Year: 2008

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Shortage Of Doctors – A 10-Point Plan To Fix The Problem

Almost every Canadian is aware that we need more doctors. Ipsos-Reid poll done for the Canadian Medical Association indicates that MD shortages rank second only to the economy in a list of election issues (CMAJ July 1, 2008).

According to Statscan, more than four million Canadians do not have a family doctor. Currently, Canada produces 2,300 new doctors a year but we need about 3,200 doctors a year (The Medical Post, June 3, 2008). How can we find 900 more doctors each year?

According to Draft 2005 Alberta’s Physician Resources Planning Committee Report Data, Alberta, one of the richest Canadian provinces, will be short of 1,541 doctors by 2010. Dr. Dale Dauphinee, executive director of the Medical Council of Canada, coauthored a report in 1999 that calculated that Canada needs to recruit 2,500 new doctors a year. This would cover both physicians retiring or leaving the country and population growth. Our own graduates can’t fill the void.

That was in 1999, which is almost 10 years ago. Has anything changed since? Looks like things are worse now.

Over the years, so much has been said and written about finding a solution to the problem that one would think that the problem would have been solved by now.

Reports indicate there are numerous factors contributing to Canada’s shortage of physicians. Some of these factors are: migration of doctors to the United States, reluctance of medical students to choose specialties and locations where they are most needed, and new practice patterns (lifestyle goals and use of the health care system) and there are fewer doctors now partly because of a 10 per cent reduction in medical school enrolment that was imposed across the country in 1993.

What Canada has failed to do is to utilize the resources already available in our country and in overseas medical schools. We know thousands of international medical graduates are in Canada who are unable to practice because they are unable to get a license. According to CMAJ (April 10, 2007), Association of International Physicians and Surgeons of Ontario has a membership of 1800. So, how many international physicians and surgeons are in Canada who are delivering pizza or driving a taxi?

We also know there are thousands of Canadian citizens who are studying abroad because they could not wait to apply to a Canadian medical school. Generally speaking, a Canadian applicant to a medical school in Canada has roughly six per cent chance of admittance (CMAJ April 10, 2007).

There are Canadians studying in Ireland, the U.K., Europe, Australia, in several medical schools in Caribbean islands, South America, Cuba and the U.S.A. I have been to the island of Antigua twice in the last eight months and visited the American University of Antigua College of Medical School (www.auamed.org) in St. John where my son is a student. I have met and spoken to some of the people who run this place.

According to Mr. Vito Barbiera, Director of Marketing for the American University of Antigua College of Medicine (commonly known as AUA), AUA has 1200 medical students. Of these 20 per cent are Canadians, 70 per cent are Americans and the rest are from Antigua and different parts of the world.

According to the Canadian Medical Association Journal (April 10, 2007), more than 300 Canadians are now studying at four Irish medical schools, and 60 to 70 new ones join them annually. Who knows how many Canadians are all over the world striving to get a medical degree.

According to Mr. Dick Woodward, AUA’s Vice President for Enrollment Management,
AUA College of Medicine provides medical education equal to the highest U.S. medical education standards. The purpose of the training at AUA is to prepare students to pass the U.S. Medical Licensing Examination (USMLE), for U.S. medical licensure, and to provide the foundation for postgraduate specialty training in the U.S.

Woodward says, “The AUA School of Medicine is fully recognized and approved by the government of Antigua to confer the degree of Doctor of Medicine upon students who fulfill the School’s admission requirements and complete the prescribed curriculum.”

Barbiera proudly reiterates what they say on their website that AUA is the first medical school in the Caribbean with a U.S. model medical education to be hospital-integrated. AUA’s program of medical education has been approved by the State of New York and pursuant to its approval, one of the few international schools that can place its students in New York Hospitals for 2 years of clinical training.

Woodward says that AUA had a first graduating class of eight in 2007. Last year AUA produced 21 doctors and this year they expect to graduate 50 doctors. He said all AUA’s graduates have been matched in the U.S. residency programs. If these graduates are absorbed in the U.S. medical system, the question is: why cannot we engage the services of these doctors in Canada?

AUA has very ambitious plan for the future. On June 15, 2007 AUA broke ground on its new $60 million, 17-acre campus. The plan is to create an educational institution on Antigua that would provide a comprehensive state-of-the-art learning facility for students who aspire to become highly skilled compassionate physicians and plan to practice medicine throughout Canada, the United States and the Caribbean region, says AUA website.

Antigua is just one example of how U.S. is taking full advantage of recruiting and absorbing international and American physicians who pass their licensing examination by giving them opportunities of doing clinical rotations and residency program.

I propose a 10 point mini-Marshall plan to be implemented on a national level to utilize the services of international graduates in Canada who have no license to practice and Canadians studying abroad:

1. A national medical manpower czar should be appointed by the federal government. He should have sufficient budget and manpower to undertake the enormous task of making Canada self-sufficient in medical manpower.
2. The czar should create a registry of all international medical graduates who are in Canada but have no license to practice medicine. This can be done by announcements in the media.
3. The czar should conduct a survey of these graduates to find out what each one of them requires to be fully licensed to practice medicine.
4. From the responses received the czar should create conditions and provide financial help (in conjunction with teaching institutions, hospitals, licensing bodies and provincial governments) to help these graduates to be fully licensed in one year.
5. Those who fail to get a license should get one more try. If they fail again then they should be told to pursue other careers.
6. Those who accept the government help should promise to work in an underserviced area for two years before they move to another city.
7. The czar should also create a registry of Canadian medical students in all overseas countries. This can be done by announcing in the media for the parents of these students to register their children with the czar’s office.
8. The czar should take survey of these students to find out how many of them want to return to Canada to do residency program and practice here.
9. The czar should constantly stay in touch with these students and encourage them to pass LMCC (Canadian licensing examination) when they prepare for the USMLE (American licensing examination). To make it easier, the Canadian licensing bodies should accept USMLE to be equivalent to LMCC.
10. The czar should offer them financial incentives to come back to Canada by offering them signing bonuses. This can be done in conjunction with hospitals and provincial governments.

The international medical graduates and the Canadians who study abroad did not cost the Canadian tax payers a single penny. What is wrong with investing some money on them and absorb them into our system? That is better than spending thousands of dollars on Canadians who obtain their M.D. in Canada and then move to U.S. Here is a free supply of precious commodity. Canada, open your arms and take it.

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Abdominal Aortic Aneurysm Is A Ticking Time Bomb

I recently saw an ad put out by the Canadian Society of Vascular Surgeons (CSVS) calling for a national screening program for abdominal aortic aneurysm (AAA). AAA has been described as a ticking time bomb.

Now, not everybody knows where this ticking time bomb is sitting in our body. Please do not rush for a total body scan to look for this bomb and do not ask, “Doc, which wire should I pull to defuse the bomb, red or blue?” Just kidding.

Let me explain and dissect the three words: abdominal aortic aneurysm. As most of you know, abdomen is a space between the diaphragm and the pelvis. Aorta is the largest vessel in the body and runs from the heart to the pelvis. That means a segment of it passes through the abdomen. Word aneurysm is derived from Greek word aneurusma, which means to dilate. So, aneurysm is a sac like widening of an artery resulting from weakening of the artery wall.

The normal aortic width is approximately two centimeters in men and a bit smaller in women. As the aorta increases in size, the risk of rupture increases. The gradual increase in the size of the aorta occurs over several years and does not produce any symptoms. But when it ruptures and leaks the patient will develop pain in the abdomen. The clinical diagnosis is not easy but the rupture can be diagnosed with a CAT scan. Emergency surgery after a rupture does not always have a good outcome. The majority of the patients do not survive.

If AAA is detected early then elective surgery has a better outcome. Five per cent of men and under one per cent of women over the age of 65 have an AAA. It is the 10th leading cause of death in Canadian men older than age 65. Studies from the United Kingdom have shown screening programs for early detection and treatment of AAA are cost-effective and save lives.

CSVS makes the following recommendation:

-National and provincial health ministries develop a comprehensive population-based ultrasound screening program for AAA detection and referral.
-All men aged age 65-75 be screened for AAA
-Individual selective screening for those at high risk for AAA. For example: women over age 65 at high risk secondary to smoking, cerebro-vascular disease and family history of AAA and men less than 65 with positive family history.

What is required for screening? AAA can be visualized by just using simple ultrasound scan of the abdomen limited to visualization of the abdominal aorta. CSVS has reviewed data that demonstrated screening men 65 to 75 will reduce aneurysm related death by half and at seven year follow-up a benefit on all cause mortality was noted.

The data also shows three aneurysms discovered by screening and repaired electively, will prevent one aneurysm death. For men, the number needed to screen to prevent one AAA mortality is similar to mammography.

What about women? CSVS says the incidence of AAA in women is significantly less and population based screening in all women has not been shown to reduce mortality. Selective screening of women is recommended as discussed earlier.

In an interview in the Medical Post, Dr. Thomas Lindsay, a vascular surgeon and a spokesman for the CSVS says that elective surgical repair of AAA is considered when the aneurysm reaches a diameter of 5.5 cm. at which point the annual risk of rupture is in the neighborhood of 10 per cent. Persons with an enlarged aorta that hasn’t yet reached that diameter would need repeat ultrasound screenings every six months to two years.

About 1,000 Canadians suffer ruptured aortic aneurysms every year and most people die as a result. But doctors say they could cut that number in half with ultrasound screening programs.

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What Women Should Know About HPV Vaccination?

Vaccination against human papillomavirus (HPV) infection is being promoted as beneficial to young teens before they have had sexual contact. The vaccine has demonstrated high level of antibody response especially in women who have not been exposed to the virus. Hence the target group is young girls. By preventing HPV infection, we can prevent deaths from cervical cancer.

The vaccine is almost 100 per cent effective against four types of HPV, two of which are responsible for 70 per cent of all cervical cancers. The vaccine may have cross-protection against some other HPV viruses.

Most common side-effect is pain at the injection site. Otherwise, it is a safe vaccine except recently, concern has been expressed as some cases of anaphylaxis have been reported. Usually, anaphylaxis due to any vaccination is rare, with an estimated incidence of 0.1–1 per 100,000 doses.

Anaphylaxis is a severe acute allergic reaction that is sudden in onset. The skin symptoms are the most common, followed by breathing difficulties and then trouble swallowing. The person goes into shock and by that time it may be too late to save life. Anybody who is in the business of providing vaccinations should be prepared to deal with anaphylaxis. An individual, after receiving any vaccination, should be observed at least for 15 minutes.

In the September 9 issue of Canadian Medical Association Journal (CMAJ), the subject of anaphylaxis after HPV vaccination has been discussed in detail.

A study done in Australia reported that from the 269,680 HPV vaccine doses administered in schools, seven cases of anaphylaxis were identified, which represents an incidence rate of 2.6 per 100,000 doses. They found this to be higher than comparable school-based delivery of other vaccines. The article says, “However, overall rates were very low and managed appropriately with no serious sequalae.” Identified cases of anaphylaxis following vaccination tend to occur less than one hour after vaccination.

The experts do not know why these girls had adverse reactions to the vaccine. The authors of the Australian study say that the estimated rate of anaphylaxis following quadrivalent HPV vaccine was significantly higher than identified in comparable school-based delivery of other vaccines. However, overall rates were very low and managed appropriately with no serious sequelae. None of the patients went into shock. That is good news.

According to CMAJ, in the United States, 15 cases of anaphylaxis or anaphylactoid reactions following HPV vaccination were reported to the Vaccine Adverse Events Reporting System in 2007. As of July 21, 2008, 11 cases have been reported in 2008. Over 13 million doses of this vaccine had been distributed as of the end of 2007. Although there may be underreporting, the rate of about one case per one million vaccinations is consistent with the rate of anaphylaxis following several other vaccines.

People opposed to this program would like to delay immunization until a young woman is sexually active. Unfortunately, HPV infection can occur with the first sexual intercourse, and half of Canada’s young women become sexually active by age 16.

What about the boys? Some young boys are sexually active as well. They show up with venereal warts from HPV infection. CMAJ says Canada and other industrialized countries (except for Australia) have only approved vaccination for females thus far, because studies involving males have not been completed. Hence, for now, only immunized women will be protected.

Finally, there is no doubt there is compelling evidence the HPV vaccine is remarkably safe. Preventing cervical cancer is very important. In Canada, an estimated 1300 women will be diagnosed with cervical cancer this year and 380 will die. In spite of years of Pap smears and regular screening, cervical cancer is still prevalent.

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Restless Legs Syndrome Can Affect Your Personal Health

When we are a sleep, our brain is not an idle machine. It stays very busy. It processes the information we have learned during the day. Sleep makes memories stronger. Sleep also finds hidden relations among memories and helps solve problems we were working on while awake (Scientific American Mind, August/September 2008).

There are at least 84 disorders of sleeping and waking that lead to a lowered quality of life and reduced personal health. Disturbed sleep can lead to traffic and industrial accidents. Restless legs syndrome (RLS) is one of those conditions which can disturb your sleep, can affect your personal health and can cause harm to others.

Sometime ago, there was an article in the New England Journal of Medicine (NEJM) on this subject. The article gives an example of a 45-year-old woman having had nightly insomnia for years. She reports having uncomfortable sensations in her legs when she lies down at night. She describes a feeling of needing to move her legs, which is relieved only by getting up and walking around.

This lady was diagnosed with RLS. It is also known as Ekbom’s syndrome. It is a movement disorder. It is not a psychological or emotional condition. It is thought to be a neurological disorder. Current studies are focused on a brain chemical known as dopamine.

About three to 15 per cent of the population is affected by RLS. It is more common in women than men. The prevalence increases with age. There may be a family history of the condition. Some medications can trigger RLS.

The following features should be present to make a diagnosis of RLS:
-A distressing need or urge to move the legs, usually accompanied by an uncomfortable, deep-seated sensation in the legs that is brought on by rest (sitting or lying down), relieved with moving or walking, or worse at night or in the evening.
-RLS can be associated with involuntary limb movements while patient is awake and/or periodic limb movements (PLM) while patient is asleep. Studies show that more than 80 per cent of people with RLS also have PLMs. But the majority of people with PLMs do not have RLS.

The diagnosis of RLS is based on the clinical history. RLS may be a symptom of iron deficiency therefore the iron status should be assessed. Overnight sleep study may be helpful. The article says that despite the distinctive clinical features of RLS, there remains substantial variability in responses to treatment and in clinical progression and outcome.

It seems all patients with RLS do not present with classical symptoms. Therefore, my impression is, many patients with leg pain go undiagnosed or inadequately treated.

Is there a good treatment for this condition?

For RLS, there are few medications in the market. But the NEJM article says that there is currently inadequate information on the efficacy of medications other than the group of drugs known as dopaminergic drugs.

For unexplained leg pain, rest as much as possible. Elevate the leg and take pain medications which you are familiar with. Gentle massage may improve comfort. Heat or cool soaks may help. If pain persists or swelling develops, see your family physician.

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