diet and DiaBeta ComposItIon: Glyburlde 5 mg. IndIcatIons: Uncomplicated diabetes mellitus of the stable, mild, nonketotic, maturity-onset type not controlled by diet alone, in patients who have failed to respond to or cannot be maintained on other sulfonylureas. Contraindlcatlons: Severely brittle and juvenile diabetes, severe ketosis, acidosis, coma, thyrotoxicosis, frank jaundice and liver disease, severe renal impairment, severe Infections, trauma, surge ry, pregnancy and .re-existing complications peculiar to di abetes. autlons: Careful selection of patients is important. It is imperative that there be riQid adherence to diet, careful adjustment of dosage, instruction of the patient on hypoglycemic reactions and their control and regular follow-up examinations. Administer with or immediately after a meal; lunchtime for patients eating a light breakfast. Periodic liver function tests, peripheral blood counts and ophthalmic examinations are advisable. The possibility of hypoglycemia should be considered when certain long-acting suiphonamides, tuberculostatics, phenylbutazone, monoamine oxidase inhibitors, coumarin derivatives, salicylates, probenecid or propranolol are administered simultaneously. Use sedatives cautiously In patients receiving oral hypoglycemic agents since their action may be prolonged. The effects of oral hypoglycemic agents on the vascular changes and other long-term sequelse of diabetes are not known; patients receiving such drugs must be very closely observed for both short-and long-term complications. Intolerance to alcohol rarely occurs. Administer oral hypoglycemic agents with caution to patients with Addison's disease. Adverse reactIons: Allergic skin reactions including photosensitivity, pruritus, headache, tinnitus, fatigue, malaise, weakness, dizziness have been reported in a small number of patients. Hypoglycemic reactions are infrequently observed. Thrombocy topenia Is uncommon. Overdosage: Symptoms: Manifestations of hypoglycemia include sweating, flushing or pallor, numbness, chilliness, hunger, trembling, headache, dizziness, increased pulse rate, palpitations, increase In blood pressure, apprehensiveness and syncope in the mild cases. In the more severe cases, coma appears. Treatment: Administer dextrose or glucagon and dextrose. Dosage and admInIstration: Total daily dosage ranges between 2.5 and 20 mg. 1. Newlydiagnosed diabetics: Initial dosage is 5 mg daily (2.5 mg In patients over 80 years of age) for 5 to 7 days. Adjust dosage by increments of 2.5 mg according to response. The maximum daily dose of DIAfiETA is 20 mg. Most cases can be controlled by 5-10 mg daily given as a single dose during or immediately after breakfast. 2. Chan9eover from other oral hypoglycemic agents: Discontinue previous oral medication and start DIAPETA 5 mg daily (2.5 mg in patients over 60 years of age). Determine maintenance dosage as in newly-diagnosed diabetics. 3. Changeover from insulin. Less than 20 units daily-discontinue insulin and start on DIA/fETA 5 m. dally (2.5mg in patients over 60 years o age). Adjust dosage according to response. Between 20-40 units of Insulin dailyreduce Insulin by 30-50% and start DIA.ETA 2.5 mg daily. Further reduce Insulin and increase DIAfiETA dosage according to response. 4. Combined treatment with biguanides. If adequate control becomes impossible with diet and maximum doses of DIA3ETA (20 mg daily), control may be restored by combining with a biguanide. Maintain D IA.ETA dosage and add 50mg of .henformln.5. Combined treatment with insulin. (relative) insulin resistance can occasionally be more smoothly controlled by adding DIAIIETA. Supply: White, oblong, scored 5 mg tablets Code (LDI) in boxes of 30 and 300. Product Monograph on request. References: 1. OSullivan, D.J. and Cashman, W.F.: Br/f. Med. J., 2:572, 1970. 2 Mueller, R. et al: Horm. Metab. Res. 1(suppl.):88, 1969. 3. Krall, LP., Sinha, S. and Goldstein, H.H., Ausf. & N.Z. J. Med., 46(suppl.):57, 1971. 4. Moses, A.M., Howanitz, J. and Miller, M.: Ann. Infern. Med., 78:541, 1973. 5. Luntz, G.R.W.N.: Postgrad. Med. J., 46(suppl.)84: 1970. 6. Schoeffling, K.: Aust. & N.Z. J. Med., 1(suppl.):47, 1971.
Hoechst
Pharmaceutical Division. Canadian Hoechst Ltd
*.,
OECvSrR.g
.v,vm,.,ivG
Montreal
1361/7096E
MEDKDAL ECONOMICS
I-low the physicianss aides can give him more time to do his work MICHAEL LANDRY Discussion generated during our pracMr. Landry is CMA's adviser to nuntice management seminars indicates elation members on the management that Canadian doctors are divided in of their professional and personal busitheir attitude toward increased proness affairs. This article substitutes for ductivity through greater task delegahis regular Questions and Answers tion. feature, which wili be resumed next month. Members' comments anti queries At the one extreme are the doctors are welcomed and will be answered who disapprove of aides' performing either In this space or privately. Readsome of the simplest office tasks, such ers should not act In matters of law as escorting patients to the examination (tax or tort) discussed lii this column room, examination preparation and without first getting the e of preliminary history-taking. In contrast a competent luwyer or accountant. are those who delegate ear irrigations, application of casts, eye refractions, IV medications and so on. forming delegated tasks should be able Critics claim that too much emphasis to improve the quality of the practice," on productivity and efficiency in a says Dr. Bartlett. physician's office will lead to a deteriHe cites history-taking. "Because my oration in physician-patient relations aides take the history of past illnesses, and an increase in medicolegal prob- more patients receive general exammalems. Others agree that quality medicine tions than receive regional exams. Nanecessarily depends on the doctor's turally, I review the history with the spending adequate time with each pa- patient and check any points that need tient. elaboration." Advocates of increased delegation One of the teaching aims of the Otdismiss these objections as unrealistic. tawa Civic Hospital family medicine They contend that better selection and centre is to expose residents to better management of personnel will yield a use of aides. This commitment extends staff capable of performing many tasks to teaching final-year baccalaureate as well as the doctor, and some better. nursing students how to carry out a For example, in a parallel occupation, basic physical examination. "By deledentistry, a recent Saskatchewan study gating the routine tasks of a prenatal concluded that dental health nurses visit, I am able to spend more time with actually place amalgam fillings better the mother," says Dr. Walter Rosser, than most dentists. Competent assist- director of the Ottawa centre. "I think ants, performing delegated tasks, will I need this valuable time to develop a provide the physician with more time relationship that is often necessary to to do the things only he can do. relieve the expectant mother's anxiWhy is it that so many doctors find eties." According to Dr. Rosser, the centre it hard to allow anyone but themselves to perform simple duties? has no public relations problems reDr. Lloyd Bartlett, a Winnipeg gen- sulting from delegating tasks traditioneral surgeon, thinks doctors are not ally performed by the doctor. In fact making sufficient use of aides because patients have told him that they feel they either have not tried it or do not more comfortable phoning the nurse have aides in whom they are complete- than him - in particular when they are embarrassed by what they might ly confident. "A properly trained assistant per- consider to be a minor problem.
926 CMA JOURNAL/APRIL 23, 1977/VOL. 116
With regard to the medicolegal aspect, he reported they have had no major problems in 7 years. "So far our aides have not overstepped their authority boundaries," he explained. "Many older physicians resist task delegation because they can't trust something they haven't experienced," says Dr. Naomi Stein, a Montreal pediatrician. "Others simply don't feel they should give away the responsibility." Dr. Stein's nurse practitioner handles 95% of callbacks. As well, her tasks include seeing healthy newborns on every second visit, routine colds and minor behaviour problems. "The decision to assign Joan more difficult tasks was easy. Her training was almost as extensive as a resident's," adds Dr. Stein. "I worked with her and found she handled the problems in the same way as I would have. By delegating less complex tasks, we have been able to handle more referrals and spend a great deal more time with patients who need my training." When we asked Dr. Stein about patient relations, she said, "At first a few patients were upset because they could not get through to the doctor. Now they are accommodated when they specifically ask for a physician. It is interesting to note that the majority of patients now ask for Joan first." The nurse practitioner program at McMaster University and the physician's assistants movement in the United States typify changing attitudes towards increased use of physician extenders. However, widespread acceptance of nurse practitioners in Canada will probably not materialize until a formula is reached for proper certification. In Physicians Management (November 1976), Alex McKenzie, internationally known lecturer and author on time-use states the primary barrier to delegation
lies in the doctors themselves. He contends that if aides are not competent enough to warrant appropriate delegation, the doctor has failed to carry out his responsibilities either by poor staffing or inadequate training. He also cites fear of losing control and unreasonable standards set by the doctors themselves as other causes of failure to delegate. There are few guidelines on delegation of medical authority. CMA's 1973 General Council did, however, offer some help to members. "In association with the physician the nurse may act as a first contact person to help define the nature of a patient's problem, decide on the urgency of the need for medical attention and deal with emergencies in the absence of the physician," declared a council resolution. The resolution added that a nurse associated with a physician may accept delegated authority for patient management by: * Carrying out procedures such as dressings, injections, vision and hearing testing etc. * Making referrals to community agencies. * Providing psychological support and counselling. * Interpreting the physician's therapeutic regimen (including activity, diet and medication). * Acting as coordinator of services for the patient and his family who need a variety of services such as home care, public health or social work as part of the treatment program. As a general rule, suggests the Canadian Medical Protective Association, a task may be delegated to a nonphysician when it does not require the aide to exercise medical discretion. Should a medicolegal problem arise, according to Dr. F. Norman Brown, secretary-treasurer of the CMPA, "the physician must
be able to demonstrate that he had reason to believe that the aide was competent to perform the task - this would include the knowledge of the person's training, experience and certification. "If the doctor can't demonstrate this, he may be open to allegations of negligence on his part for delegating tasks to someone he should have known was incompetent. The doctor might also be judged negligent if his supervision was inadequate." Could it be that many doctors underdelegate because they do not want to pay extra money for better-qualified help? A doctor's office is analogous to the corner store in many ways. Certainly in both cases inefficiency means less net income. Businessmen learned a long time ago that greater income often means spending more to earn more. The idea that physicians are partly involved in business is nothing new. Plato recognized this 2400 years ago in his "Republic" dialogue - "another art attends them which is the art of pay." We are not implying that doctors trade in their black bag for a briefcase. However, we do suggest that physicians become more aware of better management skills. The successful deployment of nonmedical personnel means that doctors must have the necessary management tools to select, train and evaluate staff. They must be alert enough to handle the unpleasant task of firing with the least amount of ill-feeling. Make no mistake about it - time is costly. For some the cost associated with inefficiency means less time for patients, family, friends or continuing medical education. To others it means a reduced net income. By definition efficiency is synonomous with competencc and capability. For that reason alone, a proper balance between art form and productivity is every physician's responsibility. U
OMA JOURNAL/APRIL 23, 1977/VOL. 116 927
Hoechst
Pharmaceutical Division. Canadian Hoechst Ltd
*.,
OECvSrR.g
.v,vm,.,ivG
Montreal
1361/7096E
MEDKDAL ECONOMICS
I-low the physicianss aides can give him more time to do his work MICHAEL LANDRY Discussion generated during our pracMr. Landry is CMA's adviser to nuntice management seminars indicates elation members on the management that Canadian doctors are divided in of their professional and personal busitheir attitude toward increased proness affairs. This article substitutes for ductivity through greater task delegahis regular Questions and Answers tion. feature, which wili be resumed next month. Members' comments anti queries At the one extreme are the doctors are welcomed and will be answered who disapprove of aides' performing either In this space or privately. Readsome of the simplest office tasks, such ers should not act In matters of law as escorting patients to the examination (tax or tort) discussed lii this column room, examination preparation and without first getting the e of preliminary history-taking. In contrast a competent luwyer or accountant. are those who delegate ear irrigations, application of casts, eye refractions, IV medications and so on. forming delegated tasks should be able Critics claim that too much emphasis to improve the quality of the practice," on productivity and efficiency in a says Dr. Bartlett. physician's office will lead to a deteriHe cites history-taking. "Because my oration in physician-patient relations aides take the history of past illnesses, and an increase in medicolegal prob- more patients receive general exammalems. Others agree that quality medicine tions than receive regional exams. Nanecessarily depends on the doctor's turally, I review the history with the spending adequate time with each pa- patient and check any points that need tient. elaboration." Advocates of increased delegation One of the teaching aims of the Otdismiss these objections as unrealistic. tawa Civic Hospital family medicine They contend that better selection and centre is to expose residents to better management of personnel will yield a use of aides. This commitment extends staff capable of performing many tasks to teaching final-year baccalaureate as well as the doctor, and some better. nursing students how to carry out a For example, in a parallel occupation, basic physical examination. "By deledentistry, a recent Saskatchewan study gating the routine tasks of a prenatal concluded that dental health nurses visit, I am able to spend more time with actually place amalgam fillings better the mother," says Dr. Walter Rosser, than most dentists. Competent assist- director of the Ottawa centre. "I think ants, performing delegated tasks, will I need this valuable time to develop a provide the physician with more time relationship that is often necessary to to do the things only he can do. relieve the expectant mother's anxiWhy is it that so many doctors find eties." According to Dr. Rosser, the centre it hard to allow anyone but themselves to perform simple duties? has no public relations problems reDr. Lloyd Bartlett, a Winnipeg gen- sulting from delegating tasks traditioneral surgeon, thinks doctors are not ally performed by the doctor. In fact making sufficient use of aides because patients have told him that they feel they either have not tried it or do not more comfortable phoning the nurse have aides in whom they are complete- than him - in particular when they are embarrassed by what they might ly confident. "A properly trained assistant per- consider to be a minor problem.
926 CMA JOURNAL/APRIL 23, 1977/VOL. 116
With regard to the medicolegal aspect, he reported they have had no major problems in 7 years. "So far our aides have not overstepped their authority boundaries," he explained. "Many older physicians resist task delegation because they can't trust something they haven't experienced," says Dr. Naomi Stein, a Montreal pediatrician. "Others simply don't feel they should give away the responsibility." Dr. Stein's nurse practitioner handles 95% of callbacks. As well, her tasks include seeing healthy newborns on every second visit, routine colds and minor behaviour problems. "The decision to assign Joan more difficult tasks was easy. Her training was almost as extensive as a resident's," adds Dr. Stein. "I worked with her and found she handled the problems in the same way as I would have. By delegating less complex tasks, we have been able to handle more referrals and spend a great deal more time with patients who need my training." When we asked Dr. Stein about patient relations, she said, "At first a few patients were upset because they could not get through to the doctor. Now they are accommodated when they specifically ask for a physician. It is interesting to note that the majority of patients now ask for Joan first." The nurse practitioner program at McMaster University and the physician's assistants movement in the United States typify changing attitudes towards increased use of physician extenders. However, widespread acceptance of nurse practitioners in Canada will probably not materialize until a formula is reached for proper certification. In Physicians Management (November 1976), Alex McKenzie, internationally known lecturer and author on time-use states the primary barrier to delegation
lies in the doctors themselves. He contends that if aides are not competent enough to warrant appropriate delegation, the doctor has failed to carry out his responsibilities either by poor staffing or inadequate training. He also cites fear of losing control and unreasonable standards set by the doctors themselves as other causes of failure to delegate. There are few guidelines on delegation of medical authority. CMA's 1973 General Council did, however, offer some help to members. "In association with the physician the nurse may act as a first contact person to help define the nature of a patient's problem, decide on the urgency of the need for medical attention and deal with emergencies in the absence of the physician," declared a council resolution. The resolution added that a nurse associated with a physician may accept delegated authority for patient management by: * Carrying out procedures such as dressings, injections, vision and hearing testing etc. * Making referrals to community agencies. * Providing psychological support and counselling. * Interpreting the physician's therapeutic regimen (including activity, diet and medication). * Acting as coordinator of services for the patient and his family who need a variety of services such as home care, public health or social work as part of the treatment program. As a general rule, suggests the Canadian Medical Protective Association, a task may be delegated to a nonphysician when it does not require the aide to exercise medical discretion. Should a medicolegal problem arise, according to Dr. F. Norman Brown, secretary-treasurer of the CMPA, "the physician must
be able to demonstrate that he had reason to believe that the aide was competent to perform the task - this would include the knowledge of the person's training, experience and certification. "If the doctor can't demonstrate this, he may be open to allegations of negligence on his part for delegating tasks to someone he should have known was incompetent. The doctor might also be judged negligent if his supervision was inadequate." Could it be that many doctors underdelegate because they do not want to pay extra money for better-qualified help? A doctor's office is analogous to the corner store in many ways. Certainly in both cases inefficiency means less net income. Businessmen learned a long time ago that greater income often means spending more to earn more. The idea that physicians are partly involved in business is nothing new. Plato recognized this 2400 years ago in his "Republic" dialogue - "another art attends them which is the art of pay." We are not implying that doctors trade in their black bag for a briefcase. However, we do suggest that physicians become more aware of better management skills. The successful deployment of nonmedical personnel means that doctors must have the necessary management tools to select, train and evaluate staff. They must be alert enough to handle the unpleasant task of firing with the least amount of ill-feeling. Make no mistake about it - time is costly. For some the cost associated with inefficiency means less time for patients, family, friends or continuing medical education. To others it means a reduced net income. By definition efficiency is synonomous with competencc and capability. For that reason alone, a proper balance between art form and productivity is every physician's responsibility. U
OMA JOURNAL/APRIL 23, 1977/VOL. 116 927
