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Deal should have patients in mind: Docs

Medicine Hat News

Thursday, November 13, 2003

Deal should have patients in mind: Docs

By DAVID FREEMAN

Doctors hope that the end result of an historic eight-year agreement reached between the province, health regions and physicians this weekend will be used to improved services for patients.

According to Dr. Noorali Bharwani, a physician in Medicine Hat, the deal is a step toward reforming the health system, but he is taking a wait and see attitude.

“I don’t know how the patients will benefit,” he said. “When patients can’t see a family doctor for a month, there’s something wrong.”

Alberta Health and Wellness and the Alberta Medical Association, along with representatives of the provincial health authorities, agreed on the eight-year deal that will see a fundamental changes in the way the three entities work together to improve patient care.

On the top of the list of changes is making the health regions equal partners in the process.

“This is the first time those who are responsible for managing the region are equal partners with those who deliver front-line services,” said Christianne Dubnyk, a spokesperson for Alberta Health and Wellness.

Representatives for the Palliser Health Region could not be reached for comment before press time.

According to Dubnyk, no labour deal in Canada has ever been eight years before. The agreement will last until March 31, 2011 and is retroactive to April 1, 2003, which was when the last agreement ended.

“[It’s] the amount of time needed to fundamentally change how the three parties interact,” she said.

“Previous terms [with the AMA] were two years. That’s simply not long enough. It’s safe to say this is new territory,” Dubnyk continued. “We definitely need time to work things out.”

The Master Agreement has four main agreement components designed to see a co-operative effort in reforming health care in this province.

The most dynamic aspect of the deal is the Primary Care Initiative agreement. It will see a co-operative effort between doctors, health region officials and the province to develop plans for each health region to identify specific needs and assign specific costs to address problems in each region.

The Local Primary Care Initiative will be entered into by physicians and the region, said Dubnyk. They will then come up with a business plan assessing the needs of the community and receive up to $50 per patient in funding if accepted by the Primary Health Care Committee and a Master Agreement Committee.

Part of the business plan will be assessing the use of other health care professionals in each region, such as nurses.

“Until we see how the agreement affects nurses and other primary health care providers, we can’t take a strong stance here,” said Jeanne Besner, president of the Alberta Association of Registered Nurses.

“The AARN supports reform of primary health care,” she continued, adding that the AARN hoped the local Primary Care Initiatives would have a collaborative approach.

“We definitely feel we need to be involved and feel physicians want us involved,” she said.

The Physician’s Services agreement, the second part of the deal, will see a modest rise in fees for physicians over the course of three years, 2.7 per cent in the first year followed by increases of 2.9 and 3.5 per cent.

“The money’s never enough for everybody,” said Bharwani, though he emphasized that he is happy with the compensation package.

He said that when doctors aren’t compensated properly, “Your performance goes down, and in the end patients suffer.

“What patients are complaining about right now is a shortage of doctors,” he continued. “Will it attract more physicians to our province? We’ll have to wait and see.”

There is also a Physicians On-call Program agreement which will see improved access to specialist and rural physicians.

Finally, the Physician Office System Program agreement will see the automation of the paper-based physician’s offices and link their files to an electronic health record. The electronic record will allow physicians immediate access to a patient’s prescription history, allergies and laboratory tests resulting in a more accurate diagnosis and treatment.

The agreement will see $1.45 billion spent in the first year, $1.52 billion in year two and $1.65 billion in 2006. The agreement has two financial re-openers in 2006 and 2008.

The largest portion of the budget will go toward the Physician Services Agreement, $1.34 billion in year one followed by $1.4 billion and then $1.49 billion in years two and three.

The Primary Care Initiative will see $20 million, $20.5 million and $59.5 million over the course of the next three years. And the Physician On-call agreement will see infusions of $68.9 million, $71.4 million and $75.3 million in the first three years.

“It may sound big, but in practical use there may still be some shortfalls,” concluded Bharwani regarding the dollars being announced.

Alberta Health and Wellness has said from the start that the amount of money isn’t as important as the way the money is spent and what is targeted.

Doctors across the province will have the details of the agreement explained to them by representatives of the AMA in the coming two to three weeks before a ratification vote scheduled for Dec. 12. The AMA tour will be in Medicine Hat on Dec. 2.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Pap Smear

How frequently should a woman have Pap smear?

The current recommendation is that all women from the age of 18 until age 69 should have a Pap smear every year. Regular Pap smear can prevent cervical cancer.

Unfortunately, 50 percent of Alberta women who develop cancer of the cervix have never had a pap smear or haven’t had smears as often as recommended, says Health Report for Albertans 2003.

This is really unfortunate. In 2002, it was estimated that 1400 Canadian women would develop cancer of the cervix and 410 would die from it, says the Health Report. Many of these lives could have been saved with yearly Pap smears.

In 1999, over 150 cases of invasive cervical cancer were recorded in Alberta, says a document produced by Alberta Cancer Board. In addition, approximately 1500 cases of cervical carcinoma in-situ (lesions that have not spread beyond the surface of the cervix) were recorded.

In the Palliser Health Region, from1996 to 2000, 19 cases of invasive cervical cancers were diagnosed (about four cases a year).

Cervical cancer used to be one of the most common and lethal cancers in women. Over the past 60 years, thanks to Pap smear, the death rate from cervical cancer has decreased dramatically.

Now some researchers are questioning the yearly screening programs.

“How often should we screen for cervical cancer?” is the title of an article in an October issue of the New England Journal of Medicine (NEJM).

The American Cancer Society (ACS) recently revised their guidelines for screening for cervical cancer because there have been reports that cost-benefit analyses of lifelong annual screening may not result in substantially better outcomes than less frequent screening and is much more costly.

ACS now recommends interval between screenings ranging from one to three years, depending on several factors, such as age, screening history, type of Pap smear, and history of patient’s immunity.

The NEJM article says that the risk of lengthening the interval for screening is that many women will forget to comply with screening recommendation.

So, it is important that every woman should remember to have a Pap smear every year unless your physician advises you otherwise.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Irritable Bowel Syndrome

Some time ago I received a letter from one of the readers. It had multiple questions. So here are the questions and appropriate answers.

Q. Please describe irritable bowel syndrome (IBS). Is it constipation or diarrhea?

Irritable bowel syndrome is the most common chronic intestinal disorder. The symptoms are due to disturbance in the movement and sensation of the bowel. The person is otherwise well but presents with chronic or recurrent abdominal pain, change in bowel habit (constipation and/or diarrhea) and bloating.

Literature suggests at least 15 percent of the population has this condition. I feel that almost everybody has some element of irritable bowel syndrome.

It affects twice as many women as men and usually begins in early adult life. Although IBS can cause much distress, it does not lead to life-threatening illness. It is also called spastic colon.

Q. What can you do for it?

First, you have to see a doctor and get some basic investigations done to rule out any other illness like infection in the bowel, cancer, ulcerative colitis, Crohn’s disease, and celiac disease. Anemia, rectal bleeding and loss weight are not symptoms of IBS.

There is no cure for IBS. However, controlling the diet and emotional stress usually relieves the symptoms. Sometimes symptoms come and go. Some medicines may also help.

IBS is like arthritis of the gut. Just as in arthritis, your doctor may have to try more than one medication to control your symptoms.

Q. Early in spring, I had diarrhea for two weeks. Things settled down a lot since. I have a lot of gas and grumbling. Could this be due to stress?

That is quite possible. Stress plays a significant negative role in many of our illnesses. But before you blame everything on stress, you should talk to your doctor and let him decide the cause of your “back door trots”.

The subject of irritable bowel syndrome has been covered in these columns previously. These columns are available on my web site: www.nbharwani.com. Or you can pick up a copy of the relevant article from my office.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Carpal Tunnel Syndrome

A young lady wants to know about carpal tunnel syndrome. What is it? Who gets it? How is it managed?

Carpal tunnel syndrome was first described in 1853. It is a common, painful disorder of the wrist and hand. It is caused by pressure on the median nerve in the wrist. The median nerve travels from the forearm into the hand through a “tunnel” in the wrist.

The cause of the pressure can be multifactorial. Some common causes and associated conditions are:
-repetitive and forceful grasping with the hands
-repetitive bending of the wrist
-broken or dislocated bones in the wrist which produce swelling
-arthritis, especially the rheumatoid type
-thyroid gland imbalance
-sugar diabetes
-hormonal changes associated with menopause
-pregnancy

Although any of the above may be present, most cases have no known cause.

It can occur at any age. The condition occurs most often in people 30 to 60 years old, and it is 5 times more common in women. It affects the dominant hand more frequently. It may affect both hands.

The symptoms start with pins and needles in three and half fingers (thumb, index finger, middle finger and half of ring finger) that are supplied by the sensory branch of the median nerve.

This may be followed by pain in the distribution of the median nerve, from the tip of the fingers to the neck. Symptoms may be worse at night and wake the patient from sleep. Relief is obtained by dangling the arm over the side of the bed.

Eventually, the median nerve supplying the small muscles of the hand may be affected. This produces wasting and weakness of the hand. There may be tendency to drop things.

A good history and physical examination is very important. Sometimes the condition may be confused with other problems affecting the shoulder and the neck. Therefore, nerve conduction study of the median nerve can provide more information.

The nerve conduction study helps localize the site of the entrapment and estimate the severity of damage. In less than 10 percent of the patients the test may be falsely negative. Clinical correlation is required to come to a final diagnosis.

Non-surgical treatment of carpal tunnel syndrome is: avoidance of the use of the wrist, placement of a wrist splint in a neutral position for day and night use, and anti-inflammatory medications.

Splinting can be combined with steroid injections. In one study, 80 percent had immediate relief of symptoms. But after one year only 20 percent were free of symptoms.

Ergonomic redesign of work stations is widely practiced for prevention and for relief of symptoms.

Surgical treatment involves a small incision on the palmar aspect of the wrist and the hand. The incision is deepened to divide the ligament to open the tunnel. Thus the pressure on the nerve is released.

The surgery requires no hospitalization and is done under local or regional anesthetic. No genera anesthetic is required. Studies have shown that surgical treatment relieves symptoms in 82 to 98 percent of the patients.

Relief of symptoms and return to normal level of physical activities may take few days to several months – depending on the damage to the nerve and the type of activity. Physiotherapy may become necessary.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!