- © 2008 Canadian Medical Association
Policing cosmetic surgery
General practitioners in Ontario will be prohibited from declaring that they are “cosmetic surgeons” or advertising that they have such capabilities, under new regulations adopted by the College of Physicians and Surgeons of Ontario.
In the wake of extended controversy over the lack of integrity in the regulation and licensing of cosmetic and aesthetic surgery (CMAJ 2008;178[3]:274-5), the College adopted new regulatory amendments on Apr. 10, 2008, that will require “physicians to be clear and accurate about their credentials and training in their advertising and other communications with patients.”
Physicians will be prohibited from implying specialty or subspecialty titles, such as “surgeon,” unless they are formally certified to use such designations by the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada. Nor will they be allowed to advertise themselves as such, a move which will prevent general practitioners to declare, for example, that they are “cosmetic surgeons,” a category which does not formally exist for most licensing and accreditation bodies.
The College stressed, though, that the intent of the regulation “is not to restrict practice; it restricts how doctors refer to themselves.”
In a related change, the College will require any physician who proposes to change or widen the scope of his practice must ensure that he or she has “the skills, training and experience necessary to practice in the area.”
Changing scope of practice is defined very broadly as a case in which a physician “significantly” alters the “procedures performed, the treatments provided, and the practice environment.”
Assessment of the adequacy of additional training required by a physician to change scope of practice will be done on an individual basis.
Supervised injection site gets lukewarm review
With the June 30th deadline looming on the Vancouver-based InSite safe injection site's exemption from the federal Controlled Drugs and Substances Act, Health Minister Tony Clement has released the final report of a government commissioned study to determine whether such facilities help lower drug use or yield health benefits.
Its findings?
A little bit of something for everyone. Supporters of the notion will be encouraged by the claim that the sites may save lives, while opponents will point to the lack of evidence about their efficacy in preventing infection or reducing addiction levels.
InSite “shows a positive/cost benefit ratio,” with every 97 cents invested yielding $2.90 in benefits, says the final report of the Expert Advisory Committee on Supervised Injection Site Research, although it also notes that the mathematical model used to derive that ratio may be flawed because it uses unsubstantiated estimates of the frequency of needle sharing between HIV positive and HIV negative injection drug users.
Based on information that InSite staff intervened in 336 overdose events between March 2004 and April 2005 and that no overdose actually occurred at the facility, the report also states that InSite “saves about 1 death by drug overdose each year.” But it warns that such a conclusion is “based on assumptions that may not be valid.”
The report also states there's no evidence that InSite — which since 2003 has provided intravenous drug users with clean needles to inject heroin and cocaine under supervision — “influences rates of drug use in the community or increase relapse rates among injection drug users.” Nor is there any compelling evidence that such facilities affect rates of blood-born diseases or injection related infections. The report states InSite made over 4000 referrals during a 2-year period and although there is no data on uptake, it may have contributed to increased use of detoxification services and increased engagement in treatment.
Authors found that between 2.6%–4.9% of all injections in Vancouver's troubled, downtown eastside neighbourhood occurred at InSite, which has an annual operating budget of $3 million. The average cost per visit was $14, with the 500 most frequent users visiting 400 times (for an average cost per person of $13 100). For all visitors since the facility opened, the average cost per person is $1380.
Over 8000 people visited InSite through August 2007, but 1506 of them account for 86% of all visits. A pair of surveys of 1000 facility users indicated that 51% inject heroin, while 87% are infected with the Hepatitis C virus and 17% with HIV.
A survey of users indicated that they believe the site mediates overdose risks. “In particular the SIS [Safe Injection Site] addresses many of the unique contextual risks associated with injection in public spaces, including the need to rush injections due to fear of arrest.”
The report, available at www.hc-sc.gc.ca, is now under review by Clement, who has in the past expressed doubts about the efficacy of safe injection sites as a means of preventing drug addiction (CMAJ 2007;177[6]:559).
While Clement studies the report and his options, a pair of InSite-related lawsuits are now before the British Columbia Supreme Court. One challenges the federal government's jurisdiction over a provincially funded facility, while the other charges that closure of the facility would violate a Canadian Charter of Rights and Freedoms right to “security of the person.” British Columbia Health Minister George Abbott has repeatedly indicated that the province supports the site and would like it to remain open.
Preventing another forensic debacle
A structural overhaul of the Office of the Chief Coroner of Ontario and the creation of a Centre for Forensic Medicine and Science to improve training and research in forensic pathology lie at the core of systemic changes the office says are required to prevent debacles like the Charles Smith autopsy scandal.
The changes are among a raft of recommendations urged by the Office in its submission to the Goudge Commission, a public inquiry struck to review the system after an international panel found that mistakes had been made in 20 cases overseen by Smith that had led to parents or caregivers being wrongly charged or convicted of killing children (CMAJ 2007;177[3]:240-1).
The coroner's office wants its forensic branch hived off and established as the Ontario Forensic Pathology Service, responsible for post-mortem examinations (roughly 7000 per year). The office argues that the new service should be given an adequate, and separate, budget to perform its duties; new facilities; higher salaries for forensic pathologists; and a measure of external oversight and accountability in the form of an independent Death Investigation Advisory Council. The new service should also be made responsible for recruiting new staff to address a current personnel shortfall and for developing “minimal standards for all post mortem examinations in Ontario.”
It should also be charged with developing a strategic plan that includes a code of conduct, conflict-of-interest guidelines and a “rededication to seeking the truth, using the scientific method, and developing evidence-based practice, where possible.”
To achieve such a wide-ranging overhaul, the chief coroner's office also recommended that its proposed Centre for Forensic Medicine and Science be established at the University of Toronto and be given a projected start-up budget of $510 700 per year, along with all infrastructure funds required to create and equip such an institution. Its duties should include the establishment of postgraduate training in “Death Investigation for Physicians.”
Ontario Court of Appeal Judge Stephen Goudge's final report on the year-long public inquiry is currently slated to be completed by Sept. 30, 2008.