European countries," said Pavilanis. -Quebec City. Quebec Chapter. Challenges. Ministry on. Perinatal Health. LOUISA BLAIR. Family physicians are best posi-.
Grants to breastfeed The government document has the noble goals of reducing child abuse, teenage pregnancies, and poverty among women. In 1991, 20% of pregnant women (18 000 women) in Quebec were living in poverty. It proposes better coordination among health services, offers better access to health care for the marginalized, and "Intervenantes" But DiTommaso discovered that the emphasizes continuity of care. It also news was not all good. The paper counts heavily on the effects of made strong allusions to midwives as increased public education. "This paper is very ambitious," exemplified by the use of the feminine term "intervenantes" to commented DiTommaso, "but it's not describe the professional attending clear how they are going achieve these births. The CFPC is officially goals." In his response, he wrote that opposed to midwives' delivering public education on contraception; infants independently of the medical breastfeeding; and the effects of alcoand nursing profession. "Quebec hol, tobacco, and drugs, for example, objects," said DiTommaso, "because does not go far enough. Instead he sugmidwives practising here are not reg- gests giving women grants to breastulated; they have little or no training feed, prohibiting tobacco, and making and no official standards. They can- drug treatment centres more available. The policy also aims to reduce not order blood tests or admit patients to hospital, so they deliver at birth defects and reduce premature home. The coroner recently said that births by 5 %. During 1990 in Quebec deliveries at home should be consid- 6.6% of babies were born prematureered dangerous." ly (nearly two thirds ofinfants who die In his five-page letter to the before they are 28 days old were born Ministry, DiTommaso also expressed prematurely). But are the policy's goals scientificoncern over the document's promoLOUISA BLAIR tion of birthing centres distant from cally practicable? The document cites hospitals. His concern is partly about primarily American studies, but even Family physicians are best posi- safety, as births will be taking place among these there are conflicting contioned to organize and coordi- far from obstetric surgeons and clusions about the effectiveness of trynate an overall improvement in neonatal intensive care units, and ing to avoid congenital deformities or Quebec's perinatal health services, partly about continuity of care. If to reduce premature births. The suggests a recent Quebec Ministry of there is a complication at the birthing Ministry document suggests that preHealth and Social Services policy centre, the "intervenante" will not be mature births can be reduced by paper on perinatal health. Released able to continue care to the hospital. increased cervical examinations and in May, the policy paper also says that Even if the "intervenante" is a family by expectant mothers' participating in family physicians should be doing practitioner, he or she is unlikely to regular programs. But other studies more obstetrics (it recommended have privileges at both places. suggest that these very measures can a minimum of 15 deliveries per year DiTommaso wrote in his response, actually increase risk: weekly cervical in addition to continuing medical "Do you want to see general practi- examinations can predispose a woman education). tioners having to go to birthing cen- to premature birth, and so can asking The CFPC was not consulted, but tres to assist deliveries, and thus her to make weekly trips to a prenatal Dr Stephen DiTommaso, the Quebec become isolated from their specialist clinic. A French study, for example, has Chapter treasurer with a special inter- colleagues, or will the birthing cen- shown that excessive traveling can est in obstetrics and pediatrics, ana- tres be the preserve of midwives, who induce birth prematurely. lyzed and responded to the will then remain set apart from docQuebec has one of the lowest perigovernment paper. tors of all kinds?" natal death rates of anywhere in the but the agenda must be determined by them. This can be frustrating for both parties; the Lithuanians want us to tell them what to do." Pavilanis is more excited by the possibilities than intimidated by the obstacles. "It's like a lab experiment in the genesis of family medicine. We would like to work out new models that neither of us know about, and try to use both countries' experience. For example, how can they integrate community-based public health into family practice? We're only fair at it in Canada. They have the chance to try it from scratch." Next summer the two countries will hold a joint family medicine conference on curriculum development and pedagogic methods. "If we get further funding, this could be a demonstration project for other east European countries," said Pavilanis. -Quebec City
"On the surface, the paper is very interesting," said DiTommaso, "as it addresses social and economic injustices as well as health problems. It proposes to help everyone from pregnant teenagers and parents who abuse drugs to children with behavioural problems."
Quebec Chapter Challenges Ministry on Perinatal Health
Canadian Family Physician VOI 38: December 1992 2903
world, DiTommaso pointed out, so perhaps it's best to leave well enough alone.
Tailying interventions He concedes that the paper makes some valid criticisms. While the number of episiotomies, cesarean sections, and epidural anesthetics leveled off during the 1 980s, rates are still unacceptably high, he said, and there are extraordinary regional inconsistencies. Last year, 55 % of women giving birth in Quebec City were given epidural anesthetics, for example, compared with only 0(.3% in the HullOutaouais region. The document suggests that institutions should keep a careful tally of their clinical interventions and that closer attention to the woman throughout pregnancy and labour would reduce unnecessary intervention. In response to the paper's hints that midwives are appropriate people for introducing a more humane and integrated approach to pregnancy and birth, DiTommaso hesitates before disagreeing. "We are in part to blame," he said, "because family doctors are abandoning their role in maternity health. In the last 10 years the percentage of FPs delivering babies has dropped from 70% to 35%. We are not going to keep that role by stopping midwives, but by keeping delivering." Quebec City
Glory Days Satisfaction high but dark days ahead T his is as good as it gets was the verdict passed on the health system by Canadian physicians in a recent national survey. While 83% of the 3387 respondents in the Angus Reid-Medical Post survey rated the system as either very good or excellent, 66% believe it has peaked and quality
can only deteriorate. The main reason for the expected decrease in quality is cost constraints, said eight in 10 doctors. Physicians see government - both federal and provincial - as the enemy and blame it for being unsupportive. Sixty percent said the Mulroney government is not committed to medicare while four out of five physicians say their provincial government has not been supportive of the medical profession. In British Columbia, where Bill 71 is viewed as both demoralizing and dictatorial, 96% said their NDP government is not supportive. Despite government intervention, cutbacks, and public disenchantment, physicians are happy with their career choice (90%), practice income (71 %), equality of health care (59%), and provincial plans (63%). In comparison with a smaller 1979 study, physician satisfaction has increased; only 47% of respondents were satisfied with their provincial medicare plans in 1979. Only 45% have considered leaving Canada to practise, down from 49% in 1979, and 52% would encourage their children to enter medicine, compared with 44% in 1979. Quebec physicians "share the same personal and professional concerns, [but] they are a little bit more content," said Leo Charbonneau, the Medical Post's Quebec Editor at a news conference in Toronto. Eighty-three percent of Quebec respondents said the system is cost-effective, in comparison to the 64% nationally. In general, Quebec physicians make less money, work fewer hours, and take more holidays. "Medicine does not seem to be this all-consuming thing," explained Charbonneau, comparing the difference in attitudes to the "Protestant work ethic versus joie de vivre." This "base contentment is born out of resignation" rather than satisfaction since the Quebec system
underwent a major restructuring (including income capping and hospital cutbacks) more than a decade ago. "They have come to terms with the changing rules," said Charbonneau. More than half (54%) believe that the increasing number of female physicians will have a positive effect on patient care, but most do not believe female physicians will affect the overall cost of treatment or the type of treatment used. In questions regarding remedies, 71 % supported a $5 user fee for emergency room use; 7 7 % supported ending medicare for all cosmetic surgery; 46% supported privatizing hospitals; 3 1 % supported limiting doctors' salaries. Forty-three percent of respondents were general practitioners. Women were overrepresented in the GP category and underrepresented in the surgical specialists category. Only 9% of surgeons were female.
Toronto
A Question of Expectations Quebec's road to relationships
LOUISA BLAIR
Y oung family physicians in Quebec know a lot about doctorpatient relationships, and through the Quebec Chapter's latest continuing medical education venture, some are sharing their knowledge with older colleagues and specialists. Quebec family physicians are not born with this knowledge; they must acquire it in order to be licensed. The College certification examination, a requirement for licensure in Quebec since 1988, includes a large component on the doctor-patient relationship. Failure of this portion of the examination results in disqualification for licensure. Canadian Family Physician VOL 38: December 1992 2905
