Letters · Correspondance

CMAJ 1999;161:1389-96

• Decrease in CMPA's legal bills M.A. Ross
• Support for support hose M. Moniuszko
• Why do we force Canadians to study medicine abroad? A. Porzecanski
• Probing Premarin T.H. Lippert, A.O. Mueck response: A.R. Baumgartner
• It's always a g'day to immunize, mate P. Badrinath
• Caring for patients with Alzheimer's disease in Italy L.G. Mantovani, A. Belisari
• Cheers and jeers for the Charter for Physicians J.J.P. Patil; T. Temple; D.M. Goodwin; A. Piver; D.H. Smith; response: J. Hoey
• Calcium-channel blockers and cognitive function in elderly people: results from the Canadian Study of Health and Aging [Correction]

I read with interest Patrick Sullivan's recent CMAJ article [full article]¹ describing the issues that were discussed at the annual meeting of the Canadian Medical Protective Association (CMPA) in August. Sullivan reports, "By last year, legal bills had declined to $83 million." I would like to point out that the CMPA's legal expenses in 1998 were not $83 million but $62 million. I assume that Sullivan was referring to the $83 million that the CMPA paid in awards and settlements on behalf of members in that year.

Margaret A. Ross
Gowlings, Strathy & Henderson
  Barristers & Solicitors
Ottawa, Ont.

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1. Sullivan P. CMPA "amazed" as number of new legal actions against MDs declines in '98. CMAJ 1999;161(6):741.

[Contents]

I enjoyed reading the article by Jeffrey Ginsberg and colleagues on post-phlebitic syndrome [abstract].¹ I would like to share my observations from 15 years of treating swollen legs related to varicose veins, leg ulcers, post-phlebitic leg and lymphedema. I am not a scientist, but as a result of my clinical experience I believe that compression support knee-highs are superior to extremity pumps because they provide continuous pressure while allowing a patient to ambulate. In my estimate, support knee-highs are one of the least understood and most underused treatment modalities in medicine.

Patients usually initially require stockings that provide 20­30 mm Hg of compressive pressure, which can be reduced to 8­15 mm Hg once the patient's condition has improved. These stockings should be worn indefinitely, a notion patients often resist. Resistance can be overcome through counselling, referral to experienced fitters in designated pharmacies and instruction in the use of devices to assist aged hands with putting on the stockings. My preferred length is the knee-high because it most easily allows for ambulation.

As an aside, I have also observed that patients with post-phlebitic syndrome seem to present more often than the general public with concomitant varicose veins. Treating varicose veins with surgery, sclerotherapy or compression seems to relieve most of the signs and symptoms of post-phlebitic syndrome.

Monika Moniuszko, MD
Vein Clinic
Edmonton, Alta.

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1. Ginsberg JS, Magier D, Mackinnon B, Gent M, Hirsh J. Intermittent compression units for severe post-phlebitic syndrome: a randomized crossover study. CMAJ 1999;160(9):1303-6.

[Contents]

Canada is in the midst of a serious shortage of physicians [full article],¹ yet another sign that the provinces were shortsighted to reduce medical school admissions in 1993/94. Enrolment should have been left alone, with newly graduated physicians encouraged to dedicate at least a few years at the beginning of their career to work in underserviced areas. The encouragement could come in the form of tax credits, extra income or some other type of "carrot."

To increase the number of physicians, we should open residency positions for foreign-trained physicians already in our midst. At the moment, they are in a catch-22 situation: they cannot take Canadian exams because they cannot get a residency position, and they cannot get a residency position because almost all of these positions go to Canadian graduates.

Patrick Sullivan's article¹ mentioned that Canada's medical schools currently receive 4 applications from qualified students for each available space. Many of the students who are rejected still want to fulfil their dreams and are accepted into medical schools abroad. My own daughter, who is currently in the fourth year of a 6-year program in Ireland, is a case in point. We should be rescuing students such as her by increasing enrolment in the clinical years, making it possible for these students to transfer to Canadian schools and graduate here.

With tuition costs in the range of $30 000 per year, my daughter will have a debt of more than $150 000 by the time she graduates, practically mandating that she apply for a residency position in the US.

It is shameful that a Canadian citizen has to exile herself to another country at a time when we are in dire need of new doctors. When are the CMA and its provincial divisions going to put their collective pants on and demand that our governments address these gross aberrations?

Alex Porzecanski, MD
Victoria, BC
aporze@access.victoria.bc.ca

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1. Sullivan P. Concerns about size of MD workforce, medicine's future dominate CMA annual meeting. CMAJ 1999;161(5):561-2.

[Contents]

In a CMAJ letter to the editor on Premarin,¹ Aldo Baumgartner states that "no other estrogen products have ever been developed that can match Premarin's unique composition of more that 10 estrogenic components." This is no doubt the case, as a large quantity of estrogenic metabolites are excreted via the urine of pregnant mares, not only of estradiol, but also of equilins, which are specific to horses. It is surprising that so many estrogenic components should be required to treat the postmenopausal lack of estrogen.

Baumgartner's offer to discuss Premarin provides the opportunity to pose the following questions: Are precise figures currently available on the number of steroid components in Premarin? To what extent has their spectrum of effects been elucidated? Has it been established that all of the metabolites produce only beneficial effects?

According to our estimates, Premarin must contain considerably more steroid metabolites than have been reported in the literature. A report recently appeared on the occurrence of hitherto unknown metabolites such as delta-8-estrone.² It is particularly important in the case of long-term treatment with the preparation to know the effects of components that do not predominate quantitatively in the extract. We now know that estrogenic metabolites can produce a number of different effects;³ some metabolites are thought to increase the risk of breast cancer.⁴

Competing interests: None declared.

Theodor H. Lippert, MD
Alfred O. Mueck, MD, PhD
Section of Clinical Pharmacology
University of Tübingen
Tübingen, Germany

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1. Baumgartner AR. Proud of Premarin [letter]. CMAJ 1999;160(13):1821.
2. Bhavnani BR. Pharmacokinetics and pharmacodynamics of conjugated equine estrogens: chemistry and metabolism. Proc Soc Exp Biol Med 1998;217:6-16.
3. Lippert TH, Seeger H, Mueck AO. Metabolism of endogenous estrogens. In: Oettel M, Schillinger E, editors. Handbook of experimental pharmacology. vol. 135/I of Estrogens and antiestrogens I. Berlin: Springer; 1999. p. 243-71.
4. Fishman J, Osborne MP, Telang NT. The role of estrogen on mammary carcinogenesis. Ann N Y Acad Sci 1995;768:91-100.

[Contents]

Premarin is a complex natural product comprised of multiple components. It has been the subject of more than 3500 citations and over 57 years of clinical use in Canada, the US and around the world. All of the estrogenic components that have been tested for biological activity have been found to be biologically active. As Theodor Lippert and Alfred Mueck state, different estrogens can produce different effects. An estrogen can be an agonist in one tissue and an antagonist in another; we know that these effects are tissue and cell dependent. Furthermore, we know that the effect of an estrogen can be different when administered acutely versus chronically and, perhaps most important, that its effect can be different, in fact opposite, when administered in conjunction with other estrogens.^1­4 Thus, the effects of Premarin cannot be ascribed to an individual metabolite or component or group of components. Effects are all too frequently ascribed to estrogens as a class by individuals whose knowledge in the area is limited; in any event the data are more often than not based on studies with Premarin. On the basis of current scientific and clinical knowledge of the mechanisms of estrogen action, an assumption that Premarin's effects apply or can be extrapolated to all estrogens is inappropriate.

Aldo R. Baumgartner, PhD
President and CEO
Wyeth­Ayerst Canada Inc.
Saint-Laurent, Que.

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1. Clark JH, Markaverich BM. The agonistic and antagonistic actions of estriol. J Steroid Biochem 1984;20:1005-13.
2. Clark JH, Paszko Z, Peck EJ. Nuclear binding and retention of the receptor estrogen complex: relation to the agonistic and antagonistic properties of estriol. Endocrinology 1977;100:91-6.
3. Anderson JN, Peck EJ, Clark JH. Estrogen-induced uterine responses and growth: relationship to receptor estrogen binding by uterine nuclei. Endocrinology 1975;96:160-7.
4. Melamed M, Castano E, Notides AC, Sasson S. Molecular and kinetic basis for the mixed agonist/antagonist activity of estriol. Mol Endocrinol 1997;11:1868-78.

[Contents]

Considering the recent adverse publicity that immunization has received in both the scientific and the lay press, I found a recent CMAJ piece on immunization by Barbara Sibbald [full article]¹ to be quite useful and timely. Your readers may also find an excellent brochure produced by the Australian government to be useful.² It can be downloaded in PDF format from the Web.

P. Badrinath, MD
Al Ain, United Arab Emirates
badrishanti@hotmail.com

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1. Sibbald B. It's wise to immunize, regardless of what the Web says. CMAJ 1999;161(6):736.
2. Hall R, O'Brien E. Immunization myths and realities: responding to arguments against immunization. Canberra: Australian Government Publishing Service; 1998. Available: www.health.gov.au/pubhlth/immunise/publications.htm.

[Contents]

We read with interest the article by Margaret Hux and colleagues on the association between cognitive function and the cost of caring for patients with Alzheimer's disease [abstract / résumé].¹ We conducted a similar study in Italy.

We sampled 10 patients at each of 9 Italian centres for the care of patients with Alzheimer's disease. At each centre we collected information on the patients' degree of cognitive impairment, as indicated by the Mini-Mental State Examination,² and the levels of care associated with different levels of impairment. We also surveyed sociodemographic characteristics of family caregivers and asked them to estimate the time and money the family devoted to caring for the family member with Alzheimer's disease. Italian National Health Service tariffs^3,4 were used to estimate the cost of medical services and the replacement approach⁵ was applied to estimate the costs of informal care provided.

We analysed the association between cognitive function (using the classification system used by Hux and colleagues) and costs using multiple linear regression. Cost was logarithmically transformed to better fit a Gaussian distribution.

Seventy-six (84%) of the patients and their caregivers agreed to participate. The patients had a mean Mini-Mental State Examination score of 12.6 (standard deviation [SD] 5.8). Their mean age was 70.8 years (SD 8.7); 23% were men, 7.9% were living in an institution and a further 7.9% had been admitted to an institution in the previous 12 months. The mean age of the caregivers was 58.5 years (SD 13.2), and 44% were men. The yearly cost of care was estimated to be Can$61 852 (SD Can$34 375). Similar findings have been reported in other studies in Italy.^6,7

The level of cognitive function was significantly associated with the cost of caring for patients with Alzheimer's disease (p = 0.005). Costs were higher for older (p = 0.027) and wealthier (p = 0.094) caregivers and younger patients (p = 0.024).

In contrast to the findings of Hux and colleagues, the care of patients living in an institution cost significantly less than that of patients living at home (p = 0.039). One possible explanation is that nurses in institutions care for several patients simultaneously, decreasing the time devoted to each patient and thereby lowering costs.

Other than the relatively lower cost of caring for patients in institutions, our findings confirm those of Hux and colleagues.

Lorenzo G. Mantovani, EconD, MSc
Andrea Belisari, PharmD
Center for Pharmacoeconomics
University of Milan
Milan, Italy

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1. Hux MJ, O'Brien BJ, Iskedjian M, Goeree R, Gagnon M, Gauthier S. Relation between severity of Alzheimer's disease and costs of caring. CMAJ 1998;159(5):457-65.
2. Folstein MF, Folstein SE, McHugh PR. "Mini-Mental State." A practical method for grading the cognitive state of patients for the clinicians. J Psychiatr Res 1975;12(3):189-98.
3. [Ministry Decree, Dec. 14, 1994. Tariffs for hospital care] Decreto Ministeriale 14 Dicembre 1994. Tariffe delle prestazioni di assistenza ospedaliera. Supplemento ordinario alla Gazzetta Ufficiale no. 300 (Dec. 24, 1994).
4. [Ministry Decree, July 22, 1996. Outpatient care deliverable within the National Health Service and their tariffs] Decreto Ministeriale 22 Luglio 1996. Prestazioni di assistenza specialistica ambulatoriale erogabili nell'ambito del Servizio sanitario nazionale e relative tariffe. Supplemento ordinario alla Gazzetta Ufficiale no. 216 (Sept. 14, 1996).
5. Rice DP, Fox PJ, Max W, Webber PA, Lindeman DA, Hauck WW, et al. The economic burden of Alzheimer's disease care. Health Aff (Millwood) 1993;12(2):164-76.
6. Bianchetti A, Frisoni GB, Ghisia KM, Trabucchi M. Clinical predictors of the indirect costs of Alzheimer disease. Arch Neurol 1998;55(1):130-1.
7. Cavallo MC, Fattore G. The economic and social burden of Alzheimer disease on families in the Lombardy region of Italy. Alzheimer Dis Assoc Disord 1997;11(4):184-90.

[Contents]

It appears that Nuala Kenny and her colleagues are still operating in the Dark Ages [full article].¹ I read the CMA Charter for Physicians² and I see nothing in it that the ordinary Canadian citizen would not demand. Most Canadians would like a work environment that is conducive to good productivity and to providing the best possible service to customers and society at large — an environment free of harassment, discrimination, intimidation and violence. Canada's Charter of Rights gives us freedom of association and speech, and the CMA charter demands nothing more.

Society has changed, as has the medical profession. Once medicine was a vocation in which people sacrificed and dedicated their lives to the care of the sick and injured. No longer is medicine a vocation of that type. It is now a profession, just like any other.

J.J.P. Patil, MB BS
Halifax, NS

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1. Kenny N, Weijer C, Baylis F. Voting ourselves rights: a critique of the Canadian Medical Association Charter for Physicians. CMAJ 1999;161(4):399-400.
2. Canadian Medical Association. Charter for Physicians [policy]. CMAJ 1999;161(4):430-1.

[Contents]

When it comes to the CMA's new Charter for Physicians, I must support Dan MacCarthy [full article].¹ The critique of it offered by Nuala Kenny and colleagues [full article]² is way off the mark in equating professional rights with the needs so succinctly expressed in the charter. When I first read the charter, it gave me the feeling that some collective support was at hand to help with the day-to-day effort required to serve patients. It is also a useful adjunct to the CMA Code of Ethics.³ MacCarthy's eloquent rebuttal stands on its own merit. I would add that the alternatives provided by the authors of the critique are completely at ease with the charter's overall focus.

Most physicians I know practise medicine for altruistic reasons, and I certainly strive in that direction. However, my colleagues and I have needs, many of which are unmet in the current divisive climate within our health care system. Yes, we are a privileged group, but please, less destructive criticism, and more encouragement. In my view, the charter achieves the latter goal.

Tim Temple, MB BS
Maple Ridge, BC
ttemple@netcom.ca

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1. MacCarthy D. Why physicians need a charter. CMAJ 1999;161(4):400-1.
2. Kenny N, Weijer C, Baylis F. Voting ourselves rights: a critique of the Canadian Medical Association Charter for Physicians. CMAJ 1999;161(4):399-400.
3. Canadian Medical Association. Code of Ethics [policy]. CMAJ 1996;155(8):1176A-B.

[Contents]

It is really terribly unfair how governments have treated doctors over the past 2 decades. At least, that is the official line the CMA board uses to justify its recently proclaimed Charter for Physicians.¹ It is not about "rights," the board hastens to add. It is about our "needs," a sort of chicken soup for the demoralized professional ego.

With respect, this is becoming just a little precious. The CMA is, of course, a creature of its provincial satellites. This might, in part, explain why the majority of the CMA board members do not seem to have noticed certain critical facts, such as the fact that politicians have not actually done anything to us, save perhaps for the GST, without permission and consent from our provincial associations.

So mark me down with Nuala Kenny [full article]² and the embarrassed ethicists, for I do not think doctors need special privileges not enjoyed by other citizens. What we do need is a national association prepared to defend our civil liberties, not one that substitutes hypocrisy when piety does not seem to be working anymore.

D.M. Goodwin, MD
Niagara Falls, Ont.

Reference

1. Canadian Medical Association. Charter for Physicians [policy]. CMAJ 1999;161(4):430-1.
2. Kenny N, Weijer C, Baylis F. Voting ourselves rights: a critique of the Canadian Medical Association Charter for Physicians. CMAJ 1999;161(4):399-400.

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[Contents]

The essence of the social role unconsciously (and, recently, ambivalently) given to physicians is crucial in sustaining the denial that is so basic to Western civilization — denial, that is, of death and of the suffering and chaos that are a normal part of life. It is fine for a parent to serve, transitionally, as a powerful and perfect object and, likewise, for physicians to be sensitive to the psychological regression that is a normal part of illness. However, there is nothing healthy for either patients or physicians in holding on to the illusion that the physician always carries boundless resources, certainty and strength. In any other relationship this would be viewed as dysfunctional.

André Piver, MD
Nelson, BC

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[Contents]

One of the compelling reasons for a Charter for Physicians, as articulated by Dan MacCarthy [full article],¹ is that physicians, and for that matter patients, need protection from intrusive government policies that ignore advice from physicians and others in the underfunded health care system. I am affronted that Nuala Kenny and her colleagues describe the charter as "morally indefensible" [full article]² while failing to acknowledge a very serious conflict of interest: Kenny does not acknowledge being Deputy Minister of Health of Nova Scotia.

Derryck H. Smith, MD
Vancouver, BC

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1. MacCarthy D. Why physicians need a charter. CMAJ 1999;161(4):400-1.
2. Kenny N, Weijer C, Baylis F. Voting ourselves rights: a critique of the Canadian Medical Association Charter for Physicians. CMAJ 1999;161(4):399-400.

[Contents]

When Nuala Kenny wrote the article with her colleagues she was a Professor of Pediatrics and Director of the Office of Bioethics Education and Research at Dalhousie University, Halifax. When the article in question was in press, Kenny accepted a temporary appointment as Acting Deputy Minister of Health in Nova Scotia. This was a short-term secondment from the university. She has now returned full-time to her academic positions.

John Hoey, MD

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[Contents]

In Table 1 of a recent article by Colleen J. Maxwell and colleagues,¹ the drug group name for the second row of data was missing: it should be ß-blocker.

The online version is correct.

1. Maxwell CJ, Hogan DB, Ebly EM. Calcium-channel blockers and cognitive function in elderly people: results from the Canadian Study of Health and Aging. CMAJ 1999;161(5):501-6.

© 1999 Canadian Medical Association or its licensors