they take their skills elsewhere. The international medical scene is becoming ever more competitive, and - apart from pure research - Canada does not seem even to be bidding. Many Western countries, particularly in Europe, now have reciprocity of higher qualifications. How much longer can we afford to be nonparticipants? Ian M.C. Clarke, MB, ChB, FFARCS Director Pain Relief Clinic Foothills Provincial General Hospital Calgary, Alta.
Dr. Oyston's Viewpoint surely demands an answer. It represents the undeserved, all-too-frequent criticism by immigrants of Canadian society and institutions. Let's enumerate Oyston's good fortune. Canada's immigration policy puts physicians low on the list of priorities. However, Oyston married a Canadian and got a position at a prestigious teaching institution of the University of Toronto. He applied for a general licence after the Ontario licensing regulations had changed, regulations that apply to all applicants and not only to immigrants. Oyston does not understand that the licensing authority has a mandate to administer a piece of provincial legislation. Its actions are not whimsy. Different decisions might have been made in other provinces. The Royal College of Physicians and Surgeons of Canada is our national body for the assessment of training and higher qualifications. Its decisions are not discriminatory. It took the good doctor 3 years of training in Canada before he could get a general licence - he was lucky. The government could have stipulated that no licences be issued to foreign graduates (the situation in many parts of the world). As for his opinion that no civilized country should treat educated immigrants in this way (I JULY 15, 1991
presume he thinks physicians are educated) I hope he will wait a while before passing judgement on his adopted country. Oyston's "quiet protest" of not using the FRCPC designation is a personal decision. I wonder whether he uses his certification to get specialist fees when submitting his accounts for payment? Manning L. Mador, MD, FRCSC 1705-3 Concorde P1. Don Mills, Ont.
physicians and that enrolment in medical schools should be reduced. Perhaps the general warning offered by immigration officers that there is no guarantee of an opportunity to practise medicine in Canada should be made more specific, so that there is no misconception in a potential immigrant's mind. Donald C. McCaffrey MD, FCRCP Director Department of Anaesthesia Grace General Hospital Ottawa, Ont.
Dr. Oyston regrets that he did not apply for a general licence in Ontario until 1987 and that "by that time the rules had changed." Over Health care problems 30 years ago I was astonished to in Ontario find that most of the residents with whom I worked were not I have never read any reported licensed, because, they said, they remarks of the deputy miniscould not afford it. When I beof health of Ontario, Dr. ter came eligible for registration in (as in Patrick SulMartin Britain I applied on the same day, livan's Barkin "Throwing more article precisely because the rules might care system will at health money be changed at any time. not solve problems, CMA told" [Can Med Assoc J 1991; 144: 576Frederick B. Singleton, MB, BS, FRCPC 577]), without being impressed by 325 Kingscourt Ave. Kingston, Ont. his endless litany of suggestions for improving the practice of I can appreciate Dr. Oyston's frus- medicine. I am even more imtration in his attempt to practise pressed by his complete lack of medicine in Canada. However, suggestions for improving the adthe problem is more complex than ministration of medicine by his government. For example, I have his analysis indicates. Canada has a duty to protect not yet heard him explain why the and preserve its citizens' career government has spent such enoropportunities in an exciting, inter- mous amounts of money sending esting and remunerative profes- patients to the United States for sion. Until recently it has failed to lithotripsy when it can be done far do this. A perusal of the Canadian more cheaply in Canada. Although he can hardly be Medical Directory will show that over one-third of Canadian phys- expected now to keep up to date icians were trained outside the with everything, the reason "that country. When I graduated from the rate of new prescriptions for a medical school in 1968 there were cholesterol-lowering agent for peomore immigrant physicians enter- ple over 65 continues to rise" is ing Canada than there were gradu- that within the last year or so it ates from all Canadian medical has been very clearly shown that a schools combined. Instead of reduction in cholesterol levels in being unfair to immigrant phys- such people can lead not only to icians I would counter that Cana- cessation of atherosclerosis but da has been unfair to its own also to its reversal. Perhaps he can youth. Now we hear rumblings explain the basis upon which we that Canada has an oversupply of should start refusing beneficial CAN MEDASSOCJ 1991; 145(2)
arrive. The consequence of this too easily fall prey to an army of incomplete use of facilities and number-crunching bureaucrats. services is reflected in the much Thomas J. Muckle, MD higher cost of that investigation in Joseph Z. Shainhouse, MD Lawrence Ave. E Director of laboratories Small-Town, USA, than in Cana- 203-2680 Scarborough, Ont. Chedoke Division da. In the hospitals in downtown Chedoke-McMaster Hospitals Toronto the patient must wait for Hamilton, Ont. the machine and technicians, Phototherapy which are working full time from Dr. Barkin has complained about Monday to Friday and are booked for neonatal escalating health care costs. He is well in advance. hyperbilirubinemia in serious error. Barkin may marvel at the The Canadian health care sys- quality car that Nissan sells for read "Effect of educational tem is based on the Hall Commis- less than Ford does, but he fails to and interview on program sion report of 1964.' Mr. Justice mention that the wages and stanof guidelines for the adoption Emmett W. Hall not only provid- dard of living of the Japanese management of neonatal hypered governments with a plan for worker may be lower than those of bilirubinemia," by Dr. Douglas the delivery of physician services the Canadian counterpart. The McMillan and associates (Can but also estimated the costs of the availability of social services Med Assoc J 1991; 144: 707-712), entire health care system up to the including government health care with keen interest, not for the year 2000. Ontario tax- stated aim of the study but as a for paid by higher The cost projections in this es - is reflected in the Ford's concrete example both of the perreport for the 1 980s and 1 990s higher cost. petuation of unfounded practices indicated a real yearly increase of If it is true that the cost of and of attempts to get the medical 4% per capita. Despite the unin one university community community to conform to stananticipated aging of the popula- care is double the cost in a second dards of care. tion and an increase in the use of one might ask why the The stated objectives were to technology the real yearly increase community extra money was allocated. Per- determine whether physicians are has been only 3.6% per capita, haps there has been some misadhering to guidelines for the about 10% under budget. management at the ministry level management of neonatal hyperTo my knowledge no other in (if not actually foster- bilirubinemia, what affects their program of government runs ing)allowing the development of such sys- decisions to investigate and treat under budget. Furthermore, it is tems over the last 20 years. the condition and what effects an improper to complain of unanticiThe reorganization of cardioprogram and clinical pated costs when a program is vascular surgery in Toronto is an educational have on compliance interview under budget. excellent example of how the with the guidelines. medical community, with a little Much of the authors' thesis Marc Baltzan, MD encouragement, can improve its relies on the 1986 report of the 200-366 Third Ave. S Saskatoon, Sask. management. But there are a few Fetus and Newborn Committee of missing details in that story. The the Canadian Paediatric Society.' Reference most important of these is that In fact, the committee skirted the although undoubtedly more orga- issue of proven indication for 1. Hall EW (chmn): Roval Commission on nized and centralized the system phototherapy for term infants but Health Services, 2 vols, Queen's Printer. is working mainly because of the did say that there is no clear Ottawa, 1964-65 sudden appearance of government scientific evidence permitting the I am quite willing to agree with funding for the long-delayed car- definition of dangerous levels of Dr. Barkin's basic premise that we diovascular unit at Sunnybrook bilirubin in premature infants. are not spending Ontario's health Health Science Centre (Barkin's Hence the basic premise in care dollars as efficiently as we old stomping grounds). the article - that "there was sufficould. But that is not the answer Quality assurance certainly cient scientific evidence to supto the questions he raises. has an important place in increas- port a standardized approach to The patient in Small-Town, ing the efficient use of funds in treatment" was not, in fact, the USA, can be evaluated quickly in the health care system. However, case. Nevertheless, the committee a day because the investigative without sharp and frequent criti- published recommendations for machinery, technicians and spe- cism of both the system and the the investigation of hypercialists are sitting around waiting, proponents of the quality assur- bilirubinemia and indications for indeed hoping, for a patient to ance movement, health care may the use of phototherapy. Then
treatment to people on the criterion of age alone.
100
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Dr. Oyston's Viewpoint surely demands an answer. It represents the undeserved, all-too-frequent criticism by immigrants of Canadian society and institutions. Let's enumerate Oyston's good fortune. Canada's immigration policy puts physicians low on the list of priorities. However, Oyston married a Canadian and got a position at a prestigious teaching institution of the University of Toronto. He applied for a general licence after the Ontario licensing regulations had changed, regulations that apply to all applicants and not only to immigrants. Oyston does not understand that the licensing authority has a mandate to administer a piece of provincial legislation. Its actions are not whimsy. Different decisions might have been made in other provinces. The Royal College of Physicians and Surgeons of Canada is our national body for the assessment of training and higher qualifications. Its decisions are not discriminatory. It took the good doctor 3 years of training in Canada before he could get a general licence - he was lucky. The government could have stipulated that no licences be issued to foreign graduates (the situation in many parts of the world). As for his opinion that no civilized country should treat educated immigrants in this way (I JULY 15, 1991
presume he thinks physicians are educated) I hope he will wait a while before passing judgement on his adopted country. Oyston's "quiet protest" of not using the FRCPC designation is a personal decision. I wonder whether he uses his certification to get specialist fees when submitting his accounts for payment? Manning L. Mador, MD, FRCSC 1705-3 Concorde P1. Don Mills, Ont.
physicians and that enrolment in medical schools should be reduced. Perhaps the general warning offered by immigration officers that there is no guarantee of an opportunity to practise medicine in Canada should be made more specific, so that there is no misconception in a potential immigrant's mind. Donald C. McCaffrey MD, FCRCP Director Department of Anaesthesia Grace General Hospital Ottawa, Ont.
Dr. Oyston regrets that he did not apply for a general licence in Ontario until 1987 and that "by that time the rules had changed." Over Health care problems 30 years ago I was astonished to in Ontario find that most of the residents with whom I worked were not I have never read any reported licensed, because, they said, they remarks of the deputy miniscould not afford it. When I beof health of Ontario, Dr. ter came eligible for registration in (as in Patrick SulMartin Britain I applied on the same day, livan's Barkin "Throwing more article precisely because the rules might care system will at health money be changed at any time. not solve problems, CMA told" [Can Med Assoc J 1991; 144: 576Frederick B. Singleton, MB, BS, FRCPC 577]), without being impressed by 325 Kingscourt Ave. Kingston, Ont. his endless litany of suggestions for improving the practice of I can appreciate Dr. Oyston's frus- medicine. I am even more imtration in his attempt to practise pressed by his complete lack of medicine in Canada. However, suggestions for improving the adthe problem is more complex than ministration of medicine by his government. For example, I have his analysis indicates. Canada has a duty to protect not yet heard him explain why the and preserve its citizens' career government has spent such enoropportunities in an exciting, inter- mous amounts of money sending esting and remunerative profes- patients to the United States for sion. Until recently it has failed to lithotripsy when it can be done far do this. A perusal of the Canadian more cheaply in Canada. Although he can hardly be Medical Directory will show that over one-third of Canadian phys- expected now to keep up to date icians were trained outside the with everything, the reason "that country. When I graduated from the rate of new prescriptions for a medical school in 1968 there were cholesterol-lowering agent for peomore immigrant physicians enter- ple over 65 continues to rise" is ing Canada than there were gradu- that within the last year or so it ates from all Canadian medical has been very clearly shown that a schools combined. Instead of reduction in cholesterol levels in being unfair to immigrant phys- such people can lead not only to icians I would counter that Cana- cessation of atherosclerosis but da has been unfair to its own also to its reversal. Perhaps he can youth. Now we hear rumblings explain the basis upon which we that Canada has an oversupply of should start refusing beneficial CAN MEDASSOCJ 1991; 145(2)
arrive. The consequence of this too easily fall prey to an army of incomplete use of facilities and number-crunching bureaucrats. services is reflected in the much Thomas J. Muckle, MD higher cost of that investigation in Joseph Z. Shainhouse, MD Lawrence Ave. E Director of laboratories Small-Town, USA, than in Cana- 203-2680 Scarborough, Ont. Chedoke Division da. In the hospitals in downtown Chedoke-McMaster Hospitals Toronto the patient must wait for Hamilton, Ont. the machine and technicians, Phototherapy which are working full time from Dr. Barkin has complained about Monday to Friday and are booked for neonatal escalating health care costs. He is well in advance. hyperbilirubinemia in serious error. Barkin may marvel at the The Canadian health care sys- quality car that Nissan sells for read "Effect of educational tem is based on the Hall Commis- less than Ford does, but he fails to and interview on program sion report of 1964.' Mr. Justice mention that the wages and stanof guidelines for the adoption Emmett W. Hall not only provid- dard of living of the Japanese management of neonatal hypered governments with a plan for worker may be lower than those of bilirubinemia," by Dr. Douglas the delivery of physician services the Canadian counterpart. The McMillan and associates (Can but also estimated the costs of the availability of social services Med Assoc J 1991; 144: 707-712), entire health care system up to the including government health care with keen interest, not for the year 2000. Ontario tax- stated aim of the study but as a for paid by higher The cost projections in this es - is reflected in the Ford's concrete example both of the perreport for the 1 980s and 1 990s higher cost. petuation of unfounded practices indicated a real yearly increase of If it is true that the cost of and of attempts to get the medical 4% per capita. Despite the unin one university community community to conform to stananticipated aging of the popula- care is double the cost in a second dards of care. tion and an increase in the use of one might ask why the The stated objectives were to technology the real yearly increase community extra money was allocated. Per- determine whether physicians are has been only 3.6% per capita, haps there has been some misadhering to guidelines for the about 10% under budget. management at the ministry level management of neonatal hyperTo my knowledge no other in (if not actually foster- bilirubinemia, what affects their program of government runs ing)allowing the development of such sys- decisions to investigate and treat under budget. Furthermore, it is tems over the last 20 years. the condition and what effects an improper to complain of unanticiThe reorganization of cardioprogram and clinical pated costs when a program is vascular surgery in Toronto is an educational have on compliance interview under budget. excellent example of how the with the guidelines. medical community, with a little Much of the authors' thesis Marc Baltzan, MD encouragement, can improve its relies on the 1986 report of the 200-366 Third Ave. S Saskatoon, Sask. management. But there are a few Fetus and Newborn Committee of missing details in that story. The the Canadian Paediatric Society.' Reference most important of these is that In fact, the committee skirted the although undoubtedly more orga- issue of proven indication for 1. Hall EW (chmn): Roval Commission on nized and centralized the system phototherapy for term infants but Health Services, 2 vols, Queen's Printer. is working mainly because of the did say that there is no clear Ottawa, 1964-65 sudden appearance of government scientific evidence permitting the I am quite willing to agree with funding for the long-delayed car- definition of dangerous levels of Dr. Barkin's basic premise that we diovascular unit at Sunnybrook bilirubin in premature infants. are not spending Ontario's health Health Science Centre (Barkin's Hence the basic premise in care dollars as efficiently as we old stomping grounds). the article - that "there was sufficould. But that is not the answer Quality assurance certainly cient scientific evidence to supto the questions he raises. has an important place in increas- port a standardized approach to The patient in Small-Town, ing the efficient use of funds in treatment" was not, in fact, the USA, can be evaluated quickly in the health care system. However, case. Nevertheless, the committee a day because the investigative without sharp and frequent criti- published recommendations for machinery, technicians and spe- cism of both the system and the the investigation of hypercialists are sitting around waiting, proponents of the quality assur- bilirubinemia and indications for indeed hoping, for a patient to ance movement, health care may the use of phototherapy. Then
treatment to people on the criterion of age alone.
100
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