The Impact and Responsibilities Inherent in a Signature

Transcription

SPÉCIALISTE
10
LE
THE FMSQ MAGAZINE
Vol. 10 no. 4– December 2008
Sogemec
Assurances,
en constante
évolution
voir texte p. 39
LE
SPÉCIALISTE
MAGAZINE DE LA FÉDÉRATION DES MÉDECINS SPÉCIALISTES DU QUÉBEC
EDITORIAL COMMITTEE
Dr. Bernard Bissonnette
Dr. Maurice Boudreault
Dr. Daniel Doyle
Me Sylvain Bellavance
Nicole Pelletier, APR, Delegated Publisher
Patricia Kéroack, Communication Consultant
and Responsible for publications
REVISION
Angèle L’Heureux
GRAPHIC DESIGNER
Dominic Armand
TRANSLATION
Anne Trindall
PRINTING
Impart Litho
PUBLICITY
France Cadieux
Tél. : 514 350-5274 ou 1 800 561-0703
Téléc. : 514 350-5175
[email protected]
CIRCULATION
12 000 copies
PUBLICATIONS MAIL
Mailing Indicia 40063082
LEGAL DEPOSIT
4th quarter 2008
Bibliothèque nationale du Québec
ISSN 1206-2081
Le Spécialiste is published 4 times per year by the Fédération des
médecins spécialistes du Québec :
2, Complexe Desjardins, porte 3000, C.P. 216, succ. Desjardins,
Montréal (Québec) H5B 1G8
Tel.: 514-350-5000
Fax: 514-350-5175
Internet: www.fmsq.org
E-Mail: [email protected]
Summary
7
Word from the President
8
In the News
14
In the News
18
Did You Know That ...
19
Economy, Politics and Negotiations
Visit of Operating Rooms:
An Unprecedented Operation
Sharing Psychiatric Care: A Pilot Project
Le Spécialiste: 10 Full Years! (Final Chapter)
Did You Know…
23
Legal Affairs
25
Great Names in Quebec Medicine
27
Continuing Professional Development
GST and QST
The When and Where
Dr. Michel G. Bergeron
CPD is a Continuing Proposition
28
DOSSIER
37
Groupe Fonds des professionnels
38
Sogemec Assurances
Medical Expertise: The Impact and
Responsibilities Inherent in a Signature
All pharmaceutical product advertisement's have been approved
by the Pharmaceutical Advertising Advisory Board (PAAB).
The Fédération des médecins spécialistes du Québec represents
the following specialties: Allergy and Clinical Immunology,
Anesthesiology, Cardiac Surgery, Cardiology, Community Health,
Dermatology, Diagnostic Radiology, Emergency Medicine,
Endocrinology, Gastroenterology, General Surgery, Geriatrics,
Hematology and Medical Oncology, Internal Medicine, Medical
Biochemistry, Medical Genetics, Medical Microbiology and
Infectious Diseases, Nephrology, Neurology, Neurology, Nuclear
Medicine, Obstetrics and Gynecology, Ophthalmology,
Orthopedics, Otorhinolaryngology, Pathology, Pediatrics, Physiatry,
Plastic Surgery, Pneumology, Psychiatry, Radiation Oncology,
Rheumatology and Urology.
CCAB audits the medical specialists and residents database
(10,105 copies audited for June 2008) The FMSQ also distributes
around 1,000 copies to Researchers and Professors of the 4 Medical
Faculties in Quebec, as well as managers and leaders of the Québec
healthcare system.
40
Members Services
41
Mot du président
Commercial Benefits
Économie, politique et négociation
This Edition’s advertisers:
The authors of signed articles are sole responsible for
the opinions expressed therein.
Cover Page Information
Artist Manon Otis produced for the FMSQ on demand, the
painting Congrès… des spécialistes which figures in part in
the bottom of the page.
• Bell
• Club Voyages Berri
• Groupe Fonds des professionnels
• IMS Health Canada
• Ipso Facto
• La Personnelle
• RBC - Banque Royale
• Sogemec Assurances
• Solutions Cliniques
• Valeant Canada
L E S P É C I A L I S T E · V O L . 1 0 no 4 · D e c e m b e r 2 0 0 8
5
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Un produit de
WORD FROM THE PRESIDENT
Dr. GAÉTAN BARRETTE
Economy, Politics and Negotiations
ike it or not, the economy is the subject dominating
people’s lives at the moment and it is reasonable to
think that this situation will continue for the next 12 to
18 months, perhaps even slightly longer. If we add to
this all the elections we have just gone through in
North America, we may well believe that there is a
sense of transition, shifting and changing cycles in the very air
we breathe. With the CHUM saga now ending, the fee measures
taken (the fees themselves, teaching, research) finally put into
effect, and various current matters being dealt with, we must
immediately turn our attention to new subjects – in a totally
different context.
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made alliances in preparation for the 2010 negotiations. The
idea of bringing everything together in 2010 is not random; it is
a plan. Evidence of this is the fact that the Association des pharmaciens des établissements de santé du Québec, which began
to apply pressure, has just been presented with a temporary
financial agreement that ends in… 2010! Everyone is together:
that has to be a first for Quebec. But it’s not a first in British
Columbia, where similar situations have been dealt with by
means of a special “mega-law” on no less than three occasions.
The plan is clear.
I invite you to pause and take stock of the road we EVERYONE IS IN THE SAME BOAT: ALL PUBLIC SECTOR
have travelled. There is no doubt about the seriousCOLLECTIVE AGREEMENTS EXPIRE IN 2010,
ness of the present economic situation. However, it
serves to amplify the importance of having taken certain INCLUDING THE AGREEMENTS WITH THE MEDICAL FEDERATIONS
measures in 2006, in addition to those we may have
to take in 2010. There is the importance of the opportune timing
However that may be, the present economic situation is an
of our latest negotiations: opportune because nobody sees the
interesting one. First of all, the recession will be finished in 2010
future at the moment action is taken. Imagine where we would
with an upturn starting, regardless of its strength. But above all,
be now if we had given way in 2006? It would be horrific! But
matters will have changed at that point because our neighbour,
let’s amuse ourselves a little. Yes, we have made significant
Ontario, will have joined our camp – i.e. they will be receiving
gains, but we did not envisage the extraordinary impact our
equalization payments. The never-ending argument about
position would have later on. We knew, and said at the time,
“Quebec’s collective wealth (poverty)” will then cease. But the
that the full value of our agreement lay in the fact it was spread
Ontario government is not half-witted and it no doubt sees the
same economic forecasts as economists, yet it has just awarded
over time. It was an enormous concession (unbelievable, in fact!)
and we made it to ensure maximum gains on our part. We had
12.25% in fee increases, together with a whole range of
measures worth hundreds of millions of dollars. This may also
no concept of the situation as it is today. Without having planned
be the case in the Maritime provinces. So?!? At the same time,
it, we have helped the Quebec government and population.
everyone is undertaking to maintain an annual increase in health
That’s right! Remember that at the beginning of the election
funding of at least 5%. So, we have to prepare ourselves, and
campaign, it was announced that Quebec would be deficit-free
that is what we are doing, because there is absolutely no
in 2009 and 2010. On November 4 this year, Mrs. Jérôme-Forget
question of us starting to fall below the Canadian average once
spoke of a slight surplus for the 2007-2008 budget ($484 million),
again. Be prepared!
but a surplus nonetheless. Even the OECD thinks Quebec would
be in a recession for only three months at the end of 2008, and
a slight upturn as early as the first quarter of 2009.
Reduction in membership fees – “Welcome baby”
The FMSQ and FMOQ agreements together represent an overall
increase of nearly $2 billion which, if they had not been spread
out over time, would have created a significant deficit this year.
This is an undeniable fact and deserves special mention. Even
though Quebec society has not thanked us, in an ideal world it
would be known as a political debt.
Finally, economy oblige, in addition to finalizing current matters,
it is time to begin preparing for our next round of negotiations.
The situation is simple. Everyone is in the same boat: all public
sector collective agreements expire in 2010, including the agreements with the medical federations, and union leaders have
But, let us end the year on a positive note. Dr. Josée Parent has
called us to order in an elegant and fitting manner. The Board of
Directors has unanimously decided to bid a welcome to medical
specialists’ babies. Parents will thus be able to take advantage of a
reduction in membership fees in the year of the baby’s birth. This
new measure entails a refund of 50% for mothers and 20% for
fathers. All that is needed is the birth or adoption certificate, and the
FMSQ will make the refund at the start of the next year. And, since
one piece of good news deserves another, this change is effective
as of January 1, 2008.
S
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7
IN THE NEWS
Dr. MICHÈLE DROUIN
DIRECTOR, ANALYSIS AND FEE PLANNING
Visit of Operating Rooms
An Unprecedented Operation
Since January 2008, a tactical team – affectionately called the
SWAT Team – has been visiting operating rooms (OR) in a number
of Quebec regions. Following is a reminder of the context, the
mandate and a report on the first six months’ activity.
ou will recall that the last agreement between the
government and medical specialists included a
“Business Relations” section. These are the 24
measures provided for in the plan to improve
access, medical specialists’ conditions of practice
and the organization of services. The first two
measures have a direct effect
Y
1. Improved patient access to operating rooms and the technical
support centre through the optimal use of equipment.
2. Introduction of incentives with regard to the practice of anesthesiology.
It was under these circumstances that the FMSQ put forward
the idea of a SWAT Team charged with visiting various operating
rooms in order to assess if any room for manoeuvre was
available, identify existing curbs to increased productivity, and
find concrete ways to achieve such an increase. In January
2008, the task force was officially formed and gave rise to a joint
FMSQ/MSSS committee on improving the functioning of
operating rooms. This is the committee that has systematically
been visiting operating rooms in all regions of Quebec since
February 20.
Composition of the committee
Translator’s note: For this
text, we have translated bloc
opératoire in operating room
as it seems to be the most
common term used in
Quebec. The terms operating
suite, surgical suite and
operating theatre are also used
by certain hospitals.
Mandate
The joint committee’s mandate is to suggest short-term solutions
related to the conditions and specific nature of each centre, in
order to increase the number of surgeries performed in the next
year. The suggestions are made following an initial analysis of
operational data and a one-day visit to each establishment
(whether they are specific problems or not).
OBJECTIVE
Through concrete action with the establishments and the physicians working in the operating room, increase production by
5% per year, with immediate effect.
THE FEDERATION BELIEVED THAT THE OBJECTIVE OF 5%
WAS A REALISTIC PRESUMPTION THAT COULD QUICKLY
BECOME REALITY. IT REPRESENTS NEARLY 20,000
ADDITIONAL SURGERIES OVERALL OR, BASICALLY, THE
TOTAL NUMBER OF SURGERIES THAT HAVE NOW
EXCEEDED THE WAITING PERIOD!
In order for the project to be successful, the parties undertook
as follows:
The joint committee is composed of a delegation from the FMSQ:
• Representing the FMSQ: Dr. Gaétan Barrette, President,
Dr. Michel Lallier, Vice President and Dr. Michèle Drouin,
Director of Analysis and Fee Planning
• The President of the Association des anesthésiologistes du
Québec, Dr Pierre Fiset, then Dr. Claude Trépanier (or his
representative)
• The President of the Association québécoise de chirurgie,
Dr. Roger Grégoire (or his representative)
• The President of the Association d’orthopédie du Québec,
Dr. Jacques Desnoyers (or his representative)
The MSSS, Health and Social Service Agencies (Agences de
santé et de services sociaux) and the Ordre des infirmières et
infirmiers du Québec are also represented on this joint committee.
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• The MSSS recognized the importance of the operation, in the
context of a first joint action following the Agreement between
the parties. It undertook to implement the solutions put forward
by the committee, whether related to problems with human
resources, equipment and small instruments, staffing plans,
etc. It was to agree with the health agencies concerned on
performance agreements and measures to follow-up the
recommendations.
• The FMSQ undertook to take the appropriate measures with
regard to solutions that had a direct impact on the practice
of the medical specialists working in the operating room.
• The agencies were required to support the establishments
and be responsible for the plan of action and following-up the
recommendations.
• The establishments visited were required to mobilize their
teams and implement the recommendations made.
Methodology and choice of establishments
visited
The method selected and used by the joint committee for all
these visits is unique in many ways. It is basically a “field”
approach. We do not carry out a performance analysis studying
recognized indicators, as consulting firms in the system often
do. We do not compare the various operating rooms visited, nor
carry out benchmarking studies using comparable establishments. We do not analyze administrative or operational support
elements in the rooms, such as budgeting, administrative
management, performance follow-up or supply logistics.
This calls for a two-pronged approach: 1) A preliminary analysis
of certain key operational data and documents; 2) On-site visits
and meetings with those working in the OR.
First of all, the MSSS asked for the cooperation of the 18 health
agencies in drawing up a list of the hospitals to be visited. The
CEO of the health agency concerned and the Director of Medical
Affairs (DGAMU) accompanies the committee for the full day.
When a choice is made, the committee takes into consideration various specific factors, such as a significant surgical volume,
the importance of specific missions or vocations (university,
regional and supraregional, traumatology, pediatrics…), establishments in difficulty, etc.
From February to June 2008, the joint committee carried out
16 visits in 18 weeks, and a further 4 visits have been added to
this number since activities resumed in September.
• 9 hospitals were visited in the Greater Montreal area: Hôpital
Maisonneuve-Rosemont, MUHC (Montreal General Hospital),
CHUM (Hôpital Notre-Dame), Hôpital Sacré-Cœur, Hôpital
Sainte Justine, Montreal Children’s Hospital, Hôpital Charles
LeMoyne, CSSS Pierre-Boucher and CSSS de Laval;
Our approach is pragmatic and focused on work organization.
We review processes and operations from a clinical and medical
standpoint, with a view to looking for short-term improvement
in efficiency, maintaining recognized standards and seeking
better practices.
Preparation for visits
The working subcommittee has developed tools to support the
analysis and structure the visits – i.e. the necessary documentation and an analysis sheet setting out the criteria, to
subsequently be given to the establishment visited.
Before the visit, each establishment receives an explanatory letter about the project, signed by both the MSSS and
the Federation, together with:
1. A summary document to be completed and returned to
us, containing the most important information to be
compiled:
- A description of the physical facilities, including the OR,
recovery room, short-stay unit.
- Surgical volumes, waiting lists
- Opening and working hours, duty roster, slow periods
- Medical staffing plans and overall professional and support
resources
- Cancellations, postponements and schedule overruns
- Certain data concerning services provided before and after
surgery, such as intensive and intermediate care beds, preadmission, prebooking
- etc.
2. A list of documents to be sent to the committee prior to
the visit:
- Operating room regulations and minutes of the latest meetings
- Descriptions of operating room coordinators’ duties
- Operating schedules for a given week in the year
- Attribution and revision process regarding operating priorities;
- Short statement of problems with the OR
- etc.
3. The timetable planned for the day and the list of people
the committee must meet.
• 4 hospitals were visited in the Greater Quebec City region:
CHAUQ (Hôpital Enfant-Jésus), Hôtel-Dieu de Lévis, CHUQ
(Hôpital Saint-François d’Assise) and CHUQ (Hôtel-Dieu de
Québec);
• 1 hospital was visited in the Greater Estrie region: CHUS
(pavillon Fleurimont);
• Lastly, 6 regional hospitals were visited: CH régional de TroisRivières, CSSS Gatineau (Hôpital de Gatineau), CSSS
Gatineau (Hôpital de Hull), CSSS Rimouski-Neigette, CSSS
de Chicoutimi and CSSS de St-Jérôme.
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Visit schedule
The timetable is designed to allow us to meet people on the
ground first, then climb the administrative ladder and end the
day with general management. In this sense, our bottom-up
approach is unique. We are able to not only identify actual
problems experienced by operating room staff and rapidly
acquire an intimate knowledge of the milieu, but also in some
cases transmit information to the establishment’s management.
The visit is timed to the minute, and systematically follows
the same schedule for all establishments.
At the end of the day, once the verification, visits and validations
is completed, a verbal report on the overall findings and recommendations is made to all those involved with the operating
room and to management. The verbal report is then to be written
up and becomes the official report on the visit.
Written report and follow-up of
recommendations
Some time after the visit (generally 1 to 2 months), a written report
is sent to top management of each of the establishments visited.
Reports have roughly12 pages and summarize the observations
made during the visit and the various meetings, defining any room
for manoeuvre found for each operating room (in percentages and
volume of surgery) ties in to waiting lists (official information from
Med-Echo, GESTRED and SIMASS data bases), and restates the
overall recommendations made by the committee during its visit
to the establishment. The joint MSSS-FMSQ letter sent to the DG
of each establishment visited states that the MSSS and
Federation requests that the general administration forward the
report to everyone met by the joint committee.
06:45
Arrival at the establishment
7:00 to 8:30
Visit OR, short-stay unit, recovery room,
minor OR
8:30 to 9:00
Debriefing
9:00 to 9:30
Meeting with Asst. Head Nurse
9:30 to 10:00
Meeting with OR coordinator
(adm. manager)
10:00 to 10:30
Meeting with Chief of Surgery
10:30 to 11:00
Meeting with Head of Anesthesiology
Department
11:00 to 11:30
Meeting with OR committee
11:30 to 12:00
Debriefing
12:00 to 13:30
Meeting with all surgery and gynecology
heads
13:30 to 14:00
Meeting with DPS, DNS and CPDP Chair
14:00 to 15:00
Committee work session
The document is sent to the establishment. It is also filed with
the agency concerned, which is responsible for a complete
follow-up. To do this, the agency has to draw up a plan of action
containing a follow-up sheet covering all the committee’s recommendations, along with a flow-chart. Each agency’s plan of action
is submitted to the MSSS for review during one of the joint
committee’s working sessions. This measure ensures that the
plan of action actually contains all the recommendations made.
15:00 to 16:00
Presentation of verbal report to administrative and medical authorities (DG, DPS, DNS,
CPDP, Department Heads (Surgery,
Anesthesiology, OB/GYN) and OR managers
After 6 months: general findings and
suggested measures
The committee clearly identified room for manoeuvre for each
operating room visited that would allow it to increase productivity. Without drawing up an exhaustive list of all the problems
encountered, following are a number of general findings:
Our committee’s mandate is always repeated to each of the
people met throughout the day (we are not mandated to rebuild
operating rooms … even if there are cases where this is sorely
needed!) and the same question is reviewed according to each
person’s perspective: “Can surgery be increased by 1 case per
day and, if so, how?”
At the end of the visit, the committee fills out the analysis sheet
and agrees on the overall recommendations made, whether
they concern human resources (additional staff, changes, etc.),
equipment and small instruments (prioritization and purchase
from additional budgets) or the medico-administrative management of the OR and surgical activities.
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• The committee noted the outmoded nature of the facilities, with
10% of rooms closed or used for storage
• The lack of small instruments, requiring postponement of
surgery or, alternatively, flash sterilization
• The lack of coordination of support personnel, resulting in
delays between cases
• Outdated laparoscopic equipment
• Lack of bed heads in recovery rooms;
• Shortage of nursing personnel and inhalation therapists
• The reluctance in certain cases to incorporate nursing assistants into OR teams, despite this shortage
• The scarcity of lead surgical nursing assistants
• End-of-day problems … cases are frequently cancelled
because it is feared they might run over the time allowed.
Such problems are linked to the shortage of resources and
to medical specialists’ method of remuneration
• Prior to surgery, the under-utilization of prebooking and preadmission
Given the volume of these establishments, that can be said to
represent more than 18,000 additional surgeries (10,000 day
surgeries) that can be added to these establishments, for a
decrease of nearly 40% in their overall waiting lists for surgery.
We are far beyond the initial objectives that called for an increase
of 20,000 additional surgeries for all hospitals in Quebec.
In the light of these data, Dr. Barrette informed the media last
May that it was possible to improve the cost effectiveness and
efficiency of operating rooms and achieve 50,000 additional
surgeries per year.
Next steps
Although most establishments and agencies provided remarkable cooperation, we nonetheless decided to carry out a
systematic follow-up of our visits.
• After surgery, the frequent absence of intermediate surgical
care and the lack of intensive care beds
• The lack of management tools: archaic information systems,
which were impossible to understand or frankly incomplete
• Changes in the practice of anesthesiology that have an impact
on the operating room, particularly because of the development of activities outside the OR.
It is obvious that some of these elements went beyond the joint
committee’s current mandate. However, our visit and findings
can be used as a lever in establishments with regard to the
agencies for the development of a functional technical plan, for
example, or the prioritization of certain types of equipment with
regard to the agency. The problem of productivity and program
completion has already been identified and the Federation has
responded with a thorough review of anesthesiology fees
(effective October 1, 2008).
In concrete terms, our recommendations for the first 16 operating
rooms visited have resulted in:
• A one-time overall sum from the MSSS of $3,900,000 for the
purchase of instruments and equipment
• The addition of 3 additional anesthesiologist positions to the
PEM/PREM
• A recurring amount of nearly $4,000,000 to be used to make
vacancies into permanent positions and create new positions
for patient aides, assistants, nurses, inhalation therapists and
lead surgical nursing assistants.
A general telephone evaluation of the establishments visited
was first carried out by the MSSS, and showed that more than
70% of the recommendations had already been introduced or
were in the course of being introduced. As mentioned previously,
a complete plan of action was to be drawn up by the agencies
for each hospital. The individual plans must be presented to the
joint committee between now and December. It is possible that
we may have to contact hospitals where specific problems
persist, or even pay them a second visit.
Then, between now and the end of the year, the committee will
draw up a final report on the activities carried out and give its
opinion on continuing the operation. It is already obvious that we
cannot visit all operating rooms in Quebec given the size of the
team required for each visit. Other means are already envisaged
so that we can contact establishments that we will be unable to
visit. In addition, the committee will make its analysis sheet and
evaluation criteria available to the entire network so that the
establishments can, at the very least, carry out a self-assessment and have the tools required to be able to submit their
demands for the upgrading of their resources and equipment.
Lastly, the Federation is drawing up a very positive report on this
first “operation” carried out as part of Business Relations. It
should be remembered that operating rooms are at the centre
of surgeons’ and anesthesiologists’ clinical activities, and these
specialists account for nearly 20% of our members. The SWAT
Team’s action not only permits an improvement in these medical
specialists’ conditions of practice, but also has a significant
impact with regard to the overall availability of surgical services,
patient access and shorter waiting lists.
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WE FOUND SIGNIFICANT ROOM FOR MANOEUVRE
IN THE FIRST 16 OPERATING ROOMS VISITED,
WITH A PERCENTAGE INCREASE IN THE NUMBER
OF SURGERIES RANGING FROM 5 TO 20%.
11
IN THE NEWS
BRIAN G. BEXTON M.D., PRESIDENT MARIE
ASSOCIATION DES MÉDECINS PSYCHIATRES DU QUÉBEC
A. PLANTE, M.D., SECRETARY
Sharing Psychiatric Care: A Pilot Project
The FMSQ’s Committee on Conditions of Practice is working with the Association des
médecins psychiatres du Québec (AMPQ) to define the conditions of practice that will enable
us to cooperate with the MSSS in introducing the “Mental Health Action Plan”. Following is a
brief view of the AMPQ’S pilot project, which will be introduced in the coming months.
Santé Québec enquiry estimated the prevalence of
mental disorders in the Quebec population at
19.5%. Psychiatrists focus their energy and
expertise on treating those whose condition is
worst; the prevalence of such patients is estimated
at more than 7% of the population. General practitioners treat most “first-line” patients who suffer from
depression, anxiety and other disorders, and such people
represent more than 20% of the practioners’ patient population.
A
is to improve not only access, but also the quality of the firstand second-line services available, and ensure that both physicians’ and professionals’ conditions of practice are appropriate
for the purpose.
The PASM described the first-line system with standards for
caregivers and services, and defined the department of psychiatry’s support role regarding the mental health team and general
practitioners. The AMPQ proposed the addition of professionals
in the psychiatric emergency department and the psychiatric
outpatient clinic to compensate for the time psychiatrists devote
to this first-line support.
In 2005, when overworked psychiatrists were calling for professional teams to support them and provide quality service to
psychiatric patients, the government gave priority to developing
first-line mental health care and a multilevel care system
with a single access point, reassigning psychiatric
resources to first-line care in CSSS’s. This is known as
THE AMPQ PROPOSED THE ADDITION OF
the Mental Health Action Plan (Plan d’action en santé
PROFESSIONALS IN THE PSYCHIATRIC EMERGENCY
mentale – PASM). The development of first-line multiDEPARTMENT AND THE PSYCHIATRIC OUTPATIENT
disciplinary teams is essential and will help support the
work of general practitioners, but this cannot be done
CLINIC TO COMPENSATE FOR THE TIME
if it is to the detriment of psychiatric patients. In addition,
PSYCHIATRISTS DEVOTE TO THIS FIRST-LINE SUPPORT.
transferring 20% of a psychiatrist’s time to first-line duties
as a psychiatrist-responder, as provided for in the PASM,
appears unrealistic when everyone is overloaded.
That is why the FMSQ has joined with the AMPQ in suggesting
a pilot project to the MSSS which is designed to meet patients’
first or second-line needs, support family physicians and provide
conditions of practice acceptable to psychiatrists so that they
continue to provide second- and third-line services, as well as
support services to first-line physicians and professional teams.
This pragmatic view will take the form of a pilot project that will
be adjusted as necessary during its implementation, and also
to circumstances in the various regions. Simultaneous projects
will be tried out in the four types of region (university, peripheral,
intermediate and outlying) based on the type of patient: pediatric,
adult and geriatric.
First- and second-line services will be available from in four
places: family physicians’ offices and CSSS mental health teams,
outpatient psychiatric clinics and emergency psychiatric
services. Given the conditions to cooperate, professionals and
physicians in these four areas can share mental health care and
provide mutual support in order to offer better service. The goal
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With regard to psychiatric emergencies, the presence of a
liaison nurse-clinician who carries out patients’ initial assessments, communicates with first-line caregivers and physicians,
and who can prescribe tests (medication assays, intoxication)
and consultations (social services and drug addiction) frees the
psychiatrist from duties that he must perform if he is alone in
the emergency room. Likewise, the presence of a social worker
is essential, because many patients have social difficulties that
contribute to their crisis and will need a crisis centre or shelter;
and the family situation must be explored in pediatric and
geriatric psychiatric emergencies. Social workers can thus carry
out an assessment and provide a fuller response, freeing the
psychiatrist. As far as drug and alcohol problems are concerned,
these are so important that an initial pilot project on the availability of drug addiction caregivers at the CHUL emergency
room is already being copied elsewhere in Quebec. This person
must be available and, depending on the size of the clientele,
may work full-time or divide his time between psychiatric
emergency and first-line psychosocial crisis services.
the MEL for the three types of patient, the FMOQ will ensure
In lower-volume psychiatric emergency rooms, the number of
the presence of a general practitioner in the first-line mental
caregivers that are added and their coverage will vary in order
health team for 10 hours a week and will encourage patient
to maximize efficiency, but the principle of providing the most
follow-up by family physicians.
relevant service by the best qualified professional, thus releasing
the psychiatrist from duties related to his field of expertise, still
Lastly, a telepsychiatry service will be tried out between outlying
remains. Liaison with psychosocial crisis services will be
and university regions.
maximized and the goal, over time, will be to refer some of those
patients who come to psychiatric emergency because
there are no other 24/7 crisis services. In the same way,
THIS PROJECT SHOULD, OF COURSE, BE PRECEDED
liaison with first-line caregivers will allow a better continuity of services and the setting-up of a safety net when
AND ACCOMPANIED BY AN INFORMATION
there is a risk but no immediate danger of suicide.
CAMPAIGN BECAUSE IT REVOLUTIONIZES THE
MANNER IN WHICH SERVICES ARE PROVIDED
In an outpatient clinic, the objective is to offer two
types of service: a consultation service, known as the
evaluation-liaison module (module d’évaluation-liaison – MEL),
i.e. an evaluation visit plus management recommendations and
a return to the care of the family physician and the first-line
mental health team and, secondly, a specialized treatment
service during the acute phase for patients with complex
problems. Therefore, even for these patients, contact with firstline caregivers will be maintained during the second-line care
episode. Two professionals are required to provide these
services: a nurse-clinician, who carries out the pre-evaluation,
liaises with first-line caregivers both for the MEL and the secondline consult, and a psychologist who contributes to the evaluation
and takes over the psychotherapeutic aspect of the treatment,
particularly in child psychiatry. Working with a team and delegating part of the evaluation work and management allows the
psychiatrist to perform a greater number of evaluations and the
direct/indirect follow-up of a larger number of patients. In
addition, care sharing enables patients to move from first- to
second-line, thus preventing a build-up in psychiatry. Should
decompensation occur, the psychiatrist takes over and, once
the patient has improved, he is returned to the care of his family
physician. In this way, part of psychiatrists’ time is freed so that
they can provide support to general practitioners and first-line
mental health teams.
EIn accordance with PASM recommendations that a psychiatrist-responder be involved with the CSSS mental health team
to discuss clinical cases and help develop the team’s competence, the AMPQ proposes that psychiatry departments provide
one half-day a week of psychiatric time to each mental health
team dealing with adults or young people in order to cover the
95 CSSS in Quebec.
The PASM also provided that general practitioners should
receive support from the psychiatrist-responder. After discussions with the FMOQ, we agreed on the need for a telephone
consultation service to help general practitioners encountering
complex situations with their patient in the office. To meet this
need, telephone consultation coverage will be introduced from
9 a.m. to 9 p.m. on weekdays. In exchange for this service and
This pilot project will be accompanied by a training program for
physicians and professional teams, offered by the relevant
authorities, and will be rounded out by evaluative research on
the organizational and clinical results, as well as service modalities and the ratio of resources.
This project should, of course, be preceded and accompanied
by an information campaign because it revolutionizes the
manner in which services are provided by introducing a multilevel system with an access point and a team response to a
request for consultation, which is traditionally made by one
physician to another.
Psychiatrists, just like general practitioners and pediatricians, and
even the general public, will undergo culture shock when faced
with such changes. Success will imply attractive conditions of
practice and the benefits will induce everyone to adopt this
system of sharing mental and psychiatric care.
The AMPQ has called its project “A proposed pilot project for
the implementation of a service organization model based on care
sharing and psychiatric-responders” (Proposition d’un projet
pilote pour l’implantation d’un modèle d’organisation des services
basé sur les soins partagés et sur la fonction de répondant en
psychiatrie). The proposal is a compromise between psychiatrists’ expectations and MSSS policies, and augurs well for the
future. It is not the final point in the organization of mental health
and psychiatric services, but it is the starting point of a cooperative effort to keep services provided to the public dynamic and
up to date. If it is necessary to combat social prejudice about
psychiatric patients and recognize their mental as well as physical
health needs, it seems equally necessary to destigmatize psychiatry and respect its teams, services and expertise, as is expected
for all medical specialties.
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IN THE NEWS
regional health agencies in Quebec failed to have the expected
results. “It came down to creating a new level, one more intermediary with its attendant costs and …. really no service in return. If
money is available, everything is fine but, if not, these agencies
manage shortages without any glimmer of transparency. It is a
case of divide and conquer ….”
Ontario Upgrades Physicians’ Salaries
As part of an agreement between the
Salaries will be adjusted
Government of Ontario and the
as follows
Ontario Medical Association, the
October 1st, 2008
3%
25,000 physicians in that province
st
October 1 , 2009
2%
will see their salaries increase by
October 1st, 2010
3%
12.25% over four years. According
September 1st, 2011 4.25%
to the Premier, Dalton McGuinty, this
increase was necessary “to attract
and keep physicians in Ontario”.
Source : Agence de presse Destination Santé : http://www.destinationsante.com/fr_depeche.php ?id_rubrique=274&id_article=26001&cat=1 (In
French)
Le Spécialiste Survey: Many Thanks!
Nearly 500 medical specialists answered
the satisfaction survey e-mailed on
October 3. Based on the results, 94% of
respondents read Le Spécialiste and
96% of them said they were very
satisfied with the new format.
The agreement also provides that $240M will be allocated to the
financing of new programs, together with $100M for one-time
incentive bonuses.
Health Reform in France: Dr. Barrette criticizes
the creation of regional agencies
We were delighted by your appreciation
of the exciting new design on which we
spent so much energy, and would like to
thank you. Please continue sending us
your comments and suggestions. Le Spécialiste is intended to
mirror specialized medicine in Quebec.
The Confédération des syndicats médicaux français (CSMF) invited
Dr. Gaétan Barrette to speak at the XIVe Université d’été held in
Cannes last September. His subject was the problems caused by
the creation of regional health agencies in Quebec. His speech
was eagerly awaited and was given before more than 300
delegates, including Roselyne Bachelot, the French Minister of
Health, who has been responsible for the wide-ranging reform
undertaken since 1998. Dr. Barrette explained why the creation of
Did You Know That …
Le Spécialiste: 10 Full Years! (Final Chapter)
For this final glance back at events discussed in the first
issues of Le Spécialiste, we wanted to see what was
happening in a field where innovation and scientific
progress are a given: in other words, Medical Genetics.
Quebec is a longtime world leader in the field of genetics. As far
back as the early 1970’s, the creation of the
Réseau de médecine génétique became a
model for the organization of genetic
services. At that time, sequencing of the
human genome, anticipated for 2005, gave
rise to the expectation of significant
improvements in clinical functioning, both
with regard to diagnosis and management.
Then, 10 years ago, this medical specialty
flagged somewhat. The shortage and
aging of geneticists posed definite
problems. Quebec only had 16 medical
geneticists and it was considered that
the specialty required a further 37 to
make up the shortfall.
So, where are we today? According to
Dr. Régen Drouin, Past President of the Association des
médecins généticiens du Québec (AMGQ), “We need 48 full-time
geneticists, but we only have 24 in active practice and 9 of them
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are over 60 years of age. Our average age is very high1 and our
medical specialty is one of the least well paid.” The new President
of the AMGQ, Dr. Emmanuelle Lemyre, strikes a more reassuring
note, saying “two or three geneticists are trained every year,
which is a start. New genetic training programs may help
somewhat. But our underfunding and significant shortage of staff
remain a problem.”
Both physicians agree that the science of genetics has made giant
strides. The genome has been fully sequenced, two years before
the anticipated date. Technology has also advanced, particularly
in the area of pharmacogenomics and with the advent of
microchips. But the financial resources necessary are not there.
“In many cases, we have to carry out or use tests that come from
outside Quebec. The government finds that they are too
expensive; they do not understand why such tests are necessary,”
commented Dr. Drouin.
According to the two specialists interviewed, there is a dichotomy
between research and application. Quebec dominates the sector
of genetic research, but it still does not have simple tools such
as the universal prenatal screening programs that can be found
elsewhere. Dr. Drouin adds that, today, “patients are better
informed. They check the Internet, hear genetics discussed and
their expectations run very high”.
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As of November 21, the average age of medical geneticists was 55.33
years versus 50.46 for members of the FMSQ.
DID YOU KNOW...
Dr. Marcel Lebel receives the
Founder’s Award for 2008
Prizes and Awards
Order of Canada
The Governor General, the Right Honourable Michaëlle Jean,
awarded honours to several noteworthy Canadians. Two medical
specialists from Quebec who are deeply engaged in their communities received the Order of Canada.
Yvette Bonny, C.M., C.Q.
© Office of the Secretary to the Governor General
of Canada 2008
Photo : Cplc Jean-François Néron, Rideau Hall
Reproduced with the permission of the Office of
the Secretary to the Governor General
Dr. Bonny, a pediatrician-hematologist, was made a Member of the
Order of Canada for her model
contribution to the Haitian
community and young black
women in Quebec, and the
devotion she has shown in the
service of children.
Margaret Becklake, C.M.
© Office of the Secretary to the Governor General
of Canada 2008
Photo : Cplc Jean-François Néron, Rideau Hall
Reproduced with the permission of the Office of
the Secretary to the Governor General
Margaret Becklake, a pneumology
specialist originally from South
Africa, was made a Member of
the Order of Canada for her
pioneering work in respiratory
medicine and epidemiology, and
also for her research into the occupational and environmental
causes of pulmonary disease.
The Canadian Kidney Foundation
presented the Founder’s Award for 2008
to Dr. Marcel Lebel, a nephrologist recognized for his work in hypertension in
Quebec. Dr. Lebel, a clinical researcher at
the Centre hospitalier universitaire de
Québec (Hôtel-Dieu) for the last 35 years,
established the first hypertension and nephrology research laboratory at Quebec City.
Dr. Michael Kramer receives the Prix
Léo Pariseau
The Association francophone pour le savoir
(Acfas) awarded the Prix Léo-Pariseau to
Dr. Michael Kramer of MUHC to reward 30
years of research work concentrated mainly
on the development of children’s health.
Throughout his career, Dr. Kramer has
studied risk factors in pregnancy and the
impact of certain medical or private practices on the health of the
mother and infant.
Medical Research Excellence Gala 2008
On October 18, the Fondation du CHUS awarded a number of
prizes during a Gala to mark the excellence of medical research.
Two medical specialists were honored as recipients:
Dr. Marek Rola-Pleszczynski,
Immunologist-Allergologist
• Medical Research Prix d’excellence
Association des neurologues du Québec (ANQ)
rewarded
The Conseil québécois de
développement professionnel
continu des médecins awarded its Prix de l’innovation
pédagogique en développement professionnel continu
for Le rallye scientifique : un
jeu éducatif innovateur. This
innovative educational tool
was developed by Dr. Mario
Ducharme (co-author and
head of the ANQ’s Continuing Professional Development Office),
Mrs. Ginette Guilbault (co-author and director of the
Association), with Réjean Laprise, PhD (co-author and expert
consultant in evaluative research and CME, FMSQ Office for
Professional Development).
This prize was awarded to honor her contribution to the advancement of biomedical
science in the field of allergies and asthma.
Dr. Rola-Pleszczynski’s work focuses on
the development of more efficient diagnostic and treatment methods. A number
of her discoveries have contributed to the development of a new
class of drugs used to treat asthma.
Dr. Diego Bellabarba, Endocrinologist
• Prix Carrière
The Prix Carrière was awarded to Dr.
Bellabarba to mark his 40 years of
research, teaching and practice at CHUS.
The prize also underlines Dr. Bellabarba’s
wisdom, commitment and unflagging
loyalty to his patients and CHUS.
19
Mr. Louis Beaulieu, Director General,
Québec-Transplant and Dr. Jean
Tchervenkov, Laureate
Dr. Tchervenkov has actively supported the creation of the
position of organ and tissue donation resource person, whose
role is to intervene with the grieving family. Today, some 20
nurses working in 12 hospital centres in Quebec recruit organ
and tissue donors.
Dr. Claude R. Lemoine awarded the
Prix Letondal 2008
The Association of Pediatricians of Quebec
awarded the Prix Letondal to Dr. Claude R.
Lemoine to highlight his commitment to the
defense of children and his unremitting efforts
to improve first-line pediatric care in Quebec.
Dr. Lemoine has held the position of Head of
the Pediatric Service and Department at CHUS, followed by that
of Director of the University Pediatric Department of the Faculty of
Medicine at Sherbrooke University. He has also acted as Director,
Secretary, President and Past President of the Association of
Pediatricians of Quebec.
The prix Letondal, created in 1989, marks the exceptional contribution made by a pediatrician to the development of pediatric care
in Quebec.
Dr. Alain Lesage named
Champion 2008
The Canadian Alliance on
Mental Illness and Mental
Health named Dr. Alain
Lesage a Champion of
Mental Health for 2008, in
the research category. Dr.
Lesage is a researcher at
the Centre de recherche Fernand-Seguin, Hôpital Louis-H.
Lafontaine, and his work has contributed to the implementation
of evaluative and epidemiological approaches to the need for
care and services for people with mental health problems.
20
Crédit photo : Louise Leblanc
Dr. Jean Tchervenkov,
Quebec-Transplant
Grand Prix Laureate 2008
Quebec-Transplant, the
organization that coordinates organ donations
in Quebec, awarded
its Grand Prix 2008 to
Dr. Jean Tchervenkov, a
surgeon at McGill University Health Centre (MUHC)
in recognition of his leadership in advancing organ
donations in Quebec.
Dr. Georges Lévesque
receives the Prix PersillierLachapelle
Dr. Georges Lévesque, an oncologist at the CH régional de
Rimouski, received the Prix
Persillier-Lachapelle, one of the
prizes for excellence awarded by
the Health and Social Services
network in recognition of his outstanding career, which Dr.
Lévesque has devoted to improving the oncological care and
services available to the population of Est-du-Québec.
SCFR Honours its Peers
The Société canadienne-française de radiologie (SCFR)
awarded prizes to certain of its members at its 45th Annual
Congress, highlighting the exceptional contribution they
have made.
The Albert Jutras Prize was
presented to Dr. Jacques
Saltiel, a retired radiologist
of the Montreal Cardiology
Institute in recognition of his
outstanding hospital and
university career.
Dr. Jeffrey Chankowsky
was awarded the Bernadette
Nogrady Prize for his
remarkable contribution to
teaching, the quality of his
patient care and his research,
even though he has been in
practice for less than 11 years.
The Dr. Jean-A.-Vézina Prize
for Innovation and Excellence
was awarded to Dr. Gilles
Soulez radiologist and
researcher and Professor
Sylvain Martel, PhD. This
prize has been given by the
Fondation Jean A.-Vézina
since 2000, to recompense a person or organization for
noteworthy innovation and excellent results in radiology or a
related field.
Lastly, Dr. Nathalie
Duchesne, was honoured
by the ARQ/SCFR
Personality Prize. Dr.
Duchesne has distinguished
herself by creating the The
Breast Course, an event now
recognized internationally.
New publication
A better future starts with a good breakfast
Le cancer du sein, une approche multidisciplinaire, 8th edition, DVD-ROM. Under the
direction of Dr. Denis Couture, a radiologist,
this DVD on a multidisciplinary approach to
breast cancer is the result of 7 years’ work by
a multidisciplinary team of radiologists, pathologists, community health specialists and
others. It is designed for all physicians interested in or with a practice focusing on the care
of women. This expanded 8th edition has
undergone substantial revision (4Go). It now has 3,000 pages, 60
original plates, as well as decision-making algorithms, digital
imaging with the clinical presentation, mammography, ultrasound,
scintimammography, monophotonic emission tomography (SPECT),
PET scan, MRI and histology. For more information or to order the
DVD-ROM, please visit www.mammographieetcancerdusein.com
The Fédération des médecins spécialiste du Québec has donated
1,000$ to the Club des petits déjeuners du Québec. This took place
during the 9th annual Radiothon held at Montreal's Complexe
Desjardins on November 20. With the Holiday Season approching, a
time of year specially appreciated by youngsters, the FMSQ wanted
to give a helping hand for kids health.
Did You Know That …
Health Canada publishes the Canadian Adverse Reaction Newsletter
four times a year. This covers cases of adverse drug interactions.
In the most recent issue (October 2008), you can find information
on such matters as botulinum toxin type A, cesium chloride and
ventricular arrhythmia, as well as a case study on IgIV and posttransfusion acute respiratory syndrome. The newsletter is available
at www.santecanada.gc.ca/bcei.
Daniel Germain, President and founder of the charity organisation
along with FMSQ's vice-president, Dr. Michel Lallier.
Interdisciplinary Education Days
On November 7, more than 200
medical specialists took part in the
first Interdisciplinary Education Day
organized by the FMSQ’s Professional Development Office. It was
held at the Palais des Congrès in
Montreal. For this event, two medical
specialties – Psychiatry and Neurology – pooled different concepts
that emphasized how these two specialties complemented each
other. For example, psychiatrists were able to improve their
knowledge of certain neurological causes and their treatment while,
at the same time, neurologists were able to learn more through the
neurological analysis of some psychiatric patients.
The Day’s organizers were satisfied with the results obtained and are
already planning a repeat event around the same time next year.
The medical specialties that will complement each other on
Education Day are not yet known, but various associations have
already demonstrated their interest by submitting specific projects.
Dr. Hudon, Director of the Professional Development Office, said
he was happy with the success of this event and invited medical
specialists who were not able to attend this year to be present
in 2009.
The FMSQ Professional Development Employees of the Neurology and
team is composed of Réjean Laprise, Psychiatry Associations were present
Lise Guindon and the Director,
to welcome participants.
Dr. Gilles Hudon.
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21
Faire partie de
la FMSQ a ses
avantages
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En tant que membre, vous obtenez:
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Conférence à trois et Appel en attente
• Frais d’activation de 35 $ annulés
Pour commander ou pour plus d’informations,
composez le 1 800 361-0040.
Offert aux membres de la FMSQ avec une nouvelle activation dans le cadre d’un contrat d’une durée min. de 3 ans. Le membre doit fournir une preuve lors de l’Activations. Sujet à changement
sans préavis. Offert avec les appareils compatibles, dans les zones de couverture du réseau numérique principal et (ou) du réseau mobile haute vitesse de Bell Mobilité, là où la technologie le permet. Chaque forfait (minutes ou volume) est facturé sur une base mensuelle et les minutes pour toute utilisation (données ou voix) sont locales dans les zones de couverture de Bell Mobilité ; sinon,
des frais d’interurbain et d’itinérance (y compris des taxes étrangères) peuvent s’appliquer. (1) D’autres frais, tels que, sur une base mensuelle, 9-1-1 (75 ¢), accès au réseau qui ne sont pas des
frais du gouvernement (8,95 $/mois) s’appliquent. Avec tout téléchargement, des frais d’utilisation d’Internet mobile de 5 ¢/Ko s’appliquent si vous n’êtes pas déjà abonné au service Internet mobile
illimité et des frais peuvent s’appliquer pour le contenu. Des frais de résiliation anticipée s’appliquent. Modifiable sans préavis et ne peut être combiné avec aucune autre offre. Taxes en sus. D’autres
conditions s’appliquent. Samsung Instinct est une marque de commerce de Samsung Electronics Co. Ltd. et de ses sociétés affiliées. HTC Touch Dual est une marque de commerce de High Tech
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LEGAL ISSUES
MAÎTRE SYLVAIN BELLAVANCE, DIRECTOR, MAÎTRE LAURENCE LE GUILLOU, LEGAL COUNSEL
LEGAL AFFAIRS
GST and QST
The When and Where
Many of you have asked questions about this subject over the years. Canadian and
Quebec tax authorities have issued various policies and directives which have not always
been clear and straightforward. Some expert and other services are taxable while others
are not, without there seeming to be any justification for the difference in treatment.
ince there has been some ambiguity on this matter,
the Federation has taken steps to clarify the
question with the tax authorities, and this has been
going on for several years. In the meantime, we
have recommended that physicians affected by this
question wait for further developments on our part
and stay with what they have been doing. For instance, in an
article that has already appeared in Le Spécialiste, we recommended you continue charging the GST and QST if you were
registered and had begun paying it or, if that was not the case,
to continue as before without registering yourself or charging
the taxes.
S
As a result of our action, new policies have been introduced by
the tax authorities. We therefore want to give you some general
information on this question so that you can act appropriately.
A few preliminary concepts
To start with, it is important to set out certain concepts and rules
in order to understand the principal ways in which the GST-QST
is applied. We will try to simplify these briefly, as follows:
1. Apart from a few exceptions, most supplies and services
rendered are subject to the GST-QST. They are considered
“taxable supplies”. The person receiving taxable goods must
pay the applicable taxes; the person supplying the goods
must charge the taxes and remit them to the tax authorities.
2. “Exempt supplies” and “zero-rated supplies” number among
the exceptions. In these cases, the GST-QST is not paid,
charged or remitted. The difference between the two is
however important with regard to enforcement of other provisions of the applicable tax legislation, including the calculation
of the small supplier threshold amount or the right of supplier
of the goods and services to obtain a refund or credit for
taxes he pays himself.
3. There is also the concept of a “tax-exempt organization”.
Because of its particular status, the organization does not
have to pay taxes on taxable goods sold to them – for example, the supply of goods or services to a government department or the SAAQ. Because it is a government organization,
it does not have to pay taxes and the supplier of the service
therefore does not have to charge them.
4. Lastly, anyone whose income from the provision of supplies
or services is lower than $30,000 over the four preceding
quarters is considered to be a small supplier. This person
therefore does not have to charge and remit taxes on goods
or services supplied, unless they choose to do so. It is
however important to understand that, in determining whether
the $30,000 threshold has been reached; the calculation
must include not only taxable goods supplied but also zerorated goods and taxable goods supplied to a tax-exempt
organization. Exempt supplies are not taken into account.
What about services supplied by a physician?
Generally speaking, medical activities are not subject to GSTQST. Health services are considered to be exempt supplies if
they fall under one of the following articles found in Part II,
Schedule V of the Excise Tax Act:
[5] A supply of a consultative, diagnostic, treatment or other
health care service (other than a surgical or dental service
that is performed for cosmetic purposes and not for medical
or reconstructive purposes) that is rendered by a medical
practitioner to an individual.
[9] A supply (other than a zero-rated supply) of any property or
service but only if, and to the extent that, the consideration
for the supply is payable or reimbursed by the government
of a province under a plan established under an Act of the
legislature of the province to provide for health care services
for all insured persons of the province.
23
All insured services reimbursed by the RAMQ therefore come
under section 9, meaning that the GST-QST does not apply to
physicians’ principal activities. This exemption applies whether
the physician practices alone, in a group with other physicians
or through an incorporated company. On the other hand,
medical services rendered for cosmetic reasons are considered
taxable.
In addition, the supply of medical and assistive devices is considered a zero-rated supply under Schedule VI of the Act.
Medical expertise and other medicoadministrative services
These distinctions were made with regard to the principal
services rendered by medical practitioners, but for some years
there has been a lack of clarity concerning the field of medical
expertise and certain other medico-administrative activities –
i.e. whether such activities could benefit from the exemption
provided for in the Excise Tax Act.
The Federation’s representations have always emphasized the
fact that section 5 of the Act should be read broadly and include
all services supplied by a physician as part of his professional
practice. The tax authorities’ interpretation was more restrictive
and insisted on the importance of the service being a “health
care service” rendered to an individual.
After much discussion with the tax authorities and requests for
interpretation and amendments, the applicable rules have been
clarified. A new GST/HST Policy Statement (p-248) was issued
on September 21, 2006 by the Canada Revenue Agency
(available at http://www.cra-arc.gc.ca/E/pub/gl/p-248/p-248e.pdf) and we later agreed various details with Revenu Québec
after discussing the subject with them.
Following is a summary of the main conclusions that came out
of these discussions, so that you can have a more specific guide
to activities for which you are required to charge GST-QST:
1. Generally speaking, medical expertise and opinions provided
by a physician are considered exempt supplies and taxes do
not have to be charged. This applies when:
• The medical opinion is given to a patient or a third party
• The medical opinion is required to determine the need for
medical treatment or simply to determine legal causation or
assessment of the percentage of disability
• The opinion is verbal or written, in a report or on various forms;
forms required by insurance companies to assess a person’s
insurability are also exempt, as are health certificates for work
or school, forms to obtain disability benefits from Employment
Insurance or the Régie des rentes du Québec, chart
summaries, etc.;
24
2. However, medical expertise and opinions to determine professional error on the part of a physician are taxable, since
Revenu Québec considers that the main element in this supply
is the evaluation of the physician rather than rendering a
health service. Although we have contested this position, it
remains in effect.
3. Acting as a witness in Court is also a taxable supply, because
Revenu Québec considers that this activity does not constitute rendering a health service.
4. With regard to the various administrative services, such as
faxes, photocopies, etc., we have not obtained a decision
from the tax authorities but there is every reason to believe
that these services would be considered taxable, when
supplied separately.
5. With regard to accessory costs, such as medication, anesthetic agents and medical supplies, although we have no
specific answer from Revenu Québec, our tax consultants are
of the opinion that the GST-QST does not apply since such
supplies are either zero-rated or exempt because they are
additional to the health services rendered.
6. We would remind you that even if you provide taxable supplies
as outlined in paragraphs 2, 3 or 4, you do not have to apply
the GST-QST when the supplies are made to a tax-exempt
organization or when they amount to less than $30,000 per
year. This allows us to conclude that, generally, almost all
physicians find themselves in a situation where they do not
have to worry about applying the GST-QST to services that
they render.
This then summarizes the situation regarding application of the
GST-QST to physicians’ various activities. We however urge
you to consult your accountant or tax consultant for any element
peculiar to your situation.
It is also important to apply these rules and principles right away.
If your current practice is different, you should be able to modify
it without fearing reprisals for past actions. During our discussions with Revenu Québec, we wanted to make sure that medical
specialists were not penalized because of the various ambiguities in and amendments to tax policy over the past few years.
Please contact us if you require any further details.
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GREAT NAMES IN QUEBEC MEDICINE
PATRICIA KÉROACK
COMMUNICATIONS CONSULTANT
Dr. Michel G. Bergeron: Pioneering the Future
he study of micro-organisms has made gigantic
strides since the discovery of penicillin. Recently,
sequencing of the genome has not only revealed the
relationship between genes and disease, it has also
enabled the development of new tests, vaccines and
therapeutic molecules. We may one day be able to
eradicate cancer and other serious conditions. The future lies
at our door, and our “Great Name” is one of its pioneers.
T
The fight against infectious diseases is becoming more focused;
high-performance, sophisticated microbial detection equipment
is becoming increasingly available. Nanoparticle research is
intensifying. Genes have been sequenced and studied; we know
more about DNA structure and its components.
But in many countries, particularly in the developing world,
people do not have access to these tools, let alone primary care
to combat endemic diseases such as HIV-AIDS and STDs,
malaria, dengue fever, etc. Uncontrolled or barely controlled
epidemics are major public health problems.
Two problems at either end of a scale, but with one common
denominator: Dr. Michel G. Bergeron, a microbiology specialist
in Quebec. A world-renowned clinical researcher, Dr. Bergeron
is also a professor at Laval University and the Director of its
Infectious Diseases Research Centre (Centre de recherche en
infectiologie – CRI) which he founded in 1974 and which is
recognized internationally for its expertise. Today, the CRI team
has more than 200 members: research fellows, associates, and
students. It has developed tests for C. difficile, vancomycinresistant enterococcus (VRE) and MRSA. “The tests my team
and I have developed are important for the health network
throughout the world. We only have to think of the devastating
effects of MRSA”.
Dr. Bergeron’s many research projects are sometimes diametrically opposed to each other, but they are all based on the fight
against infectious disease. Two of these projects are particularly
innovative and augur well for the future.
His research on the prevention of STD’s led him to develop a
system that attacks and destroys the enemy! Its weapon? The
Invisible Condom®: a microbicide spermicide polymer gel
inserted into the vagina using a special (patented) applicator. The
product is now the subject of a phase 2 study in Cameroon to
assess its long-term safety.
At the same time, Dr. Bergeron has been working on perfecting
a test that can detect various bacteria and their resistance to
antibiotics, using DNA. “In 2000, a milestone year, we were the
first in the world to demonstrate the possibility, with the aid of
DNA, to use a clinical sample to detect a
microbe responsible for an infectious disease
microbe. We showed that a Streptococcus B
microbe can be identified in under an hour in
a pregnant woman, thus enabling its action to
be neutralized before childbirth by adding the
appropriate medication. Our results were
published in the New England Journal of
Medicine in 2000”.
Since that year, a chance meeting at a
symposium with a NASA scientist who was
Dr. Michel G. Bergeron
working on various detection tests suitable for
use in space, turned out to be very important.
“In no time at all, he introduced me to microfluidics and we
discussed the scope of microphysics. I saw this as a perfect
application for other projects I was working on.
“I combined genome techniques, microfluidics, nanotechnology, DNA chips and compact disc platforms to develop a
tool that could analyze a sample right in the practitioner’s office.
Once the disk is in the drive, the various bacteria responsible
for infections can be decoded and analyzed based on the
person’s DNA. Management and medication are then more
appropriate and effective. The DNA chip allows a sample to
be analyzed in two to three minutes versus the 12 to 18 hours
required with hybridization”.
Thinking that tools like the rapid-detection test should be made
available to all clinicians and practitioners and that it would also
be attractive from a marketing aspect, Dr. Bergeron presented
his work to various companies with marketing, development
and production facilities. BD Diagnostics GeneOhm acquired the
rights and built a more than $40M plant in Quebec City which
is located very close to Dr. Bergeron’s research laboratories.
Even though he is not connected in any way with the company,
he will still be able to follow its progress.
The whole sequence of events seems rather like a dream for
this researcher (who still has a multitude of projects in mind),
progressing from a simple idea to the fundamental research
required to find a solution and its applications, then from the
publication of results in a scientific journal to the outright sale
of the manufacturing and market rights of the final product.
Are there other projects? “Most definitely. I learn something
every day. I am surrounded by brilliant colleagues who give me
new ideas, make me think or guide me towards new avenues
of work”.
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CONTINUING PROFESSIONAL DEVELOPMENT
CPD is a Continuing Proposition
Since July 2007, the Collège des médecins du Québec has required all physicians to have a continuing
professional development (CPD) plan. A number of plans are available, such as the self-directed plan of the
Collège des médecins du Québec and the Maintenance of Certification Program (MCP) of the Royal College of
Physicians and Surgeons of Canada (RCPSC). Following are the remarks of a surgeon who has found a great
deal of benefit in successfully incorporating his continuing development activities into his practice.
r.
Philippe Demers, a surgeon at CSSS des Îles,
knows the importance of keeping abreast of
developments, innovations and trends in his
particular discipline. Graduate in General Surgery
from Université de Montréal in 1999, and well
prepared for a career in an outlying rural region,
Dr. Demers arrived at Îles de la Madeleine armed with training in
many areas that had given him the ability to deal with cases that
he saw frequently, such as abdominal emergencies, and those
rarely found in his specialty in ultra-specialized urban centres.
D
“At that time, I had already started out on a path of continuing
professional development which consisted in courses or conferences that allowed me to gain a more thorough knowledge of
the technical side of my discipline. This aspect seemed vital to
me, because even though my practice was very diversified in the
Islands, some cases did not occur sufficiently often to develop
new methods, such as the use of celioscopy in intestinal resection
and thoracoscopy. Attending courses and conferences in these
fields enabled me to partially offset the low number of such procedures encountered in a small hospital.
“After four years in Îles de la Madeleine, I had
gained experience, developed certain
surgical skills, and compiled a number of
cases. Prompted by the RCPSC’s MCP, I
decided to evaluate my practice. A strict
analysis of my records made me reassess
certain aspects of my practice, including indications for antibiotic prophylaxis and other
strategies to reduce postoperative infection,
as well as antithrombotic prophylaxis. The
benefit derived from this personal evaluation
and the concrete results that resulted far
exceeded the hours I had invested.
Dr. Philippe Demers,
FRCSC, General Surgeon,
CSSS des Îles
“Then came an unexpected turn in my professional experience.
Realizing an old dream, I decided to take an unpaid leave (of
absence) to go and work at the other end of the world. I decided
on Mildura, a small rural town in Australia with 30,000 inhabitants,
known for its fruit and wines. I spent 18 months there in a context
where discussions were frequent (mainly by videoconferencing).
In fact, self-assessment activities are a requirement of the Royal
Australasian College of Surgeons.
“After a certain time, I began to feel professionally isolated
compared with my experience in Montreal. I had few opportunities to meet my confrères and discuss ideas on a regular basis,
and I wanted to try and solve this problem. I first set up a scientific reading club with specialists from various fields and had it
recognized by the RCPSC, of which I had become a Fellow.
Then, I was fortunate enough to enter a twinning arrangement
with the General Surgery Department of Hôpital MaisonneuveRosemont, where I found a team that was very open to the idea
of this type of professional discussion.
“Crammed with professional knowledge and experience, my
professional development continued following my return to the
CSSS des Îles. Surgical audit strategies (assessment of performance and quality of surgical care), together with the possibility
of developing standards and indicators, particularly for intestinal
operations, enriched my knowledge. A similar process of reflection led me to standardize the study of morbidity and mortality
numbers in my field and to create models from them which can
also serve as a learning source for my colleagues.
“These measures functioned very well for a few months but,
over time, it became increasingly difficult to maintain a critical
number of participants. Unfortunately, the attempts at group
learning collapsed.
“For some time now, I have been involved in other personal
learning projects. I find them a valuable resource, because they
help me derive the full benefit of the activities that form part of
my daily practice”.
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“I was now more experienced in the purely technical side of my
profession, so I launched myself into courses and conferences
where I could acquire a wider range of knowledge. I was attracted
by international conferences, where I could not only expand my
technical knowledge but also discover other ways of doing things
and open my eyes to the world through discussions with
colleagues from all over.
27
It is an accepted fact that all medical
specialists are called upon to give opinions
on and explanations of medical cases. It is
an integral part of their work.
However, certain aspects of this type of work
are poorly known or deserve to be better
understood. What should we know about
medical opinions? What do we have to know
to give one? Does one become an “expert”
immediately upon certification? Can you
become an “expert”? And, if so, how?
This Special Report gives a wide range of
answers concerning medical expertise, the
duties and responsibilities of medical experts,
training with regard to insurance medicine
and expertise, and other related matters.
In addition, a pediatric expert will discuss
information that can be of interest when the
subject of the expertise is a minor and, in
addition, legal considerations, youth
protection, development and growth enter
into the equation.
One important point: After reading this report
you will never look at forms, patients’
requests and/or insurance or regulatory
bodies in the same way again.
Awareness allied with experience:
an ideal combination!
28
Georges L’Espérance, M.D., Neurosurgeon
Physicians and Forms:
Their Importance for the Patient
P
\hysicians have to deal with a multitude of laws,
regulations and organizations in their practice, when
handling requests from patients: insurance forms,
certificates of all types, etc. Unfortunately, they have
very little or no training to prepare them for this type
of situation, which is so very important to patients.
While it is true that the consequences are minimal with regard
to short-term disability documents that cover only a few days,
the situation is entirely different when the certificates stop a
patient from working for more than a few weeks. Whatever the
law in question, the requirements are not the same; nor are the
consequences. If we take the error most commonly found, a
physician describes his 55 year-old patient as disabled and tells
him that he can receive benefits from the Régie des rentes du
Québec (RRQ); he thus does him a serious disservice. The
patient may well find himself without any income because, to
be recognized as disabled by the RRQ, a person must be unable
to work at all. It is only at age 60 that they can be considered
disabled if they cannot carry out their usual work.
FOR THE PATIENT, IT IS A MATTER OF FINDING SOME
INCOME TO ENSURE HE CAN CONTINUE TO LIVE
AND MAKE THE NECESSARY PAYMENTS IF HE IS ILL:
HIS SALARY, MORTGAGE AND, ABOVE ALL, HIS PEACE
OF MIND ABOUT MATERIAL THINGS.
Physicians cannot be required to know the various laws1 in effect
and the resulting administrative regulations. It is important for them
to complete the forms requested with all due care, provide accurate,
objective and clear information in line with the evidence, and understand that their word alone as a physician will not be sufficient if
questions are raised or a lawsuit possibly ensues. For the patient,
it is a matter of finding some income to ensure he can continue to
live and make the necessary payments if he is ill: his salary, mortgage
and, above all, his peace of mind about material things.
Physicians must also avoid falling into the trap of being accommodating or even sympathetic because they are affected by the
patient’s emotional state and no longer take a critical view. Sooner
or later, this will have negative effects for the patient. Insurers,
including those that are private, function using disability tables and
discrepancies are questioned, often snaring the patient in a lengthy
process of expert opinions, etc. which may be difficult for some.
After a few years practising as a medical specialist, we all have
the impression that we are carrying out our medico-administrative duties in a satisfactory manner. Scientifically-based
medicine has guided our medical conduct for many years. When
medical questions arise on which insurers (or prosecutors)
require an opinion, physicians must employ the same scientific
and moral requirements and give an opinion based on solid
scientific grounds. They must be aware that their signature at
the foot of a document has a great deal of significance in our
system. For example, we would be correct in thinking that very
few physicians would themselves accept a legal or notarial
opinion that had had little thought. And what is true in common
cases is infinitely more so when medical expertise is required.
Decisions on the various applications for compensation can fall
into the legal, social or sometimes political domain, but it is our
duty as medical specialists to keep matters straight and to
concentrate on what we know – i.e. current scientific thinking
in our respective fields. Nor should physicians consider nonmedical factors, such as demographics, the level of education,
etc. Specific provisions are incorporated into each social law and
insurer’s rules, and they will be applied.
In the society of entitlement in which we live, physicians very
frequently have input into decisions which, aside from health
questions per se, go to the very heart of many of their patients’
lives. Physicians must fulfill the obligations placed on them by
insurance companies and other parties requesting medical
expertise in a scientific manner.
They must be aware of the impact that the documents they
write and sign may have on their patient’s life, as well as the
negative effects of incorrect information even when such information is given with the best will in the world. As reported by
Lacerte2, T. Edward Damer expresses it as follows: “The only
opinion (belief, claim, thesis, position) that deserves acceptance
is one that can be defended by a good argument.3”
It is essential for attending physicians to give information that
will allow the decision-maker to properly understand the
claimant’s situation, know the precise diagnosis, treatment plan
or prognosis. Clear diagnoses usually pose no problem, whether
dealing with a cancer that is being treated, proven heart failure,
major depression with three to four months off work, longstanding rheumatic disease supported by biological evidence,
etc. Problems occur more often in the musculoskeletal field with
unconvincing physical diagnoses (e.g. cervical pain, cervical or
lumbar sprain that lasts for months) or cognitive diagnoses such
29
as a so-called post-commotional syndrome
which drags on for months following mild
skull-brain trauma and which in fact masks
a problem of depression or adaptation.
mortgage and loans being paid by the private insurer. Can one
really blame him? No. Must the physician meet the patient’s
expectations without asking himself questions and giving real
ways to solve the problem? Again, no.
And what can be said about diagnoses that
are not supported by any physical and/or
biological information: fibromyalgia, chronic
fatigue, etc. It is essential for the physician
to make the appropriate allowances in his
disability diagnosis, so that the patient is
treated for the right diagnosis and receives
the care required by his condition. Likewise,
it is essential to understand that environmental problems at work or in the home
will not change, even if the patient is off work
for months and becomes deconditioned.
Once he returns to his occupation, the same causes will result
in the same effects and the same somatic complaints will
reappear: we have to treat the right cause.
It is true that some patients begin to improve when they can
escape the grinding spiral of incessant investigations, everchanging prescriptions and varied opinions – i.e., when we stop
throwing oil on the fire, and exacerbating the nervousness
caused by the symptom at the very time when the most
important thing is to maintain a calm attitude, confidence in the
future and in the patient’s own ability to deal with his symptom,
and even manage to control it4. »
A physician is often called upon to give his opinion, as the
attending physician, on the patient’s ability to resume his own
or some other work: this leaves a margin for interpretation which
covers many factors. Real, objective partial or total disability
does not always completely correspond to the perception the
patient may have of it and still less that of his family or lawyer.
Consequently, when a physician treats a patient, he provides
the certificates required by his condition for a certain period of
time. At some point, in doing his work correctly with an objective
understanding of his patient’s best interests, the attending
physician considers that the patient is capable of totally or
partially resuming his activities. He informs him accordingly, as
well as the insurer whoever that may be.
Depending on the circumstances, the insurer or employer may
request an expert opinion and this will be given by a physician
other than the attending physician, in accordance with requirements of objectivity. The attending physician will generally be
objective concerning treatment, but it is a well-known fact that,
because of the de facto contract he has with his patient, the
one-on-one discussion, attending physicians often find themselves in a delicate situation with regard to judging the relevance
or otherwise of prolonged disability, particularly when it is
contested or there are significant side benefits. It must also be
said, political correctness notwithstanding, that for homo
economicus; certain situations are very obviously beneficial to
a given patient without any overt bad intentions. Someone
whose finds their job unsatisfying and repetitive, feels he has
no control over his activity, works in a difficult environment (e.g.
on a production line) and, in addition, receives a low salary, will
see a significant improvement in their life if they receive salary
compensation from the CSST or SAAQ, in addition to the
30
Let us look at low back pain as an example. The attending
physician must be aware of the known risk factors for pain
becoming chronic and recognize them, so that, once again, he
can give his patient proper guidance. Since the 1990’s, it has
been widely recognized and acknowledged in the international
community that psychosocial factors play a key role in the development of chronic pain and disability. Since 2000, it has also
become obvious that the role of sociodemographic factors is
just as vital.
Maître Laurence Le Guillou, Legal Counsel at the
FMSQ, adds to the reflexion.
What are a physician’s ethical obligations with regard
to disclosing information to a third party? When the
physician acts on behalf of a patient or a third party
as an assessor or expert, two questions arise with
regard to information divulged to a third party: must
the physician obtain the patient’s consent to do this and what
information can be provided?
Q
Generally speaking, the patient is entitled to professional
secrecy whether he consults his attending physician or
a physician acting in an expert capacity. The physician
must therefore obtain the patient’s consent regarding
disclosure to a third party. Depending on the circumstances, the consent can be explicit or implicit. For example, when
the physician receives a form in his office signed by a patient authorizing his medical records to be passed on to an insurer, the patient’s
consent is explicit. On the other hand, when the patient goes to a
medical expert’s office for an expert opinion that will be passed on to
a third party and the expert informs him of the purpose of his work,
the subject of his expert report and whom it will be sent to, the patient
gives his implicit consent to the expert report being sent to a third party.
A document signed by the patient stating that he has fully understood
the purpose and limits of the mandate is nonetheless preferable in this
latter situation.
A
As far as the content of the information to be disclosed to the third
party is concerned, the test is relevance. The physician must refrain
from informing a third party of information, interpretations or comments
that are not relevant to the assessment. He must likewise refrain from
obtaining such irrelevant information from the patient.
Contrary to what many caregivers believe, whether they be
physicians, physiotherapists or other professionals, sending a
patient who does not feel completely better and “like he was
before” back to work, regardless of the pathology, is not necessarily a bad thing: everything depends on the circumstances.
A construction worker cannot return to work on crutches; that
is evident. However, administrative work may very well be done
without any problem. It is, in fact, well known now that patients
who resume their activities have a better course than those who
are left disabled. The conclusions of the international Task Force
on Neck Pain, published in January 2008 have provided
important insights into this subject5.
A number of guides provide conclusive data on the natural
history of a pathology, the best treatments to offer and the
complications. It is important not to over-medicalize physical or
even mental situations that are often simple to start with but
which become complicated through close interaction with
related factors.
A number of elements play a role in this construct: the overmedicalization we mentioned earlier, the exaggerated importance
our society gives to medical intervention, the status of victim
which can rate highly for some people, the powerlessness of
“traditional” medicine with regard to “functional” discomfort,
which more often than not is the patient’s acceptable response
to internal conflict, the very nature of the doctor-patient relationship and the former’s training which often makes him feel
that he has an obligation to act. All these elements combine to
complicate situations that were originally simple and could have
saved the patient severe disappointment (and sometimes substantial disbursements) if the physician had stopped for an instant to
look for the message the patient was trying to send him.
Very often, this all begins with an insurance report that is poorly
understood, poorly completed and not sufficiently specific. It
can be answered that physicians have other things to do but,
to our mind, it is precisely this view that has to be reconstructed:
in our society of entitlement, many rights and privileges are
conferred by documents that must be clear and accurate, particularly when physicians are now paid by the patients themselves
to fill out these forms. A person is entitled to expect that the form
is filled out correctly. An incomplete, inadequate or illegible form
can result in a person losing their rights, because the decisionmakers (or prosecutors in cases of review or dispute) will have
no basis that will help them render justice to the plaintiff.
Again, it is important for the physician to clearly understand that
incomplete, confusing, inadequate and unsupported information will some day be questioned and that it will be the patient
who has to pay, both literally and figuratively.
Attending physicians have a contract obliging them to act on
behalf of their patients and they must be the prosecutor: in
addition to that being a good thing, it protects their patients’
rights. However, the obligation of “kindness” does not always
equate with one of objectivity, particularly when side benefits are
at stake.
To avoid any misinterpretation, I give a quote from Gordon
Waddell at the 9th International Forum on Low Back Pain, Palma,
2007, in its entirety:
“What we need is a fundamental shift in the whole culture that
surrounds work and health. We need to stop thinking about work
as a four-letter word and an activity that is toxic to our patients.
We have to stop regarding work as pure risk and start protecting
our patients from the dangers of prolonged work absence.”
What is true for low back pain is true for all pathologies that may
become chronic, particularly in the musculoskeletal area.
It is also important to differentiate clearly between functional
limitations or what the patient cannot do – the notion of a physical
or mental injury6 – and their possible consequences, i.e. functional restrictions or what the patient must not or should not do
– even though theoretically he can sometimes do it7.
Likewise, physicians must understand that the fact they
prescribe a method of treatment does not oblige the paying
organization to accept it, whether the latter is public or private.
The method must be included in the insurer’s regulations or the
contract signed between the parties or, alternatively, in the Act
(SAAQ - LATMP). The same applies to many therapeutic suggestions that have more to do with belief than science and
convincing data.
Conclusion
A PHYSICIAN’S SIGNATURE AT THE BOTTOM OF AN
INSURANCE DOCUMENT IS VITALLY IMPORTANT TO THE
PATIENT, AND HAS IMMEDIATE CONSEQUENCES FOR HIM.
BUT THIS ACT ALSO HAS IMPORTANT CONSEQUENCES
FOR THE PHYSICIAN, BECAUSE HE IS PLACING HIS
CREDIBILITY ON THE LINE.
If the physician takes too narrow a view or does not carry out
a full examination and, even more, if he gives an unfounded
opinion, signing a document serves no one and his report will
have little or no short- or mid-term value.
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References
Complete references for this article are available in page 43.
31
François Sestier, M.D., PhD
Program Director, Insurance medicine and medicolegal expertise, Université de Montréal
Medical Experts’ Duties and Responsibilities
What distinguishes medical expertise in Quebec? What are medical experts’ duties and
responsibilities and what damage could be caused to the litigating parties if experts have
not made every effort to compile an independent, unbiased, well-reasoned opinion?
Medical expertise in Quebec
Requests for expert opinion in Quebec
Historically speaking, Canada has inherited two legal systems from
its founding peoples: Quebec uses the Civil Code, which derives
from the Napoleonic Code; the other provinces and territories
adhere to British Common Law.
There are three situations in which an expert opinion can be
requested:
Both in Quebec and elsewhere in Canada, judicial procedures are
adversarial rather than inquisitorial. All parties in medicolegal cases
must present themselves with their expert(s). The judge can
obviously appoint an independent expert to clarify medical matters
for the Court, but this is only done on an exceptional basis. Even
if he is engaged by one of the parties, the expert’s role is to clarify
medical matters for the Court; the legal counsel’s objective is to
win the case.
1. An assessment of bodily injury can be requested from medical
experts in many situations: an employer may request an expert
opinion to justify absenteeism, check on physical limitations or
confirm when a return to work would be safe for the patient
and his/her co-workers. Private insurers or the RRQ are entitled
to verify the medical justification for the payment of disability
benefits.
The CSST, IVAC or SAAQ can ask the expert to define
diagnoses, functional limitations and restrictions, or a physiological deficit using a pre-determined scale and, more rarely,
to give an opinion on the relationship between an event and
the current sequelæ.
2. In medical liability cases, medical experts must declare whether
a colleague’s approach complies with the rules of the art. This
type of assignment can be given by a coroner, the Collège des
médecins du Québec or legal counsel instructed by a patient
or a professional liability insurer.
Medical expertise training at Université de Montréal
Although it has existed elsewhere for many, many years – in Europe, in particular – academic medicolegal training has only been available in Quebec
since the creation in January 2000, at the Université de Montréal Faculty of
Medicine, of a microprogram and then a DESS in Insurance Medicine and
Medicolegal Expertise (www.mae.umontreal.ca). More than 120 instructors from
the Faculties of Medicine and Law of the four Quebec universities have participated in this teaching program. Master’s and doctoral degrees provide further
training opportunities in both medicolegal expertise and insurance medicine.
An international French-language program covering this training has been
available on the Web since 2005. The Université de Montréal has been offering
a similar program in English on the Web since January 2007, designed for
English-language physicians outside Quebec. An international English
program will be available on the Web as of January 2009.
Such training is not compulsory when writing a medical opinion, but it was
recommended in August 2008 by the Insurance Bureau of Canada which
found that most Quebec physicians who regularly gave expert opinions had
taken or were taking this program.
32
3. In insurance law, the expert may be designated to determine the
excess mortality associated with an illness that was not declared
prior to the policy being taken out or, alternatively, give an opinion
on an insured’s life expectancy or active life expectancy.
Duties related to medical experts’ competence
Experts must use specific terms in view of the legal meaning of
certain words or adjectives. Their reasoning must be logical,
avoiding faulty opinions often based on a deliberately partial consideration of the elements of the medical chart and/or literature.
Experts must use recognized scales (LATMP, LAT, SAAQ, American
Medical Association) depending on the mandate received. A
thorough knowledge of the philosophy and use of these scales is
obviously a prerequisite to issuing a valid medical opinion.
Assessments of bodily injury must also incorporate certain analyses
of the biopsychosocial model found in the WHO’s International
Classification of Functioning.
In order to carry out his mandate in an appropriate manner, the
expert must have a basic knowledge of current legislation: access
to information, insurance, human rights, etc. He must also be familiar
with the concept of pre-existing conditions, the level of proof required
for the expert’s evidence. Lastly, he must have the tools necessary
to justify his opinion, based on conclusive, scientific data.
Experts must, above all, be fully aware of the method of reasoning
regarding the causality, imputability criteria and the difference
between medical and legal causality.
IN ORDER TO CARRY OUT HIS MANDATE IN AN
APPROPRIATE MANNER, THE EXPERT MUST HAVE A
BASIC KNOWLEDGE OF CURRENT LEGISLATION
Finding Your Way
CARRA : Commission administrative des régimes de retraite et
d’assurances
CIF
Classification internationale du fonctionnement, du handicap
et de la santé (International Classification of Functioning,
Disability and Health)
CSST :
Commission de la santé et de la sécurité au travail
DESS :
Diplôme d’éducation supérieur spécialisé (Advanced
Specialized Education Diploma)
IVAC :
Indemnisation des victimes d’actes criminels (Crime Victims
Compensation Act – department forms part of CSST)
(un organisme qui relève de la CSST)
LAT :
Loi sur les accidents de travail (Workmen’s Compensation Act)
LATMP : Loi sur les accidents de travail et les maladies
professionnelles (Act respecting industrial accidents and
occupational diseases)
LSST :
Loi sur la santé et la sécurité au travail (An Act respecting
occupational health and safety)
OMS
Organisation mondiale de la santé (World Health Organization)
RRQ :
Régie des rentes du Québec
SAAQ : Société de l’assurance automobile du Québec
Impartiality
Experts must always bear in mind that their presence has been
required to clarify a medical problem for the Court. They must hold
unswervingly to their professional ethics and thus must learn to
maintain their independence with regard to the legal counsel
employing them. Biased or partisan medical opinions only lead to
unacceptable increases in legal costs and rapidly discredit the expert’s
reputation for integrity.
Intellectual honesty
Experts must know how to weigh the quality and persuasive value
of all medical information found on the Internet. A U.S. judgment
in 1995 (Daubert v. Merrell Dow Pharmaceuticals) clearly established
the rules governing the use of scientific literature. Unfortunately
some experts still select only those scientific articles in the literature that are likely to help their principal win his/her case.
Approach
Experts must develop a faculty for maintaining a cordial atmosphere during the patient/doctor meeting by learning methods
that classically disarm any aggressiveness on the part of the
person being interviewed. This does not prevent an alert, welltrained expert from detecting any obvious exaggeration.
Current trends in medicolegal training
In France, this type of training has been given for several decades
by university medico-legal departments which issue a certification
covering both the assessment of bodily injury and medical insurance.
In most European countries, this training is a prerequisite to
practicing as an expert. Generally speaking, magistrates in
French-speaking countries are highly satisfied with the quality of
the vast majority of legal opinions.
Because of the phenomenal increase in disability applications over
the last five years, the current tendency worldwide is to require
training and certification for all medical experts or decision-makers
with regard to medical disability. This trend can be found in South
America, in both Argentine and Brazil. The Ministère de la Justice
du Québec is aware of this problem and one of the solutions put
forward would be to make more frequent use of judge-appointed
experts to settle a medical debate.
In conclusion, medical experts in Quebec in 2008 would be well
advised to acquire formal university training in order to write a sound,
independent report and be able to defend it courageously when
being examined or cross-questioned in Court.
S
L
33
Gilles Fortin, M.D., FRCP(c), Neurologist Pediatrician
Medical Expertise and Young People
As medical specialists, we are trained to issue opinions when requested by our colleagues.
However, when the opinion is requested by someone in the legal field, matters take on a
very different aspect.
he stakes are not the same, there is a risk that our
technical vocabulary is not understood, even words
in normal daily use no longer seem to have the same
meaning. Our opinion is suddenly openly questioned
if not frankly contested – sometimes by respected
colleagues – and it must be justified as probable or
certain. And even here, clinical certainty appears to be defined
differently from legal certainty. For many, a request for a
medicolegal opinion is a trap to be avoided whereas, for others,
it represents an interesting challenge.
T
necessary. There are specific rules of procedure in such cases,
including the fact that the expert opinion can often be used as
testimony. In addition, the legal decisions are tied more closely
to the weight of the evidence and the most probable conclusion,
rather than certainty which is the case in criminal court.
FOR MEDICAL EXPERTS DEALING WITH CHILD (YOUTH)
PROTECTION, THE FIRST CONCERN IS TO ESTABLISH
WHETHER OR NOT ANY SIGNIFICANT INJURY OR DELAY IN
GROWTH HAS OCCURRED
For medical experts dealing with child (youth) protection, the
first concern is to establish whether or not any significant injury
or delay in growth has occurred. Or, less commonly, as can
frequently happen in sexual assault cases, to make the court
understand that there may have been abuse even though no
clinical evidence was found upon physical examination. If physical
injuries or a delay in development are found, the possibility of
abuse or neglect will be envisaged. The physician’s second task
is then to establish whether the injuries or delays are due to
natural causes, illness or accident or whether they result from
misconduct on the part of the person responsible for the child.
The DYP or the Court will then have to rule whether such misconduct justifies corrective measures. Distinguishing between morbid
and traumatic injury is usually fairly simple. But distinguishing
between accidental trauma and that inflicted through abuse or
neglect is often far more difficult. Most of the time, the physician
cannot be the sole person to determine such situations. An investigation of the circumstances by the DYP (or the police working
with him when the abuse is flagrant) becomes an essential part
of truly understanding what has happened to the child.
In pediatrics, or when a child is involved, the stakes are often very
different from those that occur when the subject is an adult. In
pediatrics, the majority of requests concern child protection,
seeking a verdict against prisoners accused of assault, child
abuse or even murder, as well as damages for harm caused
through medical error.
When it is a matter of child protection, the Director of Youth
Protection (DYP) is generally the one requiring the medical opinion.
The child’s best interests are his chief concern, and it is essentially the youngster’s protection and rehabilitation that the DYP
wishes to establish. Debate is governed by the Youth Protection
Act and cases are heard in the Youth Courthouse, when
34
In youth protection cases, the physician only goes to court in a
tiny number of cases. His written opinion will often be sufficient
for the DYP to be able to reach a decision and establish corrective measures mutually agreed upon with the family. Even when
matters are disputed or an appearance in Court is required, the
parties often accept the written medical report as testimony.
Case
1
Four-month-old Mark (not his true name) is brought by his father
to the hospital Emergency Room, unconscious and mildly
cyanotic. Support measures are installed, the CT scan shows
significant acute subdural hemorrhaging with cerebral oedema.
Examination of the fundi shows multiple retinal hemorrhages. The
rest of the assessment is normal. The father, who has no explanation, says that the child has been with him for the last 48 hours,
as he is separated from his wife and it is his weekend for custody.
The mother states that the child was well when he left to go to
his father.
At the DYP and Youth Courthouse:
The medical expert confirms a diagnosis of non-accidental cranial
trauma or shaken baby syndrome. Based on the clinical and radiological information, he states that the trauma probably occurred
during the weekend. The father’s visiting rights are cancelled and
the child is given back to his mother.
In criminal court:
The father is accused of serious assault. He then states that the
child was perfectly well when he arrived, but that he fell off the sofa
on Saturday night. The expert tells the Court that the fall cannot
explain the injuries observed, that the child could not have caused
the severe injuries himself and that the trauma occurred after the
infant’s arrival at his father’s, provided he was perfectly well when
he arrived there. Other witnesses now have to establish the father’s
guilt beyond any reasonable doubt.
In the civil courts, it is often the medical conduct of a confrère
regarding the child that is questioned. But, once again, it is the
child or the harm he has suffered that remains at the heart of the
proceedings. The problem may be related to an accident, a fall
at school, in day care or at an amusement park but, more often
than not, it is the circumstances surrounding delivery of the child
or other care that he/she might have received that are in question.
The logic is the same in every case: was an error committed, was
there harm and, if so, is the error related to the harm. For the
physician, it is once again a matter of first establishing whether
physical or mental harm has occurred, assessing its degree, the
related care and the impact on the child’s future life, his level of
independence or dependence, and life expectancy, if necessary.
If there are no sequelæ, no compensation is generally awarded
by our Courts.
For example, in a perinatal problem, the pediatric medical expert
will have to give his opinion on the child’s physical condition and
the relationship between that and the obstetrical conduct, which
will be evaluated by a specialist in that field. The absence of error
will not entail compensation, even if there are sequelæ. The
obstetrical or perinatal care expert must explain to the Court the
approach the physician should have taken in accordance with
generally accepted rules of good practice. But it is the Court’s
responsibility to establish whether the physician’s actual conduct,
given the specific factors of the case at hand, represents a fault.
The monetary implications of the sequelæ found in the child are
not within medical competence.
In criminal cases, legal attention does not focus on the young
victim but on the degree of wrongdoing of the person to be
punished for the action they have taken. Whether the matter is
one of assault or homicide, the Court seeks solid evidence, since
reasonable doubt benefits the accused.
Clinical diagnostic certainty and legal certainty are two different
things. Medical experts must not, however, attempt to establish
legal certainty. It is the Court’s responsibility to weigh whether the
evidence submitted to it qualifies as a legal certainty. Clinically,
there are a number of possibilities in the great majority of cases:
pathognomic signs are virtually inexistent and scientifically
supported diagnostic certainty is a rarity. Our certainty is based
on the fact that, given our knowledge and experience, a credible
alternative explanation can or cannot be reported. For example,
falling a foot or so does not result in significant intracranial and
eye injury. The Court is not looking for in-depth scientific demonstrations that it will not be competent to evaluate; it wants to
know whether, as experts in the field, we consider it likely or
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35
2
Case
Two-year-old Annie (not her real name) presents with a delay in
walking, with spasticity of her lower limbs; her development is
otherwise normal. Born prematurely at 32 weeks, the monitor
reading was not reassuring at the end of labour. The person delivering the child nonetheless decided on a vaginal delivery. The
APGAR was. 31, 55 and 810, developing into a moderate respiratory distress syndrome. The child did not present with
convulsions. The transfontanel ultrasound showed grade
1 periventricular hemorrhage.
The experts on both sides agreed fairly quickly on the severity of
the sequelæ or permanent partial disability. In obstetrics, the
plaintiff’s expert claimed that a cesarean section should have
been performed, whereas the defendant’s expert claimed the
contrary. When asked, the pediatric expert stated that the sequelæ
were related to cerebral distress which a cesarean section would
have avoided, while the defendant’s pediatric expert considered
that the prematurity itself was the cause. Since no agreement
was reached between the parties, the Court had to settle the
dispute on the basis of probability.
certain. It is therefore important that we unhesitatingly establish
the limits of our expertise as witnesses and refuse to answer
questions that we consider outside our field of competence.
Likewise, when giving any opinion or testimony on an expert
basis, we must not be afraid to say we do not know. The purpose
of the exercise is not to show off our knowledge, but to try and
explain to the Court the medical information underlying the case.
Unfortunately, substantial insidious pressure is often exerted on
the medical expert, as if the outcome of the case lay in his hands.
There is difficulty in accepting that the expert does not know or
does not solve the problem. There may sometimes be a strong
temptation to take statements a little too far. We must never give
opinions that we are not prepared to substantiate.
Our testimony or expert opinion is just one link in the chain of
evidence or probabilities on which the Court will base its decision.
We must not take sides, even if our empathy with the young
victim creates a natural desire to defend him or her. To shield us
against this, it seems important to me for all experts to have an
opportunity to study the records at the request of either the
plaintiff or the defendant, the prosecution or the defence.
S
L
La direction de Groupe Fonds des professionnels a le plaisir de souhaiter la bienvenue à
M. Benoit Carra. M. Carra se joint au Groupe à titre de directeur du service à la clientèle
au sein de notre filiale Fonds des professionnels - Gestion privée*.
M. Carra possède près de 15 ans d’expérience dans le secteur des services financiers, dont
huit chez Gestion MD Ltée. Il a occupé plusieurs postes au sein de diverses institutions
financières, dont celui de directeur, services aux particuliers, pour une banque canadienne.
Benoît Carra
Titulaire d’un Baccalauréat en administration des affaires (finance), il détient les titres
Pl.Fin., Adm.A., CFA, FCSI
de CFA (analyste financier agréé), de planificateur financier, d’administrateur agréé et de
[email protected]
Fellow de l’Institut canadien des valeurs mobilières (FCSI).
Sa connaissance approfondie de la réalité des médecins spécialistes, et autres professionnels de la santé, lui permet
d’élaborer des solutions parfaitement adaptées à notre clientèle en Gestion privée.
Groupe Fonds des professionnels s’adresse aux membres actionnaires suivants : la FMSQ (Fédération des médecins
spécialistes du Québec), l’ACDQ (Association des chirurgiens dentistes du Québec) , la Corporation de service de la Chambre des
notaires, l’AAPPQ (Association des architectes en pratique privée du Québec) et l’AQPP (Association québécoise des pharmaciens
propriétaires) . Les membres de la FMRQ (Fédération des médecins résidents du Québec) , à titre de partenaire, ont également
accès aux mêmes services. Groupe Fonds des professionnels offre aujourd’hui des services complets et adaptés en fonds
d’investissement, gestion privée et planification financière personnelle intégrée. Ses solutions d’investissement
sont orientées vers le rendement à long terme et la protection du capital. Ses frais de gestion et ses honoraires sont parmi
les plus bas au Canada. Des actifs de plus de 1,6 milliard de dollars sont gérés activement pour plus de 8 500 clients.
L’entreprise, dont le siège social est à Montréal, a également des bureaux à Québec et à Sherbrooke.
* Membre FCPE
36
Renseignements : www.groupefdp.com
GROUPE FONDS DES PROFESSIONNELS
ANDRÉ MARCOTTE, M.SC., CFA – VICE-PRESIDENT AND CHIEF INVESTMENT OFFICER
ALAIN DOUCET, A.S.A., ACS, PL.FIN. – MANAGER – FINANCIAL PLANNING
Making the Best of Difficult Times
I
f adversity builds character, the current volatility of the
markets must be making a significant contribution to it!
What explanation is there for the enthusiasm caused by
the thought of buying something at a super-sale price
when a consistently flagging stock market creates fears
that induce us to liquidate part of our assets? This paradoxical behavior appears to be completely normal: many surveys
show that money is one of the main stress factors for Canadians.
Impact on your investments
The impact of this volatility on achieving the goals of our clients
who are in the accumulation phase and have a long-term investment horizon should be limited. You can use your 2008 RRSP
contribution to rebalance your portfolio in accordance with the
distribution of target assets specified in your investment policy.
Another solution would be to use our preauthorized payment
program (PPP) and thus automatically average out the investment cost. Those most
concerned could also
consider depositing their
Graph 1 Investors emotions according to market developments
payments in our shortterm fund and invest in our
Optimism
Denial
Investors favour
Investors still hope, but
Maximum Risk
equity fund from time to
stocks
with less conviction
time, so as to rebalance
Desperation
Depression
their
portfolio over the
Investors begin to sell a
Investors are still wary of
portion of their stocks
the stock market
course of the year. (In this
Hope
case, using our short-term
Euphoria
Fear
Investors slowly
Investors let go of their
Investors do not buy
fund should be a temporary
regain
their
long-term strategy to
stocks
interest in stock
Maximum Opportunity
invest even more in stocks
measure, otherwise your
markets
long-term goals may be
Optimism
Capitulation
Panic
compromised.) The impact
Investors favour
Investors are tempted to
Investors have lost all
stocks
sell their stocks
confidence and want to
should also be limited for
sell at any cost
those beginning to take
Source : Westcore Funds/Denver Investment Advisors, LLC, 1998
out money.
Are our reflexes appropriate when the time comes to make
investment decisions designed to ensure our long-term financial
security? In a buoyant market, we quickly become optimistic
about future returns. Yet that is when everything is selling at a
higher price and the risk of disappointment is at a peak. During
difficult periods, we often avoid investing, although it is then
that stock markets offer excellent opportunities for longterm investment.
Market turmoil
The turmoil in the stock exchanges is being fed by the significant economic slowdown and the severity of the US credit crisis.
These factors are, however, situational and therefore likely to be
resolved during the coming months or quarters. Some changes
must however be made before a sustained upswing can occur:
stabilization of the U.S. home market and economy, further
reductions in the price of petroleum products, healthier financial
institutions and more realistic expectations as to profit growth.
Fewer options are however
open to clients who have been drawing down their money for
several years. We suggest you make withdrawals periodically,
rather than once a year. It would also be worthwhile taking
minimum withdrawals over the next few months or making them
match your real financial needs. You could also reduce the
impact of the current situation by first withdrawing assets which
have been the least affected by the market
Your best ally is time
Despite effort to forecast how the markets will develop, studies
show that time has a far greater impact than the immediate
moment. In other words, it is preferable to keep your investments
regardless of the investment climate.
The key to good stress management? Follow your long-term
investment goals and know how to take advantage of the
situation in line with your investor profile.
37
SOGEMEC ASSURANCES
CHANTAL AUBIN,
PLAN ADMINISTRATION MANAGER
Insure Your Clinic with “The Personal”
A Solution Tailored to FMSQ Members
hysicians in office practice or operating a clinic know
that business insurance is essential if they are to
protect their investment. But how to choose the one
that best suits their needs? Members of the Fédération
des médecins spécialistes du Québec (FMSQ) are, in
fact, able to call upon a business insurance program
developed to meet their specific professional needs.
P
This is available through The Personal Insurance Group, in cooperation with Sogemec Assurances. Many FMSQ members are
already taking advantage of The Personal’s group automobile
and home insurance. The Group’s Business Insurance is just as
beneficial, and a true asset with regard to your professional
property and civil liability.
Better protection at a better price
Business insurance generally includes basic coverage that can
be upgraded upon payment of an additional amount. At The
Personal Group, FMSQ members can obtain greatly improved
protection without paying a supplement.
Going beyond basic protection
The Personal Group’s Business Insurance for members of the
FMSQ is also noteworthy for types of coverage that are usually
considered optional, thus requiring payment of a supplement.
A number of these are automatically included at The Personal.
No additional premium is required for sewer backup or flood,
for instance. When you consider that water damage rates as
one of the most common disasters that can occur, this upgrade
is very worthwhile.
Exclusive coverage with no extra premium
FMSQ members also benefit from exclusive coverage negotiated especially for them by Sogemec. This covers loss of income
and property as a result of outside energy installations. For
example, if high winds damage Hydro-Quebec installations and
you suffer a loss of income because of the ensuing power
outage, you are covered up to $25,000.
Full protection and its advantages
The Personal Group’s Business Insurance has various other
benefits that make it unique in this market.
• Higher tenant liability protection ($2,000,000 instead
of $250,000)
Examples of upgraded coverage, with no extra premium
Coverage
Basic Protection
Upgraded Protection for
FMSQ Members
Fire Department
intervention costs
$5,000
$20,000
Property temporarily
away from location
$10 000
$25,000
$5,000
$25,000
(limit per item)
(no limit per item)
$250,000
$1,000,000
Building: $250,000
Contents: $100,000
Building: $1,000,000
Contents: $500,000
Portable tools and equipment
(e.g. portable computers,
surgical equipment)
New construction on property
New acquisition
The coverage described is subject to The Personal Group’s underwriting standards. The
clauses and modality of this coverage are defined in the insurance contract, which also
contains certain conditions and exclusions.
• Lower deductibles
• No proportional rule applicable, unlike most
business insurance available. This rule sets out a
minimum amount of insurance based on a predetermined percentage, without which the insured can
be penalized. At The Personal, there is no such rule.
Lastly, as with The Personal Group’s auto and home
insurance, FMSQ members enjoy preferential rates
and a recognized, trustworthy claims service 24/7.
For more information on The Personal Group’s
Business Insurance or to obtain valuable advice from
an insurance agent, call 1 866 350-8282.
You can also obtain further details at www.sogemec.
lapersonnelle.com.
The upgrade with no extra premium also applies to a variety of
other types of protection, such as coverage of goods in transit
or the cost of preparing evidence of damage, etc.
38
SOGEMEC ASSURANCES
Dr. GILLES ROBERT,
PRESIDENT
Sogemec Assurances is Constantly Changing
Dear Colleagues,
The various plans provided by Sogemec are constantly changing,
in order to offer you maximum coverage at the best price possible.
For example, more than 2,000 medical specialists belong to the
disability insurance program which serves as a model in its field
for the quality of its plan definitions and other unique clauses. While
on this subject, I would remind you that an expert committee has
been set up to support you in case of any dispute with the insurer
concerning the definition of disability.
Because of the success of the disability plan, Sogemec expanded
its services and added general insurance – i.e. home, automobile,
multi-residence buildings, secondary residences, and medical
clinics. In addition, in 2002, wishing to improve matters even more
and as the result of a tender, we introduced a new approach to
general insurance with the goal of maximizing our competitiveness. his resulted in Sogemec entering into a special partnership
agreement with The Personal Insurance Group, a direct insurer,
so that together we could achieve our objective of providing the
best protection available at the best cost. This step proved to be
an outstanding success, because we now have nearly 8,000
contracts. Sogemec acts as guarantor of this agreement, so that
it can verify that the insurer abides by its commitments.
Another factor that I would like to bring to your attention is that
our clientele had to be expanded in order to minimize administration costs and maintain our competitive edge. The arrival of
prestigious clients such as the Réseau des ingénieurs du Québec,
the Corporation de services de la chambre des notaires du Québec,
the Fédération des médecins résidents du Québec, the Fédération
médicale étudiante du Québec and, last but not least, the
Association des médecins de langue française du Canada, all
motivated by the desire to provide value added for their respective members, enabled us to achieve a better return and be even
more competitive.
I can assure you that Sogemec is a solidly-based organization
with exceptional growth, allowing us to meet your insurance needs
in an optimal manner.
POUR TOUS VOS
BESOINS D’ASSURANCES
DES GESTES PRÉCIS,
LES IDÉES CLAIRES
::
::
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::
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VIE
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MALADIE
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SOGEMEC
LA PERSONNELLE
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: : CONTACTEZ-NOUS
1 800 361-5303
514 350-5070 / 418 658-4244
Par courriel ou Internet :
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www.sogemec.qc.ca
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FÉDÉRATION DES MÉDECINS
SPÉCIALISTES DU QUÉBEC
39
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réservés aux membres de la FMSQ,
visitez le www.fmsq.org/services
MOT DU PRÉSIDENT
DR GAÉTAN BARRETTE
Économie, politique et négociation
u’on le veuille ou non, l’économie domine actuellement la vie publique et il est raisonnable de penser
que ce sera le cas pour les 12 à 18 prochains mois,
peut-être un peu plus. Ajoutons à ceci, la phase
électorale panaméricaine que nous venons de vivre
et nous avons tous le sentiment que le fond de l’air
en est un de passage, de transition, de changement de cycle. La saga du CHUM se terminant, nos mesures
tarifaires (tarifs, enseignement, recherche) finalement mises en
application, et après avoir conclu les quelques dossiers en cours,
il faudra déjà s’engager vers de nouveaux dossiers. Ceci, dans
un contexte totalement différent.
Q
conventions collectives du secteur public arrivant à échéance en
2010, incluant les ententes des fédérations médicales, et à l’heure
où les centrales syndicales ont conclu des alliances en vue des
négociations de 2010. Vouloir ramener tout le monde en même
temps en 2010 n’est plus un hasard, c’est un plan. À preuve,
l’Association des pharmaciens des établissements de santé qui
a amorcé des moyens de pression vient de se voir présenter une
entente financière transitoire se terminant… en 2010 ! Tout le
monde ensemble, du jamais vu au Québec. Mais du déjà vu en
Colombie-Britannique, où, trois fois, ça s’est réglé par une
« méga » loi spéciale. Le plan est clair.
EN EFFET, TOUT LE MONDE SE RETROUVE DANS LE MÊME PANIER,
Je vous invite ici à une pause pour prendre la mesure
du chemin parcouru. Bien sûr, la situation économique TOUTES LES CONVENTIONS COLLECTIVES DU SECTEUR PUBLIC ARRIVANT
actuelle est sérieuse. Mais celle-ci ne fait qu’amplifier À ÉCHÉANCE EN 2010, INCLUANT LES ENTENTES DES FÉDÉRATIONS MÉDICALES.
l’importance d’avoir posé certains gestes en 2006 de
Quoi qu’il en soit, la situation économique actuelle est intéresmême que de ceux que nous aurons peut-être à poser en 2010.
sante. D’abord, en 2010 la récession sera terminée et débutera
L’importance de l’opportunité de notre dernière négociation.
alors un cycle haussier, peu importe son ampleur. Mais là et
Opportunité parce qu’on ne connaît jamais l’avenir au moment
surtout, la donne sera différente en ce sens que notre voisine
d’agir… Imaginons un peu où nous en serions si nous avions cédé
l’Ontario aura rejoint notre camp, c’est-à-dire celui des receveurs
en 2006 ? L’horreur ! Amusons-nous quand même un peu. Oui,
de transferts de péréquation. Tombera alors le sempiternel
nous avons fait des gains significatifs, mais nous n’avions pas
argument de la « richesse (pauvreté) collective du Québec ».
envisagé l’extraordinaire impact ultérieur de notre position. Nous
Pourtant, le gouvernement ontarien n’est pas imbécile et voit
savions, et l’avions dit à l’époque, que l’ampleur de notre entente
sans doute les mêmes prévisions économiques que celles des
d’alors passait par son étalement. C’était une énorme conceséconomistes et, malgré tout, il vient de donner des augmentasion (du jamais vu !), et nous l’avons faite pour nous assurer d’un
tions tarifaires de 12,25 % auxquelles s’ajoutent une panoplie de
gain maximal. C’était sans prévoir ce que nous vivons aujourd’hui.
mesures représentant des centaines de millions de dollars. Ce
Sans l’avoir planifié, nous aurons aidé l’État et la société québésera aussi possiblement le cas pour les provinces maritimes.
coise ! Eh oui ! Rappelons-nous qu’en début de campagne
Alors?!? En même temps, tous s’engagent à maintenir un
électorale, on annonçait que les finances étaient telles que le
accroissement annuel du financement en santé d’au moins 5 %.
Québec ne ferait pas de déficit en 2009, ni en 2010. Le
Alors, il faut se préparer, et c’est ce que nous faisons, car il n’est
4 novembre dernier, Mme Jérôme-Forget prévoyait un budget
pas question de recommencer à creuser l’écart avec la moyenne
excédentaire pour 2007-2008, de peu (484 millions $), mais excécanadienne. Et vous, soyez prêts !
dentaire quand même. De son côté, l’OCDE prévoit un seul
trimestre de récession pour le Québec fin 2008, et déjà une
modeste reprise au premier trimestre 2009.
Réduction de cotisation « Bienvenue bébé »
Or, les ententes de la FMSQ et de la FMOQ représentent
ensemble des augmentations globales de près de 2 milliards $
qui, s’il n’y avait pas eu d’étalement, auraient engendré un déficit
significatif dès cette année. Voilà une réalité incontestable qui
mérite d’être soulignée. Bien que nous n’ayons aucun remerciement de la société québécoise, dans un autre monde, on
appelle ça une dette politique.
Finalement, économie oblige, en plus de conclure les dossiers
en cours, il est maintenant temps de débuter notre préparation
pour les prochaines négociations. La situation est simple. En
effet, tout le monde se retrouve dans le même panier, toutes les
Terminons l’année positivement… Dre Josée Parent nous rappelant
élégamment et pertinemment à l’ordre, le conseil d’administration
a unanimement décidé de souhaiter la bienvenue aux bébés des
médecins spécialistes. Les parents pourront donc se prévaloir d’une
réduction de cotisation, l’année de l’arrivée de l'enfant. Cette nouvelle
mesure représente un remboursement de 50 % pour les mères et
de 20 % pour les pères. Sur seule présentation du certificat de
naissance ou d’adoption, le remboursement sera effectué par la
FMSQ au début de l’année suivante. Et une bonne nouvelle n’arrivant
jamais seule, cette disposition est applicable rétroactivement au
1er janvier 2008 !
S
L
41
CONCOURS PRIX IMS CANADA, 10e ÉDITION
DEUX BOURSES
DE 3 000 $ À GAGNER
Description du concours
Règlements
Le Comité consultatif sur l'information en santé d'IMS Health (Canada) a
créé les Prix IMS Canada pour souligner les travaux de médecins et
pharmaciens concernant l'utilisation clinique efficiente des médicaments.
Ces prix représentent une valeur totale de 30 000 $ qui est répartie de la
façon suivante :
L'auteur principal (premier auteur) de l'article doit être un médecin
spécialiste membre d’une association affiliée à la Fédération des médecins
spécialistes du Québec. Tout article original paru dans une revue médicale
spécialisée (excluant les entrevues et articles de journaux) au cours de
l'année civile (de janvier à December 2008) peut être soumis à condition
qu'il appartienne à l'une des catégories précisées ci-dessus. De plus,
• à la Fédération des médecins omnipraticiens du Québec (FMOQ) et à la
Fédération des médecins spécialistes du Québec (FMSQ) deux prix de
3 000 $ à chaque fédération pour un article sur l'utilisation appropriée
des médicaments ;
• aux pharmaciens, par l'entremise de l'Association québécoise des
pharmaciens propriétaires (AQPP), deux prix de 3 000 $ chacun pour un
article sur l'utilisation appropriée des médicaments ;
• à chacune des quatre facultés de médecine, un prix de 2 000 $ à un
étudiant pour la meilleure note en pharmacologie ;
• aux facultés de pharmacie (Université de Montréal et Université Laval),
deux prix de 2 000 $ aux étudiants méritants pour un stage à l'extérieur.
Objectifs
• de souligner la contribution exceptionnelle d'un pharmacien à la
formation professionnelle continue ;
• de reconnaître la qualité et le caractère innovateur de l'article soumis.
Description des prix décernés
Deux bourses de 3 000 $ seront décernées à deux médecins spécialistes
(ou deux groupes de médecins) s'étant distingués par l'excellence de leur
article sur l'utilisation efficiente de médicaments. À titre d’exemple :
• les traductions, adaptations ou reproductions d'articles ne sont
pas admissibles ;
• les articles acceptés pour publication mais non encore publiés ne sont
pas admissibles ;
• les articles en deux parties comptent pour un seul texte ;
• si un article a été rédigé par plus d'un auteur, le prix sera remis à
l'auteur principal.
Sélection des articles
Les articles seront soumis par leurs auteurs qui devront les faire parvenir,
avant le 31 janvier 2009, au Dr Gilles Hudon, directeur de l'Office de
développement professionnel de la Fédération des médecins spécialistes
du Québec, 2 Complexe Desjardins, porte 3000, Montréal (Québec) H5B 1G8.
Ils seront ensuite évalués par un comité de sélection mis sur pied par
l'Office et composé d'un représentant de chacune des quatre facultés de
médecine du Québec.
Le directeur de l'Office communiquera à IMS Canada le nom des auteurs
des deux articles retenus comme étant les meilleurs. IMS Canada remettra
officiellement le prix lors d'une conférence de presse.
• importance de l'observance du traitement médicamenteux ;
• meilleur traitement dans le cas d'une maladie donnée ;
• revue de l'utilisation de médicaments dans un contexte clinique ;
• utilisation efficiente de médicaments les uns par rapport aux autres dans
un contexte clinique.
Did you know Le Spécialiste
is also available in English?
Read your copy directly at
www.fmsq.org
REFERENCES
Page 31
1
The most frequent in Quebec and the rest of Canada : War
Veterans Allowance Act; Act respecting industrial accidents
and occupational diseases (LATMP/CSST); Automobile
Insurance Act (SAAQ); Crime Victims Compensation Act
(IVAC); Quebec Pension Plan (RRQ); the regulations of
various private insurers; various collective agreements; etc.
2
Simple Opinions vs. Considered Opinions. Michel Lacerte,
Adam Rawlings. In : http://www.csme.org/PDF/CSME_
Newsletter_Fall2006.pdf;
3
Damer TE. Attacking faulty reasoning. Wadsworth, Inc.
1995:5.
4
Tiré de : Pr. Silla M. Consoli, psychiatre, Hôpital Européen
Georges Pompidou, Université Paris V. Préface de : Troubles
fonctionnels et somatisation. Comment aborder les
symptômes médicalement inexpliqués. Cathébras P.,
Masson, 2006.
5
International Task Force on Neck Pain and Its Associated
Disorders – The Bone and Joint Decade (2000-2010). Los
Angeles, January 18, 2008. Spine, vol 33, no 4S, 2008.
6
Examples: amputation; anosmia; arthrodesis of the shoulder,
frontal syndrome. In other words, what can be seen, found,
assessed or measured.
7
Exemples. lower limb amputation : cannot be a labourer;
anosmia : cannot be a security guard, etc.
43

The Impact and Responsibilities Inherent in a Signature

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