London after Tomlinson. Clinical research.

Sir Bernard Tomlinson''s report focuses on London''s health services, but his proposals have major implications for the future of clinical research--not just in London but in the United Kingdom as a whole. They must be seen in the context of a widely perceived decline in British research and development which also threatens clinical research. This article examines the implications of Tomlinson''s proposals and related strategies and recommends the construction of a research market for the patient costs of clinical research to complement the NHS market for patient services introduced in 1991. These arrangements would help sustain the clinical research base and guarantee excellence.     

Did Osler suffer from "paranoia antitherapeuticum baltimorensis"?: A comparative content analysis of The Principles and Practice of Medicine and Harrison's Principles of Internal Medicine, 11th edition

One of the most important legacies of Sir William Osler was his textbook The Principles and Practice of Medicine. A common criticism of the book when it was first published was its deficiency in the area of therapeutics. In this article, the 1st edition of The Principles and Practice of Medicine is compared with the 11th edition of Harrison''s Principles of Internal Medicine. The analysis focuses on the treatment recommendations for 4 conditions that were covered in both books (diabetes mellitus, ischemic heart disease, pneumonia and typhoid fever). Osler''s textbook dealt with typhoid fever and pneumonia at greater length, whereas Harrison''s placed more emphasis on diabetes mellitus and ischemic heart disease. Notwithstanding Osler''s reputation as a therapeutic nihilist, the 2 books devoted equivalent space to treatment (in terms of proportion of total sentences for the conditions). For all conditions except ischemic heart disease, Osler concentrated on general measures and symptomatic care. Throughout Osler''s textbook numerous negative comments are made about the medicinal treatment of various conditions. A more accurate statement about Osler''s therapeutic approach was that he was a "medicinal nihilist." His demand for proof of efficacy before use of a medication remains relevant.     

Vancouver conference hailed as latest step in "revolution for children".

Physicians who organized a major conference on children''s health in Vancouver this summer say it provided further evidence of the growing strength of a "revolution for children." The conference, which attracted 4000 delegates, followed up on earlier meetings held to improve the health care available to children around the world.     

A system worth saving.

The country will mark Canada Health Day on May 12, so CMAJ asked Dr. Michael Gordon to reflect on Canada''s health care system and the changes it has seen and will see. The special day, cosponsored by the Canadian Public Health Association, is designed to highlight "the need for better communication between health professionals and the communities they serve." In this article, Gordon reflects on the dangers facing Canada''s medicare system and the need to protect it from the inroads threatened by privatization.     

Women's health. The childbearing years and after.

Health and development planners have tended to see women primarily in context of their reproductive role. As a result, solutions to women''s health needs have been restricted to expanding and improving maternal and child health systems. There has recently been a major shift in direction, largely because of the influence of the world conference on population and development held in Cairo in 1994. Dr Guiseppe Benagiano, director of the special programme of research, development and research training in human reproduction based at the WHO, says, "We need to remind ourselves constantly that reproductive health is not simply a biomedical issue but one with serious implications for our general health and by extension, for all our efforts in human social and economic development." The 1993 world development report on health identified the lack of a clear strategy for engaging women in health care and suggested that child health services, prenatal care, treatment of sexually transmitted diseases, and family planning services should be provided jointly at convenient times. In an example of this, the Chilean Institute of Reproductive Medicine now offers integrated family planning services at the same time as child health services, and Thailand is experimenting with mobile health clinics to reach women in their homes. As the proportion of elderly women increases, old age is increasingly being seen as a female issue. With the impact of urbanisation and industrialisation, more of these women are living isolated lives, often suffering from chronic debilitating diseases. In his opening statement to the global commission on women''s health in April 1995 which focused on health conditions of women in old age, Dr Hiroshi Nakajima, the WHO''s director general, said: "Our goal should not be solely to extend lives in the physical sense, but to ensure that the added years are worth living."     

Past presidents join forces to refurbish gravesite of Sir Charles Tupper,first CMA president.

The CMA''s past presidents have donated a plaque and refurbished the headstone and plot at the Halifax gravesite of Sir Charles Tupper, the association''s first president. "Sir Charles Tupper was a very significant personality in the conception of a national medical association and the past presidents wanted that fact to be remembered," Dr. Athol Roberts says of the endeavour.     

"Don't let others design your future", new CMA president tells physicians. Interview by Nancy Robb.

Dr. Judith Kazimirski of Nova Scotia becomes the CMA''s 126th president during the association''s annual meeting in Sydney, NS, this month. She says her priority for the next year is to help the CMA play a lead role as the debate intensifies about the future of health and health care in Canada. "The time is right for a very public debate about what people want their system to be, what problems they''re having, and how reform is moving ahead," she says, "and physicians have a critical leadership role to play."     

General practitioners' knowledge of their patients' psychosocial problems: multipractice questionnaire survey.

OBJECTIVES: To evaluate general practitioners'' knowledge of a range of psychosocial problems among their patients and to explore whether doctors'' recognition of psychosocial problems depends on previous general knowledge about the patient or the type of problem or on certain characteristics of the doctor or the patient. DESIGN: Multipractice survey of consecutive adult patients consulting general practitioners. Doctors and patients answered written questions. SETTING: Buskerud county, Norway. SUBJECTS: 1401 adults attending 89 general practitioners during one regular working day in March 1995. MAIN OUTCOME MEASURES: Doctors'' knowledge of nine predefined psychosocial problems in patients; these problems were assessed by the patients as affecting their health on the day of consultation; odds ratios for the doctor''s recognition of each problem, adjusted for characteristics of patients, doctors, and practices; and the doctor''s assessment of previous general knowledge about the patient. RESULTS: Doctors'' knowledge of the problems ranged from 53% (108/203) of "stressful working conditions" to 19% (12/63) of a history of "violence or threats." Good previous knowledge of the patient increased the odds for the doctor''s recognition of "sorrow," "violence or threats," "substance misuse in close friend or relative," and "difficult conflict with close friend or relative." Age and sex of doctor and patient, patient''s educational level and living situation, and location of practice influenced the doctor''s awareness. CONCLUSIONS: Variation in the patients'' communication abilities, the need for confidence in the doctor-patient relationship before revealing intimate problems, and a tendency for the doctors to be entrapped by their expectations may explain these findings.     

Demand-side medical education: educating future physicians for Ontario.

Initiated by Associated Medical Services (AMS), Educating Future Physicians for Ontario is a 5-year collaborative project whose overall goal is to make medical education in Ontario more responsive to that province''s evolving health needs. It is supported by AMS, the five universities with medical schools or academic health sciences centres and the Ontario Ministry of Health. The project''s five objectives are to (a) define the health needs and expectations of the public as they relate to the training of physicians, (b) prepare the educators of future physicians, (c) assess medical students'' competencies, (d) support related curricular innovations and (e) develop ongoing leadership in medical education. There are several distinctive features: a focus on "demand-side" considerations in the design of curricula, collaboration within a geopolitical jurisdiction (Ontario), implementation rather than recommendation, a systematic project-evaluation plan and agreement as to defined project outcomes, in particular the development of institutional mechanisms of curriculum renewal as health needs and expectations evolve.     

Where is the silver lining? Anxious doctors ask.

When Nova Scotia elected a Liberal government in September 1993, a wave of optimism washed over the province''s medical community. One of their own, Dr. John Savage, was now premier, and another, Dr. Ron Stewart, was minister of health. However, anticipation soon turned to anger as Stewart took aim at physician fees and hospital costs to help reduce the province''s health care budget by $62 million. Last November, relations between him and the Medical Society of Nova Scotia (MSNS) hit bottom. In an uncharacteristically political move, the society launched an ad campaign featuring slogans such as "Death by 1000 cuts" and "Uncle Sam want me. Ron Stewart doesn''t." Four months later, the health department and the MSNS called a truce, with an agreement that many physicians consider a positive step. Today the province and its doctors are speaking again, and the medical society is working hard to help define physicians'' roles in a new, regionalized health care system. But has the mood of doctors really improved? Last spring, CMAJ interviewed a cross section of Nova Scotia physicians to find out.     

For public or profession?--The new GMC performance procedures.

The upheaval in the General Medical Council two decades ago came from doctors not the consumers the council was set up to protect. Since then there have been repeated calls for doctors to improve their self regulation by amending the disciplinary procedures. Private member''s bills have failed and the GMC has now proposed performance procedures to deal with doctors who exhibit a "pattern of poor performance." After months of wide consultation in and outside the medical profession the GMC will decide next week whether to endorse the procedures, which unlike the conduct hearings will be inquiries by peers. Professor Margaret Stacey suggests that the procedures lack clarity, smacking of that "trust me" principle whose subtext is "but I''m not telling you what I''m up to."     

The Proteus syndrome: the Elephant Man diagnosed.

Sir Frederick Treves first showed Joseph Merrick, the famous Elephant Man, to the Pathological Society of London in 1884. A diagnosis of neurofibromatosis was suggested in 1909 and was widely accepted. There is no evidence, however, of café au lait spots or histological proof of neurofibromas. It is also clear that Joseph Merrick''s manifestations were much more bizarre than those commonly seen in neurofibromatosis. Evidence indicates that Merrick suffered from the Proteus syndrome and had the following features compatible with this diagnosis: macrocephaly; hyperostosis of the skull; hypertrophy of long bones; and thickened skin and subcutaneous tissues, particularly of the hands and feet, including plantar hyperplasia, lipomas, and other unspecified subcutaneous masses.     

WHO fellowships--what do they achieve?

Training health professionals is one of WHO''s major strategies for improving health care in the developing world. The aim, to strengthen a country''s own capacity rather than injecting expertise from outside, is in the best tradition of sustainable development. But how effective is this so called "capacity building in human resources"? Since it accounted for $43m of WHO''s budget in 1992-3 and is considered by WHO to be a major contribution to health in individual countries, it deserves detailed examination.     

Medical education and society.

As health care changes under the pressures of restraint and constraint our vision of the future of medical education should be based on the medical school''s responsibility to the community. The medical school is "an academy in the community": as an academy, it fosters the highest standards in education and research; as an institution in the community, it seeks to improve public health and alleviate suffering. The author argues that to better achieve these goals medical schools need to become more responsible and responsive to the population they serve. Medical schools have been slow to accept fully the social contract by which, in return for their service to society, they enjoy special rights and benefits. This contract requires that medical educators listen to the public, talk honestly and constructively with government representatives and assess the needs and expectations of the community.     

Legal obligation of physicians to disclose information to patients.

Obtaining a patient''s consent is a routine daily process for physicians, although many are unaware of the scope of this legal obligation. In 1980 the Supreme Court of Canada changed the law relating to informed consent; promotion of patient autonomy shifted the focus from a standard of professional disclosure to one of a "reasonable patient." Physicians have a legal obligation to disclose to patients specific information, the scope of which is determined by a court on the basis of a reasonable patient''s expectation and the circumstances of the case. This gives rise to many controversies in the practice of clinical medicine. It is difficult for physicians to know which treatment risks require disclosure, since this is decided by a court in a retrospective analysis of the evidence. Will the court recognize exceptions to the duty of disclosing information? If several health care professionals are involved in a patient''s care who has the duty to disclose information? Can this duty be delegated? This paper provides physicians with guidelines that are consistent with the promotion of patient autonomy and comply with the doctrine of informed consent. In addition, it suggests ways of improving awareness of the doctrine and procedures to ease its application.     

Hospital and community health service costs: England and Scotland compared.

In publications which have compared the health expenditure in the component parts of the United Kingdom by applying the Resource Allocation Working Party (RAWP) formula to the health budget of England, Scotland, Wales, and Northern Ireland it has been previously concluded that Scotland''s hospital and community health services expenditure is more than 19% above what would be a fair distribution. It has also been implied that Scotland''s allocation should be cut substantially to improve services in England. On the assumption that the purpose of examining the distribution of the health and community health service budget is to ensure "equal opportunity of access to health care for people at equal risk" it is concluded that simple RAWPing of the United Kingdom budget is flawed and a conclusion based on this is therefore untenable.     

Internet access

A 65-year-old man undergoes a routine checkup before retiring. His wife has urged him to have his prostate examined, because she has read about testing for prostate cancer and a friend has just died of this disease. During the rectal examination, the man''s physician discovers some firmness in the right lobe of the prostate gland. The patient has had no urinary symptoms and is in excellent general health. Sexual function is normal. There is no history of prostate cancer; his father died of a stroke at age 86 years. Testing shows that the patient''s prostate-specific antigen level is 9.3 ng/mL, and he is referred to a urologist. Transrectal ultrasound-guided needle biopsy reveals adenocarcinoma with a Gleason score of 7 (intermediate grade). At a follow-up meeting with his physician, the patient says, "I have been doing some research, and it appears that I should have treatment. However, what is less clear to me is what form of therapy is best--surgery or radiation treatment. Please tell me what you can about the state of the art with respect to surgery."     

Hooker and islands1

Sir Joseph Dalton Hooker (1817–1911), friend and scientific confidant of Charles Darwin, lectured in 1866 on ‘Insular floras’ at the Annual Meeting of the British Association for the Advancement of Science. His interest and knowledge of islands had been aroused when he travelled to the Antarctic aboard the Erebus under Sir James Clark Ross from 1839–43. On his return, Darwin passed on to Hooker the botanical collections he had made on the Beagle voyage, including those from the Galapagos. Hooker's conclusions from these and from his own material and experiences were important to Darwin as he developed the ideas that culminated in the publication of the Origin of Species. The 1866 lecture provided a focus for subsequent and informative studies on evolution, and islands continue to provide invaluable natural laboratories for evolutionary biology and genetics. © 2009 The Linnean Society of London, Biological Journal of the Linnean Society, 2009, 96 , 462–481.     

Canada's largest magnet finds home in new MRI program in London

Canada''s largest magnet, which is now making functional magnetic resonance imaging possible at Ontario''s Robarts Research Centre, is expected to cast some light on mysteries buried within the brain. With the huge magnet, said Dr. Ravi Menon, "I can distinguish between centres that control the thumb and the index finger."