HEALTH CARE * LES SOINS
Public service careers heaven for some MDs, hell for others
Lynne Cohen T hinking of quitting private practice for a secure, 9-to-5 job as a federal public servant? Be warned. The jobs are attractive to many doctors, but the hours are not always 9 to 5 and the posts are definitely not for everyone. Physicians who have left public service careers, and even some still in them, confess that the positions can seem boring after the hectic goings-on in a doctor's office. Dr. Maureen Law, once deputy minister in the Department of National Health and Welfare and now a senior fellow at the International Development and Research Centre, admits physicians working for the federal government generally need a great deal of "pa-
scale that starts in the low 50s and ends in the low 1 00s, many of the more than 650 medical officers MOFFs - employed by the federal government, including more than 300 in the armed forces, are happy in their work. But others aren't. Some physicians who have left the federal payroll say they did so because of job dissatisfaction and because their goals and aspirations were not being met. Although only two of them would go on the record, all five former federal employees I attempted to interview admitted
tience". They also need "internal conviction and strength to recognize that they're making a contribution over time . . . for the long-term health and well-being of all Canadians". In other words, results are rarely as tangible as they are for doctors in private practice. Despite a relatively low pay
Lynne Cohen is a freelance writer living in Ottawa.
Law: patience needed
to leaving the public service because of frustration and disillu-
sionment. In an informal survey of several current federal MOFFs and physician-managers, I discovered that their reasons for joining and staying with the government are, in descending order of importance: travel; financial security and benefits such as paid holidays, dental insurance and sick leave; interest in and commitment to public health or administrative medicine; and professional interests such as aviation medicine that cannot be pursued fully outside the federal government. Dr. George Takahashi, director of civil aviation medicine with Transport Canada, joined the federal government in 1975 because "you can't do aviation medicine outside". Takahashi, who works for the Department of National Health and Welfare as an adviser to Transport Canada, left private practice, joined the government as a low-level medical officer, and rose through the ranks until he attained his current position in 1984. "I make $92 000 and change a year", he says. As a public servant, Takahashi has little chance to pursue hands-on patient care, but he doCAN MED ASSOC J 1990; 143 (6)
555
esn't mind. As a MOFF, he did see pilots who had health problems, but he never prescribed drugs or treatment. "I would coordinate with the pilot's GP to get him flying again." Today, his job is entirely administrative. "My office advises the department on all kinds of aeronautical matters. We set medical standards for aviation personnel, including pilots and air traffic controllers, and we run programs to ensure these standards are met." His office also appoints 915 civil aviation medical officers across Canada, physicians in private practice who perform physical examinations on aviation personnel. So, he gets to set standards and write lots of memos. That beats private practice? "For one thing, I don't have the OHIP hassle", says Takahashi. "It used to drive me crazy, what with filling out cards, figuring out what was an insurable treatment, and then getting only half my pay because I forgot to dot an 'i'. I like the government because I can pursue my interest and concentrate on my work, without the worry of running a business. I also have more time to pursue medical knowledge. It's much easier to keep current because I have more time." "I find my job fascinating", says Dr. Peter Constantinidis, an internist with Health and Welfare's Medical Services Branch. Among other things, the branch is responsible for the occupational health of 120 000 government employees. "There is great variety here and it's stimulating work", he says. Now stationed in Ottawa as a manager of overseas health services, Constantinidis joined the public service 17 years ago in order to travel and live abroad. And travel he has, to Rome, Athens and elsewhere. "The work really is exciting", he says. "I was in the Canadian Embassy [in Teh556
CAN MED ASSOC J 1990; 143 (6)
"Almost nothing bothers me as much as the misconception people have about government workers. People like to throw rocks at us." - Dr. George Takahashi
ran] when the US Embassy was seized." Twenty medical officers stationed overseas, who consult with Constantinidis, are responsible for more than 100 diplomatic posts in some 80 countries. Working for the Department of External Affairs while stationed abroad, these MOFFs screen potential immigrants and look after some of the medical and health needs of diplomats and their families. However, the amount of hands-on work with patients is limited. Constantinidis says they can't act as family physicians because most federal employees stationed overseas live too far away. So what do the overseas medical officers do? "They liaise with local hospitals and physicians, supervise Health and Welfare nurses, give immunizations, stock vaccines and other supplies, do referrals, advise External Affairs on when to evacuate a citizen back to Canada for medical care, and practise medical intelligence." Medical what? "Intelligence. It means to keep the Canadian government informed, for example, if there has been a cholera outbreak, or why AIDS is particularly widespread in this area or country, or what the latest drug is
that malaria-carrying parasites are becoming resistant to. That kind of thing." Waving a stack of 30 applications from doctors wanting to work for him overseas, Constantinidis muses about the boredom of GPs in private practice: "They often see one cold after another." Even the occupational health side of medicine dealt with by the Medical Services Branch can be more interesting than family practice, Constantinidis insists. For instance, occupational hazards facing federal employees range from monkey bites and chemical spills to bureaucracy-induced stress. However, Dr. Paul Duchastel, a former MOFF now in private practice in Montreal, has different memories of his time in the public service. "Most of the time we [public service doctors] did nothing. I was bored silly." Duchastel worked for the Department of National Defence (DND) in Europe from 1968 to 1971 and for External Affairs in London and Hong Kong between 1981 and 1986. He says his DND job at least involved hands-on care of military personnel, but even that work was repetitive and boring. "You are restricted because your patient population is generally between 20 and 40 years old, and healthy." He quit DND, where he had applied for an extension, "because I had a disagreement with my boss. I wanted to work in a medical centre and my superiors decided to post me in the field". He was also upset by language problems, "which were very bad. I wanted more French to be used, but everyone would only speak English. It was 1970, the year of the War Measures Act, and many French Canadians were put in hard positions". A former Canadian Forces surgeon general, Rear-Admiral Charles Knight (ret.), agrees that military doctors might not get
wide experience while serving in the armed forces: "The patient population is young and fit so doctors often don't get the full scope of a civilian practice." Eventually, though, most do, because most leave the forces after completing their compulsory service. "The majority of our doctors come from the subsidized medical school program, which requires that they stay with us for either 3 or 4 years after graduation, depending on the amount of financial support they got", says Knight. However, more are expected to stay in uniform in the future. "We've increased pay and benefits have been improved", says Commander Mike Shannon, director of medical operations and training at DND. "More importantly, we've upgraded medical education and increased the number and range of jobs for doctors in the service. For doctors, there are now as many types of jobs inside the armed forces as outside." There were 57 vacancies for military physicians last year as doctors left after completing their obligatory service. "This year we're expecting only five vacancies", says Shannon. And, Knight adds, there are some unique experiences to be had in the military. "For some people, it's a great lifestyle, moving and working with active people in a variety of places, from the airfield to the army barracks to ships at sea." DND certainly isn't the source of Duchastel's biggest beef. He's more concerned about the "constant expansion" at Health and Welfare. "It's an excellent example of where the federal government overdoes its constitutional mandate", he says. "Health is a provincial matter and the government could save a lot of money by leaving health matters up to the provinces. I'm from Quebec, and in Quebec we take
"The patient population is young and fit so doctors in the military often don't get the full scope of a civilian practice."
Rear-Admiral Charles Knight (ret.) -
provincial rights very seriously." Specifically, he would like to see External Affairs handed complete responsibility for providing overseas medical services and, barring that, for Health and Welfare to hire more bilingual employees outside Canada and to stop being so wasteful. He says Health and Welfare posts he was stationed at outside Canada "were way overstaffed. I was told there was an urgent need for me to report to the London office immediately. So, at great inconvenience to my family, I did just that. When I got there, I discovered I was one of four doctors. We'd get our work done in less than an hour, and sit around the rest of the day. There was barely enough work for one physician". Duchastel was also frustrated by government policy. Discussing mandatory chest x-rays for every potential immigrant, he complains: "Screening for tuberculosis is a waste of time and money. The government is obsessed with a disease of 30 years ago, one that doesn't present a big public health risk anymore. Because it's so hard to get x-rays in some places, this requirement holds up immigration for years."
But other doctors have nothing but praise for jobs with Health and Welfare. "It's great to work for the government", says Dr. Brian Brett, a general practitioner from London, Ont., who joined the department 28 years ago. Now a director in the Medical Services Branch, where he supervises 25 other doctors, he spent his first 15 years as a general-duty physician with Northern Health Services. "We treated everyone in the North who didn't live in the major centres, including whites. "At times we couldn't get a plane to take us to a major hospital", recalls Brett, who was director-general of Indian and Northern Affairs Health Services from 1979 to 1981. "And there were no specialists up there then, so we often ended up doing surgery and anesthesia." He also enjoyed having the chance to deal with rare conditions: "We had to treat illnesses like meningitis and tuberculosis that most doctors rarely see." But things have changed. A transfer program that began in 1987 is shifting responsibility for northern health services to territorial governments and native bands. This, says Brett, means there will be no jobs in the North CAN MED ASSOC J 1990; 143 (6)
557
"PROLOPRIM*-2OO (trimethoprim 200 mg)
Rx SUMMARY INDICATIONS: For the treatment of acute
uncomplicated urinary tract infections due to susceptible strains of Escherichia coli and Klebsiella pneumoniae. Limited clinical experience
suggests the probability of therapeutic response in
infections due to susceptible
strains of Proteus mirabilis and Enterobacter species. For infections associated with urinary tract complications such as obstruction, or where tissue involvement is suspected, the combination of trimethoprim/sulfamethoxazole (SEPTRA, Burroughs Wellcome Inc.) has been shown to be superior to trimethoprim alone.
CONTRA-INDICATIONS:
PROLOPRIM is contraindicated in individuals hypersensitive
to trimethoprim, during pregnancy and during the
period. WARNINGS:
nursing
In elderly patients concurrently receiving certain diuretics, primarily thiazides, an increased incidence of thrombocyto-
penia with purpura has been reported.
The presence of clinical signs such as sore throat, fever, pallor, purpura or jaundice may be early indications of serious blood disorders. Complete blood count should be obtained if any of these signs are noted in a patient receiving trimethoprim and the drug discontinued if a significant reduction in the count of any formed blood element is found.
PRECAUTIONS: Trimethoprim should be given with caution to patients with possible folate deficiency. Folates may be administered concomitantly without interfering with the antibacterial action of trimethoprim, except in Enterococci infections. An increased incidence of skin rashes has been observed when double the recommended dosage was administered. ADVERSE REACTIONS: The following adverse reactions are reported to have occurred in patients receiving trimethoprim: Blood Dyscrasias: Leukopenia, agranulocytosis, thrombocytopenia, methemoglobinemia Allergic Reactions: Rash, pruritus Gastrointestinal Reactions: Nausea, vomiting, abdominal cramps, glossitis, stomatitis Miscellaneous Reactions: Headache, joint pain, apathy, fatigue, muscle weakness, nervousness The following adverse reactions have not been reported in patients receiving trimethoprim; however, based upon clinical experience with chemically related drugs, the possibility of these reactions occurring should be recognized. Blood Dyscrasias: Anemia (megaloblastic, hemolytic, aplastic) C.N.S. Reactions: Convulsions, ataxia, tinnitus, vertigo Miscellaneous Reactions: Drug fever, chills SYMPTOMS AND TREATMENT OF OVERDOSAGE: If poisoning occurs from the ingestion of an overdosage, remove the agent from the stomach by lavage and/or emesis. If renal function is normal, force fluids orally or parenterally to promote excretion. In extreme overdosage in patients with impaired renal function, consideration should be given to hemodialysis as a means of both eliminating the drug from the blood and in reducing the risk of uremia. Drug accumulation in the blood has not been a problem in renal disease, mainly because trimethoprim is readily dialyzed in patients on chronic dialysis. Calcium folinate (3 to 6 mg i.m. for 5 to 7 days) is an effective antidote for adverse reactions in the hematopoietic system caused by trimethoprim. DOSAGE AND ADMINISTRATION: The usual adult dosage is 100 mg of PROLOPRIM every 12 hours or 200 mg once daily, each for 10 days. The use of trimethoprim in patients with creatinine clearance of less than 15mL/min is not recommended. For patients with a creatinine clearance of 15 to 30 mL/min, the dose should be 100 mg every 12 hours.
AVAILABILITY: PROLOPRIM brand trimethoprim 100 mg is a white, round,
biconvex, scored tablet imprinted with PROLOPRIM on upper periphery and 09A on the lower half below the score. Bottles of 100 and 500. PROLOPRIM-200 is a yellow, round, biconvex, scored tablet printed with PROLOPRIM on the upper periphery and 200 on the lower half below the score. Bottles of 100. Product Monograph available on request.
the
MEDICAL DIVISION BURROUGHS
WELLCOME
.111.11--l --l. OUE
.- KIRKLAND,
W428 Trade Mark
PAAB CCPP
for federal physicians, "except as administrators and epidemiologists". He laments the lost opportunities. [There is also a smattering of jobs for doctors in other departments, including Correctional Service Canada and Veterans Affairs Canada.] Today, physicians with Health and Welfare are kept busy at a variety of tasks. They can help draft legislation, research native health, get involved in healthpromotion activities, study and write about mental health issues, look into drug and alcohol abuse, and so on. Such "paper-pushing" activities don't appeal to many doctors, admits Law. She says it is often difficult to fill some MOFF positions because "doctors are really trained and interested in providing acute care to patients". The other problem is that they are an independent-minded lot. "Doctors are not always in charge in the bureaucracy", she warns, "which can be a great shock." For some doctors, even the deepest desire to make a difference in the public health field can't keep them in the federal public service. Dr. Cynthia Carver, who quit in July 1989 after 4 years as a MOFF, says she entered the public service "because I'm a bleeding-heart liberal, and as a GP working in poverty districts in downtown Toronto, I didn't feel I was making a big enough impact". After studying public health, she joined the federal government in Regina, where she was senior physician and program manager for 80 Indian reserves. "My achievements in 4 years were minimal because the priority in this system is not health", says Carver, who eventually became director of intergovernmental affairs with Medical Services. "The major priorities are cover the ass of the minister, and the fiscal bottom line. There is a political drive to avoid conflict and confrontation and no real measure of
the cost-effectiveness
of pro-
grams." As an example, she points to 4-year-old program that involves hiring and training community workers to help deal with natives' alcohol problems. "The government may be [throwing] money a
away, since no one knows how it's
working." She also hated the slowness of the bureaucracy: "It took 21/2 years just to get a job classified so someone could officially run a data-collection system." And the constant disruptions: "There were four major seniormanagement reorganizations in the 4 years I was there. I mean
major." Carver feels MOFFs have too much responsibility and too little power. "If an epidemic breaks out, we do all the work. But try to influence policy or start a needed program and the lines of authority get in your way." She says she saw young doctors enter the government and leave quickly. "They could see that they would get stuck in middle management, with no power and unable to make anything happen. It was really sad." Saddest of all, though, said every current and former public service doctor I interviewed, is the image of MOFFs in the outside world. "Almost nothing bothers me as much as the misconception people have about government workers", says Takahashi. "People like to throw rocks at us. The average public servant, doctors included, is well educated, well dis-
ciplined, sensitive, responsible, hard working and concerned about all Canadians. Working within tight budgets, they think of all problems and try to give the best advice to the politicians." "The health professionals in the government are dedicated", insists Carver. "Doctors take a cut in pay and nurses go and live where almost no one else would."m
Public service careers heaven for some MDs, hell for others
Lynne Cohen T hinking of quitting private practice for a secure, 9-to-5 job as a federal public servant? Be warned. The jobs are attractive to many doctors, but the hours are not always 9 to 5 and the posts are definitely not for everyone. Physicians who have left public service careers, and even some still in them, confess that the positions can seem boring after the hectic goings-on in a doctor's office. Dr. Maureen Law, once deputy minister in the Department of National Health and Welfare and now a senior fellow at the International Development and Research Centre, admits physicians working for the federal government generally need a great deal of "pa-
scale that starts in the low 50s and ends in the low 1 00s, many of the more than 650 medical officers MOFFs - employed by the federal government, including more than 300 in the armed forces, are happy in their work. But others aren't. Some physicians who have left the federal payroll say they did so because of job dissatisfaction and because their goals and aspirations were not being met. Although only two of them would go on the record, all five former federal employees I attempted to interview admitted
tience". They also need "internal conviction and strength to recognize that they're making a contribution over time . . . for the long-term health and well-being of all Canadians". In other words, results are rarely as tangible as they are for doctors in private practice. Despite a relatively low pay
Lynne Cohen is a freelance writer living in Ottawa.
Law: patience needed
to leaving the public service because of frustration and disillu-
sionment. In an informal survey of several current federal MOFFs and physician-managers, I discovered that their reasons for joining and staying with the government are, in descending order of importance: travel; financial security and benefits such as paid holidays, dental insurance and sick leave; interest in and commitment to public health or administrative medicine; and professional interests such as aviation medicine that cannot be pursued fully outside the federal government. Dr. George Takahashi, director of civil aviation medicine with Transport Canada, joined the federal government in 1975 because "you can't do aviation medicine outside". Takahashi, who works for the Department of National Health and Welfare as an adviser to Transport Canada, left private practice, joined the government as a low-level medical officer, and rose through the ranks until he attained his current position in 1984. "I make $92 000 and change a year", he says. As a public servant, Takahashi has little chance to pursue hands-on patient care, but he doCAN MED ASSOC J 1990; 143 (6)
555
esn't mind. As a MOFF, he did see pilots who had health problems, but he never prescribed drugs or treatment. "I would coordinate with the pilot's GP to get him flying again." Today, his job is entirely administrative. "My office advises the department on all kinds of aeronautical matters. We set medical standards for aviation personnel, including pilots and air traffic controllers, and we run programs to ensure these standards are met." His office also appoints 915 civil aviation medical officers across Canada, physicians in private practice who perform physical examinations on aviation personnel. So, he gets to set standards and write lots of memos. That beats private practice? "For one thing, I don't have the OHIP hassle", says Takahashi. "It used to drive me crazy, what with filling out cards, figuring out what was an insurable treatment, and then getting only half my pay because I forgot to dot an 'i'. I like the government because I can pursue my interest and concentrate on my work, without the worry of running a business. I also have more time to pursue medical knowledge. It's much easier to keep current because I have more time." "I find my job fascinating", says Dr. Peter Constantinidis, an internist with Health and Welfare's Medical Services Branch. Among other things, the branch is responsible for the occupational health of 120 000 government employees. "There is great variety here and it's stimulating work", he says. Now stationed in Ottawa as a manager of overseas health services, Constantinidis joined the public service 17 years ago in order to travel and live abroad. And travel he has, to Rome, Athens and elsewhere. "The work really is exciting", he says. "I was in the Canadian Embassy [in Teh556
CAN MED ASSOC J 1990; 143 (6)
"Almost nothing bothers me as much as the misconception people have about government workers. People like to throw rocks at us." - Dr. George Takahashi
ran] when the US Embassy was seized." Twenty medical officers stationed overseas, who consult with Constantinidis, are responsible for more than 100 diplomatic posts in some 80 countries. Working for the Department of External Affairs while stationed abroad, these MOFFs screen potential immigrants and look after some of the medical and health needs of diplomats and their families. However, the amount of hands-on work with patients is limited. Constantinidis says they can't act as family physicians because most federal employees stationed overseas live too far away. So what do the overseas medical officers do? "They liaise with local hospitals and physicians, supervise Health and Welfare nurses, give immunizations, stock vaccines and other supplies, do referrals, advise External Affairs on when to evacuate a citizen back to Canada for medical care, and practise medical intelligence." Medical what? "Intelligence. It means to keep the Canadian government informed, for example, if there has been a cholera outbreak, or why AIDS is particularly widespread in this area or country, or what the latest drug is
that malaria-carrying parasites are becoming resistant to. That kind of thing." Waving a stack of 30 applications from doctors wanting to work for him overseas, Constantinidis muses about the boredom of GPs in private practice: "They often see one cold after another." Even the occupational health side of medicine dealt with by the Medical Services Branch can be more interesting than family practice, Constantinidis insists. For instance, occupational hazards facing federal employees range from monkey bites and chemical spills to bureaucracy-induced stress. However, Dr. Paul Duchastel, a former MOFF now in private practice in Montreal, has different memories of his time in the public service. "Most of the time we [public service doctors] did nothing. I was bored silly." Duchastel worked for the Department of National Defence (DND) in Europe from 1968 to 1971 and for External Affairs in London and Hong Kong between 1981 and 1986. He says his DND job at least involved hands-on care of military personnel, but even that work was repetitive and boring. "You are restricted because your patient population is generally between 20 and 40 years old, and healthy." He quit DND, where he had applied for an extension, "because I had a disagreement with my boss. I wanted to work in a medical centre and my superiors decided to post me in the field". He was also upset by language problems, "which were very bad. I wanted more French to be used, but everyone would only speak English. It was 1970, the year of the War Measures Act, and many French Canadians were put in hard positions". A former Canadian Forces surgeon general, Rear-Admiral Charles Knight (ret.), agrees that military doctors might not get
wide experience while serving in the armed forces: "The patient population is young and fit so doctors often don't get the full scope of a civilian practice." Eventually, though, most do, because most leave the forces after completing their compulsory service. "The majority of our doctors come from the subsidized medical school program, which requires that they stay with us for either 3 or 4 years after graduation, depending on the amount of financial support they got", says Knight. However, more are expected to stay in uniform in the future. "We've increased pay and benefits have been improved", says Commander Mike Shannon, director of medical operations and training at DND. "More importantly, we've upgraded medical education and increased the number and range of jobs for doctors in the service. For doctors, there are now as many types of jobs inside the armed forces as outside." There were 57 vacancies for military physicians last year as doctors left after completing their obligatory service. "This year we're expecting only five vacancies", says Shannon. And, Knight adds, there are some unique experiences to be had in the military. "For some people, it's a great lifestyle, moving and working with active people in a variety of places, from the airfield to the army barracks to ships at sea." DND certainly isn't the source of Duchastel's biggest beef. He's more concerned about the "constant expansion" at Health and Welfare. "It's an excellent example of where the federal government overdoes its constitutional mandate", he says. "Health is a provincial matter and the government could save a lot of money by leaving health matters up to the provinces. I'm from Quebec, and in Quebec we take
"The patient population is young and fit so doctors in the military often don't get the full scope of a civilian practice."
Rear-Admiral Charles Knight (ret.) -
provincial rights very seriously." Specifically, he would like to see External Affairs handed complete responsibility for providing overseas medical services and, barring that, for Health and Welfare to hire more bilingual employees outside Canada and to stop being so wasteful. He says Health and Welfare posts he was stationed at outside Canada "were way overstaffed. I was told there was an urgent need for me to report to the London office immediately. So, at great inconvenience to my family, I did just that. When I got there, I discovered I was one of four doctors. We'd get our work done in less than an hour, and sit around the rest of the day. There was barely enough work for one physician". Duchastel was also frustrated by government policy. Discussing mandatory chest x-rays for every potential immigrant, he complains: "Screening for tuberculosis is a waste of time and money. The government is obsessed with a disease of 30 years ago, one that doesn't present a big public health risk anymore. Because it's so hard to get x-rays in some places, this requirement holds up immigration for years."
But other doctors have nothing but praise for jobs with Health and Welfare. "It's great to work for the government", says Dr. Brian Brett, a general practitioner from London, Ont., who joined the department 28 years ago. Now a director in the Medical Services Branch, where he supervises 25 other doctors, he spent his first 15 years as a general-duty physician with Northern Health Services. "We treated everyone in the North who didn't live in the major centres, including whites. "At times we couldn't get a plane to take us to a major hospital", recalls Brett, who was director-general of Indian and Northern Affairs Health Services from 1979 to 1981. "And there were no specialists up there then, so we often ended up doing surgery and anesthesia." He also enjoyed having the chance to deal with rare conditions: "We had to treat illnesses like meningitis and tuberculosis that most doctors rarely see." But things have changed. A transfer program that began in 1987 is shifting responsibility for northern health services to territorial governments and native bands. This, says Brett, means there will be no jobs in the North CAN MED ASSOC J 1990; 143 (6)
557
"PROLOPRIM*-2OO (trimethoprim 200 mg)
Rx SUMMARY INDICATIONS: For the treatment of acute
uncomplicated urinary tract infections due to susceptible strains of Escherichia coli and Klebsiella pneumoniae. Limited clinical experience
suggests the probability of therapeutic response in
infections due to susceptible
strains of Proteus mirabilis and Enterobacter species. For infections associated with urinary tract complications such as obstruction, or where tissue involvement is suspected, the combination of trimethoprim/sulfamethoxazole (SEPTRA, Burroughs Wellcome Inc.) has been shown to be superior to trimethoprim alone.
CONTRA-INDICATIONS:
PROLOPRIM is contraindicated in individuals hypersensitive
to trimethoprim, during pregnancy and during the
period. WARNINGS:
nursing
In elderly patients concurrently receiving certain diuretics, primarily thiazides, an increased incidence of thrombocyto-
penia with purpura has been reported.
The presence of clinical signs such as sore throat, fever, pallor, purpura or jaundice may be early indications of serious blood disorders. Complete blood count should be obtained if any of these signs are noted in a patient receiving trimethoprim and the drug discontinued if a significant reduction in the count of any formed blood element is found.
PRECAUTIONS: Trimethoprim should be given with caution to patients with possible folate deficiency. Folates may be administered concomitantly without interfering with the antibacterial action of trimethoprim, except in Enterococci infections. An increased incidence of skin rashes has been observed when double the recommended dosage was administered. ADVERSE REACTIONS: The following adverse reactions are reported to have occurred in patients receiving trimethoprim: Blood Dyscrasias: Leukopenia, agranulocytosis, thrombocytopenia, methemoglobinemia Allergic Reactions: Rash, pruritus Gastrointestinal Reactions: Nausea, vomiting, abdominal cramps, glossitis, stomatitis Miscellaneous Reactions: Headache, joint pain, apathy, fatigue, muscle weakness, nervousness The following adverse reactions have not been reported in patients receiving trimethoprim; however, based upon clinical experience with chemically related drugs, the possibility of these reactions occurring should be recognized. Blood Dyscrasias: Anemia (megaloblastic, hemolytic, aplastic) C.N.S. Reactions: Convulsions, ataxia, tinnitus, vertigo Miscellaneous Reactions: Drug fever, chills SYMPTOMS AND TREATMENT OF OVERDOSAGE: If poisoning occurs from the ingestion of an overdosage, remove the agent from the stomach by lavage and/or emesis. If renal function is normal, force fluids orally or parenterally to promote excretion. In extreme overdosage in patients with impaired renal function, consideration should be given to hemodialysis as a means of both eliminating the drug from the blood and in reducing the risk of uremia. Drug accumulation in the blood has not been a problem in renal disease, mainly because trimethoprim is readily dialyzed in patients on chronic dialysis. Calcium folinate (3 to 6 mg i.m. for 5 to 7 days) is an effective antidote for adverse reactions in the hematopoietic system caused by trimethoprim. DOSAGE AND ADMINISTRATION: The usual adult dosage is 100 mg of PROLOPRIM every 12 hours or 200 mg once daily, each for 10 days. The use of trimethoprim in patients with creatinine clearance of less than 15mL/min is not recommended. For patients with a creatinine clearance of 15 to 30 mL/min, the dose should be 100 mg every 12 hours.
AVAILABILITY: PROLOPRIM brand trimethoprim 100 mg is a white, round,
biconvex, scored tablet imprinted with PROLOPRIM on upper periphery and 09A on the lower half below the score. Bottles of 100 and 500. PROLOPRIM-200 is a yellow, round, biconvex, scored tablet printed with PROLOPRIM on the upper periphery and 200 on the lower half below the score. Bottles of 100. Product Monograph available on request.
the
MEDICAL DIVISION BURROUGHS
WELLCOME
.111.11--l --l. OUE
.- KIRKLAND,
W428 Trade Mark
PAAB CCPP
for federal physicians, "except as administrators and epidemiologists". He laments the lost opportunities. [There is also a smattering of jobs for doctors in other departments, including Correctional Service Canada and Veterans Affairs Canada.] Today, physicians with Health and Welfare are kept busy at a variety of tasks. They can help draft legislation, research native health, get involved in healthpromotion activities, study and write about mental health issues, look into drug and alcohol abuse, and so on. Such "paper-pushing" activities don't appeal to many doctors, admits Law. She says it is often difficult to fill some MOFF positions because "doctors are really trained and interested in providing acute care to patients". The other problem is that they are an independent-minded lot. "Doctors are not always in charge in the bureaucracy", she warns, "which can be a great shock." For some doctors, even the deepest desire to make a difference in the public health field can't keep them in the federal public service. Dr. Cynthia Carver, who quit in July 1989 after 4 years as a MOFF, says she entered the public service "because I'm a bleeding-heart liberal, and as a GP working in poverty districts in downtown Toronto, I didn't feel I was making a big enough impact". After studying public health, she joined the federal government in Regina, where she was senior physician and program manager for 80 Indian reserves. "My achievements in 4 years were minimal because the priority in this system is not health", says Carver, who eventually became director of intergovernmental affairs with Medical Services. "The major priorities are cover the ass of the minister, and the fiscal bottom line. There is a political drive to avoid conflict and confrontation and no real measure of
the cost-effectiveness
of pro-
grams." As an example, she points to 4-year-old program that involves hiring and training community workers to help deal with natives' alcohol problems. "The government may be [throwing] money a
away, since no one knows how it's
working." She also hated the slowness of the bureaucracy: "It took 21/2 years just to get a job classified so someone could officially run a data-collection system." And the constant disruptions: "There were four major seniormanagement reorganizations in the 4 years I was there. I mean
major." Carver feels MOFFs have too much responsibility and too little power. "If an epidemic breaks out, we do all the work. But try to influence policy or start a needed program and the lines of authority get in your way." She says she saw young doctors enter the government and leave quickly. "They could see that they would get stuck in middle management, with no power and unable to make anything happen. It was really sad." Saddest of all, though, said every current and former public service doctor I interviewed, is the image of MOFFs in the outside world. "Almost nothing bothers me as much as the misconception people have about government workers", says Takahashi. "People like to throw rocks at us. The average public servant, doctors included, is well educated, well dis-
ciplined, sensitive, responsible, hard working and concerned about all Canadians. Working within tight budgets, they think of all problems and try to give the best advice to the politicians." "The health professionals in the government are dedicated", insists Carver. "Doctors take a cut in pay and nurses go and live where almost no one else would."m
