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Hard work needed in MD crisis.

August 24, 2001

The Editor,
Medicine Hat News,
Medicine Hat.

Dear Sir:

RE: Dr. Ruzycki’s letter – Service failing at Hat hospital.

I agree with Dr. Ruzycki that there is a significant crisis in the medical services offered to the people of Palliser Health Authority (PHA). It takes longer to see a specialist than getting surgery done. For example, it may take up to three months to see certain specialist. But after you have seen one, you can get in for surgery within a couple of weeks. It used to be the other way round.

Alberta Health is not interested in the welfare of specialists in places like Medicine Hat. Traditionally, specialists here have provided round the clock coverage at great cost to their own health and family life. For obvious political reasons, Albert Health only cares about specialists in Calgary and Edmonton.

The solution to the problem has to be found locally. I suggest the following five points:

1. PHA should have a proactive aggressive recruitment and retention policy. Have a recruitment officer who can foresee future trends in manpower needs. Recruitment is an ongoing project and requires time and devotion. It takes at least a year to find a physician.

2. Specialists in Internal Medicine, General Surgery, Paediatrics, Anaesthesia, Orthopaedics and Obstetrics should have one more specialist locally than what they think they need. This means drop in income but a better life style and on-call coverage. PHA should subsidies the escalating overhead costs for these specialists.

3. PHA should provide resources (operating room time, equipment and other special needs) to accommodate these extra specialists.

4. Aging specialists who do not want to provide full time service should be asked to give up certain privileges or use of resources to make room for new recruits. This should be fairly applied and not selectively favoured.

5. There should be less talk and more action to find solution to manpower needs of PHA. None of the ideas mentioned here are new. These have been discussed over the years and even recently by medical staff.

As we know, solution to any problem requires leadership, hard work, good will and teamwork. The Palliser Medical Staff and the Palliser Health Authority have people with plenty of these skills. So, what is missing?

Yours Sincerely,

Noorali Bharwani

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Indigestion

Individuals, health care institutions and Alberta Blue Cross spend millions of dollars for the use and “abuse” of pills for indigestion, heartburn and the treatment of peptic ulcer disease. Is there a sensible way of using these pills?

Recently, this subject was discussed in the DUE (drug use in the elderly) Quarterly.

Dyspepsia (indigestion) affects 29 percent of the adult population and accounts for seven percent of visits to family physicians.

Most widely prescribed and used acid suppressing agents are:

-Proton pump inhibitors (PPI)- accounts for 90 percent of Alberta Blue Cross Group (ABCG) 66’s cost of acid suppression agents (examples-Losec, Prevacid, Pantaloc)

-H2 antagonists –accounts for 10 percent of the ABCG 66’s cost of acid suppression agents (examples-Zantac, Pepcid, Axid and their generic versions)

Why would one need these pills?

-For eradication of Helicobacter pylori organism from the stomach. A protocol requires that any patient with H. pylori infection, in the presence of an ulcer, should receive one week of “triple therapy” – two antibiotics and PPI. In the absence of an ulcer, the use of “triple therapy” is controversial.

-For gastroesophageal reflux disease (heart burn) – four to eight weeks of treatment with PPI or H2 antagonist is indicated with life-style changes.

-For functional dyspepsia, also known as non-ulcer dyspepsia or indigestion. In this condition, an individual has all the symptoms of an ulcer but no ulcer is found on investigations. A difficult condition to treat satisfactorily. A person may end up using the pills for prolonged period of time for symptomatic relief.

-For NSAID-related dyspepsia – individuals who are on non-steroid anti-inflammatory drugs (NSAID) are prone to peptic ulcer disease or indigestion. These individuals are on long-term use of stomach pills.

Losec should be taken half an hour before any meal, while Pantaloc and Prevacid should be taken before breakfast. These pills should be taken whole, not broken or chewed.
The Quarterly says that PPI have been recognized to be efficient and safe in what they do. And there is not much difference in the clinical use of the three PPIs except for the cost.

The cost comparison of PPIs in Alberta shows that Losec 20mg once daily costs $66.00 per month, Pantaloc 40mg once daily costs $61.26 per month and Prevacid 30mg once daily is the cheapest at $60.00 per month.

The largest group of patients on PPI are the ones with heartburn and gastroesophageal reflux disease. Many of these patients can be treated with life style changes and over the counter medications and/or cheaper H2 receptor antagonists like Zantac, Pepcid, or Axid. Those who do not respond to these measures can be stepped up to a PPI. These patients also require investigations to assess the degree of damage to the lining of the oesophagus by gastric and biliary juices.

The next large group on PPI is one with indigestion due to NSAID use. Patients who have peptic ulcer due NSAID therapy are best treated with PPI. NSAID patients are usually on another drug called misoprostal, which offers protection against development of ulcers.

Patients with non-ulcer dyspepsia should not be on long term PPI therapy without trial of other therapies, which are cheaper, and with minimal side effects. Prolonged acid suppression in the stomach without good reason may lead to atrophy of stomach glands and deficiency of vitamin B12. Plus the cost to the patient and other institutions that pay for the prescriptions.

So, if you are on any of the pills mentioned here on long term basis then ask your doctor: Do I really need it? Is there anything cheaper? Is there anything else you can do to relieve your symptoms?

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Tamoxifen and Cancer Prevention

Dear Dr. B: Is there a pill to prevent breast cancer? Yours: Ms. Worried.

Dear Ms. Worried: There is no straight answer to this question. Studies have shown that, in some women, tamoxifen can prevent breast cancer.

Recently, an article was published on this subject in the Canadian Medical Association Journal. It is a joint guideline from the Canadian Task Force on Preventive Health Care and the Canadian Breast Cancer Initiative’s Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer.

The objective of the guideline is to assist women and their physicians in making decisions regarding the prevention of breast cancer with tamoxifen and raloxifene.

Raloxifene is a drug used for prevention and treatment of osteoporosis in
post-menopausal women. Current evidence does not support the use of raloxifene for prevention of breast cancer.

Tamoxifen is a drug used for certain categories of women who have had breast cancer. It has shown to reduce the recurrence of cancer in the same breast, reduce the occurrence of new breast cancer in the other breast, and reduce the risk breast cancer spreading to other parts of the body (metastasis).

Tamoxifen has been found to be effective in preventing breast cancer. On that basis the Task Force has made recommendation in the use of Tamoxifen for prevention of breast cancer.

How do I know tamoxifen will help me prevent breast cancer?

First, you need to determine your risk. This is not easy. You have to go on the internet and check the Gail risk assessment index. This is a model used to estimate an individual woman’s risk of breast cancer.

The index uses a series of risk factors (age, age at first period, age at first live birth, number of breast biopsies, family history and ethnic origin) to calculate a “baseline risk.” The article says that the Breast Cancer Risk Assessment Tool, which is based on the Gail index, is available online: http://bcra.nci.nih.gov/brc. This will calculate percentage risk for you.

Once you have done that, then check the following recommendations to see if they apply to you:

1. Women at low or normal risk of breast cancer (Gail risk assessment index less than 1.66 percent at 5 years): There is fair amount of evidence to recommend against the use of tamoxifen in this group.

2. Women at higher risk of breast cancer (Gail index equal to or more than 1.66 percent at 5 years): Evidence supports counselling women in this group on the potential benefits and harms of breast cancer prevention with tamoxifen.

Examples of women in the second group would be – two first-degree relatives with breast cancer, a history of breast biopsy showing lobular carcinoma-in-situ, or atypical hyperplasia. Tamoxifen reduces the risk of breast cancer by 50 percent or in atypical hyperplasia by 86 percent.

Use of tamoxifen is not without side effects like stroke, blood clots in the lung or leg veins, cancer of the uterus, hot flashes and vaginal dryness. The article says that the side effects increase with a woman’s age.

So, Ms Worried, tamoxifen will do the trick for you if you are the right candidate. And remember, the benefits are not without side effects. “The benefit of protection against breast cancer is more likely to outweigh the risks on women aged 35 to 50 years”, says the Canadian Task Forces’ guideline.

Good luck, Ms. Worried.

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Screening Can Save Your Life

Dear Dr. B: Are there any recommendations for colorectal cancer screening from the Canadian Task Force on Preventive Health Care? Yours, Mr.C.

Dear Mr. C: Yes. A statement from the Task Force on colorectal screening was published recently in the Canadian Medical Association Journal. These recommendations are for asymptomatic people with no personal history of ulcerative colitis, polyps or colorectal cancer. I will summarise the recommendations here:

Recommendations for people over the age of 50 who are at normal risk:

1. There is good evidence to suggest that these people should have annual or biennial (every two years) test to check for non-visible blood in the stool (fecal occult blood tests).

2. There is fair evidence to include flexible sigmoidoscopy (an office procedure). Some recommend this every five years.

3. There is insufficient evidence to recommend whether only one or both (1 and 2) should be performed.

4. There is insufficient evidence to include or exclude colonoscopy as an initial screening test in this age group. Some recommend colonoscopy every 10 years.

Recommendation for people at above-average risk:

1. There is fair evidence to include either genetic testing or flexible sigmoidoscopy of people in families with familial adenomatous polyposis – a condition in which multiple adenomatous polyps progressively develop throughout the colon. The polyps first appear after puberty. Other benign and malignant lesions may appear on the body.

2. There is fair evidence to include colonoscopy screening in the periodic health examination of people in families with hereditary non-polyposis colon cancer – a condition in which three family members are affected with colorectal cancer, two of whom are in successive generations and at least one is under the age of 45 years. It is unclear at what age the screening should start and how often colonoscopy should be done.

3. There is insufficient evidence to recommend colonoscopy for people who have a family history (people who have two or more first degree relatives) of colorectal polyps or cancer but who do not meet the criteria for hereditary non-polyposis colon cancer. Some experts recommend colonoscopy for this group as it is accepted that people with family history of colon and rectal cancer may be at increased risk but that this risk is not well defined.

What are the advantages of screening? To reduce the number of deaths from colorectal cancer.

What are the disadvantages? The incidence of false positive and false negative tests especially with fecal occult blood testing. There is incidence of perforation from flexible sigmoidoscopy (1.4 per 10,000 procedures) and colonoscopy (10 per 10,000 procedures).

Colorectal cancer is the third most common cancer in Canada. It accounts for more than 12 percent of cases of cancer in both sexes.

It was estimated that there would be 17,000 new cases and 6,500 deaths from colorectal cancer in Canada in 2000. These rates, especially among men, are among the highest in the world.

But how many of us are ready to submit ourselves to screening for colorectal cancer? Not many. The embarrassment and discomfort of a rectal examination, unpleasant bowel cleansing before flexible sigmoidoscopy and colonoscopy, risk of bowel perforation, and anxiety dissuade people from coming forward for screening. Even symptomatic patients take a long time before they see their doctors.

Well, Mr. C, if any of the recommendations apply to you then see your doctor and have yourself checked out. Prevention is better than…….?

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