The rural doctor: among friends on the Canada-US border DAVID WOODS Shielding his eyes against the hot sun, Cliff Schrader indicates with a sweep of his outstretched arm the 50 ha he farms at Newfane, New York, about 50 km from Canada; there are a few hectares of peaches and 70 head of cattle, but mostly it's corn, which is what he was planting the day I visited. Pausing to chat over the fence with his friend and neighbour Dr. Harry Oliver, Schrader recalls how he and his wife used to work the land with four horses: "We'd start in the morning with two of them," he says, "then bring on the other two for the afternoon and evening." At 63, Cliff Schrader still puts in a 14- to 16-hour day. "But," he says, "if I had to come this way again I'd do the same thing." Retire? "I don't know as I could," says Schrader. "Anyway, I love the work, and it keeps me in good shape - eh, Doc? I want to do the best I can.., just like you doctors with your patients." Both in Canada and the US, there have been dire predictions in recent years of the demise of the rural doctor. There have been private and government incentives to lure GPs to the country from the cities; but if Dr. Harry Oliver and his counterpart on the Canadian side of the border, Dr. R.S.H. (Bob) Twidle of Stevensville, Ontario, are typical rural GPs... the rewards and satisfactions of bucolic medicine are enormous, even though the country doctor's life - like the farmer's - has changed greatly in the past few decades. Modern medical science has given us the technology to transplant hearts and a range of drugs to control such onetime killer diseases as diabetes, diphtheria, scarlet fever and pneumonia. In the cities and suburbs of North America this is seen by many as a new streamlined chemicalized and mechanized form of medicine that tends to depersonalize health care - to make the doctor-patient relationship a more formal encounter.
But in the rural areas the old style family doctor is alive and well. The successor to the horse-and-buggy physician who ministered to his patients with the few tools of his trade tucked into his little black bag, with a few nostrums and with kindly and reassuring"ums"and" ahs" can today call on sophisticated scientific support. With the advent of medical insurance he can count on getting paid in cash, rather than in apples or eggs, too; and his "parish" is small enough that he can get to know his patients as individuals - often as friends. Whether in Newfane or 50 km away across the border in Stevensville, the rewards, the benefits and the style of this old-fashioned personal doctorpatient relationship backed up with the new technology are virtually the same - despite the seemingly major difference between Canada's governmentrun health care system and the still largely free-enterprise approach in the United States. In both rural localities - separated as they are by an international border - doctor and patient reap the rewards of an unhurried art of medicine, a more personal brand of care that's as
satisfying as the 430 cm high corn for which Cliff Schrader held a local record for several years. In Canada, a few kilometres from Niagara Falls and rather off the track beaten by the millions of tourists who come to the Falls each year, is the small (population 800) town of Stevensville. Bob Twidle has practised medicine there for the past 15 years; the 114-year old house he lives in predates Confederation and it's always been occupied by a local doctor. Twidle, 44, grew up in the countryside of his native England, where his father was a clergyman. He set up practice in Saskatchewan but headed eastward again when the province introduced its comprehensive, government-sponsored health insurance plan in 1962, which resulted in the famous doctors' "strike" and a subsequent exodus of physicians. "I like farm and country people," says Dr. Twidle, "and open spaces; but I also like freedom." He and his USborn wife Ruth arrived in Stevensville with 26 cents. "It was a gamble," she recalls, "Initially I worked with Bob as nurse, bookkeeper, receptionist and secretary."
Dr. Oliver chats with neighbour Cliff Schrader
4
Dr. Twidle leaves Ins 114-year old home for a country style housecall
Prescribing information Ventolin® Indications: To relieve bronchospasm in: Bronchial asthma of all types. Chronic bronchitis, other chronic bronchopulmonary disorders in which bronchospasm is a complicating factor. Suggested dosage: Ventolin Inhaler: One or two inhalations repeated every four hours, If required. More than eight inhalations per day is not recommended. Ventolin Tablets: To be taken three or four times daily. Adults: 2 mg . 4 mg. The optimum single dose for most adult patients is 4 mg. With elderly patients or with patients who are unusually sensitive to beta.adrenergic stimulants. it Is advisable to Initiate treatment with 2 me. Children: 6 to 12 years: 2 mg Over 12 years: adult dosage Presentation: Ventolin Inhaler: A metered aerosol, delivering 100 mcg of salbutamol per inhalation. Each 15 ml canister provides at least 200 Inhalations. Ventolin Tablets 4 mo: Each tablet contains salbutamol sulphate 4.8 mg, equivalent to salbutamol 4.0 mg. Bottles of 100. Ventolin Tablets: 2 mg: Each tablet contains salbutamol sulphate 2.4 mg, equivalent to salbutanol 2.0 mg. B6ttles of 100. Contraindication Hypersensitivity to any of the ingredients and tachyarrhythmias Wsrni ngs: The safety of salbutamol in pregnancy has not been established. Care should be taken with patients suffering from myocardial insufficiency, arrhythmia, hypertension, diabetes mellitus, or thyrotoxicosis. Precautions: Use with caution in patients sensitive to sympathomimetic amines. Other beta-adregenic drugs, e.g. isoprenaline, should not be given concomitantly. Adverse reactions: Headache, dizziness, nausea, tremor and palpitation, nervousness and leg cramps may occur. The only reported side effect of significance with Ventolin Tablets is a fine tremor of skeletal muscle in some patients usually affecting the hands. The degree of tremor is dose related and caused by a direct action on skeletal muscle, not by CNS stimulation. This effect is common to all beta-adrenergic stimulants and usually stops with reduction of dosage. Symptoms end treatment of overdoasge: Overdosage may cause peripheral vasodilation and increased irritability of skeletal muscle, tachycardia. arrhythmia and hypertension. In case of overdose, gastric lavage should be performed. In order to antagonize the effect of salbutamol, the use of a beta-adrenergic blocking agent, such as propranolol, may be considered.
Beclovent® INDICATIONS Treatment of steroid-responsive bronchial asthma: (1) In patients who in the past have not been on steroida but the severity of their condition warranta such treatment. (21 In steroid-dependent patients to replace or reduce oral medication through gradual withdrawal of systemic steroids. CONTRAINDICATIONS Active or quiescent untreated pulmonary tuberculosis, or untreated fungal. bacterial and viral infections, and in children under six. Status asthmaticus, and In patients with moderate to severe bronchiectasis. WARNINGS in patients previously on high doses of systemic steroids. transfer to BECLOVENT Inhaler may cause withdrawal symptoms such as tiredness, aches and pains, and depression. in severe cases, acute adrenal Insufficiency may occur necessitating the temporary resumption of systemic steroids. The deveiopment of pharyngeal and laryngeal candidlasis Is cause of concern because the extent of its penetration of the respiratory tract is unknown. if candidiasis develops the treatment should be discontinued and appropriate antifungal therapy initiated. The incidence of candidiasis can generally be held to a minimum by having patients rinse their mouth with water after each inhalation. PRECAUTIONS 1. It is essential that patients be informed that BECLOVENT inhaler is a preventive agent, must be taken at regular intervals, and is not to be used during an asthmatic attack. 2. The replacement of a systemic steroid with BECLOVENT inhaler has so be gradual and carefully supervised by the physician, the guidelines ueder Dosage and Administration should be followed in each case. 3. Unnecessary administration of drugs during the first trimester of pregnancy is undesirab te. Corticosteroids may mask some signs of infection and new infections may appear. A decreased resistance to localized infection has been observed during corticosteroid therapy. During longterm therapy, pituitary-adrenal function and hematological status should be periodically assessed. 4. Fluorocarbon propellants may be hazardous If they are deliberately abused. inhalation of high concentrations of aerosol sprays has brought about cardiovascular toxic effects and even death, especially under conditions of hypoxia. However, evidence attests to the relative safety of aerosols when used properly and with adequate ventilation. 5. There is an enhanced effect of corticosteroids on patients with hypothyroidism and in those with cirrhosis. 6. Acesylsalicylic acid should be used cautiously in conjunction with corticosteroids in hypoprothrombinemia. 7. Patients should be advised to inform subsequent physicians of the prior use of corticosterolds. ADVERSE REACTIONS No major side-effects attributable to the use of recommended doses of BECLOVENT Inhaler have been reported. No systemic effects have been observed when the daily dose was below mg (twenty puffal. Above this dose, reduction of plasma cortisol. indicating adrenocortical suppression, may occur. Therapeutic doses may cause the appearance of Candida a hicans in the mouth and throat. The replacement of systemic steroids with BECLOVENT Inhaler may unmask symptoms of allergies which were previously suppressed by the systemic drug. Conditions such as allergic rhinitis and eczema may thus become apparent during BECLOVENT therapy after the withdrawal of systemic corticosteroids.
812 CMA JOURNAL/OCTOBER 8, 1977/VOL. 117
Bob Twidle has no wish now to change his place, even though, now government medicare insurance covers practically every Canadian and government reins on the health care system are held ever more tightly, many of his professional colleagues are eyeing practice opportunities in the US. "Being a general practitioner," he says, "is vastly interesting. It provides pleasure in versatility, and" - echoing Farmer Schrader on the American side of the Niagara River - "it means coping with what facilities you've got ... doing the best you can." Dr. Twidle sees the rewards of rural practice as enabling him to work more informally, more intimately with patients. Even though he believes that country people are more accepting of biological changes as natural phenomena - "because they see nature changing around them" - and that they're able to cope with minor injuries and illnesses more ably than city folks, the Stevensville GP doesn't have a leisurely practice: he sees 30-40 patients a day in the office he built a few years ago a couple of hundred metres away from his house, does an average of eight housecalls a week and serves as chief of
SYMPTOMS AND TREATMENT OF OVERDOSAGE Overdosage may cause systemic steroid effects such as adrenal suppression and hypercorticism. Decreasing the dose will abolish these side-effects. DOSAGE AND ADMINISTRATION The optimal dosage of BECLOVENT may vary widely and must be individually determined, but the total daily dose should not exceed mg of beclomethasone dipropionate (25 puffs). Adults: The usual dose is two inhalations (155 mcg) three to four times daily. if this dose is not sufficient, it can be doubled initially. As a maintenance dose, many patients do well on two inhaletions daily. Children: insufficient information Is available to warrant the safe use in children under six years of age. The average daily dose for children over six years of age is 6 mcg/kg of body weight. IMPORTANT: As a steroid aerosol, Becloveof Inhaler is for maintenance therapy. It is not intended to give immediate relief, and effectiveness depends both on regular use and proper technique of inhalation. Patients must be instructed to take the inhaletions at regular intervals and not, as with bronchodilator aerosols, when they feel a need for relief of symptoms. They should also be instructed in the correct method of use, which is to exhafe completely, then place the lips tightly around the mouthpiece. The aerosol should be actuated as the patient breathes in deeply and slowly. This ensures maximum penetration into the lungs, and the breath should be held as long as possible following each inhalation. The patient's attention should be drawn to the instruction Sheet, enclosed in each Beciovent pack. in the presence of excessive mucus secretion, the drug may fail to reach the bronchioles. Therefore, if an obvious response is not obtained after ten days, attempts should be made to remove the mucus with expectorants and/or with a abort course of systemic corticosteroid treatment. Careful attention must be given to patients previously treated for prolonged periods with systemic corticosteroids, when transferred to BECLOVENT. initially BECLOVENT and the systemic steroid must be given concomitantly while the dose of the latter is gradually decreased. The usual rate of with. drawal of the systemic corticoid is the equivalent of 2.5 mg of prednisone every four days if the patient is under close observation. if continuous supervision is not feasible, the withdrawal of the systemic steroid should be slower, approximately 2.5 mg of prednisone (or equivalent) every ten days. if withdrawal symptoms appear, the previous dose of the systemic drug should be resumed for a week before further decrease is attempted. There are some patients who cannot completely discontinue the oral corticosteroid. in these cases, a minimum maintenance dose should be given in addition to BECLOVENT inhaler. SUPPLIED BECLOVENT inhaler is a metered-dose aerosol delivering SO micrograms of beciomethasone dipropionate with each depression of the valve. There are two hundred doses in a container. Official product monograph on request.
Allen & Hanburys
A Glaxo Canada Ltd. Company Toronto, Canada
EE.
staff at the hospital in Fort Erie a town of 23 000 just across the river from Buffalo, NY. But in either country, informality is the keynote of rural doctor-patient relationships, providing the reassurance and trust and confidence upon which so much of successful health care is built. As Bob Twidle puts it: "I know most of my patients by their first names; they call me Doc". All of that might sound like a far cry from the wonders of modern scientific medicine, from the crisp buttondown efficiency of urban and suburban family practice, but the close bond that exists between rural practitioner and patient isn't merely a cosy alternative to more "sophisticated" health care - it's an integral part of the therapeutic process. Not only that, but today's rural GP is more than an amiable and comforting presence: because he's not surrounded by specialists and superspecialists, he's likely to be practising more comprehensively than his city counterpart - doing surgery. anesthesia, putting casts on fractures. And since good roads and motor vehicles have supplanted horses and buggies, he can refer to urban hospitals patients that he needs more specialized help with. Moreover, there's no place for complacency, for over-reliance on "bedside manner": to retain membership in either the College of Family Physicians of Canada or the American Academy of Family Physicians, the general practitioner - whatever his location must show evidence of keeping up-todate with advances in medical knowledge and techniques. The whole idea of "family" practice is much more of a reality in the rural community than it is elsewhere: the country doctor can relate health problems from one member of a family to another and offer counselling and advice, based on close awareness of the overall picture, that may help to head off such problems before they become more serious. Such requests for advice, says Dr. Twidle's secretary-nurse-receptionist Mrs. Faye Silvestro, may be preceded by a proprietary "Is Bob in?" On one such occasion recently Ross McLean dropped in to ask whether his 87-year-old mother could get some home care. Sitting beside the concerned son (because he feels that sitting behind his office desk creates a barrier between doctor and patient) Doc Twidle explained about available home care services, said that these would bridge a gap between hospitalization and independence and saw no need to institutionalize the woman just because she was old. "But I'll come and see her," he said.
Bob Twidle knows most of his patients by their first names "I do a lot of this sort of thing on Saturday mornings," Bob Twidle told me, "bringing in relatives to work out a policy of management... it can be done so much better in person than on the phone... The Twidle family itself consists of wife Ruth, who still works as a nurse; two sons, 24 and 18, and daughter Naomi, 15. Ruth and Naomi agree that the country doctor's family becomes a part of his practice, with the locals feeling free to drop in at the house at any time the office is closed and to talk with any of the doctor's family about health. But the patients are very supportive, says Ruth: "One time I was ill and a patient forgot why she'd turned up, saying to Bob: 'You take care of your wife; I'll look after the kids'." Like Twidle, Dr. Harry Oliver in Newfane came into general practice virtually broke, has three grown children, and sings the praises of the rural practice he's conducted since 1958 in his town of 2000. "When you're an integral part of a small community," he says, "there's a closeness of association with the patient that's lacking in the city or the suburbs." Dr. Oliver, whose office is a con-
verted bungalow 1 km from the local hospital, is a 54-year-old graduate of the University of Buffalo. It's not just the scope of this type of practice, he says, noting that he does obstetrical deliveries, minor surgery and orthopedics. "But the local people identify with you. You're one of them; they see you every day in the store, at the gas station, playing tennis.. This means that health care in the predominantly farming community of Newfane is more than an office transaction. "I often eat breakfast in a local restaurant," says Harry Oliver, "and by the time I've finished I've generally given out a few prescriptions or done some counselling." As we drove from Oliver's office to his relatively modest house bordering Cliff Schrader's farm, the doctor stopped to chat with Bob Noon, a 59year-old tool designer at the local subsidiary of General Motors. Noon, who's planning to retire shortly, suffered a heart attack a couple of years ago. His routine 12-15 km walk, he says, "takes me past the doc's house each day and we've become good friends." Later, in his office again, Harry talked on a first-name basis with cancer patient Genevieve Murphy, an articulate and charming woman who is following her course of treatment with
GMA JOURNAL/OCTOBER 8, 1977/VOL. 117 813
a detached interest and an indominable spirit. Thanked for allowing us to photograph her in Dr. Oliver's office, she said: . do anything for him... One is struck less by the differences in rural practice in Canada and the United States than by the similarities. The scope, the dedication, the personal care, the satisfactions to patient and doctor alike are identical in both countries. The housecalls, the 30-40 consultations a day, the enthusiasm for keeping up-to-date with medical knowledge, the access to a nearby hospital... practically carbon copies one of the other. There are, of course, contrasts: on the Canadian side Bob Twidle works,
in essence, for the government.., his fees reimbursed by the provincial Ministry of Health. Harry Oliver deals on a cash basis except in cases for which medicare, medicaid, Blue Cross or other insurance arrangements apply. Twidle has an office staff of one; Oliver a payroll of five; the American doctor pays $2000 a year in malpractice insurance while his colleague in Canada pays about 10% of that - a reflection of the fact that there's one malpractice suit a year per 130 MDs in Canada, and one per 46 in the US. But these are relatively minor differences, particularly when you consider, Dr. Oliver points out, that "American medical care is becoming
increasingly government-regulated, and that President Carter is moving toward a universal health insurance plan." What is perhaps a little odd is that these rural practitioners on either side of the "longest undefended border in the world" don't seem to get together more often to share their unique experience instead of heading for post graduate courses in the nearest big city on their own side. But that's a small quibble. As long as rural doctors like Bob Twidle and Harry Oliver continue to dispense their personal kind of health care and to do their best for their patients, country life will be the richer for having them around. U
BC minister agrees to continue health centres GLENNIS ZILM British Columbia Health Minister centre concept but also are doing imRobert McClelland is "not convinced portant jobs. the centres are the only way to do it." "We are not convinced the centres - but he has agreed to continue opera- were the only way to do it," he said. tion of the province's four community His department will be looking at alhealth centres for at least another 3 ternatives and modifications that would bring about closer liaison between years. The provincial government agreed to members of the health team, which is continue the four centres, which com- the third main recommendation of the bine health and social services, includ- committee. ing salaried medical services, under one This recommendation called for the roof, following an evaluation and re- government to place nurse practitionport by a six-member committee ers, social workers and mental health headed by Professor Vance Mitchell workers as liaison people in principal of the faculty of commerce, University facilities where fee-for-service physiof British Columbia. The report rec- cians are working, Professor Mitchell ommended the four centres (at Gran- said. One of the biggest problems idenisle, Houston, James Bay and Queen tified by his committee related to difCharlotte Islands) be continued and ficulties doctors have in reaching out evaluated again at the end of 5 years to other workers in a "heterogeneous total operation, which would be about system of services 1980. "It is virtually impossible to refer It also recommended that, subject patients across this system of services. to some special considerations on loca- he said. Care is fragmented because tion of lack of fee-for-service doctors, zones or areas for public health servsimilar centres be opened in other ices, social workers, police, family rural, isolated areas. The government, courts, laboratories, x-rays, even hoshowever, is not prepared to go that pitals seldom coincide, especially in far at present and has said it has no large urban areas. In smaller areas, the ancillary services may not exist. plans for more. Mitchell identified this closer liaison Report premature between health and other workers in Health Minister McClelland told the centres as one of the biggest CMAJ the report, carried out after the strengths his committee found. He said centres were in operation for only doctors often are criticized for being about 2 years, was perhaps a little a big stumbling block to team care, but premature in deciding on the benefits. this is just not so when all services The main value of the centres was are readily and easily available. an upgrading of health care in the "The greatest strength is the teamcommunities, he said, but he added work that we saw that had developed there were perhaps other ways of within these centres." achieving this. He noted the REACH The other big strengths were incentre and the Downtown East Side volvement of local citizens through Centre, both in Vancouver, are not elected boards that identified medical modelled on the community health and social needs in the community and 814 CMA JOURNAL/OCTOBER 8, 1977/VOL. 117
the involvement of all citizens in the area when these health needs were so identified. For example, he said, a group program was organized by a youth worker in one centre after complaints about vandalism in the area. RCMP statistics from before and after the group program's introduction proved there was a reduction in vandalism directly related to the centre's programs. Difficult to prove benefits In each community, physicians and other team members organized preventive care activities - ranging from "health fairs" to specific courses on nutrition, dental care, self-examination for cancer, awareness of exercise and good health practices. The benefits of these were hard to prove. Perhaps most important were the cost benefits. In a review of the appropriate data, the committee found significantly lower numbers of admissions and days in hospital in areas with the centres compared to those without. "We asked ourselves why, and it just made sense: the ready, round-the-clock availability of care, the number of things caught and dealt with before they progressed to the stage requiring hospitalization, and so on." Even considering start-up costs and costs of the variety of workers, the data showed net cost savings for health care in the four communities, according to Mitchell. He added these data were carefully vetted by appropriate directors of research and finance before they were included in his report to the minister. Professor Mitchell also was willing to identify weaknesses his committee found. A major one was the lack of
But in the rural areas the old style family doctor is alive and well. The successor to the horse-and-buggy physician who ministered to his patients with the few tools of his trade tucked into his little black bag, with a few nostrums and with kindly and reassuring"ums"and" ahs" can today call on sophisticated scientific support. With the advent of medical insurance he can count on getting paid in cash, rather than in apples or eggs, too; and his "parish" is small enough that he can get to know his patients as individuals - often as friends. Whether in Newfane or 50 km away across the border in Stevensville, the rewards, the benefits and the style of this old-fashioned personal doctorpatient relationship backed up with the new technology are virtually the same - despite the seemingly major difference between Canada's governmentrun health care system and the still largely free-enterprise approach in the United States. In both rural localities - separated as they are by an international border - doctor and patient reap the rewards of an unhurried art of medicine, a more personal brand of care that's as
satisfying as the 430 cm high corn for which Cliff Schrader held a local record for several years. In Canada, a few kilometres from Niagara Falls and rather off the track beaten by the millions of tourists who come to the Falls each year, is the small (population 800) town of Stevensville. Bob Twidle has practised medicine there for the past 15 years; the 114-year old house he lives in predates Confederation and it's always been occupied by a local doctor. Twidle, 44, grew up in the countryside of his native England, where his father was a clergyman. He set up practice in Saskatchewan but headed eastward again when the province introduced its comprehensive, government-sponsored health insurance plan in 1962, which resulted in the famous doctors' "strike" and a subsequent exodus of physicians. "I like farm and country people," says Dr. Twidle, "and open spaces; but I also like freedom." He and his USborn wife Ruth arrived in Stevensville with 26 cents. "It was a gamble," she recalls, "Initially I worked with Bob as nurse, bookkeeper, receptionist and secretary."
Dr. Oliver chats with neighbour Cliff Schrader
4
Dr. Twidle leaves Ins 114-year old home for a country style housecall
Prescribing information Ventolin® Indications: To relieve bronchospasm in: Bronchial asthma of all types. Chronic bronchitis, other chronic bronchopulmonary disorders in which bronchospasm is a complicating factor. Suggested dosage: Ventolin Inhaler: One or two inhalations repeated every four hours, If required. More than eight inhalations per day is not recommended. Ventolin Tablets: To be taken three or four times daily. Adults: 2 mg . 4 mg. The optimum single dose for most adult patients is 4 mg. With elderly patients or with patients who are unusually sensitive to beta.adrenergic stimulants. it Is advisable to Initiate treatment with 2 me. Children: 6 to 12 years: 2 mg Over 12 years: adult dosage Presentation: Ventolin Inhaler: A metered aerosol, delivering 100 mcg of salbutamol per inhalation. Each 15 ml canister provides at least 200 Inhalations. Ventolin Tablets 4 mo: Each tablet contains salbutamol sulphate 4.8 mg, equivalent to salbutamol 4.0 mg. Bottles of 100. Ventolin Tablets: 2 mg: Each tablet contains salbutamol sulphate 2.4 mg, equivalent to salbutanol 2.0 mg. B6ttles of 100. Contraindication Hypersensitivity to any of the ingredients and tachyarrhythmias Wsrni ngs: The safety of salbutamol in pregnancy has not been established. Care should be taken with patients suffering from myocardial insufficiency, arrhythmia, hypertension, diabetes mellitus, or thyrotoxicosis. Precautions: Use with caution in patients sensitive to sympathomimetic amines. Other beta-adregenic drugs, e.g. isoprenaline, should not be given concomitantly. Adverse reactions: Headache, dizziness, nausea, tremor and palpitation, nervousness and leg cramps may occur. The only reported side effect of significance with Ventolin Tablets is a fine tremor of skeletal muscle in some patients usually affecting the hands. The degree of tremor is dose related and caused by a direct action on skeletal muscle, not by CNS stimulation. This effect is common to all beta-adrenergic stimulants and usually stops with reduction of dosage. Symptoms end treatment of overdoasge: Overdosage may cause peripheral vasodilation and increased irritability of skeletal muscle, tachycardia. arrhythmia and hypertension. In case of overdose, gastric lavage should be performed. In order to antagonize the effect of salbutamol, the use of a beta-adrenergic blocking agent, such as propranolol, may be considered.
Beclovent® INDICATIONS Treatment of steroid-responsive bronchial asthma: (1) In patients who in the past have not been on steroida but the severity of their condition warranta such treatment. (21 In steroid-dependent patients to replace or reduce oral medication through gradual withdrawal of systemic steroids. CONTRAINDICATIONS Active or quiescent untreated pulmonary tuberculosis, or untreated fungal. bacterial and viral infections, and in children under six. Status asthmaticus, and In patients with moderate to severe bronchiectasis. WARNINGS in patients previously on high doses of systemic steroids. transfer to BECLOVENT Inhaler may cause withdrawal symptoms such as tiredness, aches and pains, and depression. in severe cases, acute adrenal Insufficiency may occur necessitating the temporary resumption of systemic steroids. The deveiopment of pharyngeal and laryngeal candidlasis Is cause of concern because the extent of its penetration of the respiratory tract is unknown. if candidiasis develops the treatment should be discontinued and appropriate antifungal therapy initiated. The incidence of candidiasis can generally be held to a minimum by having patients rinse their mouth with water after each inhalation. PRECAUTIONS 1. It is essential that patients be informed that BECLOVENT inhaler is a preventive agent, must be taken at regular intervals, and is not to be used during an asthmatic attack. 2. The replacement of a systemic steroid with BECLOVENT inhaler has so be gradual and carefully supervised by the physician, the guidelines ueder Dosage and Administration should be followed in each case. 3. Unnecessary administration of drugs during the first trimester of pregnancy is undesirab te. Corticosteroids may mask some signs of infection and new infections may appear. A decreased resistance to localized infection has been observed during corticosteroid therapy. During longterm therapy, pituitary-adrenal function and hematological status should be periodically assessed. 4. Fluorocarbon propellants may be hazardous If they are deliberately abused. inhalation of high concentrations of aerosol sprays has brought about cardiovascular toxic effects and even death, especially under conditions of hypoxia. However, evidence attests to the relative safety of aerosols when used properly and with adequate ventilation. 5. There is an enhanced effect of corticosteroids on patients with hypothyroidism and in those with cirrhosis. 6. Acesylsalicylic acid should be used cautiously in conjunction with corticosteroids in hypoprothrombinemia. 7. Patients should be advised to inform subsequent physicians of the prior use of corticosterolds. ADVERSE REACTIONS No major side-effects attributable to the use of recommended doses of BECLOVENT Inhaler have been reported. No systemic effects have been observed when the daily dose was below mg (twenty puffal. Above this dose, reduction of plasma cortisol. indicating adrenocortical suppression, may occur. Therapeutic doses may cause the appearance of Candida a hicans in the mouth and throat. The replacement of systemic steroids with BECLOVENT Inhaler may unmask symptoms of allergies which were previously suppressed by the systemic drug. Conditions such as allergic rhinitis and eczema may thus become apparent during BECLOVENT therapy after the withdrawal of systemic corticosteroids.
812 CMA JOURNAL/OCTOBER 8, 1977/VOL. 117
Bob Twidle has no wish now to change his place, even though, now government medicare insurance covers practically every Canadian and government reins on the health care system are held ever more tightly, many of his professional colleagues are eyeing practice opportunities in the US. "Being a general practitioner," he says, "is vastly interesting. It provides pleasure in versatility, and" - echoing Farmer Schrader on the American side of the Niagara River - "it means coping with what facilities you've got ... doing the best you can." Dr. Twidle sees the rewards of rural practice as enabling him to work more informally, more intimately with patients. Even though he believes that country people are more accepting of biological changes as natural phenomena - "because they see nature changing around them" - and that they're able to cope with minor injuries and illnesses more ably than city folks, the Stevensville GP doesn't have a leisurely practice: he sees 30-40 patients a day in the office he built a few years ago a couple of hundred metres away from his house, does an average of eight housecalls a week and serves as chief of
SYMPTOMS AND TREATMENT OF OVERDOSAGE Overdosage may cause systemic steroid effects such as adrenal suppression and hypercorticism. Decreasing the dose will abolish these side-effects. DOSAGE AND ADMINISTRATION The optimal dosage of BECLOVENT may vary widely and must be individually determined, but the total daily dose should not exceed mg of beclomethasone dipropionate (25 puffs). Adults: The usual dose is two inhalations (155 mcg) three to four times daily. if this dose is not sufficient, it can be doubled initially. As a maintenance dose, many patients do well on two inhaletions daily. Children: insufficient information Is available to warrant the safe use in children under six years of age. The average daily dose for children over six years of age is 6 mcg/kg of body weight. IMPORTANT: As a steroid aerosol, Becloveof Inhaler is for maintenance therapy. It is not intended to give immediate relief, and effectiveness depends both on regular use and proper technique of inhalation. Patients must be instructed to take the inhaletions at regular intervals and not, as with bronchodilator aerosols, when they feel a need for relief of symptoms. They should also be instructed in the correct method of use, which is to exhafe completely, then place the lips tightly around the mouthpiece. The aerosol should be actuated as the patient breathes in deeply and slowly. This ensures maximum penetration into the lungs, and the breath should be held as long as possible following each inhalation. The patient's attention should be drawn to the instruction Sheet, enclosed in each Beciovent pack. in the presence of excessive mucus secretion, the drug may fail to reach the bronchioles. Therefore, if an obvious response is not obtained after ten days, attempts should be made to remove the mucus with expectorants and/or with a abort course of systemic corticosteroid treatment. Careful attention must be given to patients previously treated for prolonged periods with systemic corticosteroids, when transferred to BECLOVENT. initially BECLOVENT and the systemic steroid must be given concomitantly while the dose of the latter is gradually decreased. The usual rate of with. drawal of the systemic corticoid is the equivalent of 2.5 mg of prednisone every four days if the patient is under close observation. if continuous supervision is not feasible, the withdrawal of the systemic steroid should be slower, approximately 2.5 mg of prednisone (or equivalent) every ten days. if withdrawal symptoms appear, the previous dose of the systemic drug should be resumed for a week before further decrease is attempted. There are some patients who cannot completely discontinue the oral corticosteroid. in these cases, a minimum maintenance dose should be given in addition to BECLOVENT inhaler. SUPPLIED BECLOVENT inhaler is a metered-dose aerosol delivering SO micrograms of beciomethasone dipropionate with each depression of the valve. There are two hundred doses in a container. Official product monograph on request.
Allen & Hanburys
A Glaxo Canada Ltd. Company Toronto, Canada
EE.
staff at the hospital in Fort Erie a town of 23 000 just across the river from Buffalo, NY. But in either country, informality is the keynote of rural doctor-patient relationships, providing the reassurance and trust and confidence upon which so much of successful health care is built. As Bob Twidle puts it: "I know most of my patients by their first names; they call me Doc". All of that might sound like a far cry from the wonders of modern scientific medicine, from the crisp buttondown efficiency of urban and suburban family practice, but the close bond that exists between rural practitioner and patient isn't merely a cosy alternative to more "sophisticated" health care - it's an integral part of the therapeutic process. Not only that, but today's rural GP is more than an amiable and comforting presence: because he's not surrounded by specialists and superspecialists, he's likely to be practising more comprehensively than his city counterpart - doing surgery. anesthesia, putting casts on fractures. And since good roads and motor vehicles have supplanted horses and buggies, he can refer to urban hospitals patients that he needs more specialized help with. Moreover, there's no place for complacency, for over-reliance on "bedside manner": to retain membership in either the College of Family Physicians of Canada or the American Academy of Family Physicians, the general practitioner - whatever his location must show evidence of keeping up-todate with advances in medical knowledge and techniques. The whole idea of "family" practice is much more of a reality in the rural community than it is elsewhere: the country doctor can relate health problems from one member of a family to another and offer counselling and advice, based on close awareness of the overall picture, that may help to head off such problems before they become more serious. Such requests for advice, says Dr. Twidle's secretary-nurse-receptionist Mrs. Faye Silvestro, may be preceded by a proprietary "Is Bob in?" On one such occasion recently Ross McLean dropped in to ask whether his 87-year-old mother could get some home care. Sitting beside the concerned son (because he feels that sitting behind his office desk creates a barrier between doctor and patient) Doc Twidle explained about available home care services, said that these would bridge a gap between hospitalization and independence and saw no need to institutionalize the woman just because she was old. "But I'll come and see her," he said.
Bob Twidle knows most of his patients by their first names "I do a lot of this sort of thing on Saturday mornings," Bob Twidle told me, "bringing in relatives to work out a policy of management... it can be done so much better in person than on the phone... The Twidle family itself consists of wife Ruth, who still works as a nurse; two sons, 24 and 18, and daughter Naomi, 15. Ruth and Naomi agree that the country doctor's family becomes a part of his practice, with the locals feeling free to drop in at the house at any time the office is closed and to talk with any of the doctor's family about health. But the patients are very supportive, says Ruth: "One time I was ill and a patient forgot why she'd turned up, saying to Bob: 'You take care of your wife; I'll look after the kids'." Like Twidle, Dr. Harry Oliver in Newfane came into general practice virtually broke, has three grown children, and sings the praises of the rural practice he's conducted since 1958 in his town of 2000. "When you're an integral part of a small community," he says, "there's a closeness of association with the patient that's lacking in the city or the suburbs." Dr. Oliver, whose office is a con-
verted bungalow 1 km from the local hospital, is a 54-year-old graduate of the University of Buffalo. It's not just the scope of this type of practice, he says, noting that he does obstetrical deliveries, minor surgery and orthopedics. "But the local people identify with you. You're one of them; they see you every day in the store, at the gas station, playing tennis.. This means that health care in the predominantly farming community of Newfane is more than an office transaction. "I often eat breakfast in a local restaurant," says Harry Oliver, "and by the time I've finished I've generally given out a few prescriptions or done some counselling." As we drove from Oliver's office to his relatively modest house bordering Cliff Schrader's farm, the doctor stopped to chat with Bob Noon, a 59year-old tool designer at the local subsidiary of General Motors. Noon, who's planning to retire shortly, suffered a heart attack a couple of years ago. His routine 12-15 km walk, he says, "takes me past the doc's house each day and we've become good friends." Later, in his office again, Harry talked on a first-name basis with cancer patient Genevieve Murphy, an articulate and charming woman who is following her course of treatment with
GMA JOURNAL/OCTOBER 8, 1977/VOL. 117 813
a detached interest and an indominable spirit. Thanked for allowing us to photograph her in Dr. Oliver's office, she said: . do anything for him... One is struck less by the differences in rural practice in Canada and the United States than by the similarities. The scope, the dedication, the personal care, the satisfactions to patient and doctor alike are identical in both countries. The housecalls, the 30-40 consultations a day, the enthusiasm for keeping up-to-date with medical knowledge, the access to a nearby hospital... practically carbon copies one of the other. There are, of course, contrasts: on the Canadian side Bob Twidle works,
in essence, for the government.., his fees reimbursed by the provincial Ministry of Health. Harry Oliver deals on a cash basis except in cases for which medicare, medicaid, Blue Cross or other insurance arrangements apply. Twidle has an office staff of one; Oliver a payroll of five; the American doctor pays $2000 a year in malpractice insurance while his colleague in Canada pays about 10% of that - a reflection of the fact that there's one malpractice suit a year per 130 MDs in Canada, and one per 46 in the US. But these are relatively minor differences, particularly when you consider, Dr. Oliver points out, that "American medical care is becoming
increasingly government-regulated, and that President Carter is moving toward a universal health insurance plan." What is perhaps a little odd is that these rural practitioners on either side of the "longest undefended border in the world" don't seem to get together more often to share their unique experience instead of heading for post graduate courses in the nearest big city on their own side. But that's a small quibble. As long as rural doctors like Bob Twidle and Harry Oliver continue to dispense their personal kind of health care and to do their best for their patients, country life will be the richer for having them around. U
BC minister agrees to continue health centres GLENNIS ZILM British Columbia Health Minister centre concept but also are doing imRobert McClelland is "not convinced portant jobs. the centres are the only way to do it." "We are not convinced the centres - but he has agreed to continue opera- were the only way to do it," he said. tion of the province's four community His department will be looking at alhealth centres for at least another 3 ternatives and modifications that would bring about closer liaison between years. The provincial government agreed to members of the health team, which is continue the four centres, which com- the third main recommendation of the bine health and social services, includ- committee. ing salaried medical services, under one This recommendation called for the roof, following an evaluation and re- government to place nurse practitionport by a six-member committee ers, social workers and mental health headed by Professor Vance Mitchell workers as liaison people in principal of the faculty of commerce, University facilities where fee-for-service physiof British Columbia. The report rec- cians are working, Professor Mitchell ommended the four centres (at Gran- said. One of the biggest problems idenisle, Houston, James Bay and Queen tified by his committee related to difCharlotte Islands) be continued and ficulties doctors have in reaching out evaluated again at the end of 5 years to other workers in a "heterogeneous total operation, which would be about system of services 1980. "It is virtually impossible to refer It also recommended that, subject patients across this system of services. to some special considerations on loca- he said. Care is fragmented because tion of lack of fee-for-service doctors, zones or areas for public health servsimilar centres be opened in other ices, social workers, police, family rural, isolated areas. The government, courts, laboratories, x-rays, even hoshowever, is not prepared to go that pitals seldom coincide, especially in far at present and has said it has no large urban areas. In smaller areas, the ancillary services may not exist. plans for more. Mitchell identified this closer liaison Report premature between health and other workers in Health Minister McClelland told the centres as one of the biggest CMAJ the report, carried out after the strengths his committee found. He said centres were in operation for only doctors often are criticized for being about 2 years, was perhaps a little a big stumbling block to team care, but premature in deciding on the benefits. this is just not so when all services The main value of the centres was are readily and easily available. an upgrading of health care in the "The greatest strength is the teamcommunities, he said, but he added work that we saw that had developed there were perhaps other ways of within these centres." achieving this. He noted the REACH The other big strengths were incentre and the Downtown East Side volvement of local citizens through Centre, both in Vancouver, are not elected boards that identified medical modelled on the community health and social needs in the community and 814 CMA JOURNAL/OCTOBER 8, 1977/VOL. 117
the involvement of all citizens in the area when these health needs were so identified. For example, he said, a group program was organized by a youth worker in one centre after complaints about vandalism in the area. RCMP statistics from before and after the group program's introduction proved there was a reduction in vandalism directly related to the centre's programs. Difficult to prove benefits In each community, physicians and other team members organized preventive care activities - ranging from "health fairs" to specific courses on nutrition, dental care, self-examination for cancer, awareness of exercise and good health practices. The benefits of these were hard to prove. Perhaps most important were the cost benefits. In a review of the appropriate data, the committee found significantly lower numbers of admissions and days in hospital in areas with the centres compared to those without. "We asked ourselves why, and it just made sense: the ready, round-the-clock availability of care, the number of things caught and dealt with before they progressed to the stage requiring hospitalization, and so on." Even considering start-up costs and costs of the variety of workers, the data showed net cost savings for health care in the four communities, according to Mitchell. He added these data were carefully vetted by appropriate directors of research and finance before they were included in his report to the minister. Professor Mitchell also was willing to identify weaknesses his committee found. A major one was the lack of
