At the 2000 International AIDS Conference, South African president Thabo Mbeki sparked considerable controversy when he questioned the link between HIV and AIDS. His health minister, Manto Tshabalala-Msimang, gained infamy for downplaying the role of antiretroviral drugs and for promoting the idea that a diet of garlic, olive oil, lemon peel, and beetroot effectively combat HIV. It wasn’t until 2004 that South Africa began to offer antiretroviral drugs to HIV patients. In a country with the highest number of HIV patients in the world, such a stance by political leaders seems unbelievable.
We often take for granted that our elected officials have the wisdom to make the right decisions, especially ones where the evidence is clear and the public health issues glaringly obvious. But recent developments in BC have made such comforting assumptions less tenable.
In late December of 2008 the government announced its intention to substantially increase the scopes of practice of a number of health professions. This followed on the heels of a push to allow pharmacists greater authority regarding prescription renewals and therapeutic substitution. In this instance, it became clear that issues of quality of diagnostic processes, adequacy of training, patient safety and privacy, conflict of interest, duplication of service, and professional liability had not been at the forefront of government thinking. After discussions with BCMA staff, the government’s proposals were adapted to the extent that the BCMA ultimately supported the changes when announced.
It was therefore all the more surprising to learn in late December of an even greater series of proposals for scope expansion of other groups—proposals that went well beyond the limits of reasonable consideration and that appeared to have been prepared without a sober examination of the issues listed above.
A case in point is the changes in scope proposed for naturopaths. Naturopathy has its roots in 19th century European and North American spa and herbal remedy belief systems and is composed of a varying mix of different alternative medicine treatments and diagnostic modalities. The core of most naturopathic training programs is composed of botanical remedies, hydrotherapy, homeopathy, traditional Chinese medicine, and so-called energy healing. Many variants exist. Despite claims that naturopathy is science-based, the overwhelming majority of naturopathic diagnostic and treatment regimes fall far outside the realm of proven medical options. Incredibly, national naturopathic organizations continue to question the effectiveness of vaccines (and, akin to the South African health minister, suggest that dietary methods are effective ways to prevent epidemic diseases). Most practitioners are opposed to routine childhood immunizations.
What then would propel the stewards of a health care system, in a modern society where scientific research and information is abundantly available, to propose that groups acting contrary to the best available evidence should be allowed to:
• Prescribe most medications (except narcotics and certain other groups of drugs).
• Order laboratory tests, X-rays, and ultrasounds (this was put on hold, but was in the original regulation).
• Perform minor surgery.
The answer, of course, is politics. But the gains being sought will be paid for by patients who do not receive timely medical care for serious issues, or by children who may not receive basic immunizations.
It is time for the BCMA and the CMA to take a serious look at these issues. Changes in scope of practice are not new, and in some cases are entirely appropriate as new services, programs, and technologies become available. These should be done where the case for the public benefit is clear, proper training and education is evident, and a sensible economic rationale is brought forward.
Provinces are clearly looking to changes in scope of practice as one means of addressing health human resource shortages. While the BCMA has a very capable infrastructure for responding to such challenges, not all provinces are as fortunate. We owe it to the public and to our colleagues in other provinces to share information and experience about current or potential changes to the health care system.
We need to work with other provinces and the CMA to ensure that physicians lead the way in setting the standards for high-quality medical care. Our efforts should include:
• Developing a rapid, coordinated response to new developments—including national criteria against which to measure the merits of proposed changes to scope.
• Agreeing on what type of changes are most helpful (e.g., bringing in physician assistants).
• Advocating, with both the public and with government, on ways to develop the health care system.
• Keeping the focus on quality, particularly the idea that new investments should go to areas of proven benefit.
The BCMA has already begun building on these ideas. We have garnered support from colleagues in the western provinces and we plan to propose further action at the CMA General Council in August.
By keeping the focus on quality and patient safety, and by building on our expertise and knowledge of the health care arena, physicians can continue to lead the medical system and ensure that patients receive the guidance and care they need.
—Lloyd Oppel, MD
Chair, Allied Health Committee
1. Journ-AIDS. HIV/AIDS: Key people. www.journaids.org/keypeople.php#mbeki (accessed 1 May 2009).
2. S. Africa’s health minister must resign, AIDS conference told. CBC News. 17 August 2006. www.cbc.ca/world/story/2006/08/17/aids-south-africa-resign.html (accessed 1 May 2009).
3. Canadian Association of Naturopathic Doctors. Position Papers. www.cand.ca/index.php?id=papers&L=0 (accessed 29 April 2009).
4. Wilson K, Mills E, Boon H, et al. A survey of attitudes towards paediatric vaccinations amongst Canadian naturopathic students. Vaccine 2004;22:329-334. PubMed Abstract
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