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eas. Even though foreign specialistswill not provide the ultimate solutionto Canadas maldistribution prob-lems, they are and will likely continueto be an important element of any so-

lution.I realize the act of accreditation in-

volves tremendous responsibility andthat authorities must ensure that onlycompetent and capable specialists areallowed to practise. However, can wereally exclude, carte blanche, entiregroups of trainees from some coun-tries? It seems arrogant to suggestthat our training programs are ofhigher calibre than similar programsin Germany, France or Japan. It

would be fascinating to see the datasupporting this notion.

Shabbir M.H. AlibhaiRichmond Hill, Ont.Received via email

Patient confidentialityand the law

I t is a pleasure to see that a medicalstudent and practising physicianare sufficiently interested in the ethi-cal issues surrounding patient confi-dentiality to write a paper. However,the article From Hippocrates to fac-simile (Can Med Assoc J1997;156:847-52), by Daniel Y. Dodek andArthur Dodek, should not be consid-ered a comprehensive guide to pa-tient confidentiality in Canada. Someof the authors conclusions are so

general they are misleading and mustnot be taken at face value.

The authors based their article onthe premise that patients have a rightof inviolate confidentiality with re-spect to their medical records. Nosuch absolute right exists. They seemto acknowledge this fact by citing theCMACode of Ethics, which providesthat patient confidentiality is to be re-spected except where it might con-flict with the law or would result in

harm to the patient or others. These

significant limitations have becomeincreasingly common, and theyshould not be regarded as minoraberrations. They must be recog-nized and respected by the profes-

sion.Likewise, subpoenas requiring the

release of patient records may even-tually conflict with the confidential-ity that would otherwise attach topatient records. However, the sub-poena does not oblige the physicianto turn medical records over imme-diately to the person requestingthem but merely to bring them tocourt, where it will be determined whether they should be released.

Therefore, complying with a validsubpoena will not automatically vio-late a patients confidentiality.

The same problem exists concern-ing the mandatory-reporting obliga-tions cited by the authors. They writethat reporting AIDS, but not HIV in-fection, is mandatory in the US andin Canada. This is inaccurate. Al-though it may be true in some juris-dictions, there is strong authority that

it does not apply, for example, in On-tario. The policy of the Ontario med-ical officer of health is that, pursuantto Ontarios Health Promotion andProtection Act, physicians are re-quired to report cases of HIV infec-tion. Likewise, rules on mandatoryreporting of child abuse vary acrossthe country. Finally, gunshot andknife wounds are not subject tomandatory disclosure. It may apply inthe specific context of a criminal in-

vestigation or a coroners inquiry forwhich a subpoena or a warrant hasbeen issued, but the bold statementthat all gunshot and knife woundsmust be reported is unfounded.

The authors also state that thephysician should ask whether there isany information the patient wishes tokeep absolutely confidential. This ishighly questionable advice. Keeping2 sets of charts will create obviousrecord-keeping problems. Moreover,

even though a patient and doctor

have deemed something absolutelyconfidential, it can still be producedunder court order.

It is difficult to imagine when itwould be in a physicians interest to

consent to not documenting or delet-ing certain findings or medical infor-mation. Failure to record all relevantinformation will make it difficult toestablish the facts upon which adviceor treatment was based, and couldlead to inappropriate treatment whensomeone relies upon the incompleterecord. The evidentiary conse-quences in a malpractice actionagainst a physician could serve to de-stroy an otherwise strong defence.

Finally, if a patient requests thatonly a portion of the chart be pro-vided to a third party, the physicianshould let the party know that a por-tion has been withheld at the patientsrequest. For example, a patient with aheart condition who applies for lifeinsurance might request than an ex-purgated version of the chart to besent to the insurance company. If thecompany pays out a claim because of

this, it could bring a civil actionagainst the physician to recover itslosses.

Margaret A. RossGowling, Strathy & HendersonGeneral CounselCanadian Medical Protective AssociationOttawa, Ont.

[The authors respond:]

We appreciate Margaret Rossscomments. The article wasnot meant to be a comprehensiveguide to patient confidentiality butrather a selection of the many directand indirect ways in which patientconfidentiality can be betrayed.

There are some very specific legallimitations on patient confidentiality,and physicians certainly must abideby them. We wanted to point outhow easy it is to violate patient con-

fidentiality.

Correspondance

870 CAN MED ASSOC J 1er OCT. 1997; 157 (7)

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Correspondance

872 CAN MED ASSOC J 1er OCT. 1997; 157 (7)

Health and legal statutes do varyfrom province to province. In BritishColumbia physicians are not requiredto report patients who test positive forantibodies to HIV. We certainly do

not suggest keeping 2 sets of recordsor charts: we advised that only themedical information pertinent to a re-quest be sent to the interested party.For instance, medical information re-quested by an automobile insurancecompany should be specific to the areaof concern.

There was no documentation orintent in our article to indicate thatif a patient with a heart conditionapplied for life insurance an

abridged or modified version of thechart should be sent to an insurancecompany. Where life insurance isconcerned, all medical informationmust be divulged.

There is no misunderstandinghere. The physician must be the pa-tients advocate and abide by theCMACode of Ethics.

Daniel Y. Dodek, BScArthur Dodek, MD

Vancouver, BC

This experiment has failed

I thank Dr. Donald G. Marshall forhis letter Our future physiciansdeserve better (Can Med Assoc J1997;156:1701).

Medical students do indeed expe-rience undue anxiety about making

premature career choices. Discus-sions with my peers have been ex-tremely disquieting. I am concernedthat their preoccupation with theirfuture may adversely affect their well-being. In the rush to choose acareer and acquire a residency spot,students too often lose sight of thepurpose of medical school and whythey decided to enter medicine.

I have yet to find anyone who be-lieves the current system serves the

needs of the profession, yet it takes

people like Marshall to make us ad-mit what we have all known for along time: this experiment hasfailed! If during a clinical trial an in-tervention is found to be detrimental

to patients, the experiment isstopped. Should the next generationof physicians not be entitled to thesame respect as such patients?

Despite government cutbacks anddisillusionment among residents andpractising physicians, I look forwardto the future. I remember why I de-cided to become a doctor. I believethat medicine can be an exciting, no-ble and rewarding profession. I onlyhope my peers and future students

can feel the same way.To those charged with caring for

our education system, I make thisplea: lets have no more committeesor resolutions to look into the matter.Lets fix the problem! I would be de-lighted to work with you to ensurethat our medical schools turn out theworlds most humane, well-rounded,content and proficient physicians.

David A. Omahen, BScClass of 99University of OttawaOttawa, Ont.

Iheartily endorse the letter fromDr. Marshall, which says that re-quiring medical students to choosetheir future career path long beforethey know enough is grossly unfair.

The old system of junior rotatinginternships for everyone produced

much more balanced graduates fromboth family practice and specialtyprograms. Very few physicians-in-training have a good sense of whattrue practice entails or whether theyhave the interest and stamina for it.Every branch of medicine deservesto have only those who want to bethere. We have all experienced thelukewarm participation of those whowould rather be somewhere else. Forthe sake of our students, our profes-

sion and, most of all, our patients, we

must return to common sense in spe-cialty training.

George T. Riley, MDOakville, Ont.

Physician payment:incentives changewith supply

The articles Primary care reform:Is it time for population-basedfunding? (Can Med Assoc J1997;157:43-40, by Dr. David Mowat, and Anew primary care rostering and capita-tion system in Norway: Lessons for

Canada? (Can Med Assoc J1997;157:45-50), by Drs. Truls stbye andSteinar Hunskaar, examine differentphysician payment mechanisms.

Each of the recognized methods ofpayment results in different incen-tives, and these change when a cer-tain line is crossed. The location ofthis line depends on whether thereare too many or too few physiciansin the particular market, or, more ac-

curately, on whether the physiciansinvolved believe that there are toomany or too few of them in the mar-ket.

Fee-for-service payment providesincentives for physicians to work hardand efficiently when there are too fewphysicians, but when there are toomany physicians with too little workit encourages the generation of un-necessary work. Capitation-basedpayment encourages patient satisfac-

tion as long as the physicians arecompeting for patients; however, ashappened in Britain, once there aretoo few physicians, all with full lists,this payment system encouragesphysicians to reduce work to a mini-mum. The effect of salary payment isless clear, but it goes something likethis: if there are too few physicians inthe system, the incentive is to reducework to the minimum; whereas, ifthere are physicians trying to get into

the salaried positions, the physician