Re: Mercury and differential fees

There are two issues arising from the BCMJ of July/August 2001 which require further comment.

Dr Sehmer refers to “Dubious Mercury Poisoning Results” (BCMJ 2001; 43(6):320). If a chelating agent had been given prior to a urine sample being obtained, and the resulting heavy metals were found to be “20 to 30 times above baseline” (and Dr Sehmer does not define this entity), from where does Dr Sehmer imagine such heavy metals, including mercury to have come—out of thin air?

He also seems to have no idea of the problems which exist in measuring mercury. Because of the volatility of mercury at body temperatures, when the urine is collected the vast majority of it has evaporated before the patient has a chance to decant the urine into the container. Then, if there is any mercury left, it attaches itself to the very plastic of the container. This could be prevented by using glass containers, but the laboratories refuse to supply glass containers because they are so liable to breakage on transport. If any mercury is detectable by the laboratory, it does mean that the patient is seriously overloaded with the metal.

Albeit still controversial, the best method of assessing the state of heavy metals remains hair analysis. The snags and inaccuracies are well described. Because mercury is so tightly bonded to sulphydryl groups, even here there is a tendency to underestimate the total body load of the metal.

The use of mercury amalgams, if introduced now, could never pass the licensing requirements for safety. There has never been any scientific evidence of their harmlessness, merely dogmatic assertions.

Dr Kenefick, in the same issue, makes a well-justified plea for a differential in fees between walk-in clinic practice and full-service practice.

Paradoxically this contrasts with the paper by Verhulst and his colleagues upon which basis the Patterns of Practice Committee reveals their new tool to harass the conscientious practising family physicians of BC. Nowhere in their account do they show any way in which they distinguish between urban and rural FPs, nor do they demonstrate in any way how they propose to distinguish between full-service FPs (those most likely to draw the attention of the Patterns of Practice Committee because they try to provide better service for their patients than those in walk-in clinics). I am perfectly aware that this was not the intention of the Verhulst paper, but I see no point in their wasting their time, and the hard-earned money of the doctors of BC, with such a statistical exercise when the priority is to differentiate between the services provided by urban and rural FPs, and full-service versus walk-in FPs.

An additional factor rendering the exercise pointless is the wide variety of conditions seen by FPs. To expect us to look up the ICD-9 codes for every one of these conditions is to impose an unacceptable burden on all FPs. If Verhulst and colleagues think that they can rely on the diagnostic codes provided then they are naive indeed, their protestations to the contrary.

The time for the BCMA to be involved with the anti-good doctor policies of the Patterns of Practice Committee has come to an end.

—Erik T. Paterson, MD 
Creston