medical tourism

SPÉCIALISTE
15 YEARS ALREADY
LE
The Fédération des médecins spécialistes du Québec Magazine
Vol. 16 No. 2 ­| June 2014
MEDICAL
TOURISM
PASSPORT
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A
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IO
T
A
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INTER
CLAIM
SETTLEMENT
PROCESS:
A FEW TRICKS
TO SIMPLIFY THINGS
See text p. 40
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*
ONBREZ* BREEZHALER*
Pr
Contribuer au traitement de vos patients
symptomatiques, c’est notre travail quotidien…
PUBLICITÉ
PLEINE PAGE
Délai d’action rapide démontré (amélioration du VEMS
observée 5 minutes après la première dose de 0,1 L;
p < 0,001, évaluations successives du VEMS)1†
Bronchodilatation maintenue pendant 24 heures d’affilée
(moyenne des moindres carrés du VEMS (L) vs placebo
pendant 24 heures à la 12e semaine, p < 0,001; les jalons
temporels étaient 5 min, 30 min, 1 h, 2 h, 4 h, 6 h, 12 h,
16 h, 22 h, et 24 h)1,2†‡
Amélioration de l’indice de dyspnée de transition (moyenne des
moindres carrés, score IDT focal à la 12e semaine, 1,34 vs 0,11 pour
le placebo, p<0,001)1,3§
Maintenant couvert par la RAMQ
Novartis
ONBREZ* BREEZHALER*
¶
Le seul BALA à raison d’UNE PRISE PAR JOUR pour le traitement de la MPOC
Indication et utilisation clinique :
ONBREZ* BREEZHALER* (maléate d’indacatérol) est un ß2-agoniste
à longue durée d’action (BALA) indiqué, à raison d’une prise par jour,
pour le traitement bronchodilatateur d’entretien à long terme de
l’obstruction des voies aériennes chez les patients atteints de maladie
pulmonaire obstructive chronique (MPOC), y compris la bronchite
chronique et l’emphysème.
• N’est pas indiqué pour le soulagement des symptômes soudains et
intenses de MPOC, ni dans l’asthme, et ne doit pas être utilisé chez
les patients de moins de 18 ans
Contre-indications :
• N’est pas indiqué dans le traitement de l’asthme
Mises en garde et précautions importantes :
Mortalité liée à l’asthme: Les BALA augmentent le risque de mortalité
liée à l’asthme. On estime qu’il s’agit là d’un effet de classe des BALA,
dont fait partie le maléate d’indacatérol. ONBREZ* BREEZHALER* n’est
pas indiqué dans le traitement de l’asthme.
Autres mises en garde et précautions pertinentes :
• N’est pas indiqué en traitement d’un épisode aigu de
bronchospasme
• Risque accru d’effets cardiovasculaires
• Prudence chez les patients aux prises avec des troubles
cardiovasculaires
• Prudence chez les patients aux prises avec des troubles
convulsifs ou une thyrotoxicose, de même que les patients
qui répondent de manière particulièrement marquée aux
agonistes ß2-adrénergiques
• Risque d’hypokaliémie et d’hyperglycémie
• Bronchospasme paradoxal
• Hypersensibilité immédiate
• N’est pas indiqué pour le soulagement des symptômes
soudains et intenses de MPOC
• Ne doit pas être utilisé en concomitance avec d’autres BALA
• Peut inhiber le travail
* ONBREZ et BREEZHALER sont des marques déposées.
Monographie du produit offerte sur demande.
Exp: 05/2014
© Novartis Pharma Canada inc. 2013
Références : 1. Monographie d’ONBREZ*
BREEZHALER*. Novartis Pharma Canada inc.,
le 24 octobre 2012. 2. Données internes.
Novartis Pharma Canada inc. Étude B2355.
3. Données internes. Novartis Pharma
Canada inc. Étude B2354.
Pour de plus amples renseignements :
Veuillez consulter la monographie du produit à l’adresse www.novartis.ca/
asknovartispharma/download.htm?res=onbrez%20breezhaler_scrip_f.
pdf&resTitleId=482 pour obtenir des renseignements importants sur les
effets indésirables, les interactions médicamenteuses et la posologie qui
n’ont pas été abordés dans le présent document. Vous pouvez également
obtenir la monographie du produit en appelant le Service d’information
médicale au 1-800-363-8883.
VEMS : volume expiratoire maximal par seconde; IDT : indice de dyspnée de transition.
† B2355 : Essai multicentrique à double insu de 12 semaines, avec répartition aléatoire,
placebo et groupes parallèles dans le but d’évaluer l’efficacité et l’innocuité d’ONBREZ*
BREEZHALER* à 75 mcg, une fois par jour vs placebo chez des patients atteints de MPOC
(n = 318).
‡ Dans un sous-groupe de 239 patients de l’essai B2355. Données relatives au VEMS
d’ONBREZ* BREEZHALER* vs placebo, respectivement : 5 min : 1,56 vs 1,39; 30 min :
1,57 vs 1,38; 1 h : 1,56 vs 1,38; 2 h : 1,56 vs 1,37; 4 h : 1,51 vs 1,35; 6 h : 1,48 vs
1,33; 12 h : 1,43 vs 1,29; 16 h : 1,39 vs 1,24; 22 h : 1,44 vs 1,27; 24 h : 1,48 vs 1,34.
§ B2354 : Essai multicentrique à double insu de 12 semaines, avec répartition aléatoire,
placebo et groupes parallèles dans le but d’évaluer l’efficacité et l’innocuité d’ONBREZ*
BREEZHALER* à 75 mcg, une fois par jour vs placebo chez des patients atteints de
MPOC (n = 323).
¶ La portée clinique comparative n’a pas été établie.
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de bienvenue†, soit suffisamment de points pour un vol court-courrier.
Rendez-vous à rbc.com/voyages ou composez le 1 800 769-2511.
LES VOYAGEURS ONT LE CHOIX
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appartiennent à leur propriétaire respectif. ≈ En vigueur le 1er avril 2014. Sous réserve des disponibilités. Des restrictions peuvent s’appliquer. Pour connaître toutes les conditions, consultez le site
www.rbc.com/rachatvoyager. † Pour un vol court-courrier à destination d’une province ou d’un État adjacent, au Canada ou aux États-Unis, il vous faut 15 000 points RBC Récompenses. Le prix
maximal du billet est de 350 $. Pour que vous receviez les 15 000 points RBC Récompenses en prime qui figureront sur votre premier relevé, nous devons recevoir votre demande au plus tard le
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TABLE OF CONTENTS
7THE PRESIDENT’S EDITORIAL
Le Spécialiste is published 4 times per year by
the Fédération des médecins spécialistes du Québec.
Let’s Set the Clocks Back... to Normal
EDITORIAL COMMITTEE
Dr Harold Bernatchez
Dr Karine Tousignant
Maître Sylvain Bellavance
Nicole Pelletier, APR
Patricia Kéroack, c. w.
8FEDERATION AFFAIRS
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9IN THE NEWS
TO CONTACT US
EDITORIAL CONTENT
✆ 514 350-5021  514 350-5175
DELEGATED PUBLISHER
Nicole Pelletier, APR
Director, Public Affairs
and Communications
✉[email protected]
RESPONSIBLE FOR
PUBLICATIONS
Patricia Kéroack,
Communications Consultant
www.magazinelespecialiste.com
ADVERTISING
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11DID YOU KNOW...
14 PROFESSIONAL AFFAIRS
17CONTINUING
PROFESSIONAL EDUCATION
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
DOSSIER
GRAPHIC DESIGNER
Dominic Armand
PUBLICATIONS MAIL
Postal Indicia 40063082
MEDICAL TOURISM
ADVERTISING
France Cadieux
LEGAL DEPOSIT
2nd quarter 2014
Bibliothèque nationale du Québec
ISSN 1206-2081
B:11.125”
S:10”
T:10.875”
The mission of the Fédération des médecins spécialistes du Québec is to
defend and promote the economic, professional, scientific and social interests
of the medical specialists who are members of its affiliated associations.
The Fédération des médecins spécialistes du Québec represents the
following medical specialties: Adolescent Medicine; Anatomical Pathology;
Anesthesiology; Cardiac Surgery; Cardiology (adult or pediatric); Clinical
Immunology and Allergy; Colorectal Surgery; Community Medicine; Critical
Care Medicine (adult or pediatric); Dermatology; Diagnostic Radiology;
Emergency Medicine; Endocrinology and Metabolism; Forensic Pathology;
Gastroenterology; General Pathology; General Surgery; General Surgical
Oncology; Geriatric Medicine; Gynecologic Oncology; Hematological Pathology;
Hematology; Infectious Diseases; Internal Medicine; Maternal-Fetal Medicine;
Medical Biochemistry; Medical Genetics; Medical microbiology and infectious
diseases; Medical Oncology; Neonatal-Perinatal Medicine; Nephrology;
Neurology; Neuropathology; Neurosurgery; Nuclear Medicine; Obstetrics and
Gynecology; Occupational Medicine; Ophtalmology; Orthopedic Surgery;
Otolaryngology-Head and Neck Surgery; Pediatric Hematology/Oncology;
Pediatric Emergency Medicine; Pediatric General Surgery; Pediatrics; Physical
Medicine and Rehabilitation; Plastic Surgery; Psychiatry; Radiation Oncology;
Respirology (adult or pediatric); Rheumatology; Thoracic Surgery, Urology and
Vascular Surgery.
All pharmaceutical product advertisements 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.
• Desjardins
• Novartis (ONBREZ BREEZHALER)
• RBC Banque Royale
• Financière des professionnels
• Collège des médecins du Québec (Inscription)
• Telus
• Club voyages Berri
• Collège des médecins du Québec (Avis d’élection)
• Novartis (SEEBRI BREEZHALER)
• ims | brogan
• La Personnelle
• Sogemec Assurances
• Multi-D/FIDL
• Going Abroad for Specialized Care
• Need a Kidney? Here’s the Fast Track!
• The Zamboni Hypothesis
and its Media Effect
• Anything... To Get a Passport
• Can We Benefit from the Situation?
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MEDICAL
TOURISM
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28
30
32
35
PASSEPORT
AL
INTERNATION
36IN THE WORLD OF MEDICINE
39FINANCIÈRE DES PROFESSIONNELS
40SOGEMEC ASSURANCES
42 L’ÉDITORIAL DE LA PRÉSIDENTE
Remettre les pendules à l’heure… normale
43MEMBER SERVICES
Commercial Benefits
THE FMSQ IS ONLINE
THIS EDITION’S ADVERTISERS:
20
fmsq.org
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5
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Recommandé par la
Fédération des médecins
spécialistes du Québec.
Le service
d’accompagnement à
l’incorporation
de la Financière des
professionnels
..
.
PUBLICITÉ
PLEINE PAGE
Permet le fractionnement de revenu
Optimise le report d’impôt
Favorise plusieurs stratégies fiscales avantageuses
En tant que professionnel en pratique privée, vous pourriez
obtenir de réels avantages en vous incorporant. Et si vous êtes
déjà incorporé, savez-vous que plusieurs aspects ont évolué
avec le temps ?
Financière des professionnels
Votre fédération est le principal actionnaire de la Financière des
professionnels depuis plus de 35 ans. Nos conseillers sont vos
partenaires privilégiés pour constituer votre société par actions
ou vous aider à l’optimiser. Ils connaissent précisément votre
réalité professionnelle.
Appelez l’un de nos conseillers pour en profiter.
www.fprofessionnels.com
Actionnaire de la Financière
des professionnels depuis 1978
Montréal 1 888 377-7337
Québec 1 800 720-4244
Sherbrooke 1 866 564-0909
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 ainsi qu’un courtier en épargne collective inscrits auprès de l’Autorité des marchés financiers (AMF) qui gère et
distribue les fonds de sa gamme de Fonds, et qui offre des services-conseils en fonds d’investissement et 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.
THE PRESIDENT’S EDITORIAL
Dr Diane Francœur
Let’s Set the Clocks Back... to Normal
A
t the time I started my practice, I became aware that,
to improve medicine, not only did we have to pursue
research, but we also had to take an interest in how care
was dispensed. That’s why I also became involved in improving
our conditions of practice. I have to admit that there’s a lot to do
for specialized medicine. Being away from a full-time practice lets
me see other aspects of how the healthcare network operates.
Taking a step backwards to better go forwards, is wise, I am told.
I have always thought that things happened because we took
care of them. And, as the Greek philosopher Seneca said, “It is
not because things are difficult that we do not dare; it is because
we do not dare that they are difficult.” I therefore decided to
take control of my fate and to get involved. I have been the
head of a department, an associate professor, president of my
medical association and vice-president of my Canadian learned
society. I knew that not all physicians had this need, like I do,
to be up to date with what is going on in our profession. But,
I was never more surprised than when I took on the presidency
of the Federation and realized how many medical specialists
did not know, or only slightly understood, how the organization
mandated to represent them operates, and even protects them
from decision-makers and payers, namely the government and
the RAMQ.
I am therefore taking advantage of this space to invite you to
review what you know about the Federation.
A BRIEF HISTORICAL REMINDER
To start with, next year, the FMSQ will be 50 years old. It was,
in fact, founded in 1965 by physicians who wanted to protect
themselves from the government’s desire to impose a salaried
status and other conditions that would disadvantage the
profession. This was all the more important since the Collège des
médecins at that time had a double mandate: that of protecting
the public and that of defending the interests of physicians. This
double mandate could only result in inappropriate and, I must
say, debatable stands.
The FMSQ is a professional union regrouping associations of
physicians practising in one of the medical specialties recognized
in Quebec. From 11 associations when it was founded, the FMSQ
today represents the members of 35 affiliated associations
working in one of the 53 recognized medical specialties in
Quebec. The FMSQ’s mission is to defend and promote the
interests of medical specialists, members of the affiliated
associations, on the economic, professional, scientific and
social levels.
The FMSQ will always defend a strong and effective public system
and gets involved in a range of subjects when our expertise can
make a difference. During the last few years, we have dealt with
issues that have a direct impact on medical specialists such
as remuneration, negotiating conditions of practice, organizing
services, optimizing operating suites, extra fees, the logistical
needs of the new CHUM, the price of medications, physicians
incorporating themselves, continuing professional development,
and many others. We have also brought a “medical” light to
bear on social issues including end-of-life care, abortion, the
wearing of religious symbols, and assisted procreation. The
positions adopted by your representatives have been extensively
discussed with association presidents; we aim to represent, if not
all members, then at least the majority.
Other organizations, including the QMA and the MQRP may so
claim, but only the FMSQ is recognized as the negotiator for
medical specialists by the MSSS. We represent you and that’s
why it is to your advantage, not only to follow us, but also to
inform us of any problems you are experiencing, or to which you
are witness, in your care environments.
WHO DECIDES FOR THE MEMBERS?
I recently received emails from members saying they had never
voted for a decision taken by the FMSQ. The FMSQ is a federated
organization, a group of associations. Each medical association
affiliated with the FMSQ is proportionally represented at the
Delegates’ Assembly, the highest decision-making entity within
the Federation. The delegates, issuing from each specialty,
including association presidents, speak for you and vote in
your name. It is in fact the Delegates’ Assembly that elects the
members of the board of directors, that votes on the financial
statements, on regular and special membership dues, that
discusses the major objectives of negotiations, that votes on
agreements with the government and so on.
The trust you have in your elected representatives and their
solidarity with your peers are at the heart of your Federation’s
operations. There is also a key principle in the work we
accomplish: confidentiality. This rule applies to every serious
organization and does not in any way impact the “transparency”
of its governance. However, it must be understood and
recognized that discussing internal decisions, agreed-upon
strategies, or actions being considered in public is neither
acceptable nor desirable. Finally, I cannot insist too much on
the mutual respect we owe one another. Expressing an opinion,
even one that is emotionally deep-seated, must be done with
respect for the opinion of others and for the decision taken. My
presidency will be guided by these keywords.
Finally, I invite you to remain close – or to come closer –
to the FMSQ to help us look after the “real business” of
medical specialists!
Proudly yours!
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FEDERATION AFFAIRS
Outgoing Treasurer’s Report
BY RAYNALD FERLAND, MD
The Fédération des médecins spécialistes du Québec held its annual meeting on March 20, 2014. During this annual meeting,
the Delegates were in favour of the following recommendations by the President of the Finance Commission:
1.To approve the FMSQ’s financial statements as at
December 31, 2013 which were audited by the accounting
firm of Raymond Chabot Grant Thornton;
2.To approve budget forecasts for the year
2014 as submitted by the FMSQ;
3.To set the annual membership dues for 2014 at
$1,690 (compared to $1,902 in 2013).
Out of these membership dues, an amount of $250 is automatically transferred into the compensation fund according to the
vote taken on October 17, 2013 during the Delegates’ Assembly.
In 2013, the sum transferred to the compensation fund out of
membership dues was equivalent to $500.
Dear Colleagues, After having been Counsellor for two years,
then Treasurer of the FMSQ from March 2011 to March 2014,
I have accepted a new challenge within the Board of Directors
to sit as Vice-President. I am happy to pass on the torch to
Dr Stephen Rosenthal, our new Treasurer, who will be able take
on, I am confident, the financial watchman’s role and ensure that
our dues are well managed.
I wish to thank Ms Julie Voiselle for her valuable cooperation
and the Board of Directors for its support these past few years.
Should you have any questions concerning the budget, please
feel free to get in touch with Dr Rosenthal or myself here at
the Federation.
The financial statements confirmed that the FMSQ is in good
financial health.
A Well-Deserved Retirement for Our Colleague, Gilles Robert
On April 16, 2014, Dr Gilles Robert left the position of
Chairman of the Board of Sogemec Assurances, at
the end of the 14th renewal of this annual mandate
and after having held virtually all the positions within
this Board where he held a seat from 1984 to 2014.
Gilles had left the position he held within the FMSQ in
2012 to progressively undertake his retirement. This
is thus the final stage in an exceptionally long and
varied career.
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Three decades of loyal service to his colleagues in
the Federation and its affiliated associations, under
five successive presidents: what a remarkable and
unique accomplishment.
Always polite, courteous, impeccable in appearance,
cultured but without ostentation, Gilles is a person
of few words who respects the opinions of others.
I have to add that Gilles has been a kind of mentor
for me: his experience, his Federation memories,
his own way of doing things, of negotiating for what
he wanted... and of always succeeding through his
“gentlemanly approach” will stay with me!!!
Having graduated from Laval University in 1967,
then having obtained a diploma from the urological
Dr Gilles Robert
residency program of the Université de Montréal,
Dr Robert practiced surgery in Quebec City and
became head of the surgical department at Hôpital Saint-François
Backed up by a dedicated team, Gilles contributed to the
d’Assise (1983-1988). He became involved with the affairs of the
noteworthy success of Sogemec Assurances over recent years.
Fédération des médecins spécialistes du Québec in 1984. The
I wish to thank him, in the name of all clients who, like me, were
President at the time, Dr Paul Desjardins, invited him to take on
able to count on well-thought out advice on issues that could
the position of physician-consultant within the Economic Affairs
sometimes be difficult.
department of the FMSQ, a job title that evolved into that of Director
of Economic Affairs at the beginning of the 1990s. In parallel with
We wish you a good retirement, Gilles! May you remain healthy
this function, Dr Robert agreed to become a co-opted member of
and be able to enjoy life with your four daughters and your
the FMSQ’s Board of Directors in 1987, after which he was elected
“girlfriend”, whether it’s between two rounds of golf or a few sets
as Counsellor (1988-1989), then Treasurer (1990-1995).
of tennis in Quebec City or in Florida. Come and see us when you
wish: after all, the Federation and Sogemec are home to you too!
He also “served” under Presidents Paul Desjardins, Robert
Marier and Pierre Gauthier, but did not seek a new mandate
when Dr Yves Dugré took over, because he was then already
very busy as Director of Economic Affairs, a position he
held until his progressive retirement under the presidency of
Diane Francoeur, MD
Dr Gaétan Barrette.
President of the FMSQ
S
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IN THE NEWS
ON THE POLITICAL FRONT
IN THE HOUSE OF COMMONS
Mark Warawa, the Conservative MP for Langley, British
Columbia, is carrying on with his antiabortion offensive.
This time, he’s climbed aboard a new hobby-horse: sexoselective abortion. Under the guise of taking up the defence
of women, MP Warawa and some of his colleagues have been
tabling petitions demanding that the government condemn
discrimination towards females inherent in decisions based
on gender.
On February 12th of this year, Bill C-523, sponsored by
the NDP MP for Saint-Bruno Saint-Hubert, Ms Djaouida
Sellah, was rejected by the House of Commons at second
reading. This Bill aims to amend the Department of Health
Act to institute the obligation for suppliers of medications to
advise the Minister in case of interruption or cessation in the
production, distribution or importing of drugs on the one hand
and, on the other, the obligation for the Minister to develop
and implement an emergency response plan to remedy drug
shortages. These obligations do not exist at present and a
good number of groups have been demanding government
intervention in this direction.
In the Senate, Bill S-201, An act to prohibit and prevent genetic
discrimination, was tabled. Sponsored by James S. Cohen,
the Liberal Senator from Nova Scotia, this Bill intends, among
others, to prevent anyone from forcing people to submit to
a genetic test or to communicate the results of such a test,
as an obligatory condition for supplying them with goods or
services, for entering into or maintaining a contract with them
or for offering them special conditions in a contract. This Bill
was sent back to the Standing Senate Committee on Legal
and Constitutional Affairs on April 1st.
IN THE NATIONAL ASSEMBLY
The first session of the new Couillard government opened on
May 20th. All bills that had been proposed or that had been
the subject of work or consultations died on the Order Paper
the moment the general election was called.
At the moment of going to print, we do not know what the
legislative program will be. However, it is possible that Bill 52:
an Act respecting end-of-life care could be “resuscitated” if, as
an exception, all members of the National Assembly accepted
that it be put on the Order Paper again through a unanimous
vote and that all steps already completed during the previous
legislature be taken into account.
It is also a given that the government will present a new budget
at the beginning of June. Afterwards, parliamentarians will
undertake a study of the credits for the various departments.
It must be remembered that the budget and credits are the
priority according to National Assembly rules.
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access to all communications
of interest for you or for
your practice.
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
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.
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
9
vol. 16
No. 1
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DID YOU KNOW...
PRIZES AND AWARDS
APQ PRIZE
SFRO MEDAL
uring its annual meeting, the Association
D
des pédiatres du Québec awarded the 2014
Letondal prize to Dr Jeanne Pichette, a
reti re d p e d i atr i c i a n f ro m th e C e ntre
hospitalier universitaire de Québec. This prize
highlights the importance of a pediatrician’s
contribution to his or her field of activity.
CMQ PRIZE
During its annual meeting, the Collège des
médecins du Québec awarded its prize for
excellence to Dr Guy A . Rouleau, a
neurogeneticist and the director of the
Montreal Neurological Institute. This prize is
awarded annually to a physician who has
exceptional achievements to his or her credit
which make a difference in the lives of patients, healthcare
professionals or students and who stands out by his or her
exceptional contribution to the evolution of the profession.
The Société française de radio-oncologie
a w a r d e d i t s h i g h e s t d i s t i n c t i o n to
Dr François Brochet, a radio-oncologist at
the CSSS de Chicou timi. T his pr ize
highlights the exceptional character of his
career. For the past 20 years, Dr Brochet
has organized an annual exchange between
France and Quebec. This exchange allows a French student in
radio-oncology to attend the AROQ congress and, conversely,
a Quebec student to attend the SFRO congress.
EUROPEAN CARDIAC ARRHYTHMIA SOCIETY AWARD
r Stanley Nattel, a cardiologist at the
D
Montreal Heart Institute and professor at the
faculty of medicine of the Université de
Montréal received the 2014 Outstanding
Achievement Award from the European
Cardiac Arrhythmia Society. This award
highlights his career as a whole and his
exceptional contribution to the advancement
of research on arrhythmia.
RCPSC AWARD
r Dan Poenaru, a general surgeon at the
D
Montreal Children’s Hospital received the
Teasdale-Corti 2014 Humanitarian Award,
the most prestigious one in Canada from the
Royal College of Physicians and Surgeons
of Canada. Dr Poenaru set up a practice in
Kijabe, Kenya, where he also instituted the
first training program in pediatric surgery in
East Africa.
A THREESOME FOR AN OBSTETRICIAN-GYNECOLOGIST
Dr Michel Roy, an obstetrician-gynecologist
at the Hôtel-Dieu de Québec, received three
distinctions during the last year. Recently,
Laval University granted him the title of
professor emeritus. In 2013, Dr Roy also
received the Medal for E xcellence in
Teaching from the Council on Resident
Education in Obstetrics and Gynecology (CREOG) as well as
the Carl Nimrod Award from the Canadian Association of
Academic Professionals in Obstetrics and Gynæcology (APOG).
9TH GOLF TOURNAMENT
THANKS TO OUR SPONSORS
OF THE MEDICAL FEDERATIONS IN AID OF
THE QUEBEC PHYSICIANS’ HEALTH PROGRAM
FOUNDATION
Monday, July 28, 2014
Le Mirage Golf Club in Terrebonne
Register Without Delay!
Your participation in the Quebec Medical Federations’
Golf Tournament ($500 per individual registration and
$2,000 for a foursome) includes access to the practice
areas, the right to play under Vegas rules (best ball), a
golf cart, brunch, lunch, cocktails as well as dinner.
• The Canadian Medical
Protective Association
• Desjardins Trust
• Fiera Capital
• Association des optométristes • CIBC Global Asset
du Québec
Management Inc.
• La Capitale Insurance
• SEI Investments
and Financial Services Inc.
• The Personal, Home
• Desjardins
and Auto Group Insurance
• Desjardins Insurance
• SSQ Financial Group
Information and registration forms available on your federation’s website:
www.fmsq.org www.fmoq.org www.fmrq.qc.ca www.fmeq.qc.ca
11
vol. 16
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DID YOU KNOW...
IMS-BROGAN PRIZE
AMOQ PRIZE
For the 15th year, IMS-Brogan has awarded its prizes and grants
which recognize the contribution of Quebec pharmacists and
physicians to the education of their peers. The winners were
recognized for the publication of articles on the appropriate
use of medications. Two medical specialists were honoured:
The Association des médecins ophtalmologistes du Québec
took advantage of its annual congress to highlight the exceptional contribution of members within their sector of activity.
Dr Brian Arthurs who works at the MUHC
– Montreal General Hospital was honoured
for his overall involvement in clinical medical
education as well as in continuing
medical development.
r Louise Roy, a nephrologist at the CHUM
D
– Saint-Luc, for her article “Adherence to
antihypertensive agents improves risk
reduction of end-stage renal disease”,
published in the magazine Kidney
International 2013;84:570-7.
p o s th u m o u s h o m a g e wa s p a i d to
A
Dr Magda Barsoun-Homsy, formerly with
the Centre hospitalier universitaire de SainteJustine. Dr Barsoun-Homsy helped advance
pediatric ophthalmology through an approach
which left its mark on those who followed in
her footsteps..
r Silvy Lachance, a hematologist at
D
Hôpital Maisonneuve-Rosemont, for her
article “Defining the role of sirolimus in the
management of graft-versus-host disease:
From prophylaxis to treatment”, published
in Biological Blood Marrow Transplant,
2013;19:12-21.
2013 MÉDECIN DU QUÉBEC PRIZE
r Richard Gauthier, a pneumologist at
D
Hôpital Maisonneuve-Rosemont, received
the Coup de cœur prize from Médecin du
Québec. This prize is awarded to the author
of the article most appreciated by readers
of this maga zine aimed at general
practitioners.
NEW QPHP FUNDRAISING CAMPAIGN
The Quebec Physicians’ Health Program (QPHP) Foundation
launched its annual fundraising campaign on May 19th. Entitled
“You are lucky to be in good health”, the campaign wants to
make physicians aware of the fact that one colleague out of
two is not lucky enough to be in good health. The QPHP helps
physicians, residents and students in difficulty with toxicomania,
alcoholism, mental health problems and personal problems.
NEW BOARD OF DIRECTORS
AT SOGEMEC ASSURANCES
THE MHI HONOURS ONE OF ITS OWN
r Martin Juneau, a cardiologist and the
D
director of prevention at the Montreal Heart
Institute was honoured to highlight a 30-year
career. The work of Dr Jumeau enabled the
MHI to position itself as a leader in the
prevention of cardiovascular disease in
North America.
NEW CAHS MEMBERS
Several medical specialists were granted the title of Member
of the Canadian Academy of Health Sciences, a prestigious
distinction which highlights exceptional achievements. Among
the winners, there are three physicians who work at the Jewish
General Hospital – Sir Mortimer B. Davis:
Spring has arrived at Sogemec Assurances. Here is the
new board of directors for 2014-2015:
• President: Dr Diane Francœur
• Vice-president: Dr Michèle Drouin
• Secretary: Me Maurice Piette
• Treasurer: Mr Pierre Phénix
• Directors:
• Ms Esther Gadoua
• Dr Jean Simard
• Dr Michel Carrier
• Dr Suzie Lévesque
Of the five persons to have held the
position of President of Sogemec
Assurances, Dr Francœur is the
first woman in this position since
its creation on January 7, 1987. She
is also the third person to hold the
position of President of both the
FMSQ and Sogemec.
Dr Diane Francœur
Dr Mark J. Eisenberg
Cardiologist
12
vol. 16
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Dr Laurence Kirmayer
Psychiatrist
Dr Michael Pollak
Hematologist
Dr Pollak also received the O. Harold Warwick Prize from the
Canadian Cancer Society. This prize highlights research having
a major impact on the fight against cancer in Canada.
The previous Presidents of Sogemec were:
Dr Paul Desjardins: from its creation
on January 7, 1987 to June 26, 1991
Dr Robert Marier: from June 26, 1991 to December 16, 1993
Dr Pierre Boulianne: from December 16, 1993 to April 18, 2001
Dr Gilles Robert: from April 18, 2001 to April 16, 2014
Dr Diane Francœur: since April 16, 2014
DID YOU KNOW...
NEW RELEASES
LE BON SENS À LA SCANDINAVE
(COMMON SENSE SCANDINAVIAN STYLE)
r Marie-France Raynault, a specialist in
D
preventive medicine and public health has
published Le bon sens à la scandinave, a
work in which she presents the
Scandinavian model and how Quebec,
which shares several characteristics with
the nordic countries (geographical, demographic, cultural, etc.), could draw
inspiration from it. Nordic countries stand
out with social and health policies which
put them at the forefront of egalitarian states: they feature
smaller gaps than elsewhere between the rich and the poor
and are truly preoccupied with the well-being of the majority.
They also feature a high level of economic competitiveness and
a very enviable environmental efficiency.
L’APPAREIL DIGESTIF (THE DIGESTIVE SYSTEM)
r Pierre Poitras, a gastroenterologist at
D
the CHUM – Hôpital Saint-Luc and tenured
professor of medicine at the Université de
Montréal, has published L’appareil digestif,
a collection of texts written by some thirty
collaborators who, in his opinion, are
among the best Quebec and French
specialists in gastroenterology and
hepatology. The book establishes a link
between basic and clinical practices by
shining a light on the knowledge which has
repercussions on care.
LA DOULEUR (PAIN)
Dr Pierre Beaulieu, an anesthesiologist
and an associate professor in the pharmacology and anesthesiology departments of
the Université de Montréal as well as a
researcher associated with the CHUM, has
published the practical guide La douleur.
This work is aimed at health professionals
faced with the phenomenon of pain. It
presents a distilled approach based on
clinical practice. The work is divided into
three parts: an introduction to the phenomenon of pain and its
mechanisms; a systematic approach to the various painkillers;
and a section on the placebo effect and pharmocogenetics
which ends with the pharmacology of pain at different ages
in life.
POUR UN CURSUS D’ÉTUDES MÉDICALES AXÉ SUR
LES COMPÉTENCES
(FOR A MEDICAL CURSUS FOCUSING ON SKILLS)
POUR UN CURSUS D’ÉTUDES MÉDICALES
AXÉ SUR LES COMPÉTENCES
CADRE DE
FORMATION
Sous la direction de :
Andrée Boucher
Louis-Georges Ste-Marie
Pour le
CONSEIL CENTRAL
DES COMPÉTENCES
r Andrée Boucher, a radiologist and
D
Dr Louis-Georges Ste-Marie, an endocrin o l o g i s t, b ot h f r o m t h e C e n t r e d e
pédagogie appliquée aux sciences de la
santé (CPASS) at the faculty of medicine of
the Université de Montréal, have published
Pour un cursus d’études médicales axé sur
les compétences. This work is available at
cpass.umontreal.ca.
S
L
LA DOULEUR EN MOUVEMENT (PAIN ON THE MOVE)
13 jours/28 repas
HôTeLs 3 eT 4H  ✈aIr FraNCe
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CLINICAL BURSARIES
The Quebec Chronic Pain
Association is offering
bursaries to candidates
interested in clinical training
on chronic pain.
Several medical specialists took advantage of these
bursaries in the last years. For more information, please
visit www.douleurchronique.org.
saFari KenYa - tanZanie
13 jours/29 repas
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Chronic pain remains a phenomenon which
is not well understood and too often
difficult to relieve. With contributions by
several authors, some from medical
specialists, including Dr Pierre Beaulieu, an
anesthesiologist at the CHUM, and Dr
Mary-Ann Fitzcharles, a rheumatologist at
the MUHC, the guide La douleur en
mouvement, published by Presses de
l’Université de Montréal, draws an overall
picture of the situation, available therapies, research and new
disciplines such as physiotherapy, occupational therapy
or kinesiology.
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13
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PROFESSIONAL AFFAIRS
Physicians 70 Years Old and Over
BY FRANÇOIS GOBEIL, MD
President of the Association des
anesthésiologistes du Québec
Evaluating Skills
Quality control, CanMED competencies, knowledge acquisition, continuing professional development:
these are popular subjects that are known by all.
No one doubts the importance of quality control in the
pharmaceutical or agri-food industries and no one is surprised
by the now standard security measures in airports. Likewise,
everyone knows that, sooner or later, a medical examination will
be required by the SAAQ. And yet, while all physicians continue
their training for professional development, what happens to
evaluating the knowledge they acquire beyond medical residency
and, especially, the maintenance of skills and reflexes in critical
situations? In other fields, for example that of aviation, the airline
pilot’s permit is delivered annually after a complete medical
examination and four annual evaluations on a simulator. The
culture of safety is omnipresent and is part of daily life (checklists,
simulators, etc.).
Did you know that, since 2012, In Canada,
every Quebec physician aged 70 7.5% of hospitalizations
or more receives from the CMQ a are due to medical errors,
questionnaire to evaluate his or her 37% of which could
practice? In light of this questionnaire, have been avoided.3
certain indicators, including specialty,
place of practice and type of support,
help to determine if the physician
has a high-risk profile or not. For example, an anesthesiologist,
working alone in a remote region, could be invited to an SOI.
Beyond the question of age, a complaint or a request to the
syndic can launch an evaluation of a medical practice via a visit
or an SOI.
Of course, duty and ethics have served, and continue to serve,
as “boundaries” in the human science by excellence that is
medicine. But, is this enough in a technological universe growing
exponentially, where knowledge is constantly pushed to the limits
of our capacity to assimilate? Moreover, combined with needs
and pressures that are also growing, whether from the population
or from accrediting, teaching or controlling organizations, in
addition to various inquiries including those of a coroner, should
we be surprised by the necessity of evaluating ourselves and of
being evaluated by our peers? To ask the question is to answer it.
This is not a theoretical exam, but a formal evaluation process
with emphasis on security, effected through the practical
validation of skill maintenance. The evaluation is based on the
characteristics that are specific to the candidate’s practice and
not on a format like the exam process at the Royal College
of Physicians and Surgeons of Canada. Lasting a full day,
supervised by physicians from the field of activity being evaluated,
various standard clinical vignettes and scenarios are presented
by committees of practitioners from the specialty in question.
For example: in radiology, reading files or mammograms; in
pathology, interpreting slides; in anesthesiology, using the
simulator. The evaluation touches different aspects according to
the discipline: knowledge, technical or non technical skills such
as communications, awareness of a situation, professionalism
and teamwork.
In Quebec, the Collège des médecins du Québec (CMQ) has
taken on the role of leader in this area. Structured oral interviews
(SOI) have existed since 1990 in family medicine as well as in
specialized medicine (radiology 2002; psychiatry and pathology
2006; dermatology 2009; anesthesiology 2011). The very notion
of evaluation is a growing concern on the national level (Manitoba,
British Columbia and, just recently, Nova Scotia) as well as on the
international scene (Australia, New Zealand).
At the end of the evaluation, the candidate receives an overall
analysis of his or her strong points and weak points. An analysis
based on parameters is performed by two physicians from
the discipline in question and is the basis for a final report
that is delivered to the professional inspection committee.
EVALUATION STEPS
EOS
Excellent results
Practice judged
adequate
Recommendation to join
group CME activities
Mediocre results
Tutoring 1/2 day per week
Part-time, 2 to 3 days per week
14
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LS
Reading
recommendations
Source: Collège des médecins du Québec
Voluntary part-time clinical
training
Practice without restrictions
Clinical training imposed
by the Board
Full-time
Practice with restrictions
PROFESSIONAL AFFAIRS
Contrary to the view held by several physicians, the CMQ’s
approach in matters of professional inspection aims at prevention
rather than at punishment and this is a direction supported by all
members of the Collège’s board of directors.
POSSIBLE PATHWAYS AFTER AN EVALUATION
Although, up to now, the reaction of physicians who have already
been evaluated is favourable, and they consider the day realistic
and pertinent, it is still described by them as long, exhausting and
stressful. One thing is certain, evaluation is part of our continuing
development and is sure to evolve. It is a logical follow-up to
training and must be adapted to the discipline and to the
work performed.
In medicine at present, we are still very far from the culture of
safety adopted by the aviation industry. Limited to discussions
between colleagues, or more formally during morbidity and
mortality (M&M) meetings, the medical world is still leery of, and a
novice, in systematic evaluation. Despite the fact that all consider
it important to the maintenance of competencies and to quality
control, evaluations deter physicians, mainly due to ignorance,
but also to the culture of perfection, the lack of room for error
and intransigence. Despite these shortfalls, means of evaluation
have been instituted without bothering to prepare physicians to
this “new” reality. It’s not surprising that this generates a lot of
astonishment and unease, except for our residents in training
and those of our young colleagues who evolved with these new
concepts. Seeing that this phenomenon will continue to grow, it
becomes essential to make it known, to demystify its mechanism
and to ensure the validity of the process. Granted that no method
of evaluation is perfect, it becomes essential to develop a global
vision of the matter and to adapt it.
In this regard, the area of anesthesia, easily comparable to
the aviation industry, is a good example. By combining clinical
knowledge, pedagogy and technology, we succeeded in
developing a global evaluation by peers (the maintenance of files,
clinical observation, SOI and the use of the simulator) adapted to
the practice, designed and supervised by peers. The aim is not to
limit, restrict or prohibit the practice, but it is a concern for security,
a guarantee for our patients, a growing and essential need that
goes beyond the “mechanized” production line. Specialists talk
of a pedagogical prescription, not a punitive measure.
Whether it is the man himself or his evaluation, faced with
these two imperfections, the time is no longer set on refusal or
objection, but rather on openness and adaptability for a single
reason: the safety of our patients, demanded by them and which
they have the right to receive. It’s a question of culture!
REFERENCES
AVIS D’ÉLECTION
Les membres du Collège des médecins du Québec
sont priés de noter qu’il y aura, le mercredi
1er octobre 2014, élection des administrateurs
des régions électorales suivantes :
LAVAL
un administrateur
MONTÉRÉGIE*
un administrateur
MONTRÉAL
huit administrateurs
Tout candidat doit être membre du Collège et être inscrit
au tableau de l’ordre au moins quarante-cinq (45) jours
avant la date fixée pour la clôture du scrutin. Nul ne peut
être candidat dans une région donnée s’il n’y a pas
son domicile professionnel. La date et l’heure de clôture
du scrutin sont le mercredi 1er octobre 2014 à 16 h.
Les candidatures doivent être proposées par transmission
d’un bulletin signé par le candidat et par au moins
cinq (5) membres du Collège ayant leur domicile
professionnel dans la région électorale dans laquelle
le candidat se présente.
Les bulletins de présentation doivent être reçus par le
secrétaire d’élection au plus tard le jeudi 28 août 2014
à 16 h.
Pour obtenir des bulletins de présentation,
vous pouvez consulter le site Web du Collège
(www.cmq.org) ou vous adresser à :
Me Christian Gauvin
Secrétaire d’élection
Collège des médecins du Québec
2170, boulevard René-Lévesque Ouest
Montréal (Québec) H3H 2T8
* Conformément au Règlement divisant le territoire du Québec
aux fins des élections au Bureau du Collège des médecins du Québec,
en vigueur depuis le 18 avril 1996, il y a eu élection d’un des
deux administrateurs de la région de la Montérégie en 2012 et
il y aura élection du second administrateur de cette région en 2014.
1. Morin F. Ce qu’il faut savoir sur le comité d’inspection professionnelle.
Le Collège Hiver 2009;49(1):16-7.
2. Robert Y. Les enquêtes de révision : entre l’inquiétude et la quiétude.
Le Collège Printemps 2012;52(2):6-8.
3. Université de Montréal. Symposium sur les “ check-lists ” : du monde de
l’aviation au monde de la santé. Montréal, 3 avril 2014.
4. Billard M. Évaluation des anesthésiologistes 2001-2013. Montréal : CMQ.
5. Prégent E. Évaluation de la simulation pour l’évaluation en anesthésiologie.
Mars 2014.
S
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Ouvrez-vous à un nouvel ACLA
pour le traitement de la MPOC
UNE AMÉLIORATION DE LA QUALITÉ DE VIE DES PATIENTS A ÉTÉ OBSERVÉE
PUBLICITÉ
SEEBRI BREEZHALER
PLEINE PAGE
(Variation moyenne MC du score total SGRQ vs placebo, -3,32; p < 0,001)1,2†
Pr
*
*
Mainte
n
couver ant
t par
la RAM
Q
(liste ré
gulière
)
NOUVEAU TRAITEMENT
UNIQUOTIDIEN
DÉBUT D’ACTION EN 5 MINUTES ET EFFET BRONCHODILATATEUR PENDANT 24 HEURES DÉMONTRÉS
Amélioration du VEMS observée au cours des 5 minutes après la prise de la première dose (0,093 L vs placebo, p<0,001,
évaluations spirométriques en série)1,3‡
Moyenne des MC du VEMS significativement supérieure vs placebo démontrée à tous les jalons temporels sur 24 heures (moyenne des
MC du VEMS [L] vs placebo après la première dose, p<0,001; les jalons temporels étaient les suivants: 5 min, 15 min, 30 min, 1 h,
2 h, 3 h, 4 h, 6 h, 8 h, 10 h, 12 h, 23 h 15 min, 23 h 45 min)4§
Novartis
Indication et emploi clinique:
SEEBRI* BREEZHALER* est indiqué, à raison d’une prise par jour, pour le
traitement bronchodilatateur d’entretien à long terme chez les patients
atteints de maladie pulmonaire obstructive chronique (MPOC), y compris
la bronchite chronique et l’emphysème.
N’est pas indiqué pour le soulagement d’une MPOC qui se détériore
de façon marquée
Peut être utilisé à la dose recommandée chez les patients âgés de
65 ans ou plus
Ne doit pas être utilisé chez les patients de moins de 18 ans
Mises en garde et précautions pertinentes:
N’est pas indiqué en traitement d’un épisode aigu de bronchospasme
N’est pas indiqué pour le traitement d’une MPOC qui se détériore
de façon marquée
Aggravation du glaucome à angle fermé
Aggravation de la rétention urinaire
En cas d’insuffisance rénale grave, n’utiliser que si les bienfaits attendus
du traitement pèsent davantage que les risques pouvant y être associés
Bronchospasme paradoxal
* SEEBRI et BREEZHALER sont des marques déposées.
Monographie du produit offerte sur demande.
Exp : 05/2014
© Novartis Pharma Canada inc. 2013
Pour de plus amples renseignements:
Veuillez consulter la monographie du produit au www.novartis.ca/asknovartispharma/
download.htm?res=seebri%20breezhaler_scrip_f.pdf&resTitleId=665 pour obtenir des
renseignements importants sur les effets indésirables, les interactions médicamenteuses
et la posologie ne figurant pas dans le présent document. Vous pouvez aussi vous procurer
la monographie du produit en communiquant avec le Service d’information médicale au
1-800-363-8883.
ACLA : anticholinergique à longue durée d’action; MPOC : maladie pulmonaire obstructive chronique; MC : moindres carrés; SGRQ : St. George’s
Respiratory Questionnaire; mesure la qualité de vie liée à la santé sur le plan des symptômes, activités et répercussions sur la vie quotidienne5;
VEMS : volume expiratoire maximal par seconde.
† GLOW2 : Étude à double insu de 52 semaines, avec répartition aléatoire, placebo et groupes parallèles menée auprès de 1 060 patients
atteints de MPOC ayant reçu SEEBRI* BREEZHALER* (glycopyrronium 50 mcg 1 fois/jour; n = 525), un placebo (n = 268) ou du tiotropium
(18 mcg 1 fois/jour; n = 267) administré sans insu en tant que témoin actif. Le principal critère d’évaluation était le VEMS minimal
24 heures après l’administration de la dose après 12 semaines de traitement.
‡ GLOW1 : Étude à double insu de 26 semaines, avec répartition aléatoire, placebo et groupes parallèles visant à évaluer l’efficacité,
l’innocuité et la tolérabilité de SEEBRI* BREEZHALER* (50 mcg 1 fois/jour) chez des patients atteints de MPOC (n = 550); placebo (n = 267).
§ Moyenne des MC du VEMS (L) après la première dose; SEEBRI* BREEZHALER* (n = 169) vs placebo (n = 83), respectivement : 5 min : 1,39
vs 1,30; 15 min : 1,43 vs 1,28; 30 min : 1,44 vs 1,28; 1 h : 1,47 vs 1,28; 2 h : 1,53 vs 1,34; 3 h : 1,53 vs 1,35; 4 h : 1,52 vs 1,35; 6 h :
1,48 vs 1,33; 8 h : 1,47 vs 1,33; 10 h : 1,47 vs 1,32; 12 h : 1,45 vs 1,31; 23 h 15 min : 1,37 vs 1,27; 23 h 45 min : 1,39 vs 1,31; p < 0,001
pour tous les jalons temporels.
Références : 1. Monographie de SEEBRI* BREEZHALER*. Novartis Pharma Canada inc., le 12 octobre 2012. 2. Kerwin E, Hébert J,
Gallagher N et al. Efficacy and safety of NVA237 versus placebo and tiotropium in patients with COPD: the GLOW2 study. Eur Respir J
2012;40:1106-14. 3. D’Urzo A, Ferguson GT, van Noord JA et al. Efficacy and safety of once-daily NVA237 in patients with moderateto-severe COPD: the GLOW1 trial. Respir Res 2011;12:156(1-13). 4. Données internes. Novartis Pharma Canada inc. 5. Jones P.
St. George’s Respiratory Questionnaire Manual. Accessible au : www.healthstatus.sgul.ac.uk/SGRQ_download/SGRQ%20Manual%20
June%202009.pdf. Consulté le 5 décembre 2011.
BY SAM J. DANIEL, MD
Director
Professional Development
Office – FMSQ
CONTINUING PROFESSIONAL EDUCATION
Social Media and CPD
Social media are present everywhere in our society. Whether it’s on Facebook, Linked In,
YouTube, Twitter or others, social media have a major impact on communications and the
transfer of information.
We need to ask ourselves how these tools for spreading
information can be useful for teachers in continuing
professional development (CPD).
In order to make the best possible use of social medial, we
need to understand how they work and use them to reach our
target audience. The most significant pedagogical gains are
realized when we integrate social media into a CPD program
with specific learning objectives and when we use pedagogical
methods to ensure the participant is actively involved with the
knowledge presented.
Social media can be of service to CPD as a very powerful
communications tool. The information can be transmitted in a
single direction (for example, by placing content in a blog) or in
several directions (by allowing exchanges via an online forum).
We can imagine many ways of using social media for our CPD
congresses, sessions or activities. They can be used among
others, to locate pedagogical material we wish to use directly
in the activity we are organizing, to facilitate communication
between par ticipants (in exchange
forums) or to show videos dealing with
the content of the training (YouTube,
LE PÉCIALISTE
Vimeo, etc.). In addition, we can create
virtual communities made up of people
who share our areas of expertise, which
stimulates self-learning and cooperation.
Web 2.0
An overview of some of the specific
LA VAGUE
applications of social media for CPD is
presented below. I would like to invite
you as well to re-read the dossier in the
DEUX
December 2011 issue of Le Spécialiste,
entitled Web 2.0: The Wave.
S
Le magazine de La Fédération des médecins spéciaListes du Québec
Vol. 13 no4 | Décembre 2011
CERTITUDES...
Voir texte p. 40
It is easy to create a “page” on Facebook, to publish
information on a session or congress. We can also poll the
readers of the page, which is very useful, for example, to
identify the training needs of our audience. Thus, a Facebook
group can be created in order to publish content (including
links, documents, media, and questions) and allow us and
other members of the group to comment on these items.
Blogs allow trainers to write on various subjects of interest and
readers to comment on each article. Subscribers receive alerts
when new subjects are published, thus saving them from
having to visit the site regularly to check out new content. The
comments are useful as a foundation for creating a community
of participants to exchange ideas.
Twitter is a microblogging site where messages with a
maximum of 140 characters are published. These messages
are known as tweets. Each user can subscribe to the Twitter
feeds of people whose tweets are of interest (one “follows”
these people). One can also receive the tweets of all users as
they are published or even keep an eye on specific subjects.
Twitter can be used during a congress to attract participants
to a particular session, to make an announcement or even to
publish a reaction to a news item or presentation.
Google+ allows users to organize themselves into groups.
In Google+, Hangouts sets up video chatting between
members of a group, used to hold virtual meetings or online
training. Hangouts on Air provide for direct broadcast to a
larger audience.
When we use social media, we have to remember that we
are still subject to the ethical and professional standards
currently in effect. Any detail that can be used to identify a
patient, including images and X-rays, must never be published
online nor shared through social media. It is also important to
choose the strictest security and confidentiality parameters of
the platform we use. Moreover, we must remember that once
content is published online, as authors, we no longer have
any control over the way the information is broadcast nor over
the locations from which it emanates. It is essential that we
respect the copyrights of authors and make sure the material
being broadcast rests on probative data, without overlooking
the rules established by our own CPD organization, the
university or the hospital regarding the use of social media.
The popularity of social media in CPS is not simply a fad. As
a tool, it can be adapted to benefit several continuing medical
education activities and to enrich them.
In closing, the FMSQ is developing
a platform to manage training
material (e-learning). This platform
will be used by affiliated medical
associations as well as medical
specialists, thus being useful to
all members of the FMSQ. If you
wish to develop some educational
content for this platform (training
videos, self-appraisal modules, online
sessions, clinical tools, etc.), please
get in touch with the Professional
Development Office.
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17
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INTERVIEW AND TEXT BY
PATRICIA KÉROACK, C. W.
CONTINUING PROFESSIONAL EDUCATION
An Innovative Application
An Apple application was recently unveiled for all those who, from close or far, are interested
in cardiology. Le Spécialiste met its creator, Dr Sébastien Bergeron, a cardiologist at the
Institut universitaire de cardiologie et de pneumologie de Québec.
WHAT IS CARDIO VIRTUEL?
Cardio Virtuel is an Apple application
aimed at all those who want to develop or
deepen their knowledge in one of the areas
of cardiology.
The application first allows the user to
personalize its content according to
Dr Sébastien Bergeron his or her own level of knowledge (pre
clinic, extern, resident up to expert), then
gives him or her the choice of a category to concentrate on
(pharmacology, ECG, radiology, ultrasonography, etc.). The
application presents a clear clinical situation, well illustrated
and documented, and then asks a question. A choice of
responses is given: it’s a form of action-reaction. Once the
answer has been validated, a multimedia presentation then
explains in detail the correct answer to the question. The
presentations last from four to eight minutes each. This is how
the application places you in a clinical situation in cardiology,
where you analyze, make a decision and immediately obtain
feedback. There is nothing like it in cardiology, no matter what
the language or device.
WHY DID YOU CHOOSE TO DEVELOP YOUR PRODUCT
AS AN APP RATHER THAN FOR ANOTHER PLATFORM?
It was while I was researching the matter, talking to people and
reading a lot on the subject that I realized that we are definitely
in the instant era. No one wants to have to sit in front of a
computer, for an hour each evening, to find an answer or to
follow a class. An app can be adapted to travelling, to today’s
schedule and to current needs. Young people say: “I have a
question. I want an answer now.” It’s no longer a pleasure to
surf the net if you have to wait. We want intellectual satisfaction
quickly, and an app allows that. To check out a few notions,
between two clinical cases, especially if we know that the next
case presents a notion with which we are less familiar, that is
the future of teaching and of continuing education.
WHERE DID YOU GET THE IDEA OF
CREATING SUCH AN APP?
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I have been responsible for several years for the cardiovascular
system course for the first year in medicine at Laval University
and I wanted to find a solution to the problem of transferring
knowledge to a large group of students (lecture). I also give a
lot of conferences to my peers. I’ve noticed that it’s often the
same physicians who attend conferences, symposiums and
scientific evenings and we were wondering how to increase
the audience. Many people prefer spending time with their
families instead of attending continuing education classes after
work. That’s when I realized the potential of mobile devices
for learning.
The app has added value for the evolving reality in the teaching
of medicine. For example, we now have 220 students enrolled
in medicine at Laval University. During the fall session, we will
need to teach them how to read an ECG, the major concepts
in heart failure, etc. That doesn’t leave much time for individual
help, whether it’s at the university or in university hospitals.
Student bodies have grown with the years, but the physical
space has remained the same. When we tour the floors on
teaching rounds, it’s is even more difficult: the noise, the many
stretchers, the lack of lighting, the promiscuity of patients
some of whom are moaning in pain, the alarms and bells
of all kinds that go off, none of these make it an propitious
environment to teach. The student will learn how to examine a
patient, but for concepts and reasoning, it’s not the best place.
Imagine the possibilities for teachers and students: we tour
a floor, the professor speaks of a particular pathology and
takes his smartphone out of his lab coat pocket. With just
a few clicks, he presents the case to the students who, a
few minutes earlier, knew nothing of such a pathology and
can now visualize everything. Learning is greatly facilitated
and students can better understand what they will see at the
patient’s bedside.
In addition, students in medicine constantly need feedback in
order to adjust their academic efforts. We believe that having
the app, using it on one’s own and having one’s questions
answered without being submitted to peer pressure, will
probably be a way of reducing stress for students in medicine.
CONTINUING PROFESSIONAL EDUCATION
This kind of tool is greatly appreciated by residents and
externs, as well as by general practitioners, as it makes it
easier to understand and analyze the results of prescribed
tests. Cardiologists who are not attached to university health
centres also like it because they can review concepts with
which they are not in constant contact.
HOW DID YOU START THIS PROJECT?
Af ter several years of thinking about it, the concept
became clearer four years ago. I used to be co-director
of the cardiology section of the Chaire de transfert de
connaissances cœur/poumons de l’Université Laval.
My projects differed from those of the Chaire and I preferred
pursuing my interests separately. I gathered students and
residents who were go-getters and who had determination,
and everything came together. The costs were enormous
and we did not have any financial help. We finally launched
the app on February 14th. The Laval University Faculty
of Medicine is currently working on the acceptance of
continuing medical education credits.
Many people worked on the development of this app
including the computer specialists who developed a simple
and clean algorithm as well as the university archivists who
saw to the management of trademarks and copyrights.
Several medical specialists in cardiology and radiology
contributed their expert knowledge during evenings and
weekends to get the project started. We learnt a lot because
it was an innovative project and presented several pitfalls
along the way.
WHAT OTHER PROJECTS ARE YOU PLANNING?
The app will continue to grow: we realize that there is no
end to what we can do. We already want to add material for
general practitioners and other healthcare professionals. The
content will be adaptable according to the competencies
and knowledge of its users. This summer, a hundred or so
videos will enrich the app (pharmacology, prevention, etc.).
Laval University wants to make of Cardio Virtuel a flagship
among Francophone apps. The app has already become
mandatory in preclinical teaching and a Web version is
expected shortly. We are currently evaluating the possibility
of transposing the concept to other medical specialties.
WHAT FUTURE DO YOU FORESEE FOR YOUR APP?
In 5 or 10 years, everything will be mobile. Physicians will
go around with an iDevice in their pockets so as to be able
to refer to it at any time. We want to spread out as much
as possible in French-speaking countries, but we also
have plans to develop an English version. Cardio Virtuel is
already available in Quebec, France, Belgium and North
Africa. We hope the app will become a kind of nexus for a
global forum where we could be asked to make additions
and adjustments. The beautiful thing is that once the app is
paid for, everything else is free for life.
S
L
THE LARGEST ANNUAL MEDICAL
SPECIALIST CONGRESS IN QUEBEC!
Friday, November 21, 2014
Montreal Convention Centre
This year, the theme of the 7th IED will be:
Healthcare Safety
Here are some of the presentations:
• Disorders from the Autism Spectrum
• Cardiology and Pregnancy
• Ailments from the EENT Area
• Neuro-Infectiology
• Surgeons and Emergency Specialists: Forced
to collaborate?
• Evaluating the Vascular Patient Before and
After Surgery
• Managing Acute Aortic Syndromes in 2014: a
Multidisciplinary Approach
NEW IN 2014!
Prize Awarded to Innovative Projects
Poster Sessions
Obtaining Section 3 Credits for the
Basic Resuscitation Skills Session
DETAILS AND REGISTRATION
AT FMSQ.ORG/JFI
19
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DOSSIER
The next time you travel by airplane, while
waiting to board, look at the passengers
around you and ask yourself why they are
taking this flight.
While the majority of people travel for business
or pleasure, others do so specifically to obtain
medical care.
L
A
C
I
MED
M
S
I
R
U
TO
In a context where access to certain types of
care is problematic, turning to other sources can
be attractive to those who can afford it. These
patients do not all call on the private resources
available in Quebec: a good number prefer to
turn towards external resources, sometimes
at thousands of kilometres from home. These
people are medical tourists.
SSPORT
AL PA
NATION
INTER
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The phenomenon is no longer just emerging,
it’s expanding! So much so that associations
of suppliers have seen the light, that brokers
and agencies are now well established, that
enterprises are calling on governments to
consider these revenues to refill the coffers of
the public health system, that networks and
university researchers take an interest in the
question, and more.
Le Spécialiste has looked at the question for you
and invites you to come into a parallel reality of
healthcare. A global reality!
BY PATRICIA KÉROACK, C. W.
MEDICAL
TOURISM
Going Abroad for Specialized Care
Your patients talk about the possibility of obtaining cardiovascular treatment in Thailand,
an orthopedic prosthesis in Cuba, dental surgery in Bolivia, a kidney or corneal transplant
in India or an end to their suffering in Switzerland? Some even go ahead... and enter the
medical tourism “industry.”
For the patient, medical tourism designates being able to
obtain health care or services somewhere other than in one’s
country or province. Such care or services are generally
available in the patient’s country of origin, but there can be
obstacles to access, a lack of supplies or professionals, an
unacceptably long waiting period, etc. For all these reasons,
patients undertake what the American Medical Association
designates as a “voluntary act,” calling on providers abroad
to obtain care.
From the public healthcare network to private resources
available in the country of origin, consumers can now easily
turn towards international resources, without needing a
medical referral or having to wait. Consumers decide and
obtain what they want, when they want... all they have to do is
pay the bill. Generally, consumers from the richest countries
are the ones who opt for these resources or for providers
located mainly in emerging or less-developed countries. And
the reasons are numerous: low costs for hospitalization and
care, greater availability of resources, low-cost travel, etc.
TYPES OF MEDICAL TOURISM
Outgoing
Patients going to other countries to obtain
medical care
Incoming
Patients coming from other countries to
obtain medical care
Domestic
Patients moving within a country to obtain
medical care
Source: “Evolving medical tourism in Canada: exploring a new frontier,”
Deloitte, 2009.
We must stress that the Public Health Agency of Canada
designates medical tourism as being “the fact of travelling to
other countries in order to obtain care.”1 It does not therefore
consider interprovincial travel as medical tourism.
CONSUMER TRENDS
At the era of the consumer-king, free markets, fashions, social
movements and of all other social trends, the free circulation
of currencies, the increase in trans-border movements, as
well as the number of professionals and intervention sectors
associated with the healthcare field, are all reasons that push
individuals to look for healthcare products and services the
same way they look for any other consumer product or service.
This explains that, well beyond spas and all other types of
resourcing centres that have existed for decades, we now find
specialized centres that offer more cutting-edge care that will
become, in time, increasingly sophisticated. From correcting
eyesight with lasers to the complete implant of organs, through
coronary and gastric bypass, we can now obtain everything
against payment. Patient-consumers now have various choices
for the management of their health.
WORRYING OBSERVATIONS
AN EMERGING MARKET
To start with, we see the almost complete absence of
probative data on this phenomenon. All the actors interested in
medical tourism (governments, agents and brokers, providers
of medical services, travel agents, etc.) agree on its growing
popularity, its general organization, its financial repercussions
and its successes, but no one can provide details, statistics,
etc. And yet, patients do not hesitate to talk about their
successful surgery or treatment.
In a study published by the Organization for Economic
Cooperation and Development (OECD) in 2011, Lunt et al.
describe medical tourism as an emerging global industry. In
fact, the authors state that the increasing number of actors is
a reflection of the growing trend of this market.
Despite the lack of probative data, everything seems to
indicate that more and more people are resorting to the
purchase of services and healthcare solutions available in
other countries. The emergence of this new sphere of activity,
which we understand to be lucrative, can be explained by
various factors: unavailability of services, difficult or restricted
access in the country of origin, confidentiality required by the
patient, social or family taboos, population aging, etc. Add to
this the opening and globalization of markets, the absence
of international barriers to commerce in healthcare services,
rapid access to information via the Internet, rising hedonism
and egocentricity, in short, mobile consumers who are ready
to live an adventure while improving their health.
21
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BUSINESS CONSULTANTS GET INVOLVED
Several professional business consultants have looked into
the development of medical tourism, including McKinsey
and Deloitte who have published several documents, reports
on enquiries and studies touching several aspects of the
healthcare sector. McKinsey foresees that this sector will
advance, while Deloitte, more audaciously, is not only in favour
of medical tourism, but shows how this could help finance the
Canadian public healthcare system and contribute to reducing
wait times.
In its docume nt e ntitled
“Evolving medical tourism
in Canada : exploring a
new frontier”2 published in
20 09, Deloit te mentions
that: “Medical tourism is
an emerging global trend
t h a t i s s t a r t i n g to t a k e
root in Canada, one that
presents oppor tunities
and challenges. (…)
Outbound medical tourism
is expected to increase as
health consumers seek new
medical treatments available
abroad, and aging Boomers
choose to avoid self-paid
services for improved access
and convenience. (…) For inbound medical tourism to gain
government and public support, a clear demonstration that the
revenues generated from inbound medical tourism are used to
increase capacity for publicly-funded care. [sic]”
In addition, it says that: “Considering inbound medical tourism,
the Canadian health system has unused capacity today,
which is not funded for public service. Using this capacity to
establish Canada as a medical tourism destination creates new
opportunity for revenue generation, which in turn can increase
the availability of services in the public system.”
ACCORDING TO DELOITTE, “THE CANADIAN HEALTH
SYSTEM HAS UNUSED CAPACITY TODAY, WHICH IS
NOT FUNDED FOR PUBLIC SERVICE.”
Deloitte projected at the time that in 2010, on a global level, the
amount associated with medical tourism would be in the area
of US$40 billion (Patients Beyond Borders, an organization
providing information to consumers, estimates that the
medical tourism market is closer to US$55 billion) and that this
market would grow by about 35% between 2010 and 2012.
At that time, Deloitte observed a net increase in the number
of healthcare providers, in “medical tourism” destinations
and in the number of a accreditations granted by just one of
the recognized certification companies: JCI, which saw the
number of accreditations it granted grow from 76 in 2005 to
more than 220 in 2008 (see text box below). We can thus
speak of a new economy in full emergence.
A LUCRATIVE... AND UNEQUAL MARKET
Medical tourism is worth it for citizens of countries without a
public or semi-public healthcare system. Already, the extensive
market made up of the U.S. population (315 million inhabitants)
is making all medical providers on the planet salivate. It is also
profitable for the population of countries that have a public
system, but where access is restricted or where certain
procedures are only available in a private network (for example,
plastic surgery, corrective eyesight surgery, etc.).
AN “INDUSTRY” ORGANIZING ITSELF...
In a free healthcare market, standardization, evaluation and certification can make a significant difference for service providers.
And these standards... have to meet certain standards! In 1984, the major evaluators and accreditors of service providers,
during an international meeting to deal with the problems surrounding the safety of health care, set up the International
Society for Quality in Health Care (ISQua), an organization mandated to establish the highest standards of care within a safe
environment. The organization has now accredited 26 entities (2 from Canada: Accreditation Canada and British Columbia’s
Diagnostic Accreditation Program), established 51 standards (8 of which are managed by the two Canadian entities) and 15
training programs.
One of these accrediting organizations certified by ISQua, the Joint Commission International (JCI), certifies organizations
offering healthcare services recognized by the major brokers of medical tourism. Over the last few years, JCI has grown to
such an extent that it is recognized as a world leader in the area of safety of care: 621 clinics from 57 countries hold its “Gold
Seal of Approval®,” its highest seal of standardization and evaluation for healthcare service providers. The company records
an annual growth of at least 20% in the number of organizations it certifies.
22
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The only dark cloud in this picture, despite the “great organization” of industry players, is the lack of the most important
characteristic: a central organization, such as the World Health Organization, that can objectively establish standards with the
aim of protecting the health of the world’s populations and not the activities that seek to profit from the health (or ill-health)
of the world’s populations.
MEDICAL
TOURISM
VAST MARKET, UNCLEAR EFFECTS
On the site global-medical-facilitators.com, we find the
following comment:
Medical tourism refers to various fuzzy concepts. Observers,
such as the business consulting firms of McKinsey and Deloitte,
deplore the absence of a central organization that can evaluate,
manage, qualify and quantify medical tourism overall. And yet,
several bona fide associations were created to promote both
medical tourism and their own members.
“Medial [sic] Tourism is one of the fastest growing industries
worldwide. Fuelled by the high demand for low cost medical
procedures, easy access to quality medical care and the
number of Americans that are uninsured and unavailability of
care in Canada. (…) GLOBAL Medical Tourism Facilitators [sic]
focus is on sending patients on Medical Trips to safe, beautiful,
tourist destinations at a huge savings!” “MEDICAL TOURISM GENERATES THE EQUIVALENT
OF 0.4% OF THAILAND’S GROSS DOMESTIC PRODUCT,
BUT HAS EXACERBATED THE SHORTAGE OF MEDICAL
STAFF BY LURING MORE WORKERS AWAY FROM THE
PRIVATE AND PUBLIC SECTORS TOWARDS HOSPITALS
CATERING TO FOREIGNERS.”
Healthcare providers are betting on specific items to attract their
clientele. Here, the provider specifically targets the Canadian
population which must deal with the problem of access to
health care.
From another point of view, the absence of such measures
of control and international standards can create doubt as
to the benefits and safety of such care for patients. Studies
have proposed that an international and independent
organization, like the World Health Organization
(WHO), play a central role in this regard, thus also
delegating to it the responsibility of issuing standards,
regulations, expectations and distributing information
regarding this sector of activity. Moreover, the WHO
already attentively oversees the effects, both positive
and negative, on the economy and on the health of
populations where medical tourism has developed. In
a newsletter published in 2011, the WHO having looked
at the Thai experience, stated that: “Medical tourism generates
the equivalent of 0.4% of Thailand’s gross domestic product
but has exacerbated the shortage of medical staff by luring
more workers away from the private and public sectors towards
hospitals catering to foreigners.
COMPARATIVE LIST OF PRICES (2011) AS COMPILED BY THE MEDICAL TOURISM ASSOCIATION
Medical Procedure
Heart Bypass
Angioplasty
USA
Colombia Costa Rica
$144,000 $14,802 $25,000
$57,000 $4,500 $13,000
India
$5,200
$3,300
Heart Valve Replacement
$170,000
$18,000
$30,000
$5,500
Hip Replacement
Hip Resurfacing
Knee Replacement
Spinal Fusion
Dental Implant
Lap Band
Breast Implants
Rhinoplasty
Face Lift
Hysterectomy
$50,000
$50,000
$50,000
$100,000
$2,800
$30,000
$10,000
$8,000
$15,000
$15,000
$6,500
$10,500
$6,500
N/A
$1,750
$9,900
$2,500
$2,500
$5,000
N/A
$12,500
$12,500
$11,500
$11,500
$900
$8,500
$3,800
$4,500
$6,000
$5,700
$7,000
$7,000
$6,200
$6,500
$1,000
$3,000
$3,500
$4,000
$4,000
$2,500
Gastric Sleeve
$28,700
$7,200
$10,500
$5,000
N/A
Gastric Bypass
Liposuction
Tummy Tuck
$32,972
$9,000
$9,750
$9,900
$2,500
$3,500
$12,500
$3,900
$5,300
$5,000
$2,800
$3,000
N/A
$4,000
$4,000
Lasik (both eyes)
$4,400
$2,000
$1,800
$500
$5,000
$6,000
N/A
N/A
N/A
N/A
N/A
N/A
$4,200
$4,500
$2,800
N/A
$850
$3,250
N/A
N/A
$2,700
$7,000
$10,200
$2,180
Cornea (both eyes)
Retina
IVF Treatment
Source: medicaltourism.com
Jordan
Korea
Mexico
$14,400 $28,900 $27,000
$5,000 $15,200 $12,500
$14,400 +
$43,500 $18,000
valve
$8,000 $14,120 $13,000
$10,000 $15,600 $15,000
$8,000 $19,800 $12,000
$10,000 $15,400 $12,000
$1,000 $4,200 $1,800
$7,000
N/A $6,500
$3,500 $12,500 $3,500
$3,000 $5,000 $3,500
$4,400 $15,300 $4,900
$6,000 $11,000 $5,800
Israel
Thailand Vietnam Africa Malaysia
$27,500
$15,121
N/A $10,000 $11,430
$8,000
$3,788
N/A $8,000 $5,430
$29,712
$21,212
$125,250
$20,000
$24,850
$35,000
$2,150
$12,500
$21,000
$9,500
$16,000
$14,000
$7,879
$15,152
$12,297
$9,091
$3,636
$11,515
$2,727
$3,901
$3,697
$2,727
$9,995
$11,500
$13,636
N/A
$8,770
N/A
N/A $10,950
N/A $2,800
N/A $4,025
$11,500
$7,242
$11,000
$16,667
$2,303
$5,000
N/A
$2,850
$3,850
$3,935
$5,060
$2,530
$9,450
$2,299
N/A
$1,995
N/A
$1,818
$1,640
$4,200
$477
N/A
$3,500
$3,950
$16,700
$13,000
$2,800
$1,800
$4,242
$9,091
N/A
N/A
N/A
$6,460
$3,370
$5,620
N/A
$3,000
$3,819
N/A
N/A
$10,130 $10,580
$8,250 $10,480 $7,500
N/A $7,640 $12,350
$8,500
N/A $7,000
$6,150
N/A $6,000
N/A $5,340
$345
N/A
N/A
N/A
$3,850 $2,930
N/A
$2,100 $3,935 $1,293
$4,150 $4,620 $3,440
N/A $3,270 $5,250
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“This has raised costs in private hospitals substantially and
is likely to raise them in public hospitals and in the universal
health-care insurance covering most Thais as well. The
“brain drain” may also undermine medical training in future.
(…) Medical tourism in Thailand, despite some benefits,
has negative effects that could be mitigated by lifting the
restrictions on the importation of qualified foreign physicians
and by taxing tourists who visit the country solely for the
purpose of seeking medical treatment. The revenue thus
generated could then be used to train physicians and retain
medical school professors.”3
A MEDICAL TOURISM INDUSTRY
Scanning the various sites indexed by search engines, we
can’t help but notice the scope and effervescence of this
industry: associations, magazines and publications of all
kinds, agencies, brokers, congresses, forums for patients to
share experiences, virtual visits, fidelity programs and more.
However, we sometimes get
To attract clients,
the impression that we’re
brokers don’t hesitate to
losing the very essence of
compare (lower) prices to
the approach among all the
what is available on the
th i n g s th at s u r ro u n d th e
American market.
trip ( recreation or tourist
activitie s, rooms, f lights,
• Brazil: 20-30%
food, etc.) and take over
• Costa Rica: 45-65%
what is essential, that is to
• India: 65-90%
say the healthcare services
• Korea: 30-45%
themselves: the dear th of
• Malaysia: 65-80%
information available on the
• Mexico: 40-65%
medical team, the equipment,
prior results, preparations and
• Singapore: 25-40%
possible complications and
• Taiwan: 40-55%
the pre-operative medical
• Thailand: 50-75%
file that sometimes leaves
• Turkey: 50-65%
us perplexed.
THE DECISION TO BUY
When it comes to deciding, the factor that weighs the most for
the client is the cost. The bill can be impressive for someone
from a country where healthcare services are public. For those
who come from a country where healthcare services are totally
private, like the United States, it’s the opposite.
Barring exceptions, the patient must pay for all the costs
associated with the care received. Medical tourism is thus
aimed at those who are more fortunate, but certain countries
reimburse the cost of procedures deemed essential to save
the life of the patient, procedures which otherwise could not
be dispensed. This is the case in Canada, where provincial
departments of health have implemented procedures to
approve the reimbursement of certain medical services
obtained abroad. These same departments also have
agreements between themselves.
Then, you have to take into consideration the quality of
care, medical expertise, speed of access and availability.
In addition, we have to consider the vacations one can
take, tourism, the return to one’s country of origin or visits
by one’s family or friends.
Among the procedures most currently offered today
in medical tourism, we find orthopedic surgery, in
particular knee or hip replacement or resurfacing, organ
replacement, neurosurgery, therapies associated with
chronic cerebrospinal venous insufficiency (also known
as liberation therapy or the Zamboni technique), bariatric
surgery and other weight-loss procedures, plastic
surgery, eye surgery, dental and dental implant surgery,
cardiovascular surgery, oncology, fertility and sex-change
surgery. In an area completely opposite to this list, we can
add the end-of-life clinics in Switzerland (yes, this is a form
of medical tourism).
WHEN THE PATIENT DECIDES
“In my opinion, Quebec went through a medical tourism fad a few years ago, but today it’s quieter, almost an
anecdote. One of my patients told me one day that he wanted to go to India for his surgery. This patient was
determined to have this surgery in spite of my having counselled against it beforehand; he remained convinced
that this operation was going to be a miracle cure. It was finally in the United States that he underwent the surgery
and he had to mortgage his home to pay his medical bills. Then, the expected benefits from the surgery never
materialized. It is probable there are still people who go elsewhere for surgery. How many? It’s difficult to say
because, generally, we only hear of those with complications when they return.
“However, we clearly see patients who turn to private resources for certain interventions that can no longer be handled by clinics because
of a lack of access to surgical facilities (bunions, minor growths, etc.). We should look at everything that is done in the private sector in
Quebec as being medical tourism. At this point in time, these clinics are working all out and they are looking for specialists to respond
to increasing demands. A patient can go directly to a private clinic without having gone through the public network, request a given
surgery and write out a cheque to pay for it. Such a case is never accounted for by the healthcare network.”
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– Dr Louis Bellemare, President of the Quebec Orthopædic Association
MEDICAL
TOURISM
IF THE RAPIDITY WITH WHICH SPECIALIZED
CARE CAN BE OBTAINED IS THE MAIN REASON
INVOKED BY PATIENTS FOR TRAVELLING
ABROAD, HEALTHCARE PROVIDERS, AS FAR AS
THEY WERE CONCERNED, EMPHASIZED THAT
THIS FINANCIAL CONTRIBUTION ALLOWS
THEM NOT ONLY TO ATTRACT THE BEST
SPECIALISTS AVAILABLE ON THE PLANET...
According to a study published in 2011 by the medical tourism
research group at Simon Fraser University in Vancouver,4
“orthopaedic surgeries were the most popular procedures
sought by the participants, with others going abroad for
chronic cerebrospinal venous insufficiency therapy, eye
surgery, cosmetic surgery, gastrointestinal surgery, and
bariatric surgery.” The researchers wanted to know “how do
Canadians decide on medical tourism for elective surgical
procedures and to what extent do their decisions necessitate
justifying particular ethical considerations?” For this study,
researchers only surveyed 32 persons: 19 women and 13 men,
as well as some medical tourism agents.
The researchers observed that this group of medical tourists
was very heterogeneous and that the results of their survey
confirmed this. They also recognized that their knowledge of
the field had significant limits. In conclusion, they indicated
that “Our scoping reviews (...) revealed that much of what is
reported about medical tourism is speculative. We actually
know very little about how many patients are going abroad,
for what purposes, and where they are traveling to. (...) Our
study aimed to examine if and how Canadian medical tourists
encountered ethical issues in their decision-making (...) they
were largely unaware of the potential ethical issues posed
by the practice.” The researchers closed by adding that “It is
important, however, that further insights be gained from more
medical tourists in order to establish how similar or unique the
experiences reported to us by the participants of this study
are, particularly in an international context. (...) There is a need
to further investigate the role of regulation in the industry (...).”
GOLDEN SOLUTIONS FOR PATIENTS
If the rapidity with which specialized care can be obtained
is the main reason invoked by patients for travelling abroad,
healthcare providers, as far as they were concerned,
emphasized that this financial contribution allows them not
only to attract the best specialists available on the planet, but
also to have medical equipment available and to maintain it at
the cutting edge of technology.
We must not forget that this access also allows one to
combine vacations, tourism, sometimes to revisit family
members who live elsewhere or to return to one’s own country
of origin to obtain treatments one is already familiar with. Thus,
many countries offer a combination of medical procedures with
rest or convalescence interspersed with visits to tourist spots,
recreation areas or lodging to encourage family contacts.
Nothing is left up to chance in order to attract clients: private
concierge service, virtual visits, preparatory meetings through
the Internet, dispatching of resumes of the entire medical team,
etc. Every sales argument is used to attract clients: to start
with, one must inspire confidence. For example, Lasik surgery
(for both eyes) costs less than $500 in Malaysia (see table on
page 23). At such a price, why not combine the intervention
with an unforgettable vacation, the agents will tell you.
PRINCIPAL DESTINATIONS
FOR MEDICAL TOURISTS
The website medicaltourism.com provides a list of the most
popular destinations. Canada is one of them, but the part
of the website dedicated to it is still under construction!
Argentina
Austria
Bahamas
Barbados
Brazil
Canada
Chile
China
Colombia
Costa Rica
Czech Republic
Dominican
Republic
Dubai
Ecuador
El Salvador
France
Germany
Greece
Guatemala
Hong Kong
Hungary
India
Iran
Iraq
Ireland
Israel
Japan
Jordan
Korea
Latvia
Lithuania
Malaysia
Mexico
Nicaragua
Panama
Peru
Philippines
Poland
Portugal
Puerto Rico
Romania
Russia
Saudi Arabia
Serbia
Singapore
Slovakia
Slovenia
South Africa
Spain
Switzerland
Taiwan
Tanzania
Thailand
Tunisia
Turkey
United
Arab Emirates
United Kingdom
United States
Uruguay
Vietnam
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THE INTERNET AS A SHOPPING TOOL
It’s not a surprise that the best way of obtaining information is
the Internet. Brokers, providers and agencies are all present
on the Web, where they say they generate 99% of their work.
Hundreds of promotion and explanation sites, discussion
forums, brokers, agencies and more offer their products, invite
you to a virtual visit, present forms to request quotes, everything
without the patient ever meeting the physician. You want a new
liver? Click here to find one! (See text box on page 27.)
In this industry, everyone wins and everything is possible for
those who can pay. Defenders of justice and common rights
denounce the inequality of access to care. In some countries, it
is said that care for the richest increases poverty and damages
healthcare services for the local population, who keep on
losing them.
DIFFICULT TRACEABILITY
According to some studies, medical tourists needing organs do
not seem to care about the provenance of what they “purchase”
(see full article on this subject on page 28). This inexorably leads
to a parallel buyer’s market. Advertising attracts potential donors
by shining the light on the payment of generous sums of money.
PROFESSIONALS WHO BENEFIT
Some professionals prefer to look for an international clientele
for a number of reasons, some of which are clearly ethical:
they prefer working in the private sector; they take advantage
of budgetary restrictions or limited access to certain types of
care in a public healthcare system; they use new technological
solutions that haven’t yet been approved; they benefit from the
availability of certain resources; they profit from the laws that
allow a clinic to operate as a business, etc.
The money earned from medical tourism provides, in turn,
for the recruitment of other professionals, of specialists and
subspecialists, for an investment in cutting edge equipment or
to offer services to the local population.
AND IF SOMETHING DOESN’T GO
ACCORDING TO PLAN?
As is the case for any intervention, patients have to deal with
various risks (infection, resistance to antibiotics, adaptation
and destination). One must also realize that a cer tain
number of procedures will not have the results expected:
postoperative complications, required corrections, deterioration
of the individual’s health, bad scarring, rejection, reactions to
medications or even local contamination with parasites, viruses
or something else, resulting in the need for a hospital stay upon
returning home. Arriving with problems, several must face
complications (for example, severe diarrhoea, throwing up due
to local parasites, bleeding). In addition, people taking part are
badly informed regarding certain risks such as longer flights
(increase in the risk of embolism), drainage tubes (possibility of
infection in certain surgical interventions), etc.
It’s when things go wrong or when complications occur that
the country of origin has to absorb significant costs, sometimes
costs that are higher than if the patient had been treated at
home. Clinics abroad have fulfilled their mandate: they have been
paid to do something and their contract is finished. The medical
tourist, confident that things will turn out right, doesn’t think to
prepare for the follow-up of his care when he reaches home.
In closing, several other points need to be considered before
giving oneself over to medical teams abroad. In addition to
problems associated with ethnocultural and linguistic barriers,
and with the content and the maintenance of medical files,
you must ask yourself, for example, who is responsible or
accountable should a bad outcome result or even should the
patient pass away? How can one pursue the medical clinic or the
medical staff in court? Which law will prevail, that of the country
visited or that of the patient’s country of residence? What is the
protection guaranteed by the patient’s personal insurance with
regards to his or her present or future care, the reimbursement of
treatments, medication or to medical corrective care? If anything
went wrong, what would the personal insurance cover?
WHO PROTECTS WHOM?
“In hematology, and in medical oncology, we don’t see people who go elsewhere for health care or services. What
we see are patients who go elsewhere (for example, the Mayo Clinic) for a second opinion. They generally come
back to us with the doctor’s report to discuss available options.
“There are people who want a particular type of alternative medicine or a specific experimental treatment not
offered in Quebec. I do understand people who want to fight at all cost, even if we explain that there’s nothing left
to do. They prefer to put themselves in other hands, to hang on to hope. These cases are anecdotal.
“Sometimes, we receive patient requests for a second opinion. But, we have to be careful. A physician who decides to accept foreign
patients, who are not covered by the Interim Federal Health Program and who receives payment for fees not covered by the RAMQ,
needs to realize that he opens himself to lawsuits that would not be covered by our professional insurance, because this type of patient
is not an insured person as defined by the law. The physician has to have appropriate documents signed to indicate that the services
are rendered in accordance with the Canada Health Act.”
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– Dr Daniel Bélanger, President of the Association des médecins hématologues oncologues du Québec
MEDICAL
TOURISM
In an environment where, like in the United States, all medical
costs are charged to the patients, private insurance and
employers see clear financial advantages to seeking healthcare
services outside the country. However, in a country where
IMPACT ON HEALTHCARE POLICIES
While financial outcomes can have a significant positive impact
on the finances of countries who offer these services and
care to medical tourists, there are important considerations
associated with healthcare policies that need to be looked at.
If patient-consumers need to understand all the risks
associated with their purchase (post-intervention risks,
whether in the locality where the intervention takes place or
upon returning home; the risks associated with the effects
of travelling such as the length of the flight, pressurization
and risks of an embolism, etc.; the risks associated with
the care required upon reaching home, their availability, the
connection with information contained in the medical file; the
costs associated with post-intervention care whether for the
short, medium or long-term), they also need to know that
their decision may have an effect on the healthcare system of
healthcare services are public and paid for by the State, these
advantages disappear: the patient then becomes an individual
consumer of services, without considering possible short or
long-term consequences for him or her and for society.
their country: costs associated with post-intervention followup, medication and complementary services; and long-term
consequences for their health. But patients must also know
that their purchase can have consequences on the healthcare
network of the country visited: impact on the dispensation
of care to the local population, exodus of the most qualified
personnel towards private clinics for tourists, etc.
This shows that it is essential to have a neutral organization
that can regularly follow the evolution of medical tourism,
its implications in the countries from which tourists travel as
well as their medical destinations. This organization needs to
monitor the ethical and legal stakes, the safety of care, the
exodus of talent, the technologies, the economic and political
impacts, etc.
NEW PUBLICITY OUTLET...
A cosmetic medical clinic recently published a press release
which mentioned: “Take advantage of your lunch hour to
get some Brazilian buttocks. The ad explained how, in two
sessions, it was now possible for women to obtain beautiful,
high and rounded buttocks. “During the first visit, we will
undertake to implant surgical steel wires that, as early as
the next visit, could be sculpted and shaped to give you a
perfect silhouette.”
In another ad, one is promised a record weight-loss thanks to
the installation of a gastric ring made of rubber. Another one,
invites you to a whitening of your teeth without effort during a
tanning session, followed by an exotic “night life.” We cannot
ignore the influence of fashion on certain clients.
… AND NEW SALES
Whoever mentions advertising often refers to sales agencies
as well. Thus, many firms now offer brokerage services to help
a patient arrive at a choice and help him or her throughout
the healthcare.
In Quebec, a company is born after its founder, exasperated by
the delay needed to obtain a diagnosis, chose to go to Cuba
for her care. Happy with her experience, she became a broker
in medical services to help other people like her. To date, more
than 1,300 people have taken advantage of Cuban healthcare
services via this broker.
REFERENCES
1.travel.gc.ca/travelling/health-safety/
care-abroad
2.Evolving medical tourism in Canada: Exploring
a new frontier, Deloitte, 2009. Available at:
deloitte.com
3.NaRanong A, NaRanong V. The effects of
medical tourism : Thailand’s experience.
Bull World Health Organ 2011;89(5):336-44.
Available at : who.int
4.Crooks VA, Snyder J, Johsnston R, Kingsbury
P. Perspectives on Canadians’ Involvement
in Medical Tourism: Final Research Report.
Burnaby : Simon Fraser University, 2011.
Available atsfu.ca
27
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BY KARINE TOUSIGNANT, MD*
Need a Kidney?
Here’s the Fast Track!
Despite the efforts of the 25 active transplant programs
repertoried in Canada in 2012 and established in 7 provinces,
the deficit in kidney transplants is still a major problem.
Knowing that kidney transplants remain the therapy of choice
insofar as quality of life (Laupacis et al., 1996) and overall
survival (Wolfe et al., 1999) are concerned, the medical team
is at the end of its rope to offer quality medical care.
THE PROBLEM
We can feel a certain discomfort, and this on three fronts,
when we discuss the trade in organs with our patients.
Definitions are sometimes unclear and documentation
sparse, but the underlying bioethical principles invite us to
ask ourselves questions on all facets of this practice without,
quite often, being able to answer them. The more physicians
are informed of the need for organ transplants in Quebec and
in Canada as well as of the fashion for transplant tourism, the
more they will be able to counteract this practice and reveal
this growing problem.
THE FACTS
The prevalence of patients suffering from end-stage renal
disease (ESRD) in Canada keeps growing. According to the
Canadian Organ Replacement Register (CORR) in 2012,
some 41,252 patients needed renal therapy (hemodialysis in
a hospital centre, hemodialysis at home, peritoneal dialysis)
or were recipients of a functional renal transplant. Almost
tangentially, the incidence of new end-stage renal failures
involved 5,431 patients (corrected glomerular filtration rate of
less than 15 ml/min), including 2,591 patients in Ontario, 891 in
British Columbia and 540 in Quebec. As initial treatment,
very few patients in the country had access to a pre-emptive
transplant in 2012, only 184 (3.4% of ESRD patients). On
December 31, 2012, there were 3,428 Canadians, including
923 from Quebec, waiting for a transplant, from both adult and
pediatric populations.
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THE SOLUTIONS
The median wait for a transplant from a deceased donor can
vary from 5.8 years in British Columbia, 5.2 years in Manitoba,
4.5 years in Ontario and 2 years in Quebec as well as in
Nova Scotia (Wright et al.); an average of 3.9 years, including
all provinces (data from the CORR). The living transplant
contributes to reducing this wait, but it is not available to
everyone, since a healthy donor is needed, both physically
and psychologically, who is compatible on the biological
level and ready to make the ultimate gift, and who is found
among the patient’s entourage. When a donor is not available,
transplants via a “chain of gifts” with donors from within
Quebec or elsewhere is already established and has proven
itself. Even here, time is needed to complete the pre-transplant
assessments and organize the chain in a safe and effective
manner. In Canada, over the last decade, between 46 and
84 patients per year die while waiting for a transplant, including
24 patients in 2012 located in Quebec.
This explains the popularity of the emerging solution of
transplants from abroad, commonly called medical tourism,
or more specifically transplant tourism. Globally, commercial
transplants are estimated at close to 5 to 10% (3,500 to 7,000)
of all transplants per year (Akoh, 2012). Medical tourism refers
to the movement of patients who cross national borders to
obtain a treatment, a diagnosis, surgery in another country or
another continent.
The Declaration of Istanbul on organ trafficking and
transplant tourism in 2008 provides a clear definition of
organ trafficking, a sub-type of medical tourism:
The recruitment, transport, transfer, harbouring or receipt
of persons, by means of the threat or use of force or other
forms of coercion, of abduction, of fraud, of deception, of
the abuse of power or of a position of vulnerability, or of the
giving to, or the receiving by, a third party of payments or
benefits to achieve the transfer of control over the potential
donor, for the purpose of exploitation by the removal of
organs, tissues or cells for transplantation.
* The author is a nephrologist at the Centre hospitalier régional de Trois-Rivières and a Counsellor on the Board of the FMSQ, representing intermediate regions.
Credit: telegraph.co.uk
MEDICAL
TOURISM
Medicus Clinic near Pristina in Kosovo
Medical tourism has been emerging as a global phenomenon
in health care and services, since in 2006 the “industry” was
evaluated at $60 billion (Evans, 2008). In our case, the reason
motivating these trips is to acquire a transplant more rapidly.
Some patients will even go as far as arguing that the care that
is offered abroad is technologically more cutting edge!
In Canada, the phenomenon is increasing especially in large
cities such as Toronto, Vancouver and Montreal. Patients,
especially if they belong to a specific ethnic group, tend
to return to their country of origin to obtain a commercial
transplant (Gill, 2011).
THE WORRIES
Transplant tourism implies several elements that are generally
controversial such as the source and removal of the organ,
informed consent, the medical follow-up of the donor in the
country of origin as well as the future of the transplant and
the recipient (Cohen, 2009). Transplant tourism has been
associated in several retrospective studies with an increase
in surgical complications and acute rejection, in addition
to contributing to the entry into Canada of several invasive
microbiological (or microbial) strains: all of which could lead
to an increase in post renal transplant morbidity and mortality.
Several references establish an association between these
transplant recipients and the seroconversion of HIV, of hepatitis
B or C, of the Epstein-Barr virus (EBV), of the cytomegalovirus
(CMV) and of the varicella-zoster virus or VZV (Akoh 2012).
Quite often, both patients and physicians have little access
to the pertinent documents regarding the surgery. Since
the “donor” countr y could not provide them with any
immunosuppressors, some patients have returned to Canada
without, thus resulting in the chronic dysfunction of the kidney
or even the loss of the graft. Others spent significant sums of
money and, for various reasons, did not receive a transplant
nor did they ever recover their investment (Wright 2013). In
this regard, the trafficking of organs at the Medicus Clinic,
near Pristina in Kosovo, which was revealed in 2008, showed
that potential recipients had to pay up to $132,000 to foreign
investors in order to obtain a kidney. As for the “organ donors”,
they quite often received false promises of remuneration in
the order of less than $20,000. It is even said that several
prisoners lost a kidney...
Contrary to what we might believe, medical tourism agencies
do not exist only elsewhere. In 2011, according to a Turner
study, more than 25 Canadian organizations clearly published
their activities on the Web, including 4 networks in Quebec.
These organization, that are probably no longer active or
that have changed names, advertised accessible and rapid
healthcare services, at low cost and of an exceptional quality.
Several offered their “clients” arrangements for flights,
hotel reservations, activities and excursions and even...
guided tours!
IN SUMMARY
If a patient decides to obtain an organ transplant from
outside Quebec, it is imperative that, upon returning home,
he or she be able to consult his or her medical team for a
follow-up. This follow-up will probably be difficult, considering the items mentioned previously; however, physicians
will have to adapt to this new reality as it does exist.
Several questions remain pending: Who is responsible for
educating patients in a pre-emptive fashion on the legal
risks of this phenomenon? How do you manage a multidisciplinary team when a patient comes back with serious
postoperative complications? What strategies can be
adopted to reduce the wait time on the cadaveric list in
Canada to avoid medical tourism? How do you legislate
while leaving the patient with the freedom to choose?
In my opinion, prevention and discussion of the medical
stakes with the patient and his or her family remain the
medical specialist’s best advantage.
REFERENCES
1.Canadian Organ Replacement Register. Available at: www.cihi.ca
2.Akoh JA. Key issues in transplant tourism. World J Transplant
2012;2(1):9‑18.
7.Steering Committee of the Istanbul Summit. The declaration of Istanbul on
organ trafficking and transplant tourism. Transplantation 2008;86:1013.
3.Cohen DJ. Transplant tourism: a growing phenomenon. Nat Clin Pract
Nephrol. 2009;5:128–9.
8.Turner L. Canadian medical tourism companies that have exited the market
place: content analysis of websites used to market transnational medical
travel. Global Health 2011;7:40.
4.Evans RW. Ethnocentrism is an unacceptable rationale for health care
policy: a critique of transplant tourism position statements. Am J Transplant
2008;8(6):1089-95.
9.Wolfe et al. Comparison of mortality in all patients on dialysis, patients
on dialysis awaiting transplantation, and recipients of a first cadaveric
transplant. New England J Med.1999: Dec 2;341(23):1725-30.
5.Fortin MC, Williams-Jones B. Should we perform kidney transplants on
foreign nationals? J Med Ethics Nov 25 2013. [Epub ahead of print].
10.Wright L, Zaltzman JS, Gill J, Prasad GVR. Kidney transplant tourism: case
from Canada. Med Health Care and Philos 2013;16:921-4.
6.Gill JS, Diec AO, Landsberg DN, et al. Opportunities to deter transplant
tourism. Kidney International 2011;79(9):1026-31.
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BY J. MARC GIRARD, MD*
Multiple Sclerosis
The Zamboni Hypothesis and its Media Effect
Dr Paolo Zamboni, a vascular surgeon at the University of
Ferrara in Italy, whose wife suffers from MS, publicized the
hypothesis that multiple sclerosis could be caused by an
obstruction within the extracerebral venous system. His
hypothesis was based on observing such limitations in 100%
of the people affected by MS whom he had evaluated, but
by none of the people who were free of the disease. Without
waiting for confirmation by other groups, he went ahead,
within the framework of a preliminary study, and performed
venoplasty in people so affected. The CTV report showed
individual testimonials from people who said they had observed
an improvement in their condition after this intervention.
For patients affected with MS, this story resonated widely, in
Canada and in Italy, a little in certain European countries and
in Australia, but very little in the United States. It especially
touched patients suffering from progressive forms of the
disease, for whom current therapeutic approaches are not
effective, and who were thus the most handicapped. It also
affected other patients for whom treatments had become
exasperating, either because of having to inject oneself or
because of the side effects generated. The week after the
report was broadcast, MS clinics throughout the country
were inundated with calls requesting, to start with, the test
that would confirm the presence of venous occlusions and,
secondly, the benefit of the said treatment.
MS is without doubt the neurological disease for which
advances are the most important and Canada is among the
leading countries where knowledge has advanced the most.
Zamboni’s hypothesis in some way came in from left field
and did not fit in with established evidence. It is thus with
scepticism that neurologists heard the news. Patients received
negative answers from MS clinics not only with regard to having
venoplasty, but also to simply have the Doppler test described
by Dr Zamboni, a test that looked simple to patients and easily
available, while in fact it is a complex technique that indirectly
measures venous stenoses and the reliability of which is not
always confirmed four years later. The result was a loss of
confidence by patients in their neurologists. The patients
organized themselves by using the new social networks in
particular and thus were able to take advantage of the media
to defend their cause.
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Credit: Yury Petrovich Masloboev, wikipedia.org
In November 2009, the television show W5 on CTV broadcast a report that would both
awaken the imagination of people with multiple sclerosis (MS) and set off a chain reaction the
effects of which are still being felt today.
Doppler Test
MULTIPLE SCLEROSIS IS WITHOUT DOUBT
THE NEUROLOGICAL DISEASE FOR WHICH
ADVANCES ARE THE MOST IMPORTANT AND CANADA
IS AMONG THE LEADING COUNTRIES WHERE
KNOWLEDGE HAS ADVANCED THE MOST.
Feeling the growing demand, clinics abroad started offering the
possibility of undergoing the test and the treatment at the same
time to people ready to pay between $10,000 and $20,000.
Such clinics were set up at the beginning of 2010 in Poland,
Bulgaria, Germany, India, Mexico, Egypt and Costa Rica.
More accessible private clinics, in the United States, offered
their services as early as the end of 2010. One of the clinics
located in Frankfurt in Germany had even hired a Quebec
receptionist to respond to the influx of call from Quebec. And
yet, Dr Zamboni himself was opposed to the treatment being
offered in a context other than experimental, having himself
never offered the treatment outside of a research project. This
is unfortunately not the case with the private clinics who were
offering medical tourism. They were content to treat patients
without any medical follow-up, but against remuneration, while
guaranteeing only the dilation of venous stenoses, without
promising any improvement for the condition.
* The author is a neurologist at the Clinique de sclérose en plaques du CHUM and co-investigator of the pan-Canadian study on the treatment by venoplasty of
chronic cerebrospinal venous insufficiency possibly linked to multiple sclerosis. He is also President of the Association des neurologues du Québec.
MEDICAL
TOURISM
Starting in the spring of 2010, hundreds of Quebeckers
and thousands of Canadians left the country to undergo
venoplasty. Each clinic had its own protocol: some claimed
better results by using larger balloons during the venoplasty;
others treated all stenotic veins: jugular, azygos, renal and
sometimes even intracerebral; and still others used stents
in the hope of preventing restenosis, and this, despite the
absence of stents adapted to veins as well as Paolo Zamboni’s
known disagreement on their use. When patients came back
to the country, they had as many different recommendations
as there were clinics: aspirin, anticoagulants or not, for
variable periods after venoplasty, and recommendations for
a radiologic follow-up of their treatment, but without knowing
how or to what end. The information sent by these clinics was
often incomplete, nonexistent, or extremely variable and could
change from one month to the next for the same clinic.
All three had received stents and it is the use of the latter
that caused most of the serious complications identified
with venoplasty. The two Canadians died abroad: the first,
a woman whose first symptoms appeared a few hours
after the treatment, died in California of an intracerebral
haemorrhage; the other, a man, died in Costa Rica, because
of an haemorrhage, a few hours after an attempt by the
physicians of the clinic to remove a venous thrombosis
present for some months after a first venoplasty and using
thrombolytic medication. Despite the evident cause of these
deaths in relation to the treatments given abroad, pressure
groups for venoplasty continue to maintain that these persons
died because of a lack of care in Canada.
We know that patients who had complications following these
treatments abroad did receive appropriate care upon their
return to Canada. No one died due to complications
in Quebec.
WHEN PATIENTS CAME BACK TO THE COUNTRY,
THEY HAD AS MANY DIFFERENT RECOMMENDATIONS
AS THERE WERE CLINICS: ASPIRIN, ANTICOAGULANTS
OR NOT, FOR VARIABLE PERIODS AFTER VENOPLASTY,
AND RECOMMENDATIONS FOR A RADIOLOGIC
FOLLOW-UP OF THEIR TREATMENT, BUT WITHOUT
KNOWING HOW OR TO WHAT END.
Faced with this chaos, the Collège des médecins du Québec
(CMQ) got involved in the file. To start with, with the lack of
scientific evidence on the reliability of the Zamboni technique
to identify venous stenoses as well as the absence of
scientific confirmation of a link between these stenoses and
multiple sclerosis, it forbid that Doppler exams be offered
by Quebec physicians. Offering Dopplers in such cases
went against Section 48 of the Code of Ethics of Physicians
in Quebec. Secondly, in March 2011, the CMQ published
a guide for taking charge of patients returning to Quebec
after venoplasty treatment abroad1. This guide specified the
completely legitimate right of patients to receive medical
treatment upon their return, notwithstanding their decision to
go abroad, but that in the absence of clear scientific data,
the treating physician was under no obligation to follow the
recommendations of foreign physicians and he or she should
thus use good clinical judgment to decide.
AND THE FOLLOW-UP?
What happened to the people who were treated abroad?
Some noticed an improvement in the symptoms that had
a negative impact on their quality of life: fatigue, urinary
problems, concentration, spasticity, pain or visual problems.
Few observed a miraculous improvement in their condition.
We know of three patients who died out of the tens of
thousands treated world-wide, two of whom were Canadians.
What is the situation now? Four years later, several
articles have been published on the subject with
contradictory results, but no group has been able to
confirm Dr Zamboni’s preliminary results regarding
the presence of venous stenoses in 100% of
patients suffering from MS and not in people free
of the disease. Patients who benefitted from an
improvement saw their symptoms reappear after
a few months. The vast majority rapidly presented
restenosis after the venography and blamed them for a
recurrence of their symptoms. Some went back up to five
times for the treatment, others were even operated to replace
their jugular veins with grafts.
The enthusiasm for this approach is much weaker now than
initially, since the talk has stopped inflaming the hopes of
people stricken with MS. And yet the question remains: If
there is an improvement in symptoms, is it a real effect of
venoplasty or is it a placebo effect? The answer will only be
possible through a randomized study comparing venoplasty
with a simulated procedure. Dr Zamboni undertook such
a study in Italy. Canadian authorities have approved a
pan Canadian study, of which I am co-investigator; it will
be undertaken in Montreal, Quebec City, Vancouver and
Winnipeg. Without doubt, these studies will find answers to
some of these questions.
REFERENCE
1. Management of multiple sclerosis patients returning to Quebec after
venoplasty treatment for chronic cerebrospinal venous insufficiency
(CCSVI), Montréal: CMQ, ARQ, ANQ, 2011. Available at: cmq.org
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BY MARC-YVON ARSENAULT, MD*
Giving Birth in Canada
Anything... To Get a Passport
They usually come from afar, with different life experiences, from often different conditions,
but all with the same aim: to give birth in Canada!
There are also, and they are increasingly numerous, women
from North Africa or elsewhere, who board a trans-Atlantic
flight in order to openly give birth on Canadian soil. Their aim
is openly admitted: to obtain a Canadian passport for their
baby. They often have a file of prenatal medical follow-up
undertaken in their own country which they bring along, as
well as have organized networks to help them get through
the administrative requirements, lodging and basic care
while awaiting D Day. We’re told that there are even websites
dedicated1 to the phenomenon and that certain groups are
setting up to promote these clandestine voyages... because
the passport-baby phenomenon is growing to such an extent.
Some groups even offer lodging in transition homes in the
suburbs near birthing centres.
The phenomenon is not recent and, since I began practising
medicine – nearly 17 years of regularly sleeping in the on-duty
room of the family birthing unit of the Hôpital de LaSalle – I’ve
seen a definite increase in the phenomenon of passport-babies.
There was this lady from the Caribbean, who had been living in
Canada for more than 12 years, an illegal worker for residential
domestic services because she had no status and no work
permit. She had never had to call on healthcare services until
she became pregnant. Then, because she wasn’t covered by
the RAMQ’s public plan, the bill was stupendous.
There was the spouse of this African student registered with
the Quebec Bar. She had come to be with him on a visitor visa
which had finally expired. She became pregnant, and what
was to happen happened. She showed up one day, in labour,
at the birthing unit, without any prenatal medical supervision
nor any RAMQ coverage.
There is an ever-increasing number of patients transferred
to us by Maison Bleue (a not for profit organization offering
perinatal social services to pregnant women living in vulnerable
situations), with a scenario that is repeated from one time to
the next: the woman arrives in advanced labour, with a minimal
file, her two midwives and no financial means...
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No later than this week, there was this medical professional,
who deplaned from the Air Algérie flight, very evidently pregnant
at 37 weeks, with her jewellery and her beautiful Louis Vuitton
luggage, in order to give birth in Canada! She stayed at the
hotel until the big day; she had brought along her prenatal
medical follow-up file from a private clinic in Algiers with its
results from prenatal testing, ultrasounds, etc. All of this was
done with the admitted aim of obtaining a Canadian passport
for her child!
It is difficult to put numbers to this phenomenon because there
are no official statistics maintained on it. However, it is easy
to see that it is clearly increasing. One fact is very clear: in
more than 90% of cases, the hospital’s administration does
not manage to recover its hospitalization costs which are billed
to the patient and her newborn (close to $3000 and $1000
per day, for mother and child, respectively). And that’s without
counting the costs for professional medical care that, we
hope, will be honoured by the RAMQ, conditional on obtaining
an address proving residency in Quebec. In line with this
information, it would seem that we are quite regularly paid with
an “emergency” code and that it’s the RAMQ afterwards who
attempts to recover the costs. When we have the opportunity,
if the patient comes early enough during her pregnancy for a
prenatal follow-up, we obtain at least a deposit that will help to
pay the professional fees of the obstetrician and the anesthetist
who will assist her in giving birth. Our figures in the office speak
for themselves. We are currently experiencing an explosion of
these requests and, for the third quarter of 2014 only, we are
already past the usual number of requests for a year... Case
numbers are now in the tens! Why?
* The author is an obstetrician and gynecologist at the family birthing unit at the Hôpital de LaSalle.
MEDICAL
TOURISM
Quite often, the motivation to come and give birth here are
clear and we refer to passport-babies because that is the real
reason: to become citizens and to get the popular Canadian
passport! It would seem that this passport will be valuable
for years to come. First, it guarantees entry into a country
considered safe, where healthcare is free from one ocean
to the other, and where the costs of a quality education are
extremely low (especially here in Quebec!). Thus, the passport
is worth one’s weight in gold! We need only think of all these
people in other countries who take this passport out of their
safety deposit boxes when a conflict develops: bring me back
to Canada! The Canadian passport is also recognized worldwide and facilitates passage through the various international
customs stations without needing to obtain any particular
visas. It is easier for an African national to visit France with a
Canadian passport than it is with a passport from his or her
native country.
THERE WOULD THEREFORE SEEM TO BE AN
INCREDIBLY HIGH NUMBER OF SUCH NATIONALS,
WHO HOLD A CANADIAN PASSPORT WITHOUT
EVER, OR ALMOST EVER, HAVING SET FOOT IN THE
COUNTRY, WHO HAVE NEVER PAID THE LEAST
TAXES HERE, BUT WHO CAN CLAIM THESE FREELYPROVIDED SERVICES FROM THE GOVERNMENT,
EITHER BY WAY OF REPATRIATION REQUESTS,
HEALTHCARE COSTS OR POSTSECONDARY STUDIES.
And finally, there is this lady from Mali, who was stopped by
border authorities at the Pierre-Elliott-Trudeau International
Airport in Montreal. An irregularity in her spouse’s visa
attracted the attention of the officers and, under questioning,
the lady candidly admitted she wanted to enter Canada in
order to give birth here. The couple was travelling with a first
child who had been born in New York State. They now had the
intention of reliving the experience, but in Quebec this time,
because French is spoken here! At that point, accompanied by
border agents, she was brought into the birthing centre for an
evaluation (our hospital centre is not very far from the airport).
She was 34-weeks pregnant, with a normal pregnancy and
no unusual pre-condition. The initial evaluation showed the
foetus was in good shape, which was reassuring considering
the absence of uterine activity. This patient was therefore not
in labour, had not voiced any complaint and her baby was
doing well according to all the objective data collected. The
agents had to determine if the patient was “fit to fly.” One has
to understand that airlines have the responsibility of making
sure travellers on board all respect the rules to be welcomed at
destination (entrance fees, passports and visas) and that, if this
is not the case, the airlines are responsible for flying them back
to where they came from... After a few hours of evaluation, it
was clear that this patient was not in labour, that she did not
present any evidence of any pathological condition: her birth
channel was long and closed, she was not losing any blood
or amniotic fluid, and she was completely asymptomatic. Her
baby was moving well, the foetal rhythm graph was reactive
and an ultrasound at bedside showed everything was normal...
When the border agent asked me if she was fit to fly, I could
only answer that she had no underlying medical condition
to justify keeping her under observation any longer. Once
released from the hospital, the lady was immediately taken
back to the airport to board the flight back... fit to fly. This was
an emotionally draining experience.
SOLUTIONS WANTED
How can we remedy such a situation? According to
communications received at the Association of Obstetricians
and Gynecologists of Quebec, it would seem that the
Harper government wants to reconsider the issue of jus soli
citizenship. It is important to know that Canada and the United
States are practically the only countries in the world to grant
citizenship to an individual by virtue of jus soli and not by
jus sanguinis. In Europe, especially in France, citizenship is
obtained by jus sanguinis, but also by jus soli, by meeting
certain specific conditions.2 In Canada, one has to be born
on Canadian soil, or born abroad of at least one parent with
Canadian citizenship to obtain Canadian citizenship. Does the
solution reside simply in modifying this state of affairs? We
are speaking here of citizenship, not of fees incurred when
receiving medical care, especially for patients who are not
insured by the RAMQ.
In addition to all the considerations associated with citizenship,
as seen previously, would it not be better to require from all
visa seekers, a certificate of medical insurance with proof of
coverage for pregnancy? Also, there could be a law prohibiting
all manoeuvres to give birth in Canada. At present, a simple
letter of invitation from a relative is sufficient to obtain a visa.
No proof of medical insurance is required. By requiring it, we
could thus limit the number of these third-trimester travellers,
since no insurance company would agree to cover medical
expenses for a person who knows, in advance, that medical
care will be required... If a woman succeeds in obtaining such
an insurance, care providers and institutions would at least be
sure they would be paid.
The solution is not simple, but the problem is very real. Arriving
in a birthing room stripped of all means is never pleasant.
Giving birth is already sufficiently stressful, would it not be
better to settle all the problems associated with citizenship
and medical costs before this important moment?
REFERENCES
1. A simple search on Google with “giving birth in Canada” & “visa” yields
36,700 results where people exchange information on the practice.
2. service-public.fr
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Comparaison Québec – Canada, 2013
20 MÉDICAMENTS LES PLUS PRESCRITS – 2013
QUÉBEC
Nombre estimé d’ordoNNaNces exécutées
par les pharmacies commuNautaires
sYNthroid
8,607,485
sYNthroid
d-tabs
2,943,995
apo-atorVastatiNe
5,113,677
pro-aas ec-80
2,282,745
apo-Furosemide
4,423,949
atorVastatiNe
2,186,046
coVersYl
4,345,441
1,611,615
cipralex
3,729,821
1,574,438
taro-WarFariN
3,240,060
1,572,871
apo-hYdro
3,083,274
1,473,109
d-tabs
3,037,070
1,463,547
teVa-rosuVastatiNe
2,932,316
1,389,049
tecta
2,915,056
1,378,798
teVa-VeNlaFaxiNe
2,895,349
1,294,094
elaVil
2,883,158
1,258,095
atiVaN
2,863,408
1,235,966
teVa-amoxicilliNe
2,733,814
paNtopraZole
1,178,004
celebrex
2,630,686
alesse
1,175,475
eltroxiNe
2,585,418
celebrex
1,120,095
apo-salVeNt cFc
2,530,482
teVa-rosuVastatiNe
1,106,584
saNdoZ-bisoprolol
2,522,672
calcium
1,084,609
apo-rosuVastatiNe
2,518,437
elaVil
1,058,310
eZetrol
atiVaN
coVersYl
pro-metFormiNe
atorVastatiNe
apo-esomepraZole
coumadiN
amlodipiNe
paNtopraZole
Jamp-VitamiNe d3
saNdoZ-bisoprolol
CANADA
Nombre estimé d’ordoNNaNces exécutées
par les pharmacies commuNautaires
15,380,467
PUBLICITÉ
PLEINE PAGE
tous les autres
IMS
201,910,010
2,402,760
tous les autres
500,159,279
PART EN PoURCENTAgE D’UTILISATIoN DE MÉDICAMENTS gÉNÉRIQUES PAR PRovINCE, 2009-2013
SELoN LE NoMbRE D’oRDoNNANCES DÉLIvRÉES EN PhARMACIES CoMMUNAUTAIRES
colombie-britaNNique
2009
2010
2011
2012
2013
59.1
60.0
62.3
64.3
64.6
alberta
56.9
58.7
61.7
63.4
63.4
saskatcheWaN
56.4
57.4
61.7
65.4
66.6
maNitoba
59.3
61.1
64.0
67.7
71.1
oNtario
56.2
58.8
60.3
63.1
63.9
QUÉBEC
50.5
54.4
58.1
61.3
66.9
NouVeau-bruNsWick
60.4
60.9
62.6
65.3
66.2
NouVelle-écosse
56.0
57.5
60.0
63.6
64.7
Île-du-priNce-édouard et terre-NeuVe
58.3
59.2
61.3
63.9
66.0
source : ims brogan, canadian compuscript, avril 2014
Pour de plus amples renseignements : 1-888-400-4672 / www.imsbrogan.com
une importante source d’information, d’analyse et de consultation pour les secteurs de la santé au canada
BY PATRICIA KÉROACK, C. W.
MEDICAL
TOURISM
Conclusion: Can We Benefit from the Situation?
IN QUEBEC
Just like our neighbours in the rest of
Canada, who are already keeping an eye
on the medical tourism industry, shouldn’t
we also study this avenue as a possible new
source of revenues?
The defenders of the public healthcare
system will denounce loud and clear the
dangers and deviations of a two-speed
healthcare system, with social inequities and
unequal access to care, favouring the richest
to the detriment of others. For some, it is the
right-left view, how to get the butter and keep
the money for the butter. For others, it may
be the solution to a long-standing problem.
Could an infusion of additional capital
be of use to the healthcare network as a
whole? With the reduction of the federal
government’s contribution to health, certain
provinces, already strangled by the costs
of their healthcare system, are frantically
looking for new capital. The arguments are
known: surgeons don’t work as much as
they would like to because of financial cuts,
policies and other decisions taken by the
healthcare network. These surgeons are
even complaining about the loss of the skills
they developed with so much difficulty. They
could perform more operations if they had
the opportunity.
Quebec has many cutting-edge sectors that
are internationally renowned and several
overspecialists, who could easily be the
envy of institutions outside of Quebec. After
merging, moving or closing institutions, facilities become available, despite a certain
obsolescence in their installations or the
equipment on site.
With the avowed aim of obtaining new
financial resources to be automatically reinvested into the network, could legislators
imagine imposing a precise framework, with
an insurmountable barrier for any person
registered with the RAMQ, thus offering
the service solely to foreigners having to
prove their status via passports and other
legal documents?
IN CANADA
In 2011, a group of managers of hospitals affiliated with the university health
network in Toronto went on a tour of the Middle-East with the aim of finding
new sources of revenues for their establishments. The official visit, proved to
be very lucrative for the Toronto region. Kuwait signed service agreements with
Canadian hospitals, including one with the Princess Margaret Cancer Centre in
Toronto and another with the McGill University Health Centre (MUHC). The first,
with a value of $75 million over 5 years, would allow a limited number of Kuwaiti
patients to obtain consultation services and treatments for cancer. In Montreal, the
$86 million agreement over 5 years was essentially the same as the one signed
with Ontario and has, to date, allowed a female patient to undergo complex
cardiovascular surgery.
The promoters of medical tourism have indicated that the revenue generated
by these agreements promotes access to universal healthcare services for the
local population and that it must be seen as a solution to the healthcare system’s
problems. But the public reply is that putting a foreigner ahead of the local population results in weighting down the waiting list and moving the Canadian population
down to a second-class ranking.
These agreements were widely criticized and the Health Ministers had to react
rapidly. Réjean Hébert, then Minister of Health, indicated that such an agreement
was unacceptable and that Quebec was not open to medical tourism. The Ontario
Minister limited herself to saying that if an Ontario patient were to be displaced in
favour of a foreign patient, she would not hesitate to act.
In British Columbia, it was the Health Minister himself who, in 2010, wanted
to provide care to foreign patients by saying, “Why shouldn’t British Columbia
become the Mayo Clinic of the North?” A research group was created in 2010 by
Simon Fraser University, located in Vancouver. In one of its research reports, we
find the following information: “Canadian private business groups and government agencies are considering how to promote Canada as a medical tourism
destination.” The research group regularly publishes technical summaries on the
various medical tourism destinations (statistical and technical data, legislation,
health expenses, human resources, etc.).
Foreign patients also come knocking at hospital doors. This was the case with
Sunnybrook Hospital in Toronto which, in 2013, discretely started to court medical
tourists. A patient from Barbados and a Jamaican have already received cancer
care and others will be added to the list since the hospital has set itself the
objective of attracting a dozen paying tourists per year. Agreements have allowed
several hospitals in Toronto to offer care to strangers by virtue of specific programs
with the Canadian government, in particular care to victims of acts of war in Libya.
These have allowed hospitals to obtain the sum of $2.5 million in 2010-2011,
$11 million in 2011-2012 and $7 million in 2012-2013. But the Minister of Health,
in the midst of a media crisis because of several articles published in the Globe
and Mail, has asked for a moratorium on this practice. She wants to find a way of
making sure the sums collected will in fact be returned to the public healthcare
system’s treasury and that Canadian patients will not be negatively affected by
this practice, but rather benefit from it.
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IN THE WORLD OF MEDICINE
BY HECTOR
QUIROZ-MARTINEZ, MD*
Patient Safety in Intensive Care
BY FRANÇOIS
LAMONTAGNE, MD*
The OVATION Program
Research in healthcare is often seen as a way to improve
the quality of care by means of discoveries. This view of
things implies that progress in healthcare is based on
the invention, development and use of new diagnostic or
therapeutic interventions. But this definition is incomplete,
as it overshadows the considerable developments achieved
thanks to current practice re-evaluation exercises. We are
proposing that progress in healthcare should be looked at
more globally as being the overall gains in effectiveness,
safety and cost optimization, regardless of the newness of
proposed interventions.
RESEARCH CENTERED ON THE PATIENT
Research centered on the patient is that aspect of healthcare
research that seeks its reason for being in current care. To be
more specific, this approach targets interventions commonly
used, but whose effectiveness, safety or cost-effectiveness
are not scientifically demonstrated. The interest of the media
in research projects that do not involve a “new and promising
treatment” is often lower. And yet, questioning current
practices is essential to the extent that an important portion
of healthcare is not based on probative data.
Even in cardiology, the headquarters of Evidence-Based
Medicine, we estimate that barely 50% of guidelines issued
by the ACC/AHA (American College of Cardiology/American
Heart Association) were based on solid scientific foundations.1 In addition, examples of studies having led to improving
patient outcomes by revealing the deleterious effects of current
interventions are numerous. Having recourse to blood transfusions, 2-4 to antiarythmics after an infarct,5 to hormone
replacement therapy for menopause6 are just so many interventions that are now used with proper judgment now that
their deleterious effects have been quantified through the use
of rigorous research mandates.
This type of research presents other advantages. For example,
while studies dealing with experimental interventions are only
useful on condition that the intervention is effective, when
current practices are challenged, the idea of a “negative” study
does not exist. From the moment a study demonstrates that
one of two interventions currently used is more effective, safer
and less costly than the other, the impact is positive.
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Moreover, research targeting current care almost invariably
leads to other useful observations. As an example, it was when
quantifying the risks associated with blood transfusions that
researchers came to associate their deleterious effects to the
length of time the globular sediments were stored. A wideranging clinical trial (ISRCTN44878718) is currently testing the
hypothesis that fresh globular sediments (stored for 7 days or
less) are preferable to current standards (storage for 42 days
or less). We are currently directing a vast program of research
inspired by the examples quoted above. While final results
will only be known in a few years, the impact of this research
program centered on the patient is already measurable.
THE OVATION PROGRAM
The program entitled Optimization of VAsopressors in
hypoTensION (OVATION) is looking at the effectiveness, safety
and costs of vasoactive agents (www.OVATIONTrial.com). The
current clinical trial is studying a population of patients with
hypotension requiring resuscitation in intensive care units
(NCT01800877). It compares the survival and quality of life
associated with protocols aiming for arterial pressure targets
that are higher or lower. In fact, it is plausible that the increase
in arterial pressure to almost “normal” values improves
chances of survival and quality of life by ensuring a better
perfusion of vital organs. However, it is possible that the side
effects of vasopressors outweigh their advantages and that
it would be preferable to tolerate arterial pressure levels that
are lower.
While vasopressors have been administered for decades to
the most vulnerable patients, the dosage of these powerful
medications has not interested the scientific community until
just recently. We are working closely with a group of French
researchers who like us are interested in this question in the
hope that by combining the data from OVATION and from
SEPSISPAM7 we will be able to more accurately identify the
risks and advantages associated with higher arterial pressure
targets. In the meantime, observations during the pilot
phase of the OVATION clinical trial have already had positive
repercussions which allow us to glimpse opportunities to
improve the quality of short-term care.
IMPROVING THE QUALITY OF CARE – THE
IDEA OF A VASOPRESSOR STEWARDSHIP
The fact of paying special attention to the administration of
treatments whose therapeutic window is narrow is deeply
anchored. For example, surgical interventions and the
administration of antibiotics are, in many places, under the
scrutiny of checklists8 and computerized monitoring protocols.9
The extreme vulnerability of “unstable” patients and the risks
of excessive vasoconstriction, arrhythmia and other less wellknown side effects should logically bring us to monitor the
administration of these agents very closely. While we wait
for the results of studies that will identify optimal pressure
targets for different patients, it is still essential to monitor
the administration of these powerful agents. The expression
vasopressor stewardship refers to the objective of perfect
agreement between targets and the patient’s arterial pressure.
However, the monitoring data collected during the pilot phase
of the OVATION study show that the levels of mean arterial
pressure in patients are from 5 to 10 mmHg above prescribed
targets. This difference is enormous and all the more surprising
since Canadian intensive care specialists surveyed stated in
an almost consensual manner that they adhered to guidelines
IN THE WORLD OF MEDICINE
suggesting a mean arterial pressure target of 65 mmHg.10
This adherence by physicians to a target of 65 mmHg was
subsequently confirmed during a retrospective cohort study.11
This difference between prescribed targets and levels reached
are not seemingly limited to Canadian hospitals having taken
part in the OVATION study, since the same difference was
observed in the SEPSISPAM study7.
Following this observation, we undertook a medical procedure
quality improvement project at the Centre hospitalier
universitaire de Sherbrooke. The objective was to review,
with all the members of the multidisciplinary team,* each
prescription for vasopressors given within the intensive care
units of the institution, and this at least once a day. A form
developed to this end and filled out during multidisciplinary
rounds forced the teams to discuss and explicitly document
the following points:
1)the pressure target expressed as an allowed range in order
to clearly document that it is not desirable to allow arterial
pressure to exceed the target;
2)the indication for a vasoactive treatment resulting in a daily
re-evaluation of the pertinence of the treatment;
3)warning signs to be recognized and leading automatically
to a call to the attending physician.
AT THE END OF THIS THREE-WEEK EXERCISE,
THE STAFF MEMBERS WHO HAD TAKEN PART
WAS OF THE OPINION THAT THE PROTOCOL HAD
REDUCED THE CONFUSION ASSOCIATED WITH
THE PRESCRIPTION OF VASOPRESSORS.
CONCLUSION
The justification for research centered on the patient resides
in observing our own limits. Despite their scientific gloss,
large swaths in modern healthcare are based mainly on the
opinion of experts and on theories. While there is theoretically
no difference between theory and practice, in reality there
is one. In many cases, one has to observe that we cannot
guarantee the effectiveness or even the safety of the care we
proffer to our patients. This type of research is difficult, as it
depends on the will of the healthcare staff to challenge what
it sometimes considers to be an unassailable truth. And one
must not forget that subsidized study budgets cannot rival
those of sponsored research. But those who are willing to
follow this path are rewarded when the results lead to more
effective and safer care. As the case of OVATION proves, the
improvement of care resulting from research centered on the
patient often presents itself in an unexpected form.
* The
multidisciplinary team was made up of Dr François
Lamontagne, an intensive care internist, researcher and
associate professor at the Université de Sherbrooke, and
Hector Quiroz-Martinez, an intensive care internist and the
person in charge of improving the quality of procedures
in intensive care, as well as the intensive care physicians,
the pharmacists and the staff of the three intensive care
units of the CHUS.
REFERENCES
1.Tricoci P, Allen JM, Kramer JM, Califf RM, Smith SC, Jr. Scientific
evidence underlying the ACC/AHA clinical practice guidelines. JAMA
2009;301(8):831-41.
2.Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G,
et al. A multicenter, randomized, controlled clinical trial of transfusion
requirements in critical care. Transfusion Requirements in Critical Care
Investigators, Canadian Critical Care Trials Group. The New England
journal of medicine 1999;340(6):409-17.
3.Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads
GG, et al. Liberal or restrictive transfusion in high-risk patients after hip
surgery. The New England journal of medicine 2011;365(26):2453-62.
At the end of this three-week exercise, the staff members
who had taken part were of the opinion that the protocol
had reduced the confusion associated with the prescription
of vasopressors. The opportunities to improve the quality
of procedures revealed by this project were taken up by
the Institute for Safe Medication Practices Canada (ISMP
Canada) who made it the subject of recommendations in its
January 27, 2014 bulletin. How could these recommendations
be implemented operationally? It is up to each institution
to choose the approach that is the best adapted to its
environment: a handwritten or electronic standardized
prescription, real-time recording of arterial pressure data
with alarms to signal gaps with prescribed targets, increased
supervisory role delegated to nurses or to pharmacists
in intensive care, etc. The choice of tool is less important
than the concern for conformity between prescriptions and
results obtained.
4.Villanueva C, Colomo A, Bosch A, Concepcion M, Hernandez-Gea V,
Aracil C, et al. Transfusion strategies for acute upper gastrointestinal
bleeding. The New England journal of medicine 2013;368(1):11-21.
5.Preliminary report: effect of encainide and flecainide on mortality in a
randomized trial of arrhythmia suppression after myocardial infarction.
The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. The New
England journal of medicine 1989;321(6):406-12.
6.Marjoribanks J, Farquhar C, Roberts H, Lethaby A. Long term hormone
therapy for perimenopausal and postmenopausal women. Cochrane
database of systematic reviews (Online) 2012;7:CD004143.
7.Asfar P, Meziani F, Hamel JF, Grelon F, Megarbane B, Anguel N, et al. High
versus low blood-pressure target in patients with septic shock. The New
England journal of medicine 2014.
8.Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et
al. A surgical safety checklist to reduce morbidity and mortality in a global
population. The New England journal of medicine 2009;360(5):491-9.
9.Evans RS, Pestotnik SL, Classen DC, Clemmer TP, Weaver LK, Orme
JF, Jr., et al. A computer-assisted management program for antibiotics
and other antiinfective agents. The New England journal of medicine
1998;338(4):232-8.
10.Lamontagne F, Cook DJ, Adhikari NK, Briel M, Duffett M, Kho ME, et al.
Vasopressor administration and sepsis: a survey of Canadian intensivists.
J Crit Care 2011;26(5):532 e1-7.
11.St-Arnaud C, Éthier J, Leclair M-A, Lamontagne F. Prescribed targets
for vasopressor titration in septic shock: a retrospective cohort study.
Intensive Care Med 2011;37(Suppl.1):231.
S
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Un petit répit...
une grande caUse !
10
PUBLICITÉ
PLEINE PAGE
ceTTe année, sOUTenOns la
caUse des aIdanTs naTUrels.
Pour contribuer, vous n’avez qu’à
demander une soumission d’assurance
auto, habitation ou entreprise.
Pour chaque soumission complétée
d’ici le 31 décembre 2014,
La Personnelle et Sogemec verseront
La Personnelle
10$ à la Fondation de la FMsQ.
VoiLà une magnifique façon d’aPPuyer La cauSe deS aidantS natureLS,
une cauSe qui rejoint, à ce jour, PLuS d’un miLLion de québécoiS.
deMandeZ VOTre sOUMIssIOn
et aidez-nous à soutenir
la Fondation de la FMsQ.
1 866 350-8282
sogemec.lapersonnelle.com/fondation
La bonne combinaison.
La Personnelle désigne La Personnelle, assurances générales inc.
Modalités de la promotion sur sogemec.lapersonnelle.com/fondation.
Aucun achat requis. La promotion se termine le 31 décembre 2014.
OUR SUBSIDIARIES
PROFESSIONALS’ FINANCIAL
BY SIMON DESBIENS, BBA
Advisor
Investments Are Not Everything
Even if an investment portfolio is an essential part of your
financial security plan, we would like to suggest a few fiscal
strategies which, depending on your situation, could be very
useful in helping you reach your financial goals. In order
to help you evaluate their pertinence, we will give you the
circumstances in which they apply and will explain the strategy
in question.
INCORPORATE YOUR PRACTICE
Circumstances - Your annual savings are somewhere
above your maximum annual contribution to an RRSP and
to a tax-free savings account (TFSA). This strategy is even
more advantageous when you have a spouse with low
revenues or dependent adult children to whom you provide
financial support.
Strategy - Incorporation allows, among other advantages,
to defer income tax and to split income. The tax rate on fees
received is lower within a corporation (19% on professional
revenues up to $500,000) than on individuals (49.97%, which
is the maximum marginal tax rate for taxable income over
$136,270 in 2014). You can leave larger amounts of cash in
a corporation and thus defer taxation to a period when your
revenues have gone down. Income-splitting can also be made
by transferring a part of your revenues to a family member
who has little or no revenues and thus a lower tax rate, which
results in a tax savings.
OPTIMIZE YOUR MEDICAL BILLING
Circumstances - Medical billing evolves and constantly
becomes more complicated. We often think that doing one’s
own billing allows one to save money. In truth, most of the
time, some physicians do not bill the full remuneration to
which they are entitled, especially since the last increases.
The RAMQ has issued more than one hundred Infolettres over
the course of the last three years; with all these new rules, it is
difficult to state without doubt that you have billed all the fees
that you are entitled to.
Strategy - If you do your own billing, whether through your
secretary or an on-line billing agency, it might be a good
idea to have an analysis of your billing profile performed by
a medical billing agency, so as to make sure you have been
paid everything you are entitled to. At least once a year, have
an income statement prepared, with the help of an agency
such as Multi-D/FIDL, in order to be able to compare yourself
to your peers.
PREPARE A RETIREMENT PROJECTION
Circumstances - What amount must I amass for my
retirement? This is a question we are often asked. The strategy
we propose is aimed at persons who are thinking of retirement,
but who have not yet calculated the amount to put aside and
have questions on the subject; at those who are not yet in a
situation where they can save or who spend more than they
earn; and even at professionals at the start of their career.
Strategy - If you are able to establish your cost of living, you
are then in a position to subtract from this amount your total
pension amounts (RRQ, OAP, pension fund, etc.), estimate
your life expectancy and, factor in an estimated return and
inflation rate, then establish the level of savings you need to
reach financial independence. This exercise is essential to
determine if you need to save more.
SPLIT YOUR PENSION REVENUE
Circumstances - If you are retired and are younger than 65,
the income taken into account is the annuity received from a
pension plan; if you are 65 or older, the definition is widened
to include annuities from an RRSP or an insurance company,
as well as the payments received from a registered retirement
income fund (RRIF), from a life income fund (LIF) or from a
deferred profit-sharing plan (DPSP).
Strategy - Splitting pension revenue allows one to balance
the revenues of two spouses in order to take advantage of
the tax rate imposed on the spouse whose income is the
lowest. Since January 1, 2007, it is possible to split pension
revenues between spouses. The following revenues, however,
are not eligible to pension revenue splitting, no matter how
old the pensioner is: Old Age Security (OAS), guaranteed
income supplement (GIS), withdrawals from an RRSP, RRQ
pension payments and the amounts received by virtue of a
retirement agreement.
FOR UNINCORPORATED INDEPENDENT
WORKERS: PUTTING MONEY ASIDE AND
DEDUCTING INTEREST CHARGES
Circumstances - Useful if you have personal debts and
business expenses, this strategy can be used to catch up with
unused RRSP contributions, to pay premiums on a universal
life insurance policy or late taxes, to renovate a home or to
buy a vacation home.
Strategy - Putting money aside is a strategy that allows you
to reduce your taxes by transforming your personal debts, the
interest on which is not deductible, into a new debt to finance
your company’s expenses, in which case interest is deductible.
For more information and to implement strategies appropriate
to your situation, please get in touch with your advisor from
Professionals’ Financial.
39
vol. 16
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OUR SUBSIDIARIES
SOGEMEC ASSURANCES
BY CHANTAL AUBIN
Assistant Director
Damage Insurance Broker
Claim Settlement Process
A Few Tricks to Simplify Things
If a car or home insurance policy cannot prevent a loss, it can
reduce the stress resulting from a chance event, especially if
one is well prepared. We propose a few tricks to simplify and
accelerate the process of claim settlement after a loss.
HOME INSURANCE: THE KEY IS INVENTORY
How many Blu-ray Discs did I have in my collection before the
burglary? It’s not easy to answer such questions, especially when
one is in shock. That’s why it is important to maintain at all times
an inventory of one’s goods along with documentary proof such
as photos, videos, receipts or warranties.
In case of fire, theft or vandalism, after the firemen or police, the
first person to call is your insurance agent. He will put you in
touch with a claims adjuster who will help you to deal with urgent
issues first – for example, closing up a vandalized window until it
can be replaced or finding you a place to stay if your home has
become uninhabitable.
Once past this step, you can discuss an evaluation of damages.
By giving the claims adjuster a detailed list of your damaged
or stolen goods, with supporting proof, you will facilitate the
settlement of your claim.
A VERY ADVANTAGEOUS OPTION TO PROTECT
YOUR VALUABLE POSSESSIONS
For your home insurance, get some information on the
supplemental coverage exclusive to physicians that was negotiated
between Sogemec and its insurer, The Personal. This includes:
xx
a $100,000 coverage in case of loss
xx
or theft of your artworks;
an increase to $10,000 of the limits applicable to
xx
goods used for professional reasons.*
the replacement value without the obligation
of rebuilding or repairing;
CAR INSURANCE: A VERY SIMPLE REPORT
In Quebec, the procedure for settling a car accident claim without
injuries can be done with the help of the details contained in the
Joint Report of Automobile Accident. Ideally, every driver should
have one in his vehicle and should complete it in case of accident.
If no one has a form at hand, each party must take note of the
following information: name, address and telephone number of
the other driver, make of car, license plate number, driver’s permit
number, name of insurance company and policy number. If there
are witnesses, record their names and telephone numbers as
well. It goes without saying that the Joint Report of Automobile
Accident is preferable, as it reduces the risk of forgetting an
important detail while you are in the middle of the crisis.
40
vol. 16
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LS
If there are injuries caused by the accident, call for help. The
police report will provide you with the information needed to settle
your claim.
In all cases, get in touch with your insurance agent as soon
as possible. Depending upon your insurance contract, if you
have the needed coverage, he or she will take over the task of
evaluating damages. He will then direct you to an auto body work
specialist who will prepare an estimate of the damages or he’ll
send you a claims adjuster.
GLASS BREAKAGE
If your windshield is chipped or cracked, it’s bothersome but it
can easily be fixed! Get in touch with an
auto glass repair shop directly (if your
GOOD TO KNOW
insurance contract specifies “auto glass
breakage” coverage).
Have your
windshield fixed as
soon as possible
Make an appointment with one of our
to avoid having to
recommended auto glass repair shops
replace it and pay
(check the following website to get a
the deductible.
list – sogemec.lapersonnelle.com) who
have an agreement with us and simply
show them your auto insurance certificate. The auto glass repair
shop will contact us for payment.
You have no deductible to pay for a repair when you have the
auto glass breakage coverage.
A Service You Can Trust
You can reach The Personal’s claims department day or
night. You will be given support from the moment your
claim is opened until it is settled so that your life can return
to normal as quickly as possible.
The claims department representative who answers your
call will:
• Take down your complete statement describing
the incident;
• Verify which protections are included in your
insurance contract;
• Recommend, if work is required, a reliable company
according to what is available in your area (e.g. postdisaster cleaners, construction contractors, etc.);
• Identify the documents you will need to sent him or those
he will send you;
• Confirm the deductible amount you will need to pay;
• Provide you with your file number.
For more information or to request an insurance proposal
covering both home and automobile, please call
1-866-350-8282 to speak to a representative or
visit sogemec.lapersonnelle.com.
* Certain conditions and exceptions apply.
Protections are listed together in Appendix 25 C.
OUR SUBSIDIARIES
SOGEMEC ASSURANCES
BY CHRISTINE LAURENDEAU
Financial Security Advisor
Group Insurance Plan Advisor
An Insurance Plan for your Staff
It’s possible!
Sophie, your indispensable assistant and receptionist, has
A s a n e m p l o y e r, a m i n i m u m
You need only a minimum
c ontr ibu tion of 25% of the tota l
just told you she’s leaving. The reason for this decision is
of three employees to
premium is required. Then once your
quite simple: she has found a new position in the clinic
implement a personalized
insurance plan is implemented, you
near her home whose offer includes a group insurance
benefits plan and thus
take advantage of the kind
plan. Sophie really needed this protection, as her daughter
won’t need to spend a lot of time on it
of coverage that suits you.
has some health issues. The difficulties associated with
as the management of such plans has
her daughter’s condition require the services of several
been considerably simplified over the
healthcare professionals which, unfortunately, generate certain
years. Your employees will have direct access to the information
significant expenses.
concerning their plan via the chosen insurer’s secured site.
Thus, they will be all the more independent in managing their
You had already thought of instituting group benefits for your
personal file.
employees, but you were under the impression that your
group wasn’t numerous enough to take advantage of this
Also, don’t forget that a financial contribution from you to a
group insurance is a form of indirect remuneration for
kind of insurance plan. Think again! A benefits plan does not
necessarily involve a large number of participants or a significant
your employees as well as a pertinent element of salary
investment, since the extent of the protection varies, in large
negotiation. It will allow you to both attract valuable employees
part, as a result of the budget allocated to it and the specific
and retain your existing valuable associates.
needs of employees.
Get in touch right now with one of our Sogemec advisors who
Here are two elements that can be covered by a benefits plan:
will gladly design a benefits plan for you and with you, a plan
that will please your employees as much as it pleases you.
Group insurance (life, disability, drug,
xx
illness, eye care or dental care);
Employee Assistance Program.
xx
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
parfaitement vos besoins ainsi que ceux de chacun des
membres de votre famille.
UNE GAMME DE PROTECTIONS
QUI RÉPOND À TOUS VOS
BESOINS D’ASSURANCES
Vie
Invalidité
Frais généraux
Maladies graves
Soins de longue durée
Médicaments
Maladie
Dentaire
Entreprise
Automobile et habitation
CONTACTEZ-NOUS : 1 800 361-5303
[email protected]
41
vol. 16
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L’ÉDITORIAL DE LA PRÉSIDENTE
Dre Diane Francœur
Remettre les pendules à l’heure... normale
D
u moment où j’ai commencé ma pratique, j’ai pris conscience
que, pour améliorer la médecine, il fallait non seulement faire
avancer la recherche, mais aussi s’intéresser à la façon dont
sont dispensés les soins. C’est pourquoi je me suis aussi impliquée
dans l’amélioration de nos conditions de pratique. Force m’est
de constater combien il y a à faire pour la médecine spécialisée.
M’éloigner de la pratique à temps complet me fait voir d’autres
aspects du fonctionnement du réseau de la santé. Sage recul pour
mieux avancer, dira-t-on.
J’ai toujours pensé que les choses arrivent parce qu’on s’en occupe.
Et comme dirait le philosophe Sénèque : « Ce n’est pas parce
que les choses sont difficiles que nous n’osons pas, c’est parce
que nous n’osons pas qu’elles sont difficiles. » J’ai donc décidé
de prendre mon sort en main et de m’engager. J’ai été chef de
département, professeure associée, présidente de mon association
médicale et vice-présidente de ma société savante canadienne. Je
savais que tous les médecins n’avaient pas, comme moi, ce besoin
d’être au fait de ce qui se passe dans notre profession. Mais, quelle
ne fut pas ma surprise à mon entrée en poste à la présidence de
la Fédération de constater combien de médecins spécialistes ne
connaissent pas ou peu le fonctionnement de l’organisation chargée
de les représenter, allant même jusqu’à les protéger, auprès des
décideurs et des payeurs, je nomme le gouvernement et la RAMQ.
Je profite donc de cette page pour vous inviter à réviser vos
connaissances sur votre Fédération.
UN RAPPEL DE L’HISTOIRE
Sachez d’abord que la FMSQ aura 50 ans l’an prochain. En effet,
la Fédération a été créée en 1965 par des médecins désireux de
se protéger de la volonté du gouvernement d’imposer le salariat et
d’autres conditions désavantageuses pour la profession. D’autant
que le Collège des médecins d’alors avait un double mandat : celui
de protéger le public et celui de défendre les intérêts des médecins.
Ce double mandat ne pouvait que donner lieu à des incongruités et
à des prises de position, disons... discutables.
La FMSQ est un syndicat professionnel regroupant les associations
de médecins pratiquant dans l’une des spécialités médicales
reconnues au Québec. De 11 associations à sa création, la FMSQ
représente aujourd’hui les médecins de 35 associations affiliées
œuvrant dans l’une des 53 spécialités médicales reconnues au
Québec. La mission de la FMSQ est de défendre et de promouvoir
les intérêts des médecins spécialistes membres des associations
affiliées, sur le plan économique, professionnel, scientifique et social.
42
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La FMSQ défendra toujours un système public fort et performant et
elle intervient sur une panoplie de sujets quand notre expertise fait
une différence. Au cours des dernières années, nous avons abordé
des enjeux qui ont un impact direct sur les médecins spécialistes
tels que la rémunération, la négociation des conditions de pratique,
l’organisation des services, l’optimisation des blocs opératoires,
les frais accessoires, les besoins logistiques du nouveau CHUM,
le prix des médicaments, l’incorporation des médecins, le
développement professionnel continu, et j’en passe. Nous avons
aussi apporté un éclairage « médical » sur des enjeux sociaux, dont
les soins de fin de vie, l’avortement, le port de signes religieux,
la procréation assistée. Les positions qu’adoptent vos instances
ont été largement discutées avec les présidents d’associations ;
elles visent à représenter la majorité des membres, à défaut de
la totalité.
D’autres organismes, dont l’AMQ et le MQRP, s’en proclament,
mais seule la FMSQ est reconnue comme agent négociateur des
médecins spécialistes auprès du MSSS. Nous vous représentons,
et c’est pourquoi vous avez tout avantage non seulement à nous
suivre, mais aussi à nous informer des problématiques que vous
vivez ou dont vous êtes témoin dans vos milieux de soins.
QUI DÉCIDE POUR LES MEMBRES ?
Je recevais récemment des courriels de membres qui disaient
n’avoir jamais voté pour une décision prise à la FMSQ. La FMSQ
est une organisation fédérée, un regroupement d’associations.
Ainsi, chaque association médicale affiliée à la FMSQ est
proportionnellement représentée auprès de l’Assemblée des
délégués, la plus haute instance décisionnelle de la Fédération.
Ces délégués, issus de chaque spécialité, dont les présidents
d’associations, parlent et votent en votre nom. C’est précisément
l’Assemblée des délégués qui élit les membres du conseil
d’administration, qui vote les états financiers, les cotisations
régulières et spéciales, qui discute des grands objectifs de
négociation, qui vote les ententes avec le gouvernement, et
j’en passe.
La confiance envers vos élus et la solidarité avec vos pairs sont
au cœur du fonctionnement de notre Fédération. Il existe aussi un
principe incontournable dans le travail que nous accomplissons :
la confidentialité. Cette règle s’applique à toute organisation
sérieuse et n’empêche aucunement la « transparence » de la
gouvernance. Il faut cependant comprendre et reconnaître
que discuter sur la place publique de décisions internes, de
stratégies convenues, d’actions envisagées n’est ni acceptable
ni souhaitable. Et, finalement, je ne saurais trop insister sur la
notion de respect que nous nous devons mutuellement. En outre,
exprimer une opinion, même la mieux sentie, doit se faire dans le
respect de l’opinion de l’autre, dans le respect de la décision prise.
Ma présidence sera guidée par ces mots clés.
En terminant, je vous invite à rester près – ou à vous rapprocher –
de la FMSQ pour nous aider à nous occuper des « vraies affaires »
des médecins spécialistes !
Fièrement vôtre !
S
L
SERVICES AUX MEMBRES
NOS FI LI A LE S
AVANTAGES
COMMERCIAUX
AVANTAGES
fprofessionnels.com
1 888 377-7337
sogemec.qc.ca
1 800 361-5303
NOS PA RTE NA I RE S
SERVICES AUX MEMBRES
sogemec.lapersonnelle.com
1 866 350-8282
1 888 890-3222
estrimont.ca
manoir-victoria.com
esterel.com
manoir-saint-sauveur.com
1 800 567-7320
1 888 378-3735
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méritent votre confiance.
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Pour plus d’informations :
[email protected] ou 514 350-5274
1 800 463-6283
1 866 482-5449
groupesolution2.com 1 877 795-9399
montreal.hyatt.ca
1 800 361-8234
hotel71.ca
desjardins.com
evenko.ca
1 888 692-1171
auberge-st-pierre.com
1 800 CAISSES
514 925-2124
fairmont.com
hotelrimouski.com
chateaubromont.com
telusmd.com
rbcbanqueroyale.com/sante
1 800 441-1414
berri.clubvoyages.com
1 888 732-8688
centrecongreslevis.com
1 888 838-3811
fr.hiltonworldwide.com
514 305-1155
1 800 463-0755
1 866 673-5080
multid.qc.ca
1 888 268-1017
1 888 276-6668
1 800 807-2683
hotelsvillegia.com
1 800 363-3068
1 877 845-5344
lemassif.com
chateaumontsainteanne.com
1 877 536-2774
1 866 900-5211
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www.plusdetemps.ca
1-800-363-3068