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LE SPÉCIALISTE LE MAGAZINE DE LA FÉDÉRATION DES MÉDECINS SPÉCIALISTES DU QUÉBEC Vol. 13 no. 2 June 2011 Offre exclusive aux nouveaux membres voir texte p. 41 Les dix principales raisons de consultations auprès des médecins exerçant en cabinet au Canada, 2010 Québec Canada Nombre de consultations 75 761 170 Nombre de consultations 323 515 440 Hypertension 4 402 770 1 Hypertension 20 562 420 Examen médical courant 2 657 160 2 Diabète 10 113 200 Diabète 2 477 340 3 Examen médical courant 9 779 600 Anxiété 1 528 820 4 Dépression 8 063 920 Dépression 1 509 210 5 Anxiété 6 382 130 Hyper-lipidémie 1 315 940 6 Infection aiguë des voies respiratoires 5 251 960 Infection aiguë des voies respiratoires 1 250 230 7 Suivi normal de grossesse 5 043 990 Trouble déficitaire de l’attention avec hyperactivité 1 055 610 8 Hyper-lipidémie 4 708 690 Hypothyroïdisme 1 047 470 9 Oesophagyte 3 621 120 880 870 10 Hypothyroïdisme 3 602 050 Infection de l’oreille (otite moyenne) Pour de plus amples renseignements : 1-888-400-4672 / www.imsbrogan.com Une importante source d’information, d’analyse et de consultation pour les secteurs de la santé au Canada La Personnelle prend soin de vos biens ! POUR VOTRE ASSURANCE HABITATION, PROFITEZ DE TARIFS PRÉFÉRENTIELS ET D’UNE VALEUR SÛRE À TOUS POINTS DE VUE. Grâce au partenariat entre Sogemec Assurances et La Personnelle, optez pour une assurance habitation « tous risques » complète que vous pouvez personnaliser. De plus, vous avez accès à des compléments négociés spécialement pour vous, tels que : • l’avenant 25C, pour bénéficier d’une protection de 100 000 $ pour vos biens se rapportant à vos activités professionnelles, ou en cas de perte ou de vol d’œuvres d’art ; • les services d’Assistance juridique et d’Assistance vol d’identité pour obtenir une aide spécialisée gratuite ; • le programme de surveillance résidentielle TéléVeilleMD, une solution très abordable et unique en assurance habitation. Avant de renouveler, prenez le pouls ! Demandez une soumission : 1 866 350-8282 sogemec.lapersonnelle.com MD Marque déposée de La Personnelle, compagnie d’assurances. Le programme TéléVeille n’est pas offert dans certaines régions. Certaines conditions s’appliquent. Haute saison ou basse saison. Avec la carte Voyages , vous avez toujours le choix. MC Grâce à l’Expérience Voyages, voyager n’a jamais été aussi simple. Vous pouvez vous envoler sans période d’interdiction ni restriction de siège†. De plus, vos points n’expirent pas, et vous pouvez les échanger pour le vol et la compagnie aérienne de votre choix. Envolez-vous quand vous voulez grâce à vos 15 000 points de bienvenue†. Les Voyageurs ont le choix. ® Composez le 1-800 ROYAL 1-2 ou rendez-vous à rbc.com/voyages. ® MC Marque(s) déposée(s) de la Banque Royale du Canada. RBC et Banque Royale sont des marques déposées de la Banque Royale du Canada. MC Marque(s) de commerce de la Banque Royale du Canada. Toutes les autres marques de commerce sont la propriété de leurs détenteurs respectifs. † Pour recevoir la prime de 15 000 points RBC Récompenses, nous devons avoir reçu votre demande au plus tard le 31 octobre 2011 et l’avoir approuvée. Les 15 000 points RBC Récompenses offerts en prime à l’adhésion figureront sur votre premier relevé mensuel. Le ou les titulaires additionnels, ainsi que les titulaires existants de la carte Visa Infinite Voyages RBC au début de la période d’admissibilité, ne sont pas admissibles à cette offre. Les titulaires existants de la carte Visa Platine Voyages, Visa British Airways‡ Platine, Visa Cathay Pacific‡ Platine, Visa Platine Privilège et Visa Or Privilège au début de la période d’admissibilité qui passent à une carte Visa Infinite Voyages RBC ne peuvent pas profiter de cette offre. Cette offre ne peut être jumelée à aucune autre offre. Selon le barème d’échange de points Voyages, les échanges de points contre des billets d’avion commencent à 15 000 points pour un vol court-courrier aller-retour en classe économique dont le prix ne dépasse pas 350 $. Le voyageur est responsable de toutes les taxes, frais d’administration et suppléments. Pour en savoir plus, notamment à propos des directives relativement à l’échange de points contre un voyage aérien en classe affaires, rendez-vous au http://www.rbcbanqueroyale.com/cartes/rbcrecompenses/avion_booking.html. Pour connaître l’intégralité des conditions et des restrictions applicables au programme RBC Récompenses, rendez-vous au www.rbcrecompenses.com ou appelez au 1-800 ROYAL® 12 (1 800 769-2512). ‡ Summary 7 WORD FROM THE PRESIDENT LE SPÉCIALISTE IS PUBLISHED 4 TIMES PER YEAR BY THE FÉDÉRATION DES MÉDECINS SPÉCIALISTES DU QUÉBEC EDITORIAL COMMITTEE Dr. Bernard Bissonnette Dr. Raynald Ferland Dr. Paul Perrotte Maître Sylvain Bellavance Nicole Pelletier, APR, director Patricia Kéroack, communications consultant DELEGATED PUBLISHER Nicole Pelletier, APR RESPONSIBLE FOR PUBLICATIONS Patricia Kéroack REVISION Angèle L’Heureux PRODUCTION ASSISTANT Véronique Clément GRAPHIC DESIGNER Dominic Armand TRANSLATION Anne Trindall Annette Grimaïla PUBLICITY France Cadieux Why Make Things Easy When They Can Be Made Difficult? 8 MESSAGE FROM THE TREASURER PRINTING Impart Litho 9 INTERVIEW CIRCULATION 13,200 copies Dr. Josée Parent TO JOIN US EDITION Telephone: 514 350-5021 Fax: 514 350-5175 E-Mail: [email protected] PUBLICITY Telephone: 514 350-5274 Fax: 514 350-5175 E-Mail: [email protected] www.magazinelespecialiste.com Fédération des médecins spécialistes du Québec 2, Complexe Desjardins, porte 3000 C.P. 216, succ. Desjardins, Montréal QC H5B 1G8 Telephone: 514-350-5000 PUBLICATIONS MAIL Mailing Indicia 40063082 13 DID YOU KNOW... 18 LEGAL ISSUES An Act respecting the determination of the causes and circumstances of death 20 DOSSIER LE SPÉCIALISTE LE MAGAZINE DE LA FÉDÉRATION DES MÉDECINS SPÉCIALISTES DU QUÉBEC Legal Deposit 2nd quarter 2011 Bibliothèque nationale du Québec ISSN 1206-2081 All pharmaceutical product advertisement's have been approved by the Pharmaceutical Advertising Advisory Board (PAAB). CCAB audits the medical specialists and residents database (11,219 copies audited for December 2010) 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. The authors of signed articles are sole responsible for the opinions expressed therein. No reproduction without previous authorization from the publisher. 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. THIS EDITION’S ADVERTISERS: • IMS Brogan • La Personnelle • RBC Banque Royale • Financière des professionnels • ASSS du Bas-Saint-Laurent • Collège des médecins du Québec • Club Voyages Berri • Groupe Conseil Multi-D • Le Directeur général des élections du Québec • Sogemec Assurances • Services aux médecins MD 11 IN THE NEWS 2 3 4 6 8 11 15 16 34 41 43 Vol. 13 no. 2 UNDERSTANDING PAIN • Complex Regional Pain Syndrome • Unhappiness • Neuropathic Pain • Neuromodulation June 2011 21 24 26 29 Offre exclusive aux nouveaux membres voir texte p. 41 31 GREAT NAMES IN QUEBEC MEDICINE Dr. Christine Colin, Community Health Specialist 32 CONTINUING PROFESSIONAL EDUCATION 36 IN THE WORLD OF MEDICINE New Atrial Fibrillation Guidelines 38 FINANCIÈRE DES PROFESSIONNELS 40 SOGEMEC ASSURANCES 42 LE MOT DU PRÉSIDENT Pourquoi « faire simple » quand on peut « faire compliqué » ? 44 SERVICES AUX MEMBRES Avantages commerciaux LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 5 WORD FROM THE PRESIDENT Dr. Gaétan Barrette Why Make Things Easy When They Can Be Made Difficult? t press time, the FMSQ has just reached an agreement with the Ministère de la Santé et des Services sociaux (the MSSS) regarding the treatment of age-related macular degeneration (ARMD). A good outcome, but to achieve it we had to resort to an ultimatum. Some of the highlights of this bad film follow. A February 8 brought a complete turnabout! The Minister issued a press release announcing treatments would be free. He “asked all health establishments in Quebec to ensure treatments were free (….). In the course of the next few weeks, once the measure has been introduced, patients will no longer have to pay incidental fees.” Fall 2010. The issue of incidental fees reappears; this time with regard to ARMD. Since patients could not obtain Lucentis at hospitals (at a time when science had not yet formally decided on the added value of using Lucentis in ARMD), they had to go to clinics for their injections. The RAMQ does not reimburse ophthalmologists for the technical component of their procedures, and patients were asked to pay the fees. As you know, the 1970 Health Insurance Act has not kept up with the evolution of medical practice. The result has been that a certain artistic fog surrounds the definition of incidental fees and, in particular, many of the activities carried out in clinics. I would emphasize this point! The fog is affecting ophthalmology for the moment, but it could apply to a number of other medical specialties. On February 9, again responding to a journalist from Le Soleil, the Minister’s press attachée clarified the previous day’s announcement, stating that action to introduce this new offer of service was just beginning, and it would only be “in the coming weeks or months” that patients would learn what to expect. Let us go further back, to October 1, 2007. At the request of ex-Minister Couillard, a task force submitted the Chicoine report (named for the committee chairperson); it contained specific recommendations on the matter of incidental fees and the need to act without delay. In the summer of 2008, Mr. Bolduc made his entrance as Minister. Since then, the airwaves have been silent. The problem of incidental fees has remained untouched – and pending. On April 7, Le Devoir reported that the Minister had raised the possibility of “paying reasonable fees for injections. (…) Incidental fees could also be paid in clinics. (…) We should know which option will be selected in a few days’ time.” The first signs of a “new” crisis arrived with an article published in Le Soleil on November 18, 2010: “The government will not pay for Lucentis injections”. In making this statement, the Minister’s press attachée cited the “present budget situation” as justification for the ministère’s decision. On November 24, the Minister indicated to the same journalist that he was working on the matter with the RAMQ. The article ended by pointing out that “the matter had been submitted to Minister Bolduc for the first time in March 2009”. On February 3, via his press attachée, the Minister let it be known that he intended to continue his deliberations on incidental fees. “Discussions must take place with the various parties involved, such as the medical federations and the Collège des médecins.” The Minister hoped to move “as fast as possible” on this matter, reported Le Devoir. April 2, and a dramatic turn of events! In an article in Le Devoir headed “No Free Lucentis To Be Found. Patients caught in government and establishment tussle”, the journalist reported that, upon checking, even the MSSS did not know which establishments were currently offering the service and which ones were expected to do so. The MSSS spokesperson added, “It is hoped that (a plan) will be finalized in a few weeks and submitted for the Minister’s approval.” On Thursday, May 19, 2011 a patient with ARMD applied to the Courts for permission to launch a class action against the RAMQ, the Minister of Health and an ophthalmology clinic in Quebec City (others may be added). That same day, infuriated, the Federation gave the Minister an ultimatum: 48 working hours to settle this situation once and for all. The hours passed by, and intense negotiations (over a long weekend!) finally brought about an agreement. For years now, the FMSQ has consistently repeated to the Minister that he should, once and for all, clear away the fog surrounding the whole subject of incidental fees. By deciding to circumvent the problem, not only the delivery of care is voluntarily rationed in hospitals, but the Minister is “saving” at the expense of patients by delaying investment of the amounts required to deliver care. During this time, physicians for their part are trying to do everything possible to treat patients in clinics, with all the attendant risks. But all this should “really” end one day! Yours in solidarity! On February 6, Lucentis treatment of ARMD was “a priority” for the Minister, as reported in the Journal de Québec. LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 7 MESSAGE FROM THE TREASURER Dr. Maurice Boudreault, MD Annual Report PAST TREASURER The following motions presented by the Chair of the Finance Commission were approved at the Annual Delegates’ Assembly, held on March 24, 2011: 1. To approve the FMSQ’s financial statements as at December 31, 2010 as audited by Raymond Chabot Grant Thornton, Chartered Accountants; 2. To approve budget forecasts for the year 2011, as submitted by the FMSQ; 3. To increase annual union dues from $1,235 to $1,266. With regard to the special contribution of $2,000 levied in 2006 to fund the negotiations taking place at that time, it had been agreed that any unused portion would be returned to members. Reducing dues by $20, $950 and $275 for the years 2008, 2009, and 2010 respectively allowed us to return 62% of the special contribution to members, the balance having been used for the negotiations concluded in 2007. The financial statements again confirmed that the FMSQ is in good health financially. After having been a member of the Board of Directors of the FMSQ for six years, the last four as Treasurer, and in accordance with the bylaws, I bowed out of my duties on March 24. I can assure you that working closely with the dedicated and dynamic team that provides constant support to the various branches of our organization, as well as with my colleagues on the Board of Directors, has been one of my most satisfying experiences. It also provided me with the privilege of getting to know many of you. I feel honoured by the confidence you have shown me over the years, and I thank you most sincerely! Upon his election on March 24, 2011, Dr. Raynald Ferland replaced Dr. Boudreault as Treasurer of the Federation for the period 2011-2013. S L 8 LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 INTERVIEW By Patricia Kéroack Outgoing Vice-President of the FMSQ Dr. Josée Parent On March 24, Dr. Josée Parent resigned from her position as Vice-President of the FMSQ at the end of a third term on the Board of Directors. Le Spécialiste met with her to fill in a picture of her time on the Federation’s Board. S L Dr. Parent, what inspired you to get involved with the Federation? In the past, both as a medical student and a resident, nothing indicated that I would become involved in the union movement. To be honest, I never even gave it a thought. Then, by chance, I got involved in my medical association and found that certain issues affected me deeply. I discovered I could contribute my ideas and actions to the advancement of our profession. I was a member of the Executive of the Association des gastro-entérologues du Québec for four years then, at the suggestion of its President, I applied for a position at the FMSQ, where one thing led to another and I went from being a Counsellor to Vice-President. JP Did you have any specific objectives during your tenure? government is not inclined to listen to us, even though we have a thorough knowledge of the realities, the needs and issues for each medical specialty. Insofar as negotiations are concerned, I count myself fortunate to have been a part of the major shift that allowed us to reach the 2006-2007 Agreement. That was the one that most likely had the greatest impact, at least in my professional life. The negotiations were ground-breaking: we finally achieved recognition of academic teaching and the work of researchers, a great step forward for medical specialists who give a great deal of themselves to residents, medical students and young researchers. We managed to catch up somewhat, thus making us more competitive on the Canadian level. These elements were a great help to academic medicine in Quebec. When I stood for the Board of Directors, Dr. Josée Parent I sent a letter to the delegates which, by pure chance, I reread just recently. At the time, I wanted to be the standard-bearer for groups that I COUNT MYSELF FORTUNATE TO HAVE BEEN A were smaller or not well- represented, like women, younger people, etc. Then, federation issues came up and I dove in, always PART OF THE MAJOR SHIFT THAT ALLOWED US keeping my initial objective in mind. That is how I developed an TO REACH THE 2006:2007 AGREEMENT. THAT interest for, among other things, the issues of parental leave and WAS THE ONE THAT MOST LIKELY HAD THE membership fee waiver. What major issues have you been responsible for since you joined the Board in 2005? My principal file was the one on medical staffing, although I should also mention negotiations and conditions of practice. These major topics required in-depth work and, towards the end of my term of office, I could see they had evolved substantially. The latest medical staffing plans (PEMs) are not a panacea, but we can at least say they are an improvement over to the past. Let us not forget that the FMSQ does not have that much influence with the government regarding PEM matters. The Federation’s role on this committee is only advisory and the GREATEST IMPACT, AT LEAST IN MY PROFESSIONAL LIFE. What can you tell us about the conditions of practice file? It is an important one, and it captivated me. First of all, the Federation set up a committee (chaired by the Vice-President) to take charge of the file. That committee is still very active today and meets with members, associations, professional orders and others to advance discussions. Although at times short on resources, we do move forward and realize that we share the same objectives as the professional orders. To LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 9 INTERVIEW @SUITEA change things, you need more than willpower. Sometimes it’s a question of financing and that is precisely the area in which we have had problems with the government. But, let’s be positive: several major files have progressed, including that of psychiatrist-responders, telemedicine, chronic diseases, etc. From your point of view, what were some of the high points for the Federation? The last agreement with the government was a great moment for me and for the Federation. The emergency act, and the Federation’s reaction to it, really changed the tone of negotiations and gave the Federation and its members a certain momentum. Our agreement was historic; everyone says so. For me, signing that agreement was a very high point. I SINCERELY BELIEVE THAT THE FEDERATION HAS A GREAT FUTURE. OF COURSE, WORK WILL STILL BE NEEDED TO ENSURE THAT THE REMUNERATION GAP WITH OTHER PROVINCES DOES NOT WIDEN, BUT WE SHOULDN’T REACH THE SAME LEVEL AS DURING OUR BATTLE IN 2006. How do you foresee the Federation’s future? Although I don’t have a crystal ball or the power to see what is coming, I sincerely believe that the Federation has a great future. Of course, work will still be needed to ensure that the remuneration gap with other provinces does not widen, but we shouldn’t reach the same level as during our battle in 2006. We also have to continue working on the structural issues in our healthcare network. Then, there is the specialized medical staffing challenge, which the Federation hopes to settle with the next agreement. Finally, we’ll have to adapt to demographic changes linked to age and gender... What should we hope for to settle the problems in the area of medical staffing? If we could settle the issue of part-time physicians, it would be an enormous step forward. The situation absolutely has to be recognized, be it for physicians nearing the end of their careers, researchers who spend half their time (or more!) on medical research or medical specialists who want to balance work and family life... Contrary to what people may think, it isn’t female medical specialists who work part-time (or are more inclined to do so): it is more the case with physicians nearing the end of their careers. What are the greatest stakes at present and in the future? Demographics are changing within the specialized medical community. There are more women among younger physicians, and the Federation will have to take this into account. The situation is not as desperate as with general practitioners, but we need to be able to meet the needs of this group of physicians and facilitate their involvement with the Federation. 10 LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 How did it feel to resume full-time work? Getting back to normal took one week! I took a few days off to rest, and then started working full-time at the hospital. Since then, I have often spoken with Dr. Barrette: he keeps me up to date on matters. I had six wonderful years, and I’m not ready to forget them. My youngest daughter has just turned five; I was pregnant when I joined the Federation’s Board of Directors. It just goes to show that time does fly by! Can you see yourself as Minister of Health? What are your plans? The position of Minister of Health doesn’t interest me at all. I don’t have any political ambitions. I know other people who might certainly be interested, but not me! At present, I do not have any new career plans, but I do intend to become an active member of my medical association once again. I have to admit that I regret that the parental leave agreement was not signed before the end of my term. I believe however that it is on the verge of being approved and signed. And, believe me, I’ll be there to applaud when it is! Still, you were the initiator of the Welcome Baby Program… Yes, and it was a very good start. The Welcome Baby Program was launched in 2008 and offers a membership fee reduction for our members who have or adopt a child. This is not a waiver of fees, but it is a first step in the right direction. Do you have a favourite story to share with us concerning your time at the Federation? Working with Dr. Barrette has been a great pleasure for me. We call one another for all sorts of reasons, to ask for news or to test ideas... That being said, I have to tell you of an instance when we really argued fiercely. Yes, it did happen! But it didn‘t concern a federation file, stakes in negotiations, nothing like that. It was about the colour of the new chairs we wanted to order for the boardroom! Dr. Barrette wanted chairs covered in white leather and I, being pragmatic and having a mother’s instinct, disagreed. White shows stains and dirt too easily. We got into a verbal fight over it and it was so funny! I argued the practical side and he was adamant about the importance of the “look”. The whole situation was topsy-turvy! Finally, I took advantage of his absence to place the order. The chairs are a deep navy blue and it’s really very attractive. In fact, even though he was astounded when he saw them arrive, he candidly agreed in front of everyone.... “Blue is better. You were right!” S L IN THE NEWS SMC Safety Standards According to the Act respecting health services and social services (Loi sur les services de santé et les services sociaux or LSSSS), the services provided by specialized medical centres (SMC) must be accredited within three years of an operating permit being issued. The accreditation must be obtained from an entity recognized by the Minister (section 333.4). The MSSS has mandated the Conseil québécois d’agrément and Accreditation Canada to act jointly in this matter, and SMCs will thus have to apply to them for accreditation. As part of the consultation process undertaken by the accreditation bodies regarding standards for Independent Medical/Surgical Facilities, the FMSQ set up a working group to study and evaluate the proposals made. After the group had completed its work, the FMSQ drew up a list of comments and recommendations. It considered that accreditation criteria must be adapted to the reality of SMC practice, in particular its size. Accreditation standards applicable to SMCs cannot be the same as those that apply to hospital centres or polyclinics. A number of SMCs are small clinics with few physicians and a minimum of support staff. Accreditation criteria must not require a hospital-style organizational structure, but must relate to the type of procedures performed and their level of risk. The wide range of procedures that can be performed in an SMC must be kept in mind, and the criteria adjusted accordingly. For instance, an SMC that provides cataract surgery under local anesthetic should obviously be subject to different standards than those applicable to an SMC that offers complex and high-risk plastic surgery. Accreditation Canada, the standards will guarantee uniformity, thus helping healthcare providers in these establishments deliver safe, high-quality services to their clients. Non-hospital establishments that perform procedures covered by the Act (LSSSS) or by the Regulation respecting the specialized medical treatments provided in a specialized medical centre will use these standards. As far as Accreditation Canada is concerned, and given the diversity of the surgeries that can be delivered in these establishments, the standards take into account both the various levels of sedation used and the types of surgery. Most of the recommendations presented to Accreditation Canada and to the Conseil québécois d’agrément were not accepted. However, physicians’ offices must still abide by them. This is therefore an issue that requires ongoing scrutiny. To learn more about the standards, see the Accreditation Canada site at www.accreditation.ca or the Conseil québécois d’agrément’s site at www.agrement-quebecois.ca. In a March 17 press release, Accreditation Canada published the new accreditation standards applicable to SMCs. It states that these standards were developed in response to quality and overall safety concerns for non-hospital establishments in Canada where surgery is performed. According to S L Dpujtbujpo Dpujtbujp po boovfmmff Votre inscription et le paiemennt de votre cotisation doivent être reçus au Collège des médecins au plus tard le 30 juin 2011, à 17 h. EBUF MJNJUF Ì SFUFOJS ; SIMPLIFIEZ-VOUS LA VIE ! 41 KVJO 3122 28 i p r ttout défaut ess délais. S F O T F J H O F N F O U T ; 514 933-4087 ou 1 888 633-32 246 * Par souuci d’efficacité et par respect de l’enviroonnement, l’avis de cotisation ne seraa plus im mprimé à compter de l’an prochain. Le renoouvellement de la cotisation devra donc êttre effectué exclusivement en ligne. LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 11 IN THE NEWS Building the new UHCs Since September, we have been reporting photographically on how construction work is advancing on the new university hospital centres being built in Quebec. As a picture is worth a thousand words, what better way to keep track of these projects! The new McGill University Health Centre will open its doors in the fall of 2014, while the CHUM is expected to open in 2018. CHUM Picture taken on May 13, 2011 MUHC Picture taken on May 13, 2011 S L 12 LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 DID YOU KNOW... On the Political Scene Bill 127 On December 9, 2010 the Minister of Health and Social Services tabled Bill 127, An Act to improve the management of the health and social services network. This proposed legislation was the subject of individual and public consultations from March 14 to March 18, 2011. The Health and Social Services Commission was mandated to hear representations from 27 organizations, associations and experts and received briefs from 12 other organizations who did not take part in the consultations. The FMSQ’s brief can be accessed on its website (www.fmsq.org) under Publications (Mémoires) – in French only. Most stakeholders criticized the Bill, questioning its relevance, orientation, objectives and ultimate purpose. Some groups went so far as to request its total withdrawal. The Minister indicated he would present amendments to the text, in particular by immediately withdrawing section 39, the most contested and criticized portion. The Commission submitted its report on March 22. It remains to be seen whether the Bill will be adopted during the current session that is expected to end on June 10. Section 39 of Bill 127 reads as follows: 39. The Act is amended by inserting the following division after section 182.0.1: to improving the health and well-being of the population; “DIVISION II.0.1 (5) the results targeted over the period covered by the plan; and “ORGANIZATION OF SERVICES “182.0.2. In accordance with province-wide and regional orientations and recognized standards of accessibility, integration, quality, effectiveness and efficiency, and taking into account available resources, the institution is responsible for preparing a multi-year strategic plan containing the following elements: (1) a description of the mission of the institution; (2) a statement of the social and health needs of the clientele served or the local population, based on an understanding of the health and well-being of that clientele or population; (3) a description of the context in which the institution acts and the main challenges it faces; (4) the directions and objectives to be pursued with respect to, among other things, the accessibility, continuity, quality and safety of care and services with a view (6) the performance indicators to be used in measuring results. The strategic plan must also take into account the priorities established in the clinical and organizational projects with which the institution is associated. “182.0.3. The strategic plan must be approved by the agency and sent to the Minister. “182.0.4. The institution must present its service organization plans and any other substantive policy document to the agency before submitting them to its board of directors for approval. “182.0.5. The president and executive director of the agency, the executive director of the institution and, when required, the chairman of the board of directors must determine how to monitor the results of implementing the strategic plan and the management and accountability agreement entered into by the institution and the agency.” Bill 133 Watch Out for… Piloted by Michelle Courchesne, Chair of the Conseil du Trésor, Bill 133, An Act respecting the governance and management of the information resources of public bodies and government enterprises, was also the subject of individual and public consultations on March 24 and 29 and April 5, 6 and 7. This text was also criticized by some stakeholders, who consider that it simply creates additional bureaucratic levels. The Commission des finances publiques submitted its report on April 12. We expect the bill to proceed normally, and to be adopted during the current session. A new piece of legislation will be required to allow “patient” information to be shared between institutions. The Minister of Health confirmed this on March 22 during an update on the Electronic Health Record (EHR) project. At present, legislation prohibits institutions from sharing this type of information (which is considered to be confidential) with a third party. At the time of writing, we have no specific indication as to when such a Bill will be tabled in the National Assembly. Le 6e Tournoi de golf des fédérations médicales Merci à nos commanditaires au profit de la Fondation du Programme d’aide aux médecins du Québec • Association des optométristes du Québec • Association canadienne de protection médicale • La Capitale assurances et gestion du patrimoine • Desjardins Sécurité financière • Fiducie Desjardins • Fiera Sceptre inc. • Gestion globale d’actifs CIBC inc. • Industrielle Alliance • Investissements SEI • La Personnelle, assurance de groupe auto et habitation • Sheer Rowlett & Associés et New Star Canada Inc Lundi 25 juillet 2011 Club de golf Le Mirage à Terrebonne Inscrivez-vous sans tarder ! Votre participation au Tournoi de golf des fédérations médicales du Québec (500 $ pour une participation individuelle, 2 000 $ pour un quatuor) inclut l’accès au terrain de pratique, un droit de jeu au club de golf Le Mirage en formule Vegas (meilleure balle), une voiturette, le brunch, le lunch, le cocktail ainsi que le souper. Informations et formulaires d’inscription disponibles sur le site Internet de votre fédération: www.fmsq.org www.fmoq.org www.fmrq.qc.ca LE SPÉCIALISTE www.fmeq.qc.ca VOL. 13 NO. 2 JUNE 2011 13 DID YOU KNOW... @SUITEA Prizes and Awards The AMEQ’s Endocrinologist Emeritus AMMIQ Prize Dr. Khalil Khoury, a pediatric endocrinologist at the Centre hospitalier universitaire de Sherbrooke, was named Endocrinologist Emeritus for 2011. He received the prize during the Annual Meeting of the Association des médecins endocrinologues du Québec. The Association des médecins microbiologistes infectiologues du Québec awards the prestigious Louis Pasteur Prize every two years to mark the high-quality contribution of one of its members to the advancement and development of this medical discipline in Quebec. The prize was presented to Dr. Gilles Del ag e, Vice-President, Medical Affairs in Microbiology, Héma-Québec. AMPQ Annual Prizes To highlight the organization of the colloquium Démence et souffrance psychique, une dyade souvent oubliée, held in October 2010, the Professional Development Prize was given to Drs. Arthur Amyot and Nathalie Shamlian. Dr. Pierre Lalonde has received the Heinz E. Lehmann Prize for Excellence in Psychiatry. The prize, accompanied by a cheque for $5,000, recognizes exceptional contributions to the progress and advancement of the profession. Dr. Arthur Amyot Dr. Hans Lamarre is the winner of the Jacques-Voyer Prize for Humanitarianism to highlight his role in the development of Québec-Haiti intergovernmental relations. The prize was given to him for his role as a facilitator in coordinating humanitarian actions associated with visits to the area, as well as promoting action by government bodies and civil organizations in Haiti. Dr. Nathalie Shamlian Dr. Vincenzo Di Nicola has received the Camille-Laurin Prize for the accomplishment of the year: publication of his book, “Letters to a Young Therapist: Relational Practices for the Coming Community.” The SCFR Recognizes Excellence • Dr. Jacques Boisvert and Dr. Dominique Màrton jointly received the Albert-Jutras Prize in recognition of their careers as pioneers. Five Quebec radiologists were honoured at the 48th Annual Meeting of the Société canadienne-française de radiologie. The prizes were awarded in recognition of the exceptional contributions of certain radiologists to the profession or to a related area of activity. • The Bernadette-Nogrady Prize was given to Dr. Marie-France Giroux to underline her remarkable contribution to research and teaching, as well as for the quality of her patient care, after less than 11 years of practice. • The Dr. Jean-A.-Vézina Prize for Innovation and Excellence was given to Dr. Michel Lafortune (jointly with Dr. Stephanie Wilson of the University of Alberta). • Dr. Guy Breton received the 2011 SCFR Prize for Personality to highlight his being appointed Rector of the Université de Montréal. Dr. Jacques Boisvert Dr. Marie-France Giroux Dr. Dominique Màrton Dr. Michel Lafortune 14 LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 Dr. Guy Breton DID YOU KNOW... @SUITEA APQ Prize AMSMNQ Prizes At its annual convention, the Association des pathologistes au Québec gave the PierreMasson Prize to Dr. André Bonin. This prize is awarded every two years to a pathologist who has made a significant contribution to the practice and development of his/her specialty in Quebec, whether in the scientific, educational or clinical spheres. The Association des médecins spécialistes en médecine nucléaire du Québec awarded prizes for excellence at its annual convention held in April. D r. Ra ymon de Ch artran d received the Lantheus Homage Prize to highlight her commitment to nuclear medicine. CMQ Prize Dr. Pierre J. Durand, a geriatrician and the outgoing dean of the Faculty of Medicine at Université Laval, received the Prize for Excellence from the Collège des médecins du Québec to highlight his exemplary contribution to the healthcare and education systems in Quebec. Dr. Gilles Julien, a pediatrician, received the Prize for Humanism for developing a model of social pediatrics and for his actions overall in favour of children from underprivileged backgrounds. Dr. Julien is the first recipient of this prize created to recognize the values of humanism extolled by the Collège among its members. QMA Awards At its annual convention, the Québec Medical Association recognized the exceptional contribution of two Quebec medical specialists to the development of their profession. Dr. P ie rre G agn é, a nuclear medicine specialist at the Centre hospitalier régional de Trois-Rivières (CHRTR) and the outgoing vice-dean of the Université de Montréal Campus (Trois-Rivières) received the Teaching-Clinician Award. This award recognizes the exceptional contribution of a physician with teaching responsibilities in a faculty of medicine. Dr. André J. Luyet, a psychiatrist at Hôpital Louis-H. Lafontaine, has received the Prestige Award, the highest distinction given to a member of the QMA. This prize recognizes excellence and contributions to the advancement of medicine and of society in the humanitarian, ethical, scientific, socioeconomic and educational or communications fields. Did you know? New program to reimburse living donors for expenses incurred Since the adoption of the Act to facilitate organ and tissue donation, the MSSS has implemented a program to reimburse living donors for expenses incurred. This program is administered by Québec-Transplant, and is intended to support the donor’s action by compensating him/her for a portion of the expenses related to the donation process. For additional information, visit www.quebec-transplant.qc.ca. S L Visages du Vietnam Départ garanti du 2 au 14 novembre À partir de 3349$ 13 jours / 11 nuits / 21 repas Combo Hilton sur Pilotis Tahiti – Moorea – Bora Bora Super spécial réservez-tôt – départs en novembre À partir de 4699$ 11 jours / 9 nuits / 17 repas Suisse – Allemagne – Autriche Départ garanti du 18 juillet au 1er août À partir de 4760$ 15 jours / 13 nuits / 27 repas Plusieurs autres départs et destinations disponibles... Consultez les spécialistes en voyages de votre agence partenaire. Appelez-nous pour tous les détails ! BERRI-UQAM 920, boul. de Maisonneuve E. 1 888 732-8688 Prix par personne en occupation double, incluant toutes les taxes et réductions selon les conditions des brochures Europe et Horizons lointains 2011. Prix au départ de Los Angeles pour le produit Combo Hilton sur Pilotis. Les prix de cette publicité peuvent être modifiés advenant une augmentation de nos coûts. Voir à ce sujet les conditions générales des brochures Europe et Horizons lointains 2011, rubrique « prix et garanti de prix ». La TPS et la TVQ sont incluses lorsque applicables Club Voyages est une division de Transat Distribution Canada Inc. Permis No 753141 au Québec. Prix excluant le 3,50$/1000$ de services touristiques achetés qui représente la contribution des clients au Fonds d’indemnisation des clients des agents de voyages. LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 15 Depuis 1969 Guichet unique icale Facturation méd ble Gestion compta ratégique Planification st on* t en incorporati Accompagnemen l’impôt Traitement de Pour une vision vision financière claire financière de votre stion personnelle personnelle gestion professsionnelle profe et professionnelle 18 800 00 363-3068 363-3068 [email protected] [email protected] www.multid.qc.ca www .multid.qc.ca *Groupe conseil Multi-D n’accomplit aucun des actes réservés aux avocats et not notaires. aires. ous les documents légaux sont exécutés par des avocats et not notaires aires de son réseau indépendant. Tous Fiers partenaires = la force de l’union Notre personnel d’expérience Notre vous o offre ffre un service de facturation médicale personnalisé, éthique et qui vous rapporte g gros. ros. Depuis 1985, 400 médecins font confiance à Diane Legault. Montréal St-Jérôme Rive-Nord 450.431.7470 DID YOU KNOW... Information and Power By Patricia Kéroack There is an old saying that knowledge (or, to extrapolate, information) is power. But, is that still true? Can a person or an organization (like a corporation or a government) exploit the information they have and share, in order to increase their power? In the final analysis, can information be controlled – and who would benefit? As the Editor and person responsible for Le Spécialiste, I always look closely and critically at the various communications we receive for the magazine. I pay especial attention to press invitations, particularly when they arrive at strange hours or outside normal working hours. For example, the media can be invited on a Sunday evening to attend an important announcement being made the next morning. It seems that, over time, this method has gained in popularity among our political leaders. It happened for the official launch of work on the CHUM last February 25. The press invitation was issued on the news wire, early in the evening of Thursday, February 24, for an official announcement the next morning at 9:00 a.m. Furthermore, the invitation was issued by the Premier’s Office, not the CHUM, the MSSS or even the Conseil du Trésor. However, after checking with a few guests at the venue the next morning, we confirmed the official launch had been planned and announced a long time ago to project stakeholders, CHUM employees (closed circuit television sets were even made available in the various buildings for those who could not attend in person), partners and other VIPs. So, why wait until the last minute to invite those who actually convey information to the general public? Now, let’s talk about the press conference in question… In an article published on Cyberpresse,i reporters Ariane Lacoursière and Sara Champagne wrote: “Invited to a technical briefing one hour before the official announcement, reporters had their cellphones confiscated at the door. When questions from the media became too searching, an attempt was made to cut short the technical briefing. Then, immediately prior to Mr. Charest’s speech, Health Department spokespersons refused to return the cellphones to reporters, until one journalist threatened to call the police if it was not immediately returned.” I was present at this press conference and personally experienced this strange behaviour towards reporters. My personal cellphone (which I had carefully turned off) was confiscated and was returned to me... turned back on! And then there was the glacial welcome, or rather non-welcome, we encountered: a few chairs reserved for the media (deliberately placed at the back of a room already overflowing with guests), some mumbled invectives and the all-encompassing suspicious glares from the Premier’s bodyguards. This was not an isolated occurrence. If we restrict ourselves to last-minute invitations alone, a quick search of press invitations from the Government of Quebec provides further similar instances. For example, on August 27 last year (a Friday), an invitation was sent out at 5:49 p.m. for an important announcement by Minister Normandeau, on Sunday morning, on the subject of shale gas. Then the CHUM once again made the hit parade with a press invitation sent out on Sunday afternoon at 3:30 p.m. (December 19, 2010) for a technical briefing at 9:15 a.m. on Monday morning (December 20, 2010), followed by a press conference with several Ministers at 10:00 a.m. Is this a normal way of acting? A good communicator must know the public he or she is addressing, as well as those who transmit the information in question. Communicators know that most media operate with different teams during the week (Monday to Thursday) and at weekends (Friday to Sunday), that deadlines affect the coverage of events, that electronic media reporters are subject to technical production details (and, particularly, the time of news broadcasts), etc. The FMSQ’s Public Affairs and Communications Department makes every effort to know the people who convey its information. For instance, it keeps an up-to-date database of reporters with an interest in health and the other areas in which the Federation is involved. In the best of all possible worlds, our team carefully plans the timing of press conferences and other media activities to accommodate the multiple conditions under which reporters work. Finally, if an invitation has to be issued with a short lead time, everything is done to ensure that press invitations reach reporters rapidly (cellphones, personal e-mails, calls to news desk editors, etc.). After all, knowledge (like information) is power! i http://www.cyberpresse.ca/actualites/quebec-canada/sante/ 201102/25/ 01-4373923-construction-du-chum-cest-parti.php S L LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 17 LEGAL ISSUES By Maître Majorie E. Talbot COUNSEL (INTERIM), LEGAL AFFAIRS Do you know your obligations? An Act respecting the determination of the causes and circumstances of death The Act respecting the determination of the causes and circumstances of death1 (the “Act”) empowers the Coroner to search for the causes of a death and its circumstances when the probable medical cause of death is unknown or when the circumstances are obscure or violent. As part of his duties and during an investigation or inquest, the Coroner can formulate “any recommendation directed towards the better protection of human life.”2 In the last year, several recommendations for improving the quality of our healthcare have been issued by the Coroner’s Office.3 To carry out his mission, the Coroner must be informed of all deaths requiring investigation. In particular, he must be informed of all deaths occurring in certain places, regardless of the cause or circumstances. In the healthcare network, the locations currently covered by this requirement are rehabilitation centres, family-type resources and foster homes. The Coroner must also be immediately informed of the death of a person under confinement in an institution. However, the law does not require automatic notification to the Coroner when death occurs in a residential and long-term care centre (CHSLD), an intermediate resource (IR) or in a residence for the elderly. Until 1991, the Coroner nevertheless had to be notified of all deaths occurring in nursing homes.4 The latter accommodated users whose profiles were similar, if not identical, to those of persons currently living in a CHSLD.5 The requirement has been abolished since, in most cases (98% of them, according to the Coroner’s Office) such notifications concerned natural deaths, which are not within the purview of the Coroner.6 The Commission des droits de la personne et des droits de la jeunesse (the “Commission”) considers that the law does not take into consideration the vulnerability and loss of independence of the elderly in a CHSLD, IR or home for the elderly.7 In a notice dated last December, it recommended that the Act be amended to require that the Coroner should be notified of all deaths in these institutions.8 The Commission also advocated heightening physicians’ knowledge of the various current provisions of the Act.9 Some coroners suspect an “under-notification” of deaths in relation to the current Act, one of the causes of which would be an inadequate knowledge of their obligations on the part of certain physicians.10 Notifying the Coroner when unable to establish the probable cause of death A physician who confirms a death must prepare an attestation of death, giving the name and gender of the deceased, as well as the place, date and time of death.11 It is important to differentiate between the time and the confirmation of death. For example, if rigor mortis is present, the time at which the body is discovered and death is confirmed will obviously differ from the time of death (or in this case, the presumed time of death). This distinction will be very pertinent, particularly with regard to succession.12 As for the notice of death, various people are responsible for completing it depending on the circumstances. However, the physician has the initial responsibility for filling out the notice of death (or form SP-313) for a person in an institution.14 When death occurs outside a healthcare institution, “the last physician having cared for the person” is responsible for completing it.15 Should that physician not be available, another physician, nurse or Coroner can complete the notice.16 When the death forms the subject of a Coroner’s investigation or inquest, it is up to the latter to complete the notice of death.17 The notice must specify, as accurately as possible, the cause of death and the disease from which the deceased suffered.18 If the death was a violent one, the circumstances surrounding the death must also be included.19 When it is impossible for the physician to decide on the medical cause of the death, he/she must immediately notify a Coroner.20 When seeking the probable cause of death, the Coroner is therefore called upon to establish which “disease, pathological condition, trauma or intoxication” could have “caused, contributed, or resulted” in the death.21 The physician can also notify a peace officer of the death.22 That person must immediately notify the Coroner of such death.23 The Act also contains a provision that the Director of Professional Services (DPS) in a hospital centre or “a person under his authority” can take steps to ensure a physician determines the probable cause of death.24,25 If the circumstances of the death are obscure or violent, or if deceased’s identity is unknown, the Coroner’s authorization must first be obtained.26 The author wishes to thank Maître Claire Bernard (Commission des droits et libertés de la personne) and Maître Dana Deslauriers (Bureau du coroner) for their collaboration in this article’s preparation. 18 LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 LEGAL ISSUES @SUITEA Should the cause of death remain unknown, an autopsy may be required to establish it.27 In such cases, the DPS must take the measures necessary to proceed with due diligence.28 What happens, then, when death occurs in “obscure or violent” circumstances? Notifying the Coroner when a death occurs in obscure or violent circumstances The physician who confirms a death that seems to him/her to have occurred in obscure or violent circumstances, even if the probable cause of death is known, must immediately notify the Coroner or a peace officer.29 Everyone has an obligation to inform the Coroner or a peace officer of a death that appears to have occurred in obscure or violent circumstances, or when the identity of the deceased is unknown.30 This requirement applies unless it is reasonable to assume a Coroner, peace officer or physician has already been informed of the death.31 Unfortunately, the law does not define “obscure” or “violent”. The dictionary defines “obscure” as referring to something that is “… 3. Not well-known; 4. Not easily discovered; 5. Not distinct, not clear; …”32 According to the Coroner’s Office, a death occurs in “obscure” circumstances when there is a “lack of trauma, intoxication or obvious adverse effects”, but clues or information surrounding the death leave doubt as to the possibility of “external causal or contributory elements”33. A death where the cause of death is “not clear” or is “not wellknown” must therefore be notified to the Coroner. For example, the sudden death of a baby would be considered a death occurring in “obscure circumstances.” We have to conclude that there is a certain overlap between deaths for which probable cause cannot be established and those occurring in obscure circumstances. Insofar as “violent” is concerned, it is defined as “1. Acting or done with, or characterized by the use of strong, rough, harmful force; 2. Caused by strong, rough force; 3. Showing or caused by very strong feeling, action, etc…”34 The Coroner’s Office considers that a death occurs in “violent circumstances” when it results from “an external agent responsible for a trauma, intoxication or any other adverse effect, whether of an intentional nature or not.”35 Restraint asphyxia, falls, medication overdoses, suicides, homicides and any act denoting harmful treatment are considered violent deaths that must be notified to the Coroner.36 While some circumstances leave no room for ambiguity, others are more difficult to interpret. In such situations, the Coroner’s Office encourages physicians to contact the Coroner in their region. deceased was under confinement; correctional facilities; penitentiaries; “security units within the meaning of the Youth Protection Act”;37 police stations; daycare centres;38 foster families and family-type resources.39,40 In all of the above places, the director41 must immediately inform a Coroner or a peace officer when a death occurs. If the director is absent, this responsibility devolves to “the person in authority.”42 If this person is a physician, it will be his/her duty to notify the Coroner or the peace officer of the death in question. Legislators wanted to ensure stricter control with regard to deaths occurring in places where personal liberty is restricted, or when dependent and vulnerable persons are in the charge of the State.43 But, what about CHSLDs, IRs and residences for the elderly where those residing there are vulnerable and losing their autonomy? The Commission considers that deaths occurring there should be automatically notified to the Coroner, even though most are from natural causes.44 The Coroner’s Office seems to want to rely on the current provisions of the Act, which allow it to fulfill its mandate and guarantee such individuals’ fundamental rights. While deaths occurring in obscure or violent circumstances or where the probable cause is unknown are the Coroner’s responsibility, that is not so for deaths from natural causes. We await legislators’ reactions impatiently. Penalties and sanctions We must remind you that failing to notify the Coroner (or a peace officer) of a death when probable cause cannot be established, which occurred in obscure or violent circumstances, or which requires automatic notification of the Coroner, is an offence and subject to a fine of $125 to $6,075.45 The Coroner’s Office informs us, however, that these provisions have never been applied. In conclusion, it must be noted that the law prohibits the Coroner from making any statement concerning a person’s civil liability or criminal responsibility.46 Nor is it within the coroner’s purview to act as a substitute for the Collège des médecins du Québec or any other professional order, or to judge the quality of professional acts. Thus, physicians must notify the Coroner when so required by the Act, and thereby contribute, once again, to reducing the number of avoidable deaths. References and Tools Notifying the Coroner or a peace officer based on the place where a death occurred Certain deaths must be notified to the Coroner or a peace officer regardless of the causes or circumstances involved. Such places are as follows: rehabilitation centres; adapted enterprises for handicapped persons; facilities where the Complete references for this article are available in page 43. For further information, please contact Maître Sylvain Bellavance, Director of Legal Affairs. S L LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 19 Dossier One person in five lives with some form of chronic pain. How can pain be properly qualified and quantified? Which mechanisms are responsible for pain? In this issue, Le Spécialiste presents a few texts from the book ‘Working Together When Facing Chronic Pain’ (Faire équipe face à la douleur chronique), published in French and in English in 2010 under the direction of Louise O’DonnellJasmin. The book deals with all aspects of chronic pain, from the medical and psychological points of view as well as that of the patient. Three medical specialists who contributed to the book have agreed to review their texts (as published) in order to adapt and present them to a specialized medical audience. This issue’s Special Report also contains a text detailing the most recent diagnostic criteria published on the subject of the complex regional pain syndrome, a pathology that is still unknown to a great extent. WORKING TOGETHER WHEN FACING CHRONIC PAIN A BOOK DESIGNED FOR PATIENTS AND WRITTEN BY THEIR HEALTH PROFESSIONALS i 20 Working Together When Facing Chronic Pain (Faire équipe face à la douleur chronique), Laval, Les Productions Odon, 2010. www.productionsodon.com LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 By Nicole Beaudoin, MD, physiatrist* Yves Bergeron, MD, physiatrist** François Fugère, MD, anesthesiologist*** Complex Regional Pain Syndrome Complex regional pain syndrome (CRPS) is probably one of the most disabling of the known chronic pain syndromes. Adopted in 1993 by the International Association for the Study of Pain (IASP)1, the term is more general and descriptive than reflex sympathetic dystrophy. CRPS is characterized by pain of disproportionate intensity in relation to the initial lesion. It usually occurs after trauma or immobilization and is associated with sensitivity problems, vasomotor changes, or abnormal sudomotor function. In almost all cases, motor functions are affected, and may be related or not to trophic changes. Two forms of CRPS are recognized, and are based on the absence (type 1) or presence (type II) of nervous lesions. The pathophysiology of CRPS is not completely understood. Several processes may be involved in its onset and continuation, including neurogenic inflammation, 2 described by Birklein and Weber, and the phenomena of central and peripheral neuromodulation.3,4 A hyperactive sympathetic nervous system is no longer considered the central element in the pathophysiology of CRPS.5 CRPS predisposing factors Nearly 65% of CRPS cases occur following trauma.6,7 Impairment of the locomotor system predisposes patients to CRPS without any real link to the severity of the injury. Two to five percent of trauma or musculoskeletal injuries and one to two percent of fractures result in CRPS.8 Incorrectly applied or prolonged immobilization, particularly when treating complex fractures, can contribute as much to the appearance of the syndrome as to its chronicity. Lesion of a peripheral nerve, in particular the median nerve, results in type II CRPS in essentially 2% to 5% of cases. Central nervous system involvement is often accompanied by this syndrome, which is found much more rarely with regard to visceral pathologies or neoplasias. In 10% to 17% of cases, there is no identifiable etiology.9 Signs and symptoms Patients presenting with CRPS describe various symptoms, usually located at the distal portion of a limb, regardless of the type of initial trauma. The signs and symptoms are not limited to a single dermatome; the idea that they are found only in injured tissue has now been abandoned. They can appear rapidly, even during the week following trauma. The predominant symptom is pain10 which is usually spontaneous, intense, continuous, at times excruciating and, more often than not, prevents the functional use of the limb involved. Characteristically, it is exacerbated by joint movement, as well as by being in an inclined position, by variations in temperature and by anxiety. In 69% of cases, the presentation of hyperalgesia or allodynia is described at the level of the affected limb. Most patients describe episodes of periarticular swelling and hyperhidrosis11 as the condition evolves, mainly with regard to the limb in question. They also report skin discoloration, often increased or caused by painful stimuli, stress loading, changes in body or surrounding temperature, as well as by being inclined.12 Despite a significant improvement in symptoms, the patient may complain of muscle fatigue and lack of coordination or endurance when undertaking manual tasks or those requiring fine dexterity. Severe disabilities can develop, even resulting in non-use of the limb or avoidance behaviour. Upon clinical examination, signs of sensitivity continue to suggest CRPS. Hyperesthesia, dysesthesia and hyperpathia are frequently observed.13 Allodynia is present in 30% to 74% of patients.14 Pain caused by lateral pressure on the metacarpophalangeal joints and by pulling on the fingers is highly indicative of the presence of CRPS. The first autonomic signs to look for are hyperhidrosis and edema.15 Fingers are often the first affected. Chronic recurrent edema can suggest a case of Münchhausen syndrome.16 The skin can become mottled, reddish or bluish. Changes in skin coloration and temperature are often caused by aggravating factors, and can vary in the course of a single day. T hey have very l ittl e s peci fici ty. The presence of bruising does not lead to a diagnosis of CRPS and should make us look for other etiologies. Motor function impairment is frequently observed, such as weakness, loss of active movement, coordination problems or dystonia. These problems tend to persist in the chronic phase and are, to a large extent, responsible for the loss of function. Loss of finger flexion or wrist extension appears early. Articular limitations at the shoulder joint are often LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 21 associated with the presence of CRPS at the distal extremity. Amyotrophy is most often related to non-use. Other trophic problems are seen in the chronic phase; nail splitting and growth disorders, hair loss or thin, shiny skin is seen in almost half the cases. It is still difficult to clinically distinguish between the normal course of an injury and CRPS in the first four weeks after the initial event, since the specificity of clinical examinations at this period is very low. Continuous pain, loss of active finger movement (difficulty in making a fist), hyperhidrosis or edema extending to the dorsal side of the hand or even to the forearm lead us to consider CRPS.17 Diagnostic criteria CRPS diagnostic criteria were first published in 1994 by the IASP.18 They led to an improvement in identifying the syndrome. Sensitivity was evaluated at 98%, but specificity at only 36%. Grouping vasomotor and sudomotor signs and symptoms within a single criterion could explain the low specificity. The absence of trophic and motor signs in the IASP criteria also prevented differentiating CRPS from other pain syndromes.17 In 2004, an expert panel proposed new diagnostic criteria that are now used by the majority of pain specialists. IN 2004, AN EXPERT PANEL PROPOSED NEW DIAGNOSTIC CRITERIA THAT ARE NOW USED BY THE MAJORITY OF PAIN SPECIALISTS. Diagnosis Diagnosing CRPS is based mainly on case history and physical examination. Clinical tests are used to rule out other pathologies. There is no clear link between radiological imaging and the clinical picture, regardless of the stage of the disease. Osteoporosis may never be present; it is not a diagnostic criterion. A bone scintiscan showing hyperfixation involving several joints of the affected limb during the third phase of the disorder – also known as the late or bony phase – has long been used as a good indicator of CRPS.19 However, very few prospective studies have enabled its evaluation as a useful diagnostic tool. Scintigraphy has a sensitivity of only 50% during the first six months following diagnosis; this is further reduced as the condition progresses.20 It is not a di agno stic criteri on. Interdisciplinary approach to rehabilitation and medication The treatment of CRPS presents a serious challenge because of our incomplete understanding of pain mechanisms. It requires an interdisciplinary approach for the purpose of preventing complications as well achieving remission and an acceptable quality of life for the patient.21 Immobilization for CRPS must be avoided. The fear of pain22 usually prevents patients from using the affected limb in daily life. It thus contributes to the persistence of pain and disability. Mobilizing the affected limb and integrating it functionally helps prevent or reverse the process of pain centralization which could lead to hemisensory neglect of the affected limb. Progressive motor activation seems to help reorganize the mental imagery of movement.23 The treatment sequence must be flexible to achieve adaptation to the clinical picture, the phase of the condition and the patient’s pain level. No controlled randomized studies have evaluated the impact of physiotherapy on the natural CRPS Diagnostic Criteria 1. Continuous and disproportionate pain in relation to the initial event 2. At least one symptom in three of the four following categories: a. Sensitivity: hyperesthesia b. Vasomotor: asymmetric variation in skin temperature or colour c. Sudomotor/edema: edema, asymmetrical sweating d. Motor/trophic: amplitude reduction and/or motor dysfunction (weakness, tremors, dystonia) or trophic changes (hair, nails, skin) 3. At the time of the exam, at least one sign in two of the following four categories: a. Sensitivity: hyperalgesia or allodynia b. Vasomotor: asymmetric variation in skin temperature or colour c. Sudomotor/edema: edema, asymmetrical sweating d. Motor/trophic: amplitude reduction or motor dysfunction (weakness, tremor, dystonia) or trophic changes (hair, nails, skin) 4. No other diagnosis that can better explain signs and symptoms. Source: Harden RN, Bruehl S, Stanton-Hicks M, Wilson PR (2007), Proposed new criteria for complex regional pain syndrome. Pain Med 8:326–31 22 LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 course of the disorder. However, it remains first-line treatment,24 although it does not produce beneficial effects in the chronic phase of CRPS.25 Controlling edema; desensitization techniques; active and prudent joint mobilization, based on patient tolerance; the intermittent use of a splint to rest the wrist and fingers; as well as avoiding aggravating factors are the approaches used.26 Passive or intensive exercises should be avoided for patients presenting with severe chronic pain or allodynia. Using the affected limb in the activities of daily life and during recreation is encouraged. A weight-relieving brace, with kneecap support, allows partial weight-bearing for patients who cannot tolerate putting weight on the foot. The use of a mirror to reprogram central motor function can be useful for patients presenting a motor disorder.27 Behavioural techniques can be added when there is movement phobia. 28 Patients can take part in a cardiovascular conditioning program according to abilities and interests. As the disorder evolves, psychological intervention can often prove essential for patients with CRPS.29 Depression is very often a major obstacle to rehabilitation, as is chronic anxiety disorder or post-traumatic stress syndrome.30 Pain control is key in the treatment of CRPS. Persistent pain, or pain that is too intense, prevents integration of the affected limb into functional activities. Relaxation or visualization techniques can be used. Multiple drugs are often necessary if, for example, anxious or depressed patients have, a sleep disorder or daytime sleepiness.31 Various drugs have been proposed for the treatment of CRPS; however only some of them have been evaluated in double-blind, randomized trials, with control groups. The efficacy of corticosteroids for CRPS is reported in the literature32,33 as well as that of nasal calcitonin in the acute phase.34,35 Bisphosphonates have proven to be effective in reducing pain and increasing joint amplitude, also in the acute phase, although optimal dosage regimens are still unknown.36,37,38 Tricyclic antidepressants are frequently used in the chronic phase. Anticonvulsants such as gabapentin39 and pregabalin40 have been shown to be effective in reducing neuropathic pain. Topical analgesic agents (aerosols, creams, gels or 5% lidocaine patches) have proven effective for neuropathic pain, including CRPS.41 Clinical experience has shown that muscle relaxants such as baclofen and tizanidine or intra-articular injections of corticoids can reduce pain. Opioids, administered in the acute phase for a short period, can facilitate functional reactivation during physiotherapy or occupational therapy. There is very little evidence to establish the best time, number and need for regional anesthetic techniques (sympathetic and parasympathetic nerve blocks) in the diagnosis and treatment of CRPS. Few randomized prospective studies have evaluated their effecticacy. Clinical evolution and prognosis With time, slightly more than 10% of CRPS patients experience a relapse, half of them without any new related event.42 Initially, the signs and symptoms are located at the site of the trauma. They can become more diffuse, migrate proximally or, far more rarely, to another limb.43,44 They can reappear more than two years after the initial symptoms. CRPS can last from a few weeks to several years. All patients do not progress towards an amyotrophic, dystonic picture or major functional crippling. Sixty-four percent of patients evolve relatively well over the years, but barely half of them have no symptoms. Only 15% recover grip strength that is more than 50% of their former strength.45 In more than 60% of cases, patients are restricted in their daily or domestic activities.46 Mood and sleep disturbances are frequent and quality of life is diminished.47 The pathophysiology of CRPS is still unknown to a large extent. Diagnostic criteria are still essentially clinical. A better understanding of this syndrome will prevent mistaken or missed diagnoses of CRPS. References Complete references for this article are available in page 44. S L * Dr. Beaudoin is physiatrist at the Institut de réadaptation Gingras-Lindsay de Montréal and associate professor at the Université de Montréal ** Dr. Bergeron is physiatrist at the CHUM (Hôpital Notre-Dame) and assistant clinical professor at the Université de Montréal *** Dr. Fugère is anaesthesiologist at Hôpital Maisonneuve-Rosemont LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 23 By Guylène Cloutier, MD* PSYCHIATRIST When Pain is Synonymous with Unhappiness... Mood Disorders and Chronic Pain The Role of the Psychiatrist in a Pain Clinic The psychiatrist plays an important role within the interdisciplinary team treating chronic pain. His or her sole mission is to confirm the existence of a psychiatric pathology with an impact on the clinical presentation and treatment of the chronic pain condition. Major depression and pain make up a complex clinical presentation and the exact interrelationships between these conditions have not yet been clearly established even though several hypotheses have been suggested. The treatment of chronic pain must involve the treatment of major depression, when it is present; a medical team that neglects one or the other of these facets risks giving rise to a chronic condition or, through the persistence of residual symptoms from one or the other, place the patient at risk of suffering a relapse. Psychiatrists are also sleep experts. Sleep disorders in patients with chronic pain are also associated with a more unfavourable prognosis. Insomnia can aggravate psychological and somatic symptoms. Chronic Pain and Depression: the Chicken or the Egg? Pain, especially when it is acute, is a sensation that plays a role in survival. When this sensation extends over a long period of time, regardless of whether the cause can be identified and treated, it becomes chronic pain, which is a predisposing factor for depression. Approximately 40% to 60% of individuals with chronic pain will suffer from major depression. Depression itself also brings on pain, pain that is not only emotional but physical. For several years now, although pain as a symptom is not a diagnostic criterion for major depression, researchers have agreed that pain symptoms (headaches, back pain, musculoskeletal pain, muscular tension, heartburn, etc.) can be part of a mood disorder in about 60% to 85% of cases. Some people have criticized the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSMIV-TR) for giving psychological criteria priority over somatic criteria. Not only are these types of pain part of the clinical presentation, but the treatment of this disease can occasionally lead to the complete resolution, or at least the alleviation of this category of symptoms. 24 LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 Depression and pain have a complex and reciprocal relationship. Each of these conditions aggravates the severity of the other. Pain is an obstacle to the achievement of remission in the patient who suffers from a depressive episode. Depression accentuates an individual’s pain. The overlapping of pain and depression demonstrates the need for combined and simultaneous treatment of both medical conditions. Is Depression a Weakness of Character? Depression is a disease that is still too often tainted with shame. In Canada, in 2002, 4.8% of the population suffered from a major depressive disorder. One person out of five will suffer from depression during the course of their lifetime. Depression does not strike randomly: clearly identified risk factors can predispose us to the development of this medical condition. The presence of chronic pain increases the risk of developing major depression. Although major depression can be qualified as mild, it will still require pharmacological treatment or psychotherapy. Left untreated, it modifies the neurobiological structure of the brain and causes emotional, physical and/or cognitive symptoms that can be irreversible if they persist for several years. Fortunately, major depression, when it is treated early and effectively, can also at times be completely healed. This is one of the reasons why we must continue to demand better access to first-, second-, and third-line care. People suffering from depression and those around them tend to find a multitude of reasons to account for the presence of depressive symptoms: “You have to understand, she’s just lost her job. Her daughter is very ill. He’s suffering so much; I’d be depressed too if I were in his shoes. He just has to push a little. She likes to wallow in her sadness.” It is essential to treat depression as early as possible if we want to avoid it progressing to a chronic state. Sleep Disorders Sleep disorders are closely associated with psychiatric problems and chronic pain conditions. The three conditions make up an infernal triangle for the patient. The presence of insomnia is associated with greater morbidity in the primary condition. Text adapted by the author especially for Le Spécialiste. The original text was published in Working together When Facing Chronic Pain. Les Productions Odon, Laval (2010), www.productionsodon.com Several epidemiological studies have shown that patients with insomnia tend to present with more serious psychic distress as well a reduced capacity to manage stressors. Chronic pain is associated with a greater prevalence of sleep disorders. Pain aggravates sleep disorders and sleep disorders negatively alter the perception of pain. Sleep disorders can include difficulty falling asleep, difficulty staying asleep or sleep that is not perceived as having been restful by the patient. This last category has been studied especially in fibromyalgia patients. Treatments studied up to now include cognitive-behavioural interventions, teaching the patient good sleep hygiene, as well as a regimen of physical activities. Pharmacological treatments that have been the subject of studies include the benzodiazepines (triazolam), tricyclic antidepressants (amitriptyline) as well as zolpidem and zopiclone. These molecules have not however been successful in reversing EEG anomalies encountered in insomniac patients. The close availability of a psychiatrist is then of great assistance. Along the same lines, psychotherapy plays an essential role as well. It must focus on change, not only on providing reasons for an individual’s difficulties. Cognitive and behavioural interventions are those that have been studied the most. Conclusion Some people have wanted to believe that major depression results from a lack of courage, that it is a failure, a reflection of a patient’s inability to adapt to a chronic pain condition. This is not so. Depression is not synonymous with weakness, regardless of the cause. It is a disease that can have lasting effects, and that can recur if it is not treated in time. Depression is contagious: the spouses and children of those who suffer from depression are more at risk of becoming depressed themselves. Depression can result in death (15% risk of successful suicide). Depression must be treated, whatever its cause. Treating Major Depression Several chronic pain conditions are being treated with increasing effectiveness. Certain types of chronic pain, combined with a mood disorder or a functional somatic syndrome, have not yet been characterized and are occasionally attributed, at least in part, to faking or exaggeration on the part of the patient. If the treatment is to succeed, health professionals and patients must share the same understanding of the clinical picture and the treatment plan. A therapeutic partnership is essential and is built upon the quality of the dialogue between the care-giver and the patient. Several therapeutic means can be chosen to treat mild or moderate depression. Commonsense is always appropriate and good personal health practices may lead to a prompt recovery. It is often necessary and essential to add other therapeutic means, such as a pharmacological treatment or psychotherapy, or a combination of these. Medication includes various classes of antidepressants, several of which are also used to treat pain conditions that are not necessarily associated with depression. As mentioned earlier, these various conditions probably share common psychopathological mechanisms. When antidepressants are used by non psychiatrists, it is important to take into consideration the possible existence of depression associated with a bipolar disorder that can sometimes clinically resemble major depression, but that is associated with a response that can be catastrophic (euphoric, depressive, or mixed episodes). References CME Institute. Academic highlights, depression and pain. J Clin Psychiatry 2008 ;69:1970-8. Fava M. Somatic symptoms, depression, and antidepressant treatment. J Clin Psychiatry 2002 ; 63:305-7. Gameroff MJ, Olfson M. Major depressive disorder, somatic pain, and health care costs in an urban primary care practice. J Clin Psychiatry 2006;67:1232-9. Graziono O, Bernabei R. Association between pain and depression among older adults in Europe: Results from the aged in home care (AdHOC) project: a cross-sectional study. J Clin Psychiatry 2005 ;66:982-8. Lee P, Dossenbach M. Frequency of painful physical symptoms with major depressive disorder in Asia: Relationship with disease severity and quality of life. J Clin Psychiatry 2009 ;70:83-91. Ohayon MM. Specific characteristics of the pain/depression association in the general population. J Clin Psychiatry 2004 ;65(suppl 12):5-9. Stahl SM. Stahls’ essential psychopharmacology, Neuroscientific basis and practical applications. Cambridge: Cambridge University Press, 2008. Workman EA, Hubbard JR, Felker BL. Comorbid psychiatric disorders and predictors of pain management success in patients with chronic pain. Primary Care Companion. J Clin Psychiatry 2002 ;4:137-40. Zimmerman M, McGlischey JB, Posternack MA, Friedman M, Boerescu D, Attiullah M. Differences between minimally depressed patients who do and do not consider themselves to be in remission. J Clin Psychiatry 2005;66:1134-8. Benca RM, Ancoli-Israel S, Modolfsky H. Special consideration in insomnia diagnosis and management: depressed, elderly and chronic pain populations. J Clin Psychiatry 2004 ;65(suppl 8):26-35. * The author is psychiatrist at the Clinique États d’Esprit. S L LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 25 By René Truchon, MD* ANESTHESIOLOGIST Neuropathic Pain Of the three principal types of chronic pain, neuropathic pain is the one that has seen enormous progress with respect to understanding its underlying mechanisms and developing new pharmacological agents. Chronic pain affects approximately 20% of the adult Canadian population, ranking it ahead of diabetes and asthma. Recent Canadian surveys reveal that 5.7% of the pediatric population also suffers from chronic pain. Moreover, neuropathic pain affects 2% to 3% of the Canadian population which represents close to one million Canadians. Physiopathology can be used to classify chronic pain into three broad categories (excluding visceral pain): nociceptive, idiopathic (psychological) and neuropathic. The underlying mechanisms are complex and involve a multitude of receptors and biochemical substances. When the pain process becomes chronic, various types most often overlap resulting in what is called mixed neuropathic pain. Pure neuropathic pain, as a result, is clinically rarer. In this article, we will only discuss the neuropathic component of chronic pain. Neuropathic pain results from a dysfunction of the nervous system at several levels (brain, spinal cord and peripheral nerves). It is important to understand that once pain has become chronic, it is independent of the initial trauma or lesion and is maintained by the patient’s own nervous system. The syndrome then evolves according to the dysfunction of the nervous system, not necessarily as the consequence of an anatomical pathology. Pathophysiology Unlike nociceptive pain which we feel as a result of tissue trauma when we burn or prick ourselves, neuropathic pain results from a dysfunction of the nervous system at various sites throughout the human body. It is maintained by the nervous system itself, even when the initial trauma or painful lesion is healed. Notable changes in the nervous system (brain, spinal cord, nerves) involved in the appearance of neuropathic pain include: • Spontaneous discharge of painful impulses from peripheral nerves and the spinal cord, which causes the patient to experience electrical discharges; • At the level of nerves and the spinal cord, increased transmission and amplification of normal nerve impulses; for example, where touch is concerned, the signals can be perceived as a burning sensation rather than a light stroke of the skin (allodynia); 26 LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 • The appearance of spontaneous impulses from the pain coordination center (the thalamus may present phenomena similar to the ones observed in the nerves and spinal cord); these spontaneous discharges can themselves be painful or exaggerate pain messages from other regions of the body. In addition, at the level of the spinal cord, the mechanisms in a healthy subject that partially block the conduction of pain signals to the brain, have become very weak or inexistent in the affected patient, thus increasing the sensation of pain. Numerous protective hormones, such as endorphin, serotonin, noradrenaline and various neurotransmitters, become much less effective at reducing or blocking neuropathic pain. Thus, in order to relieve neuropathic pain, the physician will use specific classes of medication that will act on the different portions of the nervous system: • On the cutaneous or mucous levels, by blocking the spontaneous triggering of pain and the conduction of painful impulses: this is the mode of action of local topical anaesthetics, such as lidocaine; • On the medullar and cerebral levels, by blocking the transmission of pain signals with anticonvulsants (pregabalin and gabapentin) or antidepressants (amitriptyline, venlafaxine, duloxetine) that modify the action of serotonin and noradrenaline that our body produces. • When pain is intense or disabling, treatment on both peripheral and central levels will be sought through the use of medication with analgesia as the principal effect: opioids (morphine, hydromorphone, methadone), tramadol, and acetaminophen. Symptoms Chronic pain with a neuropathic component is accompanied by numerous physical signs and symptoms (see table). The specific characteristics of neuropathic pain include the perception of a cutaneous burning sensation, spontaneous and continuous spasms often associated with tingling sensations or electrical shocks in a given region. Other symptoms are allodynia, hyperalgesia or hyperpathia. The physician will systematically look for pain located more distally, but still linked to the injured area (for example, pain in the right hand after a lesion to the right shoulder). When nerve tissue has suffered a direct lesion, the healing process attempts to repair the injury in the following weeks or months. Thus, a nerve that has been cut or crushed tries to regenerate by forming a bud or neuroma. The latter can automatically trigger activity in the damaged nerve, which the patient experiences as an electrical discharge or muscular contraction. Moreover, neuromas cause exaggerated responses to touch. The patient describes extreme sensitivity to touch and spontaneous tingling sensations. At times, the sympathetic component of the nerve may be affected by the same nerve dysfunction that provokes neuropathic pain. The syndrome is then called complex regional pain syndrome (CRPS). Autonomic signs and symptoms develop superfluous components that are characterized by a sensation of burning heat or cold in a painful or injured part of the body. A complete limb may be affected and develop edema and present sudomotor anomalies or abnormal hair growth that may increase or totally disappear. Very frequently, sudden variations in colour in the painful region can manifest themselves; for example, the affected hand becomes deep red or pasty white. Without specific treatment, such as a sympathetic nerve block combined with intensive physiotherapy, a limb affected by complex regional pain syndrome may become totally disabled, with severe atrophy of the muscles, complete ankylosis of the joints, swelling of the fingers, and continuous pain. At the severe dystrophy stage, the affected hand can also become twisted into the shape of claw if it is not submitted to intensive treatment rapidly. Pain treatment centres undertake the evaluation of this condition and provide urgent treatment. Characteristics of Neuropathic Pain • Sensation of cutaneous burn • Spontaneous and continuous spasms • Spontaneous or provoked tingling or electrical discharges • Allodynia: pain caused by a stimulus that is not intrinsically painful • Hyperalgesia: intense pain perceived when the triggering stimulus is only slightly painful • Hyperpathia: long-term, intense pain after repetitive pain is provoked Multi-Dimensional Evaluation During the patient’s initial evaluation, the physician makes an indepth examination of the events that led to the problem; he will be looking for clinical signs of neuropathic pain through the use of specific and multi-dimensional evaluation tools such as the following questionnaires: EVA, McGill, BECK, MPI, BPI, MMPI2, SIP, etc. These questionnaires are used to measure the functional, psychological and social effects on the individual. Neuropathic Evaluation Various specialized questionnaires enable us to measure the impact of neuropathic pain (Neuropathic Pain Scale, DN4 and Pain Detect). These have been validated scientifically and are used as well to track the progress of treatments, both physical and psychosocial. Treatment The treatment of neuropathic pain has three objectives: 1. to minimize the pain or make it tolerable; Most common sources of neuropathic pain CENTRAL • • • • • • • Hemicorpus pain following a CVA AIDS-related myelopathy Spinal cord injury Multiple sclerosis Phantom limb pain Parkinson’s disease Spinal cord lesion PERIPHERAL • • • • • • • • • • • Trigeminal neuralgia Complex regional pain syndrome Nerve compression in a limb Nerve damage caused by HIV Diabetic neuropathies Postherpetic neuralgia Post-thoracotomy and post-thoracoscopy neuralgia Radicular disc herniation Neuropathy following anti-cancer chemotherapy Nerve amputation (as part of a limb amputation) Post-mastectomy pain 2. to improve the functioning of the body and the individual; 3. to improve the patient’s quality of life. These objectives have to be reached with a minimum of side effects from treatments and medication. All therapeutic means must be integrated into the patient’s treatment schedules and plans, while relying on his or her active involvement in the therapy. Non-Pharmacological Treatments Non-pharmacological categories: treatments include the following • Physical treatment (physiotherapy, occupational therapy, kinesiology); • Rehabilitation and psycho-social treatments (psychiatric and psychological evaluations and treatments, individual and group therapies); • Evaluation of the patient’s social and professional circumstances along with current and future effects resulting from the neuropathic pain syndrome diagnosis. LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 27 Text adapted by the author especially for Le Spécialiste. The original text was published in Working together When Facing Chronic Pain. Les Productions Odon, Laval (2010), www.productionsodon.com Pharmacological Treatment Pharmacological treatment of neuropathic pain follows treatment algorithms developed by experts. These were based on the evaluation of treatment protocols, randomized and controlled studies and a systematic review of the therapeutic effectiveness of various pharmacological agents. When neuropathic pain is diagnosed, the first objective is to relieve the pain by following the recommendations contained in the Québec treatment algorithm for neuropathic pain. Treatment starts with the use of a single agent (in Class 1). Following this, a second pharmacological agent may be combined with the first or may be substituted for it. When certain symptoms are present, specific therapies, such as the use of a topical anaesthetic (lidocaine) or a ketaminebased cream may be proposed, as is done in the case of postherpetic pain. Depending on circumstances, an antidepressant can be prescribed to provide pain relief (nortriptyline, amitriptyline, desipramine and venlafaxine). Medication can also be prescribed to prevent painful impulses from being conducted through the spinal cord. Other drugs can also be used at the start of the treatment, such as anticonvulsants that block pain through their effect on the alpha-2-delta nerve receptor. For patients with severe, debilitating pain, analgesic medication can be administered concomitantly, namely a morphine derivative or tramadol. The purpose of adjusting the medication is to obtain pain relief with an EVA evaluation of less than 4/10 or tolerable for the patient. Pharmacological treatment that effectively inhibits pain will frequently involve a combination of several medications from the four classes in the treatment algorithm. These medications will be adjusted to obtain the fewest side effects possible with effective relief. Specialized Treatments at a Pain Treatment Center Pain treatment centres are located in large urban centres. The advantage of these centres lies in the multidisciplinary and interdisciplinary treatment team who have superspecialized invasive techniques available. These services are offered to all the patients who have not responded adequately to the treatment algorithm’s Class I and Class 2 medications, even though they have been receiving physical and psychological therapies. In the case of CRPS, specific treatments include sympathetic and parasympathetic nerve blocks, chemical or thermal neurolysis, epidural cortisone injections or cortisone * The author is medical director of the RUIS Université Laval Chronic Pain Centre. injections near a nerve root, and the destruction of small sensitive fibres or neuromas by radiofrequency techniques. Neuromodulation may also be proposed. Major pain treatment centres can also call upon specific programs to combine interventions by several practitioners (physical medicine, rehabilitation, psychology, psychiatry, anaesthesiology, etc.) so as to improve the physical, psychological and social aspects of the patient’s life. Treatment Options for Chronic Neuropathic Pain PHYSICAL • Normal physical activities • Swimming, physiotherapy, passive and active occupational therapy • Stretching • Physical training • Weight loss • Massage and acupuncture • TENS • Physical rehabilitation • Physical retraining PSYCHOLOGICAL • Psychotherapy • Stress management and reduction • Behavioural therapy • Cognitive therapies • Mirror imaging • Reprogramming • Individual and group therapies • Family therapy INVASIVE PROCEDURES • Steroids • Infiltration anesthesia • Sympathetic block • Peripheral and central nervous blocks • Therapeutic epidurals • Specific rhizotomy by radiofrequency treatment or by cryotherapy • Implanting central and peripheral spinal stimulation • Spinal injection of opiates with co-analgesics in a closed circuit • Nerve decompression surgery • Central cerebral stimulation PHARMACOLOGICAL • Canadian and Québec pharmacological protocol for the treatment of neuropathic pain The goals of the ‘best’ therapy • • • • • Greatest evidence of effectiveness; Most readily available; Least costly; Fewest secondary or harmful effects; Least painful. S L 28 LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 By Christian Cloutier, MD* NEUROSURGEON Neuromodulation There are many approaches to dealing with pain: drug therapy, physical therapy, psychological therapy, etc. Occasionally, these approaches do not successfully relieve painful conditions, particularly those of a neuropathic nature and it then becomes necessary to refer the patient to a physician for an invasive treatment. Occasionally, curative surgery is indicated (for a herniated disk, a nerve compressed by a pulsating artery, etc.), or the implanting of a neuromodulation device for certain types of refractory pain (in pre-selected and well-prepared patients). These treatments may appear risky, yet, since they are known to be effective, they may be less dangerous than the over-use of conventional approaches. Above all, they can be very beneficial for the individual who is dealing with severe, incapacitating pain that is destroying his or her life. When so-called conservative medical treatment fails, it is occasionally possible and necessary to have recourse to what are known as invasive techniques (surgical). As mentioned previously, any treatment for chronic pain must be multimodal. Health Canada had already put out the following warning in 1990: “… no specialty or therapeutic intervention can remedy this problem on its own. We can only overcome it by calling upon the skills of specialists in several disciplines.” In certain cases of severe, rebellious and refractory pain, the patient must be referred to an interventionist surgeon. Most often, this will be a neurosurgeon. Surgical Approaches Curative surgical approaches Occasionally, there is a clear indication for surgery to correct the cause of the pain, as in the case of a herniated disc, lumbar spinal stenosis, a tumorous mass, a vascular loop compressing the trigeminal nerve (causing facial pain like an electrical discharge), etc. There is a possibility these surgical treatments will remedy the anomaly and often eliminate the pain completely. However, certain types of interventions that create lesions (destructive) are very useful in certain situations, such as irradiating the Gasserian ganglion of the sensitive facial nerve (trigeminal nerve), with a Gamma Knife. This device creates a partial lesion through ionized radiation with concentrated gamma rays on the ganglion. In order to relieve facet pain (one of the causes of neck pain and non-specific lower back pain), we can perform a thermolesion on the posteromedial branch of the nerve of the zygoapophyseal joint (the posterior joint of the vertebra, called the facet). Such a procedure is indicated for patients who experienced adequate but temporary relief (lasting only a few weeks) following an infiltration (xylocaine and cortisone). Thermolesion provides an extended, but highly variable effect (a few months to a few years). Augmentative surgical approaches Finally, there are the augmentative surgical approaches, so called because they involve the addition of specialized equipment, such as neurostimulators or intrathecal pumps. If no beneficial analgesic effect is obtained, the equipment is removed and there is usually no consequence for the patient nor, more importantly, any damage to the central nervous system. Neuromodulation The term ‘neuromodulation’ refers to a specialized medical treatment, used to modulate the functioning (and not alter the anatomy) of the nervous system and to alleviate pain. This is done by surgically implanting a device that either electrically stimulates or chemically inhibits the transmission of the signal or neuron activity, in order to produce a therapeutic effect. Two very different systems are used: • The first, known as neurostimulation, consists of electrically stimulating certain parts of the nervous system (the spinal cord or the brain); • The second involves injecting substances into the cerebrospinal fluid in the spinal column through an intrathecal pump. Destructive surgical approaches For a long time, it was believed that cutting off the painful nerve impulse was the only effective solution. For example, the nerve or nerve bundle was sectioned in the spinal cord at the level corresponding to the zone of pain. Nowadays, we know that the central nervous system reacts very poorly to such an insult, that the pain returns within 6 to 12 months, often intensified, and that the consequences of a loss of function can be devastating. These approaches are rarely used, except in the case of palliative care provided to terminal phase patients, with a life expectancy of less than three to six months. Compared to destructive techniques, neuromodulation systems are clearly better in clinical terms. Before an internal neuromodulation system is installed, care must be taken to accurately identify the medical pathology, as well as ensure the patient is a good candidate for this invasive surgical approach (indication and risks), that he or she is psychologically prepared to undergo this type of surgery (profile, expectations) and that he or she has a clear understanding of the consequences of the surgery. LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 29 Text adapted by the author especially for Le Spécialiste. The original text was published in Working together When Facing Chronic Pain. Les Productions Odon, Laval (2010), www.productionsodon.com The exact mechanisms involved in neuromodulation through the stimulation of the posterior cords of the spinal cord remain unknown: electrical effect on the neurotransmitters of the posterior horn or activation of the long ascending or descending nerve bundles of the spinal cord. These interventions are called invasive because there is a risk of complications. The one most feared is an epidural hematoma (rare: 1 case out of 700) along with paraparesis, or even paraplegia, a paralysis of the lower limbs with urinary incontinence. Most often, it can be reversed through the exeresis (removal) of accumulated blood, but there is a very low possibility of irreversible damage. Does the effect occur at the spinal level, where the electrode is placed, or at the supraspinal level; or at the cerebral level from a distance? Articles in the past related evidence that stimulation was only effective 50% of the time over the long-term.1 In 2007, a group of researchers at the European Federation of Neurological Societies (EFNS) published a complete review of the literature, encompassing the most recent articles based on evidence.2 This review attributes B-level effectiveness, i.e. probably effective, to neurostimulation in cases of refractory lumbar sciatica (or Failed Back Surgery Syndrome, for patients with at least one but especially several lower back operations); and cases of Type 1 complex regional pain syndrome (CRPS), i.e. the type with no neurological lesions. In the most refractory situations, it is possible to place the electrode in the cortical motor epidural region of the brain when dealing with neuropathic pain, or to insert the electrode in the thalamus for nociceptive pain. Motor cortex stimulation or MCS, the type most commonly used at present, produces good results4 for neuropathic pain of the face and arms, and for pain secondary to a cerebral vascular accident (CVA), formerly referred to as thalamic syndrome. Neuropathic pain in the lower limbs is excluded, since there is a problem with accessibility and the procedure for inserting the electrode on the median line (of the brain), the falx cerebri. Neurostimulation, spinal cord and brain The review attributed D-level effectiveness, or the one based on descriptive, non-comparative studies, for the relief of pain caused by Type 2 CRPS (with nerve damage); a traumatic, diabetic or postherpetic neuropathy; a plexopathy; an amputation (phantom limb) or a partial spinal injury. To summarize, effectiveness is recognized for neuropathic lesions, particularly those that are peripheral and result in neuropathic pain, clearly identified by means of the DN43 questionnaire, and which must be accompanied by a sensory deficit, a state of deafferentation. On the other hand, purely nociceptive pain (somatic and visceral, not neurological) does not respond to this technique, unless the cause is vascular, as in the case of chronic ischemia of the lower limbs, and serious refractory angina. Once again, the mechanism is not understood, although probably managed by interaction via the autonomic sympathetic system, since neurostimulation serves to improve vascularization. Results for these patients are excellent in the context of a progressive disease. The condition improves initially, then deteriorates in the long term, but with a lot less pain. It is difficult to conduct comparative placebo-controlled studies on surgical treatments with equipment installation; such randomized studies are rather rare. Yet, the lack of evidence does not necessarily mean the absence of effectiveness. The relief rate is 70% to 85% for well-selected cases. In a review of 101 patients, conducted by the author, the effectiveness rate was 85% (article in preparation). It should not be forgotten that we are at the top of the ladder in terms of pain treatment. The cases selected were difficult-to-treat refractory ones. Intrathecal pump The intrathecal pump is exceptionally effective in the case of spasticity (using baclofen), and significantly effective in the case of refractory pain, particularly neuropathic pain (using an anaesthetic substance, an opiate or clonidine). It is possible to insert a catheter in the spinal column and the pump under the skin of the abdomen without too great a risk. The principal inconvenience for the patient is the need to return to the outpatient clinic every three months to fill the pump, except for baclofen, where this can be done every six months if the amount to be injected does exceed the capacity of the pump‘s reservoir. This localized and targeted pharmacotherapy5 allows a gradient of 100:1, on average, for the dosage the patient is to receive. As a result, systemic secondary effects can be reduced considerably, except in the case of opiates that deregulate the hypothalomo-hypophyseal axis. This could create a series of endocrinal problems, for example, this could result in amenorrhea for women and hypogonadism in men. Conclusion As in any other surgical intervention, these invasive techniques can result in complications which are for the most part perioperatory, yet rarely significant and permanent. For this reason, these invasive approaches are reserved for well selected clinical conditions. In a therapeutic context, at times both difficult and burdensome, this approach serves not only to reduce the pain but also to increase the physical activities of daily life and reduce the quantity of drugs that in turn have their own load of complications. References * The author is clinical Professor, Department of Surgery, Centre hospitalier universitaire de Sherbrooke (CHUS); President of the Quebec Pain Society; Medical Officer, Pain Expertise Centre, Sherbrooke RUIS. Complete references for this article are available in page 45. S L 30 LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 GREAT NAMES IN QUEBEC MEDICINE By Patricia Kéroack Where There’s a Will, There’s a Way “Why is my best friend poor, and why does she live in such difficult conditions?” These were Christine Colin’s first great observations as a youngster living in Nancy and discovering the extent of social inequities. The painful observation created the desire to find an explanation and a solution, in order to compensate for the negative effects linked to social differences. Extremely gifted in science, one day she received the book Great Men of Medicine by Ruth Fox Hume as a school prize; she found it fascinating. She realized that medicine was the path she could follow some day to help people, and it was the clinical side that attracted her. However, during the course of her studies and meeting professors who had an influence on her, she realized that fixing a broken arm was easy; but if we could avoid breaking the bone, the situation would be better, both for the person and for society. That was what made her opt for a career in public health, bringing together the prevention aspect and the battle against inequalities in healthcare. She received her medical degree in France, where her thesis dealt with the epidemiology of newborns from disadvantaged areas. An in-depth study of patient medical files caused her to observe that the incidence of certain problems, such as premature birth rates, delayed development and the low birth weight of the newborns was directly related to living conditions, as well as health problems suffered by the mothers. Her thesis gave her a desire to follow through on the question. Then, she received a proposal to continue her training in Quebec. She fell in love with Quebec and... with a Quebecker, with whom she has two children. Since 1985, Dr. Colin has worked as a medical specialist in the field of community health, department head and director of the community health department, while at the same time being a professor (at the clinical level, as a full professor, then as a tenured professor). She became the first dean of the Faculty of Nursing Sciences at the Université de Montréal who did not hold the professional title of nurse. She published and produced numerous prevention programs, including Naître égaux – Grandir en santé and Le défi de l’intervention prénatale en milieu défavorisé. Dr. Colin says she has never had a career plan. “I knew I wanted to work on identifying the healthcare needs of the underprivileged and set up prevention programs to respond to them.” She did everything possible to advance the fight against social inequity: developing strategic plans, taking stands and presenting reports to parliamentary committees. She took advantage of every opportunity to defend her ideas and her convictions. Recognized for her expertise, she was selected to fill the position of Assistant Deputy Minister for Public Health and General Manager of Public Health (MSSS) in 1993; a position, however, that would force her to live away from her family. She was convinced that the position would help her advance public health issues. But the political environment at the time was difficult, with Quebec going through a period of severe budgetary cutbacks and major reforms. Dr. Christine Colin Community Health Specialist With respect to her time at the MSSS, Dr. Colin has good memories of the major projects to which she contributed a great deal. She is especially proud of the production of the first Quebec public health priorities (1997-2002), upon agreement between the various parties. She is also glad she helped create the Institut national de santé publique du Québec, and was in at the beginning of the redistribution of regional financial resources. Back in Montreal, Dr. Colin became Director of the International Adoption Secretariat, an ideal position for someone who has for years represented Quebec on missions abroad. Since 2010, she has directed the Health Promotion Centre of Sainte-Justine University Hospital Centre, an innovative project that draws together all those who care about children. Dr. Colin is currently on a sabbatical from the university: a period to recharge her professional batteries, but definitely not a rest, as she maintains her hospital obligations and her international schedule. And these already keep her busy full-time! If we had to summarize Dr. Colin’s career, we could certainly say she is a physician who is totally committed to her professional practice, someone with vision who knows how to bring together all areas of public health, whether at the level of management, planning and practical aspects, as well as field organization. It is therefore not surprising that she has received numerous prizes and awards for an exceptional career. In June 2010, Dr. Christine Colin became a Chevalière de l’Ordre national, the highest distinction awarded by the government of Quebec. S L LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 31 CONTINUING PROFESSIONAL EDUCATION By Gilles Hudon, MD DIRECTOR, HEALTH POLICIES AND PROFESSIONAL DEVELOPMENT OFFICE 3rd Cycle Changes RCPSC Maintenance of Certification Program Officially launched in 2001, after a one-year pilot project, the first and second five-year cycles of the Maintenance of Certification (MOC) Program ended in 2005 and 2010 respectively. The program’s third cycle starts in 2011 and changes are being made at 3 levels: the educational activity framework is reduced from 6 to 3 sections; the number of credits granted for each hour of learning is unchanged for certain activities, reduced or increased for others; finally, the requirement for 400 credits over 5 years or, at a minimum, 40 credits per year remains unchanged, although no more than 75% of credits will be applicable to a single section within a cycle from now on. In 2010 in Quebec, 6,077 medical specialists were Fellows and close to 90% of them participated in the MOC program. In addition, some 325 Quebec medical specialists not certified by the Royal College also took part in the Royal College of Physicians and Surgeons of Canada’s (RCPSC) continuing professional development program (CPD). Framework of activities During its first 10 years, the MOC offered Fellows a framework of educational activities divided into 6 sections. This framework was widely criticized by Fellows because, after 10 years, they claimed they still could not memorize it. The lack of logic in the presentation seemed to annoy many. From now on, the new framework will contain three sections in an easily-remembered order: group learning activities (certified or not), self-learning activities and assessment activities (knowledge assessment and performance assessment). New credit system The first 2 cycles have kept the same initial system of credits or learning units, whereby only non-certified activities in section 2 have a limit of 20 credits per year, for a total of 100 credits per 5-year cycle. The program’s designers had assumed that over the years Fellows would use the more personal type of activities, such as the certified selfassessment programs (section 3), structured educational projects (section 4) or practice assessment (section 5). That was their aim, but the reality turned out to be different. Credited group activities, basically conferences and hospital meetings, was the section used most often to claim credits: 32 LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 a Fellow could meet the requirements of the Maintenance of Certification Program by just passively attending accredited group activities. Almost everywhere around the world, CPD is increasingly being defined as an endeavour to improve the quality of care and not simply the acquisition of new knowledge. In the United States, a new association, the National Institute for Quality Improvement and Education (NIQIE), wants to abolish continuing medical education in classrooms and move it to the workplace, calling for it to be coupled with Continuing Quality Improvement (CQI) Departments in U.S. hospital centres. In France, the new HPST (Hôpital Patient Santé Territoire) law defines CPD as being a combination of continuing medical education (CME) and the assessment of professional practice (APP). Thus, the current direction taken by the RCPSC is not a Canadian invention, but follows the CPD trend taken in all Western countries. The proposed new credit system encourages Fellows to devote more time to reflection and self-assessment of their practice. An assessment activity would thus allow a Fellow to claim three learning units per hour of participation. On the other hand, group learning activities would continue to receive one credit per hour of participation, while noncertified activities would be reduced to one-half credit per hour of participation. Self-learning activities will no longer be evaluated based solely on the number of hours of participation, but also in terms of accomplishment. Credits for personal learning projects will be increased to two per hour, and reading specialized journals would receive one credit per activity. Developing guidelines or taking part in a patient safety committee would receive 20 or 15 credits per year, respectively. Useful links towards the MOC Section www.collegeroyal.ca/mdc www.collegeroyal.ca/mainport CONTINUING PROFESSIONAL EDUCATION @SUITEA Concerns The members of the RCPSC Board are aware that altering the MOC some medical specialists’ concerns as to their ability to carry out knowledge or performance assessment activities. Such concerns are legitimate, but they should resolve as the appropriate tools are made available to medical specialists. Other specialists wonder how they should evaluate their own practice and foresee a gigantic and insurmountable review of files, etc. Some authors1 have already started on the task and have found that reviewing 10 clinical charts is enough to gain a valid assessment of a particular aspect of a medical specialist’s practice. This is a reassuring finding. This personal assessment, which is simple to undertake in one’s own setting, also meets the concerns of other physicians who have found it especially taxing, both in time and money, to have to travel to medical conferences that do not necessarily prove of benefit to them. Various measures will be taken to assist medical specialists. At the RCPSC level, the Director of Professional Affairs has set up a team of CPD educators to help their colleagues with their own CPD. Two Quebec medical specialists have accepted the invitation: Dr. Sam Daniel, an ENT specialist at the Montreal Children’s Hospital, and Dr. Nina Verreault, an allergist at CHUL Quebec City. The FMSQ Office of Professional Development (OPD) will develop the necessary tools to facilitate access to sections 2 and 3 of the new program. It will also continue to be available to assist Continuing Professional Development units of the affiliated associations. Finally, the OPD remains available to any medical specialists seeking help or answers in managing their own continuing professional development. Additional information is available on the Royal College’s website at http://rcpsc.medical.org/opa/moc-program/ index.php or by contacting your CPD leader (Dr. Sam Daniel in Montreal or Dr. Nina Verreault in Quebec City) via e-mail at ens-dpc4@ collegeroyal.ca (same e-mail address for both educators). 1 À votre agenda Vendredi 11 novembre 2011 Palais des congrès de Montréal ASSOCIATIONS PARTICIPANTES : Association des médecins psychiatres du Québec Association des obstétriciens gynécologues du Québec Association des médecins rhumatologues du Québec Association des médecins microbiologistes infectiologues du Québec Association des pneumologues de la province de Québec Association des médecins spécialistes en santé communautaire du Québec Association Québécoise de chirurgie Association des radiologistes du Québec Association des médecins hématologues et oncologues du Québec Association d'oto-rhino-laryngologie et de chirurgie cervico-faciale du Québec Association des médecins radio-oncologues du Québec Wooster DL. A structured audit tool of vascular ultrasound interpretation reports: a quality initiative. J Vascular Ultrasound 2007;31(4):207-10. S L Détails à venir sous peu LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 33 LA DÉMOCRATIE NE S’ACHÈTE PAS POUR PRÉSERVER LA CONFIANCE EN NOTRE DÉMOCRATIE, L’ASSEMBLÉE NATIONALE A ADOPTÉ DE NOUVELLES RÈGLES DE FINANCEMENT DES PARTIS POLITIQUES 7RXWHFRQWULEXWLRQGHHWSOXVGHVWLQpHjXQSDUWLSROLWLTXHjXQGpSXWpRXjXQ FDQGLGDWLQGpSHQGDQWDXSDOLHUSURYLQFLDOGHYUDGRUpQDYDQWrWUHYHUVpHDX'LUHFWHXU JpQpUDOGHVpOHFWLRQV /HVpOHFWHXUVGRLYHQWVHOLPLWHUjXQGRQPD[LPDOGHSDUDQQpHjFKDFXQ GHVSDUWLVGHVGpSXWpVHWGHVFDQGLGDWVLQGpSHQGDQWV /¨pOHFWHXUGHYUDGpFODUHUSDUVDVLJQDWXUHTXHVDFRQWULEXWLRQHVWYHUVpHjPrPH VHVSURSUHVELHQVYRORQWDLUHPHQWVDQVFRPSHQVDWLRQQLFRQWUHSDUWLHHWTXHFHWWH FRQWULEXWLRQQHSHXWIDLUHO¨REMHWG¨XQTXHOFRQTXHUHPERXUVHPHQW 1RVORLVpOHFWRUDOHVSUpYRLHQWGRUpQDYDQWGHVVDQFWLRQVSOXVVpYqUHV/HVDPHQGHV PLQLPDOHVLPSRVpHVSRXUFHUWDLQHVLQIUDFWLRQVVRQWPXOWLSOLpHVSDUSRXU XQHSHUVRQQHSK\VLTXHHWSDUSRXUXQHSHUVRQQHPRUDOH'HSOXVXQH FRQGDPQDWLRQSRXUFHUWDLQHVLQIUDFWLRQVHQWUDvQHXQHLQWHUGLFWLRQGHFRQFOXUH XQFRQWUDWDYHFWRXWRUJDQLVPHSXEOLFSURYLQFLDOPXQLFLSDORXVFRODLUHSRXU DXPRLQVWURLVDQV 32853/86'¨,1)250$7,21(/(&7,21648(%(&4&&$ CONTINUING PROFESSIONAL EDUCATION By Réjean Laprise, Ph. D. CONSULTANT, OFFICE OF PROFESSIONAL DEVELOPMENT A reading club in your own living-room! Almost everyone has heard of “webinars”, interactive conferences that allow you to take part regardless of where they may be given in the world and ask questions directly from any computer, as long as it is connected to the Internet. But what about virtual reading clubs? Do you know of any? Despite the prodigious volume of biomedical research published each year, it is estimated that only four to eight studies have a significant impact on the practice of a given specialty. In theory, therefore, a specialist would only need to read four to eight texts per year to keep abreast of developments in his/her specialty. But, it’s not that simple. Even if some extensively sponsored studies generate a lot of noise, they are not necessarily all valid statistically. The methodology used can also limit the extrapolation of a study’s conclusions beyond the population studied. Recommendations are sometimes difficult to apply in the context of our healthcare system. These are the issues studied in reading clubs and the reason they are so useful to the profession. In a university setting, methodology experts can often assist clinical experts to ascertain the underlying aspects of a study. They then have all the information they require to decide collegially if the factual data presented justify changing practice conduct. Unfortunately, such resources are not always available in all areas. The FMSQ’s Office of Professional Development, in cooperation with the Association des pneumologues de la province de Québec and the Vice-Dean’s Office for Education and Continuing Professional Development at the Faculty of Medicine, Université Laval, has developed and validated a new educational concept that allows all Quebec medical specialists to host and take part in a high-grade reading club via Internet. This is sure to be of interest to those who practise with a limited number of colleagues in their own specialty, those who have difficulty accessing experts in the various areas of their specialty, or those who simply wish to update their knowledge while balancing their work and family life. In addition to the pneumologists, the Association des spécialistes en médecine interne du Québec and the Association des médecins gériatres du Québec joined in the pilot project to develop and validate the concept. The associations organized five on-line reading clubs, each lasting 60 minutes, between January 2010 and March 2011. Activities took place in the evening (from 7:30 to 9:00 p.m.) and everyone could take part while at home. Participants had the benefit of a critical analysis by a methodology expert and by a clinical expert, and were able to interact with other participants and also with the experts. Emphasis was placed on the validity of the study, comparing it with previous studies, evaluating the applicability of the results and seeking to establish a consensus as to its impact on medical practice. Eighty-seven participants, who were representative of medical specialists in Quebec (regions, age, gender, type of practice), signed up for the pilot on-line reading clubs offered by their respective associations. The content and technological environment used were both highly appreciated. Among aspects needing improvement, several participants suggested that their associations should offer this type of activity on a regular basis... That says it all! As a result of the pilot project’s great success, the FMSQ and the Vice-Dean’s Office at Université Laval have formed a partnership that enables the Federation and interested affiliated professional associations to use the technological infrastructure of the Université Laval at a low cost to hold real-time reading clubs and other continuing development activities for their members. Université Laval will also offer personalized technical support and accredit activities. The content and conduct of on-line educational activities will still depend on associations, who are solely responsible for training their members. The pilot project defined the concept, established procedures and developed an organization guide and standard templates (e.g., on-line evaluation forms) that should make it much easier for each association to organize this kind of activity. A participant’s guide is also available on line from the FMSQ website, so that medical specialists can check their computer equipment’s compatibility, update it if necessary, and become familiar with the technological environment used (www.fmsq.org/f/medecins/dpc/activites enligne.html). Everything is now set up for you to take part in a reading club and in high level conferences right in the comfort of your own home! S L LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 35 IN THE WORLD OF MEDICINE By Christian Constance, MD* New Atrial Fibrillation Guidelines CARDIOLOGIST Why were new atrial fibrillation (AF) guidelines issued in 2010? Essentially, because new studies now allow us to confidently make suggestions based on clinical evidence. Major advances have been made since the Canadian Cardiovascular Society’s (CCS) last recommendations for AF in 2005, including clinical trials that have led to drug therapy for the management of AF, antithrombosis treatments, the continuing development of catheter ablation, etc. dation, weak quality evidence). The aim is to evaluate the symptomatic disorder caused by AF, develop a treatment strategy to relieve symptoms, evaluate and manage the risk of thromboembolism, establish a prognosis and, when possible, identify the underlying cause of AF. For the first time, recommendations were developed using the GRADE 1 system (Grading of Recommendations Assessment, Development and Evaluation) to weigh the value of studies (table 1), i.e. evaluate the quality of the evidence provided in the literature (very weak, weak, medium or high quality). This system replaces the scale of evidence levels previously used by the American Heart Association. Based on the CCS example, other specialties could eventually use the GRADE system for their recommendations, should they find it interesting and worthwhile. This latter aim (identifying the underlying cause) is particularly important as it may allow AF risk factors to be identified and, once these have been treated, could reduce or eliminate a subsequent recurrence of AF, improve the patient’s general health, or help establish the optimal AF treatment strategy in the patient’s case. Hypertension constitutes one of the major risk factors associated with AF. Recommendations in this regard stipulate that risk factors need to be identified and treated (strong recommendation, high quality evidence). Recommendations for the emergency room treatment of AF Table 1. GRADE Evaluation System Quality of evidence High Comments Future research is not expected to modify current knowledge; for example, numerous well-designed and carefully-conducted clinical trials. Medium Future research will probably have an important impact on current knowledge and could modify it; for example, limited clinical trials, inconsistent results or study limitations. Weak Future research is likely to have an important impact on current knowledge and will probably modify it; for example, a small number of clinical or cohort studies. Very weak Data are very uncertain; for example, case studies, consensus opinions. Extract from Gillis AM et al. Can J Cardiol 2011;27:27-30 Very weak quality studies are excluded, as a matter of course. This grading of information quality is one of the main factors in determining the strength of recommendations (strong, or conditional – in other words, weak). For example, when initially evaluating AF,2 the guidelines recommend establishing a familial, social and medication history, carrying out a complete physical examination, electrocardiogram, echocardiogram and laboratory tests (strong recommen- 36 LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 Atrial fibrillation is the type of arrhythmia most often seen by emergency physicians and represents approximately onethird of all hospitalizations for cardiac rhythm problems. Two treatment strategies are used: controlling ventricular rate by the administration of oral anticoagulants, or controlling and maintaining sinus rhythm (cardioversion) via a pharmacological or electrical approach. The decision as to which of these two strategies should be used in the initial treatment of emergency AF depends upon multiple factors such as the type and duration of AF, severity of symptoms, medical condition and AF-related cardiovascular illnesses, as well as physician and patient3 preferences. In such situations, the guidelines recommend either strategy when treating a stable patient with AF or recent-onset atrial flutter (strong recommendation, high quality evidence). Once the ventricular rate is controlled, AF treatment comes down to slowing the pulse rate and administering anticoagulants. While we previously insisted on maintaining the pulse rate at 60 beats/minute, new studies indicate that slowing it to less than 100 beats/minute at rest (< 110 during moderate exercise such as walking) is quite sufficient. Intravenous medication, such as metoprolol (a beta-blocker), verapamil or diltiazem (both calcium channel blockers) is the IN THE WORLD OF MEDICINE @SUITEA first-line treatment. If the patient continues to present symptoms and has been on anticoagulants for more than four to six weeks, electrical or chemical cardioversion can be used to restore sinus rhythm in certain cases (mentioned in the previous paragraph). More complex alternatives With the sinus rhythm control strategy, antiarrhythmia drugs are the first line of treatment. However, their efficacy in controlling sinus rhythm over time is relatively modest. Adverse effects also limit their usefulness over the long term, especially in young patients. Catheter ablation is an alternative if drugs prove ineffective or poorly tolerated.8 This surgery isolates the arrhythmia- initiating foci by THE CCS GUIDELINES ARE THE ONLY ONES THAT cauterization at the junction of the pulmonary veins and RECOMMEND DABIGATRAN TO PREVENT STROKE IN the left atrium. HIGH:RISK PATIENTS AND SUGGEST THIS MEDICATION IS PREFERABLE TO WARFARIN IN MOST CASES. With regard to anticoagulation, a new treatment option is now available: dabigatran etexilate is a new reversible anticoagulant that inhibits thrombins and can be administered at fixed doses by mouth without having to monitor coagulation on a regular basis. The results of the RE-LY4 study have shown the advantages of this drug versus warfarin: no further need for blood tests, anticoagulation stability and reduced incidence of hemorrhage (intracranial, in particular). The most recent data from two sub-group analyses in the RE-LY5-6 study, presented at the 2011 Annual Scientific Session of the American College of Cardiology, show that 150 mg BID of dabigatran is consistently superior to warfarin in the prevention of AF-related stroke, regardless of the level of the risk of stroke or the type of AF. Dabigatran is contraindicated in patients with a creatinine clearance rate lower than 30 cc/min. In addition, there is no antidote (such as vitamin K for Coumadin) for dabigatran. If the patient presents with serious bleeding, PTT can be used to establish the intensity of the agent’s anticoagulation effect. Several strategies are available depending on the severity of the bleeding: local compression, volemic repletion, blood transfusions, cryoprecipitates and fresh frozen plasma (this agent is dialyzable in cases of serious bleeding and, if there is an acute intoxication, activated charcoal must be tried). The CCS guidelines are the only ones that recommend dabigatran to prevent stroke in high-risk patients and suggest this medication is preferable to warfarin in most cases. That being said, the European Society of Cardiology (ESC) guidelines and those of the American College of Cardiology Foundation/American Heart Association/Heart Rhythm Society (ACCF/AHA/HRS) contain similar recommendations without, however, specifically identifying dabigatran for the moment.7 Techniques and technology have evolved since surgical AF ablation was first described more than 10 years ago, giving high success rates, particularly in patients suffering from paroxysmal AF. In such patients, the success rate in maintaining sinus rhythm without using anti-arrhythmia drugs, is 60% to 75% after a first procedure and 75% to 90% following two procedures. However, the rate of major complications is 2% to 3%. It is therefore recommended this approach only be considered for patients with symptomatic AF who do not respond to pharmacological treatment. Should both anti-arrhythmia drugs and catheter ablation fail, there remains the possibility of AF surgery,9 which is an effective treatment to restore and maintain sinus rhythm. Although it is possible to use such surgery as a single primary intervention, it is mainly provided to patients who need other types of cardiac surgery (for example, coronary bypass, aortic valve surgery, mitral valve repair or replacement). Atrial fibrillation and other concomitant illnesses In conclusion, it may be useful to recall that AF is often present in patients with atherosclerosis, hypertension or diabetes. The international registry known as REACH10 (The REduction of Atherothrombosis for Continued Health), which is designed to study all of the clinical aspects of atherothrombosis, confirms that, in AF patients, morbidity and mortality rates are twice as high for each of these pathologies. As a result, the new guidelines are not addressed solely to cardiologists, electrophysiologists or cardiac surgeons; they also concern general practitioners, those who work in emergency rooms and all other specialists, such as neurologists for example, who may be confronted with stroke patients with atrial fibrillation. References * The author is assistant clinical professor at the Université de Montréal Department of Medicine and chief of the Coronary and Haemodialysis Unit at Hôpital Maisonneuve-Rosemont) Complete references for this article are available in page 446. S L LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 37 FINANCIÈRE DES PROFESSIONNELS By Alain Doucet, a.s.a., acs, Financial Planner Impact of new quebec pension plan rules SENIOR MANAGER, FINANCIAL PLANNING The last provincial budget amended rules for the Quebec Pension Plan. What impact will these new provisions have on your decision to request a pension before or after age 65? To start with, to be eligible for a pension before age 65 (the earliest age is 60), you have to meet one of the following conditions: you have to have stopped working, cut back your working hours by at least 20% (this is more difficult to demonstrate for the self-employed) or confirmed that your work income does not exceed 25% of the maximum pensionable earnings (MPE), i.e. 25% of $48,300 in 2011 ($12,075). If you do not fulfill any of these conditions, at present your pension will be reduced by 0.5% for each month you retire before age 65 – i.e., 6% per year or 30% at age 60. The new budget has increased the reduction applicable prior to age 65. For those retiring in 2014, their pension will be reduced by 6.36% per year, or 31.8% at age 60. For those retiring in 2015, their pension will be reduced by 6.72% per year, or 33.6%, and for those taking retirement in 2016, the reduction will be 7.2% per year for a total reduction of 36%. Please note that if your career average employment income is less than the MPE, the reduction percentage will be slightly less. However, since this is unlikely to be the case for most medical specialists, we will not be dealing with it in this article. If a pension starts to be paid after age 65, current rules stipulate that the pension amount is increased by 0.5% per month after age 65 (or 6% per year) up to a maximum total of 30% at age 70. As a result of the latest budget, the 38 LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 pension will be increased by 0.7% per month (or 8.4% per year) starting in January 2013, for a maximum increase of 42% at age 70. How can you evaluate these changes? Several factors have to be taken into account to determine whether an eligible person should start drawing down a pension before 65, at 65 or, alternatively defer it to age 70, in order to receive the maximum amount. Comparison - 60 to 65 years Without returns At age 60 Age Annual pension At age 65 Cumulative Before taxes After taxes Cumulative Annual pension Before taxes After taxes 60 $7,373 $7,373 $3,834 61 $7,520 $14,893 $7,745 62 $7,671 $22,564 $11,733 63 $7,824 $30,389 $15,802 64 $7,981 $38,369 $19,952 65 $8,140 $46,510 $24,185 $12,719 $12,719 $6,614 66 $8,303 $54,813 $28,503 $12,973 $25,692 $13,360 71 $9,167 $98,887 $51,421 $14,324 $94,557 $49,170 72 $9,351 $108,238 $56,284 $14,610 $109,167 $56,767 73 $9,538 $117,776 $61,243 $14,902 $124,069 $64,516 With returns At age 60 Âge Annual pension At age 65 Cumulative Before taxes After taxes Cumulative Annual pension Before taxes After taxes 60 $7,373 $7,373 $3,834 61 $7,520 $15,262 $7,844 62 $7,671 $23,696 $12,037 63 $7,824 $32,705 $16,419 64 $7,981 $42,321 $20,996 65 $8,140 $52,578 $25,774 $12,719 $12,719 $6,614 66 $8,303 $63,510 $30,762 $12,973 $26,328 $13,532 73 $9,538 $162,317 $72,153 $14,902 $151,032 $71,407 74 $9,729 $180,162 $79,088 $15,200 $173,784 $81,168 75 $9,923 $199,093 $86,304 $15,504 $197,978 $91,340 FINANCIÈRE DES PROFESSIONNELS (SUITE) 1) In fl ation: Generally speaking, the MPE increases faster than inflation and thus encourages putting off benefits. When the pension amount is established, it is calculated on the basis of an average of MPEs; pensions paid are increased each year based on inflation. 2) Taxat ion Rate: If the retired physician is taxed at the maximum marginal rate, there is little advantage in delaying his/her retirement benefit claim. 3) H eal th: If the physician’s state of health is not the best, it is definitely preferable to apply for a pension as soon as possible. 70, $16,358 (+42%). The tables without returns will be useful for those applying their entire pension to expenses, while those with returns will be useful for those not using their pension to meet expenses. The tables show that, under the new rules, waiting until age 65 before drawing down a pension lowers the break-even point by about 3 years, from age 75 to age 72, without returns, and from age 77 to age 74, respectively. For rules after the age of 65, if you live longer than age 80 (without returns), it would be better to delay applying for a pension until age 70. But who can predict the age at which you will die? 4) Break-Even Point: When do pension payments received from age 65 on equal those received starting at age 60 (given certain assumptions)? The same question applies in the case of a pension received starting at age 70 compared with one received starting at age 65. The following assumptions are used in the tables below: inflation rate, 2%; rate of return, 5%; tax rate, 48%; annual pension (AP) at age 60, $7,373 (-36%), AP at age 65, $11,520, and AP at age 5) Contributory Period: To be eligible for a full pension, physicians must have contributed during 85% of the contributory period, starting on January 1, 1966, or from the age of 18 for physicians who turned 18 after that date. The contributory period ends the month preceding the one for which the pension is paid. Other criteria can also come into play, but they are not discussed here. Thus, if a physician retires at age 60 (or before) and waits until age 65 to apply, five additional years of zero contriComparison - 60 to 65 years butions (from age 60 to 65) will Without returns be taken into account when At age 65 At age 70 calculating the pension and Cumulative Cumulative Annual could reduce the amount paid at pension Before taxes After taxes Before taxes After taxes age 65. The impact of this choice $11,520 $5,990 would extend the break-even $23,270 $12,101 point to age 76, without returns, $35,256 $18,333 and age 79, with returns. Age Annual pension 65 $11,520 66 $11,750 67 $11,985 68 $12,225 $47,481 $24,690 69 $12,470 $59,951 $31,174 70 $12,719 $72,670 $37,788 $18,061 $18,061 $9,392 71 $12,973 $85,643 $44,534 $18,422 $36,483 $18,971 . . . . . . 79 $15,200 $199,220 $103,594 $21,585 $197,763 $102,837 80 $15,504 $214,725 $111,657 $22,016 $219,779 $114,285 81 $15,814 $230,539 $119,880 $22,457 $242,236 $125,963 . With returns At age 65 At age 70 Cumulative Age Annual pension Before taxes 65 $11,520 $11,520 $5,990 66 $11,750 $23,846 $12,256 67 $11,985 $37,024 $18,807 68 $12,225 $51,100 $25,653 69 $12,470 $66,125 $32,805 70 $12,719 $82,150 71 $12,973 $99,231 . Cumulative Annual pension Before taxes $40,271 $18,061 $18,061 $9,392 $48,065 $18,422 $37,386 $19,215 After taxes After taxes . . . . . . 81 $15,814 $342,442 $146,576 $22,457 $317,641 $144,753 82 $16,131 $375,695 $158,775 $22,906 $356,429 $160,427 83 $16,453 $410,933 $171,459 $23,364 $397,615 $176,748 6) Other Income: There may be a reason to postpone or advance drawing down your pension if other income (e.g. Old Age Security) might be subject to a decrease. In conclusion, it used to be generally held that a retirement pension from the Quebec Pension Plan should be drawn down as early as possible. Greater caution is now required, and you should take all the factors listed above into account. Do not hesitate to talk to one of our Financial Solutions Advisors: they will guide you through the process! LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 39 SOGEMEC ASSURANCES By Chantal Aubin Insuring Pleasure with The Personal DIRECTOR, PLAN ADMINISTRATION MANAGER Motorcycle Insurance: Freedom and Simplicity Motorcycle fans can obtain complete protection from The Personal for a wide range of brands and models, at very competitive prices. Regardless of whether you are shopping for a new motorbike or renewing your insurance, asking for a quote online makes your life easier. You can obtain a quote rapidly, 24 hours a day, so that you can compare offers and make an informed choice. Recreational Vehicle Insurance: Worry-Free Adventure Whether you enjoy ATVs, or want to cross Canada or the United States in your truck camper, The Personal offers you the protection to meet your needs. The Personal insurance covers most RVs: all-terrain vehicles, trailers, campers, boats, personal watercraft, etc. The Personal’s consultants will be happy to help you choose the protection that suits you. 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This reduction, combined with the exclusive group discounts available to members of the Fédération des médecins spécialistes du Québec, makes rates highly competitive. Marine insurance is reserved for clients who already have their homes insured with The Personal. This is another advantage offered by your group insurer. Thinking of Staying Outsi de Quebec? Specialists from The Personal, the automobile, home and commercial group insurer chosen by Sogemec A ssurances, know this full well. They are used to responding to the needs of their clients eager to hit the road or set sail while confident that they are well protected. Whether you are thinking of exploring the east coast of the United States on a motorcycle, visiting national parks with your camper or even sailing on Lake Champlain... it is important to start by checking into your protection with your insurer. Basically, The Personal offers you the same privileges as with its automobile and home insurance, i.e. preferential group rates, sound advice from a team of certified agents and firstclass service. Then you add in the various specifics for each insurance product. Some limits may apply on your automobile, motorcycle or marine insurance. Checking will take five minutes of your time and will prevent any unpleasant surprises, as your agent will be able to offer you the appropriate protection. For example, an umbrella policy will allow you to increase your public liability insurance, which might be important should you find yourself liable for third-party injuries while you are out of the country. For more details on the various RV insurance policies or to ask for pricing, please contact one of our agents at 1-866-350-8282 or visit our website at www.sogemec.lapersonnelle.com. 40 LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 SOGEMEC ASSURANCES By Yves Martel WEALTH MANAGEMENT CONSULTANT Join an insurance plan with no medical proof required New FMSQ members You have just completed your residency! Congratulati ons! As you know, the insurance plans covered by the Agreement between the Fédération des médecins résidents du Québec (FMRQ) and the Ministère de la Santé et des Services sociaux du Québec (MSSS), expire on July 1. Coverage with no medical proof* Under age 35 $3,000 Disability insurance $3,000 Office overhead insurance $100,000 Life insurance * If you are 35 or over, please get in touch with our consultants for details on the amounts for which you are eligible without proof. Coverage tailored to your profession Since 33 years, the Fédération des médecins spécialistes du Québec has been working closely with Sogemec Assurances, to offer you the best insurance products available, as well as coverage tailored to your profession. The only broker Just for you As a new medical specialist, the FMSQ, by the means of its subsidiary, Sogemec Assurances, offers you to subscribe to its life, disability and office overhead insurance programs to you, without requiring medical proof. However, you must join within 90 days of the end of your residency. POUR TOUS VOS BESOINS D’ASSURANCES Sogemec Assurances is the only broker offering the FMSQ’s insurance programs, which also include prescription drug, disability, automobile and home coverage, as well as individual products from other insurance companies. Contact the consultants at Sogemec Assurances without delay. We understand your needs! Grâce au SERVICE PRÉFÉRENCE SOGEMEC ASSURANCES ÉVOLUE AVEC VOUS Avec le SERVICE PRÉFÉRENCE de Sogemec Assurances, toutes vos assurances sont pensées en fonction de votre style de vie et de vos besoins. POUR EN SAVOIR PLUS : 1 800 361-5303 / 514 350-5070 / 418 990-3946 Par courriel ou Internet : [email protected] / www.sogemec.qc.ca SOGEMEC ASSURANCES filiale de la LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 41 LE MOT DU PRÉSIDENT Dr Gaétan Barrette Pourquoi « faire simple » quand on peut « faire compliqué » ? u moment d’aller sous presse, la FMSQ vient de conclure une entente avec le ministère de la Santé et des Services sociaux (MSSS) quant au traitement de la dégénérescence maculaire liée à l’âge (DMLA). Une finale heureuse. Mais pour y arriver, il nous aura fallu imposer un ultimatum. Un mauvais film dont voici quelques faits saillants. A Le 8 février : volte-face ! Par voie de communiqué de presse, le ministre annonce « la gratuité des traitements ». Il a « demandé à l’ensemble des établissements de santé du Québec d’assurer la gratuité des traitements (…). Au cours des prochaines semaines, une fois la mesure mise en œuvre, les patients n’auront plus à assumer les frais accessoires ». Automne 2010. Le dossier des frais accessoires refait surface. Cette fois, dans le cas de la DMLA. Faute d’avoir accès au Lucentis à l’hôpital (à une période où la science n’a pas encore déterminé formellement la valeur ajoutée de l’utilisation du Lucentis pour la DMLA), les patients doivent se tourner vers les cliniques pour recevoir leur injection. Parce que la RAMQ ne rembourse pas les ophtalmologistes pour la composante technique, des frais sont exigés aux patients. Rappelons que la Loi sur l’assurance maladie date de 1970 et n’a pas suivi l’évolution de la pratique médicale. Résultat : un flou artistique entoure la définition des frais accessoires, flou qui touche une grande partie des activités dispensées en clinique. J’insiste ! Ce flou frappe pour l’instant l’ophtalmologie, mais pourrait s’appliquer à plusieurs autres spécialités médicales. Le 9 février, toujours en réponse à une journaliste du Soleil, l’attachée de presse du ministre précise l’annonce de la veille en indiquant que les travaux pour mettre en place cette nouvelle offre de services ne font que commencer, et ce n’est que « dans les prochaines semaines ou les prochains mois » que les patients sauront à quoi s’en tenir. Avançons en arrière : le 1er octobre 2007. À la demande de l’ex-ministre Couillard, un comité de travail dépose un rapport (le rapport Chicoine - du nom du président du comité) dans lequel se trouvent des recommandations précises sur la question des frais accessoires et sur la nécessité d’agir rapidement. Été 2008 : entrée en scène du ministre Bolduc. Depuis, silence radio. La problématique des frais accessoires demeure entière et en suspens. Le premier signe d’une « nouvelle » crise arrive avec un article publié dans Le Soleil du 18 novembre 2010 : L’État ne paiera pas l’injection de Lucentis. C’est ce qu’affirme l’attachée de presse du ministre, qui évoque « le contexte budgétaire actuel » pour justifier la décision du ministère. Le 24 novembre, le ministre indique à la même journaliste qu’il travaille ce dossier avec la RAMQ. L’article se termine en rappelant que « le dossier a été soumis au ministre Bolduc pour la première fois en mars 2009 ». Le 3 février 2011, par la voie de son attachée de presse, le ministre fait savoir qu’il entend poursuivre sa réflexion sur les frais accessoires. « Des discussions doivent avoir lieu avec les intervenants concernés, tels que les fédérations de médecins et le Collège des médecins. » Le ministre souhaite par ailleurs bouger « le plus rapidement possible » rapporte Le Devoir. Le 6 février, le dossier du traitement de la DMLA avec le Lucentis est « un dossier prioritaire » pour le ministre, comme le rapporte le Journal de Québec. 42 LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 Le 2 avril : coup de théâtre ! Dans un article du Devoir intitulé : Le Lucentis gratuit reste introuvable. Les patients font les frais d’un bras de fer entre le ministère et les établissements, la journaliste rapporte que, vérification faite, même le MSSS ignore quels sont les quelques établissements qui offrent présentement le service et lesquels sont pressentis pour le faire. La porte-parole du MSSS, ajoute : « On peut espérer qu’[un plan] sera arrêté d’ici quelques semaines et soumis pour approbation au ministre ». Le 7 avril, Le Devoir rapporte que le ministre soulève la possibilité de « payer des frais raisonnables par rapport à l’injection. (…) Des frais accessoires pourraient aussi être payés en clinique. (…) Nous devrions savoir d’ici quelques jours quel scénario sera retenu ». Le jeudi 19 mai dernier, un patient atteint de DMLA demande à la cour la permission d’intenter un recours collectif contre la RAMQ, le ministre de la Santé et une clinique d’ophtalmologie de Québec (d’autres pourraient s’ajouter). La même journée, excédée, la Fédération lance au ministre un ultimatum de 48 heures ouvrables, et ce, pour régler la situation une fois pour toutes dans ce dossier. Les heures s’égrènent et d’intenses négociations (pendant un long weekend !) déboucheront sur une entente. Depuis des années, la FMSQ n’a cessé de répéter au ministre qu’il doit mettre un frein au flou et régler, une fois pour toutes, l’ensemble du dossier des frais accessoires. En décidant de ne pas s’attaquer à cette problématique, non seulement la desserte des soins est volontairement rationnée en centre hospitalier, mais le ministre « économise » sur le dos des patients en tardant à investir les sommes nécessaires à la dispensation des soins. Pendant ce temps, les médecins, eux, font tout en leur pouvoir pour traiter les patients en clinique avec les risques que cela encourt. Mais cela devra « vraiment » finir un jour ! Syndicalement vôtre ! S L REFERENCES References (page 18) 23 1 24 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 19 20 21 22 Act respecting the determination of the causes and circumstances of death, R.S.Q., Chapter R-0.2. Ibid, Section 3. Some recommendations aim at improving the organization of care, others at encouraging better communications between facilities. For more information see: Coroner's Office, Rapport des activités des coroners en 2010, Government of Quebec, 2011 (in French only). Ibid, article 37 paragraphe 3. This requirement represents Section 37 of the Act respecting the determination of the causes and circumstances of death, R.S.Q., Chapter R-0.2, until its amendment on October 31, 1991. Nursing homes are no longer included in the category of "centres" provided for in the Act respecting health services and social services, R.S.Q., Chapter S-4.2, with respect to where institutions deliver care and services. They are however included in the Act respecting health services and social services for Cree Native persons, R.S.Q., Chapter S-5. Opinion on the application of the Act respecting the determination of the causes and circumstances of death in institutions, resources and homes for the elderly: Me Claire Bernard, December 2010, p. 19. This opinion (in French only) is available on line at: http://www2.cdpdj.qc.ca. Me Claire Bernard, Opinion on the application of the Act respecting the determination of the causes and circumstances of death in institutions, resources and homes for the elderly, December 2010. Ibid, p.26. The Commission also recommends that the Coroner be granted discretionary powers allowing him to decide whether there are grounds or not to proceed with an investigation into the deaths reported to him. This procedure would avoid needless investigations while protecting users' fundamental rights. It must be understood that the Act respecting the determination of the causes and circumstances of death, (Section 45) specifies that an investigation "must take place every time notice (as provided for in the Act) is given to the coroner." Ibid, page 22. Ibid, pages 19 to 21. Ibid, pages 19 to 21. Civil Code of Québec, C-1991, Sections 122 and 124. Leclerc (Estate of) c.Turmel, J.E. 2005-805 (S.C.): In this decision, the Court was called upon to establish the time at which a mother and son died, following a highway accident, in order to reach a conclusion as to the rights of their heirs. Regulation respecting the application of the Act respecting medical laboratories, organ and tissue conservation and the disposal of human bodies, Chapter L-0.2, r.1, Section 18. Public Health Act, R.S.Q., Chapter S-2.2, Section 46, Par. 1. Public Health Act, R.S.Q., Chapter S-2.2, Section 46, Par. 2. Ibid. Ibid, Section 46, Par. 3. Regulation respecting the application of the Act respecting medical laboratories, organ and tissue conservation and the disposal of human bodies, c. L-0.2, r.1, Section 19. Ibid, Section 19. Act respecting the determination of the causes and circumstances of death, R.S.Q., Chapter R-0.2, Section 34 and Section 2, Par. 3 and 4. Ibid, article 19. Loi sur la recherche des causes et des circonstances de décès, L.R.Q., chapitre R-0.2, article 34 et article 2 paragraphes 3 et 4. 25 26 27 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 Ibid, article 2 paragraphe 3. Ibid, Section 34. Ibid, Section 44. Ibid, Section 35. The Act refers to the PSD of an "an institution operating a hospital centre" and therefore to the PSDs of institutions that carry on the mission of a hospital centre – e.g., health and social services centres, hospital centres and universityaffiliated hospital centres. Québec Coroner, L’investigation, Gouvernement du Québec, March 2001, p 39 to 40 (in French only): The authors of this manual provide for a three-stage process to help institutions establish probable cause of death. Act respecting the determination of the causes and circumstances of death, R.S.Q., Chapter R-0.2, Section 35, Par. 2 and Section 36. Ibid, Section 73. Ibid, Section 76, Par. 1. Act respecting the determination of the causes and circumstances of death, R.S.Q., Chapter R-0.2, Section 34. Ibid, Section 36. Ibid, Section 36. Gage Canadian Dictionary, Toronto; Gage Educational Publishing Company, a Division of Canada Publishing Corporation, 1997, page 1021. Québec Coroner, L’investigation, Gouvernement du Québec, March 2001, page 37 (in French only). Gage Canadian Dictionary, Toronto; Gage Educational Publishing Company, a Division of Canada Publishing Corporation, 1997, page 1640. Québec Coroner, L’investigation, Gouvernement du Québec, March 2001, page 37 (in French only). Nolet, Louise; Perron, Paul-André; Le Médecin du Québec, Les morts violentes et inattendues en milieu hospitalier, 2005:40(10); 105-9. Québec Coroner, L’investigation, Gouvernement du Québec, mars 2001, p.36. This term no longer exists in the Youth Protection Act, R.S.Q., Section P-34 ("YPA"). The YPA now refers to "an intensive supervision unit maintained by an institution operating a rehabilitation centre" (Section 11.1.1 YPA). Act respecting the determination of the causes and circumstances of death, R.S.Q., Chapter R-0.2, Section 39: This section refers in particular to the death of children while they are in the custody of the holder of a permit issued by the Minister of Families, Seniors and the Status of Women. Act respecting the determination of the causes and circumstances of death, R.S.Q., Chapter R-0.2, Sections 37 to 40. 43 Ibid. 44 Avis sur l’application de la Loi sur la recherche des causes et des circonstances de décès dans les établissements, ressources et résidences pour personnes âgées, Me Claire Bernard,, Décembre 2010, p.7-8. 45 Ibid. 46 Loi sur la recherche des causes et des circonstances de décès, L.R.Q., chapitre R-0.2, articles 170-171. 47 Ibid, article 4. 48 Loi sur la recherche des causes et des circonstances de décès, L.R.Q., chapitre R-0.2, article 96. 49 À ce sujet, voir entre autres : Robert c. Hôpital de Chicoutimi inc, AZ-91011590 (Cour d’appel du Québec). LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 43 SUMMARY Do you know your obligations? (page 18) Physicians must notify the Coroner or a peace officer in the following situations: • Upon confirming a death for which no probable medical cause can be established • Upon confirming a death that seems to have occurred in obscure circumstances • Upon confirming a death that seems to have occurred in violent circumstances Should the director be absent and the physician is the person in authority in one of the following places, he/she must immediately notify the Coroner or a peace officer of any death occurring in: • A rehabilitation centre • An adapted enterprise for handicapped persons • A facility where the deceased person was under confinement • A correctional facility • A penitentiary • A security unit within the meaning of the Youth Protection Act • A police station • A daycare centre • A foster family • A family-type resource Source: Sections 34 to 40 of the Act respecting the determination of the causes and circumstances of death, R.S.Q., chapter R-0.2 44 LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 REFERENCES References (page 23) 1 2 3 therapy ? 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An updated interdisciplinary clinical pathway for CRPD: report of an expert panel. 2002 World Institute of Pain, Pain practice 2002:2(1):1-16. 41 Maleki J, Lebel AA, Bennet GJ, Schwartzman RJ. Patterns of spread in complex regional pain syndrome, type 1 (reflex sympathetic dystrophy). Pain. 2000 ;88:259-66. 19 Crombez G, Vlaeyen JWS, Heuts PH, Lysens R Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic pain disability. Pain 1999 ;80:329-39. 42 Zyluk A. The sequelae of reflex sympathetic dystrophy. J Hand Surg. 2001 ;26:151-154. 43 20 Janig W, Baron R. Experimental approach to CRPS. Pain 2004 ;108 ;3-7. 21 Perez RSGM, Kwakkel G, Zuurmond WWA, de Lange JJ. Treatment of reflex sympathetic dystrophy (CRPS Type 1): a research synthesis of 21 randomnized clinical trials. J Pain Manage 2001 ;21(6):511-25. Geertzen JH, Dijkstra PU, van Sonderen EL, Groothoff JW, ten jDuis HJ, Eisma WH. Relationship between impairements, disability and handicap in reflex sympathetic dystrophy patients: a long-term follow-up study. Clin Rehab. 1998 ;12:405-12. 44 Galer BS, Henderson J, Perander J, Jenson MP. Course of symptoms and quality of life measurement in complex regional pain syndrome: A pilot survey. J Pain Symptom Manage. 2000 ;20:286-92. 22 Kemler MA, Rijks CP, de Vet HC. Which patients with chronic reflex sympathetic dystrophy are most likely to benefit from physical LE SPÉCIALISTE VOL. 13 NO. 2 JUNE 2011 45 REFERENCES References (page 29) References (page 37) 1. Day M. Neuromodulation: spinal cord and peripheral nerve stimulation. Current Review of Pain 2000 ;4(5):374-82. 1. Gillis AM et al. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: implementing GRADE and achieving consensus. Can J Cardiol 2011 ;27:27-30. 2. Bouhassira D et al. 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