vol 10 no 1 le spécialiste, the fmsq magazine vol. 10 no. 1 – march 2008. special issue...

8/18/2019 Vol 10 no 1 Le Spécialiste, The FMSQ Magazine Vol. 10 no. 1 – March 2008. Special issue featuring a "Dossier" on …

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LESPÉCIALISTE

THE FMSQMAGAZINE

Vol. 10 no. 1 – March 2008

• QUERULOUSNESS AND VEXATIOUS BEHAVIORS

• DANGEROUS BEHAVIOR

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Summary

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EDITORIAL COMMITTEEDr. Bernard Bissonnette

Dr. Maurice Boudreault

Dr. Daniel Doyle

Me Sylvain BellavanceNicole Pelletier, APR, Delegated Publisher

Patricia Kéroack, Communication Consultant

and Responsible for publications

REVISION Angèle L’Heureux

GRAPHIC DESIGNERDominic Armand

TRANSLATION Anne Trindall

PRINTINGImpart Litho

PUBLICITY

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PUBLICATIONS MAILMailing Indicia 40063082

LEGAL DEPOSIT1st quarter 2008

Bibliothèque nationale du Québec

ISSN 1206-2081

Le Spécialiste is published 4 times per year by the Fédération des

médecins spécialistes du Québec :

2, Complexe Desjardins, porte 3000, C.P. 216, succ. Desjardins,Montréal (Québec) H5B 1G8

Tel.: 514-350-5000

Fax: 514-350-5175

Internet: www.fmsq.org

E-Mail: [email protected]

All pharmaceutical product advertisement's have been approved

by the Pharmaceutical Advertising Advisory Board (PAAB).

The Fédération des médecins spécialistes du Québec represents

the following specialties: Allergy and Clinical Immunology,

Anesthesiology, Cardiac Surgery, Cardiology, Community Health,

Dermatology, Diagnostic Radiology, Emergency Medicine,

Endocrinology, Gastroenterology, General Surgery, Geriatrics,

Hematology and Medical Oncology, Internal Medicine, Medical

Biochemistry, Medical Genetics, Medical Microbiology and

Infectious Diseases, Nephrology, Neurology, Neurology, Nuclear

Medicine, Obstetrics and Gynecology, Ophthalmology,

Orthopedics, Otorhinolaryngology, Pathology, Pediatrics, Physiatry,

Plastic Surgery, Pneumology, Psychiatry, Radiation Oncology,Rheumatology and Urology.

CCAB audits the medical specialists and residents database

(10,081 copies audited for Dec. 2007) The FMSQ also distributes

around 1,000 copies to Researchers and Professors of the 4 Medical

Faculties in Quebec, as well as managers and leaders of the Québec

healthcare system.

The authors of signed articles are sole responsible forthe opinions expressed therein.

Cover Page Information

Artist Manon Otis produced for the FMSQ on demand, the

painting Congrès… des spécialistes which figures in part in

the bottom of the page. L E S P É C I A L I S T E · V O L . 1 0 n o 1 · M a r c h 2 0 0 8 5

LESPÉCIALISTETHE FMSQMAGAZINE

9 Current Affairs

Interview with Dr. Michel Lallier, Vice President

14 Legal Issues

16 Did You Know That …

Le Spécialiste: 10 Full Years!

18 In the News

33 Great Names in Quebec Medicine

Dr. Yves Fradet

34 Continuing Professional Development

36 Groupe Fonds des professionnels

37 Sogemec assurances

39 In the Medical World

Weight Gain with Antipsychotics: Can it be avoided?

41 Mot du président

Le rapport Castonguay : un guide de survie

11 Current Affairs

Business Relations in Obstetrics/Gynecology

23 Extreme BehaviorDOSSIER

7 Word from the President

The Castonguay Report: a Survival Guide

32 Members Services

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L E S P É C I A L I S T E · V O L . 1 0 n o 1 · M a r c h 2 0 0 8 7

he mandate of the group chaired by Mr. Castonguaywas clear and straightforward: to address theproblem of health financing. That is what it did, notonly with regard to sources of income, but also theiruse. This was perfectly legitimate, because what isthe point of talking about income if you do not make

sure it is properly managed?

We believe that Mr. Castonguay’s diagnosis is correct. Basically, hefound that the collective wealth of Quebec cannot keep pace withthe growth of government health expenditures and the result will be

a yearly deficit of $7 billion in 2017 if nothing is done. To correct thesituation, he suggested two sets of measures: one relating tosources of income, the other to their management.

Let us first look at the increase in health costs. What really can beadded? Of all the areas for which government is responsible, hereor elsewhere, health is probably the only field where the economicforecasts of government and university experts and analysts, andthose of the economic world in general, have come to pass. Theytold us health would account for 25%, then 33% and shortly 50%of the government budget, and they were right. There is certainlyno reason to believe that current forecasts will not prove true. Theforecasts have always called for decisions to be made to controlexpenditures, but the most that can be said is that this was veryrarely done – which begs the question of when will action be taken?When the health budget represents 55% of government spending– or 60%, even 70%? In fact, when the population of Quebec finallystops burying its head in the sand, it will have to decide where thisextra money is going to come from! That is the subject of theCastonguay report.

As far as financing is concerned, the question is not whether thesolutions put forward are ideal, but whether they deliver the goods.We believe that they do. And, if so, will their impact mean that theywill have to be swept aside? We do not think so. On the contrary,we note that Mr. Castonguay has been very careful to lay out all theguidelines needed so that such problems can be avoided, and the

report shows a great deal of moderation in this regard. It is, in fact,a survival guide for the public system if we accept the fact that costscan only continue to rise and ultimately exceed the government’sability to pay. The mixed approach (provided that the public network is protected) bears no problem; nor does using a deductible which,as proposed by Mr. Castonguay, is still a very progressive step; areturn to a higher sales tax, which we have mentioned several timesin the past; and also the introduction of insurance.

The report’s approach is also innovative as far as management isconcerned. Who can possibly argue with productivity andefficiency? Or, alternatively, an improvement in the system’s way of

doing things? As a background, the uneasiness expressed (or not)by most observers (even the Minister), who have not noted anysufficiently tangible change even though no less than $6 billion hasbeen added to health expenditures since 2000. But neither thepublic nor commentators realize that this amount has, to a greatextent, been used to renovate a system that has been impoverishedfor too long. As an example, nearly $1 billion has been spent duringthis period on upgrading specialized medical equipment, $2.3 billionhas been used to absorb hospital deficits, and how much has beenspent on revamping decrepit facilities? It goes without saying thatupgrading is like renovating. One room is added at best, but that

does not mean the house is new because a portion of it now meetscurrent standards. Not considering any tangible gains in terms of accessibility would then be normal.

The dangers of the report lie in the political arena, particularly if thepolicy is to move in the direction of only doing what is easy orpolitically advantageous – i.e., everything that concerns manag-ement and productivity. That is the danger. Remember whathappened to the Rochon report when only half of it was put intoeffect. The next 15 years were disastrous. Yet Mr. Castonguay’sreport is clear. Whatever the scenario. Other sources of financingmust be found. We find it extraordinarily simplistic to think that onlynew management methods, a changeover to “purchasing services”,

or increased productivity will halt the rise in costs. The reasons areboth simple and obvious. For some years now, the government hashad measures in place that enable it to obtain goods for the lowestcost possible, and this particularly applies to medical supplies. It isalso the case for medications and specialized medical equipment.Probably, no financial benefit can be gleaned from this area. Undersuch circumstances, do we really think that we can achieve a nearly10% gain ($4 billion) in productivity and “improved” management?Productivity means producing a larger number of services, each ata lower unit cost. Since the related costs (to those services) arealready low, does this mean that the next round of gains will be atthe expense of health professionals, who include physicians? Thegovernment could move in this direction.

The Castonguay report gives a measured statement of the situationand suggests avenues that we believe to be viable and those includetogether , and not separately, management and financing measures.as a result it should be clearly understood that, although we supportthe principles underlying healthy management and productivity, wewill never agree to physicians’ professional independence beingcalled into question nor to them being penalized because of aninability to make appropriate and timely decisions when we finallycome up against the unavoidable and clearly signposted bankruptcyof Quebec’s health budget.

L S

DR. GAÉTAN BARRETTEWORD FROM THE PRESIDENT

The Castonguay Report: a Survival Guide

T


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Dr. Lallier, what topics are currently under

consideration at the Federation?

Life at the Federation has been very full over the past few months, and we’re not finished yet. A great deal of progress has been made on some matters and others should be concluded shortly. Adjusted average income(AAI), a very important subject for the FMSQ, has beentaking much of our time during recent months. The

Federation has carried out a thorough review of the mathematical model developed some ten years ago. Wecan safely say that this matter has caused strong feelings

and required a great amount of work. And that is not all.Since the Agreement was signed last fall, many other

points have had to be discussed; the FMSQ and the government have had to find common ground for agreement on business relations, a major issue. Intensivediscussions have been held. Memoranda of Understanding

have already been signed and… and other agreements should be signed very soon, to the great satisfaction of medical specialists, of course!

On the subject of such Memoranda, is the

payment of the Department Head Group one of

them?

Yes, and this has finally been settled. The FMSQ and MSSS have recently initialed a Memorandum of Understandingthat members of the Department Head Group should be

properly compensated for this administrative task.

It should be remembered that the specialized medicinedepartment head regional groups were introduced as a

result of action by the FMSQ. The objective was to have a regional equivalent of the general medicine groups in order to improve the organization of specialized care.Establishment of the Department Head Groups led to the

abolition of the regional medical commissions (CMR).

The Department Head Group executive committee is today composed of eight to ten department heads, three of whom

are elected by medical specialists with the remaining five to seven being co-opted (i.e., appointed by the three who are

elected). The FMSQ has assisted the individual regional groups since the beginning, helping them become properly

organized and call the meetings necessary for the election and appointment of the executive committee. The Federation

then started to tackle the question of payment for Department Head Group members’ activities.

Do you have more details

on this compensation?

As far as the FMSQ was concerned from the outset, it was out of the question for executive com-

mittee members to receive the general hourly rate given in theMaster Agreement – i.e., $80/hour.

As it was a new activity – and keeping in mind the Federation’s goal of significantly increasing medical specialists’ clinical and medico-administrative remuneration – it was important to negotiate a more competitive level of compensation. The negotiationswere long and hard and it is thanks to the Federation’s

insistence and perseverance that we can report today that our objectives have been reached (Note : see page 10 for details). This is an important step forward in recognizingthe expertise of medical specialists, and we intend tocontinue negotiations along these lines for all other medico-

administrative activities.

Has the same degree of progress been made

on other matters?

Substantial progress has also been made on two other major dossiers: remuneration for teaching activities and remuneration for research activities. Discussions onuniversity remuneration are proceeding swiftly. No

memorandum or letter of agreement has yet been signed, but we can say that we have really advanced on this subject. Everything is still under discussion, but I can say that giant strides have been made.

What exactly is involved?

On the subject of university remuneration, the FMSQ is requesting that this task be recognized and the appropriatefees paid. It is a clearly established fact, it is the funda-

mental principle of remuneration: clinical supervision of both clerks and residents must therefore… rather, will therefore be covered by a fee.

The FMSQ has met residents and mentors for each medical specialty in order to list all forms of teaching activity, supervision and hands-on training. A comparative analysis

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L E S P É C I A L I S T E · V O L . 1 0 n o 1 · M a r c h 2 0 0 8 9

The FMSQ in actionDr. Michel Lallier, Vice President of the FMSQ, between two meetings and asked him to give us

an overview of topics that have been dealt with and those now in hand.

CURRENT AFFAIRSInterview and report by PATRICIA KÉROACK, COMMUNICATIONS CONSULTANT


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has been made establishing a typical profile. We hope that this analysis will lead to a denominator being put in place todetermine the fees applicable. Keep in mind that an overall

envelope of $65 million has been allocated for university remuneration. We will be very careful to ensure that thosewho supervise training will be properly paid for this task. Just

how this will be done will be known in the near future.

Dr. Lallier, are you going to proceed in the

same way with regard to paying for activities

in teaching units?

We know that the work carried out in a teaching unit (TU) is more complex. This complexity must be recognized.

What are the Federation’s plans for uncoded

courses?

We are actively working on this subject. At present, payment is generally made in two ways: fees-for-serviceor the mixed method. Those paid under the flat mixed rate

already receive recognition for the courses they give. Those paid by fees-for-service are not paid for actual teaching and therefore suffer a clear loss. The goal here is for everyone to be paid for the teaching they give.

Payment for teaching activities also includes other aspects.For instance, we are studying the differentiation between

residents and clerks. There could be a fee schedule that could be modulated based on the student’s level. But a

great deal of work still needs to be done on this subject,

which is still in the discussion stage.

What about compensation for research

activities?

We must upgrade the payment of research activitiescarried out by medical specialists in Quebec. The FMSQ

stressed this point with regard to the last Agreement and obtained an additional investment of up to $20M for such

activities. Discussions with the Fonds de la recherche en santé du Québec have already allowed us to find variousways of increasing the remuneration received by research

investigators. The FMSQ has reopened discussions withthe MSSS on this subject and we intend to finalize the

terms and conditions without delay.

Turning to conditions of practice and

business relations …

The Committee on Conditions of Practice is now a permanent fixture at the FMSQ. The Business RelationsCommittee reports directly to the Negotiating Committeewith subcommittees for the 24 business relation measures

agreed upon with the government during the most recen round of negotiations.

The Committee on Conditions of Practice will work

together with the other committees on such matters as

waiting lists, data bank access and the multidisciplinary

teams’ project. A musculoskeletal multidisciplinary team

project is now under way in Arthabaska. The UETMIS(*) is

evaluating this dossier to see whether it can be extended

throughout Quebec.

Specialized medicine groups (SMG – GMS) is a joint projecof the Committees on Conditions of Practice and BusinesRelations. Two projects are being developed by thOB/GYN and pediatricians’ associations respectively, andothers are under way.

I’ve been hearing about specialist responders …

That is a Business Relations dossier. The government has appeared open and willing to review and redefine the psychiatrist responder project. The FMSQ hopes that theconcept of a psychiatrist responder, as defined by the

Association des psychiatres and which both the Associatio and the FMSQ requested the government to review …. thathe concept of a medical specialist responder (MSR) can be

applied to all specialists wishing to undertake this type owork. A number of associations are ready to embark on thi

project, including geriatricians, endocrinologists, obstetricians-gynecologists and pediatricians.

Unfortunately, we don’t have any more time and I would have liked to talk to you about other projects and topics like interdisciplinary educational days, visits to operating rooms and the Partners’ Committee which is tackling thequestion of sterilization.

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10 L E S P É C I A L I S T E · V O L . 1 0 n o 1 · M a r c h 2 0 0 8

Members: The hourly rate is $80 to $84 for the period January 1- August 31, 2007. The hourly rate will gradually and substantiallyincrease to $120 as of September 1, 2007; $135 as of April 2008and $150 per hour as of April 1, 2009. The remuneration isretroactive to January 1, 2007.

Chair: The hourly rate is $80 to $84 for the period January 1- August 31, 2007. Given the importance of the Chair’sresponsibilities, the fee will be $150/hour as of September 1,2007; $170 as of April 1, 2008 and $190 as of April 1, 2009. Theremuneration is retroactive to January 1, 2007

(*) UETMIS : Unité d’évaluation des technologies et desmodes d’intervention en santé

Progressive Remuneration of Department Head Groups


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ver the past few months, an AOGQ task force hasbeen working on identifying the problems of

access of care. One of the AOGQ’s solutions onhow to promote access to specialized care is tomaximize the use of already-existing resources byintroducing a new operations model based on

well-established care protocols and making greater use of partners in multidisciplinary teams. The operations modelassumes that the partners are properly trained and form anintegrated, coherent and stable work team whatever theirenvironment (teaching hospitals, affiliated hospital centres,regional centres or offices).

Present situation

Obstetricians/gynecologists are called upon to deal with medicaland surgical emergencies on a daily basis and cannot respond

without other necessary (but less urgent) services beingpostponed or simply left undone. An ideal practice mode couldchange this situation. With that in mind, the Association desobstétriciens gynécologues du Québec has suggested anoperations mode to the MSSS that would provide Quebecwomen with quicker access to the care they need.Reorganization is essential that would make medical specialiststhe centre of a multidisciplinary team, create specializedmedicine groups (SMG) and set up birth centres. But, first,certain conditions must be met.

Prerequisites

Obstetricians’ and gynecologists’ offices are already overflowingwith patients and there must be an incentive to increaseproductivity. On the hospital side, the glaring shortage of human,financial and material resources blocks any improvement toaccessing OB/GYN care, such as ultrasound during the first andsecond trimesters, prenatal screening and the management of emergency situations.

We cannot ignore the present crisis regarding to the availabilityof prenatal screening morphology ultrasounds. Immediatededicated financing is essential for the urgent training of

specialized ultrasound technicians and the acquisition of qualityultrasound equipment, which must be available throughoutQuebec with the possibility of remote transmission for outlyingregions. The creation and financing of designated ultrasoundcentres to screen for congenital abnormalities in hospitals viathe RUIS, is also vital, together with high-performance secretarialassistance to manage emergency appointments and forwardinformation to the referring physician.

L E S P É C I A L I S T E · V O L . 1 0 n o 1 · M a r c h 2 0 0 8 1 1

Business Relations in Obstetrics/GynecologyThe Association des obstétriciens gynécologues du Québec (the AOGQ) intends to take

advantage of the recent agreement between the FMSQ and the MSSS and suggest a plan for

optimizing access to obstetric/gynecological care in Quebec. The AOGQ is determined to bring

our practice more closely in line with members’ expertise, and make care more easily

accessible to women in Quebec. From the Business Relations viewpoint, the government health

care system would then be more effective and efficient for patients, more attractive and

pleasant for physicians and, consequently, of more beneficial for the taxpayers who finance it.

O

OBSTETRICIANS/GYNECOLOGISTS ARE CALLED UPON

O DEAL WITH MEDICAL AND SURGICAL EMERGENCIES

ON A DAILY BASIS AND CANNOT RESPOND WITHOUT

OTHER NECESSARY (BUT LESS URGENT) SERVICES

BEING POSTPONED OR SIMPLY LEFT UNDONE.

CURRENT AFFAIRSDIANE FRANCOEUR, MD, FRSCS

PRESIDENT OF AOGQ AND CHIEF OF OBSTETRICS/GYNECOLOGSAINTE-JUSTINE UNIVERSITY HOSPITAL CENTRE


12/43

With regard to prenatal screening more specifically, blood tests

that are already available or planned must be improved and new

markers added in accordance with recent Canadian recommen-

dations. Clerical staff specialized in interpreting these new datamust be planned. The quality of prenatal screening should be

followed up by monitoring groups. The RUIS should ensure the

quality of the procedure and the introduction of corrective

measures in any centres that do not meet the criteria, using

the Fetal Medicine Foundation (FMF) as their example. Costs

associated with the fees and salaries of medical teams in the

designated centres must allow for continuing education in

this field.

Management of emergencies

The MSSS requires that we guarantee access to second-line

care for patients at all times. If we are to

see patients in our offices (which arealready teeming) who are referred by a

hospital ER with a request for an urgent

(24 hours) or semi-urgent (1 week)

consultation, we must plan periods

when we will be available, at the

expense of elective appointments. This

method could be used by obstetri-

cians/gynecologists who have decided

to take part in this type of agreement

and would apply only to physicians on

duty in hospital centres.

This type of practice presupposes the pooling of our professional

efforts through the creation of specialized medical groups

(SMGs) which, like family medicine groups (FMG), should receive

the funding necessary to ensure independent support in the form

of human resources (nurses, clerical staff) and material resources

(office computerization with electronic access to computerized

imaging and laboratory examinations, etc.). The offices would

have equipment permitting minor surgery under sedation,

together with basic surgical and resuscitation equipment.

Obstetric practice

Improving access to pregnancy care, with planned prenatal

testing and the identification of patients at risk, justifies an

increase in the number of first-line professionals, so that

obstetrician/gynecologists can be immediately available in case

of abnormal results or acute problems. Over the last ten years,

obstetricians/gynecologists have looked after approximately

60% of pregnancies. The remaining 40% were handled by family

physicians and merely 1 to 2% by birth centres. The

disproportionate amount of time specialists now devote to

primary care means that either parturients are seen too late for

access to screening or that semi-urgent gynecological care is

deferred. It is a poor use of obstetricians’ and gynecologists’

expertise when they themselves have to deal with normal pre-,

peri- and postnatal care.

Obstetricians/gynecologists should remain responsible for the

same percentage of pregnancies but in partnership with othe

health professionals (such as nurses and midwives), in offices

general and specialized hospitals or affiliated hospitalsMidwifery as currently practised in Quebec is incompatible with

this project, which requires certified midwives to be integrated

into first-line care teams and that they change their presen

place of practice. Midwives could work in hospitals with the

teams already in place (as is done in other countries) and could

assume broader first-line responsibilities in offices. Nutrition

prevention and preparation would be handled on a collegia

basis by other health professionals. It appears clear to us that a

significant change is required in the present concept of birth

centres (whether already established or being planned by the

MSSS). Birth centres must group together all healt

professionals likely to intervene during a pregnancy, and these

people must be physically located in the immediate vicinity oestablishments that can provide potentially urgent services a

and when required.

Gynecology and oncology

The same concept of a multidisciplinary team applies to the

practice of medical and surgical gynecology in the case o

cancer or other conditions. Primary care would be provided by

a care team of first-line health professionals working on a

collegial basis with medical specialists, thus freeing up the

specialists to deal with emergencies and general practitioners

or others’ requests for consultation on second- and third-line

specialized care.

Conclusion

In conclusion, more rapid access to specialized OB/GYN car

and the improved management of emergencies require

structured, hierarchical care. Primary care can easily be handled

by our partners in most cases, freeing obstetricians

gynecologists to provide specialized second- and third-line care

in a timely fashion. This presupposes the availability of additiona

human resources (general practitioners, nurses, midwives

ultrasound and laboratory technicians) and also materia

resources (hospital space and offices with modern ultrasound

and computer technology). The pooled efforts will ensure the

optimal use of obstetricians’ and gynecologists’ specialized

skills, with remuneration being based on the improvedmanagement of a large portion of the patient population and

greater availability for urgent consultations.

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13/43

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› La CSST ne peut autoriser la poursuite des soins de

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› Au moment de remplir ce formulaire, vous deveztout d’abord faire part de l’appréciation du bilan

fonctionnel de votre patient. Il faut y indiquer les

améliorations notées, depuis le début des traite-

ments, sur le plan de la fonction et ne pas simple-

ment y mentionner les symptômes résiduels. Voustrouverez des exemples au verso de la page d’infor-

mation qui accompagne le formulaire.

› Par la suite, vous devez indiquer vos recommandations

concernant les traitements de physiothérapie et d’ergo-

thérapie en cours ou à venir.

› Lorsque vous recommandez la poursuite des traite-

ments, vous devez motiver votre avis en regard desaméliorations recherchées sur le plan fonctionnel,

et non pas seulement des symptômes.

› Le formulaire rempli et signé doit être retourné au

physiothérapeute ou à l’ergothérapeute qui donne

les traitements.

› Idéalement, le formulaire Avis motivé du médecin qui a

charge devrait être rempli peu avant le moment où le

travailleur atteint la première des deux échéances(8 semaines ou 30 traitements).

› Exceptionnellement, pour certaines lésions sévères,

vous pouvez indiquer de façon précoce que les soins

devront se poursuivre au-delà de 8 semaines ou de

30 traitements en expliquant la situation particulière.

› Un seul avis motivé est nécessaire pour une même récla-mation. Il n’y a pas d’autre avis requis une fois passé leseuil des 8 semaines ou de 30 traitements. Il n’y a donc

qu’un seul avis payable pour une réclamation.

› Ces changements ont été mis en place avec la partici-

pation et le soutien des fédérations médicales et des

associations de spécialistes concernées.

› Le formulaire Avis motivé du médecin qui a charge,

lorsqu’il est dûment rempli, donne droit à une rému-

nération de 110 $ en fonction du code d’acte 09900.

Pour toute question ou information complémentaire, vous

pouvez communiquer avec un médecin-conseil du bureau

régional de la CSST le plus près de chez vous.

PUBLIREPORTA


14/43

ver the years, the tax authorities have issued variousinterpretations and instructions concerning the rulesgoverning the deduction of expenses incurred byphysicians in such cases, but there have been few

decisions in this regard. On December 10, 2007,however, the Quebec Court of Appeal handed down

a decision which clarifies some of these rules. The question wasto determine whether a tax payer could deduct expenses formore than two conventions per year from his income.

The facts

Dr. Robert Adam is an orthopedic surgeon who has been practisingin Abitibi for more than 30 years. Under the Master Agreement,medical specialists located in remote regions are entitled to amaximum of 20 days resourcing per year. During this time,specialists can receive $375.00 per day for resourcing, in additionto the payment of transportation and accommodation expenses.

In 1996, Dr. Adam took part in seven continuing educationactivities. On his tax returns, he therefore deducted a total of $12,000 covering the cost of taking part in conventions andcontinuing education activities.

Upon analyzing his income tax return, Revenu Québecconsidered that four of his activities were related to furthereducation and three were conventions. The expenses for thefour educational activities were accepted but expenses for onlytwo of the conventions were approved. Revenu Québec basedits decision on the fact that the Tax Act provided for a maximumof two conventions per year. Expenses for the Annual

Symposium of the Association d’orthopédiedu Québec (the AOQ)held at Montebello were

rejected; the Symposiumincluded both continuingmedical education activi-ties on back pain as wellas the AOQ annualgeneral meeting. Dr. Adam contested this decision before the Quebec Court.

Quebec Court

The question to be settled was the relationship between twosections of the Tax Act – i.e. sections 128 and 157(c).

Section 128 is the general rule that allows any tax paye

earning a business income (which, generally speakingincludes physicians’ fees-for-act or mixed method remunerationto deduct expenses incurred in earning this businessincome. Section 157(c) is a specific rule which provides thaa tax payer can only deduct expenses incurred for amaximum of two conventions per year.

Dr. Adam’s lawyer argued that it should first be determinedwhether the expenses of the Montebello symposium representedallowable expenses under the general rule at section 128. If sothe expenses were deductible, despite the maximum of twoconventions set out in section 157(c). That would mean thasection 157(c) – and hence the deduction of expenses for amaximum of two conventions – would only apply in cases wher

section 128 did not allow such a deduction.

On the other side, Revenu Québec lawyers argued that theprovisions of section 128 did not apply and section 157(c) shouldprevail. Consequently, convention expenses could only be deductedfor a maximum of two conventions under this latter section.


OVER THE YEARS, THE TAX AUTHORITIES HAVE ISSUED

VARIOUS INTERPRETATIONS AND INSTRUCTIONS

CONCERNING THE RULES GOVERNING THE DEDUCTION

OF EXPENSES INCURRED BY PHYSICIANS IN SUCH CASES,

BUT THERE HAVE BEEN FEW DECISIONS IN THIS REGARD.

The Deduction of Convention Expenses:New Decision by the Court of Appeal

A physician must assume various expenses in the practice of his profession in order to take part

in activities organized by professional, commercial or scientific organizations. These generally

take the form of symposiums, conventions, seminars, professional development or resourcing

workshops, etc.

O

LEGAL ISSUESMaître SYLVAIN BELLAVANCE DIRECTOR, LEGAL AFFAIRS


15/43

Mr. Justice Denis Lavergne of the Court of Quebec agreed withDr. Adam and authorized the expenses of the MontebelloSymposium. He concluded that the first step would be to

determine whether the expense was deductible under thegeneral rule contained in Section 128 and, if this was not thecase, only then would section 157(c) and the maximum of twocongresses apply. In the judge’s opinion, the expense in questionwas deductible under the general rule in section 128, mainlybecause there was a direct link between expenses for theMontebello symposium and Dr. Adam’s income, as the latter hadincluded in his return the amount obtained under the Master

Agreement for resourcing expenses.

Quebec Court of Appeal

Disagreeing with this decision, Revenu Québec decided toappeal the matter to the Quebec Court of Appeal. At Dr. Adam’s

request, and because the decision could have an impact onmedical specialists as a whole, the Federation decided tointervene in order to assist him before the Court of Appeal.

The results of the appeal were highly positive. In its decision, theCourt dismissed the Revenu Québec appeal and upheld thedecision of the Quebec Court. It confirmed that Dr. Adam wasentitled to deduct the expenses of the Montebello symposiumand also awarded costs of $17,208.52 against Revenu Québecin order to reimburse the greater part of the legal fees incurredwith regard to this matter.

Following the example of the Quebec Court, the Court of Appeal judges also confirmed that the first step was to determinewhether the expense was deductible under the general rule insection 128. This article therefore prevails over section 157(c),which can only be examined subsequently. In the judges’opinion, the symposium expense was deductible under section128, but for a different reason than that held by the first judge inthe Quebec Court. They considered that there was no reason toconclude that the amount could be deducted simply becauseDr. Adam had received a refund of $375.00 per day forresourcing costs. The Court of Appeal instead authorized thededuction of the Montebello symposium because it consideredit was not a convention per se but a continuing education activity.

The Court dismissed the arguments of Revenu Québec lawyersthat a symposium is similar to a convention. The Court stated

that the theme of the meeting was not the only criterion: instead,the nature of the meeting should be determined. The detailedprogram revealed that out of the five half-days of the symposium,four were devoted entirely to courses on back pain that wereorganized by the AOQ continuing medical education committee.

The only actual convention activity took place during the finalhalf-day of the program when the Association’s annual generalmeeting was held.

The Court thus dismissed the argumentput forward by Revenu Québec lawyersthat once a convention-type activity is

included, an event has to be deemed aconvention even if the greater part ofthe activity is devoted to continuingeducation. The Court held instead thatthe principal or predominant purpose of the activity should be taken intoconsideration. As the main objective of the symposium was to dispenseeducation, the expenses incurred weredeductible under the general rulecontained in section 128.

In conclusion

Although the Court of Appeal decisionfavoured Dr. Adam, its scope should beclearly understood. Contrary to whatmight be thought, this does not meanthat a physician is no longer affected by the rule of a maximumof two conventions per year. However, the Court of Appealdecision does allow far greater flexibility when determining thenature of the activity attended by the physician. Once the mainand predominant objective is to dispense education, expensesincurred could be deductible under the general rule at section128 regardless of what the activity is called or whether aconvention-type activity is grafted on to it. In such cases, aphysician can deduct an unlimited number of educational

activities from his “business” income provided all conditions aremet. The limit of two conventions a year can only apply if themain purpose of an activity is that of a convention.

Professional and scientific unions should therefore take this judgment into account when organizing their activities, in orderto ensure that the physicians attending them are not subject toany tax penalties.

L S


THE COURT HELD INSTEA

THAT THE PRINCIPAL ORPREDOMINANT PURPOS

OF THE ACTIVITY SHOUL

BE TAKEN INTO

CONSIDERATION. AS THE

MAIN OBJECTIVE OF THE

SYMPOSIUM WAS TO

DISPENSE EDUCATION, T

EXPENSES INCURRED WE

DEDUCTIBLE UNDER THE

GENERAL RULE CONTAIN

IN SECTION 128.

1 These other conditions are not discussed in this article. It should be

remembered that education must be directed at updating existing

skills and not acquiring new ones because, at that point, the expense

could be considered a capital expense and not deductible.

2 The question remains open when it is shown that the physician earns a

specific income from the convention activity – i.e. when he receives

payment of the resourcing costs. We consider that the Court of Appeal

did not totally set aside this argument of the Quebec Court and it could

always be argued that, under such circumstances, expenses could be

deducted for more than the limit of two conventions.


16/43

lthough the Fédération des médecins spécialistesdu Québec issued information folders on threeoccasions in 1997 and 1998 (also called “Lespécialiste”), the magazine format we know todaywas first published in April 1999. This thereforegives us a chance to not only celebrate our first

ten years of continuous information about Federation activities,but also to take a look back so that we can have an idea of theprogress made with regard to the Federation and theorganization of the Quebec health system.

Casting a curious eye over the content of the very first numbers,it is interesting to note how some topics developed (ordisappeared). We will be giving short extracts in every issue thisyear concerning matters covered in Le Spécialiste in 1999. It willalso be an opportunity to add input on certain topics that are stillmaking news today.

Extract from Vol. 1, No.1

Expected in the fall of 1999

Quebec gains a medical staffing

plan

Dr. Jacques Provost, the FMSQ’sDirector of Professional Services(1999) was confident that repre-sentatives of medical specialists’associations wanted to set up a first,true medical staffing plan. He said

that the MSSS appeared to be paying a great deal of attention

to associations’ suggestions. However, he also recognized tha“We continue to surround ourselves in Quebec witadministrative structures to try and justify a legal health systeminstead of trying to solve problems by viewing the organizationof medical care as fundamental to medical staff planningmeeting human objectives and thus ultimately improving thehealth of Quebecers”.

Ten years later, Dr. Provost’s successor, Dr. Serge Lénis is sad torelate that nothing has changed. “A staffing distribution plan musbe able to distribute medical staff that actually exists. At presentwe are distributing shortages, estimated at 800 medicaspecialists in 2008. This is not only impossible to manage, buleaves absolutely no room for manoeuvre. Worse still, the plans

totally ignore human factors and other considerations such asage or gender. For example, with the present type of planning, iis still hard to factor in two physicians, husband and wife, whowould like to work in the same region or hospital; a replacemenbecause of illness; maternity leave; or a decrease in professionaactivities for family reasons or age”.


A

DID YOU KNOW THAT...

“A STAFFING DISTRIBUTION PLAN MUST

BE ABLE TO DISTRIBUTE MEDICAL STAFF

THAT ACTUALLY EXISTS”

Le Spécialiste: 10 Full Years!In 2008, the FMSQ’s magazine will be

celebrating its 10th anniversary. L e S p é c i a l i s t e ’ s F i r s t E d i t i o n


17/43

Extract from Vol. 1 No.4

Remote Health Care

Monitoring: A Choice for

Society

In “Did you know that …”, the late Dr. Alain Cloutier, a cardiologist andpediatrician responsible for the remotehealth care program at CHUQ, dis-cussed remote health care monitoringin 1999 as an essential tool foraccessing care. “These new infor-

mation and communication technologies (…) open up freshdiagnostic and therapeutic possibilities that will change the way careis provided and help create a true network of services”. Theexpected growth in new advanced communication technologies

was expected to solve major issues in the health system: distributionof medical staff, access to care, and increasing costs. However, theauthor admitted that there would be a lot of ground to cover beforeremote monitoring would be introduced, particularly with regard toremuneration. Dr. Cloutier concluded his article by saying that“remote health care monitoring is a choice for society, a collectivechallenge” and that all should have their say in it. Ten years ago, Dr.Cloutier was responsible for coordinating and deploying the remote

health care monitoring network available in more than a dozenhospitals in Eastern Quebec. Since that time, “an assessment bythe Centre de Santé publique at Quebec City has once again

highlighted the importance of such a tool in the distribution of healthcare and confirmed its economic potential1”.

Today, Dr. Jean-Paul Fortin, Dr. Cloutier’s successor, agrees thatmuch is still to be done to allow Quebec to catch up in the field of remote health care. As he says, “Many teams are already using thistechnology in the field; they are its champions and people of vision. They are working on convincing confirmed unbelievers. Quebecalready has 350 fully-equipped videoconferencing outlets on theRTSS2. We are awaiting funding from Canada Health Infoway toallow us to continue with our development plan. Today, remotehealth care monitoring tools are mainly used for consultation,conferences, training and a whole host of other types of remotefollow-up. All medical teams can benefit from its many applications,particularly those in remote regions or those who do not have fullmedical resources on site.”

L S


1 Réseau québécois de télésanté,http://www.rqt.qc.ca/fr/historique/index.asp, accessed February 21, 2008(In French).

2 RTSS : réseau de télécommunication sociosanitaire

Annonce du 1er CONGRÈS CANADIEN SUR LA SANTÉ RESPIRATOIRE

H ôt e l H il t on Bon ave n t u r e • Mon t r é a l , Q u é b e c

1 9 – 2 1 J U I N 2 0 0 8

Pour vous inscrire, veuillez consulter www.poumon.ca/crc

En collaboration avec :

P r ésen té pa r


18/43

Computerized Health Records: CouillardChanges Mind and Advocates Opting Out

On November 27 last, the Minister of Health and Social Servicesannounced, with the tabling Bill 70, his intention to return to theprinciple of tacit consent – i.e. the principle whereby it iassumed that everyone consents to information circulatedunless they explicitly exclude themselves.

According to the Minister, that is the wish of most people in thehealth system and, in particular, health professionals andestablishments. He admitted that introducing an opting-inmechanism, or expressed consent (which is now the case) isextremely complex, cumbersome and costly.

In the last issue of Le Spécialiste, Dr. Gaétan Barrette indicatedthat the FMSQ “will not hesitate to issue guidelines to its

members” if the government continued with the opting-in planand the coercive measures affecting physicians now in the BilDr. Barrette considers that the return to opting-out is a step inthe right direction, but that there is still a great deal of work tobe done to make this matter acceptable to both physicians andthe public at large. One of the things to be ensured is thamedical specialists will be reimbursed for all the costs involvedin computerizing health records. The FMSQ will continue tomonitor this issue, which has a direct impact on the organizationof health care in Quebec.

A pilot project on computerized health records should start thisspring in the Quebec City region where a Family PhysicianGroup (GMF), two medical clinics, the three CHUQ hospitaland some pharmacies will test such health records for a periodof 6 months.

The SMEQ becomes the SEEMLQ

The Société des médecins experts du Québechas changed its name and is now known asthe Société d’évaluation et d’expertise médico-

légale du Québec. The change was made official in December2007 during a meeting of the Board of Directors chaired by Dr.Georges L’Espérance. The Society has more than 160 activemembers, selected by means of a specific process based on theirprevious expert reports. The SEEMLQ’s aim is to promoteexcellence in the field of medicolegal evaluation.


IN THE NEWS

GOLF! Yes! It’s time to start thinking about summer! The FMSQinvites you to take part in the 3rd Medical Federations’Tournament in support of the Quebec Physicians

Assistance Program (PAMQ). In 2007, this event raised$135,000 for the PAMQ which was very much appreciated,all the more so because the number of requests receivedfor help and support has literally exploded.

The upcoming Tournament will be held

on July 28, 2008, at Le Mirage Golf

Course, Terrebonne. The organizers are

proud that the Royal Bank has once again

agreed to be the main sponsor.

You can register right now for this activity which, year after year, remains a memorable event for those who take partin it. Download the registration form from www.fmsq.org.

New arrival at the FMSQ

Doctor Michèle Drouin becomes Director, Analysisand Fee Planning

On the job since the

beginning of the year, Dr.

Michèle Drouin heads up a

new department: Analysis

and Fee Planning. One of

the functions of this new

entity is to support

Economic Affairs in setting

up the fee schedule and

carrying out the distribution

policy. The new department

plays a central, strategic rolein the analysis and follow-up

of economic information as

a whole, in conjunction with Actuarial Services and

Information Technology.

Dr. Drouin is a diagnostic radiology medical specialist.

She has more than 15 years of clinical work, and acquired

solid medico-administrative experience in her capacity as

a Department Head and Chair of the CPDP. She has been

a member of the Association of Radiologists’ Board of

Directors for ten years, six of them on the Executive

Committee as Secretary.

A consultant to health establishments for ten years or so,Dr. Drouin has been in charge of performance analyses

and organizational reviews of hospitals in various regions

of Quebec for the firms CGO and CGI.


19/43

Call for candidates – Prizes and grants

The Conseil québécois de développement professionnel continu

des médecins (CQDPCM), which reports to the Collège des médecins du Québec, is launching the Prix de la recherche enDPC and the Prix de l’innovation pédagogique en développement

professionnel continu 2008.

Prix de la recherche en DPC:

A prize of $1,000 will be awarded to a health professional orContinuing Professional Development trainer residing in Quebec,who has authored a CPD research project.

Prix de l’innovation pédagogique en DPC :

A prize of $1,000 is awarded to a physician or group of Quebechealth professionals or educators who have developed aninnovative Continuing Professional Development project designed

for physicians. The project may still be under way or ended, andits objective will be the improvement of medical practice orcontinuing education activities.

For more details on this call for candidates, please consultthe CEMCQ French-language site at www.cemcq.qc.ca/fr/ index_prix.cfm.

Grants for clinical training

The Quebec Association for Chronic Pain is offering grants tocandidates interested in clinical training with regard to chronic pain.For further details, please consult www.douleurchronique.org.

New Books

Psychologie du vieillissement – Comprendre pour intervenir

Published by Groupéditions, this book introduces the principalconcepts, theories and models put forward by the latest researchin gerontology. It includes many case studies and indications asto when intervention is required.

Médecine tropicale, santé internationale et santé de

l’enfant immigrant

Drs.Selim Rashed, Louise Trudel, Tinh-Nhan Luong, and CarolinePedneault

This book is designed to improve medicalpractice with regard to tropical, parasitical,viral or bacterial diseases. It contains a

section on international pediatrics which, inaddition to dietary problems, anemia andcontagious diseases, deals with problemsituations that might arise from immigrationor international adoption and the difficultiesfamilies must sometimes face. A laboratory

section describes the various methods used to identify parasitesas well as the principal methods used to stain bacteria.

L S


Le Spécialiste


20/43

Selon Dr Gary Stenzler, bon nombre deprofessionnels de la santé pensent qued’être un bon clinicien les maintiendra àl’avant-garde dans leur domaine. « Or,vous devez également gérer votre entre-prise convenablement », déclare DrStenzler, propriétaire d’un cabinet dedentiste en Ontario.

Pour rester à « l’avant-garde », il faut savoirprendre les bonnes décisions en matière

d’équipement - non seulement quellespièces acquérir et quand, mais égalements’il est préférable d’acheter ou de louer, etde qui.

De telles transactions peuvent avoird’énormes répercussions sur votre pratiqueet vos finances. Ainsi, Dr Stenzler a négociéun crédit-bail par l’entremise de RBCBanque Royale®, qui lui a permis de réaliserd’importantes économies en versementsmensuels comparativement à cequ’offraient les concurrents.

Son conseiller, Craig Gibson, affirme queDr Stenzler est un homme d’affaires trèsavisé. Mais M. Gibson, premier directeur decomptes, Professionnels de la santé RBC,ajoute que plusieurs dentistes et médecinsne sont pas aussi à l’aise avec l’aspectaffaire de leur pratique, y compris avec lesdécisions en matière d’équipement.

Ces décisions peuvent être complexes etde nombreux facteurs entre en ligne decompte, par exemple la nécessité d’acquérir

l’équipement et sa durée de vie ; il fautaussi voir aux questions financières,notamment les liquidités et les incidencesfiscales.

Voici ce que les médecins et les dentistesdoivent garder à l’esprit pour faire les choixles plus judicieux en matière d’acquisition.

Combien de temps dureral’équipement ?

Commencez par la sorte d’équipement.

Lucy Carvalho, associée dans le cabinet dechirurgie plastique de son mari, le docteurCharles Guertin de Montréal, envisagesouvent les décisions en matière

d’équipement de la même façon que lorsqu’ils’agit d’acheter une maison ou une voiture.

Certaines pièces d’équipement sontcomme une maison – elles durerontlongtemps et représentent un investisse-ment solide (pensez à un fauteuil den-taire). Dans un tel cas, comme pour unemaison, Mme Carvalho préfère êtrepropriétaire.

D’autres pièces d’équipement, déclare-t-elle, sont comme une voiture – ellesfonctionnent bien actuellement mais vouspourriez désirer les changer assezrapidement (pensez à un ordinateur). Toutcomme dans le cas d’une voiture, où elledésire avoir le plus récent modèle, uncrédit-bail est plus logique pour elle.

« La technologie change rapidement »,précise Mme Carvalho, alors la décision delouer ou d’acheter repose sur le fait desavoir si l’équipement durera longtemps ous’il deviendra rapidement désuet.

Les décisions de location ou d’achat nesont toutefois pas toujours aussi évidentesen raison des nombreuses questionsfinancières en jeu. Mme Carvalho et

Dr. Guertin, qui sont également tous deuxcomptables, le savent très bien.

« Il n’y a pas de bonnes ou de mauvaisessolutions – mais il y a une série de pouret de contre à analyser », préciseMme Carvalho.

Liquidités et souplesse

« Il faut d’abord considérer les liquidités,ajoute Dr Stenzler. Je dispose d’une margede crédit pour ma pratique. Je peux donc

faire un achat à l’aide de cette marge, maiscela réduira mes liquidités disponibles. Lecrédit-bail peut servir de solution derechange qui me permettra de ne pastoucher à mon coussin financier. »

Une marge de crédit-bail préapprouvée peutêtre avantageuse, ajoute Dave Magier, vice-président, financement d’équipement RBCBanque Royale. Tout comme pour leshypothèques préapprouvées, cette margede crédit-bail est assortie d’une valeur

préétablie. Ainsi, les médecins et dentistesdisposent de la souplesse nécessaire pourprofiter des occasions d’achat rapidement,à leur gré et au moment propice.

Outre le montant d’argent, pensez auxautres modalités. Par exemple, vous pouveznégocier un crédit-bail pour y inclurel’entretien, les mises à niveau et d’autresservices. La durée d’un crédit-bail joueégalement un rôle ; il serait logique dechoisir un bail de cinq ans lorsquel’équipement peut durer de sept à dix ans,

mais une autre solution serait plus adéquatesi l’équipement risque de devenir désuetdans trois ans.

À la fin du bail, vous aurez l’option deracheter l’équipement, ou encore de lerenouveler ou simplement de le retourner.Vous profitez donc d’une souplessemaximale. Si vous songez au rachat, tenez

Préparez-vous à prendre lesmeilleures décisions pour votre pratiqueLes professionnels de la santé comparent le crédit-bail et l’achat d’équipements

PUBLIREPORTAGE


21/43

compte de ce montant dans le total de voscoûts, et pensez à la valeur de l’équipementà la fin du bail.

Dans le cas du Dr Stenzler, le coût du rachatétait plus élevé que le simple petit montantqu’il aurait eu à débourser auprès d’unautre fournisseur de crédit-bail. Par contre,les économies mensuelles, sur plus de60 mois, compensaient grandement.

N’oubliez pas la structure de propriété devotre pratique, ajoute M. Magier. Il cite lecas d’une clinique qui compte de nombreuxassociés. Lorsqu’ils effectuent des rénova-tions à leur bureau, plutôt que d’utiliserl’argent de leur compte capital (le montantqu’ils mettent en commun comme unepartie de leur investissement dans lasociété en nom collectif), ils louentl’équipement. Si un associé quitte la sociétéou s’y joint avant la fin du bail, il n’a à payerqu’une part proportionnelle de l’utilisationde l’actif.

Le crédit-bail peut également être avantageuxlorsque vous essayez de nouveaux modesde traitement. Mme Carvalho et sonconjoint ont loué un nouveau laser, avecoption d’achat, parce qu’ils ne savaient pascomment les clients allaient réagir, et s’ilsauraient suffisamment de nouveaux clientspour justifier cette dépense. Dans ce cas, lalocation constituait un moyen de tester lepotentiel de l’équipement, sans faire un

gros investissement incertain.Toutefois, l’achat comporte également unecertaine forme de souplesse, affirme DrStenzler. « Vous pouvez avoir un crédit-bailà long terme, et constater que l’équipementne convient pas à votre pratique. Si vousl’aviez acheté plutôt que loué, vous pourriezle vendre dans le marché secondaire. »

Autre point à prendre en compte – « Certainsprofessionnels de la santé préfèrent êtrepropriétaire et avoir le contrôle de leur

équipement », ajoute M. Magier.

Songez aux incidences fiscales

Les médecins et les dentistes doivent voirl’ensemble de la situation lorsqu’ils ont des

décisions à prendre au sujet de leuréquipement, précise M. Magier. Disons quevous décidez d’acheter. Avec un prêt dedurée standard, vous devez payer toutes lestaxes (c.-à-d. la TPS et la taxe de venteprovinciale) au moment de l’acquisition, etle prêteur à long terme peut également vousdemander un montant forfaitaire (certainsprêteurs à terme, non pas RBC, peuvent

demander jusqu’à 25 %).« Avec l’option de crédit-bail, nous pouvonsfournir jusqu’à 100 % du coût, affirmeM. Magier, ce qui accorde un certain répitaux liquidités, préserve votre fonds deroulement pour d’autres fins et vous permetde payer les taxes à mesure plutôt qu’aumoment de l’acquisition. »

Le crédit-bail peut être avantageux du pointde vue fiscal, parce que d’habitude, unepart équivalant à 100 % des loyers estdéductible. Par contre, lorsque vous êtespropriétaire, vous ne pouvez radier quel’intérêt, et devez déprécier l’actif sur unecertaine période de temps (qui varie selonl’actif).

Il existe toutes sortes d’incidences fiscaleset diverses solutions créatives s’offrent àvous lors de l’acquisition de l’équipement.Il est préférable d’en parler avec votrecomptable.

Par exemple, Dr Ian McKee, un orthodontisted’Edmonton, a décidé d’établir, avec son

associé, une compagnie distincte de crédit-bail mobilier, d’acheter de l’équipement aumoyen du financement fourni par RBC, et dele louer à sa pratique par l’entremise decette nouvelle compagnie. La raison ? À titred’orthodontiste, Dr McKee pouvait récupérer100 % de la TPS sur ses achats, dans lamesure où il faisait l’achat par l’entremised’une compagnie de crédit-bail distincte.

Outre l’argent, la souplesse et les taxes,les professionnels de la santé devraient

également penser au temps qu’ils désirentpasser à gérer le processus.

« Nous savons que pour la plupart desmédecins ou dentistes, le temps estprimordial, affirme M. Magier. Si leur

équipement provient de plusieursfournisseurs, nous pouvons grouper toutesles factures en une seule transaction decrédit-bail - et nos représentants peuventgérer le processus de financement auprèsde tous les fournisseurs. »

Demander les conseils de spécialistes

Dr McKee souligne que les coûts, les taux et

les termes sont tous des éléments essentielslorsqu’on prend des décisions d’acquisitiond’équipement. Mais des conseils pertinentset neutres ont encore plus d’importance.

Peu importe la façon dont vous voulezfinancer l’équipement, il est sage d’avoirrecours à des spécialistes, qu’il s’agissed’un avocat, d’un notaire, d’un comptableou de votre banque.

RBC, par exemple, a des directeurs decomptes partout au Canada qui sont

spécialement formés pour venir en aide auxmédecins et aux dentistes et qui peuventprocéder à une analyse personnalisée pourdémontrer les avantages éventuels ducrédit-bail par rapport à l’achat.

« Il se trouve que RBC offre un meilleur tauxd’intérêt. De plus, j’ai traité directementavec un spécialiste des soins de santé, quiconnaît notre situation, conclut Dr McKee.RBC a compris toute la dynamique dema pratique. »

POUR EN SAVOIR PLUS SUR NOS SERVICES ET

SOLUTIONS POUR VOS BESOINS PROFESSION-

NELS ET PERSONNELS, COMMUNIQUEZ AVEC :

Nader Guirguis, MBA, B.I.B.C.

Vice-président,

Marché des professionnels de la santé,

RBC Banque Royale,

1 Place Ville-Marie, 8e étage, aile Est,Montréal (Québec) H3C 3A9.Téléphone : 514 874-5042

Ou visitez notre site Webwww.rbcbanque royale.com/santé

Ou composez le 1 800 80 SANTÉ(1 800 807-2683).

Les stratégies, les conseils et le contenu de la présente publication sont offerts à titre indicatif seulement, au profit de nos clients. Les lecteurs devraient consulter leur fiscaliste,leur conseiller juridique, leur conseiller en affaires lors de la planification de l’implantation d’une stratégie ou d’une stratégie de planification fiscale afin de s’assurer que leursituation particulière fait l’objet d’un examen approprié reposant sur les derniers renseignements disponibles

®Marques déposées de la Banque Royale du Canada, RBC et Banque Royale sont des marques déposées de la Banque Royale du Canada. (02/2008) VPS45024


22/43

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EXTREMEBEHAVIORLast November, the 2007 Pierre-Forcier Symposium, presented by theSociété des médecins experts du Québec (which has since become theSociété d’évaluation et d’expertise médico-légale du Québec), dealt withthe issue of querulous or vexatious behavior, a very topical subject in our society, but one that is little known. Querulousness can have a number of implications for medical specialists and should, therefore, be more

clearly understood.

t is important for health professionals to recognize individuals or situations which

might degenerate into legal proceedings or similar scenarios. The Quebec health

system allows patients to seek a second opinion or counter-expertise. However,

looking for a “fifth second opinion” or the umpteenth counter-expertise may be an

indication of querulousness.

There is no need to declare someone a vexatious litigant for him to demonstrate

vexatious tendencies. Democratic access to the internet allows all kinds of information

to be obtained, particularly on sites that give medical information in lay language and

other popular sites where patients can grade and give an opinion on the service

received from their physician. While patients may be increasingly informed, are theyactually better-informed? They come in with documents and do not hesitate to

contradict or doubt the opinion of the specialist they are consulting. Because of the

lack of real-time access to patient records, there is no way of knowing whether the

person is going from one clinic or hospital after another in order to find a specialist who

will give him the opinion he is seeking.

Some demands made of physicians are indicative, such as an interview with a witness

present or one that is recorded. We know that information and communication

technologies now permit discussions or meetings to be secretly recorded. A vexatious

individual might want to use remarks gathered in this way as evidence before a Court.

In this special dossier on extreme behavior, “Le Spécialiste” has asked a psychiatrist

to explain the complex condition of querulousness or vexatious behavior. A judge then

explains the legal aspects of vexatious litigation. Some patients are not querulent, yet

still present a certain degree of danger to themselves and others. The dossier also

contains an article on such dangers: how to recognize dangerous patients, their

assessment, measurement scales, threats and an overview of the treatments available.

Please let us have your comments. We are always interested in what you have to say:

[email protected].

DOSSIER

L E S P É C I A L I S T E · V O L . 1 0 n o 1 · M a r s 2 0 0 8 2 3

I


24/43

EXTREMEBEHAVIOR

personally had the experience of dealing with someonewho had mobilized considerable resources to win his case– which was, in actual fact, fairly minor – against hisemployer. In this legal saga, the person attacked hisemployer, the chief executive of the company, his union

and the physicians who had assessed his case. Hemultiplied his complaints to the Collège des médecins duQuébec, which rejected them. He lost his case on appeal afterwhat had been a costly legal saga for all concerned. It was morethan stubbornness; it was a case of someone who wanted towin his point of view at any price, regardless of the cost.

Querulousness is first of all a clinical concept and has describeda specific psychiatric entity for many years. The nature andcharacteristics by which this entity can be recognized are givenbelow, together with some examples.

Definition

Querulousness, as a social behavior manifested by the abusiveuse of the court system, can be explained by the person’spsychological profile. By extension, we can include similarbehaviors that take place outside the judicial process: forexample, claims made to administrative or political authorities.

Vexatious or querulous litigants have been described assuffering from systematic chronic dementia (or paranoia), makingclaims and close to the frenzied passion of erotomaniacs and

jealousy. “They will ruin themselves in the courts in order to win aclaim which is sometimes derisory. They defend their honor, rightsor property regardless of their very obvious best interests”.

Their claims may be real or imaginary. In all cases, their judgmenis seriously altered by the feeling that someone deliberatelywished to harm them. Those who oppose them quickly becomtheir new enemies and are included in their legal proceedings

The police, physicians, social workers, lawyers and judges ar

shown no mercy and may be sued. Querulous litigators show adeep distrust of authorities who do not share their point of viewleading to the vexatious actions they take against them.

As they have confidence in no one, such litigators representhemselves. They find it difficult to accept an approach that isless radical than their own, and thus rapidly dispense with theservices of a reasonable lawyer. They base their arguments onpremises that are false or wrongly interpreted. They stubbornldefend their point of view, and do not let themselves bedemoralized by failures or warnings. They consider these aadditional proof that the legal system is unjust. Their applicationto the Courts become increasingly numerous. They appea

judgments right up to the Supreme Court, as if their case was o

national interest.

Vexatious litigators who are intelligent are also inventive. Themake unexpected detours which have the effect of multiplyinginterventions and slowing down the legal process.

In rare cases, such litigators can go so far as to kill theipersecutor. They will defend themselves, feeling no remorsedespite their awareness of wrongdoing, because they arapplying their version of justice since they have no confidence inthe judicial system. Valery Fabrikant was one such litigator whoresorted to murder in order to have his rights recognized andrecover his honor.

Social and psychological profile

Vexatious or querulous behavior becomes apparent mainlybetween the ages of 40 and 60 in intelligent people with sufficienknowledge to succeed in their mission. They have ofteexperienced failure or frustration in their personal or professionalives. Their injured narcissism is the catalyst; the judicial procesbecomes their stage. They already know or learn what they needto about the law and legal process in order to proceed with theicomplaints. Apart from their assertions, they may behavnormally in society, be well organized and hard-working.


SUCH PEOPLE DEVELOP ANABERRANT TYPEOF

SOCIAL BEHAVIOR, STUBBORNLY CLAIMING

REPARATIONANDMAKING EXCUSES SO THAT

THEY CAN RECOVER THEIR HONOR ORTHE

RIGHTSTHEY BELIEVE THAT THEYHAVE LOST.

Querulousness You may have a colleague or friend who has at some time become the victim of a stubborn,

vindictive plaintiff who pursues his/her complaints, legal action and recrimination well beyond

reasonable bounds. Such actions give rise to considerable concern and consequences that are

worrisome from the point of view of both health and career. Let us hope that you never find

yourself in the sights of such a person.

I

By Dr. Jacques Gagnona


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Those most severely affected demonstrate a structured, sectorialmanic thought process with a persecution complex. Theirparanoid thoughts originate in the fundamental, implacablepremise that they are the victim of persecution, theft or someother scheme to discredit them. This unshakable conviction,despite a lack of any proof, alters their judgment which appearsto us to be inchoate, categorical and without any sign of nuance.

They do not experience hallucinations or cognitive impairment.Others show no manic thought process, but present apathological personality profile. This would be paranoid in nature:cold, rigid and distrustful, with mental projection sufficientlyanchored in reality that they cannot be considered manic.

There is also the narcissistic profile: grandiose, haughty,distrustful, seeking admiration and success.

Narcissistic or paranoid characteristics are virtually necessary toexplain their excessively demanding behavior. As people are notmade to fit our nosological entities, a mixture of borderline,histrionic or sociopathic personality traits can be observed.

An exemple

Valery Fabrikant, born in 1940, is married and the father of 2children. He was an Associate Professor of MechanicalEngineering at Concordia University. His application to becomea titular professor had previously failed.

In 1992, he sued two colleagues requiring that they withdrawtheir names from articles he had published. He accused Mr.Justice Gold, the University’s Chancellor, of appointing corrupt judges to hear his case. On August 24, 1992, the eve of hiscontempt of court hearing, he shot four professors who werehis colleagues and wounded a secretary.

The long and difficult trial was stopped by the judge after fivemonths of delaying tactics and abusive language. ValeryFabrikant was imprisoned for life. The Court rejected theconcept of psychosis, which would allow a verdict of not guiltyby reason of mental disorder.

The Court declared him to be a vexatious litigator in 2000, afterhe presented multiple suits, appeals and frivolous proceedings.

On November 5, 2007, Valéry Fabrikant again appeared beforethe Court to resume the legal action begun in 1992, which wasinterrupted by his killing spree. He still demanded reparationfrom the professors he had killed. He also wanted to sue the judge of a previous trial and obtain his apologies for havingconvicted him. Mr. Justice Gilles Hébert recused himself onNovember 13, after just a few days, because he could nolonger endure Fabrikant’s insults and recriminations. Hisreplacement, Madam Justice Nicole Morneau, took the caseand, after one week, terminated the trial on the basis that it wasfrivolous and without foundation.

Conclusion

Vexatious or querulous litigants suffer from a psychiatric disorderthat changes their social behavior. The cost is high for everyone:their family, society and the functioning of the Courts. Judicialprocedures can limit the damage by declaring such people tobe vexatious (querulous) complainants, which means that theymust obtain prior permission from a judge before bringing a caseto court.

Psychiatry is poorly equipped to help such people because of their projective defense. They do not feel ill; they believe they arevictims of the system. They are alert to any contradiction likely todemonstrate their basic premise – i.e. even therapists can formpart of the system persecuting them.

In theory, a therapeutic approach should concentrate on thenarcissistic injury that triggered the storm, focus on the person,acknowledge behavior adaptation, and avoid criticizing vexatiousbehavior. The care team must have an unshakable cohesion anda high degree of transparency.

Neuroleptics, if the patient agrees to take them, seldom curesystematic dementia but, in some cases, a reduction in tensionand behavioral lapses can be hoped for.

Close cooperation between psychiatry and the justice systemmust be ensured in order to respond to the highly predictablemanoeuvres of people who bring their internal psychodramabefore the forum of a court of justice.

L S


THEIR CLAIMS MAY BE REAL OR IMAGINARY.IN ALL CASES, THEIR JUDGMENT IS SERIOUSLY

ALTERED BY THE FEELING THAT SOMEONEDELIBERATELY WISHED TO HARM THEM.

a Jacques Gagnon M.D., CSPQ, FRCP, Psychiatrist, C.H. Maisonneuve-Rosemont, Assistant Clinical Professor, Université de Montréal.

QUERULOUSNESS AND VEXATIOUS BEHAVIORS


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“querulous person” is defined in the Rules of theCode of Civil Procedures as someone who, whileexercising his/her right to start legal proceedings,will do it in an excessive or unreasonable manner. A further definition in the Grand Robert de lalangue française also gives an accurate idea of

the troubling behavior observed in certain litigants: “A pathological tendency to seek out quarrels and to claimcompensation for a prejudice, real or imaginary, in a mannerdisproportionate to the case”. Although there are few vexatiousor querulous litigants in absolute numbers, such individualscreate serious problems for the people who have to face themin court and they take up the time and resources of the courts

to an egregious degree. One characteristic of such people isthat they represent themselves, either because they do not wantto retain legal counsel or because they cannot find a lawyerprepared to represent them.

Judicial control of the problem

Since 2003, various regulatory provisions have been adoptedin Quebec to permit certain courts to control the behavior of litigants with this type of profile. Local jurisprudence had, in fact,already introduced such measures severalyears beforehand. A 1994 case, Yorke vs.Paskell-Mede [Yorke], which set a prece-dent, established that, in exercising its

“inherent” powers, the Superior Court can,by special order, prevent the abuse of process by vexatious litigants.

It might therefore be thought that the legalsystem’s apprehension concerning thisphenomenon is fairly recent, and thateverything necessary has already been doneto contain the most obvious occurrences. The reality, however, is not so simple.

The origin of control measures

First of all, it is very likely that this pheno-

menon, even though it may be marginalstatistically speaking, has existed here for avery long time. It was in 1887 that the British courts made officialthe type of judicial control that became part of Quebec jurisprudence in 1994. A well-known vexatious litigant, HectorWilliam Grepe, plagued the courts in a civil suit that lastedseveral years and on which final judgment was rendered in1879. On several occasions after th

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