Vol 10 No 1 Le Spécialiste, The FMSQ Magazine Vol. 10 No. 1 - March 2008. Special Issue Featuring A "Dossier" On EXTREME BEHAVIOR

SPCIALISTE
10 YEARS
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THE FMSQ MAGAZINE

Vol. 10 no. 1 March 2008
EXTREME
BEHAVIOR
QUERULOUSNESS AND
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Word from the President

The Castonguay Report: a Survival Guide
Current Affairs
Interview with Dr. Michel Lallier, Vice President
Current Affairs
Business Relations in Obstetrics/Gynecology
Legal Issues
Did You Know That
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Weight Gain with Antipsychotics: Can it be avoided?
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Le rapport Castonguay : un guide de survie
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WORD FROM THE PRESIDENT

DR. GATAN BARRETTE
The Castonguay Report: a Survival Guide

he mandate of the group chaired by Mr. Castonguay
was clear and straightforward: to address the
problem of health financing. That is what it did, not
only with regard to sources of income, but also their
use. This was perfectly legitimate, because what is
the point of talking about income if you do not make
sure it is properly managed?
We believe that Mr. Castonguays diagnosis is correct. Basically, he

found that the collective wealth of Quebec cannot keep pace with
the growth of government health expenditures and the result will be
a yearly deficit of $7 billion in 2017 if nothing is done. To correct the
situation, he suggested two sets of measures: one relating to
sources of income, the other to their management.
Let us first look at the increase in health costs. What really can be
added? Of all the areas for which government is responsible, here
or elsewhere, health is probably the only field where the economic
forecasts of government and university experts and analysts, and
those of the economic world in general, have come to pass. They
told us health would account for 25%, then 33% and shortly 50%
of the government budget, and they were right. There is certainly
no reason to believe that current forecasts will not prove true. The
forecasts have always called for decisions to be made to control
expenditures, but the most that can be said is that this was very
rarely 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 finally
stops burying its head in the sand, it will have to decide where this
extra money is going to come from! That is the subject of the
Castonguay report.
As far as financing is concerned, the question is not whether the
solutions put forward are ideal, but whether they deliver the goods.
We believe that they do. And, if so, will their impact mean that they
will 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 the
guidelines 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 costs
can only continue to rise and ultimately exceed the governments
ability 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; a
return to a higher sales tax, which we have mentioned several times
in the past; and also the introduction of insurance.
The reports approach is also innovative as far as management is
concerned. Who can possibly argue with productivity and
efficiency? Or, alternatively, an improvement in the systems way of
doing things? As a background, the uneasiness expressed (or not)

by most observers (even the Minister), who have not noted any
sufficiently tangible change even though no less than $6 billion has
been added to health expenditures since 2000. But neither the
public nor commentators realize that this amount has, to a great
extent, been used to renovate a system that has been impoverished
for too long. As an example, nearly $1 billion has been spent during
this period on upgrading specialized medical equipment, $2.3 billion
has been used to absorb hospital deficits, and how much has been
spent on revamping decrepit facilities? It goes without saying that
upgrading is like renovating. One room is added at best, but that
does not mean the house is new because a portion of it now meets
current 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 the
policy is to move in the direction of only doing what is easy or
politically advantageous i.e., everything that concerns management and productivity. That is the danger. Remember what
happened to the Rochon report when only half of it was put into
effect. The next 15 years were disastrous. Yet Mr. Castonguays
report is clear. Whatever the scenario. Other sources of financing
must be found. We find it extraordinarily simplistic to think that only
new management methods, a changeover to purchasing services,
or increased productivity will halt the rise in costs. The reasons are
both simple and obvious. For some years now, the government has
had measures in place that enable it to obtain goods for the lowest
cost possible, and this particularly applies to medical supplies. It is
also the case for medications and specialized medical equipment.
Probably, no financial benefit can be gleaned from this area. Under
such circumstances, do we really think that we can achieve a nearly
10% gain ($4 billion) in productivity and improved management?
Productivity means producing a larger number of services, each at
a lower unit cost. Since the related costs (to those services) are
already low, does this mean that the next round of gains will be at
the expense of health professionals, who include physicians? The
government could move in this direction.
The Castonguay report gives a measured statement of the situation
and suggests avenues that we believe to be viable and those include
together, and not separately, management and financing measures.
as a result it should be clearly understood that, although we support
the principles underlying healthy management and productivity, we
will never agree to physicians professional independence being
called into question nor to them being penalized because of an
inability to make appropriate and timely decisions when we finally
come up against the unavoidable and clearly signposted bankruptcy
of Quebecs health budget.
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CURRENT AFFAIRS
Interview and report by PATRICIA KROACK, COMMUNICATIONS CONSULTANT
The FMSQ in action

Dr. 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.
Dr. Lallier, what topics are currently under

consideration at the Federation?
Life at the Federation has been very full over the past few
ML months, and were not finished yet. A great deal of
As far as the FMSQ was concer-
ML ned from the outset, it was out 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 been
taking much of our time during recent months. The
Federation has carried out a thorough review of the
mathematical model developed some ten years ago. We
can 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. Intensive
discussions 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
ML have recently initialed a Memorandum of Understanding
that members of the Department Head Group should be

properly compensated for this administrative task.
It should be remembered that the specialized medicine
department 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?
the question for executive committee members to receive the

general hourly rate given in the
Master Agreement i.e., $80/hour.
As it was a new activity and
keeping in mind the Federations
goal of significantly increasing
medical specialists clinical and
medico-administrative remuneration
it was important to negotiate a
more competitive level of compensation. The negotiations
were long and hard and it is thanks to the Federations
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 recognizing
the expertise of medical specialists, and we intend to
continue negotiations along these lines for all other medicoadministrative activities.
Has the same degree of progress been made

on other matters?
Substantial progress has also been made on two other
ML major dossiers: remuneration for teaching activities and

remuneration for research activities. Discussions on
university 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
ML requesting that this task be recognized and the appropriate

fees paid. It is a clearly established fact, it is the fundamental 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
has been made establishing a typical profile. We hope that

this analysis will lead to a denominator being put in place to
determine 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 those
who supervise training will be properly paid for this task. Just
how this will be done will be known in the near future.
The Committee on Conditions of Practice is now a
ML permanent fixture at the FMSQ. The Business Relations
Committee reports directly to the Negotiating Committee,

with subcommittees for the 24 business relation measures
agreed upon with the government during the most recent
round of negotiations.
Dr. Lallier, are you going to proceed in the

same way with regard to paying for activities
in teaching units?
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.
We know that the work carried out in a teaching unit (TU)
ML is more complex. This complexity must be recognized.
What are the Federations plans for uncoded

courses?
We are actively working on this subject. At present,
Specialized medicine groups (SMG GMS) is a joint project

of the Committees on Conditions of Practice and Business
Relations. Two projects are being developed by the
OB/GYN and pediatricians associations respectively, and
others are under way.
ML payment is generally made in two ways: fees-for-service
or 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.
L
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 students 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 activities
ML carried 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
sant du Qubec have already allowed us to find various
ways of increasing the remuneration received by research
investigators. The FMSQ has reopened discussions with
the MSSS on this subject and we intend to finalize the
terms and conditions without delay.
Turning to conditions of practice and

business relations
Ive been hearing about specialist responders

That is a Business Relations dossier. The government has
ML appeared open and willing to review and redefine the

psychiatrist responder project. The FMSQ hopes that the
concept of a psychiatrist responder, as defined by the
Association des psychiatres and which both the Association
and the FMSQ requested the government to review . that
the concept of a medical specialist responder (MSR) can be
applied to all specialists wishing to undertake this type of
work. A number of associations are ready to embark on this
project, including geriatricians, endocrinologists, obstetricians-gynecologists and pediatricians.
Unfortunately, we dont 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 the
question of sterilization.
Progressive Remuneration of Department Head Groups

Members: The hourly rate is $80 to $84 for the period January 1August 31, 2007. The hourly rate will gradually and substantially
increase to $120 as of September 1, 2007; $135 as of April 2008
and $150 per hour as of April 1, 2009. The remuneration is
retroactive to January 1, 2007.
Chair: The hourly rate is $80 to $84 for the period January 1August 31, 2007. Given the importance of the Chairs
responsibilities, the fee will be $150/hour as of September 1,
2007; $170 as of April 1, 2008 and $190 as of April 1, 2009. The
remuneration is retroactive to January 1, 2007
(*) UETMIS : Unit dvaluation des technologies et des
modes dintervention en sant
10
CURRENT AFFAIRS
DIANE FRANCOEUR, MD, FRSCS
PRESIDENT OF AOGQ AND CHIEF OF OBSTETRICS/GYNECOLOGY,

SAINTE-JUSTINE UNIVERSITY HOSPITAL CENTRE
Business Relations in Obstetrics/Gynecology

The Association des obsttriciens gyncologues du Qubec (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.
ver the past few months, an AOGQ task force has
been working on identifying the problems of
access of care. One of the AOGQs solutions on
how to promote access to specialized care is to
maximize the use of already-existing resources by
introducing a new operations model based on
well-established care protocols and making greater use of
partners in multidisciplinary teams. The operations model
assumes that the partners are properly trained and form an
integrated, coherent and stable work team whatever their
environment (teaching hospitals, affiliated hospital centres,
regional centres or offices).
OBSTETRICIANS/GYNECOLOGISTS ARE CALLED UPON

TO 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.
Present situation
Obstetricians/gynecologists are called upon to 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. An ideal practice mode could
change this situation. With that in mind, the Association des
obsttriciens gyncologues du Qubec has suggested an
operations mode to the MSSS that would provide Quebec
women with quicker access to the care they need.
Reorganization is essential that would make medical specialists
the centre of a multidisciplinary team, create specialized
medicine groups (SMG) and set up birth centres. But, first,
certain conditions must be met.
Prerequisites
Obstetricians and gynecologists offices are already overflowing
with patients and there must be an incentive to increase
productivity. On the hospital side, the glaring shortage of human,
financial and material resources blocks any improvement to
accessing OB/GYN care, such as ultrasound during the first and
second trimesters, prenatal screening and the management of
emergency situations.
We cannot ignore the present crisis regarding to the availability
of prenatal screening morphology ultrasounds. Immediate
dedicated financing is essential for the urgent training of
specialized ultrasound technicians and the acquisition of quality
ultrasound equipment, which must be available throughout
Quebec with the possibility of remote transmission for outlying
regions. The creation and financing of designated ultrasound
centres to screen for congenital abnormalities in hospitals via
the RUIS, is also vital, together with high-performance secretarial
assistance to manage emergency appointments and forward
information to the referring physician.
11
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 recommendations. Clerical staff specialized in interpreting these new data
must 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 are
already 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 obstetricians/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.
12
Obstetricians/gynecologists should remain responsible for the

same percentage of pregnancies but in partnership with other
health professionals (such as nurses and midwives), in offices,
general and specialized hospitals or affiliated hospitals.
Midwifery 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 present
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 collegial
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 health
professionals likely to intervene during a pregnancy, and these
people must be physically located in the immediate vicinity of
establishments that can provide potentially urgent services as
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 of
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 care
and the improved management of emergencies requires
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 additional
human resources (general practitioners, nurses, midwives,
ultrasound and laboratory technicians) and also material
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 improved
management of a large portion of the patient population and
greater availability for urgent consultations.
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ces traitements.
Le formulaire Avis motiv du mdecin qui a charge peut
tre remis au travailleur par la clinique o il reoit ses
traitements. Vous pouvez galement obtenir des exemplaires de ce formulaire pour les utiliser au besoin.
Au moment de remplir ce formulaire, vous devez
tout dabord faire part de lapprciation du bilan
fonctionnel de votre patient. Il faut y indiquer les
amliorations notes, depuis le dbut des traitements, sur le plan de la fonction et ne pas simplement y mentionner les symptmes rsiduels. Vous
trouverez des exemples au verso de la page dinformation qui accompagne le formulaire.
0OUR OBTENIR DES EXEMPLAIRES DU FORMULAIRE

VOUS POUVEZ NOUS JOINDRE AU #334
OU CONSULTER LE SITE 7EB WWWCSSTQCCA
Par la suite, vous devez indiquer vos recommandations

concernant les traitements de physiothrapie et dergothrapie en cours ou venir.
Lorsque vous recommandez la poursuite des traitements, vous devez motiver votre avis en regard des
amliorations recherches sur le plan fonctionnel,
et non pas seulement des symptmes.
Le formulaire rempli et sign doit tre retourn au
physiothrapeute ou lergothrapeute qui donne
les traitements.
Idalement, le formulaire Avis motiv du mdecin qui a
charge devrait tre rempli peu avant le moment o le
travailleur atteint la premire des deux chances
(8 semaines ou 30 traitements).
Exceptionnellement, pour certaines lsions svres,
vous pouvez indiquer de faon prcoce que les soins
devront se poursuivre au-del de 8 semaines ou de
30 traitements en expliquant la situation particulire.
Un seul avis motiv est ncessaire pour une mme rclamation. Il ny a pas dautre avis requis une fois pass le
seuil des 8 semaines ou de 30 traitements. Il ny a donc
quun seul avis payable pour une rclamation.
Ces changements ont t mis en place avec la participation et le soutien des fdrations mdicales et des
associations de spcialistes concernes.
Le formulaire Avis motiv du mdecin qui a charge,
lorsquil est dment rempli, donne droit une rmunration de 110 $ en fonction du code dacte 09900.
Pour toute question ou information complmentaire, vous

pouvez communiquer avec un mdecin-conseil du bureau
rgional de la CSST le plus prs de chez vous.
LEGAL ISSUES
Matre SYLVAIN BELLAVANCE
DIRECTOR, LEGAL AFFAIRS
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.
ver 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. On December 10, 2007,
however, the Quebec Court of Appeal handed down
a decision which clarifies some of these rules. The question was
to determine whether a tax payer could deduct expenses for
more than two conventions per year from his income.
OVER THE YEARS, THE TAX AUTHORITIES HAVE ISSUED

VARIOUS INTERPRETATIONS AND INSTRUCTIONS
Symposium
of
the
Association dorthopdie
du Qubec (the AOQ)
held at Montebello were
rejected; the Symposium
included both continuing
medical education activities on back pain as well
as the AOQ annual
general meeting. Dr.
Adam contested this decision before the Quebec Court.
Quebec Court
The question to be settled was the relationship between two
sections of the Tax Act i.e. sections 128 and 157(c).
CONCERNING THE RULES GOVERNING THE DEDUCTION

OF EXPENSES INCURRED BY PHYSICIANS IN SUCH CASES,
BUT THERE HAVE BEEN FEW DECISIONS IN THIS REGARD.
The facts
Dr. Robert Adam is an orthopedic surgeon who has been practising
in Abitibi for more than 30 years. Under the Master Agreement,
medical specialists located in remote regions are entitled to a
maximum of 20 days resourcing per year. During this time,
specialists can receive $375.00 per day for resourcing, in addition
to the payment of transportation and accommodation expenses.
In 1996, Dr. Adam took part in seven continuing education
activities. On his tax returns, he therefore deducted a total of
$12,000 covering the cost of taking part in conventions and
continuing education activities.
Upon analyzing his income tax return, Revenu Qubec
considered that four of his activities were related to further
education and three were conventions. The expenses for the
four educational activities were accepted but expenses for only
two of the conventions were approved. Revenu Qubec based
its decision on the fact that the Tax Act provided for a maximum
of two conventions per year. Expenses for the Annual
14
Section 128 is the general rule that allows any tax payer
earning a business income (which, generally speaking,
includes physicians fees-for-act or mixed method remuneration)
to deduct expenses incurred in earning this business
income. Section 157(c) is a specific rule which provides that
a tax payer can only deduct expenses incurred for a
maximum of two conventions per year.
Dr. Adams lawyer argued that it should first be determined
whether the expenses of the Montebello symposium represented
allowable expenses under the general rule at section 128. If so,
the expenses were deductible, despite the maximum of two
conventions set out in section 157(c). That would mean that
section 157(c) and hence the deduction of expenses for a
maximum of two conventions would only apply in cases where
section 128 did not allow such a deduction.
On the other side, Revenu Qubec lawyers argued that the
provisions of section 128 did not apply and section 157(c) should
prevail. Consequently, convention expenses could only be deducted
for a maximum of two conventions under this latter section.
Mr. Justice Denis Lavergne of the Court of Quebec agreed with

Dr. Adam and authorized the expenses of the Montebello
Symposium. He concluded that the first step would be to
determine whether the expense was deductible under the
general rule contained in Section 128 and, if this was not the
case, only then would section 157(c) and the maximum of two
congresses apply. In the judges opinion, the expense in question
was deductible under the general rule in section 128, mainly
because there was a direct link between expenses for the
Montebello symposium and Dr. Adams income, as the latter had
included in his return the amount obtained under the Master
Agreement for resourcing expenses.
Quebec Court of Appeal

Disagreeing with this decision, Revenu Qubec decided to
appeal the matter to the Quebec Court of Appeal. At Dr. Adams
request, and because the decision could have an impact on
medical specialists as a whole, the Federation decided to
intervene in order to assist him before the Court of Appeal.
The results of the appeal were highly positive. In its decision, the
Court dismissed the Revenu Qubec appeal and upheld the
decision of the Quebec Court. It confirmed that Dr. Adam was
entitled to deduct the expenses of the Montebello symposium
and also awarded costs of $17,208.52 against Revenu Qubec
in order to reimburse the greater part of the legal fees incurred
with regard to this matter.
Following the example of the Quebec Court, the Court of Appeal
judges also confirmed that the first step was to determine
whether the expense was deductible under the general rule in
section 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 section
128, but for a different reason than that held by the first judge in
the Quebec Court. They considered that there was no reason to
conclude that the amount could be deducted simply because
Dr. Adam had received a refund of $375.00 per day for
resourcing costs. The Court of Appeal instead authorized the
deduction of the Montebello symposium because it considered
it was not a convention per se but a continuing education activity.
The Court dismissed the arguments of Revenu Qubec lawyers
that 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 detailed
program revealed that out of the five half-days of the symposium,
four were devoted entirely to courses on back pain that were
organized by the AOQ continuing medical education committee.
The only actual convention activity took place during the final
half-day of the program when the Associations annual general
meeting was held.
The Court thus dismissed the argument

put forward by Revenu Qubec lawyers
that once a convention-type activity is
included, an event has to be deemed a
convention even if the greater part of
the activity is devoted to continuing
education. The Court held instead that
the principal or predominant purpose of
the activity should be taken into
consideration. As the main objective of
the symposium was to dispense
education, the expenses incurred were
deductible under the general rule
contained in section 128.
In conclusion
THE COURT HELD INSTEAD

THAT THE PRINCIPAL OR
PREDOMINANT PURPOSE
OF THE ACTIVITY SHOULD
BE TAKEN INTO
CONSIDERATION. AS THE
MAIN OBJECTIVE OF THE
SYMPOSIUM WAS TO
DISPENSE EDUCATION, THE
EXPENSES INCURRED WERE
DEDUCTIBLE UNDER THE
GENERAL RULE CONTAINED
IN SECTION 128.
Although the Court of Appeal decision

favoured Dr. Adam, its scope should be
clearly understood. Contrary to what
might be thought, this does not mean
that a physician is no longer affected by the rule of a maximum
of two conventions per year. However, the Court of Appeal
decision does allow far greater flexibility when determining the
nature of the activity attended by the physician. Once the main
and predominant objective is to dispense education, expenses
incurred could be deductible under the general rule at section
128 regardless of what the activity is called or whether a
convention-type activity is grafted on to it. In such cases, a
physician can deduct an unlimited number of educational
activities from his business income provided all conditions are
met. The limit of two conventions a year can only apply if the
main 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 order
to ensure that the physicians attending them are not subject to
any tax penalties.
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.
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.
15
DID YOU KNOW THAT...
Le Spcialiste: 10 Full Years!

In 2008, the FMSQs magazine will be
celebrating its 10th anniversary.
lthough the Fdration des mdecins spcialistes

du Qubec issued information folders on three
occasions in 1997 and 1998 (also called Le
spcialiste), the magazine format we know today
was first published in April 1999. This therefore
gives 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 the
progress made with regard to the Federation and the
organization 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 (or
disappeared). We will be giving short extracts in every issue this
year concerning matters covered in Le Spcialiste in 1999. It will
also be an opportunity to add input on certain topics that are still
making news today.
Extract from Vol. 1, No.1

Expected in the fall of 1999
Quebec gains a medical staffing
plan
Dr. Jacques Provost, the FMSQs
Director of Professional Services
(1999) was confident that representatives 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
16
Le Sp
cialiste
s First
Edition
to associations suggestions. However, he also recognized that

We continue to surround ourselves in Quebec with
administrative structures to try and justify a legal health system,
instead of trying to solve problems by viewing the organization
of medical care as fundamental to medical staff planning,
meeting human objectives and thus ultimately improving the
health of Quebecers.
A STAFFING DISTRIBUTION PLAN MUST

BE ABLE TO DISTRIBUTE MEDICAL STAFF
THAT ACTUALLY EXISTS.
Ten years later, Dr. Provosts successor, Dr. Serge Lnis is sad to
relate that nothing has changed. A staffing distribution plan must
be able to distribute medical staff that actually exists. At present,
we are distributing shortages, estimated at 800 medical
specialists in 2008. This is not only impossible to manage, but
leaves absolutely no room for manoeuvre. Worse still, the plans
totally ignore human factors and other considerations such as
age or gender. For example, with the present type of planning, it
is still hard to factor in two physicians, husband and wife, who
would like to work in the same region or hospital; a replacement
because of illness; maternity leave; or a decrease in professional
activities for family reasons or age.
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 and
pediatrician responsible for the remote
health care program at CHUQ, discussed remote health care monitoring
in 1999 as an essential tool for
accessing care. These new information and communication technologies () open up fresh
diagnostic and therapeutic possibilities that will change the way care
is provided and help create a true network of services. The
expected growth in new advanced communication technologies
was expected to solve major issues in the health system: distribution
of medical staff, access to care, and increasing costs. However, the
author admitted that there would be a lot of ground to cover before
remote monitoring would be introduced, particularly with regard to
remuneration. Dr. Cloutier concluded his article by saying that
remote health care monitoring is a choice for society, a collective
challenge 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 dozen

hospitals in Eastern Quebec. Since that time, an assessment by
the Centre de Sant publique at Quebec City has once again
highlighted the importance of such a tool in the distribution of health
care and confirmed its economic potential1.
Today, Dr. Jean-Paul Fortin, Dr. Cloutiers successor, agrees that
much 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 this
technology in the field; they are its champions and people of vision.
They are working on convincing confirmed unbelievers. Quebec
already has 350 fully-equipped videoconferencing outlets on the
RTSS2. We are awaiting funding from Canada Health Infoway to
allow us to continue with our development plan. Today, remote
health care monitoring tools are mainly used for consultation,
conferences, training and a whole host of other types of remote
follow-up. All medical teams can benefit from its many applications,
particularly those in remote regions or those who do not have full
medical resources on site.
L
1
Rseau qubcois de tlsant,

http://www.rqt.qc.ca/fr/historique/index.asp, accessed February 21, 2008
(In French).
RTSS : rseau de tlcommunication sociosanitaire
Annonce du 1er CONGRS CANADIEN SUR LA SANT RESPIRATOIRE
19 21 JUIN 2008
Prs ent pa r
Htel Hilton B onaventure Montral, Q ub ec
En collaboration avec :
Pour vous inscrire, veuillez consulter www.poumon.ca/crc

17
IN THE NEWS
New arrival at the FMSQ
Doctor Michle Drouin becomes Director, Analysis
and Fee Planning
On the job since the
beginning of the year, Dr.
Michle 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 role
in 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.
Computerized Health Records: Couillard

Changes Mind and Advocates Opting Out
On November 27 last, the Minister of Health and Social Services
announced, with the tabling Bill 70, his intention to return to the
principle of tacit consent i.e. the principle whereby it is
assumed that everyone consents to information circulated
unless they explicitly exclude themselves.
According to the Minister, that is the wish of most people in the
health system and, in particular, health professionals and
establishments. He admitted that introducing an opting-in
mechanism, or expressed consent (which is now the case) is
extremely complex, cumbersome and costly.
In the last issue of Le Spcialiste, Dr. Gatan Barrette indicated
that the FMSQ will not hesitate to issue guidelines to its
members if the government continued with the opting-in plan
and the coercive measures affecting physicians now in the Bill.
Dr. Barrette considers that the return to opting-out is a step in
the right direction, but that there is still a great deal of work to
be done to make this matter acceptable to both physicians and
the public at large. One of the things to be ensured is that
medical specialists will be reimbursed for all the costs involved
in computerizing health records. The FMSQ will continue to
monitor this issue, which has a direct impact on the organization
of health care in Quebec.
A pilot project on computerized health records should start this
spring in the Quebec City region where a Family Physician
Group (GMF), two medical clinics, the three CHUQ hospitals
and some pharmacies will test such health records for a period
of 6 months.
GOLF !
The SMEQ becomes the SEEMLQ

The Socit des mdecins experts du Qubec
has changed its name and is now known as
the Socit dvaluation et dexpertise mdicolgale du Qubec. The change was made official in December
2007 during a meeting of the Board of Directors chaired by Dr.
Georges LEsprance. The Society has more than 160 active
members, selected by means of a specific process based on their
previous expert reports. The SEEMLQs aim is to promote
excellence in the field of medicolegal evaluation.
18
Yes! Its time to start thinking about summer! The FMSQ

invites 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 received
for 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 part
in it. Download the registration form from www.fmsq.org.
Call for candidates Prizes and grants
New Books
The Conseil qubcois de dveloppement professionnel continu

des mdecins (CQDPCM), which reports to the Collge des
mdecins du Qubec, is launching the Prix de la recherche en
DPC and the Prix de linnovation pdagogique en dveloppement
professionnel continu 2008.
Psychologie du vieillissement Comprendre pour intervenir

Published by Groupditions, this book introduces the principal
concepts, theories and models put forward by the latest research
in gerontology. It includes many case studies and indications as
to when intervention is required.
Prix de la recherche en DPC:

A prize of $1,000 will be awarded to a health professional or
Continuing Professional Development trainer residing in Quebec,
who has authored a CPD research project.
Mdecine tropicale, sant internationale et sant de

lenfant immigrant
Drs.Selim Rashed, Louise Trudel, Tinh-Nhan Luong, and Caroline
Pedneault
Prix de linnovation pdagogique en DPC :

A prize of $1,000 is awarded to a physician or group of Quebec
health professionals or educators who have developed an
innovative Continuing Professional Development project designed
for physicians. The project may still be under way or ended, and
its objective will be the improvement of medical practice or
continuing education activities.
For more details on this call for candidates, please consult
the CEMCQ French-language site at www.cemcq.qc.ca/fr/
index_prix.cfm.
This book is designed to improve medical

practice with regard to tropical, parasitical,
viral or bacterial diseases. It contains a
section on international pediatrics which, in
addition to dietary problems, anemia and
contagious diseases, deals with problem
situations that might arise from immigration
or international adoption and the difficulties
families must sometimes face. A laboratory
section describes the various methods used to identify parasites
as well as the principal methods used to stain bacteria.
Grants for clinical training
The Quebec Association for Chronic Pain is offering grants to

candidates interested in clinical training with regard to chronic pain.
For further details, please consult www.douleurchronique.org.
Le Spcialiste
19
Prparez-vous prendre les

meilleures dcisions pour votre pratique
Les professionnels de la sant comparent le crdit-bail et lachat dquipements
Selon Dr Gary Stenzler, bon nombre de

professionnels de la sant pensent que
dtre un bon clinicien les maintiendra
lavant-garde dans leur domaine. Or,
vous devez galement grer votre entreprise convenablement , dclare Dr
Stenzler, propritaire dun cabinet de
dentiste en Ontario.
Pour rester lavant-garde , il faut savoir
prendre les bonnes dcisions en matire
dquipement - non seulement quelles
pices acqurir et quand, mais galement
sil est prfrable dacheter ou de louer, et
de qui.
De telles transactions peuvent avoir
dnormes rpercussions sur votre pratique
et vos finances. Ainsi, Dr Stenzler a ngoci
un crdit-bail par lentremise de RBC
Banque Royale, qui lui a permis de raliser
dimportantes conomies en versements
mensuels comparativement ce
quoffraient les concurrents.
Son conseiller, Craig Gibson, affirme que
Dr Stenzler est un homme daffaires trs
avis. Mais M. Gibson, premier directeur de
comptes, Professionnels de la sant RBC,
ajoute que plusieurs dentistes et mdecins
ne sont pas aussi laise avec laspect
affaire de leur pratique, y compris avec les
dcisions en matire dquipement.
Ces dcisions peuvent tre complexes et
de nombreux facteurs entre en ligne de
compte, par exemple la ncessit dacqurir
lquipement et sa dure de vie ; il faut
aussi voir aux questions financires,
notamment les liquidits et les incidences
fiscales.
PUBLIREPORTAGE
Voici ce que les mdecins et les dentistes

doivent garder lesprit pour faire les choix
les plus judicieux en matire dacquisition.
Combien de temps durera

lquipement ?
Dr. Guertin, qui sont galement tous deux

comptables, le savent trs bien.
Il ny a pas de bonnes ou de mauvaises
solutions mais il y a une srie de pour
et de contre analyser , prcise
Mme Carvalho.
Commencez par la sorte dquipement.

Lucy Carvalho, associe dans le cabinet de
chirurgie plastique de son mari, le docteur
Charles Guertin de Montral, envisage
souvent les dcisions en matire
dquipement de la mme faon que lorsquil
sagit dacheter une maison ou une voiture.
Certaines pices dquipement sont
comme une maison elles dureront
longtemps et reprsentent un investissement solide (pensez un fauteuil dentaire). Dans un tel cas, comme pour une
maison, Mme Carvalho prfre tre
propritaire.
Dautres pices dquipement, dclaret-elle, sont comme une voiture elles
fonctionnent bien actuellement mais vous
pourriez dsirer les changer assez
rapidement (pensez un ordinateur). Tout
comme dans le cas dune voiture, o elle
dsire avoir le plus rcent modle, un
crdit-bail est plus logique pour elle.
La technologie change rapidement ,
prcise Mme Carvalho, alors la dcision de
louer ou dacheter repose sur le fait de
savoir si lquipement durera longtemps ou
sil deviendra rapidement dsuet.
Les dcisions de location ou dachat ne
sont toutefois pas toujours aussi videntes
en raison des nombreuses questions
financires en jeu. Mme Carvalho et
Liquidits et souplesse
Il faut dabord considrer les liquidits,
ajoute Dr Stenzler. Je dispose dune marge
de crdit pour ma pratique. Je peux donc
faire un achat laide de cette marge, mais
cela rduira mes liquidits disponibles. Le
crdit-bail peut servir de solution de
rechange qui me permettra de ne pas
toucher mon coussin financier.
Une marge de crdit-bail prapprouve peut
tre avantageuse, ajoute Dave Magier, viceprsident, financement dquipement RBC
Banque Royale. Tout comme pour les
hypothques prapprouves, cette marge
de crdit-bail est assortie dune valeur
prtablie. Ainsi, les mdecins et dentistes
disposent de la souplesse ncessaire pour
profiter des occasions dachat rapidement,
leur gr et au moment propice.
Outre le montant dargent, pensez aux
autres modalits. Par exemple, vous pouvez
ngocier un crdit-bail pour y inclure
lentretien, les mises niveau et dautres
services. La dure dun crdit-bail joue
galement un rle ; il serait logique de
choisir un bail de cinq ans lorsque
lquipement peut durer de sept dix ans,
mais une autre solution serait plus adquate
si lquipement risque de devenir dsuet
dans trois ans.
la fin du bail, vous aurez loption de
racheter lquipement, ou encore de le
renouveler ou simplement de le retourner.
Vous profitez donc dune souplesse
maximale. Si vous songez au rachat, tenez
compte de ce montant dans le total de vos

cots, et pensez la valeur de lquipement
la fin du bail.
Dans le cas du Dr Stenzler, le cot du rachat
tait plus lev que le simple petit montant
quil aurait eu dbourser auprs dun
autre fournisseur de crdit-bail. Par contre,
les conomies mensuelles, sur plus de
60 mois, compensaient grandement.
Noubliez pas la structure de proprit de
votre pratique, ajoute M. Magier. Il cite le
cas dune clinique qui compte de nombreux
associs. Lorsquils effectuent des rnovations leur bureau, plutt que dutiliser
largent de leur compte capital (le montant
quils mettent en commun comme une
partie de leur investissement dans la
socit en nom collectif), ils louent
lquipement. Si un associ quitte la socit
ou sy joint avant la fin du bail, il na payer
quune part proportionnelle de lutilisation
de lactif.
Le crdit-bail peut galement tre avantageux
lorsque vous essayez de nouveaux modes
de traitement. Mme Carvalho et son
conjoint ont lou un nouveau laser, avec
option dachat, parce quils ne savaient pas
comment les clients allaient ragir, et sils
auraient suffisamment de nouveaux clients
pour justifier cette dpense. Dans ce cas, la
location constituait un moyen de tester le
potentiel de lquipement, sans faire un
gros investissement incertain.
Toutefois, lachat comporte galement une
certaine forme de souplesse, affirme Dr
Stenzler. Vous pouvez avoir un crdit-bail
long terme, et constater que lquipement
ne convient pas votre pratique. Si vous
laviez achet plutt que lou, vous pourriez
le vendre dans le march secondaire.
Autre point prendre en compte Certains
professionnels de la sant prfrent tre
propritaire et avoir le contrle de leur
quipement , ajoute M. Magier.
Songez aux incidences fiscales

Les mdecins et les dentistes doivent voir
lensemble de la situation lorsquils ont des
dcisions prendre au sujet de leur

quipement, prcise M. Magier. Disons que
vous dcidez dacheter. Avec un prt de
dure standard, vous devez payer toutes les
taxes (c.--d. la TPS et la taxe de vente
provinciale) au moment de lacquisition, et
le prteur long terme peut galement vous
demander un montant forfaitaire (certains
prteurs terme, non pas RBC, peuvent
demander jusqu 25 %).
Avec loption de crdit-bail, nous pouvons
fournir jusqu 100 % du cot, affirme
M. Magier, ce qui accorde un certain rpit
aux liquidits, prserve votre fonds de
roulement pour dautres fins et vous permet
de payer les taxes mesure plutt quau
moment de lacquisition.
Le crdit-bail peut tre avantageux du point
de vue fiscal, parce que dhabitude, une
part quivalant 100 % des loyers est
dductible. Par contre, lorsque vous tes
propritaire, vous ne pouvez radier que
lintrt, et devez dprcier lactif sur une
certaine priode de temps (qui varie selon
lactif).
Il existe toutes sortes dincidences fiscales
et diverses solutions cratives soffrent
vous lors de lacquisition de lquipement.
Il est prfrable den parler avec votre
comptable.
Par exemple, Dr Ian McKee, un orthodontiste
dEdmonton, a dcid dtablir, avec son
associ, une compagnie distincte de crditbail mobilier, dacheter de lquipement au
moyen du financement fourni par RBC, et de
le louer sa pratique par lentremise de
cette nouvelle compagnie. La raison ? titre
dorthodontiste, Dr McKee pouvait rcuprer
100 % de la TPS sur ses achats, dans la
mesure o il faisait lachat par lentremise
dune compagnie de crdit-bail distincte.
Outre largent, la souplesse et les taxes,
les professionnels de la sant devraient
galement penser au temps quils dsirent
passer grer le processus.
Nous savons que pour la plupart des
mdecins ou dentistes, le temps est
primordial, affirme M. Magier. Si leur
quipement provient de plusieurs

fournisseurs, nous pouvons grouper toutes
les factures en une seule transaction de
crdit-bail - et nos reprsentants peuvent
grer le processus de financement auprs
de tous les fournisseurs.
Demander les conseils de spcialistes

Dr McKee souligne que les cots, les taux et
les termes sont tous des lments essentiels
lorsquon prend des dcisions dacquisition
dquipement. Mais des conseils pertinents
et neutres ont encore plus dimportance.
Peu importe la faon dont vous voulez
financer lquipement, il est sage davoir
recours des spcialistes, quil sagisse
dun avocat, dun notaire, dun comptable
ou de votre banque.
RBC, par exemple, a des directeurs de
comptes partout au Canada qui sont
spcialement forms pour venir en aide aux
mdecins et aux dentistes et qui peuvent
procder une analyse personnalise pour
dmontrer les avantages ventuels du
crdit-bail par rapport lachat.
Il se trouve que RBC offre un meilleur taux
dintrt. De plus, jai trait directement
avec un spcialiste des soins de sant, qui
connat notre situation, conclut Dr McKee.
RBC a compris toute la dynamique de
ma pratique.
POUR EN SAVOIR PLUS SUR NOS SERVICES ET

SOLUTIONS POUR VOS BESOINS PROFESSIONNELS ET PERSONNELS, COMMUNIQUEZ AVEC :
Nader Guirguis, MBA, B.I.B.C.

Vice-prsident,
March des professionnels de la sant,
RBC Banque Royale,
1 Place Ville-Marie, 8e tage, aile Est,
Montral (Qubec) H3C 3A9.
Tlphone : 514 874-5042
Ou visitez notre site Web
www.rbcbanque royale.com/sant
Ou composez le 1 800 80 SANT
(1 800 807-2683).
Les stratgies, les conseils et le contenu de la prsente publication sont offerts 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 limplantation dune stratgie ou dune stratgie de planification fiscale afin de sassurer que leur
situation particulire fait lobjet dun examen appropri reposant sur les derniers renseignements disponibles
Marques dposes de la Banque Royale du Canada, RBC et Banque Royale sont des marques dposes de la Banque Royale du Canada. (02/2008) VPS45024
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Un produit de
DOSSIER
EXTREME
BEHAVIOR
Last November, the 2007 Pierre-Forcier Symposium, presented by the

Socit des mdecins experts du Qubec (which has since become the
Socit dvaluation et dexpertise mdico-lgale du Qubec), dealt with
the 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 they
actually 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 Spcialiste 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:
communications@fmsq.org.
L E S P C I A L I S T E V O L . 1 0 no 1 M a r s 2 0 0 8
23
EXTREME
BEHAVIOR
By Dr. Jacques Gagnona
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.
personally had the experience of dealing with someone
who had mobilized considerable resources to win his case
which was, in actual fact, fairly minor against his
employer. In this legal saga, the person attacked his
employer, the chief executive of the company, his union
and the physicians who had assessed his case. He
multiplied his complaints to the Collge des mdecins du
Qubec, which rejected them. He lost his case on appeal after
what had been a costly legal saga for all concerned. It was more
than stubbornness; it was a case of someone who wanted to
win his point of view at any price, regardless of the cost.
Querulousness is first of all a clinical concept and has described

a specific psychiatric entity for many years. The nature and
characteristics by which this entity can be recognized are given
below, together with some examples.
Definition
Querulousness, as a social behavior manifested by the abusive
use of the court system, can be explained by the persons
psychological profile. By extension, we can include similar
behaviors that take place outside the judicial process: for
example, claims made to administrative or political authorities.
SUCH PEOPLE DEVELOP AN ABERRANT TYPE OF

SOCIAL BEHAVIOR, STUBBORNLY CLAIMING
REPARATION AND MAKING EXCUSES SO THAT
THEY CAN RECOVER THEIR HONOR OR THE
RIGHTS THEY BELIEVE THAT THEY HAVE LOST.
Their claims may be real or imaginary. In all cases, their judgment

is seriously altered by the feeling that someone deliberately
wished to harm them. Those who oppose them quickly become
their new enemies and are included in their legal proceedings.
The police, physicians, social workers, lawyers and judges are
shown no mercy and may be sued. Querulous litigators show a
deep distrust of authorities who do not share their point of view,
leading to the vexatious actions they take against them.
As they have confidence in no one, such litigators represent
themselves. They find it difficult to accept an approach that is
less radical than their own, and thus rapidly dispense with the
services of a reasonable lawyer. They base their arguments on
premises that are false or wrongly interpreted. They stubbornly
defend their point of view, and do not let themselves be
demoralized by failures or warnings. They consider these as
additional proof that the legal system is unjust. Their applications
to the Courts become increasingly numerous. They appeal
judgments right up to the Supreme Court, as if their case was of
national interest.
Vexatious litigators who are intelligent are also inventive. They
make unexpected detours which have the effect of multiplying
interventions and slowing down the legal process.
In rare cases, such litigators can go so far as to kill their
persecutor. They will defend themselves, feeling no remorse
despite their awareness of wrongdoing, because they are
applying their version of justice since they have no confidence in
the judicial system. Valery Fabrikant was one such litigator who
resorted to murder in order to have his rights recognized and
recover his honor.
Social and psychological profile

Vexatious or querulous litigants have been described as
suffering from systematic chronic dementia (or paranoia), making
claims and close to the frenzied passion of erotomaniacs and
jealousy. They will ruin themselves in the courts in order to win a
claim which is sometimes derisory. They defend their honor, rights
or property regardless of their very obvious best interests.
24
Vexatious or querulous behavior becomes apparent mainly

between the ages of 40 and 60 in intelligent people with sufficient
knowledge to succeed in their mission. They have often
experienced failure or frustration in their personal or professional
lives. Their injured narcissism is the catalyst; the judicial process
becomes their stage. They already know or learn what they need
to about the law and legal process in order to proceed with their
complaints. Apart from their assertions, they may behave
normally in society, be well organized and hard-working.
QUERULOUSNESS AND VEXATIOUS BEHAVIORS
THEIR CLAIMS MAY BE REAL OR IMAGINARY.

IN ALL CASES, THEIR JUDGMENT IS SERIOUSLY
ALTERED BY THE FEELING THAT SOMEONE
DELIBERATELY WISHED TO HARM THEM.
Those most severely affected demonstrate a structured, sectorial

manic thought process with a persecution complex. Their
paranoid thoughts originate in the fundamental, implacable
premise that they are the victim of persecution, theft or some
other scheme to discredit them. This unshakable conviction,
despite a lack of any proof, alters their judgment which appears
to 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 a
pathological personality profile. This would be paranoid in nature:
cold, rigid and distrustful, with mental projection sufficiently
anchored 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 to
explain their excessively demanding behavior. As people are not
made 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 2
children. He was an Associate Professor of Mechanical
Engineering at Concordia University. His application to become
a titular professor had previously failed.
In 1992, he sued two colleagues requiring that they withdraw
their names from articles he had published. He accused Mr.
Justice Gold, the Universitys Chancellor, of appointing corrupt
judges to hear his case. On August 24, 1992, the eve of his
contempt of court hearing, he shot four professors who were
his colleagues and wounded a secretary.
The Court declared him to be a vexatious litigator in 2000, after

he presented multiple suits, appeals and frivolous proceedings.
On November 5, 2007, Valry Fabrikant again appeared before
the Court to resume the legal action begun in 1992, which was
interrupted by his killing spree. He still demanded reparation
from the professors he had killed. He also wanted to sue the
judge of a previous trial and obtain his apologies for having
convicted him. Mr. Justice Gilles Hbert recused himself on
November 13, after just a few days, because he could no
longer endure Fabrikants insults and recriminations. His
replacement, Madam Justice Nicole Morneau, took the case
and, after one week, terminated the trial on the basis that it was
frivolous and without foundation.
Conclusion
Vexatious or querulous litigants suffer from a psychiatric disorder
that changes their social behavior. The cost is high for everyone:
their family, society and the functioning of the Courts. Judicial
procedures can limit the damage by declaring such people to
be vexatious (querulous) complainants, which means that they
must obtain prior permission from a judge before bringing a case
to court.
Psychiatry is poorly equipped to help such people because of
their projective defense. They do not feel ill; they believe they are
victims of the system. They are alert to any contradiction likely to
demonstrate their basic premise i.e. even therapists can form
part of the system persecuting them.
In theory, a therapeutic approach should concentrate on the
narcissistic injury that triggered the storm, focus on the person,
acknowledge behavior adaptation, and avoid criticizing vexatious
behavior. The care team must have an unshakable cohesion and
a high degree of transparency.
Neuroleptics, if the patient agrees to take them, seldom cure
systematic dementia but, in some cases, a reduction in tension
and behavioral lapses can be hoped for.
Close cooperation between psychiatry and the justice system
must be ensured in order to respond to the highly predictable
manoeuvres of people who bring their internal psychodrama
before the forum of a court of justice.
The long and difficult trial was stopped by the judge after five
months of delaying tactics and abusive language. Valery
Fabrikant was imprisoned for life. The Court rejected the
concept of psychosis, which would allow a verdict of not guilty
by reason of mental disorder.
Jacques Gagnon M.D., CSPQ, FRCP, Psychiatrist, C.H. MaisonneuveRosemont, Assistant Clinical Professor, Universit de Montral.
25
Mr. Justice Yves-Marie Morissette

Quebec Court of Appeal
EXTREME
BEHAVIOR
Judicial Control of Querulous Litigants

querulous person is defined in the Rules of the
Code of Civil Procedures as someone who, while
exercising his/her right to start legal proceedings,
will do it in an excessive or unreasonable manner.
A further definition in the Grand Robert de la
langue franaise also gives an accurate idea of
the troubling behavior observed in certain litigants: A
pathological tendency to seek out quarrels and to claim
compensation for a prejudice, real or imaginary, in a manner
disproportionate to the case. Although there are few vexatious
or querulous litigants in absolute numbers, such individuals
create serious problems for the people who have to face them
in court and they take up the time and resources of the courts
to an egregious degree. One characteristic of such people is
that they represent themselves, either because they do not want
to retain legal counsel or because they cannot find a lawyer
prepared to represent them.
to the same affair. The court referred to a previous, unreported

decision in Suir v. Newton (date unknown), where it had issued
the same type of order.
Several years later, in 1896, the British Parliament, concerned by
the problem of vexatious litigants (of whom querulous litigants
are probably the most harmful) adopted a law that generalized
the mechanism created by the Grepe decision, with a few
changes. Under this law, the Attorney General could henceforth
apply to the High Court for an order prohibiting a vexatious
litigant from taking any type of legal action without first obtaining
the permission of a judge of that same court. The party being
harassed by a vexatious litigant could always apply for a Grepe
order. In addition, the Attorney General could intervene to
prevent vexatious litigants from multiplying abusive proceedings
against new parties.
The solution under Quebec law

Judicial control of the problem
Since 2003, various regulatory provisions have been adopted
in 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 several
years beforehand. A 1994 case, Yorke vs.
Paskell-Mede [Yorke], which set a precedent, 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 legal
systems apprehension concerning this
phenomenon is fairly recent, and that
everything necessary has already been done
to 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 phenomenon, even though it may be marginal
statistically speaking, has existed here for a
very long time. It was in 1887 that the British courts made official
the type of judicial control that became part of Quebec
jurisprudence in 1994. A well-known vexatious litigant, Hector
William Grepe, plagued the courts in a civil suit that lasted
several years and on which final judgment was rendered in
1879. On several occasions after that date, Grepe again tried to
apply to the court to reopen the same dispute. Finally, in
November 1887, the English Court of Appeal, in its decision on
Grepe v. Loam [Grepe] required that henceforth he first obtain
the courts leave before initiating any further proceedings relating
26
Aside from a few nuances, the measures now in place in

Quebec seek the same objectives as those adopted more than
a century ago in England. Firstly, the Yorke system of orders is
very like that of Grepe orders. Secondly, even though Quebec
law has no text similar to the 1896 British
Act, the higher courts have adopted internal
management rules that give virtually the
same result. These are articles 84 to 90 of
the Rules of Civil Proceedings of the
Superior Court of Quebec and articles 94
and 95 of the Rules of the Quebec Court of
Appeal in Civil Matters.
In extreme cases, under articles 85
(Superior Court) and 95(2) (Court of Appeal),
the court can even bar physical access to
its premises. This measure, which is meant
to protect court employees in particular, may
seem draconian in nature, but that denotes
an incomplete understanding of the
problem. The Quebec courts, once again,
no doubt based their decision on a British
precedent. In 2002, in Attorney General v.
Ebert , the Appeal Court in England handed down an important
decision imposing this type of prohibition against a vexatious
litigant called Ebert. The facts of the matter illustrate the often
dramatic nature of such a litigants behavior. Despite four Grepe
orders being issued against him and a further order obtained by
the Attorney General under the Act already mentioned above,
Ebert, according to the evidence, persisted and, among other
actions, had, in the course of about three and a half years made
at least 151 applications for permission to issue fresh
proceedings. Along the way, he behaved in a thoroughly
outrageous manner towards court employees. Several years

before the Ebert order in 2002, the Quebec Court of Appeal in
a virtually unnoticed decision in 1996 had confirmed a similar
measure that barred a citizen from communicating by fax or
telephone, directly or via a third party, with any judge of the
Superior Court of the Quebec City Appeal District or with any
secretary or other employee in the support personnel of the
judges of the Superior Court, at any fax or telephone number in
service at the Palais de justice in Quebec City.
Another tool that can be used by parties targeted by
vexatious litigants was also introduced when these regulatory
measures were adopted. Article 90 of the Superior Court
Rules of Civil Procedure provides that, when an order is
issued, the clerk shall forward a copy of such order filed in his
court to clerks of the court in all judicial districts and to the
Chief Justice in Montreal for inclusion in the public register
covering vexatious litigation.
The intranet site of the Ministre de la Justice keeps an up-todate list of all inclusions in the register; this means that it can
also be used to consult judgments applying the Yorke precedent
or the provisions of the Rules of Civil Procedure concerning
vexatious litigants. As at December 31, 2007 ninety-five persons
or entities were shown on the register: 67 men, 26 women and
two groups of persons. Some of these litigants were covered
by a number of orders as many as five in one instance, and
sometimes two or three, showing that the person in question
had taken action against several successive parties. There is
every reason to think, however, that this list only provides an
incomplete picture of the reality. It is common for judges to see
parties appear in their court who have no legal counsel and who
fit the profile of a vexatious litigant, without however having been
declared as such by court order. Traces of such behavior can be
found in published jurisprudence, both before and after 1994,
without the authors of the abusive proceedings having been the
subject of an order requiring that they receive permission before
they could access the justice system.
These measures are supplemented by the means available to
litigants under common law to terminate an abusive dispute or
to remedy its prejudicial effects. This is the case in the
peremptory dismissal, in response to an application made under
article 75.1 of the Code of Civil Proceedings, of procedures that
are clearly frivolous or unfounded; the peremptory dismissal
under article 501 of the same Code of abusive, time-consuming
appeals or those that have no reasonable chance of success;
as well as amounts awarded to the party who is a victim of an
abusive procedure, and damages obtained by taking legal
action against the party abusing its right to access justice.
The effectiveness of control measures

Positive law in Quebec has developed greatly since the mid1990s. There is therefore no doubt that people confronted with
a vexatious litigant and forced to defend themselves now have
greater resources at their disposal than they did ten to fifteen
years ago. Nonetheless, they still have to be patient and suffer
several assaults before being able to benefit from the control
measures introduced in 2003. In the meantime, problems and
often major costs accrue, and these are beyond the intervention
of the courts, even today.
Just recently, the Superior Court handed down a decision on
an action by Valery I. Fabrikant, the same person that the court
declared vexatious in 2000. The case had started in 1995
(therefore, prior to the restrictions being imposed) and had been
going through the courts since that time. In the decision
dismissing this action, the judged charged with the matter
noted that:
[30] [Fabrikant] acts like someone who, having nothing else
to do, enjoys taking unfounded legal action. He obviously
does not care what consequences this has for others; in
fact, the opposite is true. His provocative attitude, his
sniggering and his insults show that he is acting
deliberately and maliciously, and he clearly enjoys it.
[31] We forget too often that defendants also have rights, that
they are citizens who can go before the courts and that
they are entitled to the protection of the Law and the legal
system. The courts cannot leave them at the mercy of
vexatious litigants who, in some cases, become veritable
torturers. We are however forced to admit that that is
what is happening here, in direct contravention of article 7
of the Civil Code of Quebec already cited.
[32] We have seen above that this case, begun more than
15 years ago, has absolutely no chance of succeeding. It
has, however, haunted the defendants throughout that
time. It has not allowed them to forget the killings
committed by Fabrikant on August 24, 1992 at Concordia
University where they were professors. The emotion and
distress of Doctors Sankar and Swamy throughout their
examination by the defendant was obvious. The pleasure
Fabrikant took in seeing them suffer was equally obvious.
Awarding damages for abuse of the right to access justice can

sometimes partially remedy problems of this nature. But the
question is whether the party against whom the award is made
the party whose vexatious behavior risks appearing either as
a defendant or a claimant is able to fulfill the judgment made.
In a case like this, it would be most unlikely.
Finally, during the exercise of their inherent or general powers,

courts of common law can control the procedures taking place
before them and thus neutralize some of the abusive behavior
typical of vexatious litigants.
27
EXTREME
BEHAVIOR
In addition, while some courts have specific judicial means to

prevent the most prejudicial effects of vexatious actions, the
same is not true of administrative tribunals, which cannot rely on
the inherent powers referred to at the beginning of this text. Yet
a very high proportion of Quebec litigation is, first, the
responsibility of such bodies. Some, like the Commission des
lsions professionnelles, have the legal right to subject abusive
recourse to certain conditions. But we are still far from control
orders which do not target the recourse taken, but the actual
vexatious litigant.
The undoubtedly relative effectiveness of the control
measures described here call for deeper reflection on the
fundamental causes of the problem that they are designed to
relieve or even eliminate.
The immediate reason for the problem is a personality disorder
which, in its extreme form, can be transformed into paranoia.
Vexatious behavior falls, first and foremost, within the field of
psychiatry and it is up to specialists in this discipline to
determine the appropriate treatment.
But extraneous factors may very likely exacerbate the behavior
of vexatious litigants. As long as such factors remain, vexatious
actions will continue at the edge of the judicial system. Two
theories deserve particular mention in this respect.
The first is that of anomie, a sociological concept first described
by mile Durkheim and explored in his La Division du travail
social (1893) and Le Suicide (1897). It can be defined as the
temporary lack of regulatory social norms that ensure
cooperation between specialized functions, or as a sickness
resulting from uncontrolled human desire, a lack of definite goals
and uncertainty about legitimate hopes. In a thesis published in
1999 , one author explained Valery Fabrikants behavior as being
the consequence of institutional anomie at Concordia University:
in short, since he had never encountered real resistance, he was
carried away by his tendencies and then his mania until, finally,
he became dangerous.
The second theory presents certain similarities with the first. It
suggests that the growing incidence of vexatious litigants
before the courts and administrative tribunals is perhaps an
unfortunate effect of the desire demonstrated to facilitate
access to justice. An international symposium was held in June
2006 at Prato, near Florence, on access to justice and
vexatious or querulous litigants. In a speech upon this occasion,
Sir Anthony Clarke, Master of the Rolls and Head of Civil Justice
in England, stated that a total of 175 orders were issued up
until 2006 under the Vexatious Actions Act of 1896. Eightyeight of these arose after 1995, the year in which a major reform
to simplify civil procedure and reduce its costs came into effect.
Judge Clarke found that there was a relationship of cause and
effect between these two phenomena:
28
Simplifying procedure brings with it the obvious benefits of

cost and time-savings for litigants and the courts benefits
which all civil justice systems continue to spend considerable
time and effort in seeking to achieve. It also has the benefit
that it opens up access to the courts to those who cannot
afford legal representation, or for perfectly valid reasons
choose not to appoint such representatives. Those are the
benefits. Unfortunately it also creates the circumstances
where, with greater ease than under a more complicated
regime that required the input of legal professionals before a
claim could be commenced, a litigant in person (LIP) can
more easily bring vexatious claims. The greater ability to bring
claims gives rise to a greater ability to bring vexatious claims.
The same idea has already been put forward with regard to
Quebec law, where a reform of civil procedure comparable in
scope to the British reform, came into effect in 2002.
Other factors undoubtedly tend to exacerbate the problem, one
example most certainly being the increasing cost of legal
services which drives people going before the courts to act on
their own behalf. It would be futile to believe that the solution to
the problem is exclusively clinical in nature
Notes
1
[1996] R.J.Q. 1964 (C.A.).
(1887) 37 Ch.D. 168 (CA).
An Act to prevent Abuse of the Process of the High Court or other

Courts by the Institution of Vexatious Proceedings, 1896
(the Vexatious Actions Act ).
[2002] 2 All E.R. 789 (C.A.).
Droit de la famille 2500, J.E. 96-1846 (C.A.)
See Saraffian c. SMBD Jewish General Hospital, J.E. 2005-24 (C.A.)

et Wozny c. R., J.E. 2005-802 (C.A.).
2007 QCCS 5431.
See the Loi sur les accidents du travail et les maladies

professionnelles, L.R.Q., c. A-3.001, art. 429.27, and the Loi sur la
justice administrative, L.R.Q., c. J-3, art. 115. See, the Charte des
droits et liberts de la personne, L.R.Q., c. C-12, art. 77, al. 2, 1, the
Code du travail, L.R.Q., c. c-27, art. 188, 1, the Loi sur la police,
L.R.Q., c. P-13.1, art. 168, 1 and article 143.1 of the Code des
professions, L.R.Q., c. C-26, in effect December 18, 2007 through the
Loi modifiant la Loi sur le Barreau and the Code des professions, L.Q.
2007, c. 35.
Boudon, Raymond et Franois Bourricaud, Dictionnaire critique de la

sociologie (2e d.), Paris, Presses Universitaires de France, 2002.
10
Beauregard, Mathieu, La folie de Fabrikant, Paris, LHarmattan, 1999.
11
Morissette, Yves-Marie, Abus de droit, qurulence et parties non

reprsentes (2003), 49 Revue de droit de McGill 23, p. 34-8.
A Portrait of Querulous Behavior

Based on Abus de droit, qurulence et parties non reprsentes (2003),
49 Revue de droit de McGill 23, p. 30-1.
With the kind collaboration of Mr. Justice Y.-M. Morissette
Querulous litigants are opinionated and

narcissistic. If, in a society with a fully mature legal
system, each person always took advantage of
his subjective rights as he perceived them before the trial,
everyone would be constantly making applications to the
courts and it is probable that life in such a society would
become intolerable. The law must have some room for
manoeuvre, and most people understand that intuitively. It
may be one of the reasons, at least partly, for the high
number of actions that are resolved before coming to trial.
But this fact escapes querulous litigants, for whom
confrontation with an honest contradictor exacerbates their
feelings of injustice. Any opposition therefore is likely to
result on their side in new claims which will be pursued to
the very end.
Querulous litigants tend to act as claimants rather
than defendants and, given the wide-ranging
means that they use, the opposing party would
also risk being taxed with stubbornness, if it were not for
the fact that the latter is forced, since it cannot choose the
means, to defend itself inch by inch.
Querulous litigants multiply the number of actions
they take, including against court employees. It
is fairly common, in fact, for such proceedings
and complaints to be made against lawyers, court staff
or even judges personally, with complaints of bias or
ethical misconduct.
Reiteration of the same questions in successive
and amplified proceedings and the search for the
same results despite the repeated dismissal of
previous claims is frequent. The querulous party generally
negotiates upwards and, if damages are claimed, the
amounts tend to increase along the way as the number of
proceedings grows.
Legal arguments put forward by querulous

litigants are notable because of their inventiveness
and incongruity. They certainly appear judicial in
form, but they are barely rational. The position adopted by
the plaintiff in the main Byer affair (based on an extravagant
reading of one section of the Insurance Act) or by Fabrikant
in one of his numerous cases (invoking a law passed in
1495 during the reign of Henry VIII as foundation for an
appeal in forma pauperis) are just two examples.
The repeated failure of actions brought by
querulous litigants results, sooner or later, in an
inability to pay legal expenses and costs awarded
against them. This precise situation was invoked in Grepe
v. Loam, the first decision reported in English law where a
litigant was required to obtain legal permission prior to his
claim being presented in court. This situation is difficult to
evaluate, because it is more a matter of judicial sociology,
but it may well deserve in-depth study.
Querulous litigants appeal most, if not all, adverse
decisions or apply for their revision or retraction.
Finally, as previously noted, querulous litigants

represent themselves.
Source: Yves-Marie Morissette, Abus de droit, qurulence et parties

non reprsentes (2003), 49 Revue de droit de McGill 23, p. 30-1.
See also Lester, Grant, Beth Wilson, Lynn Griffin et Paul E. Mullen,
Unusually persistent complainants (2004), 184 British Journal of
Psychiatry, p. 352-6.
The text valuation de la dangerosit du malade mental psychotique

is not available on Internet, nor is it translated in English.
29
Coup dil sur
Les inhibiteurs des

rcepteurs H2 et les
inhibiteurs de la pompe
protons
es inhibiteurs des rcepteurs H2 et les inhibiteurs de la

pompe protons sont deux classes de mdicaments trs
connues et frquemment utilises dans le traitement
de maladies telles le reflux gastro-oesophagien (RGO) et les
ulcres peptiques ou encore pour la prvention des effets
gastriques nfastes relis lutilisation danti-inflammatoires
non-strodiens.
Bien que les IRH2 aient fait leur apparition sur le march
canadien au tournant des annes 80, la ranitidine, la cimtidine,
la famotidine et la nizatidine sont encore recommandes
comme traitement de premire ligne pour ce qui est du reflux
gastro-oesophagien lger modr ou rcurrent et ce, dans
la majorit des provinces canadiennes, dont le Qubec.1,2
Pour ce qui est des IPP, ils sont recommands en deuxime
ligne de traitement pour le reflux gastro-oesophagien lger
modr au Qubec3, en Colombie-Britannique4, en
Ontario5, en Saskatchewan, au Manitoba, au NouveauBrunswick, en Nouvelle-cosse et lle-du-Princedouard lorsque les IRH2 ont chou6. Ils sont toutefois
recommands comme traitement de premire ligne
dans les cas de reflux gastro-oesophagien grave ou avec
complications et ce, travers le Canada.
un peu plus de 10 pour cent des cas de reflux gastrooesophagien. Au Qubec, l ou lon retrouve le taux de
recommandation le plus faible, le pourcentage stablit
un peu plus de sept pour cent.
Dans ce contexte, il nest pas surprenant dobserver que les
IPP soient, partout au Canada, le traitement le plus courant
pour le reflux gastro-oesophagien et la dyspepsie.
Si lon en juge par la proportion dinitiation de nouvelles
thrapies au Canada en 2006, il est parier que les IPP
auront tt fait de rejoindre et mme surpasser les IRH2
(FIGURE 2). En effet, au Qubec moins de 10 pour cent des
nouvelles thrapies taient inities avec un IRH2 en 2006.
Il sagit du plus faible pourcentage de toutes les provinces
canadiennes. Dans lensemble du Canada, prs de 25 pour
cent des nouvelles thrapies sont inities avec un IRH2. Ce
pourcentage augmente jusqu environ 50 pour cent dans
les quatre provinces maritimes et en Saskatchewan. Seules
lAlberta et lOntario accompagnent le Qubec en-dessous
de la moyenne canadienne. Le Pantoloc est le traitement
initial le plus souvent prescrit au Qubec, alors que dans
les autre provinces, les IRH2 ont encore la cote.
Dans la mme foule, les mdecins qubcois sont ceux

Cependant, si lon consulte les donnes de 2006 (FIGURE 1), qui prescrivent le plus souvent le Pantoloc ou le Nexium
on constate que, pour ce qui est de lensemble du Canada, en premier lieu. Les mdecins qubcois sont aussi moins
les IRH2 ne sont recommands par les mdecins que dans ports que leurs collgues canadiens se tourner vers les
PUBLIREPORTAGE
% de recommandations
100 %
90 %
80 %
70 %
60 %
50 %
40 %
30 %
20 %
10 %
0%
10,4%
10,6%
7,9%
9,3%
7,4%
21,6%
83,6%
84,6%
86,7%
84,6%
83,7%
73,2%
NA
CA
DA
C- B
Pra
ir ie
IPP
io
ta r
On
ec
b
Qu
ri
Ma
tim
es
IRH2
* Ne comprend pas les autres traitements pharmaceutiques recommands

par les mdecins pratiquant en cabinet priv.
Source: IMS Health Canada, Index canadien des maladies et traitements
IRH2 lorsque vient le temps de changer le traitement de

leur patient. ce moment, les mdecins qubcois optent
majoritairement pour le Pantoloc ou le Nexium. Ailleurs
au Canada, les mdecins se tournent plus souvent vers les
versions gnriques de lomprazole ou le Pariet. Il faut dire
que le Qubec est la seule province canadienne o tous les
IPP, y compris le Pantoloc et le Nexium, sont rembourss
par le rgime dassurance-mdicaments publique.
% de nouvelle thrapie
FIGURE 2
Proportion dinitiation de nouvelle thrapie dIPP
et dIRH2 en 2006
FIGURE 1
Traitements de premire ligne recommands* pour
le reflux gastro-oesophagien en 2006
100 %
90 %
80 %
70 %
60 %
50 %
40 %
30 %
20 %
10 %
0%
NA
CA
DA
C-B
AB
SK
MB
ON
ec
N-
Qu
Prevacid Fastab
Nexium
Prevacid
Omprazole gnriques
Pariet
Losec (omprazole)
Pantoloc
IRH2
N- t T-N
Ee
IP
Les IRH2 sont

recommands comme
traitement de 1re ligne
pour le RGO dans
la majorit des
provinces canadiennes.
Source: IMS Health Canada, donnes longitudinales
le Pariet doit tre le premier IPP utilis aprs un chec

thrapeutique avec des IRH2 ou lomprazole gnrique,
on constate que les mdecins de cette province favorisent
grandement lutilisation de cette molcule comparativement
au Nexium et au Pantoloc.
On peut donc conclure que les pratiques dans lutilisation

des IPP et des IRH2 varient considrablement dune
province lautre et que cela est sans doute reli au statut
Si lon regarde du ct de la Colombie-Britannique, o, des molcules sur les diffrents formulaires provinciaux.
selon les recommandations du programme gouvernemental,
1
2
3
4
5
6
Biomed EBMA report, vol. 1 (1) 2005

Critres dutilisation optimale concernant les IRH2 (Conseil du mdicament) 2002
Critres dutilisation optimale concernant les IPP (Conseil du mdicament) 2002
Canadian Society of Intestinal Research, The BC Pharmacare experience, January 2005
Biomed EBMA report, vol 1 (1) 2005
Listes des mdicaments des diffrentes provinces
Pour de plus amples renseignements : 1-888-400-4672 / www.imshealthcanada.com

Une importante source dinformation, danalyse et de consultation pour les secteurs de la sant au Canada
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GREAT NAMES IN QUEBEC MEDICINE

PATRICIA KROACK
COMMUNICATIONS CONSULTANT
Dr. Yves Fradet: The Multiplier Effect
alking to Dr. Yves Fradet is like holding a conversation

with several people at the same time, because he
holds so many positions and sets up so many
projects. Maybe he has found a way to roll back time,
has the gift of ubiquity or simply manages to pursue
his many interlocking passions with success.
Born in Montreal, the Quebec City urologist founded

DiagnoCure with the aid of two investors, a company
specializing in manufacturing tests to detect prostate cancer.
Today, he holds a number of medicoadministrative positions:
he is Chief of Surgery, Director of the Urology Department and
Experimental Uro-Oncology Laboratory at CHUQ Htel-Dieu
de Qubec, a Full Professor in the Department of
Surgery/Urology at Universit Laval, in addition to continuing
his clinical activities.
Coming late to medicine, Dr. Fradet made up for lost time by
taking just one year to complete all the college-level science
courses he needed to enter university. But it was the various
aspects of his training that were to be a determining factor. An
initial period spent in research allowed him to discover
immunology, for which he still has a passion today. Later, he
would rotate to surgery and urology, where working with cancer
would consolidate and combine all his interests a whole set
of circumstances that would play a vital part in his career,
although at that point he saw himself as an internist.
After qualifying as a urologist in 1981, Dr. Fradet took urologic
oncology as a subspecialty at the Sloan Kettering Memorial
Hospital in New York, together with clinical oncology with
Dr.Willet F. Whitmore Jr., considered to be one of the fathers of
urologic oncology. His research during subspecialization
covered tumor immunology and specifically monoclonal
antibodies, the technology in vogue at that time.
Professor-Researcher-BusinessmanClinician-Surgeon-Urologist
When he started his clinical practice, he created a laboratory so
that he could continue his research, which he did by means of
research grants and bursaries. Among other activities, he
developed new monoclonal antibodies. In addition to teaching,
Dr. Fradet also combined his clinical work and laboratory
research in order to expand knowledge about screening for
urological cancers and develop the tools needed.
One idea kept coming back to him. If you can develop a
molecule or a test and have the ability to reproduce it and
market it, why not do it yourself and avoid having to sell the
intellectual property rights to a foreign laboratory? Putting his
business acumen to good use, Dr. Fradet began to explore
various avenues, tools and programs that would allow him to
market his detection tests and other

molecules in Quebec, retaining all his rights
and intellectual property.
Convinced of the potential of his work, he
took advantage of the platform provided by
the very first Bio-Contact, an annual
biotechnology symposium designed to serve
Dr. Yves Fradet
as a link between the more than 1,200
researchers and investors attending the event. It was there that
he met his two future partners and founded DiagnoCure. One
year later, after drawing up an exhaustive business plan, the
business would look for initial financing of $6 million from the
private sector while continuing with the marketing of a bladder
cancer screening test in addition to other research activities.
Today, DiagnoCure is a major company that develops tests for
detecting bladder, prostate, colon and breast cancer. It has
agreements with universities, other businesses and research
laboratories for the marketing, development or purchase of
molecules and screening tests, as well as research activities.
DiagnoCure has also licensed many molecules and products
to specific companies and is listed on the Stock Exchange.
Today, the company has approximately forty employees,
including a number of Ph.Ds and research associates in the
laboratory. Dr. Fradet is Executive Vice President and Head of
Scientific Affairs.
Because of his outstanding reputation in his field of expertise,
Dr. Fradet is often called upon to speak at meetings, present his
research and take part in various gatherings attended by
researchers from all over the world. Yet he still remains a very
active member of his clinical group, is involved in departmental
management while continuing with his teaching responsibilities
and the supervision of his subspecialty. His passion for
immunology, kidney grafts and surgical oncology that started
him on his career has not waned.
Dr. Fradet says that there is still a great deal of work to be
done in this field. Quebec does not yet have a prostate
screening program like the one for breast cancer. There is also
more to learn about treatment combinations and their use.
Detection tests would allow appropriate treatments to be
targeted more specifically.
Dr. Fradet strongly believes that the future of his work lies in
good hands. His eldest son is also a urologist, now doing a
fellowship in California. Maybe he will follow in his fathers
footsteps. His daughter is a general practitioner and his
youngest son is an engineer. Three years ago, though, Dr.
Fradet sadly lost his wife to ovarian cancer, a harsh experience
that confirmed for him the validity of his research work.
L
33
CONTINUING PROFESSIONAL DEVELOPMENT

RJEAN LAPRISE
COUNSELLOR, OFFICE DE DVELOPPEMENT PROFESSIONNEL
Working behind the scenes

Over the past few years, there has been a great deal of talk about the continuing professional
development (CPD) of physicians. Everyone has an interest in the subject.
the universities discuss recent advances made in our
specialty, technological changes and needs not felt. A fiveyear plan is drawn up based on the needs determined; it
is revised annually. Our most important role is undoubtedly
that of identifying the needs of our target audience for the
different activities that will take place in the coming year.
We use a group technique for our two main yearly
meetings: the Entretiens Ophtamologiques de lUniversit
de Montral (EOUM) and the Journes
Ophtalmologiques de lUniversit Laval. The
Dr. Alain Rousseau, a well-known ophthalmologist,
Delphi technique is also used upon occasion.
is one such person. Now reaching age 79, his
The results of this work are then forwarded to
contributions to research, university teaching and
the committees responsible for each activity,
scientific societies have already been recognized. A
and they will construct their educational goals
member of the Order of Canada, a recipient of the
in measurable terms based on this information.
125th Anniversary of the Confederation of Canada
At present, our greatest challenge is to
Medal and the Queen Elizabeth II Jubilee Medal, Dr.
broaden the sphere of active ophthalRousseau has also received many other awards,
mologists knowledge and action, so that we
including one from the Canadian Ophthalmological
can make more specialized care available to
Society honoring his career achievements.
patients. We also encourage experienced
speakers to visit the regions. We give a list of
Do you know what he has accomplished with
the speakers available to all groups of
Dr Alain Rousseau
regard to CPD, or that he has chaired his Assospecialists who are interested. We have, in
ciations committee for the last 28 years, even though he has
fact, issued a reference manual on organizing CME
been retired for the last 11 of them? Do you know that he is the
activities. Finally, we look after university accreditation for
first chair of the Canadian Ophthalmological Society CPD
activities when asked to do so by local organizers.
Committee of which he was a member for five years, developing
and directing the Societys Maintenance Certificate Program
Why do you spend so much energy on this?
over the same period? That he has been responsible for
L
organizing the Journes opthalmologiques at Universit Laval
Because I like doing it! I have other things to do, but I find
for 27 years and is still organizing the Journes de la recherche,
AR this one interesting. I did my subspecialty in retinal surgery
which he has done since 1997? That he has helped organize
at the Massachusetts Eye and Ear Infirmary Retina
around a dozen national and international congresses?
Foundation, a place where there was a great incentive to
The list of his achievements is even longer, but we preferred to
carry out research and where teaching was just as
meet with him and give you his thoughts. Smiling as ever, he
important. When I finished my training, I couldnt really see
agreed to talk to us about his vision of CPD, saying he was
medical practice as my sole occupation. I said to myself,
surprised and touched by all the attention being paid to him.
Im going to practice as a specialist in problems of the
The humility shown by great men never ceases to amaze me.
retina, do clinical research and teach. I obtained a
position at Universit Laval, where I started the training
What does your Associations CPD
program for ophthalmology residents. Then, around 1970,
L
Committee do?
I became interested in continuing education. I had
attended many congresses all over the world, where I had
been very active and met a great number of scientists.
Our Committee supports and coordinates CPD activities
There were a lot of interesting things, and I said, Why
AR with regard to ophthalmology in Quebec. Its members
wouldnt they come and talk about them to Quebec
represent the regions and the four universities. It meets
ophthalmologists? That is how the Journes
once a year or more often if necessary. The regional
ophtalmologiques saw the light of day. Our objective was
representatives inform us about needs in their area, and
owever, too little is said, it seems, about the
considerable changes that have occurred in this
field during the last 10-15 years, and about the
extremely rapid evolution of medicine and health
care. Even less is being said about the people who
dedicate themselves, often on a voluntary basis
and completely behind the scenes, in helping their colleagues
maintain their competence despite all the changes that have
taken place.
34
to broaden the field, in which eye disease specialists were

active, bring them up to date on developments and new
approaches being used. It was very enjoyable. Only, now,
we have to plan for someone new to take over.
I think the most important thing for our Association at this
AR time is to answer the question of whether we are really

changing our members practice. I am not convinced that
we are doing it correctly. I sometimes have the impression
that specialists who find themselves a niche have a
problem leaving it, even if there is a need elsewhere. My
No. 1 challenge is to find out how we can change and
adjust specialists behavior to meet needs. If we can
manage to do that, Ill retire!
How would you say CPD has evolved in your

Association?
In most cases, we have the appropriate educational
AR objectives. We are now trying to modify the format of our

activities, making them more interactive and less the
typical lecture style. I think participants like that. They want
to take an active part, and we are doing this more and
more. In 2005, during a session on ophthalmological
imaging and diseases of the retina, we had case studies
followed by a general discussion among those attending.
There was a lot of interaction and it was great. We filled the
room every day. It was even full for the last session on the
last day! Physicians need to share their problems.
What advice do you have for colleagues who

might want to become involved in organizing
CPD activities?
To remember that the main purpose will always be patient
AR care, whether it is to improve their condition or cure them.

The challenge for organizers is to identify the problems
and find the best way to pass on questions to their
colleagues, at the same time giving them some indication
as to the answer. Very often, they are the ones to find the
answers. It is therefore a matter of submitting the problem
to them.
What do you think about the self-management

of CPD?
I think it is very important. We have to develop this aspect,
AR but its still not all that obvious, even for the organizers.
We all tend to have the same background. Teaching, for a
long time, has been having a speaker up front showing
slides, and then we doze off. It is also easier to be passive.
While there is no need to make a 180 degree turn human
nature hates changes that are too sudden we could
change our approach so that the audience participates
more and we could incorporate self-management into
that. I am currently trying to suggest a project: select one
or two subjects from the various themes of our annual
activities, one that would raise questions that might be a
bit existential for some participants. For instance, is my
diagnostic and therapeutic approach to corneal ulcers up
to date? This question is raised during a talk. The speaker
suggests a self-managed program that candidates can
take later at home and comply with section 3 of the Royal
Colleges self-management accreditation program.
Seminars can also be a stimulus for self-management and
have the advantage of making a greater range of problems
available. Its up to participants to choose. Furthermore, its
not necessary for everyone to attend every session. That is
perhaps another way of encouraging self-management.
How do you see CPD in the future?
What is your message to residents?

Keep on learning. Residents dont finish learning when
AR they reach the end of their courses. In fact, they are only
just beginning. What they learn today will be thoroughly
outdated in 10 years time. It will be absolutely different; if
they are still doing the same thing, its because they
havent done their work. Continuing education is an ability,
an attitude and a way of working acquired during
residency and which carries over into the practice.
Residents must master todays information, but above all
they must learn to apply tomorrows information.
It is because of the often little-known efforts of people like Dr.

Rousseau that Quebec can count on physicians who are
among the most competent in the world. I would like to
thank him for his outstanding generosity and, through him,
thank all specialists involved in CPD committees in the
affiliated associations. As a patient, I hope that they will
continue to give us the benefit of their time, knowledge and
talent for a long while to come.
35
GROUPE FONDS DES PROFESSIONNELS

FINANCIAL PLANNING DEPARTMENT
As a shareholder, will I be entitled to the old age

security pension when I retire?
The OAS pension is clawed back in full when a pensioner's net
income is $104,903 or more.
Upon retirement, the flexibility of withdrawals from RRSPs or
RRIFs might lower the clawback somewhat, but it should be
remembered that the minimum compulsory withdrawal from
RRIFs from age 72 on will limit this flexibility, particularly for
individuals with substantial RRSPs.
As a shareholder, can I hope to avoid the OAS clawback by
receiving high dividends one year and nothing the following
year?
To answer this question, let us consider the two examples given
below:
Total taxable income before dividends = $64,718
ld Age Security (OAS) is a monthly pension paid to
most Canadians who are at least 65 years of age,
meet the residency requirements and apply for it.
The pension is funded from the general tax
receipts of the Government of Canada, which
means that, unlike the Quebec Pension Fund, no
reserves are accumulated.
At present, pensioners with an individual net income of over

$64,718 must repay part or the entire maximum Old Age
Security pension amount. The repayment amounts are normally
deducted from their monthly payments before they are issued.
Yearly dividends
Year 1
QPF
OAS
It is therefore possible to recover your OAS pension by receiving

dividends every two years. However, in our example, the benefit
is only $1,511 over two years, or slightly more than $14.50 per
week (just enough for a reasonable bottle of wine). You should
realize that the higher your cost of living and the dividends to
be paid, the less worthwhile the benefit gained.
Regardless of your needs, it is preferable to plan your retirement
withdrawals several years ahead of time, in order to avoid an
OAS clawback and reduce the amount of tax payable.
Ideally, you should set up your financial
planning as soon as possible. Talk to your
consultant about it.
2-yearly dividends
Year 2
$7,000
Yearly dividend required to maintain cost of living =

$35,000
Year 1
$7,000
Year 2
$7,000
$7,000
$6,028
$6,028
$6,028
$6,028
RRSP/RRIF
$51,690
$51,690
$51,690
$51,690
Dividend(1)
$35,000
$36,693(2)
$70,000
$0
$0
$0
$0
$1,351(3)
$99,718
$101,411
$134,718
$66,069
OAS clawback
- $6,028
- $6,028
Taxable income
$102,440
Total tax
- $23,697
Interest
Total income
Net income
Net income over 2 years
Benefit
$69,993
$104,556
- $24,273
$71,110
- $6,028
$146,190
- $36,182
$92,508
$141,103
$142,614
$1,511
36
(1)
We have assumed that the entire dividend was not

eligible.
(2)
Since the company paid $35,000 the first year instead

of $70,000, we have assumed that a 6% rate of interest
on $35,000 (less tax) is added to the second years
dividend payment.
(3)
6% interest on the difference between the first year of

the 2-yearly dividends and the first year of annual
dividends ($92,508 - $69,993)
- $203
$65,866
- $15,760
$50,106
SOGEMEC ASSURANCES
Dr. GILLES ROBERT
DIRECTOR ECONOMIC AFFAIRS AND PRESIDENT,

SOGEMEC ASSURANCES INC.
Sogemec assurances inc. Today

You may have noticed that the insurance market is becoming more and more competitive, and
that you are therefore being contacted on a regular basis.
How does Sogemec differ from the others?
Sogemec has been able to stand out from the competition
because it is unique in certain ways. First of all, our standard of
business ethics is irreproachable. In addition, it may reassure you
to know that our Board of Directors includes five medical
specialists, appointed directly by your Federation, in addition to
representatives from our partners (notaries, engineers and
medical residents), ensuring good governance and that all our
members are fully represented. But what really sets us apart from
our competitors is that our prime objective is to offer impeccable
service at all times, particularly if you have a claim, and we can
even provide guidance if specific representation is required.
To give you an idea of our activities, we settled 1,409 home and
automobile insurance claims through our insurer in 2007,
representing an outlay of $5,578,362 or one claim for every four
clients! Despite the size of this amount, we have been able to
maintain a very high degree of satisfaction with our clientele

because of the rapid payment on such claims. And we are there
to support you if a problem ever arises.
With regard to disability insurance, despite pressure on the
premiums because of the high number of claimants, we have
been able to provide equally impeccable service, as can be seen
from our clients satisfaction with the fact that they received their
benefits promptly.
Finally, I would like to thank the newcomers to our ranks who
added more than 2,100 new contracts in 2007, bringing the total
number to 21,079.
Sogemec belongs to you. We are there to help you, above all.
That is why we are in business.
POUR TOUS VOS

BESOINS DASSURANCES
DES GESTES PRCIS,

LES IDES CLAIRES
::
::
::
::
::
SOGEMEC
VIE
INVALIDIT
MDICAMENTS
MALADIE
DENTAIRE
SOGEMEC
LA PERSONNELLE
: : AUTOMOBILE
: : HABITATION
: : ENTREPRISE
: : CONTACTEZ-NOUS
1 800 361-5303
514 350-5070 / 418 658-4244
Par courriel ou Internet :
information@sogemec.qc.ca
www.sogemec.qc.ca
Le seul courtier recommand par :
FDRATION DES MDECINS

SPCIALISTES DU QUBEC
37
SOGEMEC ASSURANCES
CHANTAL AUBIN
DIRECTOR, PLAN ADMINISTRATION
Take advantage of the exclusive coverage

available to medical specialists
hether you are an owner, co-owner or
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to be considered, of course, but also
the quality of the coverage available.
Some home insurances are more attractive than others,
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Summary of some upgraded protections offered with Endorsement 25c

Specific or high value items examples
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$100,000
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Boat trailers
The insurance you need ...

the outstanding coverage we provide!
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transactions, including by Internet)
25c (exclusive to FMSQ members) provides superior
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Actual examples of your benefits

You may be an art collector and possess many pictures, sculptures
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stolen from your house or elsewhere.
Jewellery, watches and furs are subject to a limit of $3,000 under
your home insurance policy. If you opt for endorsement 25c, your
coverage increases to $10,000 in case of loss or theft.
In addition, if you do have a claim, your insurance policy provides
that no deductible is payable but only when all the insured property
is a total loss. If you add endorsement 25c, you will pay no deductible
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38
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The FMSQs size is a major advantage and it has therefore been

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La Personnelle is the largest automobile and home insurance
group in Quebec and a leader in Canada as a whole. More than
550 organizations are partners in La Personnelle, including the
FMSQ for the past six years.
La Personnelle also works very closely with Sogemec
Assurances, the FMSQs group insurance broker, which carries
out spot checks to ensure that La Personnelle remains highly
competitive with respect to automobile, home and business
insurance. That means:
Competitive group rates
Excellent basic protection and exclusive coverage upgrades
Excellent claim service, available 24/7.
For more information on La Personnelle coverage or to obtain a

quote on your automobile, home or business insurance, contact a
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You can also request a quote for automobile or home insurance
on line at www.sogemec.lapersonnelle.com. Certain eligibility
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with La Personnelle to find out whether you can take advantage
of this worthwhile offer.
IN THE MEDICAL WORLD

By Jean-Philippe Chaput, MSc, Marie-Jose Poulin, MD, FRCPC and Angelo Tremblay, PhD
Weight Gain with Antipsychotics:

Can it be avoided?
All-cause mortality and morbidity rates are higher in patients with schizophrenic,
schizoaffective or bipolar disorders than in the general public(1).
heir risk of obesity is 3.5 times higher, and that of type

2 diabetes 2-4 times higher(2). Their health problems
are underdiagnosed and undertreated because of
inadequate screening, non-existent or chaotic
medical follow-up, non-compliance with treatment, a
lack of etiological and statistical data and a dearth of
clinical programs that meet their specific needs(3). Their lifestyle
is often poor; they are sedentary and smokers, and generally
neglect their overall health. In addition, they are exposed to
various medications (including atypical antipsychotics) that are
associated with weight gain problems and suspected of being
linked to various metabolic problems, such as hyperglycemia,
glucose intolerance, type 2 diabetes, dyslipidemia, abnormalities
of the thyroid and pituitary glands (hyperprolactinemia). In
addition, most of them will require drug treatment for very long
periods of time, maybe even throughout their
lifetime(4).
THIS DEMONSTRATION IS ENCOURAGING BECAUSE
The efficacy of atypical (or second generation)

THE WEIGHT GAIN CAUSED BY TAKING ATYPICAL
antipsychotic agents, most of which have
ANTIPSYCHOTICS HAS VARIOUS HARMFUL
appeared since the 1990s, is considered
EFFECTS ON HEALTH.
equivalent or superior to that of their predecessors,
but they can all cause weight gain(5). This side
effect should not be underestimated in view of the
In an effort to compensate for the lack of current scientific data
many health risks associated with gaining weight and thus
on this subject, we recently conducted and published a
affecting such individuals quality of life. Unfortunately, studies
prospective study to assess the efficacy of a behavioral
on the efficacy of specific clinical programs to prevent and treat
intervention clinical program that focused on maintaining a
obesity and the metabolic problems associated with this
healthy weight by means of good dietary habits and regular
population are few, lack validity, were conducted in small groups
physical activity in patients with schizophenic, schizoaffective or
of patients and by personnel that had little experience in
bipolar problems who were taking atypical antipsychotics:
psychiatry.
clozapine, olanzapine, quetiapine and/or risperidone(6). This
study, the strongest in the field to date, brings a glimmer of hope
because results have shown that body weight and the metabolic
risk profile in patients receiving atypical antibiotics can be
managed effectively by such a program.
Jean-Philippe Chaput is studying for a Doctorate in
Kinesiology at the Department of Social and Preventive
Medicine, Universit Laval, Angelo Tremblay is a professor
in the Kinesiology Branch at Universit Laval (Quebec City).
and Dr. Marie-Jose Poulin is a psychiatrist at the University
Institute of Mental Health CHRG (Quebec City), Clinical
Head of Action-Sant and a professor in the Department of
Psychiatry, Universit Laval.
In arriving at this conclusion, we recruited 130 patients being

treated for psychiatric problems at Hpital de lEnfant-Jsus and
the Centre hospitalier Robert-Giffard (Quebec City), dividing them
into two random groups. Patients in the experimental group were
invited to a 90-minute training session on the principles of good
diet and physical activity. They then took part in two one-hour
physical exercise sessions per week for 18 months. Under the
39
supervision of a kinesiologist (Ms. Vronique Simard),

IN AN IDEAL WORLD, IT WOULD SEEM THAT EACH
the session took place in a room at Hpital de lEnfantPRESCRIPTION FOR ANTIPSYCHOTIC AGENTS SHOULD BE
Jsus and included aerobic and muscle-strengthening
ACCOMPANIED BY ANOTHER ONE FOR PHYSICAL EXERCISE.
exercises. To evaluate the efficacy of the program, we
measured different physical and biochemical variables
in these patients and compared them with a control
integral part of psychiatric care programs* and is not generally
group that matched the characteristics of the experimental
covered by health insurance, we hope that this study will have an
group. All these patients had been taking atypical antipsychotics
impact on the importance of weight control programs designed
for slightly more than two years on average and continued their
specifically for patients taking atypical antipsychotics.
In an ideal world, it would seem that each prescription for
antipsychotic agents should be accompanied by another
one for physical exercise.
Weight change during the study

Experimental group
Change in body weight (kg)
Control group
This type of program is now incorporated into psychiatric care at

Centre hospitalier Robert-Giffard in Quebec City.
*p 0,01
Time (months)
Adapted from Poulin et al. (6)
usual psychiatric follow-up with their attending physician(s). At

the end of 18 months, we noted a difference of some 6.7 kg in
body weight between the two groups, as shown in the figure.
Waist circumference and body mass index (BMI) of patients in
the control group had also increased by 4.2% and 5.5%
respectively over the period of the study. Circulating
concentrations of poor cholesterol (LDL) and plasma triglycerides
had increased by 14.8% and 12.3% respectively. On the other
hand, patients in the weight control program reversed these
trends. Their weight, waist circumference and BMI had
decreased by 4% or more, and their HDL cholesterol levels
(21.4% increase), LDL cholesterol (13.7% decrease) and plasma
triglycerides (26.2% decrease) demonstrated the programs
positive effects.
This demonstration is encouraging because the weight gain
caused by taking atypical antipsychotics has various harmful
effects on health. It disrupts the lipid profile, increases the risk of
cardiovascular disease and type 2 diabetes, and hinders proper
compliance with the treatment. In addition, since the level of
adherence to treatment was noted to be 85% in both groups
and patients compliance with the physical activity program was
remarkable, such results are promising. They are far from
insignificant because this large study decreased the risk of
cardiovascular problems by 75% in patients doing 2 hours
physical exercise per week for 18 months versus the control
group. In addition, the antidepressive effect of physical exercise
is well-known and can have a positive effect on self-esteem and
social integration(7). As this type of program does not form an
40
References
1. Brown S, Inskip H, Barraclough B. Causes of the excess mortality
of schizophrenia. Br J Psychiatry 2000 ; 177: 212-217.
2. Allison DB, Casey DE. Antipsychotic-induced weight gain: a review
of the literature. J Clin Psychiatry 2001 ; 62 (Suppl 7): 22-31.
3. Poulin MJ, Cortese L, Williams R, Wine N, McIntyre RS. Atypical
antipsychotics in psychiatric practice: practical implications for
clinical monitoring. Can J Psychiatry 2005 ; 50: 555-562.
4. Baptista T, Kin NM, Beaulieu S, de Baptista EA. Obesity and
related metabolic abnormalities during antipsychotic drug
administration: mechanisms, management and research
perspectives. Pharmacopsychiatry 2002 ; 35: 205-219.
5. Taylor DM, McAskill R. Atypical antipsychotics and weight gain: a
systematic review. Acta Psychiatr Scand 2000 ; 101: 416-432.
6. Poulin MJ, Chaput JP, Simard V, Vincent P, Bernier J, Gauthier Y,
Lanctt G, Saindon J, Vincent A, Gagnon S, Tremblay A.
Management of antipsychotic-induced weight gain: prospective
naturalistic study of the effectiveness of a supervised exercise
programme. Aust N Z J Psychiatry 2007 ; 41: 980-989.
7. Lawlor DA, Hopker SW. The effectiveness of exercise as an
intervention in the management of depression: systematic review
and meta-regression analysis of randomised controlled trials.
BMJ 2001 ; 322: 763-767.
MOT DU PRSIDENT
DR GATAN BARRETTE
Le rapport Castonguay : un guide de survie

e mandat du groupe prsid par M. Castonguay
tait clair et net : sadresser la problmatique du
financement de la sant. Cest ce quil a fait. Non
seulement en termes de sources de revenus, mais aussi
en termes dutilisation de ceux-ci. Ctait lgitime de sa
part, car quoi sert de parler de revenus si on ne
sassure pas que ceux-ci soient grs correctement ?
Nous croyons que le diagnostic pos par M. Castonguay est le bon.

Essentiellement, M. Castonguay constate quil y a inadquation entre
le rythme de croissance des dpenses publiques de sant et celle
de la richesse collective du Qubec, inadquation qui mnera un
dficit annuel de 7 milliards $ en 2017 si rien nest fait. Pour corriger
cela, il propose deux trains de mesures, lun sadressant aux sources
de revenus, lautre la gestion de ceux-ci.
Dabord sur la question de la croissance des cots en sant. Quy at-il rajouter ? De tous les domaines publics, ici ou ltranger, le
domaine de la sant est probablement le seul o se sont ralises les
prvisions conomiques des experts et analystes, quils soient
gouvernementaux, universitaires ou du monde conomique en
gnral. On nous avait prdit le quart, puis le tiers, bientt la moiti
du budget de ltat et cest arriv. Il ny a aucune raison de croire
que les prvisions actuelles ne se raliseront pas. Ces prvisions ont
aussi toujours appel la prise de dcisions quant au contrle de
ces dpenses et celles-l furent pour le moins rarissimes. Do la
question : quand agira-t-on? Quand la part du budget de la sant
sera de 55 % du budget de ltat? De 60 % ? De 70 % ? Dailleurs,
quand la socit qubcoise se sortira la tte du sable, il faudra bien
quelle dcide do viendront ces sommes supplmentaires ! Cest
ce quoi sadresse le rapport de M. Castonguay.
Du ct financement, la question nest pas de savoir si les solutions
proposes sont idales. Il sagit plutt de dterminer si elles livrent la
marchandise. Nous croyons que la rponse est oui. Et si oui, limpact
gnre-t-il des travers tels quil faudrait les balayer du revers de la
main ? notre avis, la rponse est non. Au contraire, nous notons
que M. Castonguay a pris bien soin de jeter toutes les balises
ncessaires pour paver une voie qui vitera de tels travers et, en ce
sens, ce rapport est empreint dune grande modration. Ce rapport
est en ralit un guide de survie pour le rseau public si on accepte
le fait que les cots ne pourront quaugmenter jusqu excder la
capacit de payer de ltat. La mixit, dans la mesure o le service
public est protg, ne pose aucun problme ; ni la franchise qui, tel
que propos par M. Castonguay, demeure une mesure trs
progressive; encore moins la reprise des points de TPS comme nous
lavions dj propos prcdemment plusieurs reprises ; non plus
lintroduction dassurances.
Du ct gestion, le rapport est l aussi innovateur. En ralit, qui
pourrait tre contre lefficience et la productivit ? Ou encore,
lamlioration de ce qui est maintenant convenu dappeler les faons
de faire du rseau ? En toile de fond, le malaise exprim (ou non) de
la plupart des observateurs (mme du Ministre) qui nont pas not de

changements suffisamment palpables alors que pas moins de
6 milliards $ ont t ajouts aux dpenses de sant depuis 2000.
Mais ni le public ni les commentateurs ne ralisent que ce montant a
servi en grande partie la remise niveau dun rseau en disette
totale depuis trop longtemps. Par exemple, prs de 1 milliard $ ont
t investis durant cette priode pour mettre niveau le parc
dquipements mdicaux spcialiss, 2,3 milliards $ ont servi
ponger les dficits des hpitaux, et combien ont servi revamper
des installations en dcrpitude ? Or, il va de soi que de remettre
niveau cest comme rnover ; au mieux, on ajoute une pice, mais
on na pas une nouvelle maison, celle-ci ne devenant quen partie
conforme aux normes actuelles. Normal alors de ne pas constater
de gains palpables en termes daccessibilit par exemple.
Les dangers de ce rapport relvent du politique, plus prcisment si
le politique continue aller dans la direction de ne prendre que le
facile ou le politiquement rentable, savoir tout ce qui concerne la
gestion et la productivit. Le danger est l. Rappelons-nous les suites
du rapport Rochon qui ne fut appliqu qu moiti. Sen sont suivies
15 annes de dsastre. Pourtant, le rapport de M. Castonguay est
clair. Peu importe le scnario, il faudra des sources additionnelles de
financement. Il nous apparat extraordinairement simpliste de penser
que seules de nouvelles faons de grer, de passer en mode
dachat de services , ou daugmenter la productivit permettront
de freiner la croissance des cots. Les raisons sont simples et
videntes. Depuis plusieurs annes, ltat sest dot de mcanismes
lui permettant dobtenir le plus bas cot possible notamment pour
toutes les fournitures mdicales. Cest aussi maintenant le cas pour
les mdicaments et les quipements mdicaux spcialiss. Il ny a
probablement l plus aucun gain financier obtenir. Alors si cest le
cas, peut-on vraiment penser quon peut aller chercher des gains
hauteur de prs de 10 % (4 milliards $) dans la productivit et la
meilleure gestion ? Car, qui dit productivit, dit produire chaque
service un cot unitaire infrieur, mais dit aussi produire en plus
grande quantit. Puisquon a vu que les cots affrents ces services
sont dj bas, est-ce dire que les prochains gains se feront sur le
dos des professionnels de la sant, dont les mdecins ? Cest dans
cette direction que pourrait tre forc daller le gouvernement.
Le rapport Castonguay tale un constat adquat de la situation et
propose des avenues qui nous apparaissent viables et celles-ci
incluent la fois, et non sparment, des mesures de financement
et dordre managrial. Alors quil soit clairement dit que bien que nous
souscrivions de tels principes que sont ceux qui sous-tendent saine
gestion et productivit, jamais il ne sera acceptable que soit remise
en question lautonomie professionnelle des mdecins ni que ceuxci fassent les frais de lincapacit de prendre les dcisions
appropries au moment adquat quand nous atteindrons le mur
inluctable et parfaitement annonc de lchec financier vers lequel
nous nous dirigeons quant au budget de la sant au Qubec.
41
MD
RENSEIGNEMENTS SOMMAIRES CONCERNANT

LA PRESCRIPTION
CRITRES DE SLECTION DES PATIENTS
CLASSE THRAPEUTIQUE : Agent antimtique
INDICATIONS ET USAGE CLINIQUE : CESAMET est indiqu chez des patients adultes pour le
traitement de la nause et du vomissement aigus lis la chimiothrapie anticancreuse.
CONTRE-INDICATIONS : CESAMET est contre-indiqu pour les patients particulirement sen-
sibles la marijuana ou dautres cannabinodes, de mme que pour les patients ayant des
antcdents de ractions psychotiques.
POPULATIONS SPCIALES : CESAMET nest pas recommand pour les femmes enceintes et
allaitantes ni pour les enfants de moins de 18 ans, car aucune tude na port sur linnocuit
du mdicament chez ce type de patient. tant donn que CESAMET lve la frquence
cardiaque en dcubitus et en station debout et cause une hypotension orthostatique, des
prcautions particulires doivent tre prises lors de ladministration du mdicament des
personnes ges ou atteintes dhypertension ou de maladie cardiaque.
RENSEIGNEMENTS SUR LINNOCUIT

MISES EN GARDE : CESAMET doit tre prescrit avec une extrme prcaution aux patients
atteints dun dysfonctionnement grave du foie ou ayant des antcdents de troubles affectifs
non psychotiques. CESAMET est incompatible avec lalcool, les sdatifs et les hypnotiques
ou autres substances psychotomimtiques. CESAMET nest pas recommand pour les
femmes enceintes et allaitantes ni pour les enfants de moins de 18 ans, car aucune tude
na port sur linnocuit du mdicament chez ce type de patient.
PRCAUTIONS : CESAMET dtriore souvent les habilets mentales et/ou physiques
requises pour lexcution de tches risque, telles la conduite automobile ou

lopration de machinerie; le patient doit en tre clairement averti et se voir interdire
la conduite dune voiture ou toute autre activit dangereuse tant que persisteront les
effets secondaires du nabilone.
Les effets secondaires psychotropes peuvent persister de 48 72 heures aprs
larrt du traitement.
tant donn que CESAMET lve la frquence cardiaque en dcubitus et en station
debout et cause une hypotension orthostatique, des prcautions particulires
doivent tre prises lors de ladministration du mdicament des personnes ges
ou atteintes dhypertension ou de maladie cardiaque.
INTERACTIONS MDICAMENTEUSES : Les interactions entre CESAMET et le diazpam, le
scobarbital de sodium, lalcool et la codine ont t values. Les effets dpresseurs de

ces agents sont cumulatifs. Les fonctions psychomotrices sont particulirement touches
par linteraction avec le diazpam.
EFFETS SECONDAIRES : Les effets secondaires les plus frquents du nabilone et leur
incidence observe dans le cadre dessais cliniques sont les suivants : somnolence (66,0 %),
vertige (58,8 %), agitation psychologique (38,8 %), scheresse de la bouche (21,6 %),
dpression (14,0 %), ataxie (12,8 %), vision brouille (12,8 %), perturbation des sensations
(12,4 %), anorexie (7,6 %), asthnie (7,6 %), cphale (7,2 %), hypotension orthostatique
(5,2 %), euphorie (4,0 %) et hallucinations (2,0 %).
Les effets secondaires suivants ont t signals chez moins de 1 % des patients traits au
nabilone dans le cadre dessais cliniques : tachycardie, tremblements, syncope, cauchemars, distorsion de la perception du temps, confusion, dissociation, dysphorie, ractions
psychotiques et crises.
SIGNALISATION DEFFETS SECONDAIRES SOUPONNS : Sant Canada se charge de
surveillance des mdicaments et recueille des renseignements sur leurs effets secondaires
graves et inattendus. Si vous souponnez que vous avez subi une raction aigue ou
inattendue ce mdicament, vous pouvez en aviser Sant Canada par :
Tlphone sans frais : 1-866-234-2345

Tlcopieur sans frais : 1-866-678-6789
Courriel :
cadrmp@hc-sc.gc.ca
Par la poste :
Programme canadien de surveillance des effets indsirables des
mdicaments (PCSEIM)
Sant Canada, Localisateur dadresse : 0201C2
Ottawa, ON K1A 1B9
NOTE : Avant de communiquer avec Sant Canada, vous devez appeler votre mdecin ou
votre pharmacien.
ADMINISTRATION
CHEZ LES ADULTES : La posologie de routine pour les adultes est de 1 mg ou 2 mg de
CESAMET, deux fois par jour. La premire dose doit tre prise la nuit prcdant la premire
administration du mdicament de chimiothrapie. La deuxime dose est gnralement
administre de 1 3 heures avant la chimiothrapie. Au besoin, ladministration de
CESAMET peut se poursuivre jusqu 24 heures aprs ladministration du mdicament de
chimiothrapie. La dose maximale quotidienne est de 6 mg en plusieurs administrations.
Afin de permettre des ajustements dans les doses en dedans des zones thrapeutiques,
des capsules de 0,5 mg de CESAMET sont disponibles. Ces ajustements peuvent savrer
ncessaires pour les besoins individuels des patients en ce qui a trait la raction et la
tolrance au traitement. Le surdosage peut se produire mme des doses prescrites si des
symptmes psychiatriques troublants sont prsents. Dans ces cas, le patient devra tre mis
sous observation dans un environnement paisible et des mesures de soutien, comme la
rassurance, devront tre utilises. Les doses subsquentes devront tre retenues jusqu
ce que les patients reviennent leur tat psychique initial; la posologie habituelle pourrait
tre r-instaure si lindication clinique est maintenue. Dans de tels cas, une plus petite
dose de dpart est suggre.
CESAMET est un mdicament en capsules contenant du nabilone et doit tre administr
par voie orale uniquement.
RENSEIGNEMENTS ADDITIONNELS SUR LE PRODUIT
EFFETS SECONDAIRES SIGNALS APRS LE DBUT DE LA COMMERCIALISATION :
Les ractions suivantes, listes par systme physiologique en ordre dcroissant de frquence, ont t signales depuis que
CESAMET a t mis en march. Tous les episodes sont inclus, sans gard lvaluation des causes. Systme sanguin et hmatopotique : Leucopnie. Systme cardiovasculaire : Hypotension et tachycardie. Yeux et oreilles : Troubles de la vision. Systme
gastro-intestinal : Scheresse de la bouche, nause, vomissements et constipation. Systme nerveux : Hallucinations, dpression
du SNC, stimulation du SNC, ataxie, stupeur, vertige, convulsions et paresthsie prilabiale. Effets psychiatriques : Somnolence,
confusion, euphorie, dpression, dysphorie, dpersonnalisation, anxit, psychose et labilit motionnelle. tats divers et mal
dfinis : tourdissements, cphale, insomnie, raisonnement anormal, douleurs thoraciques, absence deffet et dme facial.
SYMPTMES ET TRAITEMENT DU SURDOSAGE : Signes avant-coureurs et symptmes :
Les signes avant-coureurs et les symptmes rsultant dun surdosage sont des pisodes psychotiques pouvant
comporter des hallucinations, de lanxit, une dpression respiratoire et le coma (des cas de surdosage de plus de
10 mg/jour nont pas t signals ce jour).
TRAITEMENT :
On peut considrer quun surdosage sest produit, mme la dose prescrite, si des symptmes psychiatriques
incommodants sont apparus. Dans ce cas, le patient doit tre gard sous observation dans un milieu calme et des
mesures de soutien, y compris rassurer le patient, doivent tre prises. Ladministration du mdicament doit tre
suspendue jusqu ce que le patient revienne son tat psychique normal. Ladministration de routine peut alors tre
reprise, si cela est indiqu cliniquement. Dans ce cas, une dose initiale plus faible est conseille.
Lorsque des pisodes psychotiques surviennent, le patient doit tre trait de la manire la plus conservatrice possible.
Dans le cas dpisodes psychotiques moyens et danxit, un soutien verbal et un rconfort peuvent suffire. Dans les
cas plus graves, une mdication antipsychotique peut tre utile. Cependant, lefficacit des antipsychotiques dans le
soulagement des psychoses induites par les cannabinodes na pas t tudie de manire systmatique. Leur emploi
se fonde sur un nombre restreint de cas o des surdoses de cannabis ont t traites avec des agents antipsychotiques.
Compte tenu des interactions potentielles avec dautres mdicaments (c.--d. effets dpresseurs cumulatifs sur le SNC
du nabilone et de la chlorpromazine), les patients ainsi traits doivent tre surveills de prs.
On doit protger la voie arienne du patient et maintenir la ventilation et la perfusion. Les signes vitaux du patient,
les gaz sanguins, les lectrolytes sriques, etc. doivent tre mticuleusement mesurs et maintenus dans les limites
acceptables. Labsorption du mdicament dans le tractus gastro-intestinal peut tre rduite par ladministration orale
de charbon activ qui, dans bien des cas, est plus efficace que lmse ou un lavage. Il est recommand dutiliser le
charbon au lieu de la vidange gastrique. Ladministration rpte de charbon pendant un certain temps peut acclrer
llimination de plusieurs mdicaments. Il est important de protger la voie arienne du patient lors de la vidange
gastrique ou de ladministration de charbon.
Lutilisation de diurse force, de dialyse pritonale, dhmodialyse, dhmoperfusion de charbon ou de cholestyramine
na pas t signale. Sous un fonctionnement rnal normal, la plupart de la dose de nabilone est limine par le
systme biliaire.
Le traitement de la dpression respiratoire et du coma consiste en une thrapie symptomatique et de soutien. Des
prcautions particulires doivent tre prises lgard des risques dhypothermie. Si le patient montre des signes
dhypotension, lemploi de fluides, dagents inotropes et/ou de vasoconstricteurs est envisager.
STABILIT ET RECOMMANDATIONS DENTREPOSAGE
Conserver temprature ambiante contrle de 15-30 oC.
FORMES POSOLOGIQUES OFFERTES
Capsules de CESAMET 1 mg : chaque capsule de glatine dure no 2, corps blanc et calotte bleu opaque, portant le logo ICN
sur la calotte et linscription 3101 sur le corps, contient 1 mg de nabilone, disponible en bouteilles de 50 capsules.
Capsules de CESAMET 0.5 mg : chaque capsule de glatine dure no 4, corps blanc et calotte rouge opaque, portant le logo ICN
sur la calotte et linscription 3102 sur le corps, contient 0.5 mg de nabilone, disponible en bouteilles de 50 capsules.
CESAMET est considr comme un narcotique et assujetti aux contrles en vigueur pour ce type de substance.
Pour obtenir ce document, ainsi que la monographie complte rdige lintention des professionnels de la sant, communiquez
avec Valeant Canada limite/Limited au numro: 1-800-361-4261. Ce document a t rdig par Valeant Canada limite/Limited.
Dernire rvision : 15 septembre 2004.
Distributeur : Valeant Canada limite/Limited, 4787, rue Levy, Montral, Qubec H4R 2P9
UN TRAITEMENT DAPPOINT SIMPOSE

#1 des cannabinodes oraux distribus aux patients
25 ans dexprience clinique au Canada
Rembours par tous les rgimes provinciaux
travers le Canada, sauf l.P.E.
Relatifs aux teneurs 0,5 mg et 1 mg. Mdicament dexception en Saskatchewan.
MD
N
CESAMET (nabilone) est indiqu pour le traitement de la nause et du vomissement aigus lis la chimiothrapie anticancreuse.
MD
N
CESAMET est contre-indiqu pour les patients particulirement sensibles la
marijuana ou dautres cannabinodes, de mme que pour les patients ayant des
antcdents de ractions psychotiques.
MD
N
CESAMET doit tre prescrit avec une extrme prcaution aux patients atteints
dun dysfonctionnement grave du foie ou ayant des antcdents de troubles
affectifs non psychotiques.
Les effets secondaires les plus frquents du nabilone et leur incidence observe
dans le cadre dessais cliniques sont les suivants : somnolence (66,0 %), vertige
(58,8 %), agitation psychologique (38,8 %), scheresse de la bouche (21,6 %).
Veuillez consulter la monographie de produit pour une information complte sur
les mises en garde, les prcautions, les effets secondaires et la posologie.1
IMS Health Canada : Canadian Compuscript Audit, donnes mensuelles, janvier 2006 novembre 2007,
prescriptions totales distribues.
0,5 mg
Service la clientle 1-800-361-4261
Rfrence : 1. Monographie de produit CESAMET, septembre 2004.
1 mg
Voir le sommaire posologique en page

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