More news from a pharmacist and pharmacy. a.k.a. healthcare providers.

Shoppers Drug Mart at Queen and Carlaw in Toronto removes butter tarts & cheap cakes from the shelves and substitutes hundreds of cases of soft drinks. Check out these photos. This is in support of their corporate commitment found on the web site of the Canadian Diabetes Association. “. . . Shoppers Drug Mart continues to positively influence the health, well being and quality of life for people affected by diabetes.” In the meantime large chain grocery stores nearby are unable able to match this drug mart’s unfailing commitment to chocolate, candy, soft drinks, chips and more.

Fat Zombies, Pleistocene Tastes, Autophilia and the "Obesity Epidemic"

Canadians are fat and getting fatter: so say surveys up to and including the series of papers last August in Health Reports. By actual measurement, nearly a quarter of us (adults) are obese. So what? Obesity is clearly hazardous to health, but reports that 60% of us are "obese or overweight" border on fear-mongering. A body mass index (BMI) over 25 is not a death sentence, and obesity will not bankrupt the healthcare system. The trends, though, are worrying. So will we rebuild cities - and, especially, suburbs - to be more pedestrian-friendly, suppressing auto-induced urban sprawl? Will we take on the fast-food industry as we did tobacco? Obesity is not destiny; Canada could do better.

We Have Met the Enemy, and He Is Us (Sort Of) - Pogo
Does an effective response to obesity include putting MacDonald's and Coca-Cola out of business? Good luck! But if not … ? If sales of calorie-rich, nutrient-poor foods cannot be trimmed back, what hope is there for a lighter population? The industry can claim that it is simply responding to "consumer demand" - which on one level is true. Sellers of tobacco, pornography and illegal drugs could make the same claim (and some have). But influencing the food industry issue is much tougher than trying to suppress a noxious and widely unpopular industry. Promoting healthy eating requires some complex fine-tuning of a large industry with a high level of public support, in ways that will certainly restrict profit opportunities. Not surprisingly, our politicians have little stomach for this.

Effective tobacco control backs up aggressive anti-smoking messages with a combination of heavy taxation, restrictions on industry promotion and legal prohibition of smoking in public spaces. Left on their own, the health promoters would be massively outgunned; they wouldn't stand a chance. Are any of these seriously contemplated for the food industry?

Efforts to keep soft-drink and fast-food promotion out of schools are commendable, and a lot more could be done through the schools - starting very early - to promote both healthy eating and more exercise. (A national daycare program could have provided an effective vehicle.) But that will require making greater fitness a serious public priority, that is, with organization, regulation and money. Like planning and re-building our urban environments, it is a large and long-term commitment. Is anyone really serious about this? Or should we just settle for preaching at the fatties?

[for the full article click on the title]

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Dr. Robert Evans, OC, a faculty member of the Department of Economics at the University of British Columbia, is one of the world's leading health economists.

Dr. Alan Hudson on Wait Lists

A healthy dose of market reality
David Reevely

Ottawa Citizen | 23 January 2007 | C4

Getting a cataract removed in Ontario costs about $580. We know that thanks to a doctor who had the nerve to tell the government that starting to fix public health care would mean subjecting it to market forces.

The doctor is Alan Hudson, assigned by Health Minister George Smitherman to slash waiting times for key surgical procedures in Ontario.

Hudson is a South-African-born neurosurgeon, former chief executive of Toronto's University Health Network (UHN). Teaching awards and a research chair are named after him at the University of Toronto. When he met the Citizen's editorial board last week on a swing through Ottawa, he wore the pin that marks him as an officer of the Order of Canada.

Imagining a heavier hitter in Canadian medicine is impossible. And he knows something about market incentives -- the provincial salary disclosure list says Hudson made $374,002 in 2005.

Yet when he was made chief executive of the UHN, Hudson described it to an interviewer as like making a poacher the head gamekeeper, and he's brought that attitude to the job he's been doing since 2004. The health system is full of perverse incentives, he says, the most obvious being that doctors are paid to see patients, while hospitals are paid by the government regardless of how many patients they treat.

"A hospital gets one bag of gold to run for a year," he says. "It's called a global budget. So your incentive in running a hospital, like I was running UHN, is to look after one patient. That's all. You look after two, you've just doubled your costs. There's no profit, there's no margin. So you're incented to look after one patient a year.

"Before I became the CEO I was a surgeon on a piecework, pay-for-performance deal. So my incentive was to operate as much as I could -- maximize my income. So within one company, you've got one incentive going this way, one incentive going the other way."

In 2004, everybody knew the situation was out of hand, but nobody knew how bad it was. Ontario had no system for tracking how long people were waiting for cataract surgery, joint replacements, heart surgery, or anything else. Nobody even knew what those procedures cost.

With half a billion public dollars at its disposal, Hudson's team figured out a way to solve both problems at once: "[We] take a hospital and say, 'Here's your global budget. You've been doing X cataracts a year. God only knows how you ever got that number because there's no system and no way of measuring it, but that's sort of what you did, and presumably you did a little bit more than last year.' So we said: 'That's your base, that's it ... Now on top of that, how many additional cataracts do you want to do at $750 a pop?'

"This is a voluntary contract. So your CEO comes back and says, 'We'll do another 200 or something, on top of' “the cataract surgeries the hospital was already doing.

Before a hospital executive can decide to do 200 more cataract surgeries for $750, he or she has to figure out whether the hospital's per-procedure costs are more or less than that.

Dr. Brian Day, the president-elect of the Canadian Medical Association, is controversial because his regular job is running a private surgical centre in Vancouver, but he's said his proudest accomplishment has been to force B.C. hospitals to figure out how much their procedures cost them. Sometimes they contract out overflow public cases to Day's private clinic. Before any hospital started doing that, its administrators had to find out whether paying Day's fees was cheaper than finding more staff and space for the hospital to do the operations itself.

Here's the clever part of Hudson's plan: Every time the waiting-times team dispenses surgery contracts, it offers less for each procedure. Cataract procedures started out at $750, but by the time the team was done paying out for the last bunch of surgeries, Hudson says, the wait-times team was spending only $580 per procedure. It's like a series of auctions. He's says he's convinced that before long, the price will be down to $400.

Hospitals that wanted to make more money by doing more operations had to join the wait-times information system. The result: 80 per cent of Ontario's hospitals have joined and waiting times for the five procedures Hudson has been assigned to deal with have been slashed almost everywhere in the province.

The next set of conditions the wait-times team is putting on its hospital contracts is participation in a province wide system for tracking safety and quality standards, which is also meant to ensure that hospitals aren't allowing operations on patients who don't really need them.

Smitherman, the Ontario health minister, for all his public raging in defence of the existing public system, has done nothing about Hudson's work other than take credit for it. Good decision. Call it what you like -- pay-for-performance, marketizing, whatever -- as long as you call it progress.

David Reevely is a member of the Citizen's editorial board. E-mail: dreevely@thecitizen.canwest.com

Listen to a recording of the editorial board's meeting with Alan Hudson at 'current features' on ottawacitizen.com .

A Tamping Iron, Phineas Gage and Genetically Modified Food

A careful reading of this story* about Phineas Gage may explain why some are nervous about accepting genetically modified food. What seems to be just fine on first investigation . . . may just not be. [a Longwoods comment.]

Until fairly recently, scientists thought it was not much good at all, because people whose frontal lobes were damaged seemed to do pretty well without them. Phineas Gage was a foreman for the Ruthland Railroad who, on a lovely autumn day in 1848, ignited a small explosion in the vicinity of his feet, launching a three-and-a-half-foot-long iron rod into the air, which Phineas cleverly caught with his face. The rod entered just beneath his left cheek and exited through the top of his skull, boring a tunnel through his cranium and taking a good chunk of frontal lobe with it. Phineas was knocked to the ground, where he lay for a few minutes. Then, to everyone’s astonishment, he stood up and asked if a coworker might escort him to the doctor, insisting all the while that he didn’t need a ride and could walk by himself, thank you. The doctor cleaned some dirt from his wound, a coworker cleaned some brain from the rod, and in a relatively short while, Phineas and his rod were back about the same business.10 His personality took a decided turn for the worse – and that fact is the source of his fame to this day – but the more striking thing about Phineas was just how normal he otherwise was. Had the rod made hamburger of another brain part – the visual cortex, Broca’s area, the brain stem – then Phineas might have died, gone blind, lost the ability to speak, or spent the rest of his life doing a convincing impression of a cabbage. Instead, for the next twelve years, he lives, saw, spoke, worked, and traveled so uncabbagely that neurologists could only conclude that the frontal lobe did little for a fellow that he couldn’t get along nicely without.11 As on neurologist wrote in 1884, “Ever since the occurrence of the famous American crowbar case it has been known that the destruction of these lobes does not necessarily give rise to any symptoms.”12

But the neurologist was wrong. In the nineteenth century, knowledge of brain function was based largely on the observation of people who, like Phineas Gage, were the unfortunate subjects of one of nature’s occasional and inexact neurological experiments. In the twentieth century, surgeons picked up where nature left off and began to do more precise experiments whose results painted a very different picture of frontal lobe function. In the 1930’s, a Portuguese physician named António Egas Moniz was looking for a way to quiet his highly agitated psychotic patients when he heard about a new surgical procedure called frontal lobotomy, which involved the chemical or mechanical destruction of part of the frontal lobe. This procedure had been performed on monkeys, who were normally quite angry when their food was withheld, but who reacted to such indignities with unruffled patience after experiencing the operation. Egas Moniz tried the procedure on his human patients and found that it has a similar calming effect. (It also had the calming effect of winning Egas Moniz the Nobel Prize for Medicine in 1949.)

Over the next few decades, surgical techniques were improved (the procedure could be performed under local anesthesia with an ice pick) and unwanted side effects (such as lowered intelligence and bed wetting) were diminished. The destruction of some part of the frontal lobe became a standard treatment for cases of anxiety and depression that resisted other forms of therapy.13 Contrary to the conventional medical wisdom and the previous century, the frontal lobe did make a difference. The difference was that some folks seemed better off without it.
But while some surgeons were touting the benefits of frontal lobe damage, others were noticing the costs. Although patients with frontal lobe damage often performed well on standard intelligence tests, memory tests, and the like, they showed severe impairments on any test – even the very simplest test –that involved planning. For instance, when given a maze or a puzzle whose solution required that they consider an entire series of moves before making their first move, these otherwise intelligent people were stumped.14 Their planning deficits were not limited to the laboratory. These patients might function reasonably well in ordinary situations, drinking tea with out spilling and making small talk about drapes, but they found it practically impossible to say what they would do later that afternoon. In summarizing scientific knowledge on this topic, a prominent scientist concluded: “No prefrontal symptom has been reported more consistently than the inability to plan….They symptom appears unique to dysfunction of the prefrontal cortex…[and] is not associated with clinical damage to any other neural structure.”15
Now, this pair of observations – that damage to certain parts of the frontal lobe can make people feel calm but that it can also leave them unable to plan – seem to converge on a single conclusion. What is the conceptual tie that binds anxiety and planning? Both, of course, are intimately connected to thinking about the future. We feel anxiety when we anticipate that something bad will happen, and we plan by imagining how our actions will unfold over time. Planning requires that we peer into our futures, and anxiety is one of reactions that we may have when we do.16 The fact that damage to the frontal lobe impairs planning and anxiety so uniquely and precisely suggests that the frontal lobe is the critical piece of cerebral machinery that allows normal, modern human adults to project themselves into the future. Without it we are trapped in the moment, unable to imagine tomorrow and hence unworried about what it may bring. As scientists now recognize, the frontal lobe “empowers healthy human adults with the capacity to consider the self’s extended existence throughout time.”17 As such, people whose frontal lobe is damaged are described by those who study them as being “bound to present stimuli,”18 or “locked into immediate space and tme,”19 or as displaying a “tendency toward temporal concreteness.”20 In other words, like candy guys and tree climbers, they live in a world without later.

*Excerpt from the book “Stumbling on Happiness” by Daniel Gilbert
Published by Random House of Canada (www.randomhouse.ca) 2006

Dr. Penny Ballem, Leadership & the CBC

Leadership comes in many forms. Dr. Penny Ballem is one. BC providers and policy makers can be proud of presentations she makes in other parts of the country. To find her December 06 presentation click here. After hearing and seeing this, radio pundits (including the CBC) interviewed her and bloggers took note of her comments. Listen here.

Leaders in research are not the same!

What constitutes leadership in research units? Leading a group of researchers is a very different proposition than leading in healthcare organizations, and the product is different. How do research leaders attract researchers to work in their units particularly under circumstances when the unit does not pay the salaries of the unit members? What is the relationship between leader and unit members? How does the agenda for research get developed and what is the role of the leader in setting the agenda? Are there some leadership styles that are more effective in research units than others and how do effective leaders figure this out?

Interdisciplinarity has become the watchword for research funding in Canada; however, it may not be as dominant in other countries. What is the interdisciplin-ary constitution of research units, how was that reached, and what are the advantages and disadvantages? Is there a difference in attracting nurse researchers and non-nurse researchers to nurse-led research units? See the whole article here.

Dorothy Pringle, PhD

Editor in Chief

Canadian Journal of Nursing Leadership

Federation of Medical Women of Canada condemns Libyan Action

Ottawa - December 21, 2006 The Federation of Medical Women of Canada joins other Canadian National Medical Organizations in expressing their outrage against a Libyan court decision to sentence a Palestinian doctor and five Bulgarian nurses to death.

Members of the Federation were distressed to learn that the court did not investigate conditions at the Benghazi hospital where the physician and nurses worked. As well, the scientific evidence that the children had contracted HIV prior to these health professionals working there was disregarded.

“Our members working on behalf of Medical Women’s International Association have traveled to Africa to assist in projects related to HIV. These health care workers are our colleagues and we will not stand for scientific ignorance with respect to HIV-AIDS,” says President, Dr. Gail Beck, “We urge all Canadians, and especially health care professionals to ask Foreign Minister Peter MacKay to vigorously take up this issue with the Libyan Ambassador to Canada.” Mr. MacKay can be reached here:peter.mackay@international.gc.ca

For Further Information:
Dr. Gail Beck, President
613-722-6521 ext. 6288

Andrée Poirier, Executive Coordinator
613-569-5881

From: Federation of Medical Women of Canada
Fédération des femmes médecins du Canada
780 prom Echo drive, Ottawa, Ontario, K1S 5R7
Tel: (613) 569-5881 or/ou 877-771-3777;
Fax/Téléc: (613) 569-4432 or/ou 877-772-5777
E:fmwcmain@fmwc.ca
W:www.fmwc.ca

Interdisciplinarity and leadership. Whewww

What constitutes leadership in research units? Leading a group of researchers is a very different proposition than leading in healthcare organizations, and the product is different. How do research leaders attract researchers to work in their units particularly under circumstances when the unit does not pay the salaries of the unit members? What is the relationship between leader and unit members? How does the agenda for research get developed and what is the role of the leader in setting the agenda? Are there some leadership styles that are more effective in research units than others and how do effective leaders figure this out?

Interdisciplinarity has become the watchword for research funding in Canada; however, it may not be as dominant in other countries. What is the interdisciplinary constitution of research units, how was that reached, and what are the advantages and disadvantages? Is there a difference in attracting nurse researchers and non-nurse researchers to nurse-led research units?

Read the whole article here.

Dorothy Pringle PhD
Editor in Chief
Canadian Journal of Nursing Leadership

House of Healing, House of Disrespect: A Kantian Perspective on Disrespectful Behaviour among Hospital Workers

Respect toward patients is one of the most fundamental and central tenets guiding both modern bioethical practice and the everyday behaviour of all healthcare professionals. However, similar courtesy and respect is often breached in day-to-day interactions between hospital workers. Many examples are relatively minor, while egregious examples such as gender discrimination and physical abuse do occur. The more egregious transgressions may be handled by formal processes, even legal proceedings. However, the innumerable smaller examples of disrespectful behaviour are ubiquitous and insidious in their erosion of a productive collaborative approach to patient care and other aspects of functioning within the institution.

Mark Bernstein and Rita Fundner

To see the full article click on the title or here

Nursing Practice Models: Time for Change

The organization of nursing care in acute care hospitals is increasingly challenging. The traditional models of primary, team and functional nursing, or even total patient care and combinations thereof, are insufficient in today's complex healthcare environments. Patient units in acute care are now characterized by extremely ill patients who require high levels of technical and assessment skills on the part of nurses; significant numbers of novice nurses who do not have these skills but must be integrated into these units; student nurses who require mentoring from experienced nurses; lack of continuity in patient assignments; short lengths of stay on any given unit, hindering nurses' ability to develop relationships and to negotiate patient participation in care decisions; 12-hour shifts that test nurses' energy and enthusiasm; lack of technology to support nurse-to-nurse and interprofessional communication within and across shifts; and increased pressure for evidence-based and outcomes-oriented practice so that individuals and cohorts of patients achieve the highest possible outcomes of care. And these are just a few of the pressures confronting the average unit.

Dorothy Pringle, PhD
Editor-in-Chief, Canadian Journal of Nursing Leadership

[full article is available by clicking on the title above]