine
in Quebec is excellent, but it could
easily degenerate if we, medical
specialists, do not assume our place
at the centre of our (new) institutions
to defend our patients, especially in
this period where it is easy to curtail
our prerogatives.
We are responsible for giving our
patients the required details regarding
the difference to be paid if we really
believe that a generic drug is less
effective than the original. We are
responsible for advising our patients if
the excessive waiting period for tests
risks compromising their prognosis.
We are responsible for working hand
in hand with our teams to prioritize
urgent consultations and to find a
way of monitoring this clientele.
We are responsible for doing our work
while involving and assuring ourselves
that the second line is effectively on
duty when our expertise is needed.
We are responsible for providing
second-line coverage, everywhere
and at all times. All of this, of course,
if we allowed to work!
How can we translate these
obligations in our daily lives?
By becoming involved in our service
or department, by taking our place
on the CMDP and by daring to go
to the President and telling him that
the decisions he has taken are not
adequate and to remind him that,
even if his decisions are well within
the framework of the Minister’s
operating specifications, a hospital
centre is there to care for patients
and not to shuffle papers. We don’t
need a contract with the hospital to
remind us of this: no matter what
some rightminded individuals may
propound, yes, we do have a contract
with patients!
I cannot close this editorial without
mentioning Bill 20. It carries the
smell of a gag order... again! We
have made our representations and
defended the interests of specialized
medicine. There’s no need for
legislation. What the Minister is
asking for is feasible, as long as the
offer of services by institutions is at
the height of expectations. This is
the direction our negotiations have
taken. However, to expedite our end
of things, it will be much easier to
reduce waiting lists when the issue of
the technical component of accessory
charges is settled, and this solely for
the sake of transparency towards
patients, physicians and the Collège!
Remember: 58% of the population has
private insurance or participates in a
group insurance plan.
The countdown has already started
and July 7th is rapidly coming closer!
Even if the Minister has shown a
certain openness, you will have to
follow the Collège’s new code of ethics
to the letter starting on July 8th. It’s
up to you to measure the financial
health of the services you provide in
your offices since, according to the
law, you will only be allowed to bill
for bandages and medication... not for
the necessary equipment, not for the
sterilization of devices, not for the time
your staff spends in the recovery room
or elsewhere. Just like the Collège,
we are saying that the ball is in the
Minister’s camp. He is fully familiar with
the issue, in all its complexity, as he
defended it repeatedly not so long ago.
The question is “Will he drop the ball?”
Have a great summer. Rest up well.
Fall will soon be here with its many
jobsites: massive departures of
personnel, network disorganization,
activity-based funding, relevance of
tests, and judicious use of medication.
We are still being threatened with the
bat, but it doesn’t scare us!
S
L
THE PRESIDENT’S
EDITORIAL
SOCIAL ACCOUNTABILITY
7
FEDERATION AFFAIRS
OUTGOING TREASURER’S REPORT
BY STEPHEN E. ROSENTHAL, MD
The Fédération des médecins spécialistes
du Québec (FMSQ) held its annual
meeting on March 19, 2015. During this meeting, Delegates
accepted the recommendations of the Finance Committee
President, as follows:
its negotiations with the MSSS. In order to continue to
support the members of the Board in their undertakings, a
new contribution will be required in 2015 amounting to a
maximum of $500 per member.
1. Approve the FMSQ’s financial statements as at
December 31, 2014 according to the audit performed
by the accountants of the firm Raymond Chabot
Grant Thornton;
2. Approve the budget projections for the year 2015 as
submitted by the FMSQ;
3. Set the annual dues for 2015 at $1,362 (compared to
$1,440 in 2014).
The financial statements have once again shown that the
FMSQ is in good financial health and that its accounts are
maintained with accuracy and rigour.
The legal proceedings instituted by the Council for the
Protection of Patients against the FMSQ on the issue of
the three (3) study days were settled by the payment of a
penalty of approximately $1,470,700. Over the last two (2)
years, the Federation had accumulated a total of just over
$7 million through special member contributions. The
unused portion of these contributions will be refunded
to members by way of a reduction in dues for 2015 that
could amount to a maximum of $555 per member.
During the 2014 fiscal year, the Federation received a sum
of money by way of a special contribution amounting
to a maximum of $750 per member. This contribution
was used to support the actions of the FMSQ during
Dear Colleagues,
After having held the position of Treasurer for the FMSQ for
one year, from March 2014 to March 2015, I have decided
to take up a new challenge. I am happy to pass on the
torch to Dr Karine Tousignant, your new Treasurer, who
will, I am certain, take on the responsibility of supervising
finances and the good management of your contributions.
I wish to thank Ms Julie Voiselle, Director of the
Federation’s Administrative Services, for the great
cooperation she has afforded me, as well as the Board of
Directors for its support during this year.
For any questions regarding the budget, I would ask you
to get in touch with Dr Tousignant or myself by email
at [email protected].
IMPORTANT AWARDS FOR THE FMSQ
8
AWARD-WINNING CRISIS MANAGEMENT
The campaign “We Keep our Word” will
receive an award from the Société
québécoise des professionnels de
relations publiques (SQPRP), in the
category Strategic Excellence: Managing
the Stakes and Communicating in a
Crisis. What we still don’t know is what
colour the award will be? The answer to
this question is expected on June 2nd.
We would like to remind you that this campaign was
implemented by the Public Affairs and Communications
Directorate team in order to respond to the government’s
demands, in the public arena, to unilaterally reopen the
agreement on medical specialist remuneration. The FMSQ
used this opportunity to show that it was of good faith
and that it wanted to negotiate... as long as the
government wanted to do so as well!
LE SPÉCIALISTE, THREE-TIME WINNER!
Two issues of the Federation magazine were recognized:
“The Mémento: Your CPD Handbook” and “Concussions:
A Headache for Neurologists.”
SPÉCIALISTE
SPECIAL ISSUE
LE
Le magazine de La Fédération des médecins spéciaListes du Québec
Vol. 16 no HS-1 | January 2014
“The Mémento: Your CPD Handbook”
was awarded Silver in the Best Writing
Project category by the
le SpécialiSte
Canadian Public Relations
Society (CPRS).
15 YEARS ALREADY
THE MÉMENTO
Your CPD Handbook
Vol. 16 No. 4 – December 2014
CONTINUING PROFESSIONAL DEVELOPMENT
CONCUSSIONS
TRAINING
A HEADACHE FOR
NEUROLOGISTS
The issue dedicated to
concussions was also
recognized by the CPRS,
winning Bronze in the Best Writing Project
category. The issue will also receive an award
from the Société québécoise des professionnels
de relations publiques in the Tactical Excellence: Writing
category. As is the case for the “We Keep Our Word”
campaign, we are waiting to learn the colour of this award!
CASE STUDIES
BACK TO THE
DRAWING BOARD... AGAIN
THE IMPORTANCE
OF BEING METICULOUS
page 7
page12
S
L
Dr Denis Sasseville
Page 38
PLANNING TO TRAVEL ABROAD? HERE ARE A FEW TIPS FROM SOGEMEC TO HELP YOU PREPARE (PAGE 41)
As we were writing these lines, we learnt that the FMSQ had won four significant awards:
one for its campaign “We Keep Our Word” and three for the magazine Le Spécialiste.
IN THE NEWS
ON THE POLITICAL SCENE
FROM THE NATIONAL ASSEMBLY
BILL 28
After a mere fifteen hours of detailed study by a
parliamentary committee, and under the pretext of the
urgent need to implement various measures aimed at
reaching a zero deficit, the government had recourse
again to a gag order on April 20th, to force the adoption
of Bill 28, being an Act mainly to implement certain
provisions of the Budget Speech of 4 June 2014 and
return to a balanced budget in 2015-2016. This Bill, which
opposition parties have qualified as “mammoth” because
of the 337 sections it contains, has resulted in modifying
some 60 laws while imposing various modifications
to fees, including the remuneration of pharmacists for
certain acts.
BILL 20
The debate around the adoption in principle of Bill 20, an
Act to enact the Act to promote access to family medicine
and specialized medicine services and to amend various
legislative provisions relating to assisted procreation,
began on April 14th. A motion to divide was presented
by the MNA for Lévis on April 15th and was found to be
admissible by the presidency.
To be ruled admissible, a motion to divide must clearly
establish that a Bill contains more than one subject or
principle and that these can be dealt with in complete
and separate Bills that can exist independently and make
up a coherent whole. Here is an extract of the decision
by the President of the National Assembly: “This motion
does in fact aim to separate completely distinct and
different principles into two bills. In addition, the manner
in which the motion to divide separates the different
elements of the Bill results in two coherent Bills that could
exist independently as there is no reference from one
to the other.” The argument held forth by the Minister
and the government, that the Bill dealt only with the
issue of physician remuneration, was therefore without
foundation. The motion was rejected by the ministerial
majority, i.e. 57 to 40.
The debates concerning the adoption in principle of
Bill 20 were adjourned on April 16th to make way for
the annual study of budgetary credits. When debates
resumed on May 7th, a hoist motion was tabled by the
MNA for Berthier, forcing a two-hour limited debate at the
end of which the motion was rejected. The principle was
adopted on May 20th and was deferred to Parliamentary
Commission for detailed analysis.
BUDGETARY CREDITS
Each year, 200 hours are dedicated to the statutory annual
study of budgetary credits, 25 of which are dedicated to
those of the MSSS. Please note that the data supplied in
response to the Opposition’s written questions are based
on the expenses incurred over previous years. This year,
the books containing the MSSS responses to Opposition
questions total 1,933 pages. Budgetary credits for the year
2015-2016 were adopted on May 7th.
NEW BILL
Bill 44, An Act to bolster tobacco control, was tabled
on May 5th by the Minister for Rehabilitation, Youth
Protection and Public Health. As indicated in the
explanatory notes, “This bill amends the Tobacco Act to
further restricts [sic] tobacco use both in enclosed spaces
and outdoors. It prohibits smoking in motor vehicles in
which a minor under 16 years of age is present and on
terraces. […] The bill extends the scope of the Act by
considering electronic cigarettes to be tobacco and sets
rules for tobacco use in certain places, in particular by
determining standards for outdoor smoking shelters.”
This Bill will be submitted to public consultations and to
individual audiences. At the time of writing these lines, no
date had yet been announced.
The current session ends on June 12th and work will
resume on Tuesday, September 15th.
The round of petitions condemning sex-selection abortions and calling for the government to intervene by forbidding
this practice is continuing under the sponsorship of Mark Warawa (Langley) and his Conservative MP colleagues on the
back benches.
The current session of Parliament will conclude on June 23rd. Debates will resume on September 21st, but for a very short
period because of the general election, which now takes place on a set date and is planned for Monday, October 19th.
With the elections being called, any Bills that have not been adopted will die on the Order Paper.
S
L
FROM THE HOUSE OF COMMONS
Bill S-225, An Act to amend the Criminal Code (physician-assisted death), submitted by Senator Nancy Ruth, was at the
stage of second reading, after a sixth session held on May 7th. As for Bill C-377, An Act to amend the Income Tax Act
(requirements for labour organizations), the Standing Senate Committee on Legal and Constitutional Affairs met three
times and heard some 23 representatives of interested groups and organizations, and as many white papers were tabled.
9
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offre une protection optionnelle
exclusive aux membres de la FMSQ
PUBLICITÉ
PLEINE PAGE
Extensions de garanties – FMSQ (avenant 25c)
Cet avenant accorde notamment :
• Des modalités de règlement additionnelles en cas de sinistre, soit :
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(pour votre bâtiment d’habitation et ses dépendances)
La Personnelle
- Valeur à neuf sans obligation de réparer ou de remplacer (pour vos biens meubles)
• L’augmentation des montants de couverture pour certains biens particuliers ou de valeur, notamment :
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Informez-vous dès maintenant !
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Le présent texte est un résumé non exhaustif des protections offertes. Les clauses et modalités relatives
aux protections décrites sont précisées au contrat d’assurance, lequel prévaut en tout temps.
Certaines conditions, limitations et exclusions s’appliquent.
La Personnelle désigne La Personnelle, assurances générales inc.
La bonne combinaison.
DID YOU KNOW...
PRIX DE L’UNIVERSITÉ
DE SHERBROOKE
For the 10th year, the
faculty of medicine and
health sciences
awarded its prizes for
excellence during its
Gala du mérite. Among
the recipients, Dr John Robb, a
specialist in internal medicine,
received the Prix André-Plante. This
prize is awarded to professors who
stand out due to the quality of their
clinical supervision.
THE PERSONAL AND SOGEMEC
SUPPORT CAREGIVERS
Within the framework of their
promotion Un petit répit…
une GRANDE CAUSE!, which
ended on December 31, 2014,
The Personal and Sogemec
gave $10 to the Foundation of
the Fédération des médecins
spécialistes du Québec (FFMSQ)
for each request they received
for an auto, home or business
insurance proposal. “This
promotion was a great success”
declares Lucie Labbé, account
manager at The Personal. A
cheque in the amount of $15,670
was handed to the President of
the la FFMSQ, Dr Diane Francœur,
on April 29th. “We are proud to
have been able to support the
cause of caregivers in our own
way, a cause which touches over
one million Quebeckers.” added
Chantal Aubin, Assistant Director
of Sogemec Assurances.
LETONDAL PRIZE
The Association des
pédiatres du Québec
awarded the Prix
Letondal to Dr Pierre
Gaudreault, a
pediatrician at the
Sainte-Justine University Hospital
Centre. This prize highlights the
importance of the pediatrician’s
contribution to his field of endeavour.
Dr Gaudreault has worked mainly
in clinical pharmacology and
toxicology and was involved within
his association and sat on the Board
of Directors of the FMSQ.
A SURGEON RECOGNIZED IN
AN UNUSUAL WAY
It was the little patients
who paid homage to
Dr Michel Lallier, a
pediatric surgeon
specializing in organ
transplants at the
Sainte-Justine University Hospital
Centre. During an activity to raise
awareness of organ transplants held
at the Hôpital du Sacré-Cœur de
Montréal, some twenty youngsters
who received transplants by
Dr Lallier, including a 14-year old girl
who received a liver transplant at the
age of 4 weeks, came to thank their
hero during a touching ceremony.
AN INFLUENTIAL AND
EXCEPTIONAL PERSON
Dr Joanne Liu, a
pediatrician, currently
International President
of Doctors Without
Borders (MSF), is among
the 100 most-influential
personalities of the planet according
to the American magazine Time.
Dr Liu was chosen for her
involvement and determination
during the Ebola crisis, where she did
not hesitate to alert decision-makers
regarding the urgency of acting to
eradicate this epidemic.
Le Spécialiste has previously referred
in detail to Dr Liu’s career with
MSF. In particular, she granted us
two interviews: one for the June
2007 issue, when she spoke of her
work and passion for humanitarian
medicine; the second, for the June
2009 issue, when she described her
projects in telemedicine in aid of
humanitarian workers.
At the time of going to press, Dr Liu
was awarded the Prix d’humanisme
2015 by the Collège des médecins du
Québec, highlighting her exceptional
humanitarian commitment.
IMS BROGAN AWARDS
Since the year 2000, IMS Brogan has been offering grants in recognition
of the contribution of physicians and pharmacists to the education of
their peers by having scientific articles published on the appropriate use of
medicines. Two grants are awarded to medical specialists. The recipients
of the 2014 awards are:
Dr Francine M. Ducharme, a pediatrician at Sainte-Justine
University Hospital Centre, and colleagues, for the article
entitled “Diagnosis, Management, and Prognosis of Preschool
Wheeze”, published in The Lancet 2014:383;1593-1604.
From left to right: Ms Lucie Labbé from
The Personal, Ms Chantal Aubin from
Sogemec Assurances, Dr Diane Francœur,
President of the FMSQ Foundation, and
Ms Monique Richard from The Personal.
Dr Paul Brassard, a medical specialist in community health at
McGill University Health Centre, and colleagues, for the article
entitled “Oral Corticosteroids and the Risk of Serious
Infections in Patients with Elderly-Onset Inflammatory Bowel
Diseases”, published in The American Journal of
Gastroenterology 2014:109;1795-1802.
PHOTO CREDIT: USHERBROOKE
PRIZES AND AWARDS
11
DID YOU KNOW...
CANADIAN SOCIETY OF ENDOCRINOLOGY
AND METABOLISM AWARD
Dr Johnny Deladoëy, an endocrinologist and
researcher at the Sainte-Justine University
Hospital Centre, an associate clinical professor in
the department of pediatrics and an accredited
member of the department of biochemistry and
molecular medicine at Université de Montréal,
was given the Charles Hollenberg Young Investigator Award by
the Canadian Society of Endocrinology and Metabolism. This
award was given to support his research as a member of the
faculty of a Canadian university having demonstrated
excellence and as an independent researcher in basic science.
NEW RELEASES
L’ADOLESCENT SUICIDAIRE : LE RECONNAÎTRE,
LE COMPRENDRE ET L’AIDER
(SUICIDAL ADOLESCENTS: RECOGNIZING,
UNDERSTANDING AND HELPING THEM)
Supported by the analysis of different
clinical cases, the book written by Dr Nagy
Charles Bedwani, a pediatric psychiatrist
and Director of the Centre des adolescents
of the Albert-Prévost pavilion at Hôpital
Sacré-Cœur, allows healthcare
professionals to better understand the
problem of suicide in adolescents, to
identify individuals at risk and to develop
means of intervention.
LA MIGRAINE : AU-DELÀ DU MAL DE TÊTE
(MIGRAINES: BEYOND HEADACHES)
Written by Dr Élizabeth Leroux, a
neurologist and the Director of the Clinique
de la migraine at the CHUM, this book
intended for the general public answers
questions regarding migraines: triggers,
mechanisms, categories. It also provides
practical tools and advice in line with the
three recommended treatment paths,
namely lifestyle modifications, crisis
intervention and preventative treatment.
Follow-up on Previous Issue
MEDICATION OR MEDITATION?
Vol. 17 no. 1 – March 2015
12
A BETTER YOU
A BETTER PHYSICIAN
2015 – A Year to Remember!
NEW COLUMNS
Dr Mimi Israël
page 7
pages 12 and 15
Page 38
CAR RENTAL: DO I HAVE TO TAKE THE INSURANCE OFFERED BY THE RENTAL COMPANY? (PAGE 44)
A study published in “The Lancet”
confirmed that mindful meditation is
an alternative treatment for depression,
just as effective as anti-depressants.
Over a period of two years, researchers
at Oxford University conducted
MINDFULNESS
a double-blind study involving
424 patients who had already suffered
from acute episodes of depression.
At the end of the study, the researchers found that therapy
based on mindfulness was the preferred alternative for
patients who were not able to take anti-depressants.
le SpécialiSte
S
L
DID YOU KNOW...
10TH GOLF TOURNAMENT
OF THE MEDICAL FEDERATIONS IN AID
OF THE QUEBEC PHYSICIANS’ HEALTH
PROGRAM FOUNDATION
THANKS TO
OUR SPONSORS
Monday, July 27, 2015
Le Mirage Golf Club in Terrebonne
Make sure you don’t miss the tee-off!
Your participation in the Quebec Medical Federations’
Golf Tournament ($500 per individual registration and
$2,000 for a foursome) includes access to the practice
area, a golf cart, the right to play under Vegas rules
(best ball), brunch, lunch, cocktails as well as supper.
For sport enthusiasts who choose the cycling activity:
Fees include a support vehicle service throughout the
course, with technical support and monitoring, as well
as all meals mentioned above.
• CMPA
•Desjardins
• Desjardins Insurance
• Desjardins Trust
• Fiera Capital
•CIBC Asset Management Inc.
•La Capitale Insurance and
Financial Services Inc.
•The Personal, Home and
Auto Group Insurance
•NATIONAL Public
Relations Inc.
•Publicis
• SSQ Financial Group
Information and registration forms available on fmsq.org.
M O N I N S C R I P T I O N A U TA B L E A U D E L’ O R D R E
30
JUIN
Quel que soit votre mode de paiement, les mêmes
règles s’appliquent : votre paiement par carte de crédit
ou votre chèque, accompagné du formulaire approprié,
doit être reçu au Collège avant le 30 juin, 17 h.*
* Une pénalité de 250 $ sera exigée pour tout défaut de paiement dans les délais.
L’inscription en ligne : sécuritaire, rapide et facile www1.cmq.org
J’effectue mon renouvellement et mon paiement
Mode de paiement • Vous avez le choix de deux
avant le 30 juin, 17 h.
modes de paiement : par carte de crédit ou par chèque.
13
BY MAÎTRE SYLVAIN BELLAVANCE | DIRECTOR
LEGAL AFFAIRS AND NEGOTIATIONS – FMSQ
LEGAL ISSUES
A REVIEW OF CERTAIN CURRENT ISSUES
FOR THE FEDERATION
I
t has now been more than a year
since the liberal government has
taken over in Quebec City and
since the new Minister of Health
and Social Services started happily
meddling in several files. As we have
all seen, this last year has not been
very restful and physicians in Quebec
remain the target of politicians
in several ways. After having agreed
to stagger the sums that were due
to them, a succession of Bills came
down on physicians in Quebec.
In order to understand the nature
of the current stakes for specialized
medicine, let’s go over each of the
issues that involve medical specialists
and briefly summarize what it means
(WIM), what we have done (WID) and
what remains to be done (WRTD).
BILL 10
WIM: The objective of this Bill was
to modify the organization and
governance of the health network,
in particular by abolishing regional
agencies. With close to 200 sections
originally, this Bill was finally adopted
amid protests, under a gag order
and after the tabling of hundreds of
amendments. It came into effect on
April 1, 2015.
14
WID: Like many other stakeholders,
the Federation made representation
to the parliamentary committee to
denounce the magnitude of this
reform, as well as the improvisation
and precipitation with which it
was to be implemented in spite
of the fact that all the stakes had
not been delimited. While all the
stakeholders did not convince the
Minister to abandon this reform,
some amendments were made to
modify the regrouping of certain
institutions and to review the process
of nominating certain members of
the boards of directors.
The Federation also intervened in
favour of maintaining local medical
governance in each of the facilities of
a CISSS, in particular by nominating
local representatives responsible
for services and departments and
a local presence of the CMDP.
The Minister undertook to hear our
representations in the course of
preparing the regulations needed
to support this new organization,
regulations we are waiting for.
The Federation also proposed
amendments in order to better
structure the new obligation
imposed on physicians in one facility
to offer temporary support in another
facility. We have thus succeeded in
better structuring this temporary
support by limiting it to problems
of urgent or semi-urgent access,
by implementing an initial duration
of 3 months and by stipulating a
maximum distance for this support
(although we had asked for the limit
to be set at 40 km, it has in fact been
set at 70 km).
WRTD: Undoubtedly, the gradual
implementation of this new
organization will bring with it various
problems within the network and we
are asking each and every physician
to write to us in order to document
the problems experienced in the field.
We will remind the Minister of his
commitment to consult us regarding
the maintenance of a certain level of
local medical governance, as he has
so far defaulted on his commitment.
We will also submit modifications
to the agreement in order to affect
elsewhere the financing that was
dedicated to certain measures,
including the work accomplished for
an agency or for the Regional panel
of heads of departments.
BILL 28
WIM: This is an omnibus Bill that
involves the implementation of
various measures aimed at a return
to a balanced budget. Among
these measures, there is the power
granted to the Minister to unilaterally
modify the agreement reached
with pharmacists, as well as a
provision concerning the unilateral
modification of the financing
included in our Agreement when a
service stops being insured.
WID: The Federation submitted a
white paper to the parliamentary
committee in which we denounced
the extraordinary power granted
to the Minister to unilaterally
modify an agreement reached
with an organization representing
health professionals, in this
case pharmacists. Insofar as the
provided for in our Agreement,
we have once again rejected the
unilateral approach advocated by the
government and have instead offered
to negotiate the modifications
required to the Agreement whenever
a service becomes uninsured.
Bill 28 was adopted under a gag
order on April 21st without any
positive follow-up being given to
our arguments.
WRTD: With regards to the
provided for in the Agreement when
a service becomes uninsured, we
intend to remain vigilant and to
oppose any reduction of financing
that would not take into account
the transfer of activities resulting
from the removal of insurance for
certain acts.
BILL 20
WIM: This Bill aims to promote
access to family medicine and
specialized medicine services and to
modify insured services for assisted
procreation. Under the pretext of
accessibility, the Bill provides for
extraordinary powers that would
allow the Minister to modify the
agreements reached with medical
federations and imposes various
practice obligations and quotas on
physicians under threat of financial
penalties. In specialized medicine,
these quotas concern access to
specialized consultations for the first
line, specific delays for emergency
consultations, case management of
hospitalized patients and surgical
interventions for patients who
have been waiting for more than
six months.
LEGAL ISSUES
Insofar as assisted procreation is
concerned, we have also denounced
the government’s decision to abolish
this program rather that implement
appropriate corrections.
WRTD: At the time of writing, we
are pursuing our discussions with
the MSSS, in the continuing hope
of convincing them to modify
their approach and to choose
instead a negotiated path. Ongoing
discussions lead us to believe that
a negotiated solution is possible,
which would be beneficial to the
entire population. Should this not
be the case, the Federation will
unfortunately have no choice but
to react to every coercive and
punitive measure imposed by the
government, which could even go
as far as legal challenges. Insofar as
assisted procreation is concerned,
we are actively collaborating with
the Collège des médecins on the
preparation of a guide that would
allow for the needed corrections to
the program.
THE FINANCING OF
MEDICAL CLINICS
WIM: The issue of inadequate
financing of private offices has
lagged for many years. Despite
the Chicoine Report, which dates
back to 2007 and which demanded
the government act, as well as the
repeated requests of the Federation
at the negotiation table, the
government continues to refuse to
take a position, which has resulted
in the filing of a class action suit by
patients, among others. Moreover,
last January, the Collège des
médecins du Québec announced
modifications to its Code of Ethics in
order to limit the amounts that could
be claimed from patients.
WID: Faced with the effective date
of the specific measures of the Code
of Ethics, the Federation has again
insisted on negotiating with the
MSSS for possible solutions to the
financing of medical clinics. Various
options are possible, whether by
way of negotiating the technical
components so as to cover the
operating costs of certain services
or by delimiting the nature and the
amounts that could be claimed
from patients. While several clinics
threaten to cease offering certain
services, it is important to rapidly
reach a solution in order to ensure
the continuation of specialized
services dispensed in medical clinics.
WRTD: At the time of writing, we are
still awaiting a response from the
MSSS and will continue to request
the implementation of adequate
solutions. We are convinced that
this issue can be settled through
negotiations. Failing this, the
conclusion is clear: the current
situation can no longer be tolerated.
In order to protect medical specialists
and preserve access to their care, we
will have no other choice but to take
appropriate measures to settle this
issue once and for all.
RENEWAL OF THE AGREEMENT
WIM: The Agreement that links
medical specialists and the
government of Quebec expired
on March 31, 2015 and is now
maintained in effect by law.
Nonetheless, it is important to open
negotiations for its renewal for a
period of three to five years. Within
the framework of the agreement
reached last fall on the staggering of
the sums due to medical specialists,
it was agreed that the renewal of the
Agreement would be donein a way
to grant at least the increases that
will be given to public and parapublic
sector employees.
WID: We have not yet opened
negotiations to renew
the Agreement.
WRTD: At the time of writing,
negotiations between the
government and the personnel in the
public and parapublic sectors were
not progressing. The government
was offering a total increase of 3%
over five years while the labour
organizations were demanding 13.5%
over three years. Strike mandates
are being obtained by the labour
organizations for the fall. The
Federation will follow developments
in these negotiations and we expect
our negotiations to start in the fall.
CONCLUSION
As you can see, the Federation is at
work on several important issues that
affect medical specialists and will
continue to defend their interests
and access to their services for the
population. This brief summary of
our actions is in no way exhaustive
and we are also working in concert
with other stakeholders, like the
FMOQ, in addition to actions at the
media level. We continue to prefer
to negotiate, since this is the most
promising way of implementing
solutions that are beneficial to the
population of Quebec as a whole.
We thus continue to hope that the
government will favour this route
and will abandon that of coercion
and punishment. The next month
will be ideal for several developments
and it is important to remain vigilant.
Do not hesitate to contact us if you
have any questions or comments.
S
L
WID: The Federation went to the
parliamentary committee in order
to condemn the government’s
approach, an approach whose aim
is to turn physicians into scapegoats
when it comes to the problem of
patient access while physicians
are the first to militate in favour
of better access to the care they
offer and to fight the limits that are
often imposed on them. In addition,
while we had begun discussions
with the Minister last November in
order to improve access to care and
had confirmed our agreement to
collaborate on the four measures of
accessibility that had been identified,
we condemned the government’s
attitude that flouts the process of
negotiation that existed between the
government and physicians and that
imposes instead standards of practice
that will not contribute in any way
to better access. In early spring, we
reopened discussions with the MSSS
in order to recreate a climate of
cooperation and negotiation to allow
for improvement in access to care for
patients and to insist upon the need
to leave aside the coercive approach.
15
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©2015 IMS Health Inc. et ses affiliés. Tous droits réservés.
BY MICHÈLE DROUIN, MD | DIRECTOR
ECONOMIC AFFAIRS – FMSQ
ABOUT BILLING
BILLING BY ANALOGY:
NOT A GOOD HABIT TO DEVELOP!
A. You assume the act is included in the consultation and do not
bill anything;
B. You bill for another act whose descriptor is similar to the service you
have provided;
C. You call the RAMQ;
D. You ask your association.
Let’s look at each answer in
greater detail:
A) A
CTS INCLUDED IN THE FEES
FOR THE CONSULTATION OR
THE MAIN CARE PROVIDED.
It can, in fact, happen that some acts
do not carry fees because they are
included in another procedure or are
considered as an integral part of the
consultation. More than 200 acts are
thus designated and listed in Letter
of Agreement No. 3. You will find
this information in Brochure No. 1,
Appendix 11, in Section A: Numbered
Letters of Agreement. For example,
removing earwax and inserting an
intravenous catheter are listed under
included acts.
B) BILLING BY ANALOGY
The title of this article made it easy
to avoid this option! It is important
that your billing should reflect your
practice as accurately as possible.
Billing by analogy is not covered in
the Agreement and could give rise
to recovery of fees in the context of
verifications by the RAMQ (remember
that the Régie can, within the context
of its normal auditing processes,
perform random checks). Moreover,
you may not be getting the right fee
for the act you performed nor access
to the supplements that could apply.
In short, this is something to avoid.
C) CALLING THE RAMQ
Although the people working in
professional support are there to help
you, they do not have the medical
knowledge that, in many cases, is
needed to accurately identify an act
code in association with a specific
procedure. What is more, the act in
question may not even be covered in
the current version of the Manuel.
D) ASKING YOUR ASSOCIATION
You’ve guessed right: this is the
correct answer. Your association is
in the best position to help since
it’s your association, in cooperation
with the FMSQ, which establishes
the descriptors and sets fees for all
acts performed by physicians in
your specialty.
YES, BUT…
You’ve asked your association, and
the procedure you performed does
not have a set fee, because it’s a new
technique. What are the next steps?
This situation is covered in the
Agreement, under the heading
Tarification nouvelle. You will find it
in the Manuel, under tab A Préambule
général, rule 4. This rule specifies the
procedure to follow to ask for a fee to
be established for a new act.
To start with, you send the RAMQ
a statement of fees detailing your
request. The act code you should
use is 09990; you write neither fee
nor any other act on this request.
You need to indicate the other usual
details, such as the date, the role
and modifiers, as the case may be.
In addition, you need to supply a
description of the technique or the
surgery performed (if applicable,
a copy of an article or any other
scientific text to help fully explain the
act performed).
Upon receiving this request, the
RAMQ will get in touch with the
FMSQ and forward the applicable
documentation. The Economic Affairs
Directorate (EAD) takes charge of
the file and contacts the association
involved. If the association decides
to set a fee for this new act, the EAD
develops a descriptor, creates the
associated rules and sets the fee.
Afterwards, the EAD presents this act
at a technical committee meeting
(FMSQ/MSSS/RAMQ) in order to
begin negotiations. In the case of
agreement between negotiating
parties, the new act code is added
to the table of fees, at the next
modification to the Agreement,
and physicians are informed via a
RAMQ Infolettre.
This way of doing things does indeed
involve a delay, which can sometimes
reach a year between the date of
the service and the payment of fees.
You should know, however, that the
fact of having made a request with
a 09990 code records and, in a way,
protects your request. The new fee
has a retroactive effect on all requests
pending, no matter how much time
has passed. In addition, the work
performed by your association
and the Federation prevents any
ambiguity as to the descriptor
developed and allows for logical
and coherent billing in relation to
existing acts.
CONCLUSION
Looking for something in the RAMQ’s
manuals and brochures is a laborious
task, sometimes fruitless... Billing by
analogy is a dangerous exercise and
must be avoided!
Writing a simple email to your
association or to the Economic Affairs
Directorate can help you avoid a lot
of problems.
S
L
You are billing an act for the first time. You have looked in
the Manuel des tarifs but haven’t found
an answer. So, what do you do?
17
BY SAM J. DANIEL, MD | DIRECTOR
PROFESSIONAL DEVELOPMENT OFFICE – FMSQ
CONTINUING PROFESSIONAL
EDUCATION
On-line Learning Platform
DOCTORS, ARE YOU CONNECTED?
D
Since November 2014, the On-line Learning Platform, also known as the FMSQ’s Continuing Professional
Development (CPD) platform, offers all members continuing education activities, on-line information modules,
clinical tools as well as guidelines. As of today, there are more than 1,000 medical specialists who have taken
on-line courses, which are offered without charge on the platform and are available 24 hours per day, 7 days per
week. As at May 15th, there was a total of 30 on-line modules, 6 of which earned credits in Section 1, 18 in Section 2,
and 6 in Section 3. In addition, the toolbox alone contained more than 51 documents, including guidelines,
recommendations, clinical documents and various resources including the modifications to the new Code of Ethics…
It is never too late to log on to your CPD platform. The following is a user’s testimonial. You too can do what he did.
Don’t hesitate to send us your comments and suggestions. I can’t wait to read your opinion!
WHAT I LEARNED, OVERALL
Last November,
during the 7th
Interdisciplinary
Education Day
(IED), the
FMSQ’s new CPD
platform was
Janik Sarrazin, MD
unveiled
to participants. Like
many colleagues, I was pleasantly
surprised by its user-friendly format
and by the potential such a tool can
represent. And, like a good proportion
of those who were present, because
I was busy with my various clinical
and administrative activities, I did not
go back. Then, a colleague asked
me a question that induced me to log
onto the platform and go through it.
That’s when I realized how well
it was built!
My aim today is to induce you
to visit the platform as well... for
the first time! I’m ready to bet that
you’ll go back afterwards...
18
TO GET THERE
The first step is, naturally, to log
onto the Federation’s portal (fmsq.
org). Then, access the section FOR
MEDICAL SPECIALISTS and enter the
secure zone with your password.
Did you forget your password? Don’t
worry, you can easily recover it
or, if the problem seems insoluble,
a call to the FMSQ will get you a
temporary password. Your password
is important because it’s what
allows you, among other things, to
download your annual income tax
slips and statements.
You can now access the CPD
platform, which is made up of several
sections. Two of these were of special
interest to me. The first is the Boîte à
outils: this is a directory containing
a multitude of documents (in PDF
format) dealing with the practice
of medicine and CPD. For example,
there is the Code of Ethics from the
Collège des médecins du Québec,
various guidelines, presentations as
well as the certification standards
that are in effect. Although a good
number of these files will only be
accessed once in a while because
of specific needs or questions, it is
indeed practical to find them all
together in a coherent whole. In fact,
the value of this section will increase
over time as a result of the number
of documents the affiliated medical
associations will upload to it.
The other section that is important
to me, the Catalogue de cours, is
at the heart of the platform. That’s
where we find the video capsules
recorded during various conventions,
inside of which an interactive
questionnaire has been added. What
this involves, essentially, is to watch
the presentations which last between
30 and 45 minutes, interspersed with
multiple-choice questions to which
the speaker will provide answers as
his talk progresses. I have to admit
that having to listen for the right
answers adds a stimulating active
element and, since none of us like
to be wrong too often, we end
up playing the game and paying
attention. Among the new activities
REMINDER
Section 1: Group-Learning Activities
Section 2: Self-Learning Activities
Section 3: Evaluation
that were recently added, there
is a simulation on leadership and
influential communication, case
studies to resolve and pedagogical
formulas that are increasingly varied
and enriching, as associations
start up more and more projects
(Editor’s note: see the complete
list appended).
After having regularly modified its
requirements regarding CPD credits,
the Royal College of Physicians
and Surgeons of Canada (RCPSC)
seems to have attained a certain
stability recently. In addition to the
400 credit requirement, starting in
2014, the College requires that we
obtain 25 credits in Section 3 during
each 5-year period. While there is
still a certain confusion in my mind
as to the nature of each category
of credits, I took note of the fact
that those of Section 3 are rather
rare and difficult to obtain. A brief
overview of the platform, however,
allowed me to identify the possibility
of earning 12 credits in Section 3.
And, these are available to everyone,
anytime, anywhere!
CONTINUING PROFESSIONAL
EDUCATION
My experience tells me that the
long-term success or failure of this
platform will depend on how each
affiliated medical association will be
able to enrich it. While the structure
seems to be well built and robust
insofar as using it is concerned, it’s
the number of available courses
that will ensure its survival. Yes,
this is a message to my colleagues
in the other medical associations.
As for myself, I experienced
the willingness of the FMSQ’s
Professional Development Office
personnel to help with the recording
of presentations given during
different association conventions.
Each year, several members
cannot attend their association
convention because they are on
call in their hospital centre. Thanks
to the platform, they can watch the
principal presentations recorded
during the convention.
In closing, the technological
foundation was well thought out
and the educational content that
is already on line is of excellent
quality and is expected to increase
in terms of quantity. This being said,
I still invite you to use your own
judgment and log on to see and
develop your opinion.
Janik Sarrazin, MD, president,
Association of Otorhinolaryngology
and Head and Neck Surgery
of Quebec
EDUCATIONAL CONTENT OF THE ON-LINE LEARNING PLATFORM AS
AT MAY 15, 2015
On-Line Section 1 Modules
Title (language of title is same
as that of content)
1 Une touche de fièvre
2 A Lick of Fever
Initiatives en sécurité des soins
3
au Québec
Traitement de l’asthme et
4 grossesse : où trouver l’information
et comment l’interpréter
Les habiletés de gestion d’un
5
chef de département
6 Lecture critique d’un article
Type
Length
Credits
Étude de cas
Case study
1 hr
1 hr
1
1
Forum d’échange
1 hr
1
Webdiffusion en présentation
différée
1 hr
1
3 hr
3
1 hr
1
Module d’autoapprentissage
en ligne avec forum d’échange
Module d’autoapprentissage
en ligne avec forum
d’échange
On-Line Section 2 Modules (Self-Learning Modules)
1
2
3
4
5
6
7
8
9
Title (language of title is same as that of content)
Évaluation de la dysphagie chez l’enfant
Former et évaluer en ligne par la concordance de script
Diagnostic de l’apnée du sommeil (AOS)
Les cancers différenciés de la thyroïde
Lignes directrices en amygdalectomie
Le diagnostic et le traitement des nodules thyroïdiens
Pediatric Laryngology Advances Section
Sialendoscopy: Latest in Salivary Gland Endoscopy Surgery
La grossesse… une histoire de cœur: dyspnée, palpitations et syncope
On-Line Section 2 Modules (Self-Learning Modules from the CMPA, with
French versions available). These modules can earn credits in Section 3 if the
participant completes an exercise in reflection.
1
2
3
4
5
6
7
8
9
Title
Medical certificates, forms, notes, legal reports
Anatomy of a lawsuit
Informed discharge
Informed consent
Documentation: Charting medical records
Acute compartment syndrome of the lower extremity
Documentation: Charting medical records, Part 2
Privacy and confidentiality
Negligence and civil liability
On-Line Section 3 Modules (Self-Learning Modules)
Title (language of title is same as that of content)
1
2
3
4
5
6
Mieux gérer son temps
Ce n’est pas ma faute
Traitement du reflux chez l’enfant
Update on Laryngeal Reinnervation
Pour influencer, bâtir un consensus : le cas du pont
Jacques-Cartier
Imagerie cérébrale chez le patient en soins critiques
Length
Credits
1 hr
1 hr
1 hr
1 hr
3
3
3
3
2 hr
6
1 hr
3
Note: To review your learning or to understand the Royal College’s Maintenance of Certificate (MOC)
program, we invite you to consult the article entitled “The Pedagogical Principles of the Royal College’s
MOC Program - Keep Your Practice at the Heart of Your Learning Program” which appeared on page 16
of the Memento handbook.
S
L
The platform’s designers developed
the system to record your progress
in real time. You never need to
save your work, nor can you lose it
inadvertently. Those who abandon
a presentation midway will find it
a few weeks later exactly where
they left off along with a record
of the answers they provided
previously. Completed courses are
automatically saved in memory so
that, as the Royal College’s annual
deadline of January 31st looms near,
it is easy to quickly find the list of
accumulated credits.
19
DOSSIER
The sun.
The simple fact of mentioning
its name calls up feelings of
warmth and happiness for some.
For others, it causes problems,
but nonetheless remains an
essential part of life. The sun is
at the heart of our daily lives.
We frantically search for it when
it hides, but we run away from it
when it is present in excess.
The Egyptian sun god Ra, the
Land of the Rising Sun, the Sun
King, the Temple of the Sun,
the Cirque du Soleil... cults and
cultures have been inspired,
it seems like forever, by the
sun and its light.
In this dossier (a hot one!),
just a few days before the
official arrival of summer and
as we await its heat waves,
Le Spécialiste goes over the
main health issues associated
with the sun.
20
HERE COMES
THE SUN
HERE COMES THE SUN
BY PHILIPPE LAFAILLE, MD*
SKIN CANCER… A PLAGUE!
The treatment of skin cancers today requires an essential cooperation between
several medical specialties: in particular, dermatology, oto-rhino-laryngology,
plastic surgery, oncological surgery, oncology, oculoplasty, pathology
and radio‑oncology.
not responded to the standard
treatments of surgery or radiation
and it has shown good results in
controlling these lesions.
BASAL CELL CARCINOMA IS
THE CANCER MOST FREQUENTLY
FOUND IN HUMANS. CLINICALLY,
IT OFTEN PRESENTS AS AN
ERYTHEMATO‑SQUAMOUS PLAQUE
OR AS A PEARL-SHAPED NODULE
THAT SPONTANEOUSLY CRUSTS
OVER OR BLEEDS.
Squamous cell carcinoma, also called
epidermoid carcinoma, is a lesion
with a more aggressive potential
whose overall risk of lymph node
metastases is approximately 4%,4
although this can reach 9% when
the lesion is located on an ear, 14%
on a lip and more than 30% if it
appears within a scar. It is important
to treat these lesions aggressively,
as the five-year survival rate of a
patient with lymph-node metastases
is only 25 to 45%.5 Contrary to
basal cell carcinoma, precursor
lesions, or actinic keratoses, can
be detected. The latter are most
often treated with liquid nitrogen
or topical treatments to prevent
their transformation. It is estimated
that precursors can transform into
squamous cell carcinoma at the rate
of approximately 1 to 20% per year.6,7
*The author is a dermatologist and a Mohs surgeon at the Maisonneuve-Rosemont Hospital, where he is also the head of the Dermatology Department.
THREE PRINCIPAL
A REVIEW OF SKIN CANCERS
SKIN CANCERS
AND THEIR TREATMENTS
The three principal skin cancers
Squamous cell
are basal cell carcinoma (80%),
carcinoma
squamous cell carcinoma
Melanoma
(16%) and melanoma (4%).1
Exposure to the sun represents
a major risk factor for these
three cancers and, in spite of
prevention campaigns touting
sun protection, the number of
basal cell and squamous cell
Basal cell
carcinomas has continued to
carcinoma
increase in the period from
the 1970s to the year 2000 in
Canada; the lifetime risk of
developing one of these cancers
has almost tripled.2 Melanoma
remains the most lethal cancer;
it is directly responsible for close to
Basal cell carcinoma is the cancer
9,000 deaths each year in the United
most frequently found in humans.
States.3 However, squamous cell
Clinically, it often presents as an
carcinoma which is responsible for
erythemato-squamous plaque
close to 3,000 deaths each year also
or as a pearl-shaped nodule that
needs constant attention.
spontaneously crusts over or bleeds.
A patient who has developed basal
cell carcinoma has a one-in-two risk
of developing another one within
the next five years. Treatments vary
according to the aggressiveness
of the lesion. A lesion with a low
risk of recurrence can simply be by
curettage and cauterised or excised,
while a lesion with a higher risk of
recurrence would benefit from Mohs
surgery. The risk of metastases for
this type of skin cancer is anecdotal,
but basal cell carcinoma can be
very destructive locally, which
can at times require some very
morbid reconstructive surgery or
exenteration for a lesion invading
the eye. A new drug, vismodegib,
an oral antineoplastic, has recently
been approved for metastatic lesions
or locally advanced ones that have
21
MELANOMA IS THE MOST LETHAL SKIN
CANCER AND ITS INCIDENCE HAS CONTINUED
TO INCREASE OVER THE LAST THREE DECADES.
IT IS ESTIMATED THAT ONE PERSON OUT OF FIFTY
WILL DEVELOP AN INVASIVE MELANOMA OVER
THE COURSE OF THEIR LIFETIME.
While squamous cell carcinomas
(with a low risk of recurrence or
metastases) are most often treated
by margin-inclusive excision, lesions
with a higher risk would benefit from
Mohs surgery and, based on their
aggressiveness, will be evaluated with
the help of complementary imagery,
by performing a lymph‑node
dissection or by radiation therapy.
Transplant patients, those with a
suppressed immune system or
suffering from certain chronic
illnesses - such as kidney failure with a squamous cell carcinoma
need special attention due to their
propensity to develop into a more
aggressive disease.
Melanoma is the most lethal skin
cancer and its incidence has
continued to increase over the last
three decades. It is estimated
that one person out of fifty
will develop an invasive
melanoma over the course
of their lifetime. The average
age of those diagnosed with
a melanoma is 52 (35% of
melanomas are diagnosed
before the age of 45),8
which makes it one of those
cancers that, when it is lethal, costs
the greatest average number of years
of life lost. Several risk factors such as
skin phototype 1, family history, the
presence of more than 100 nevi and
genetic mutations have been well
documented, but the main elements
on which it is possible to have an
impact are reducing sun exposure, in
particular severe sunburns and the
use of tanning salons at a young age,9
as well as early melanoma detection.
Prognosis depends on several factors,
the main ones being the thickness
of the lesion at the time of diagnosis,
the presence of metastases in the
sentinel lymph node or distant
metastases. Unfortunately, the
prognosis for a patient with distant
metastases is very limited, with a
five-year survival rate of less than
20% and a median survival of less
than a year.10 It is only recently
that the first therapies showing an
improvement in the rate of survival
have been approved. Ipilimumab,11
an intravenous immunotherapy and,
for patients with a BRAF mutationcarrying melanoma (40 to 60% of
melanomas), targeted molecular
therapies such as BRAF-mutation
inhibitors have succeeded in
improving survival in many patients.12
These new therapies as well as more
recent ones such as PD-1 blockers
(pembrolizumab, nivolumab)13
open the way to encouraging new
therapeutic options.
MOHS SURGERY: A TREATMENT OF CHOICE
22
PHOTO CREDIT: Dr PHILIPPE LAFAILLE
Little or inadequately known, Mohs surgery consists
of excising a skin cancer with the pathological
control of all of the margins of the lesion in the
course of the procedure. This technique helps to limit
recurrence of the cancer while preserving healthy
tissue to the maximum. It was developed in the 1930s
by Dr Frederic E. Mohs, a general surgeon at the
University of Wisconsin. It was subsequently perfected
to the point where today it is the treatment of choice
for several types of skin cancers.
When removing a simple basal cell or squamous
cell carcinoma, the excision is done by resecting
the clinically-visible lesion as well as a margin of
approximately 5 mm of healthy tissue. The skin
specimen is then sent to pathology to be cut
perpendicularly into several slices as one does with a
loaf of bread. It is estimated that only 1% of the tissue
margins are examined by the pathologist when this
technique14 is used which increases the risks of an
undetected incomplete resection.
HERE COMES THE SUN
REFERENCES
1.
Rogers HW, Weinstock MA, Harris AR,
Hinckley MR, Feldman SR, et al. Incidence
estimate of nonmelanoma skin cancer in
the United States, 2006. Arch Dermatol
2010 Mar;146(3):283-7.
2.
Demers AA, Nugent Z, Mihalcioiu C,
Wiseman MC, Kliewer EV. Trends of
nonmelanoma skin cancer from 1960
through 2000 in a Canadian population.
J Am Acad Dermatol 2005;53(2):320-8.
3.
American Cancer Society. Cancer facts &
figures 2009. Atlanta : American Cancer
Society, 2009.
4.
5.
6.
Brantsch KD, Meisner C, Schönfisch B,
Trilling B, Wehner-Caroli J, et al. Analysis
of risk factors determining prognosis of
cutaneous squamous-cell carcinoma:
a prospective study. Lancet Oncol 2008
Aug;9(8):713-20.
Clayman GL, Lee JJ, Holsinger FC,
Zhou X, Duvic M, et al. Mortality risk from
squamous cell skin cancer. J Clin Oncol
2005 Feb 1;23(4):759-65.
Carag HR, Prieto VG, Yballe LS, Shea CR.
Utility of step sections: demonstration
of additional pathological findings in
biopsy samples initially diagnosed as
actinic keratosis. Arch Dermatol 2000
Apr;136(4):471-5.
7.
8.
9.
10.
11.
12.
Ackerman AB, Mones JM. Solar (actinic)
keratosis is squamous cell carcinoma.
Br J Dermatol 2006 Jul;155(1):9-22.
Horner MJ, Ries LAG, Krapcho M,
Neyman N, Aminou R (eds), et al. SEER
Cancer statistics review, 1975-2006.
Bethesda, MD : National Cancer Institute,
http://seer.cancer.gov/csr/1975_2006/,
based on November 2008 SEER data
submission, posted to the SEER web
site, 2009.
International Agency for Research on
Cancer Working Group on artificial
ultraviolet (UV) light and skin cancer.
The association of use of sunbeds with
cutaneous malignant melanoma and other
skin cancers: a systematic review. Int J
Cancer 2007 Mar 1;120(5):1116-22.
Tsao H, Atkins MB, Sober AJ. Management
of cutaneous melanoma. N Engl J Med
2004;351:998-1012.
Robert C, Thomas L, Bondarenko I,
O’Day S, Weber J, et al. Ipilimumab plus
dacarbazine for previously untreated
metastatic melanoma. N Engl J Med. 2011
Jun 30;364(26):2517-26.
Chapman PB, Hauschild A, Robert C,
Haanen JB, Ascerto P, et al. Improved
survival with vemurafenib in melanoma
with BRAF V600E mutation. N Engl J Med.
2011 Jun 30;364(26):2507-16.
13.
Bhatia S, Tykodi SS, Lee SM, Thompson JA.
Systemic therapy of metastatic melanoma:
on the road to cure. Oncology 2015
Feb 15;29(2):126-35.
14.
Rapini RP. Comparison of methods for
checking surgical margins. J Am Acad
Dermatol 1990 Aug;23(2 Pt 1):288-94.
Leibovitch I, Huilgol SC, Selva D,
Hill D, Richards S, Paver R. Cutaneous
squamous cell carcinoma treated with
Mohs micrographic surgery in Australia
I. Experience over 10 years. J Am Acad
Dermatol 2005 Aug;53(2):253-60.
15.
16.
17.
18.
19.
Rowe DE, Carroll RJ, Day CL Jr.
Long‑term recurrence rates in
previously untreated (primary) basal
cell carcinoma: implications for patient
follow-up. J Dermatol Surg Oncol 1989
Mar;15(3):315‑28.
Rowe DE, Carroll RJ, Day CL Jr. Mohs
surgery is the treatment of choice for
recurrent (previously treated) basal cell
carcinoma. J Dermatol Surg Oncol 1989
Apr;15(4):424-31.
Malhotra R, Huilgol SC, Huynh NT, Selva D.
The Australian Mohs database, part I:
periocular basal cell carcinoma experience
over 7 years. Ophthalmology 2004
Apr;111(4):624-30.
Malhotra R, Huilgol SC, Huynh NT, Selva D.
The Australian Mohs database: periocular
squamous cell carcinoma. Ophthalmology
2004 Apr;111(4):617-23.
The Mohs surgical technique was developed in order to
The principal advantage and the raison d’être of Mohs
ensure a complete examination of 100% of the margins
surgery is a reduction in the rate of recurrence of skin
of the excised specimen. The first step consists of cutting
cancers that have been operated on. This has been
the periphery of the lesion at a 45° angle down to the
demonstrated in various studies over the last 30 years.15-19
depth of the lesion parallel to the surface of the skin. It is
Secondly, it also minimizes the surgical defect to the face
thus possible to obtain a disk that, once incised on the
since it avoids having to take significant margins. The
surface, will flatten out so that the entire
initial excision is very conservative
circumference of the disk (lateral margins)
and there will be additional
and its underside (deep margin) will be in a
IT IS FOR ALL OF THESE REASONS resections only if the analysis shows
single plane. The specimen is immediately
the presence of tumour and then,
THAT MOHS SURGERY HAS BECOME only at the precise spot where
frozen and incised, not perpendicularly to
THE TREATMENT OF CHOICE tumour remains. The defect from
the surface, but along this plane, which
will include the circumference and the
FOR SKIN CANCERS WITH lesions located on a lip, an eyelid, a
underside of the disk.
nostril, an ear or close to the edge
A HIGH RISK OF RECURRENCE of a cosmetic unit will potentially
Once the specimen is incised, coloured
be less important and could benefit
and fixed on a slide, the resulting image will
from less-morbid reconstructive
allow for all the lateral and deep margins of the specimen
surgery. Finally, because the analysis is performed on
to be visualized. Another element of the surgery consists
frozen specimens, rather than paraffin-imbedded ones,
of mapping the specimen. A fine cut is made at 12 noon,
Mohs surgery is performed over the course of the
at 4 o’clock and at 8 o’clock on the disk and each incision
same day.
is dyed with a different colour. A sketch of the entire
specimen is drawn to be used during the interpretation
It is for all of these reasons that Mohs surgery has become
process. If a residual portion of the tumour is seen
the treatment of choice for skin cancers with a high risk
under the microscope, thanks to the mapping described
of recurrence such as facial lesions measuring more
previously, it will be possible to establish exactly where the
than one centimetre, carcinomas that have recurred
tumour is sited on the patient. A second excision can then
after a first excision or with more aggressive histological
be performed immediately, at the precise spot where the
characteristics, lesions located on an eyelid, on the
tumour was seen under the microscope, and the process
nose, a lip, an ear, or again in transplant patients, those
will be repeated, on the same day, until all the margins
suffering from chronic lymphoid leukemia or those with a
are healthy.
weakened immune system.
23
BY FRANCINE MATHIEU-MILLAIRE, MD*
BEWARE OF INVISIBLE LIGHT!
After a winter that is long, dark and cold, we all want to take advantage of
the sun, but watch out for its rays! Some of them are harmful to our eyes.
Here is what you need to know.
The cornea is burnt which frequently
happens to skiers, sailing enthusiasts
or anyone after a day spent near the
water. Symptoms appear at the end
of the day or overnight: minor eye
redness, tearing, discomfort, pain,
photophobia and blurred vision.
Artificial tears can relieve symptoms.
Generally, everything returns to
normal within 24 hours.
S
unlight can be decomposed into
several forms of radiation
according to their wavelengths.
Among these, we are familiar with
ultraviolet radiation (UV), the visible
spectrum (white light) and infrared
radiation.
ULTRAVIOLET RADIATION
UV radiation is invisible,
asymptomatic and very dangerous
for the eyes. Its wavelength varies
from 10 to 400 nm and it is better
known as UVA, UVB and UVC. UV rays
are more intense between 10 a.m.
and 2 p.m. They are intensified when
reflected on water, sand or snow.
Careful, some 90% of UV rays pierce
through clouds, in particular UVAs
and UVBs.
24
GAMMA
RAYS
400 nm
X RAYS
ULTRA
VIOLETS
10 to 400 nm
480 nm
VISIBLE
LIGHT
EYE PROBLEMS
The acute eye problem is a sunburn,
also known as snow blindness.
The chronic eye problem results
from the cumulative effects of UV
rays, in particular on the eyelids, on
the crystalline lens (20% of cataracts
are the result of UV rays) and on
the retina. The eyelid is the site of
the greatest number of cancers per
centimetre of skin linked to the sun
(basal cell carcinoma is the most
frequent one, principally on the lower
lid), but we are most familiar with
crow’s feet. To protect yourself, wear
sunglasses with a frame that is large
enough to fully cover your eyelids.
Over the long term, UV rays are
factors in macular degeneration: they
affect the central part of the retina,
which is responsible for the acuity of
vision. In children, these rays reach
the retina more rapidly and intensely
since they are not absorbed by the
crystalline lens. To protect yourself,
wear sunglasses with UV protection
(look for the indication 100% UV or
400 UV). You should also wear a hat
with a wide brim.
INFRARED RAYS
780 nm and over
580 nm
*The author is an ophthalmologist at the Maisonneuve-Rosemont Hospital.
MICROWAVES
THE VISIBLE SPECTRUM
The visible spectrum makes up
the sun’s white light. This light is
made up of different wavelengths
(from 400 to 780 nm), from red
to indigo. We can easily observe
this prismatic phenomenon when
there’s a rainbow. Even if this light
is not dangerous for the eye, it is
responsible for blinding us on very
sunny days.
Despite our natural means of
protection (superciliary arch, eyelids
and pupils), we often have to add
sunglasses. The colours green,
brown and grey are the ones that
offer the most comfort in sunlight.
WARNING: Blue-tinted glasses
are dangerous, as they let though
blue‑violet light rays which are
harmful to the retina.
INFRARED RADIATION
Like UV rays, infrared radiation is
invisible (780 nm and more), but it is
a source of heat and is responsible
for macular burning (retina) in
people who look directly at the sun,
for example during solar eclipses or
after taking drugs.
WARNING: It only takes a few
seconds of looking fixedly at the sun
to irreversibly burn the cells of the
macula and thus cause the loss of
your central vision.
RADIO FREQUENCIES
680 nm
780 nm
HERE COMES THE SUN
BY GENEVIÈVE THÉRIEN, MD*
SUN ALLERGIES
When the next patient to arrive in your office presents with a bright red
face, arms and chest, instead of asking from which tropical paradise he or
she has just returned, ask yourself if a medical prescription could be the
cause of the condition!
POLYMORPHOUS LIGHT ERUPTION
IS A FREQUENT PHOTODERMATOSIS
THAT AFFECTS PEOPLE OF ALL RACES.
WOMEN ARE AFFECTED SLIGHTLY MORE
OFTEN THAN MEN.
P
hotosensitivity reactions
or photodermatoses regroup
several cutaneous illnesses.
The most frequent ones are
polymorphous light eruption and
solar urticaria; patients commonly
call them “allergies to the sun.”
In addition, certain medications,
whether prescribed or not, can
have phototoxic or photoallergic
side effects.
To explain photodermatoses,
ultraviolet (UV) radiation must
be understood. It includes UVCs
(from 200 to 290 nm) which only
penetrate the epidermis very
superficially. These rays are stopped
by the ozone layer and are not
found on the Earth’s surface. Then,
there are UVBs (from 290 to 320 nm)
POLYMORPHOUS
LIGHT ERUPTION
Polymorphous light eruption (PLE)
is a frequent photodermatosis that
affects people of all races. Women
are affected slightly more often
than men. The prevalence of PLE is
higher in temperate climates where
it affects from 10 to 20 percent of
people. It often starts at age twenty
to thirty and the condition improves
over the years in most people. The
itchy eruptions may be papular or
plaque-like, often coalescing. It can
also appear as bullae, vesicles or
edematous plaques, which gave it
its name of polymorphous eruption.
It usually attacks skin surfaces
exposed to the sun, but very rarely
those covered by clothing. Patients
do, on the other hand, remain in
EPL IS TREATED BY AVOIDING
THE SUN AND BY USING
PROTECTIVE CLOTHING OR WIDE
SPECTRUM SUNSCREEN.
good general health. PLE results
from UVBs only in one quarter of
patients, from UVAs and UVBs in
another quarter, and from UVAs only
in one half. It occurs a few hours
after sun exposure and can last from
a few days to a few weeks.
EPL appears after the very first
exposure to the sun and diminishes
or stops with prolonged exposure
towards the end of the vacation
period or the summer, since the
skin acquires a tolerance to UV
radiation. This explains why people
who live in sunny climes are little
affected (between 1 and 5 percent of
the population).
EPL is treated by avoiding the sun
and by using protective clothing
or wide spectrum sunscreen. If
the condition is very symptomatic,
dermocorticoids can be used.
Phototherapy using UVBs or UVAs,
3 times a week, for 4 to 6 weeks
prior to exposure, or antimalaria
drugs such as hydroxychloroquine
can be tried.
*The author is a dermatologist at the CHU de Québec- Hôpital Saint-Sacrement and is responsible for clinical teaching at Laval University.
which penetrate a bit more deeply
in the epidermis and the superficial
dermis. These rays are responsible
for sunburns and skin cancers.
They are mainly present during
the hours of maximum sunlight,
between 10 a.m. and 4 p.m., and do
not penetrate through windows.
Finally, UVAs (from 320 to 400 nm),
penetrate deeply into the dermis
and are responsible for skin ageing
as well as skin cancers. They are
present from sunrise to sunset and
do penetrate through windows.
25
SOLAR URTICARIA IS MUCH RARER THAN POLYMORPHOUS LIGHT ERUPTION.
LIKE PLE, IT CAN AFFECT ALL POPULATIONS AND WOMEN SOMEWHAT
MORE OFTEN THAN MEN.
Rarely, in very severe cases,
prednisone or immunosuppressors
can be used.
SOLAR URTICARIA
Solar urticaria (SU) is much rarer
than polymorphous light eruption.
Like PLE, it can affect all populations
and women somewhat more often
than men. It also generally starts
in the twenties (or thirties) and
presents with papules and
pruriginous edematous
plaques (like a reaction to
nettles), just like other forms
of urticaria, but only in
zones exposed to light.
Phototoxic reactions are caused
by substances which, when taken
in sufficient quantities, will induce
increased sensitivity to the sun in an
individual. They will manifest with
erythema, edema and occasionally
bullae only in areas exposed to
light, within a few hours after
exposure to the sun, just like a very
severe sunburn. UVAs are generally
responsible for this reaction.
It presents within minutes
of sun exposure and persists
for an hour or more and,
in most cases, less than 24.
In the most severe cases,
an anaphylactic reaction
can occur. Solar urticaria is
often caused by visible light
(from 400 to 760 nm), but
UVBs or UVAs alone or in
combination can also be the
cause. Continuing exposure
can bring on a certain
tolerance for some. SU tends
to persist for life.
Basic treatment consists of
non-sedating antihistamines.
Corticosteroids can sometimes help
reduce pruritus. Sun protection
remains important, but is less
effective when only visible light is
involved. Very recently, omalizumab
has been tried with success in
certain cases.
26
OTHER DERMATOSES
All prescribing physicians must
be aware of drug-induced solar
dermatoses, while differentiating
phototoxic reactions and
photoallergic reactions.
Among causative medications,
we find amiodarone, furosemide,
naproxen, chlorpromazine,
ciprofloxacin, doxycycline and
hydrochlorothiazide. This is not a
complete list. The Vigilance Santé
database lists some 300 medications
with photosensitivity side effects.
Photoallergic reactions are less
frequent and only touch certain
predisposed individuals, just like
allergic reactions.
In reality, it is a Type IV
delayed‑hypersensitivity reaction
that involves a sensitization phase, an
incubation phase lasting 7 to 10 days
after first exposure, then a clinical
reaction after subsequent exposures.
Photoallergic reactions are caused by
the application of a substance on the
skin rather than its ingestion. Clinical
presentation is that of a localized
eczema limited to the area where the
product was applied then exposed to
the sun. The principal agents
involved in photoallergic
reactions are, ironically,
organic sunscreen products.
Inorganic (or physical)
sunscreens such as titanium
dioxide or zinc oxide are
never the cause and can be
used without fear by these
patients. Among the other
causes of photoallergic
reactions, are fragrances
and certain antibacterial
products like chlorhexidine
or hexachlorophene.
Polymorphous light eruption
and solar urticaria are not
rare, nor are photosensitivity
reactions caused by
drugs. Do not forget all
the dermatoses that are
aggravated by the sun, including
lupus and dermatomyositis, for
example. Much more rarely, we see
cases of actinic prurigo, hydroa
vacciniforme or chronic actinic
dermatitis. In all cases, sun protection
including a hat, glasses and clothing,
as well as the use of a wide spectrum
sunscreen (FPS 60 and higher) are
essential in addition to staying in
shade areas.
REFERENCES
•
Hawk JL, Lim HW. Photodermatoses, chapter 87 in: Bolognia JL, Jorrizzo JL, Rapini RP.
Dermatolgy. First edition. New York: Mosby, 2003.
•
Hawk JL, Norris P, Hönigsmann H. Abnormal responses to ultraviolet radiation: idiopathic,
probably immunologic, and photoexacerbated, chapter 135 in : Freedberg IM, Eisen AZ, Wolff K,
Austen KF, Goldsmith LA, et al. Fitzpatrick’s dermatology in general medicine. Sixth edition.
New York: McGraw-Hill, 2003.
HERE COMES THE SUN
BY GENEVIÈVE THÉRIEN, MD
VITAMIN D: YES OR NO?
Vitamin D has been the subject of controversy for the last few years.
Should we expose ourselves to the sun? Should we or should we not take
vitamin D supplements? Does vitamin D play a role in protecting us from
certain cancers? Several difficult questions… with answers that are just
as difficult.
In addition, several factors limit the
generation of vitamin D by the skin.
In our cold climate, the synthesis
of vitamin D is inadequate from
November to February-March
because there is less UVB radiation
reaching the earth at our latitude.
As well, people with dark skin
synthesize a lot less vitamin D than
do people with light skin. After the
age of 70, the skin’s capacity to
synthesize vitamin D also diminishes
and that’s not taking into account
that the elderly go outside very
seldom. Then, there are those
who avoid the sun for medical or
other reasons.
SUNBURNS
UVB radiation is needed for the
synthesis of vitamin D, but it also
results in sunburns as well as in
skin neoplasia... without forgetting
that it is always associated with an
exposure to UVA radiation which
is even more damaging, and also
causes skin neoplasia as well as
premature aging of the skin in the
long term. A recent study performed
in Copenhagen among vacationing
occasional skiers has shown that,
after an exposure to UVB radiation
during 6 days, serum levels of
vitamin D increased, but so did urine
levels of thymine-thymine dimers
and toxic photoproducts resulting
from damage to the DNA of skin
cells.3 This study clearly showed that
the creation of vitamin D through
UVB radiation inevitably results in
permanent damage to DNA with all
associated long-term risks.
One fact needs to be noted: in
humans, no study has been able
to demonstrate in any significant
fashion the benefits of vitamin D as
protection against cancer, nor any
other illness, with the exception of
osteoporosis.4 However, some animal
studies did show anti-inflammatory
and anticancerous effects from
doses reaching up to 2,000 units of
vitamin D per day.
In conclusion, vitamin D is important
for our health, in particular for
our bones. However, generating
it through sun exposure results in
permanent damage to DNA with
an increased risk of developing skin
neoplasia over the long-term. Since
sun exposure alone is not able to
provide all our daily requirements
throughout the year and since
food offers very little vitamin D, it
is preferable for people younger
than 70 to take 600 units of daily
supplements, and for healthy people
aged 71 and older, 800 units.5
REFERENCES
1. Helfrich YR, Sachs DL, Kang S. Topical
vitamin D3, chapter 37, in Wolverton SE.
Comprehensive dermatologic drug
therapy. Second edition. Philadelphia :
Elsevier, 2007.
2. Norval M, Wulf HC. Does chronic
sunscreen use reduce vitamin D
production to insufficient levels?
Br J Dermatol 2009 Oct;161(4):732-6.
3. Petersen B, Wulf HC, Triguero-Mas M,
Philipsen PA, Thieden E, et al. Sun and
ski holidays improve vitamin D status,
but are associated with high levels of
DNA damage. J Invest Dermatol 2014
Nov;134(11):2806-13.
4. Oral presentation by Henry W Lim who
reviewed the literature regarding vitamin D
on the occasion of the American
Dermatology Academy conference in
San Francisco in March 2014.
5. Ross AC, Manson JE, Abrams SA, Aloia JF,
Brannon PM, et al. The 2011 report on
dietary reference intakes for calcium and
vitamin D from the Institute of Medicine:
what clinicians need to know. J Clin
Endocrinol Metab 2011 Jan;96(1):53-58.
LET’S RECAP
First off, we need to understand how
vitamin D is synthesized by the skin.
Provitamin D3 is present in plants and
animals and is ingested by humans
through food. In the epidermis,
provitamin D3 is transformed into
previtamin D3 (also called vitamin D2)
by UVB radiation, then into vitamin
D3 under the action of body heat.
Vitamin D3 is then transported to
the liver where it is converted into
25 hydroxyvitamin D3 through the
25 hydroxylase enzyme, then on to
the kidneys where it is converted into
1,25 dihydroxyvitamin D3 or calcitriol,
which is the active form.1 Under the
effects of 1 alpha hydroxylase, the
synthesis of vitamin D by the skin
requires very little sun exposure for
light-skinned people, i.e. exposing
hands, forearms and the face for
5 minutes, 2 to 3 times per week,1
which is quite a lot less than the
population in general, even when
applying sun screen. In truth, the
normal use of sunscreen does not
bring about a vitamin D deficit2 since
most people do not use sunscreen
in sufficient quantities to obtain
the specified sun protection factor
(SPF) and that’s without taking into
account the fact they don’t apply it
uniformly and often don’t reapply it
during the day.
27
BY ÉLISE ST-ANDRÉ, MD*
LIGHT THERAPY: SUNLIGHT ON DEMAND...
L
ast March 29th, La Presse
published a special section
entitled Le printemps exécrable
(A Rotten Spring) in which there was
a text by the humourist, Boucar
Diouf, on our weather-based
schizophrenia, as well as another text
entitled Un printemps de rêve... la
lumière au bout de l’hiver1 (A Perfect
Spring... the Light at the End of
Winter), written by the clinical and
scientific directors of the Centre
d’études avancées en médecine du
sommeil (CEAMS). They described
the effects of light on humans, its
rays at the same time affecting
(whether by their presence or
absence) our moods, sleeping
patterns, concentration, and
attention. Fortunately, people who
are seriously affected by the lack of
light can effectively turn
to phototherapy.
SEASONAL AFFECTIVE DISORDER
Seasonal affective disorder (or SAD)
first appeared in the Diagnostic
and Statistical Manual of Mental
Disorders (DSM) in 1987.3 The
symptoms of depression present a
variability linked to the seasons, with
complete remission at a specific
time of the year. This depression is
often atypical, with symptoms like
daytime fatigue, irritability, excessive
sleepiness, and an increased craving
for carbohydrates resulting in
weight gain.3
28
The theories of causation show an
association with mood disorders at
the physiological and psychological
levels.2 The link between seasons and
psychiatric disorders (manias and
depression) were noted more than
4,700 years ago by the monk, Wong
Tai Sin, then by Hippocrates some
370 years BCE.3 In 1978, Dr Daniel
Kripke linked the variations of bipolar
affective disorder to the seasons.
In 1981, he published a first placebocontrolled study of light therapy in
depression.3
Several studies have tried to further
explain this condition. On the
biochemical side, tryptophan
depletion or serotonergic stimulation
tests suggest that the system in
question could be dysfunctional in
seasonal depression. Other in vivo
tests have shown an immediate
response of the serotonergic system
to light exposure.3
According to one meta-analytical
study in 2001, and while the studies
we reviewed used heterogeneous
methods, the link between the effect
of latitude on daylight and on the
incidence of this disorder is “at best
rather weak.”4 Hypotheses on the
phase deregulation of the circadian
rhythm and the dysfunction of the
serotonergic system, mentioned
earlier, are the physiological
mechanisms that attract the most
attention. There is also increasing
proof of a genetic influence in the
development of SAD.8
TREATMENT
To begin with, light has been used
therapeutically in medicine for a long
time, for various conditions,3 such as
psoriasis, lupus vulgaris or jaundice
in the newborn. Sunlight has also
been used to prevent rickets. A more
modern example is the surgical laser.3
The success of light therapy has
been documented in numerous
controlled studies over recent years.
However, we still do not completely
understand the mechanism of
action in light therapy,8,3 although
we are familiar with the side effects
of bright light therapy (10,000 lux),
i.e. headaches and eye or vision
problems. These effects are rarely
serious or prolongued.8
The neurobiological effect of
light therapy is achieved through
stimulation of the retina which has
a group of specialized neurons to
measure light intensity; it will also
influence the pineal gland and
the production of melatonin (its
*The author is a psychiatrist and the person in charge of continuing medical education at the CHUM.
secretion is suppressed by light).3
In contrast, certain extraoculary
stimulation tests (light directed to
the popliteal fossa) have shown that
the circadian rhythm is affected in
healthy individuals, with a magnitude
and direction corresponding to
the moment of light stimulation
(humoral phototransduction model,
or exposing blood to light would
activate photoreceptors therein).8
When it comes to seasonal
depression, the minimal intensity of
artificial light, needed to generate an
antidepressive effect, is of 2,500 lux
for 2 hours or exposure to a light
of 10,000 lux for 30 minutes. This
latter treatment seems to be safe
(with few side effects) if the light
does not contain substantial energy
from the ultraviolet spectrum.2
Moreover, radiation from the red
wavelengths of the light spectrum
are relatively ineffective. Treatment
with 10,000 lux has a recognized
rapid effect from the 3rd or 4th day
and can also help in cases of sleep
disorders, premenstrual syndrome,
bulimia, seasonal lethargy, jet lag
and to compensate for the effects
of shift work.2 Another method,
simulating daybreak, reduces
the severity of SAD symptoms.
Conclusions diverge regarding the
benefit of adding light therapy to
the pharmacological treatment of
non seasonal depression, with some
stating that it does not add anything
therapeutically,5 while others
recommend its use.3
Light therapy does, however, carry
some inconveniences in terms of the
time required to use it, the cost of the
equipment, and the risk of mania in
bipolar patients. It would be wise to
prescribe the number of lux required
and the amount of time using it, so
that the patient can benefit from its
use... clearly!
The references quoted in this text are available
on the FMSQ portal (fmsq.org).
HERE COMES THE SUN
BY JOËL CLAVEAU, MD*
Information and
complaints :
1 855-729-6688
www.sante.gouv.qc.ca
E
fforts were deployed many years
ago to pass a law in Quebec
aimed at preventing skin cancer
caused by artificial tanning. They
finally succeeded in 2013.
Starting in 1980, scientific proof was
mounting and had demonstrated
the damaging effects of ultraviolet
radiation on the skin. Sun exposure
was clearly linked to the development
of skin cancers. The role of UVA and
UVB radiation was subsequently
identified and linked with damage
to DNA, photodermatoses such as
lupus erythematosus, sun allergies,
a weakened immune system and
photoageing the premature ageing of
the skin.
The Association des dermatologistes
du Québec (ADQ), formerly called
Association des dermatologistes et
syphilligraphes de la province du
Québec, decided to intervene to
protect the lives of the population
and to reduce the morbidity and
mortality associated with skin cancer.
A detailed report which drew a
portrait of current knowledge and
recommendations regarding artificial
tanning was submitted to the Ministry
of Health in April 1988. Despite an
exhaustive review of the literature
and of the scientific evidence at that
time, the government of Quebec
did not take any official position on
the issue.
In September 1988, the Association
des dermatologistes du Québec,
represented by its President, Dr Pierre
Ricard, undertook to approach
the government. A first letter was
sent to then Minister of Health and
Social Services, Madam Thérèse
Lavoie-Roux, asking that tanning
salons be forbidden throughout the
province of Quebec. At the same
period, the American Association
of Dermatology had already taken
position on the danger from artificial
tanning booths using ultraviolet A
radiation. Nevertheless, the popularity
of artificial tanning continued
to grow.
In 1996, I had the opportunity to
work, in cooperation with doctors
Louise Deguire and Marc Rhainds,
on the development of a survey
among the population in order to
measure the prevalence of artificial
tanning equipment use in Quebec.
More than a thousand fair-skinned
individuals, aged between 18 and 60,
were interviewed for this survey. We
were able to establish that 20% of
responders had used this equipment
at least once over the five previous
years. A high proportion of young
women (aged from 18 to 34) and
unmarried individuals were identified
as frequent users of tanning salons
and 36% of them presented with
side effects associated with the
lamps used. In spite of this, a high
proportion of users mentioned
they would revisit tanning salons
in the future, mainly to improve
their appearance.
Adoption and
implementa
tion of a law
making
artificial
tanning illegal
for people
younger
than 18
Expert
committee
mandated
by the MSSS
2013
2012
2011
2010
2009
2008
INSPQ report
demands a
ban of artificial
tanning for
people younger
than 18
WHO asks
world powers
to legislate
2007
2006
2005
2004
2003
2002
2001
2000
The World
Health
Organization
takes a
position and
declares
that artificial
tanning is
harmful
1999
1998
1997
1996
1995
1994
(SEPTEMBER)
The
Association
des
dermatologistes
du Québec
asks the
government
for a total ban
of tanning
salons
1993
The ADQ
evaluates the
use of tanning
equipment
through a
survey
1992
1991
1990
1989
1988
(APRIL)
The MSSS
receives a
detailed report
on the effects
of artificial
tanning
1987
During this same period, a group
made up of representatives from the
field of public health, the Ministry
of Health and medical specialists
(ophthalmologists, geneticists,
community health specialists,
dermatologists and medical
researchers) took part in the joint
committee’s work on the issue of
exposure to ultraviolet radiation and
artificial tanning.
* The author is a dermatologist at the Clinique du mélanome du CHUQ – Hôtel-Dieu de Québec.
1986
1985
1984
Accumulation
of scientific
proof on
the harmful
effects of UV
radiation
1983
1982
1981
1980
LE SPÉCIALISTE I VOLUME 17 • NUMÉRO 2
It is unlawful for minors to use the ultraviolet
ray artificial tanning services offered at this
establishment. You may be required to show
photo identification.
12-269-15A
It’s the law!
© Gouvernement du Québec, 2013
THE RESULT OF
A LONG BATTLE
29
Doctors Ricard, Jacques Tanguay, and myself represented the ADQ
within this working group..
Years passed and more and more scientific publications, fundamental,
clinical as well as epidemiological, confirmed the damaging effects of
artificial tanning and the increase in the risk of developing skin cancers.
In 2004, the World Health Organization (WHO) took a firm stand on
artificial tanning beds, clearly stating that this equipment was harmful
to health by increasing the risks of skin cancers, skin ageing, and
even eye lesions. In 2009, the WHO reiterated its position and asked
government authorities around the world to draw up legislation against
artificial tanning.
Following this position statement from the WHO as well as the
various publications linking artificial tanning to an increased risk of
developing melanoma and other skin cancers, a new working group
was established in Quebec in order to study the problem again. This
committee brought together members of the Institut national de santé
publique, the Canadian Cancer Society, the Direction de la protection de
la santé publique as well as the Ministry of Health and Social Services.
ELSEWHERE IN
THE WORLD
In 2009, Brazil was the first
country to promulgate
a total ban of artificial
tanning. Afterwards,
Australia and England
followed. Other countries
are considering doing the
same as these precursors,
France and New Zealand
in particular.
The ban of tanning booths
for people younger than
18 has been decreed in
California, Germany, Illinois,
Texas and Prince Edward
Island. Other Canadian
provinces will be doing the
same shortly. (PK)
30
In 2011, a document (Analyse des mesures
réglementaires portant sur l’utilisation
des appareils de bronzage par les jeunes
âgés de moins de 18 ans) was produced
under the supervision of the Institut
national de santé publique and delivered
to the MSSS. The document contained a
firm recommendation to regulate tanning
salons in Quebec for people younger than
18 and was presented to the Minister at the
time, Yves Bolduc.
All of these efforts took place at the same
time as an important petition launched
by the Canadian Cancer Society was
deposited to the Ministers and Delegates
of the National Assembly. An information
campaign aimed at the public, the
media and elected representatives
also contributed to tipping the scales.
This finally led to the adoption of the
Act to prevent skin cancer caused by
artificial tanning, which took effect in
February 2013.
This important team effort, led by the Association des dermatologistes
du Québec finally gave rise to the implementation of a clear policy
aimed at protecting our young people: a collaborative effort in which
dermatologists worked relentlessly under Presidents Pierre Ricard,
Pascale Marinier, Chantal Bolduc and Dominique Hanna. The next steps
now consist of making sure the law is effectively implemented and
possibly to widen its application to the entire population.
WHAT ABOUT
CLIMATE CHANGE?
Is there a link between climate
change, a subject many are talking
about, and ultraviolet radiation?
Le Spécialiste consulted a public
health expert. Here is his response.
W
orried about the
depletion of the
ozone layer, which
blocks UV radiation in the
stratosphere (altitude from
12 to 50 km),
Yv Bonnier Viger, MD environmentalists have been
wondering about the
influence of UV radiation on climate change.
But will climate change, for its part, have an
effect on UV radiation?
UV radiation contributes to our planet’s
warming. It has the power to modify the
carbon cycle both in the seas and on dry
ground. Thus, climate change and the increase
in UV radiation together play a role that can
“reduce the biological fixation of carbon in
aquatic systems, thus modifying the
absorption of CO2 by the oceans. Researchers
agree that climate change can also reduce the
upwelling and availability of nutrients for
phytoplancton, thus resulting in new
interactions between the sun’s UV radiation
and the biological fixation of carbon.”1
In turn, climate change modifies the
temperature of the stratosphere. Low altitude
warming, because of the greenhouse effect,
is accompanied by a cooling of the
stratosphere.2 This cooling diminishes the
speed of ozone regeneration.3 So, yes, it does
seem that climate change will contribute to an
increase in UV radiation on our planet.
If the multiplication of heat islands, the
reduction of food production, the
multiplication of parasites and the risks of
extreme weather events were not enough to
worry us, we can now add the effects of
climate change on the health of our
populations and the increase in UV radiation!
Yv Bonnier Viger, MD,
President of the Association des médecins spécialistes
en santé communautaire du Québec
The references quoted in this text are available on the FMSQ portal (fmsq.org).
The references quoted in this text are available on the
FMSQ portal (fmsq.org).
PHOTO: LANOUVELLE.NET
HERE COMES THE SUN
BY CHARLES BEAURIVAGE, MD*
A
heat wave in mid-July:
33 oC with a humidex factor
at 38. I would so like to take
advantage of this great weather
and ride my bike, but I’m on call
in the Intensive Care Unit. No matter,
my vacation is approaching and
I’ll have the opportunity then
to go biking! At this point, an elderly
lady is brought in, having been found
in her overheated apartment: she
is confused and feverish. On my way
to her bedside, I silently review what
I know.
Our body temperature is essentially
generated by our cellular metabolism
and by absorption of ambient
temperature. Everything is closely
regulated by the nuclei of the anterior
hypothalamus which are linked by
fibres to the autonomous nervous
system which in turn controls
sweating and skin vasodilation.
Getting rid of heat can thus be
achieved through four mechanisms:
evaporation (which does not work if
the humidity level is higher than 75%),
radiation, conduction and convection
(the latter three are ineffective if the
external temperature is higher than
body temperature). When these
mechanisms are overloaded or when
metabolic activity increases, a harmful
increase in body temperature occurs
with greater oxygen intake (O2),
tachycardia, tachypnea, uncoupling
of oxidative phosphorylation (beyond
42 oC) resulting in a systemic
inflammatory response mediated by
cytokines and the synthesis of thermal
shock enzymes. The splanchnic bed
is diverted thus benefitting skin and
muscle circulation and increasing the
permeability of the intestinal mucosa.
This will be followed by dysfunction
of the liver, of the vascular
endothelium and of neural tissues
ending with multi-organ dysfunction
and disseminated intravascular
coagulation (DIC).
DIFFERENTIAL NOTIONS
These notions help to differentiate the
classic heat stroke from heat exhaustion
induced by exercise, according to
the population that is affected and
the circumstances surrounding
its appearance:
1. Classic heat stroke occurs most
often in geriatric patients, but also in
those who cannot escape extreme
temperatures and humidity and
who do not hydrate sufficiently.
The latter are generally individuals
with reduced mobility, children
abandoned in a vehicle, individuals
with neurological or psychiatric
disorders, or those under the effect
of drugs;
2. Heat exhaustion occurs in a young
and active population exercising
under conditions of extreme
heat and humidity. People with a
certain susceptibility to malignant
hyperthermia are also included in
this group.
The most common signs of heat
stroke are tachycardia, low blood
pressure, body temperature over
40 oC, weakness, nausea and bleeding,
pulmonary edema, irritability and
delirium that can even lead to a coma.
The skin is usually hot, but it will be
cool in cases of severe dehydration.
To summarize, within 48 to 72 hours,
the condition may be complicated
by the addition of acute respiratory
distress syndrome (ARDS), disseminated
intravascular coagulation, acute
renal failure (ARF), occasionally
massive hepatolysis, hypoglycemia,
rhabdomyolysis and convulsions.
Based on an appropriate case history,
a diagnosis is easy to reach, but for a
differential diagnosis one must always
take into consideration the possibility of
a stroke (or CVA), sepsis, a neuroleptic
malignant syndrome, a thyroid storm,
acute antipsychotic withdrawal or
anticholinergic intoxication.
Prevention is needed during hot
summer days, in particular through the
use of air conditioning. It is much easier
in cases involving exercise by having
*The author is a specialist in internal medicine and the coordinator of university teaching at the
Hôtel-Dieu d’Arthabaska.
Treatment is in three stages:
1. At first, stabilize vital signs,
reanimate and protect airways
(up to 85% of people affected
will develop respiratory
failure requiring intubation).
If needed, this could include
the installation of a central line,
hydration by isotonic saline IV
while avoiding alpha-adrenergic
medication.
2. Then, proceed with rapidly
cooling the person in order to
reduce morbidity and mortality,
which varies from 21 to 63% and
is directly linked to the body
temperature that was reached,
the delay before cooling
manoeuvres are implemented
and the number of dysfunctional
organs. There are no studies
that recommend a particular
approach, but ice baths should
be avoided except in cases of
physical exertion. Cooling by
spraying with lukewarm water
and by pushing the air around
is easy and fast: chills and
discomfort are relieved by the
intravenous administration of
benzodiazepine. Other methods
can be used if needed, such
as IV solutions at 22 ºC, cold
packs applied to the groin and
underarm areas and, where the
situation requires more invasive
interventions, pulmonary,
bladder or peritoneal lavages.
3. Finally, deal with the
complications that can
develop within 72 hours of the
heat stroke.
good hydration, avoiding stimulants
and alcohol before the exercise,
acclimatizing the athlete over a period
of 10 to 14 days before the exercise
and by evaluating the environmental
risks for heat-related disorders (wet
bulb globe temperature, if available, or
humidex factor) in order to choose the
training intensity and duration.
All in all, the day I spent at my patient’s
bedside convinced me that it would be
better for me to delay my bike ride until
the end of the day, when the heat is
less intense.
The references quoted in this text are available
on the FMSQ portal (fmsq.org).
BAD HEAT STROKE!
31
PREVIOUSLY IN THE NEWS
Don’t miss the most important
interdisciplinary assembly
of medical specialists in Quebec!
THE DARK SIDE
OF SOCIAL MEDIA
Response to Dr Pascale Hamel’s text
published in March
Friday
November 13, 2015
Québec City Convention Centre
Dear Doctor,
I read with interest your article entitled
“The Dark Side of Social Media” in the last issue
of the Spécialiste magazine. I am entirely of
the same opinion, having witnessed the same
injustices myself for 50 years.
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(limited space)
LES ACTUALITÉS
LE CÔTÉ OBSCUR DES MÉDIAS SOCIAUX
Le 15 décembre dernier, la une d’un journal présentait l’histoire de parents
qui se disaient insatisfaits des soins donnés à leur bambin dans
un centre hospitalier.
L’
histoire n’allait pas
s’arrêter là pour ces
parents, puisque
ceux‑ci ont également
entrepris une campagne de
dénonciation dans les
médias sociaux. La liberté
d’expression est un droit pour
tous et permet l’ouverture de
multiples voies de communication
démocratiques : tout un chacun peut à
loisir critiquer et expliquer sa position.
Pascale Hamel, M.D.*
Il en est tout autrement en médecine :
le code de déontologie interdit toute
information concernant un dossier
ou un patient. Lorsqu’une enquête est
ordonnée sur un cas, le médecin ne
peut émettre de commentaires. Les
armes sont inégales : l’une des parties
est souvent condamnée d’emblée…
à tort ou à raison.
Dans l’histoire en question, des parents
insatisfaits des soins prodigués à
leur enfant ont écrit sur Facebook
un texte sur leur vision de l’état de
leur enfant et des soins donnés à ce
dernier, et ce, en citant le nom des
intervenants, autant les infirmières
que les médecins, et « leur supposée
incompétence ». Le texte a, en peu
de temps, été partagé par des milliers
d’internautes et des menaces ont été
faites directement et indirectement
envers l’hôpital et les médecins !
L’histoire a été reprise telle quelle par
d’autres médias.
Or, nous savons avec l’expérience,
que, souvent, lorsque les gens sont
inquiets, ils n’entendent pas ou
n’écoutent pas ce que le médecin
leur explique. En pédiatrie, on
comprend que des parents peuvent
être paniqués par le diagnostic de
leur enfant. Les docteurs doivent
composer avec cette fragilité et
trouver comment les rassurer. Qu’on
se le dise, certains parents sont
difficiles à rassurer et sont convaincus
d’avoir raison. Malheureusement,
certains n’hésitent pas à dénoncer, à
prendre des photos à l’insu des gens,
à donner des noms et des détails
pour expliquer leur mécontentement.
La suite est catastrophique : les
cicatrices laissées par ces propos ne
peuvent que blesser profondément
ceux qui se dévouent pour la santé de
la population.
Cependant, en soutien au
personnel affecté et pour dénoncer
l’intimidation, spontanément, j’ai
rédigé cette lettre d’opinion.
INTIMIDATION ET DIFFAMATION DANS LES MÉDIAS SOCIAUX : JUSQU’OÙ PEUT‑ON ALLER ?
Pédiatre depuis vingt ans, présidente de l’Association des pédiatres du Québec depuis cinq ans, je ne peux rester muette face à
ce qui est parfois publié dans les réseaux sociaux à l’égard de certains de mes collègues, depuis quelques mois. Comme parent et
comme pédiatre, j’essaie d’éduquer mes enfants et mes patients sur ce qu’est l’intimidation, mais je crois que même les parents ont
besoin d’être éduqués sur ce fléau !
En utilisant les médias sociaux, il est maintenant trop facile de salir la réputation de quelqu’un en un clic. Politiciens, policiers,
chauffeurs d’autobus, professeurs ; tous sont susceptibles d’y passer ! Encore plus facile, s’il s’agit d’un médecin, simplement en
manifestant son insatisfaction pour les soins prodigués par le médecin et en publiant son nom, sa profession et son lieu de travail.
Le médecin, lui, est tenu au silence par le « secret professionnel ». Et, quand celui-ci dit qu’il ne fera pas de commentaires, ce n’est
pas parce qu’il ne souhaite pas donner sa version des faits, mais plutôt parce qu’il ne le PEUT PAS, ni dans les médias sociaux ni
dans les médias traditionnels.
HERE ARE A FEW OF THE SESSIONS
THAT WILL BE PRESENTED:
32
•
Vascular surgery in the geriatric patient:
an interdisciplinary adventure
•
For a better “head and neck” practice: ORL
and radiologists get together
•
Gastroenterologist and surgeon: an
unavoidable partnership
•
Seeing with the brain
•
Neurotoxicity: what if a piece of the puzzle was in
the workplace?
•
Fire and blood: cytopenias and infectious
complications in oncology
•
Adverse food reactions from immunological
causes: from an IgE-mediated allergy to a
non‑IgE enteropathy
•
Eosinophilic oesophagitis: an issue for children
and adults
•
High-sensitivity troponins: advantages and
challenges of daily use
•
Sick building syndrome
•
As well as several Federation workshops
LE SPÉCIALISTE I VOLUME 17 • NUMÉRO 1
Or, les plaintes à l’égard des médecins sont tout à fait possibles et souhaitables, si fondées. La population peut s’en référer au
Collège des médecins du Québec dont le mandat est de promouvoir une médecine de qualité pour protéger le public et de
contribuer à l’amélioration de la santé des Québécois. Le processus est sérieux et les médecins fautifs sont sanctionnés.
8
Hélas, il est maintenant trop facile d’aller sur la place publique, de propager des informations partielles ou erronées, de dénigrer,
d’abonder dans les ouï-dire ; bref, de porter atteinte à la réputation d’une personne.
Jusqu’où peut-on aller sans que les choses ne dérapent ? Les médias sociaux ont du bon, mais ils peuvent aussi faire beaucoup de
tort, gratuitement, sans possibilité de réagir, de s’expliquer, de se défendre, à tout le moins pour un médecin…
Il est important de se servir de son jugement avant de cliquer sur le bouton « partager » de Facebook. La sagesse, c’est connu, ne
fait de mal à personne !
* L’auteure est pédiatre à la Cité‑de‑la‑Santé de Laval et présidente de l’Association des pédiatres du Québec
However, I ask myself if
there is a way to modify
to our advantage
this show of strength
between aggressive
patients and intimidated
physicians. Because,
we have to admit, our
attitude resembles
that of an ostrich with
its head in the sand
waiting for our lawyers
to settle the issue.
I believe that a more aggressive attitude on our
part could have an enormous impact.
Why not immediately undertake a counter-suit
against these patients and reporters seeking fame
as was recently done in France, for example, in
the case of the no less famous neurosurgeon
to the stars, Dr Stéphane Delajoux? The good
doctor held on to his reputation and everything
died down gently, despite the commotion
caused by the media and relayed unceasingly on
the Internet.
Should we modify the laws dedicated to the
protection of patients, or should there simply be a
new one designed to protect physicians?
In this country, anyone can attack any reputation,
no matter how many years it took to establish it.
Social media are the proof of it every day. It’s time
for this to stop and for us to find a way to make
it clear that one cannot say whatever one wants
against a physician and avoid the consequences.
Wouldn’t this be a fine issue for the CMPA?
Jacques Laferrière, MD
Oto-rhino-laryngologist, CSSS Pierre-Boucher
For complete details:
fmsq.org/jfi
S
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GREAT NAMES
IN QUÉBEC MEDICINE
BY PATRICIA KÉROACK, C.W.
THE INDOMITABLE POISON HUNTER
In May, our Great Name in Quebec Medicine received the
Prix d’excellence 2015 from the Collège des médecins du Québec (CMQ)
in recognition of his ceaseless efforts to create the Québec Poison Control
Centre and to earn respect for its mission. It was by chance that, at the same
time, Dr Blais was being considered by the magazine Le Spécialiste.
After classical high school studies
in Montmagny, he went to
Sainte‑Anne‑de-la-Pocatière to
finish his classical course, then was
accepted at the Faculty of Medicine
of Laval University. In 1972, diploma
in hand, he became, and remained
until the year 2000, a physician in
the Emergency Department of the
CHUL. The work was demanding,
but very stimulating! He says that the
lifestyle suited him perfectly. Dr Blais
especially liked to find himself in the
middle of the action, looking for a key
to the enigma that would allow him to
save a life in extremis, or sometimes
that of several people. At the
beginning, emergency medicine
was not recognized as a medical
specialty but, taking Dr Blais’ practice
history into consideration, the Royal
College accepted his candidacy for a
fellowship in emergency medicine.
Within its emergency department,
the CHUL had instituted a poison
control centre. That is where Dr Blais
met with toxicologists , collaborated
with them, and thereby discovered
a sector of activity from which he
added to his knowledge. With his
toxicologist colleagues, he equipped
his department with treatment
guides for intoxication by various
products (in particular, household
products) or by medications, for
adverse reactions, on antidotes, and,
in fact, on everything he had seen
in emergency. He developed links
with colleagues all over Quebec
who, in turn, contributed to the
guides and tools at the CHUL’s
Dr René Blais
Emergency Medicine Specialist
poison control centre. His expertise
extended way past the framework
of his hospital duties: he multiplied
his scientific presentations and
clinical training. He was interested
in all the substances that could
cause an intoxication: chemical
products of all kinds, food, natural
products, medications, etc. The rest
of his career was proof of it. Our
Emergency Medicine Fellow decided,
in 1986, to take the exams that would
lead to a diploma from the American
Board of Medical Toxicology.
Thanks to financing obtained from
the Ministry of Health, in 1986, the
CHUL converted its regional centre
into a new service available to
the entire population of Quebec.
This was the start of the Québec
Poison Control Centre (CAPQ),
a telephone reference service in
case of intoxication; a telephone
number that is still found on the
refrigerators and notebooks of
parents, corporate managers and
healthcare professionals. Dr Blais is
its medical director.
THE CENTRE OF A CAREER
It can be said that the CAPQ is
intimately linked to Dr Blais’ career…
the reverse is also true! When he
accepts to speak of himself, it’s
mainly the Centre he speaks of...
with reason, since the Centre is the
only facility specialized in toxicology
in Quebec.
The CAPQ is also called upon to
participate in committees working on
issues for industries using dangerous
or toxic products. “For example,
we worked with the Association
québécoise de la gestion parasitaire
to make sure that the substances
and compounds are used as securely
as possible. Today, exterminators
have a flyer for each product used
and, on each flyer, there’s the CAPQ
telephone number,” he explains.
The Sûreté du Québec, the Ministère
de la Sécurité publique, the Royal
Canadian Mounted Police have
all called upon Dr Blais’ expertise,
in particular for the development
of anti-terrorist measures, for the
use of Cayenne pepper or stun
guns, for illegal drugs, for the
development of scientific documents
on antidotes and to write the
guidelines for crisis management
in case of exposure to various toxic
substances (for example, suicide by
hydrogen sulphide).
Dr Blais’ expertise is also called upon
to contribute to medical-legal, civil,
criminal or coroner’s investigations.
His expertise is always solicited and
Dr Blais hopes to continue this kind
of activity after he retires.
O
riginally from the Montmagny
region, René Blais was the
sixth child in a family of nine.
As a young man, he realized he had
an affinity for science, in particular
pharmacology. His elder brother,
a medical physicist in a large
hospital in Québec City, became
his inspiration. Each day, René Blais
dreamt of having his own career
in health care.
33
GREAT NAMES
IN QUÉBEC MEDICINE
A CENTRE THAT MOVES AROUND
At the start, and to Dr Blais’ great
satisfaction, the CAPQ was located in
and was an integral part of a hospital.
Physician toxicologists could then
provide clinical consultations and
follow patients who needed to be
hospitalized. “It was the best of
worlds,” said Dr Blais.
Numerous hospitals would have
liked to welcome the CAPQ, but in
Dr Blais’ opinion, “it would seem
that the MSSS had decided that
it would remain in Québec City,
possibly because we could then
benefit from the resources of the
toxicology centre which was at the
same location. At the time, we were
in the CHUL. Then, in 1999, Minister
Jean Rochon, by creating the Institut
national de santé publique (INSPQ)
transferred the Centre de toxicologie
du Québec and the CAPQ to it.”
This move didn’t last for long.
Because it was providing services
directly to the population, the
CAPQ was returned to the direct
care network. In 2001, because
of the 24/7 telephone services it
offered, the Centre was moved to
be partnered with the Info-Santé
de Québec service, an entity of the
CLSC Haute-Ville et des Rivières.
If, at first glance, once could think
that everything was for the best,
Dr Blais says that “This was only
the case at the administration level,
because for us, we suffered a loss.
Personally, I would never have
moved the Poison Control Centre
out of the hospital. We lost the
clinical consultation aspect, as well
as contact with the patient and even
with our replacements,” he tells us.
Today, the CAPQ still has the same
administration, but it is situated in
offices in the Jeffrey-Hale pavilion.
34
Even though all these forced moves
created a lot of worries for him,
Dr Blais always knew how to the
keep the CAPQ in operation. Even
after 29 years of existence, some of
his colleagues, who were with him at
the beginning of the CAPQ, are still
actively on duty there.
AN IMPORTANT TEACHING ROLE
The Centre is also recognized
for its teaching role. No less than
300 residents have already spent
at least a month there. “Until 1999,
our residents could accompany us
on rounds of hospitalized patients.
We could then interest them in
our work, but this was not possible
afterwards. It’s a part of the work that
could have been preserved,” he says.
Even if the hospital setting is missing,
the CAPQ continues to pursue
its mission to welcome residents
who will learn the art of telephone
listening and of calling back patients.
It’s during the first call that advice is
given to reduce the urgency of the
situation. Calling back allows us to
look further into the case. “I often
tell my residents that, if they miss a
diagnosis, they should go back and
see which question they should
have asked the patient. They should
go back to their notes. There’s the
temptation to perform a bunch of
costly texts in order to finally arrive
at the wrong answer.” It is Dr Blais’
opinion that this is very valuable in
training these residents who will
often become emergency medicine
specialists, pediatricians or intensive
care specialists.
FOLLOWING DEVELOPMENTS
Dr Blais has been on many podiums
to ensure the CAPQ is known.
He collaborated with multiple
stakeholders to develop all kinds
of tools to help treat intoxications.
Among these, there is a guide
entitled Les antidotes en toxicologie
d’urgence, published in 1997 for
the first time. The Centre recently
developed and put on line an
Internet site on antidotes, a precious
tool for healthcare professionals.
There is now the question of
converting it into a mobile
application. This tool could be
translated and exported worldwide...
on condition of having the money
to launch such a project!
In addition, with the pharmacist
Pierre-André Dubé, Dr Blais
collaborated on the creation of
an antidote registry. “Very often,
these antidotes are not bought or
stocked by hospitals, because they
are expensive. The registry allows
us to rapidly see who has some on
hand. The day a case of poisoning
arrives, this tool allows us to find the
needed antidote and save lives,” he
declares proudly.
FROM ONE PASSION
TO ANOTHER
Over the years, Dr Blais has knitted
professional links with mycologists.
This collaboration led to the creation
of a list of available mycologists in
case there is a need to identify a
mushroom. Mycologists provided
him with a lot of knowledge for his
work, in particular for the creation
of treatment guides. He co-wrote
a chapter of the book L’univers des
champignons where he dealt with
fungal intoxications. But it was the
field trips that really developed his
passion. Unfortunately, this passion
is in conflict with another one:
the game of golf. All mycologists
will say that “The best day to hunt
mushrooms is a mild day... especially
after warm rains.” On the other hand,
the golfer interrupted by rain thinks
only of going back to the links, as
soon as the last raindrop has fallen.
And, since both activities require
practice to improve, the choice
becomes difficult for Dr Blais!
When the weather is not right
for field trips, our antidote expert
likes to experiment with agar,
calcium lactate, sodium citrate and
everything that can foam, pearl,
emulsify, gel, etc. This passion for
molecular cuisine, he intends to
develop later, after retirement!
Dr Blais still has a lot of projects
in mind. He dreams, that, after
retirement, he will continue to
provide the nearly unique expertise
which took him years to develop
to benefit people who have a need.
Teaching has always been one of
his passions, as well. A few decades
later he likes to repeat that medicine
is an art and that we have to remain
vigilant and keep loving our work.
S
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OUR SUBSIDIARIES
BY NATHALIE B. POISSON, LLB, DDN | NOTARY
PROFESSIONNALS’ FINANCIAL
REFORM OF THE QUEBEC CODE
OF CIVIL PROCEDURE
Several changes are notable,
specifically in matters of the law
of succession and homologation
procedures for protection mandates
in anticipation of incapacity. Here is
a summary:
LAW OF SUCCESSION
The most important addition to
be made is in the third paragraph
of Section 478 of the new Code of
Civil Procedure which specifies that,
following the death of an individual
renting a safe deposit box, minutes
will have to be drawn up to list the full
contents of the safe deposit box and
that only a notary will be authorized
to draw up such minutes. No such
rule exists at present, since the
liquidator of the estate is authorized
to open the safe deposit box of a
deceased person alone and to remove
its contents. Interested persons are
reduced to trusting the liquidator’s
good faith to declare the objects of
value or the sums of cash money it
contains. Creditors of the deceased
individual (including tax authorities)
could benefit if the minutes of all safe
deposit boxes were to be found in the
Registers of Quebec notaries!
HOMOLOGATION OF A
PROTECTION MANDATE
Another new item: as soon as the
new Code of Civil Procedure is
adopted, the term to designate
a mandate in anticipation of
incapacity will be “protection
mandate.” At present, requests for
the homologation of a protection
mandate need to be signified and
notified to the incapacitated person
directly, to the mandatary, to the
substitute mandatary (named in case
it is impossible for the mandatary to
act), to the Public Curator as well as
to the spouse, a close family member
or a person showing a special interest
for the incapacitated person (Section
884.7, Paragraph 2 of the current Code
of Civil Procedure). Section 404 of the
new Code stipulates that it will also
be necessary to notify the person
designated in the protection mandate
to receive a rendering of account, or
the report of the mandatary during
his or her administration. An alternate
must therefore also be named. In
the absence of a substitute, and
if only one person is named and
he or she passes away before the
mandator’s incapacity, if he or she
refuses the mandate or cannot accept
it, the homologation procedure for
the protection mandate could be
unduly complicated.
A modification, but a disappointing
one, in the second paragraph of
Section 313 of the new Code:
beginning next January 1st, if
requested by one of the persons
who has received notification of an
application for homologation of a
protection mandate, the notary is
required to call a meeting of relatives,
persons connected by marriage or
civil union, and friends, even during
the homologation procedure for the
protection mandate. If such a request
is made when family feelings are
tense or conflictual, we can assume
that the homologation procedure
will become cumbersome and that
several complications could ensue.
This measure is surprising as it
appears contrary to the objective of
simplifying procedures as planned
by the legislator. By virtue of current
laws, the advantage of having a
protection mandate resides in
the fact that, if a person becomes
incapacitated and has a protection
mandate, he or she avoids the long
and costly procedure of instituting
protective supervision that, among
others, requires that the assembly of
peers mentioned above be convened.
TECHNOLOGICAL SHIFT
Section 26 of the new Code of
Civil Procedure advocates the use
of all appropriate technological
means, as much for the parties
as for the court. In the case of
applications regarding a minor or
an adult, for example, Section 405
of the new Code allows the use
of technological means (such as
FaceTime, Skype or a teleconference)
during an assembly of relatives,
persons connected by marriage or
civil union, and friends, in order to
facilitate communication between
the persons convened: it would be
authorized if these individuals reside
in different locales. However, a lot
of the information shared during
these meetings being confidential
(the reading of the medical and
psycho-social evaluations of an
incapacitated person, for example)
it will be necessary to ensure that
all participants are in an isolated
and private place and this, in order
to respect the integrity of the
incapacitated person concerned.
Do you have any questions
concerning the impact of this
reform? Professionals’ Financial offers
assistance services for the writing of
a will and protection mandate: talk to
your advisor about it!
Professionals’ Financial Inc. is the exclusive owner of Professionals’ Financial – Mutual Funds Inc. and Professionals’ Financial –
Private Management Inc. Professionals’ Financial – Mutual Funds Inc. is a portfolio manager and mutual fund manager which
manages its family of funds and offers financial planning advisory services. Professionals’ Financial – Private Management Inc. is
an investment broker, member of the Investment Industry Regulatory Organization of Canada (IIROC) and the Canadian Investor
Protection Fund (CIPF), which offers portfolio management services.
Our current Code of Civil Procedure,
in effect since 1965, has been in great
need of updating and the time has
come to simplify rules of procedure
to lighten the load on our courts.
Preliminary provisions of the new
Code of Civil Procedure of Quebec,
which should come into effect next
January 1st, stipulate that its adoption
aims at ensuring access, quality and
promptness of civil justice.
35
JE SUIS UN MÉDECIN
ASSURÉ PAR SOGEMEC
SOGEMEC vous comprend le mieux
puisqu’il fait partie de vous depuis 35 ans.
Une filiale de la Fédération des médecins spécialistes
du Québec, conçue par des médecins pour des
médecins : Voilà pourquoi nos protections suivront
PUBLICITÉ
PLEINE PAGE
parfaitement vos besoins ainsi que ceux de chacun
des membres de votre famille.
Sogemec Assurances
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NOUVEAUX MEMBRES DE LA FMSQ
Dans les 90 jours suivants la fin de votre résidence, vous pouvez adhérer sans preuve médicale aux
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Assurance frais généraux de bureaux
Assurance vie
3 000 $
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100 000 $
CONTACTEZ-NOUS : 1 800 361-5303
[email protected]
* Montants adminissibles pour les moins de 35 ans. Pour les plus de 35 ans, communiquez avec nos conseillers pour connaître les montants
admissibles sans preuve.
Communiquez sans tarder avec un conseiller pour en savoir plus !
OUR SUBSIDIARIES
BY CHANTAL AUBIN | ASSISTANT DIRECTOR
DAMAGE INSURANCE BROKER
SOGEMEC ASSURANCES
COMPARE AND YOU WILL UNDERSTAND!
MUCH MORE THAN
A DRUG INSURANCE
Like all Quebeckers, you must have
a drug insurance policy. Because
you are members of a professional
association, you are not eligible
for the public drug insurance plan.
This is why you turn to private
plans offered by your Federation,
your employer, your spouse’s
insurance plan or other professional
associations of which you are
a member.
It can be difficult to separate the
advantages and costs of the different
insurance plans to which you could
be eligible. Our team at Sogemec
Assurances is there to help you see
clearly. The FMSQ’s plan provides you
with a protection that is not limited
to the drugs on the approved RAMQ
list (options 1 and 2 of the plan
offered), but rather to all prescription
drugs, in addition to reimbursing you
for preventative vaccines. Here are a
few important provisions that should
be included in your contract. If you
are unable to find these provisions,
get in touch with us without delay in
order to discuss and compare them.
A FEW IMPORTANT PROVISIONS
TRIP AND TRIP
CANCELLATION INSURANCE
Whether you travel to take part in
a congress or simply for pleasure,
Sogemec Assurances allows you to
leave worry-free.
In fact, you and your family benefit
from trip and trip cancellation
insurance protection at all times. This
protects you in case of any health
problem that can suddenly and
unexpectedly occur while you are
abroad. The protection offered by the
FMSQ plan covers you for all stays
abroad lasting up to 182 days. For
those of you who foresee staying for
a longer period, such as in the case
of a fellowship, this protection can
be extended to cover the complete
length of your stay a no extra cost.
WAIVER OF PREMIUMS DURING
TOTAL DISABILITY
Should you become totally disabled
(for a period of six consecutive
months of total disability in the
FMSQ disability plan) as a result of an
accident or illness, the plan offered
by Sogemec exempts you from the
premium, which means that you
would not need to pay the premium
during your period of disability.
AGE OF INSURANCE
TERMINATION AND EXTENSION
OF PROTECTION IN CASE
OF DEATH
While some plans end when
members reach the age of 70, 80
or 90, and even age 55 for the
Association des jeunes médecins
du Québec plan, you will be happy
to learn there is no age limit for
health insurance coverage in your
Federation’s plan. The coverage
remains in effect as long as
you wish, as long as you pay
the premium!
In addition, your spouse will have
the possibility of retaining the
health insurance coverage in
case of your death. This provision
allows you to ensure your family
is protected after your death and
allows them to keep the same level
of insurance coverage.
SERVICE OFFERED
While it’s true this is not specified in
an insurance contract, you will agree
that the provision of service is one of
the important aspects of insurance
coverage. For example, what would
you do if the insurance broker, who
convinced you to sign up for the
plan he is promoting, provided no
service whatsoever once you paid
your premium? It is important you
make sure you do have the benefit of
pre-sale service, as well as after-sale
service to help you if needed when
putting in a claim. As you know, it is
not always easy to make one’s way
through the clauses in insurance
contracts. Descriptions vary from one
insurer to the next. Know that you
can always count on the members
of the Sogemec team to help you
and explain your coverage. They will
make sure your insurer reimburses
you what you are entitled to.
TELL US WHAT CONSTITUTES AN
IMPORTANT PROVISION FOR YOU
As you know, our objective is to
offer you products that meet your
needs. We would thus like to know
what your expectations are insofar
as the coverage that is currently
offered to you is concerned.
We therefore invite you to send us
any comments or suggestions to:
[email protected]
We will compile the suggestions we
receive and, in cooperation with a
firm of actuaries, we will evaluate the
impact this would have on premiums
in order to offer you the plan that
you want.
Don’t hesitate. Get in touch today
with members of the Sogemec
Assurances team to compare your
current plan and to make your
suggestions concerning the FMSQ’s
insurance plan so that it becomes
or remains YOUR drug and health
insurance plan.
Since January 1, 1997, through its
subsidiary Sogemec Assurances,
the FMSQ is required to offer a
drug insurance plan to its members
in order to comply with the Act
respecting prescription drug
insurance. It is important, however,
to remember that the FMSQ had
set up health insurance protections
for its members long before the
adoption of the Act respecting
prescription drug insurance.
37
L’ÉDITORIAL
DE LA PRÉSIDENTE
L’IMPUTABILITÉ SOCIALE
Dr Diane Francœur
V
olontairement ou par
ignorance, on tait le fait que
le futur médecin ne fait pas
qu’apprendre durant toutes ses années
de formation, que, pendant ses années
de résidence, il travaille déjà ! Mais
qu’en est-il vraiment de l’imputabilité
des médecins spécialistes envers leurs
patients dans un système où la norme
d’austérité budgétaire devance
la responsabilité sociale ? Comment
le médecin peut-il rester redevable
de l’utilisation optimale du système
et des ressources alors qu’en catimini,
l’administration coupe les soins aux
patients ? Le ministre de la Santé
et son chef ont beau répéter qu’ils
ne couperont pas dans les services
aux patients et à la population,
mais les faits parlent : un bain par
semaine est suffisant… un bon lavage
à la débarbouillette suffit !
Non-remplacement de personnel
malade, mauvaise planification des
cliniques externes, coupures de salles
d’opération en période estivale : non,
non, personne ne coupe dans les
soins aux patients ! Au fait, où est donc
l’imputabilité sociale du ministre ? En
cette période d’austérité, un budget
équilibré pardonne tout. Il efface toutes
traces de promesses non livrées.
EN CETTE PÉRIODE D’AUSTÉRITÉ, UN BUDGET
ÉQUILIBRÉ PARDONNE TOUT. IL EFFACE TOUTES
TRACES DE PROMESSES NON LIVRÉES.
38
Cela dit, nous, médecins spécialistes,
avons des devoirs envers la population
et nous les accomplissons. Nous avons
tous des obligations hospitalières
et, sous la supervision du conseil
d’administration, c’est le rôle des chefs
de départements et du CMDP de les
définir, comme c’est le rôle du DSP
de s’assurer que nous les respections.
Lorsque chacun livre la marchandise,
la qualité et les obligations sont
au rendez-vous. Comme dans un
orchestre bien rodé, tout le monde
participe au bon moment.
Dans cette ère de changements aussi rapides que bouleversants
pour le réseau de la santé, il devient facile pour les politiciens et
les journalistes d’y aller d’une nouvelle « attaque », cette fois sur
le professionnalisme du médecin et sur ses obligations envers
la population. D’aucuns posent LA question : « Puisque former
un médecin coûte cher aux contribuables…, les médecins ne
devraient-ils pas s’engager dans le service public, comme dans
l’armée, pour rembourser leur (soi-disant) dette à la société ? »
La qualité de la médecine spécialisée
au Québec est excellente, mais elle
pourra facilement dégénérer si nous,
médecins spécialistes, ne prenons pas
notre place au sein de nos (nouveaux)
établissements pour défendre nos
patients, surtout en cette période où il
est facile de couper dans les acquis.
Nous sommes responsables de donner
les informations nécessaires à nos
patients concernant le différentiel
à payer si nous croyons vraiment
qu’un médicament générique est
moins efficace que l’original. Nous
sommes responsables d’aviser nos
patients si des délais d’investigation
trop longs risquent de compromettre
leur pronostic. Nous sommes
responsables de travailler de concert
avec nos équipes pour prioriser les
consultations urgentes et trouver une
façon de suivre cette clientèle. Nous
sommes responsables de faire notre
travail en nous impliquant et en nous
assurant qu’effectivement la deuxième
ligne est présente au poste lorsque
cette expertise est requise. Nous
sommes responsables d’offrir une
couverture en deuxième ligne, partout
et en tout temps. Tout cela, si on nous
laisse travailler, bien entendu !
Comment traduire ces obligations
au quotidien ? En s’impliquant dans
son service ou son département, au
sein du CMDP et en osant aller voir
le PDG de l’établissement pour lui
expliquer que ses décisions ne sont
pas adéquates et lui rappeler que,
même si ses décisions cadrent avec
les recommandations du ministre
dans son carnet de charges, un
centre hospitalier est là pour soigner
des patients et non pour brasser des
papiers. Nul besoin d’un contrat avec
l’hôpital pour nous rappeler cela :
n’en déplaise à certains bien-pensants,
oui, nous avons un contrat avec
les patients !
Je ne peux terminer cet éditorial
sans parler du projet de loi no 20.
Ça sent le bâillon… encore ! Nous
avons fait nos représentations et
défendu les intérêts de la médecine
spécialisée. Pas besoin d’une loi. Ce
que demande le ministre est réalisable
pourvu que l’offre de service des
établissements soit à la hauteur des
attentes. Nos négociations vont
dans ce sens. Toutefois, pour livrer la
marchandise, il sera beaucoup plus
facile de diminuer les listes d’attente
lorsque l’enjeu de la composante
technique des frais accessoires sera
réglé, et ce, par pure transparence
pour les patients, les médecins et le
Collège ! Rappelons‑nous que 58 % de
la population détient une assurance
privée ou participe à un régime
collectif d’assurance.
Le décompte est déjà amorcé, et le
7 juillet arrive à grands pas ! Même si
le ministre a démontré une certaine
ouverture, à compter du 8 juillet,
vous devrez appliquer à la lettre le
nouveau Code de déontologie du
Collège. À vous de décider de la santé
financière de votre offre de service
dans vos cabinets puisque, tel que
prévu par la loi, ne sera permise que
la facturation des pansements et des
médicaments…, pas l’équipement
nécessaire, pas la stérilisation des
appareils, pas le temps du personnel
en salle de réveil, et autres. Tout
comme le Collège, nous disons que
la balle est dans le camp du ministre,
qui connaît ce dossier dans toute sa
complexité pour l’avoir défendu à
maintes reprises à une époque pas si
lointaine. Saura-t-il attraper la « balle
au bâillon » ?
Je vous souhaite un bel été,
reposez‑vous, l’automne arrivera bien
assez vite avec ses chantiers : départs
massifs de personnel, désorganisation
du réseau, financement à l’activité,
pertinence des analyses et utilisation
judicieuse des médicaments.
Le bâton est encore à l’agenda,
mais nous n’avons pas peur !
S
L
NOS FILIALES
SERVICES AUX MEMBRES
AVANTAGES
COMMERCIAUX
AVANTAGES
fprofessionnels.com
sogemec.qc.ca
1 888 377-7337
1 800 361-5303
NOS PARTENAIRES
SERVICES AUX MEMBRES
sogemec.lapersonnelle.com
1 866 350-8282
desjardins.com/fmsq
1 800 CAISSES
Nos filiales et partenaires
méritent votre confiance.
hotelpremieresnations.ca
Vous gagnez à les découvrir !
1 800 441-1414
Pour plus d’informations :
[email protected] ou 514 350-5274
groupesolution2.com telusmd.com
rbcbanqueroyale.com/sante
1 866 673-5080
evenko.ca
1 877 795-9399
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montreal.hyatt.ca
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514 925-2124
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fairmont.com
hotelrimouski.com
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estrimont.ca
manoir-victoria.com
esterel.com
manoir-saint-sauveur.com
1 800 567-7320
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.
multid.qc.ca
1 800 363-3068
1 888 378-3735
1 800 463-0755
1 888 276-6668
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450 687-2440
hotel71.ca
centrecongreslevis.com
1 888 838-3811
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hotelsvillegia.com
1 877 845-5344
Québec • Lac-Leamy
fr.hiltonworldwide.com
514 305-1155
aubergegodefroy.com
1 800 361-1620
lemassif.com
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1 877 536-2774
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1 877 522-8108
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1
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1
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annuel de base de 3000 $. Un rabais supplémentaire de
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Pour en savoir plus, téléphonez au 1-800-363-3068.
Partenaire :

Here comes the sun

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