Questions and answers: building morale in your practice M.G. LANDRY Napoleon once observed that "an army's effectiveness depends on its size, training, experience and morale and morale is worth all the other factors combined." No matter how able your aides may be, a sagging morale leads to mediocre performance, high staff turnover and an unhealthy practice environment. Good pay is only part of the solution in building good office morale. This article will discuss a number of ways you can encourage staff members to be loyal, enthusiastic and cooperative. Studies conducted by Dr. Abraham Maslow and Dr. Frederick Herzberg indicate that a sense of accomplishment is the primary source of motivation. Feedback on performance and encouragement are vital elements in eliminating apathy and lack of motivation.
* Do your homework before the interview session. This will include reviewing the list of pluses and minuses that you made when hiring and updated in previous review sessions. Mark your current evaluations on the employee's chart before the review session. Note areas of improvement on which you can compliment the employee, and areas where the person is weak and improvement is needed. * Start with the positives - the things on which you can compliment employees. In reviewing the negatives, let the employees discuss their own deficiencies. Find out plans for improvement. If these are acceptable, help formulate them to fit in with office procedure. Encourage employees to be specific when outlining their goals. A general statement like, "I plan to improve my typing" is not productive. A plan to do 15 minutes typing practice Evaluation routine daily outside the normal office routine While certainly the best policy is to in order to achieve a goal speed of 60 conduct an on-going evaluation process, wpm within 6 weeks is more likely to advising members of your staff daily achieve the desired results. Assure on their performance, a semi-annual or employees that you do not expect perat least an annual assessment is a neces- fection overnight, but that you are insity. A formal routine for this purpose terested in helping improve their skills. should be established. Here are a few * If problems exist, the culprit may guidelines: be office procedure and not the em* An employee should know that ployee. If the workload has greatly the assessment interview is a standard increased with no additional personnel, operating procedure, and that he or she or if the office equipment is inadequate is not being singled out. Therefore, to do the job, criticism of the employee avoid conducting an interview imme- in this area is counterproductive. diately after something has gone wrong * Close the interview with a comin the office or if the employee has pliment. If you can't think of anything been involved in a serious mistake. nice to say, you should be looking for * The interview should be held at a new employee. a time and place where the discussion * Do not discuss salary at the percan be confidential and where neither formance review. The salary review the employee nor the physician will be should be held at a different time. interrupted. Remember, it is your privilege to * If the interview is to be produc- criticize the work of your employees. tive, there must be two-way commu- The key in performance evaluation, nication. Try to establish an atmosphere whether on-going or periodic, is to that will enable the employee to talk recognize that criticism does not mofreely. tivate people so much as praise does. 176 CMA JOURNAL/JANUARY 21, 1978/VOL. 118
With criticism people work harder because they have to - with praise they try harder because they want to. So whenever you have to criticize, try to work in some praise first, then focus on the problem. Team spirit Aides who feel they are an integral part of a team effort are more likely to be happy and productive. The trick is to make your employees feel they are working with you and not for you. Your staff is composed of individuals. Although they have certain specific functions to perform, they do not like to think of themselves as jobholders whose sole reason for existence is to perform a certain function day in and day out. You will get eager cooperation if you recognize that everyone feels important in his or her own world. Regular staff meetings are another method of boosting morale. These will provide an opportunity to clear the air and encourage exchange of ideas for improving office procedures. An agenda and minutes are important tools that will prevent your meetings from turning into nonproductive gripe sessions. If you are uneasy about holding meetings during regular hours, you could close the office during mealtime and order a first class lunch. If you order Chinese food rather than coffee and sandwiches, your staff will not only be willing but eager to pass up their usual lunch hour. The physicial environment in which your staff works has an effect on office efficiency and morale. Coloured telephones and typewriters have a brightening effect. A staff room outfitted with kitchen facilities will give employees a place to eat, mix and relax. There are many other things that you can do to keep your aides enthusiastic about you and your practice, including the following:
* Develop an appointment system that will enable you to close the office on time. * Provide your aides with the best office equipment. Allow them to participate in the decision to purchase a new typewriter or copy machine. * Always check with your aide in charge of making appointments before asking a patient to drop in. * Give extra holidays after an employee has worked for a certain number of years. * Let your staff know where you can be reached. Salaries and bonuses Skimping on salaries is counterproductive. Ideally, you should arrive at a pay structure that is fair to both you and your aides. This will require some research into the going rates for different jobs in your community. Rather than surveying wages paid by other doctors, find out what. industry and government are paying for similar jobs. Staff salaries should be reviewed regularly and voluntarily. Increases should take into consideration general price increases in your area, the aide's growing value to your practice and the amount that you can realistically afford. Tenure increases can be made on the basis of performance within a given salary range. Once the range ceiling is reached, further wage hikes for that job should be made only to preserve the employee's purchasing power. Some will argue that pay ceilings cause frustration and low morale. Perhaps. Salaries, however, represent a major portion of your expenses and these have to be controlled. You shouldn't have any problem if your wage scales remain competitive and you practise some of the morale boosters mentioned above. Some doctors overcome the ceiling problem by paying cash bonuses. An extra few dollars at Christmas comes in handy. Others reward employees with an all-expense paid trip at the end of a certain number of years' work. Studies have shown that people who stay on the job for more than 3 or 4 years are most likely to become longterm staff. If you were to give a trip at the end of 4 years, your chances of keeping the employee on a long-term basis would increase as the trip approaches. Also, if spouses are included in the deal, you will receive strong third-party influence about the job at home. Expensive habit you say - not when you consider the expense as a percentage of 4 years' salary. For example, a $1500 outlay for a trip for a medical assistant making $8000 a year is only 4.69%.
The practice of paying bonuses on the basis of greater patient volume or increased collections can be dangerous. A medical assistant might overload your appointment schedule without your knowledge, or cause poor public relations with patients by being overzealous about collecting overdue accounts. Whether you review wages annually or semi-annually is not important. What is important is that your staff knows that you have a policy of reviewing salaries on a regular basis. For the time being, you should be able to maintain high morale and productivity with the above guidelines. Times are changing, however and you may have to consider some of the high ticket fringe benefits such as retirement, dental and insurance plans if you want to attract and hold top personnel. Although you should not underestimate the appeal of hard cash, employees fringe benefit packages offering financial security will allow you to compete more successfully with business and industry. Studies have shown that the gap is narrowing between employees who prefer pay increases over additional fringe benefits. Wall Street Journal reports that 44% of those surveyed by Roper prefer new fringe benefits - up from 39% in 1973. The survey also indicates that most workers over 45 actually prefer increased fringe benefits. Here are a few benefit plans that you may want to consider: Health Insurance Many employers pay all or a portion of their employees medicare payments, others share or pay part of the premiums for extended health care plans which are designed to supplement the existing provincial hospital and medical insurance plans. For example a plan might cover such non-medicare costs as private hospital room, ambulance service, medical supplies, medical care outside of Canada etc. Life Insurance This benefit would be of particular interest to widows or divorced aides who are sole providers for their children and dependent relatives. An employer can pay premium term insurance coverage up to $25 000 without the employee incurring a taxable benefit. Disability and Sickness Plans These schemes provide continuing salary or wage payments to employees who are absent from work because of accident or sickness. Depending on the employer's objectives these plans may include payment of:
* A percentage of earnings during absence due to accidents or sickness. * A percentage of earnings during absence for other personal reasons if the employee has "earned" sick leave credit. * An income for disabilities of short duration or * An income for disability for a prolonged period. Some plans even include the maintenance and continuance of accrued pension plan credits during periods of extended disability. If you pay any part of the disability insurance premium this will not be a taxable benefit to the employee. However, the disability income will be taxable when received. Dental insurance Although relatively new, this benefit is growing in importance. In the Roper survey referred to above, over 24% of the respondents preferred this form of coverage over any other fringe benefit. Dental insurance will provide coverage to groups of 6 or more for almost any dental service possible -it just depends on how much premium is paid. Because of the elective nature of many of the procedures, dental insurance is usually only practical where there is a deductible and/or a coinsurance factor. The deductible factor is much the same as car insurance where an amount of eligible expense must be paid in cash by the insured before benefits become payable under the policy. The deductible amount is usually quoted on a "calendar year basis" or a "per disability basis". The co-insurance factor represents the portion of eligible expenses which the insured must pay out of his own pocket. For example the individual would have to pay 25% of all expenses incurred. Pension Plans Most solo or small group physicians feel they do not need retirement plans, because of improved social factors in other business sectors and many clinics and large group practices are including pension plans in their benefit packages. There are numerous types of pension plans. However, most fall into two categories: * Benefit plans * Contribution plans
The benefit plans include: final earnings plans where the pension is based on average earnings over a specific period of time and length of service; career earning plans in which the employee earns a unit of pension equal CMA JOURNAL/JANUARY 21, 1978/VOL. 118 179
(levodopa and carbidopa combination) INDICATIONS Treatment of Parkinson's syndrome with exception of drug induced parkinsonism. CONTRAINDICATIONS When a sympathomimetic amine is contraindicated; with monoamine oxidase inhibitors, which should be discontinued two weeks prior to starting SINEMET*; in uncompensated cardiovascular, endocrine, hematologic, hepatic, pulmonary or renal disease; in narrowangle glaucoma; in patients with suspicious, undiagnosed skin lesions or a history of melanoma. WARNINGS When given to patients receiving levodopa alone, discontinue levodopa at least 12 hours before initiating SINEMET* at a dosage that provides approximately 20% of previous levodopa. Not recommended in drug-induced extrapyramidal reactions; contraindicated in management of intention tremor and Huntington's chorea. Levodopa related central effects such as involuntary movements may occur at lower dosages and sooner, and the 'on and off' phenomenon may appear earlier with combination therapy. Monitor carefully all patients for the development of mental changes, depression with suicidal tendencies, or other serious antisocial behaviour. Cardiac function should be monitored continuously during period of initial dosage adjustment in patients with arrhythmias. Upper gastrointestinal hemorrhage is possible in patients with history of peptic ulcer. Safety of SINEMET* in patients under 18 years of age not established. Pregnancy and lactation: In women of childbearing potential, weigh benefits against risks. Should not be given to nursing mothers. Effects on human pregnancy and lactation unknown. PRECAUTIONS General: Periodic evaluations of hepatic, hematopoietic, cardiovascular and renal function recommended in extended therapy. Treat patients with history of convulsions cautiously. Physical Activity: Advise patients improved on SINEMET* to increase physical activities gradually, with caution consistent with other medical considerations. In Glaucoma: May be given cautiously to patients with wide angle glaucoma, provided intraocular pressure is well controlled and can be carefully monitored during therapy. With Antihypertensive Therapy:Assymptomatic postural hypotension has been reported occasionally, give cautiously to patients on antihypertensive drugs, checking carefully for changes in pulse rate and blood pressure. Dosage adjustment of antihypertensive drug may be required. With Psychoactive Drugs: If concomitant administration is necessary, administer psychoactive drugs with great caution and observe patients for unusual adverse reactions. With Anesthetics: Discontinue SINEMET* the night before general anesthesia and reinstitute as soon as patient can take medication orally. ADVERSE REACTIONS Most Common: Abnormal Involuntary Movements-usually diminished by dosage reduction-choreiform, dystonic and other involuntary movements. Muscle twitching and blepharospasm may be early signs of excessive dosage. Other Serious Reactions: Oscillations in performance: diurnal variations, independent oscillations in akinesia with stereotyped dyskinesias, sudden akinetic crises related to dyskinesias, akinesia paradoxica (hypotonic freezing) and 'on and off' phenomenon. Psychiatric: paranoid ideation, psychotic episodes, depression with or without development of suicidal tendencies and dementia. Levodopa may produce hypomania when given regularly to bipolar depressed patients. Rarely convulsions (causal relationship not established). Cardiac irregularities and/or palpitations, orthostatic hypotensive episodes, anorexia, nausea, vomiting and dizziness.
Other adverse reactions that may occur: Psychiatric: increased libido with serious antisocial behaviour, euphoria, lethargy, sedation, stimulation, fatigue and malaise, confusion, insomnia, nightmares, hallucinations and delusions, agitation and anxiety. Neurologic: ataxia, faintness, impairment of gait, headache, increased hand tremor, akinetic episodes, akinesia paradoxica, increase in the frequency and duration of the oscillations in performance, torticollis, trismus, tightness of the mouth, lips or tongue, oculogyric crisis, weakness, numbness, bruxism, priapism. Gastrointestinal: constipation, diarrhea, epigastric and abdominal distress and pain, flatulence; eructation, hiccups, sialorrhea; difficulty in swallowing, bitter taste, dry mouth; duodenal ulcer; gastrointestinal bleeding; burning sensation of the tongue. Cardiovascular: arrhythmias, hypotension, nonspecific ECG changes, flushing, phlebitis. Hematologic: hemolytic anemia, leukopenia, agranulocytosis. Dermatologic: sweating, edema, hair loss, pallor, rash, bad odor, dark sweat. Musculoskeletal: low back pain, muscle spasm and twitching, musculoskeletal pain. Respiratory: feeling of pressure in the chest, cough, hoarseness, bizarre breathing pattern, postnasal drip, Urogenital: urinary frequency, retention, incontinence, hematuria, dark urine, nocturia, and one report of interstitial nephritis. Special Senses: blurred vision, diplopia, dilated pupils, activation of latent Homers syndrome. Miscellaneous: hot flashes, weight gain or loss. Abnormalities in laboratory tests reported with levodopa alone, which may occur with SINEMET*: Elevations of blood urea nitrogen, SGOT, SGPT, LDH, bilirubin, alkaline phosphatase or protein bound iodine. Occasional reduction in WBC, hemoglobin and hematocrit. Elevations of uric acid with colorimetric method. Positive Coombs tests reported both with SINEMET* and with levodopa alone, but hemolytic anemia extremely rare. DOSAGE SUMMARY In order to reduce the incidence of adverse reactions and achieve maximal benefit, therapy with SINEMEP must be individualized and drug administration continuously matched to the needs and tolerance of the patient. Combined therapy with SINEMEP has a narrower therapeutic range than with levodopa alone because of its greater milligram potency. Therefore, titration and adjustment of dosage should be made in small steps and recommended dosage ranges not be exceeded. Appearance of involuntary movements should be regarded as a sign of levodope toxicity and an indication of overdosage, requiring dose reduction. Treatment should, therefore, aim at maximal benefit without dyskine.ias. Therapy in Patients not receiving Levodopa: Initially 1/2 tablet once or twice a day, increase by 1/2 tablet every three days if desirable. An optimum dose of 3 to 5 tablets a day divided into 4 to 6 doses. Therapy in Patients receiving Levodepa: Discontinue levodopa for at least 12 hours, then give approximately 20% of the previous levodopa dose in 4to 6 divided doses. FOR COMPLETE PRESCRIBING INFORMATION, PARTICULARLY DETAILS OF DOSAGE AND ADMINISTRATION, PLEASE CONSULT PRODUCT MONOGRAPH WHICH IS AVAILABLE ON REQUEST. HOW SUPPLIED Ca8804-Tablets SINE MET* 250, dapple-blue, oval, biconvex, scored, compressed tablets coded MSD 654, each containing 25 mg of carbidopa and 250 mg of levodopa. Available in bottles of 100 and 500. '.Trademark SNM-8-480-JA
C
ERCK ARP CANADA LIMITED POINTE CLAIRE QUEBEC
to the percentage of his earnings in that year; and flat benefit pension where the employer receives a fixed dollar pension. While the final earnings and career pension plans are the best for employees, they are also the most expensive to employers. Although not as expensive the flat benefit pension is somewhat unfair because it disregards the differences in earnings and sometimes the length of service. We suggest the money purchase or contributions plan which defines the contribution placed to the credit of the employee. The pension amounts to whatever pension can be purchased with the accumulated contributions plus interest and or capital gains. Money purchase plans are easy to set up and administer and require little expertise in servicing. The physician's costs are under strict control since his contributions are a fixed percentage of payroll. In other words you are not tied in to a benefit which you may not be able to afford later on. In most cases the employees' contributions to a registered pension plan are tax deductible and the employees do not pay tax on the employer's contribution. The medical assistants associations in Ontario and British Columbia have set up pension plan vehicles for their members. In Ontario the plan is administered by an insurance company and invested equally in stocks and fixed income. Both the physician and the employee contribute 4% of salary per annum. If employees leave the practice they can withdraw their accumulated benefits or transfer them to another registered plan. The employer's portion accumulates to age 65 at which time the funds are used to purchase a corresponding pension. The BC plan is administered by a Credit Union and invested in guaranteed securities. The plan requires both employer and employee to make a contribution equal to 5% of the employee's salary. When an employee leaves the practice all accumulated benefits plus interest can be withdrawn in cash or transferred to another registered plan. Building and maintaining a practice requires a loyal and effective medical team. Perhaps some of the above morale building suggestions will help you to develop more enthusiasm and esprit de corps among your staff members. High morale benefits everyone. It can mean the difference between "just another job" and a pleasant place to work. To the patient it can mean a warm office atmosphere instead of an impersonal medical factory and for you the employer it can mean the difference between frequent staff turnover or loyal long term employees.E
CMA JOURNAL/JANUARY 21, 1978/VOL. 118 181
* Do your homework before the interview session. This will include reviewing the list of pluses and minuses that you made when hiring and updated in previous review sessions. Mark your current evaluations on the employee's chart before the review session. Note areas of improvement on which you can compliment the employee, and areas where the person is weak and improvement is needed. * Start with the positives - the things on which you can compliment employees. In reviewing the negatives, let the employees discuss their own deficiencies. Find out plans for improvement. If these are acceptable, help formulate them to fit in with office procedure. Encourage employees to be specific when outlining their goals. A general statement like, "I plan to improve my typing" is not productive. A plan to do 15 minutes typing practice Evaluation routine daily outside the normal office routine While certainly the best policy is to in order to achieve a goal speed of 60 conduct an on-going evaluation process, wpm within 6 weeks is more likely to advising members of your staff daily achieve the desired results. Assure on their performance, a semi-annual or employees that you do not expect perat least an annual assessment is a neces- fection overnight, but that you are insity. A formal routine for this purpose terested in helping improve their skills. should be established. Here are a few * If problems exist, the culprit may guidelines: be office procedure and not the em* An employee should know that ployee. If the workload has greatly the assessment interview is a standard increased with no additional personnel, operating procedure, and that he or she or if the office equipment is inadequate is not being singled out. Therefore, to do the job, criticism of the employee avoid conducting an interview imme- in this area is counterproductive. diately after something has gone wrong * Close the interview with a comin the office or if the employee has pliment. If you can't think of anything been involved in a serious mistake. nice to say, you should be looking for * The interview should be held at a new employee. a time and place where the discussion * Do not discuss salary at the percan be confidential and where neither formance review. The salary review the employee nor the physician will be should be held at a different time. interrupted. Remember, it is your privilege to * If the interview is to be produc- criticize the work of your employees. tive, there must be two-way commu- The key in performance evaluation, nication. Try to establish an atmosphere whether on-going or periodic, is to that will enable the employee to talk recognize that criticism does not mofreely. tivate people so much as praise does. 176 CMA JOURNAL/JANUARY 21, 1978/VOL. 118
With criticism people work harder because they have to - with praise they try harder because they want to. So whenever you have to criticize, try to work in some praise first, then focus on the problem. Team spirit Aides who feel they are an integral part of a team effort are more likely to be happy and productive. The trick is to make your employees feel they are working with you and not for you. Your staff is composed of individuals. Although they have certain specific functions to perform, they do not like to think of themselves as jobholders whose sole reason for existence is to perform a certain function day in and day out. You will get eager cooperation if you recognize that everyone feels important in his or her own world. Regular staff meetings are another method of boosting morale. These will provide an opportunity to clear the air and encourage exchange of ideas for improving office procedures. An agenda and minutes are important tools that will prevent your meetings from turning into nonproductive gripe sessions. If you are uneasy about holding meetings during regular hours, you could close the office during mealtime and order a first class lunch. If you order Chinese food rather than coffee and sandwiches, your staff will not only be willing but eager to pass up their usual lunch hour. The physicial environment in which your staff works has an effect on office efficiency and morale. Coloured telephones and typewriters have a brightening effect. A staff room outfitted with kitchen facilities will give employees a place to eat, mix and relax. There are many other things that you can do to keep your aides enthusiastic about you and your practice, including the following:
* Develop an appointment system that will enable you to close the office on time. * Provide your aides with the best office equipment. Allow them to participate in the decision to purchase a new typewriter or copy machine. * Always check with your aide in charge of making appointments before asking a patient to drop in. * Give extra holidays after an employee has worked for a certain number of years. * Let your staff know where you can be reached. Salaries and bonuses Skimping on salaries is counterproductive. Ideally, you should arrive at a pay structure that is fair to both you and your aides. This will require some research into the going rates for different jobs in your community. Rather than surveying wages paid by other doctors, find out what. industry and government are paying for similar jobs. Staff salaries should be reviewed regularly and voluntarily. Increases should take into consideration general price increases in your area, the aide's growing value to your practice and the amount that you can realistically afford. Tenure increases can be made on the basis of performance within a given salary range. Once the range ceiling is reached, further wage hikes for that job should be made only to preserve the employee's purchasing power. Some will argue that pay ceilings cause frustration and low morale. Perhaps. Salaries, however, represent a major portion of your expenses and these have to be controlled. You shouldn't have any problem if your wage scales remain competitive and you practise some of the morale boosters mentioned above. Some doctors overcome the ceiling problem by paying cash bonuses. An extra few dollars at Christmas comes in handy. Others reward employees with an all-expense paid trip at the end of a certain number of years' work. Studies have shown that people who stay on the job for more than 3 or 4 years are most likely to become longterm staff. If you were to give a trip at the end of 4 years, your chances of keeping the employee on a long-term basis would increase as the trip approaches. Also, if spouses are included in the deal, you will receive strong third-party influence about the job at home. Expensive habit you say - not when you consider the expense as a percentage of 4 years' salary. For example, a $1500 outlay for a trip for a medical assistant making $8000 a year is only 4.69%.
The practice of paying bonuses on the basis of greater patient volume or increased collections can be dangerous. A medical assistant might overload your appointment schedule without your knowledge, or cause poor public relations with patients by being overzealous about collecting overdue accounts. Whether you review wages annually or semi-annually is not important. What is important is that your staff knows that you have a policy of reviewing salaries on a regular basis. For the time being, you should be able to maintain high morale and productivity with the above guidelines. Times are changing, however and you may have to consider some of the high ticket fringe benefits such as retirement, dental and insurance plans if you want to attract and hold top personnel. Although you should not underestimate the appeal of hard cash, employees fringe benefit packages offering financial security will allow you to compete more successfully with business and industry. Studies have shown that the gap is narrowing between employees who prefer pay increases over additional fringe benefits. Wall Street Journal reports that 44% of those surveyed by Roper prefer new fringe benefits - up from 39% in 1973. The survey also indicates that most workers over 45 actually prefer increased fringe benefits. Here are a few benefit plans that you may want to consider: Health Insurance Many employers pay all or a portion of their employees medicare payments, others share or pay part of the premiums for extended health care plans which are designed to supplement the existing provincial hospital and medical insurance plans. For example a plan might cover such non-medicare costs as private hospital room, ambulance service, medical supplies, medical care outside of Canada etc. Life Insurance This benefit would be of particular interest to widows or divorced aides who are sole providers for their children and dependent relatives. An employer can pay premium term insurance coverage up to $25 000 without the employee incurring a taxable benefit. Disability and Sickness Plans These schemes provide continuing salary or wage payments to employees who are absent from work because of accident or sickness. Depending on the employer's objectives these plans may include payment of:
* A percentage of earnings during absence due to accidents or sickness. * A percentage of earnings during absence for other personal reasons if the employee has "earned" sick leave credit. * An income for disabilities of short duration or * An income for disability for a prolonged period. Some plans even include the maintenance and continuance of accrued pension plan credits during periods of extended disability. If you pay any part of the disability insurance premium this will not be a taxable benefit to the employee. However, the disability income will be taxable when received. Dental insurance Although relatively new, this benefit is growing in importance. In the Roper survey referred to above, over 24% of the respondents preferred this form of coverage over any other fringe benefit. Dental insurance will provide coverage to groups of 6 or more for almost any dental service possible -it just depends on how much premium is paid. Because of the elective nature of many of the procedures, dental insurance is usually only practical where there is a deductible and/or a coinsurance factor. The deductible factor is much the same as car insurance where an amount of eligible expense must be paid in cash by the insured before benefits become payable under the policy. The deductible amount is usually quoted on a "calendar year basis" or a "per disability basis". The co-insurance factor represents the portion of eligible expenses which the insured must pay out of his own pocket. For example the individual would have to pay 25% of all expenses incurred. Pension Plans Most solo or small group physicians feel they do not need retirement plans, because of improved social factors in other business sectors and many clinics and large group practices are including pension plans in their benefit packages. There are numerous types of pension plans. However, most fall into two categories: * Benefit plans * Contribution plans
The benefit plans include: final earnings plans where the pension is based on average earnings over a specific period of time and length of service; career earning plans in which the employee earns a unit of pension equal CMA JOURNAL/JANUARY 21, 1978/VOL. 118 179
(levodopa and carbidopa combination) INDICATIONS Treatment of Parkinson's syndrome with exception of drug induced parkinsonism. CONTRAINDICATIONS When a sympathomimetic amine is contraindicated; with monoamine oxidase inhibitors, which should be discontinued two weeks prior to starting SINEMET*; in uncompensated cardiovascular, endocrine, hematologic, hepatic, pulmonary or renal disease; in narrowangle glaucoma; in patients with suspicious, undiagnosed skin lesions or a history of melanoma. WARNINGS When given to patients receiving levodopa alone, discontinue levodopa at least 12 hours before initiating SINEMET* at a dosage that provides approximately 20% of previous levodopa. Not recommended in drug-induced extrapyramidal reactions; contraindicated in management of intention tremor and Huntington's chorea. Levodopa related central effects such as involuntary movements may occur at lower dosages and sooner, and the 'on and off' phenomenon may appear earlier with combination therapy. Monitor carefully all patients for the development of mental changes, depression with suicidal tendencies, or other serious antisocial behaviour. Cardiac function should be monitored continuously during period of initial dosage adjustment in patients with arrhythmias. Upper gastrointestinal hemorrhage is possible in patients with history of peptic ulcer. Safety of SINEMET* in patients under 18 years of age not established. Pregnancy and lactation: In women of childbearing potential, weigh benefits against risks. Should not be given to nursing mothers. Effects on human pregnancy and lactation unknown. PRECAUTIONS General: Periodic evaluations of hepatic, hematopoietic, cardiovascular and renal function recommended in extended therapy. Treat patients with history of convulsions cautiously. Physical Activity: Advise patients improved on SINEMET* to increase physical activities gradually, with caution consistent with other medical considerations. In Glaucoma: May be given cautiously to patients with wide angle glaucoma, provided intraocular pressure is well controlled and can be carefully monitored during therapy. With Antihypertensive Therapy:Assymptomatic postural hypotension has been reported occasionally, give cautiously to patients on antihypertensive drugs, checking carefully for changes in pulse rate and blood pressure. Dosage adjustment of antihypertensive drug may be required. With Psychoactive Drugs: If concomitant administration is necessary, administer psychoactive drugs with great caution and observe patients for unusual adverse reactions. With Anesthetics: Discontinue SINEMET* the night before general anesthesia and reinstitute as soon as patient can take medication orally. ADVERSE REACTIONS Most Common: Abnormal Involuntary Movements-usually diminished by dosage reduction-choreiform, dystonic and other involuntary movements. Muscle twitching and blepharospasm may be early signs of excessive dosage. Other Serious Reactions: Oscillations in performance: diurnal variations, independent oscillations in akinesia with stereotyped dyskinesias, sudden akinetic crises related to dyskinesias, akinesia paradoxica (hypotonic freezing) and 'on and off' phenomenon. Psychiatric: paranoid ideation, psychotic episodes, depression with or without development of suicidal tendencies and dementia. Levodopa may produce hypomania when given regularly to bipolar depressed patients. Rarely convulsions (causal relationship not established). Cardiac irregularities and/or palpitations, orthostatic hypotensive episodes, anorexia, nausea, vomiting and dizziness.
Other adverse reactions that may occur: Psychiatric: increased libido with serious antisocial behaviour, euphoria, lethargy, sedation, stimulation, fatigue and malaise, confusion, insomnia, nightmares, hallucinations and delusions, agitation and anxiety. Neurologic: ataxia, faintness, impairment of gait, headache, increased hand tremor, akinetic episodes, akinesia paradoxica, increase in the frequency and duration of the oscillations in performance, torticollis, trismus, tightness of the mouth, lips or tongue, oculogyric crisis, weakness, numbness, bruxism, priapism. Gastrointestinal: constipation, diarrhea, epigastric and abdominal distress and pain, flatulence; eructation, hiccups, sialorrhea; difficulty in swallowing, bitter taste, dry mouth; duodenal ulcer; gastrointestinal bleeding; burning sensation of the tongue. Cardiovascular: arrhythmias, hypotension, nonspecific ECG changes, flushing, phlebitis. Hematologic: hemolytic anemia, leukopenia, agranulocytosis. Dermatologic: sweating, edema, hair loss, pallor, rash, bad odor, dark sweat. Musculoskeletal: low back pain, muscle spasm and twitching, musculoskeletal pain. Respiratory: feeling of pressure in the chest, cough, hoarseness, bizarre breathing pattern, postnasal drip, Urogenital: urinary frequency, retention, incontinence, hematuria, dark urine, nocturia, and one report of interstitial nephritis. Special Senses: blurred vision, diplopia, dilated pupils, activation of latent Homers syndrome. Miscellaneous: hot flashes, weight gain or loss. Abnormalities in laboratory tests reported with levodopa alone, which may occur with SINEMET*: Elevations of blood urea nitrogen, SGOT, SGPT, LDH, bilirubin, alkaline phosphatase or protein bound iodine. Occasional reduction in WBC, hemoglobin and hematocrit. Elevations of uric acid with colorimetric method. Positive Coombs tests reported both with SINEMET* and with levodopa alone, but hemolytic anemia extremely rare. DOSAGE SUMMARY In order to reduce the incidence of adverse reactions and achieve maximal benefit, therapy with SINEMEP must be individualized and drug administration continuously matched to the needs and tolerance of the patient. Combined therapy with SINEMEP has a narrower therapeutic range than with levodopa alone because of its greater milligram potency. Therefore, titration and adjustment of dosage should be made in small steps and recommended dosage ranges not be exceeded. Appearance of involuntary movements should be regarded as a sign of levodope toxicity and an indication of overdosage, requiring dose reduction. Treatment should, therefore, aim at maximal benefit without dyskine.ias. Therapy in Patients not receiving Levodopa: Initially 1/2 tablet once or twice a day, increase by 1/2 tablet every three days if desirable. An optimum dose of 3 to 5 tablets a day divided into 4 to 6 doses. Therapy in Patients receiving Levodepa: Discontinue levodopa for at least 12 hours, then give approximately 20% of the previous levodopa dose in 4to 6 divided doses. FOR COMPLETE PRESCRIBING INFORMATION, PARTICULARLY DETAILS OF DOSAGE AND ADMINISTRATION, PLEASE CONSULT PRODUCT MONOGRAPH WHICH IS AVAILABLE ON REQUEST. HOW SUPPLIED Ca8804-Tablets SINE MET* 250, dapple-blue, oval, biconvex, scored, compressed tablets coded MSD 654, each containing 25 mg of carbidopa and 250 mg of levodopa. Available in bottles of 100 and 500. '.Trademark SNM-8-480-JA
C
ERCK ARP CANADA LIMITED POINTE CLAIRE QUEBEC
to the percentage of his earnings in that year; and flat benefit pension where the employer receives a fixed dollar pension. While the final earnings and career pension plans are the best for employees, they are also the most expensive to employers. Although not as expensive the flat benefit pension is somewhat unfair because it disregards the differences in earnings and sometimes the length of service. We suggest the money purchase or contributions plan which defines the contribution placed to the credit of the employee. The pension amounts to whatever pension can be purchased with the accumulated contributions plus interest and or capital gains. Money purchase plans are easy to set up and administer and require little expertise in servicing. The physician's costs are under strict control since his contributions are a fixed percentage of payroll. In other words you are not tied in to a benefit which you may not be able to afford later on. In most cases the employees' contributions to a registered pension plan are tax deductible and the employees do not pay tax on the employer's contribution. The medical assistants associations in Ontario and British Columbia have set up pension plan vehicles for their members. In Ontario the plan is administered by an insurance company and invested equally in stocks and fixed income. Both the physician and the employee contribute 4% of salary per annum. If employees leave the practice they can withdraw their accumulated benefits or transfer them to another registered plan. The employer's portion accumulates to age 65 at which time the funds are used to purchase a corresponding pension. The BC plan is administered by a Credit Union and invested in guaranteed securities. The plan requires both employer and employee to make a contribution equal to 5% of the employee's salary. When an employee leaves the practice all accumulated benefits plus interest can be withdrawn in cash or transferred to another registered plan. Building and maintaining a practice requires a loyal and effective medical team. Perhaps some of the above morale building suggestions will help you to develop more enthusiasm and esprit de corps among your staff members. High morale benefits everyone. It can mean the difference between "just another job" and a pleasant place to work. To the patient it can mean a warm office atmosphere instead of an impersonal medical factory and for you the employer it can mean the difference between frequent staff turnover or loyal long term employees.E
CMA JOURNAL/JANUARY 21, 1978/VOL. 118 181
