Allied health professions To the editor: References to the role and training of allied health professionals and concerns about their professional development have increased in frequency and intensity in recent months;516 it is hard to ignore all the voices. Much of the current debate about physiotherapy has been sparked by the recent change in the code of ethics of the Canadian Physiotherapy Association (CPA), which recognizes as "an acceptable and ethical standard of practice for its members, the assessment and treatment of clients following the acquisition of adequate and appropriate information" rather than medical referral alone. Certain parties who clearly view this step as 51n the Correspondence section of the Aug. 4 issue of the Journal four more letters on this topic appeared. Contributions to the Correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double-spaced and, except for case reports, should be no longer than 1½ manuscript pages.
a threat rather than as a challenge to physiotherapists have deliberately taken the intent of this change out of context.6 From the perspective of physiotherapists, a number of factors have led the profession to its stand on its need, or otherwise, for medical referral. Among these factors are concerns about the quality and quantity of information obtained from referring physicians, a changing health care system that increasingly de-emphasizes the traditional sickness model,7 and the professional development of physiotherapists. Traditionally, physiotherapists worked exclusively within the medical model, in which medical diagnosis and advanced screening by a qualified medical doctor were considered essential in every case. This process is still preferred by physiotherapists for patients with discernible medical problems, established complex diseases or concomitant conditions. Teamwork and followup in such cases provide a mechanism for the detection of
outpatients referred to physiotherapists suffer from specific musculoskeletal problems, which, although they may not hamper a patient's overall ability to function, may contribute to temporary limitation of activities. An open system would enable a physiotherapist to obtain a history, conduct a physical examination and, if required, provide the necessary treatment in a safe and cost-effective manner. The skills required to resolve these problems are not complex and constitute part of the undergraduate education of all university-based programs for physiotherapists. Because these noninvasive procedures produce the most essential information, a physiotherapist who is sufficiently competent in their use is performing a task similar to that of a physician when physiotherapy is the indicated treatment. If the presenting problem is more complex, physiotherapists have sufficient knowledge to recognize their limitations and refer the patient to a physician for more extensive investigation.
intercurrent problems, so that dis-
Although other means of access
ability due to complications of a disease or its treatment will be minimized. However, at least half the
to physiotherapists is implied in the change in the CPA's code of ethics, most patients will continue to be
Tb. Canadian Medical Association/l'Association ni6dicate canadienase 1867 Alta Vist Dr, Ottawa, Oat. KIG SYG; (613) 731-P31 . P.'esldent/pr4s1dei.t: 0,I.. WilSon. MD. F.1GP(GJ Secretary general/seoritaire g6n6rel: FI.G. Wilson, MD Director .f OQmmuplcatlons/dlrsoteur des communications: D.A. Geekie. BPN., OPH
CMA Journal/Journal de I'AMC ScientIfic edlter/r6dscteur aclentlfiqus: N.J.B. Wiggin, MD, MSc, PhD News and features editor/rddacteur des nouvelles at reportagas; J. Gamer Asoc[te scientific dltoi/r4decteur eclentltlque essocl4. P.P, Morgan, MD, DPH. DEpid Senior assIstant edltor/r6daetrice adjointe en chef: A. Bolster. BA AssIstant editora/rdectrlcee adjoirttee: L.D. MacDougall. 1. Whitney. BSc Contributing editora/oollakoisteurs: .. Roblilard, PhD; C.L Jarrett. PhD. MD: M.G. Landry, BA; Wt. .Ogl., MD, PhD. MPH; D. Woods Business manager/direeteur g6n6ral: 4..K. Goodman Sales manager/chef du service ties ventee: N. Hutton Productloe manager/chef du service tIe Is preductlon. R.M. Slnnott
514 CMA JOURNAL/SEPTEMBER 8, 1979/VOL. 121
The Canadian Medical Association Jour-
nal is published twice a month by the Canadian Medical AssociatIon, P0 Box 865G. Ottawa, Ont. 1(10 (103 and Is printed by Herpell's Press Cooperative. Gardanvale, PD HOA 180. Subscription rates and Information for contributors of manuscripts are Published in the llrst issue of each volume. All reproduction
- m rights are reserved.
Note: All drug advertisements In the Journal have been pre. cleared by the Pharmacstitlcsl 1S.±!.t Adver.lsing Advisory Board.
referred by physicians. The most striking result of this change is the requirement to obtain adequate and appropriate information before treatment begins. This rule is designed to avoid the present problem - that information obtained on medical referral is more often than not of questionable value and incomplete, and is sometimes inaccurate. The obligation to obtain the required information is placed squarely on the shoulders of physiotherapists; however, physicians must provide the information that is beyond the scope of physiotherapists. The greater emphasis placed on health care and its maintenance, rather than medical care, requires that physiotherapists reach the public directly. Prevention programs must not be impeded by a requirement in the code that is no longer relevant to the present health care issues. While the overall value of prevention strategies, such as screening programs and health education, has not yet been demonstrated, their potential merit cannot be denied, nor can the emphasis placed on these activities by health care planners and politicians be ignored. Across Canada physiotherapists are already engaged in these programs, and their contributions to our knowledge of cardiovascular endurance training, preparation of athletes and early detection of postural problems in public schools and industry is likely to expand and become significant. The tremendous expansion of scientific knowledge in recent years makes it impossible for an individual practitioner to be knowledgeable in all branches of the health care services. This factor has led many physicians and increasing numbers of physiotherapists and other health care workers to develop specific interests in a special field, and in some cases within restricted areas of a special field - specialties within specialties.8 This trend is likely to continue as more knowledge becomes available and its application becomes more sophisticated. Even the hallowed tradition of general practice is being eroded by the emergence of the more advanced field of family medicine. For the past two decades mem-
bers of the CPA have responded to these challenges by establishing and maintaining acceptable standards of education and practice, and they have resolved to upgrade the standards as new knowledge unfolds. To this extent all university-based education programs, which are closely allied to faculties of medicine, lead to an undergraduate degree, and three universities have approved programs leading to master's degrees in physiotherapy. The CPA predicts that within the next few years doctoral programs will be offered in Canada to persons eager to combine teaching and scientific enquiry. Guidelines for the accreditation of education programs and physiotherapy services have been developed, and a cooperative project with the federal government to evaluate the quality of care in physiotherapy is under way. These developments did not occur by accident; they are the result of a carefully laid strategy designed to enhance the scientific credibility and potential of physiotherapy.9 This goal can only be spearheaded by physiotherapists working cooperatively with such academic disciplines as medicine and the social and applied sciences. Inevitably a sound scientific base for physiotherapy, balanced with the art of caring, can only result in improved outcomes of therapy. On the other hand, a code of ethics that forbids direct access to the public is stifling and tends to generate a dependency that is not conducive to the critical appraisal required of all branches of physiotherapy. I hope the medical profession will continue to work with the CPA in the further development of physiotherapy. The posture assumed by a small but vocal minority within the CMA, who confuse medical collaboration with medical dominance. is not conducive to good relations in the future.6 Physiotherapists do not wish to become physicians, but rather more effective health care providers of physiotherapy. These steps, which are not unlike those taken by other professions, are necessary and inevitable. Physicians may find solace in a quote attributed to Cyrus Vance about foreign policy in the United States: "The realization that we are
518 GMA JOURNAL/SEPTEMBER 8, 1979/VOL. 121
DERMOVATE (clobetasol Pr.ionate 0.05%)
TOPICAL CORTICOSTEROID
Rapid relief can mean an early return to normal living. INDICATIONS ¶lbpical therapy of recalcitrant corticosteroidresponsive dermatoses, including severe cases of psoriasis and ecrematous dermatitis. CONTRAINDICATIONS Infected skin lesions if no anti-infective agent is used simultaneously; fungal and viral infections of the skin, including herpes simplez vaccinia and varicella; pregnancy and lactation; hypersensitivity to any of the ingredients. ¶lbpical corticosteroids are also contraindicated in tuberculous lesions of the skin. WARNINGS Dermovate should not be used in the eye. When used over extensive areas for prolonged periods, it is possible that sufficient absorption may take place to give rise to systemic effects. It is advisable, therefore, to use Dermovate for brief periods only, and to discontinue its use as soon as the lesion has cleared up. Do not use more than fifty grams of Dermovate per week. Patients should be advised to inform subsequent physicians of the prior use of corticosteroids. PRECAUTIONS ¶lbpical corticosteroids should be used with caution on lesions close to the eye. Posterior subcapsular cataracts have been reported following systemic use of corticosteroids. Although hypersensitivity reactions are rare with topically applied steroids, the drug should be discontinued and appropriate therapy initiated if there are signs of hypersensitivity. In cases of bacterial infections of the skin, appropriate antibacterial agents should be used as primary therapy. if it is considered necessary, the topical corticosteroid may be used as an adjunct to control inflammation, erythema and itching. ifs symptomatic response is not noted within a few days to a week, the local application of corticosteroid should be discontinued until the infection is brought under controL Significant systemic absorption may occur when steroids are applied over large areas of the body, especially under occlusive dressings. Because the degree of absorption of clobetasol 17-propionate when applied under occlusive dressing has not been measured, its use in this fashion is not recommended Because the safety and effectiveness of Dermovate has not been established in children, its use is not recommended. ADVERSE REACTIONS Local burning, irritation, itching, skin atrophy, striae, change in pigmentation, secondary ininfection, hypertrichosis and adrenal suppression have been observed following topical corticosteroid therapy. DOSAGE AND ADMINISTRATION Dermovate Cream and Dermovate Ointment are applied thinly to cover the affected area, and gently rubbed into the skin. Frequency of application is two to three times daily, according to the severity of the condition. The total dose of .ermovate applied weekiy should not exceed fifty gramaTherapy should be discontinued if no response is noted after a week or as soon as the lesion heals. It is advisable to use Dermovate for brief periods only. Note: if maintenance therapy is required, a lower strength topical steroid, such as Betnovate, is indicated DOSAGE FORMS Dermovate Cream and Dermovate Ointment are available in 15 and 60 g tubes, and in 100 gjars. Product monograph available on request REFERENCE: 1. Floden, C.H. et at, Current Med Research and Opimon, 3:875-877,1975.
.1."GIaxo Laboratories
V
L
AGLAXO CANADA UMITUD COMPANY
not omnipotent should not make us fear we have lost our power or the will to use it. It requires us to exercise leadership creatively, to inspire others to work with us toward goals we share but cannot achieve separately."
should always be a mutual affair or both professions suffer. Research and learning must be a shared experience in medical schools and schools of physiotherapy. Both professions have much to learn.
ANTOINE HELEWA, M Sc Former president Canadian Physiotherapy Association Toronto, Ont.
Chairman Subcommittee on allied medical education Council on Medical Education Canadian Medical Association
References 1. Proliferation of paramedics causes concern. Can Med Assoc J 119: 60, 1978 2. GRAY C: Podiatrists and optometrists mounting provincial lobby campaigns to get greater treatment authority. Ibid, p 370 3. LIvINGsToN M: Paramedics, chiropractors and health planners (C). Ibid, p 1391 4. FRASER DM, NEsnvrr LI, BENNETT JS: Role and training of paramedical groups (C). Can Med Assoc J 120: 122, 1979 5. Canadian Physiotherapy Association wants direct patient access without
MD referral. Can Fain Physician 25: 137, 1979 6. BLAiR DC: Allied health professions and the non-physician-referred practice of physiotherapy (E). Can Med Assoc J 120: 519, 1979
7. LALONDE M: A New Perspective Ofl the Health of Canadians. A Working Document, Govt of Canada, Ottawa, 1974 8. OGRYZLO MA: Specialty of rheumatology - manpower requirements (E). J Rheumatol 2: 1, 1975
9. Activities for 1978-79 Relating to the Association's Seven Long-term Goals, Canadian Physiotherapy Association,
Toronto, June 1978 To the editor: A recent article and subsequent editorial in the New England Journal of Medicine place under scrutiny the time-honoured practice of physiotherapy for patients with chest diseases.1'1 Blair3 has suggested that because of a lack of knowledge on the part of many physicians, a striving for independent professional status by physiotherapists, and a need to recognize and regulate what is often current practice, physiotherapists are isolating themselves from the mainstream of scientific research in medicine. There is a serious need for scientifically oriented physicians and physiotherapists to come together to place much of current practice on a solid footing. The training of physicians and physiotherapists
A.A. SCOTT, MD, FRCP[C]
References 1. GRAHAM WGB, BRADLEY DA: Efficacy of chest physiotherapy and intermittent positive-pressure breathing in the resolution of pneumonia. N Engi J Med 299: 624, 1978 2. MURRAY JE: The ketchup-bottle method (E). N Engi J Med 300: 1155, 1979 3. BLAIR DC: Allied health professions and the non-physician-referred practice of physiotherapy (E). Can Med Assoc J 120: 519, 1979
Salaried medical services
To the editor: In response to Dr. D.G. Cottrell's letter (Can Med AsSoc 1 120: 1053, 1979), I wish to add my support for the establishment of a salaried medical service, but only for the doctors who would opt for it. What I consider to be the basic elements of such a service are as follows: * A basic salary computed on a 40-hour week plus benefits for any postgraduate qualifications and the number of years in practice. * Overtime paid at time-and-ahalf rates for hours worked after 10 pm, during statutory holidays and on Saturdays and Sundays. * Paid sick leave to a maximum of 2 weeks for recent graduates, increasing by 1 week per year to a maximum of 42 weeks by 65 years of age. * Sabbatical leave of absence to a maximum of 3 months after 3 years' service, 6 months after 6 years' service and 1 year after 10 years' service. * A pension amounting to half of the average best 5 years' earnings, paid annually. * Prolonged disability insurance, and dental and medical premium coverage. * Payment of annual membership fees (including medicolegal coverage) of the Canadian Medical
520 CMA JOURNAL/SEPTEMBER 8, 1979/VOL. 121
Association (CMA) and the provincial medical associations. * Payment of practice expenses, including an automobile allowance. * All these benefits should be tied to the Consumer Price Index. (Federal politicians and civil servants have a pension plan tied to this index.) * The CMA and provincial medical associations must hire nonmedical professional negotiators who know how to deal with politicians and civil servants. The proposals I have outlined will, no doubt, raise the hackles of many doctors in Canada. To those who demur or who are antagonistic to these suggestions, I ask that they do not bury their heads in the sand, because the sands are moving fast. Socialism in Canada is a fact of life for better or for worse according to one's political persuasion. In my opinion one must be toughminded and realistic about the path medicine has taken in Canada. I have practised in three socialist countries - Britain, Sweden and Denmark - as well as in Canada and the United States. In Denmark and Sweden doctors have the benefits I have outlined. In general, their working conditions are excellent and they are highly respected by their patients. Their hospitals are extremely well equipped and well staffed. Yes, taxes are very high in Denmark and Sweden, but if the people demand first-rate medical care they must be prepared to pay for it, directly or indirectly, or they will have to accept a second- or third-rate medical care delivery system. I believe that this has already become so in many areas of Canada. The younger doctors in Denmark and Sweden have extremely powerful unions that, through tough bargaining, have demanded and received good working hours, good hospitals, good equipment and good fringe benefits. Nonmedical professional negotiators acting on our behalf should, and in fact could, achieve for us conditions of service and remuneration comparable to those in Denmark and Sweden. JoHN SHONE, MD, FRCP[C]
690 Coxwell Ave. Toronto, Ont.
a threat rather than as a challenge to physiotherapists have deliberately taken the intent of this change out of context.6 From the perspective of physiotherapists, a number of factors have led the profession to its stand on its need, or otherwise, for medical referral. Among these factors are concerns about the quality and quantity of information obtained from referring physicians, a changing health care system that increasingly de-emphasizes the traditional sickness model,7 and the professional development of physiotherapists. Traditionally, physiotherapists worked exclusively within the medical model, in which medical diagnosis and advanced screening by a qualified medical doctor were considered essential in every case. This process is still preferred by physiotherapists for patients with discernible medical problems, established complex diseases or concomitant conditions. Teamwork and followup in such cases provide a mechanism for the detection of
outpatients referred to physiotherapists suffer from specific musculoskeletal problems, which, although they may not hamper a patient's overall ability to function, may contribute to temporary limitation of activities. An open system would enable a physiotherapist to obtain a history, conduct a physical examination and, if required, provide the necessary treatment in a safe and cost-effective manner. The skills required to resolve these problems are not complex and constitute part of the undergraduate education of all university-based programs for physiotherapists. Because these noninvasive procedures produce the most essential information, a physiotherapist who is sufficiently competent in their use is performing a task similar to that of a physician when physiotherapy is the indicated treatment. If the presenting problem is more complex, physiotherapists have sufficient knowledge to recognize their limitations and refer the patient to a physician for more extensive investigation.
intercurrent problems, so that dis-
Although other means of access
ability due to complications of a disease or its treatment will be minimized. However, at least half the
to physiotherapists is implied in the change in the CPA's code of ethics, most patients will continue to be
Tb. Canadian Medical Association/l'Association ni6dicate canadienase 1867 Alta Vist Dr, Ottawa, Oat. KIG SYG; (613) 731-P31 . P.'esldent/pr4s1dei.t: 0,I.. WilSon. MD. F.1GP(GJ Secretary general/seoritaire g6n6rel: FI.G. Wilson, MD Director .f OQmmuplcatlons/dlrsoteur des communications: D.A. Geekie. BPN., OPH
CMA Journal/Journal de I'AMC ScientIfic edlter/r6dscteur aclentlfiqus: N.J.B. Wiggin, MD, MSc, PhD News and features editor/rddacteur des nouvelles at reportagas; J. Gamer Asoc[te scientific dltoi/r4decteur eclentltlque essocl4. P.P, Morgan, MD, DPH. DEpid Senior assIstant edltor/r6daetrice adjointe en chef: A. Bolster. BA AssIstant editora/rdectrlcee adjoirttee: L.D. MacDougall. 1. Whitney. BSc Contributing editora/oollakoisteurs: .. Roblilard, PhD; C.L Jarrett. PhD. MD: M.G. Landry, BA; Wt. .Ogl., MD, PhD. MPH; D. Woods Business manager/direeteur g6n6ral: 4..K. Goodman Sales manager/chef du service ties ventee: N. Hutton Productloe manager/chef du service tIe Is preductlon. R.M. Slnnott
514 CMA JOURNAL/SEPTEMBER 8, 1979/VOL. 121
The Canadian Medical Association Jour-
nal is published twice a month by the Canadian Medical AssociatIon, P0 Box 865G. Ottawa, Ont. 1(10 (103 and Is printed by Herpell's Press Cooperative. Gardanvale, PD HOA 180. Subscription rates and Information for contributors of manuscripts are Published in the llrst issue of each volume. All reproduction
- m rights are reserved.
Note: All drug advertisements In the Journal have been pre. cleared by the Pharmacstitlcsl 1S.±!.t Adver.lsing Advisory Board.
referred by physicians. The most striking result of this change is the requirement to obtain adequate and appropriate information before treatment begins. This rule is designed to avoid the present problem - that information obtained on medical referral is more often than not of questionable value and incomplete, and is sometimes inaccurate. The obligation to obtain the required information is placed squarely on the shoulders of physiotherapists; however, physicians must provide the information that is beyond the scope of physiotherapists. The greater emphasis placed on health care and its maintenance, rather than medical care, requires that physiotherapists reach the public directly. Prevention programs must not be impeded by a requirement in the code that is no longer relevant to the present health care issues. While the overall value of prevention strategies, such as screening programs and health education, has not yet been demonstrated, their potential merit cannot be denied, nor can the emphasis placed on these activities by health care planners and politicians be ignored. Across Canada physiotherapists are already engaged in these programs, and their contributions to our knowledge of cardiovascular endurance training, preparation of athletes and early detection of postural problems in public schools and industry is likely to expand and become significant. The tremendous expansion of scientific knowledge in recent years makes it impossible for an individual practitioner to be knowledgeable in all branches of the health care services. This factor has led many physicians and increasing numbers of physiotherapists and other health care workers to develop specific interests in a special field, and in some cases within restricted areas of a special field - specialties within specialties.8 This trend is likely to continue as more knowledge becomes available and its application becomes more sophisticated. Even the hallowed tradition of general practice is being eroded by the emergence of the more advanced field of family medicine. For the past two decades mem-
bers of the CPA have responded to these challenges by establishing and maintaining acceptable standards of education and practice, and they have resolved to upgrade the standards as new knowledge unfolds. To this extent all university-based education programs, which are closely allied to faculties of medicine, lead to an undergraduate degree, and three universities have approved programs leading to master's degrees in physiotherapy. The CPA predicts that within the next few years doctoral programs will be offered in Canada to persons eager to combine teaching and scientific enquiry. Guidelines for the accreditation of education programs and physiotherapy services have been developed, and a cooperative project with the federal government to evaluate the quality of care in physiotherapy is under way. These developments did not occur by accident; they are the result of a carefully laid strategy designed to enhance the scientific credibility and potential of physiotherapy.9 This goal can only be spearheaded by physiotherapists working cooperatively with such academic disciplines as medicine and the social and applied sciences. Inevitably a sound scientific base for physiotherapy, balanced with the art of caring, can only result in improved outcomes of therapy. On the other hand, a code of ethics that forbids direct access to the public is stifling and tends to generate a dependency that is not conducive to the critical appraisal required of all branches of physiotherapy. I hope the medical profession will continue to work with the CPA in the further development of physiotherapy. The posture assumed by a small but vocal minority within the CMA, who confuse medical collaboration with medical dominance. is not conducive to good relations in the future.6 Physiotherapists do not wish to become physicians, but rather more effective health care providers of physiotherapy. These steps, which are not unlike those taken by other professions, are necessary and inevitable. Physicians may find solace in a quote attributed to Cyrus Vance about foreign policy in the United States: "The realization that we are
518 GMA JOURNAL/SEPTEMBER 8, 1979/VOL. 121
DERMOVATE (clobetasol Pr.ionate 0.05%)
TOPICAL CORTICOSTEROID
Rapid relief can mean an early return to normal living. INDICATIONS ¶lbpical therapy of recalcitrant corticosteroidresponsive dermatoses, including severe cases of psoriasis and ecrematous dermatitis. CONTRAINDICATIONS Infected skin lesions if no anti-infective agent is used simultaneously; fungal and viral infections of the skin, including herpes simplez vaccinia and varicella; pregnancy and lactation; hypersensitivity to any of the ingredients. ¶lbpical corticosteroids are also contraindicated in tuberculous lesions of the skin. WARNINGS Dermovate should not be used in the eye. When used over extensive areas for prolonged periods, it is possible that sufficient absorption may take place to give rise to systemic effects. It is advisable, therefore, to use Dermovate for brief periods only, and to discontinue its use as soon as the lesion has cleared up. Do not use more than fifty grams of Dermovate per week. Patients should be advised to inform subsequent physicians of the prior use of corticosteroids. PRECAUTIONS ¶lbpical corticosteroids should be used with caution on lesions close to the eye. Posterior subcapsular cataracts have been reported following systemic use of corticosteroids. Although hypersensitivity reactions are rare with topically applied steroids, the drug should be discontinued and appropriate therapy initiated if there are signs of hypersensitivity. In cases of bacterial infections of the skin, appropriate antibacterial agents should be used as primary therapy. if it is considered necessary, the topical corticosteroid may be used as an adjunct to control inflammation, erythema and itching. ifs symptomatic response is not noted within a few days to a week, the local application of corticosteroid should be discontinued until the infection is brought under controL Significant systemic absorption may occur when steroids are applied over large areas of the body, especially under occlusive dressings. Because the degree of absorption of clobetasol 17-propionate when applied under occlusive dressing has not been measured, its use in this fashion is not recommended Because the safety and effectiveness of Dermovate has not been established in children, its use is not recommended. ADVERSE REACTIONS Local burning, irritation, itching, skin atrophy, striae, change in pigmentation, secondary ininfection, hypertrichosis and adrenal suppression have been observed following topical corticosteroid therapy. DOSAGE AND ADMINISTRATION Dermovate Cream and Dermovate Ointment are applied thinly to cover the affected area, and gently rubbed into the skin. Frequency of application is two to three times daily, according to the severity of the condition. The total dose of .ermovate applied weekiy should not exceed fifty gramaTherapy should be discontinued if no response is noted after a week or as soon as the lesion heals. It is advisable to use Dermovate for brief periods only. Note: if maintenance therapy is required, a lower strength topical steroid, such as Betnovate, is indicated DOSAGE FORMS Dermovate Cream and Dermovate Ointment are available in 15 and 60 g tubes, and in 100 gjars. Product monograph available on request REFERENCE: 1. Floden, C.H. et at, Current Med Research and Opimon, 3:875-877,1975.
.1."GIaxo Laboratories
V
L
AGLAXO CANADA UMITUD COMPANY
not omnipotent should not make us fear we have lost our power or the will to use it. It requires us to exercise leadership creatively, to inspire others to work with us toward goals we share but cannot achieve separately."
should always be a mutual affair or both professions suffer. Research and learning must be a shared experience in medical schools and schools of physiotherapy. Both professions have much to learn.
ANTOINE HELEWA, M Sc Former president Canadian Physiotherapy Association Toronto, Ont.
Chairman Subcommittee on allied medical education Council on Medical Education Canadian Medical Association
References 1. Proliferation of paramedics causes concern. Can Med Assoc J 119: 60, 1978 2. GRAY C: Podiatrists and optometrists mounting provincial lobby campaigns to get greater treatment authority. Ibid, p 370 3. LIvINGsToN M: Paramedics, chiropractors and health planners (C). Ibid, p 1391 4. FRASER DM, NEsnvrr LI, BENNETT JS: Role and training of paramedical groups (C). Can Med Assoc J 120: 122, 1979 5. Canadian Physiotherapy Association wants direct patient access without
MD referral. Can Fain Physician 25: 137, 1979 6. BLAiR DC: Allied health professions and the non-physician-referred practice of physiotherapy (E). Can Med Assoc J 120: 519, 1979
7. LALONDE M: A New Perspective Ofl the Health of Canadians. A Working Document, Govt of Canada, Ottawa, 1974 8. OGRYZLO MA: Specialty of rheumatology - manpower requirements (E). J Rheumatol 2: 1, 1975
9. Activities for 1978-79 Relating to the Association's Seven Long-term Goals, Canadian Physiotherapy Association,
Toronto, June 1978 To the editor: A recent article and subsequent editorial in the New England Journal of Medicine place under scrutiny the time-honoured practice of physiotherapy for patients with chest diseases.1'1 Blair3 has suggested that because of a lack of knowledge on the part of many physicians, a striving for independent professional status by physiotherapists, and a need to recognize and regulate what is often current practice, physiotherapists are isolating themselves from the mainstream of scientific research in medicine. There is a serious need for scientifically oriented physicians and physiotherapists to come together to place much of current practice on a solid footing. The training of physicians and physiotherapists
A.A. SCOTT, MD, FRCP[C]
References 1. GRAHAM WGB, BRADLEY DA: Efficacy of chest physiotherapy and intermittent positive-pressure breathing in the resolution of pneumonia. N Engi J Med 299: 624, 1978 2. MURRAY JE: The ketchup-bottle method (E). N Engi J Med 300: 1155, 1979 3. BLAIR DC: Allied health professions and the non-physician-referred practice of physiotherapy (E). Can Med Assoc J 120: 519, 1979
Salaried medical services
To the editor: In response to Dr. D.G. Cottrell's letter (Can Med AsSoc 1 120: 1053, 1979), I wish to add my support for the establishment of a salaried medical service, but only for the doctors who would opt for it. What I consider to be the basic elements of such a service are as follows: * A basic salary computed on a 40-hour week plus benefits for any postgraduate qualifications and the number of years in practice. * Overtime paid at time-and-ahalf rates for hours worked after 10 pm, during statutory holidays and on Saturdays and Sundays. * Paid sick leave to a maximum of 2 weeks for recent graduates, increasing by 1 week per year to a maximum of 42 weeks by 65 years of age. * Sabbatical leave of absence to a maximum of 3 months after 3 years' service, 6 months after 6 years' service and 1 year after 10 years' service. * A pension amounting to half of the average best 5 years' earnings, paid annually. * Prolonged disability insurance, and dental and medical premium coverage. * Payment of annual membership fees (including medicolegal coverage) of the Canadian Medical
520 CMA JOURNAL/SEPTEMBER 8, 1979/VOL. 121
Association (CMA) and the provincial medical associations. * Payment of practice expenses, including an automobile allowance. * All these benefits should be tied to the Consumer Price Index. (Federal politicians and civil servants have a pension plan tied to this index.) * The CMA and provincial medical associations must hire nonmedical professional negotiators who know how to deal with politicians and civil servants. The proposals I have outlined will, no doubt, raise the hackles of many doctors in Canada. To those who demur or who are antagonistic to these suggestions, I ask that they do not bury their heads in the sand, because the sands are moving fast. Socialism in Canada is a fact of life for better or for worse according to one's political persuasion. In my opinion one must be toughminded and realistic about the path medicine has taken in Canada. I have practised in three socialist countries - Britain, Sweden and Denmark - as well as in Canada and the United States. In Denmark and Sweden doctors have the benefits I have outlined. In general, their working conditions are excellent and they are highly respected by their patients. Their hospitals are extremely well equipped and well staffed. Yes, taxes are very high in Denmark and Sweden, but if the people demand first-rate medical care they must be prepared to pay for it, directly or indirectly, or they will have to accept a second- or third-rate medical care delivery system. I believe that this has already become so in many areas of Canada. The younger doctors in Denmark and Sweden have extremely powerful unions that, through tough bargaining, have demanded and received good working hours, good hospitals, good equipment and good fringe benefits. Nonmedical professional negotiators acting on our behalf should, and in fact could, achieve for us conditions of service and remuneration comparable to those in Denmark and Sweden. JoHN SHONE, MD, FRCP[C]
690 Coxwell Ave. Toronto, Ont.
