Contemporary Medicine

Medicine, Contemporary

The years since 1939 have seen great changes in Canadian medicine. In the armed forces, which were served during WWII by many of Canada's most talented medical practitioners and specialists, medical services were responsible for advances in the management of physical and psychological trauma, for research on infections, motion sickness and high-altitude aviation, and for perfecting methods of preventing blackout during rapid descent of fighter planes.

The effectiveness of penicillin against many bacterial infections was established when the drug was provided (largely through the efforts of AVENTIS PASTEUR LTD. in Toronto) to the Canadian armed forces at the time of the invasion of Europe after D-Day. Since then, antibiotic-resistant bacteria have developed, creating devastating effects from mutated organisms and strains of contagious disease that were once thought to have been eradicated.

During the early postwar years the Dept of Veterans Affairs organized medical and HOSPITAL services for veterans. Some of the hospitals were closely associated with university medical schools, with the result that medical teaching and research were carried out in the hospitals and the staffs of the hospitals were in most cases members of the medical faculty. This arrangement, which ensured a high level of medical care for veterans and provided universities with teaching facilities, continued until the 1970s when the Department of Veterans Affairs began converting its facilities to general hospitals regulated by provincial hospital programs.

In the 1940s Saskatchewan and BC developed hospital insurance programs; Saskatchewan also provided medical coverage. The origin of universal healthcare in Canada can be traced back to this era and former premier Tommy DOUGLAS' experiences on the Canadian prairie during the GREAT DEPRESSION. Many people lived in very harsh circumstances, unable to afford basic necessities or medical care. He determined that political action was needed to alleviate the suffering.

In 1957 the federal government began to give assistance to the provinces for programs of hospital services and in 1966 a countrywide medical-care program was developed (see HEALTH POLICY). In 1984 the federal government passed new legislation, the Canada Health Act, designed to discourage user fees for hospital services and extra billing by physicians through the threat of withheld transfer payments.

An issue with the potential to affect the country's universal health care system is the expansion of private surgical services, such as orthopaedic clinics in Alberta, British Columbia, Ontario and Quebec. Of concern is the possibility that the availability of general and specialist physicians for the public health system may be negatively affected by for-profit medical clinics. The higher salaries that private clinics offer could siphon away Canada's medical professionals from the universal system. Additionally, access to private medical care services is limited to people who can afford to pay for care in private clinics, either through supplemental insurance or out of pocket. High surgical fees may be a deterrent to access. Inequity to access is counter to the policies of most, if not all, regional health authorities.

Diagnostic and Treatment Methods

Many advances in diagnosis and DISEASE treatment have occurred since 1945. The development of a large number of antibiotics has provided means of combatting bacterial infections, although the ability of some bacteria to develop resistance to antibiotics is still of increasing concern.

ANTIBIOTIC RESISTANCE became a major health issue in the late 20th and early 21st century. The development of drug-resistant strains of bacteria causes difficulty treating the infection and is more costly. An example is extra drug-resistant tuberculosis (XDR-TB). This form of TB is resistant to the common antibiotics and must be treated by a more expensive combination of drugs. "Super" staphylococcus bacterial strains have developed in hospital settings in Canada, and caused highly contagious and difficult-to- treat infections. Hospitals now require that staff members take extra care to prevent spreading a pathogen. Individuals can help reduce their contribution to the development of resistant bacteria by taking all medications as prescribed and not requesting antibiotics for viral infections, such as the common cold or the flu. Viruses cannot be treated with antibiotics.

Many viral diseases are now controlled by the use of vaccines. For example, the last epidemic of poliomyelitis in Canada occurred in the mid-1950s; because of effective vaccination programs it is not the threat it once was. INFLUENZA vaccines are now routinely provided to children, seniors and people with a compromised immune system. A vaccine developed for pre-teen and adolescent girls is now available to prevent infection with human papillomavirus. This virus is transmitted sexually and may also be spread by normal contact among children. It is extremely common and may be linked to the development of certain types of cancers, such as throat, cervical and penile cancers. The vaccine has been a source of controversy raising issues such as unnecessary vaccines, sexually transmitted disease and parental control over adolescent sexual behaviour. Advocates argue for its use on a preventative basis and separate the vaccine from debates about morality.

The use of ultrasound and radioactive isotopes and the development of the nuclear magnetic resonance method of examination have enabled cardiologists to assess the state of the heart muscle. Surgical procedures involving correction of congenital heart defects, valvular abnormalities and coronary artery disease are being carried out in many centres across Canada. The widespread use of cardiopulmonary resuscitation in hospitals and by paramedical personnel has resulted in recovery in many cases of cardiac arrest. Pacemakers have enabled patients with life-threatening cardiac rhythm problems to survive many years. The development of coronary care units and intensive care units in hospitals has resulted in improved management of patients suffering from severe illness or injury.

Canada has made a significant contribution to the field of CANCER diagnosis and early detection with the "Pap" smear tests for uterine cervical cancer. Programs for the early detection of breast cancer by self-examination and mammography have also been developed. Canadian scientists were responsible for the development of the "cobalt bomb" used in radiation treatment of cancer, and for the discovery of the vinca alkaloids, chemotherapeutic agents used in the treatment of many types of cancer. Cancer diagnostic treatment and research centres have been established in all major cities in Canada. The establishment of the federal Canadian Society for Cancer Control created an organization that is focused on cancer prevention, screening, early detection, practice guidelines, research, surveillance and patient centred cancer care. The not-for profit organization is the national central place for information, resources and cancer research.

The availability of radioactive isotopes (used in the diagnosis of many conditions, including cancer and disease of the lungs) has led to the development of the specialty of nuclear medicine. The diagnosis and treatment of certain conditions, eg, thyroid disease, has been greatly improved with technological advances. The development of dialysis units and kidney transplants for chronic kidney failure have enabled patients to carry on useful lives, in many cases, for years longer than expected.

Centres for the treatment of the many types of ARTHRITIS have been established in many Canadian communities, greatly assisted by The Arthritis Society. These centres provide an integrated program of treatment including medical, physiotherapy and occupational therapies and social service assistance. New medications and developments in surgery involving replacement of joints with plastic or metal materials have improved the outlook of patients suffering from chronic arthritis.

The management of patients with mental illness has changed quite markedly in recent years. Outpatient community treatment clinics and departments of PSYCHIATRY based in general hospitals have been established. Patients with mental health conditions can be treated with various types of medication, thus avoiding long periods of hospital care. Issues such as depression and stress, frequently treated with anti-depressant drugs, are now commonly reported illnesses in Canada.

Early ambulation after surgical operations has been very effective in preventing postoperative complications such as venous clotting, lung congestion and general muscle weakness. Anesthetic methods have improved so that extensive surgical procedures can be performed even on elderly patients. Cardiac surgery and neurosurgery have made great advances. TRANSPLANTATION of organs is much more common and raises new ethical questions for the medical profession. Surgery of the blood vessels has progressed with the use of artificial replacement materials. The provision of blood transfusions by the Canadian RED CROSS SOCIETY has made possible many of the advances in surgery but that role was transferred to a new Canadian Blood Services Agency in 1988 after a controversy over Red Cross-managed blood supplies having become contaminated with the AIDS and hepatitis C viruses in the late 1980s.

Surgical advancements in Canada are significant. A significant development is surgery using a thin tube, such as an endoscope or laparoscope, with a light and camera on the end, which is inserted into the body and can be used to diagnose and treat a wide variety of diseases. Endoscope procedures are performed for upper digestive system like gastroesophageal reflux disease and laparoscopy for lower digestive and pelvic conditions. Abdominal surgery such as hysterectomy can now be performed using a laparoscope, greatly reducing recovery time and side effects for patients.

Emergency departments of hospitals have been provided with personnel and equipment to handle serious injuries, because trauma continues to be a major cause of disability requiring surgery. Microsurgery has made possible the repair of small blood vessels and operations on the ear to relieve deafness. In OPTHALMOLOGY LASERS have been used in the treatment of some retinal diseases and to correct common vision problems such as myopia.

DIABETES research and treatment was improved with the development of the breakthrough Edmonton Protocol at the University of Alberta. This transplant of pancreatic islet cells increases the production of insulin in a person with diabetes, and may end the need for injected insulin.

The understanding and treatment of epilepsy has advanced, and there has been considerable improvement in the outlook of patients with strokes because of extensive study by Canadian neurologists of this common affliction. The treatment of berry aneurysms of the arteries of the brain by neurosurgeons has been an outstanding Canadian development. Increasingly, people survive a STROKE. Quick treatment after a stroke with clot-destroying medications reduces the patient's chance of permanent brain damage. Knowledge of positive rehabilitation methods has improved patient recovery after stroke.

The application of ultrasound to many conditions, eg, liver and gall bladder disease, obstetrics, and cardiac function, has improved diagnosis and treatment. The introduction of computerized axial tomography (CAT scans) revolutionized the diagnosis of intracranial conditions, spinal cord lesions, abdominal masses and other conditions. The application of fiber optics to diagnostic instruments has greatly enhanced the examination of the stomach, duodenum and colon. This modification of equipment has allowed the catheterization of the common bile duct without surgical intervention and in some cases impacted gallstones can now be removed without surgery. Similarly, the lithotripter has been used to smash kidney stones in a safe way that also involves no surgery.

There have been many advances in the knowledge and treatment of autoimmune diseases. INFLAMMATORY BOWEL DISEASE, such as Crohn's disease, is becoming better understood, which improves patient outcome. Fibromyalgia is now a recognized autoimmune disorder, which has helped improve scientific knowledge of the effects of the disease. An increasingly important issue for patients with autoimmune diseases in Canada is access to treatment. Some medications have been developed that are very effective but also expensive. For example a modern biologic response modifier medication can treat inflammatory bowel disease, but the medication is very expensive and it is not universally available across Canada.

In obstetrics the emphasis has been on careful prenatal investigation, to discover high-risk situations in order to anticipate and prevent complications during delivery. The prenatal programs of preparation of the mother for the birth of the baby have allowed for delivery with a minimum of anesthesia. Other advances in the management of pregnancy include fetal monitoring during delivery, ultrasound examination of the fetus and placenta with vaginal ultrasound, and examination of the intrauterine amniotic fluid for genetic abnormalities in the fetus.

Diagnostic laboratories have greatly improved with automation and such developments as have been made in electron microscopy. Great advances have been made in the application of immunology and genetics in diagnoses. For example, by the use of monoclonal antibodies there is a much greater detection rate for malignancies and hopes for improved cancer treatment. It is now possible to detect abnormalities in fetuses and to offer prospective parents sound genetic information and analyses.

New Attitudes

There has been a complete change in attitude towards pregnant women, one result of which is increased family involvement in the birthing process. Midwives are also being incorporated into birthing plans more frequently, and in some provinces are covered by public and private insurance. Alberta, Saskatchewan, Ontario, Quebec, Manitoba, British Columbia and Northwest Territories all cover midwife services. In vitro fertilization has been carried out in Canada since 1983, resulting in successful pregnancies for women who could not otherwise have borne a child.

Departments of PEDIATRICS have changed considerably during the last century. Infectious diseases have declined markedly in incidence, and isolation hospitals have been closed. Emphasis has been directed toward neo-natal intensive care nurseries, congenital diseases, child neoplastic conditions and adolescent problems.

Some medical faculties have established divisions of SPORTS MEDICINE to study and treat the special needs of those engaged in athletic activities. The medical advancements made in sport medicine have also improved the outcome of hip and knee surgeries performed to relieve pain and damage to joints.

Emphasis has been paid to the rehabilitation of patients after injuries, following the development of disabling illnesses and after surgical procedures such as amputations. A specialty of rehabilitation medicine has been recognized, and rehabilitation centres have been established in many Canadian communities. Patients with paraplegia, strokes and other neurological and musculoskeletal diseases benefit from these programs, which include physiotherapy, occupational therapy, speech therapy and the use of facilities such as therapeutic pools.

Increased medical attention is being paid as well to the particular problems of the AGING population. A large proportion of medical and hospital care is devoted to the needs of individuals above 65 years of age. Many older patients become disabled to the extent that they require continual hospital care. The need for extended care or chronic care hospital facilities has always been greater than the supply. Geriatrics (the study and care of aging individuals) became recognized as a specialty in the 1980s.

For patients with terminal malignant cancers, some hospitals have established special hospice facilities that administer to the patients' emotional and spiritual needs and not just to the physical.

The health professions have become increasingly concerned with prevention of disease and injury, not only as a means of improving the health of their patients but also to reduce the cost of health care. To this end they have advocated the use of seat belts and participation in suitable FITNESS activities, and have supported anti-SMOKING campaigns and information programs concerning diet. Excessive weight is becoming a serious health concern in Canada, as it is in the US and around the world. The percentage of Canadians who are overweight or obese has been rising, creating increased risk for type 2 diabetes, cardiovascular disease, high blood pressure, osteoarthritis, some cancers and gallbladder disease. Additionally, excess weight is linked to psychosocial problems, functional limitations and disabilities. Medical and government agencies have implemented education programs to inform people of the risks and encourage healthier lifestyles.

For some people, bariatric (weight loss) surgery is a tool of last resort to assist with weight loss. It involves reducing the stomach to a small pouch, which is connected to the small intestine. The surgery does not offer a cure for the cause of obesity; candidates for the surgery must be committed to changing their dietary habits. Most provincial health care plans cover the surgical treatment of morbid obesity, but a wait time of 5 to 7 years for the surgery is not unusual. Private clinics offer the surgery for those who have private insurance or the means to pay the high cost. To qualify for bariatric surgery, patients must have a body mass index (BMI) of at least 35 and serious co-morbid conditions. Despite the narrow indications for the surgery, the number of people undergoing bariatric surgery in Canada has risen dramatically. In 2000, there were 78 procedures; in 2003 there were more than 1100. The number has fluctuated since then.

The use of complementary and alternative medicine is growing in Canada. Acupuncture, homeopathy, naturopathy and herbal medicine are being used more frequently, often as preventative medicine. Chiropractors are used by approximately 4 million Canadians annually for conditions like whiplash, and back and joint pain. British Columbia has recently started covering acupuncture under provincial healthcare plans, while chiropractors are usually covered across the country.

Challenges

The outstanding advances in many branches of medicine have led to improvement in the treatment and prevention of illness and injuries but have also created problems, eg, increasing costs of providing all available health care universally. Imaging devices now include computed tomography (CT) scans and magnetic resonance imaging technology (MRI) that use radio and ultrasound waves to depict two and three dimensional structures of the body, such as organs and blood vessels. The machines that make these imaging techniques possible are expensive in both cost and maintenance of the device. Significantly increasing the number of these machines across the country may not be feasible if insurance is to remain universal.

The health professions and the public must also confront ethical problems that arise with technical advances New medical technologies typically advance without governing regulations, which must be developed as the potential for use, or abuse, of the technologies is understood. Often a ROYAL COMMISSION is struck to investigate the public interest and social, ethical, legal, health, economic and other implications of new technologies to determine what safeguards should be applied and whether to disallow some aspect of a technology.

See also MEDICAL EDUCATION; MEDICAL ETHICS; MEDICAL RESEARCH