Dr. Max King: the sad life and early death of Mackenzie King's physician brother

While researching her best-selling biography, Mrs. King: The Life and Times of Isabel Mackenzie King, CMAJ contributing editor Charlotte Gray discovered a wealth of information about Dr. Dougal Macdougall (Max) King. Although he never became as famous as his older brother Mackenzie, Gray presents a convincing argument that Dr. Max King''s life and early death speak volumes about medicine and the medical profession at the turn of the century. She also argues that Mackenzie King''s own life would have been much different had his brother not died at the too young age of 42. Gray''s book was nominated for the Viacom Award, which honours the best nonfiction book published annually in Canada.     

Rural background and clinical rural rotations during medical training: effect on practice location

BACKGROUND: Providing health care services in rural communities in Canada remains a challenge. What affects a family medicine resident''s decision concerning practice location? Does the resident''s background or exposure to rural practice during clinical rotations affect that decision? METHODS: Cross-sectional mail survey of 159 physicians who graduated from the Family Medicine Program at Queen''s University, Kingston, Ont., between 1977 and 1991. The outcome variables of interest were the size of community in which the graduate chose to practise on completion of training (rural [population less than 10,000] v. nonrural [population 10,000 or more]) and the size of community of practice when the survey was conducted (1993). The predictor or independent variables were age, sex, number of years in practice, exposure to rural practice during undergraduate and residency training, and size of hometown. RESULTS: Physicians who were raised in rural communities were 2.3 times more likely than those from nonrural communities to choose to practise in a rural community immediately after graduation (95% confidence interval 1.43-3.69, p = 0.001). They were also 2.5 times more likely to still be in rural practice at the time of the survey (95% confidence interval 1.53-4.01, p = 0.001). There was no association between exposure to rural practice during undergraduate or residency training and choosing to practise in a rural community. INTERPRETATION: Physicians who have roots in rural Canada are more likely to practise in rural Canada than those without such a background.     

Refugee MD not wasting skills even though door to medical practice in Canada is closed

Dr. Lula Hussein, a Somali refugee with a medical degree from East Germany, is not licensed to practise in Canada, but she is making her mark in Ottawa''s Somali community by counselling, advising and helping her fellow refugees. One of her particular interests is in ending the practice of female genital mutilation, which still finds favour among some of Canada''s refugees and immigrants.     

Bioethics for clinicians: 12. Ethical dilemmas that arise in the care of pregnant women: rethinking "maternal-fetal conflicts".

When a pregnant woman makes a decision or acts in a manner that may be detrimental to the health and well-being of her fetus, her physician may be faced with an ethical dilemma. Is the physician''s primary duty to respect the woman''s autonomy, or to promote behaviour that may be in the best interest of the fetus? The controversial concept of "fetal rights" or the "fetus as a patient" contributes to the notion that the pregnant woman and her fetus are potential adversaries. However, Canadian law has upheld women''s right to life, liberty and security of the person and has not recognized fetal rights. If a woman is competent and refuses medical advice, her decision must be respected even if the physician believes that her fetus will suffer as a result. Coercion of the woman is not permissible no matter what appears to be in the best interest of the fetus.     

A new primary care rostering and capitation system in Norway: Lessons for Canada?

Providing every patient with a personal primary care physician or, from the physician''s perspective, establishing a stable roster or list of patients is currently being actively debated in Canada. Norway''s system of primary care medicine, similar to Canada''s, faces many of the same problems. In 1992 a trial rostering system with blended funding (capitation, fee-for-service and user fees) was established in 4 Norwegian municipalities. After 3 years of close monitoring, the results of system evaluations have attracted strong interest. This article reports on the benefits and problems encountered with the new rostering system in Norway. If Canada is moving in the same direction, some of the lessons learned may be helpful.     

Jehovah's Witnesses leading education drive as hospitals adjust to no blood requests.

Jehovah''s Witness representatives have visited more than 10 Canadian medical schools and 200 hospitals in an attempt to educate future and practising physicians about nonblood medicine. The trend is becoming more popular since the advent of HIV, and there are now about 100 bloodless medicine and surgery centres around the world, including 52 in the US. However, a Jehovah''s Witness spokesman says Canada is "conspicuously absent" from the list of countries that offer bloodless-medicine programs.     

"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."     

Canadian perspectives on seabed mining: The case of the production limitation formula

Abstract

This paper will analyze the position Canada took on seabed mining in the Third United Nations Law of the Sea Conference (UNCLOS III). Canada is a major land‐based producer of nickel, an industrialized country with private interests in seabed mining, a NATO member, a major ally of the United States, and a country with extensive ties to less‐developed countries. At UNCLOS III Canada was concerned primarily about the management and control of its coastal resources and the protection of the marine environment. After having secured these interests, Canada emerged as the leader of the land‐based mineral‐producer group advocating production controls on seabed mining. The production limitation formula was one of the major reasons for the United States’ decision not to sign the Law of the Sea Treaty. In so forcefully advocating a production limitation formula, the Canadian delegation relinquished Canada's potential as a middle power to bridge the gap between the Group of 77 and the Western industrialized countries in order to formulate a widely acceptable regime to govern the seabed. A production limitation formula was not in Canada's best interests, given her potential role in seabed mining, and was rejected by officials in the Department of Energy, Mines, and Resources, as well as the Canadian private sector.     

Do you have any regrets about entering medicine?

Do today''s students have any second thoughts about their decision to pursue a career in medicine? Gabriel Leung, who graduates in June from the University of Western Ontario, considers the problems and dilemmas that have confronted him and his classmates during their short careers and muses on the uncertain future today''s physicians face.     

Population Dynamics of Heterodera glycines in Conventional Tillage and No-Tillage Soybean/Corn Cropping Systems

The effects of no-tillage (NT), conventional tillage (CT), and crop rotation on soybean yield and population dynamics of Heterodera glycines were compared during a 7-year study in a silty clay loam soil with 6% organic matter. Either H. glycines-resistant ''Linford'' soybean or susceptible ''Williams 82'' soybean was rotated with corn and grown on 76-cm-wide rows in both tillage systems. Soybean was planted in 1994, 1996, 1998, 1999, and 2000. Yield of Linford was significantly greater than Williams 82 in all years. Soybean yield was affected by tillage in 1999 and 2000. No-tillage production tended to support more reproduction (R = number of eggs at harvest/number of eggs at planting) on both cultivars. The largest R for Williams 82 were in 1998: 58.35 for NT plots and 11.78 for CT plots. For Linford, the largest R were 12.09 for NT plots in 1996, and 3.71 for CT in 1999. When corn was planted, R decreased more in NT. When soybean was planted in years subsequent to 1994, numbers of eggs at harvest (Pf) were greater for Williams 82 NT than for Williams 82 CT or Linford in both tillage systems; however, crop rotation with corn negated these population increases. The soil became suppressive to H. glycines in 1999 and was suppressive in 2000. After the 3 years of continuous soybean, Pf per 250 cm[sup3] soil were 2,870 for Williams 82 NT, 791 for Williams 82 CT, 544 for Linford NT, and 990 for Linford CT in 2000, compared with Pf of 13,100 for Williams 82 NT, 15,000 for Williams CT, 2,360 for Linford NT, and 2,050 for Linford CT in 1994. Describing population dynamics solely on the basis of R was not adequate, but also required independent examination of initial populations following overwintering and Pf after the growing season. Planting soybean either NT or CT in rotation with corn did not result in long-term increases in numbers of H. glycines eggs.     

Tailoring family medicine residency programs to meet community needs

This paper describes how members of the Department of Family Medicine of the University of Ottawa developed lists of problems and procedures common and important in family practice in Canada and, on the basis of these lists, drew up guidelines for content in the 2-year residency program for family medicine. A computerized data retrieval system is used to monitor every resident''s practice to ensure that he or she gains appropriate exposure to common problems and procedures.     

Making sense of shadows: Dr. James Third and the introduction of x-rays, 1896 to 1902.

The discovery of x-rays was announced by German physicist Wilhelm Conrad Röntgen in December 1895. This review of the introduction of the use of x-rays in Kingston, Ont., shows the rapidity of their adoption in Canadian medicine. By February 1896 "x-ray photographs" were being taken by Captain John Cochrane of the Royal Military College of Canada in Kingston. Initially a scientific and popular curiosity, the new rays were quickly applied to medicine, and by the fall of 1896 the Kingston General Hospital had acquired its own x-ray apparatus. The hospital superintendent, Dr. James Third, became a leading practitioner and promoter of radiographic diagnosis and radiation therapy. He published, in 1902, the first comprehensive review of the diagnostic and therapeutic uses of x-rays by a Canadian physician. Third''s writings reveal his technical knowledge, his organized approach to the application of radiography to clinical medicine and his cautious attitude. Like other physicians who have witnessed the introduction of new diagnostic techniques, Third feared that the new technology would usurp the physician''s clinical skills.     

The impact of a new geriatric program in a hospital for the chronically ill.

Reports of the rapidly increasing proportion of persons aged 65 years and more in Canada and the resultant need for changes in the country''s health care system prompted experimental changes in the operation and training procedures at St. Mary''s of the Lake Hospital, Kingston, Ont. Aimed at better patient care and at better education of medical house staff in geriatrics and long-term care, the revised program is permeated with the philosophy of rehabilitation. It includes full-time staff, a geriatric outpatient clinic, a day hospital, a team approach to patient care (with regular team audits), problem-oriented medical records, a formal physical medicine section with a district inpatient unit, and an intensive inservice education program. After the first year of the program patient outcome had improved and more efficient use was being made of continuing care beds because of larger numbers of patinets being discharged home after shorter stays. This may be one avenue for deceleration of our country''s dismal rate of institutionalization.     

The Class of 1989 and physician supply in Canada

BACKGROUND: "The Class of 1989" is a study of 1722 people who were awarded an MD degree by a Canadian university in 1989. This paper reports on migration, specialty choices and patterns of post-MD training in order to assess the contribution of the graduating cohort to the physician workforce of Canada. METHODS: A longitudinal study was conducted over 7 years after graduation to trace the current location, the post-MD training history and the professional activity of the graduating cohort. Several medical professional and educational associations in Canada and the United States provided year-by-year information on field and location of post-MD training, certification achieved, whether in practice and location of practice through to spring 1996. Information from all sources was linked to a list of 1989 medical school graduates. RESULTS: From entry to medical school through to 7 years after graduation the cohort was diminished by about 16%. The main reason for loss was migration to other countries: 193 graduates (11.2%) were outside Canada in 1995-96. Internal migration was extensive also; for example, by 1995-96 relatively few of the graduates were located in Newfoundland or Saskatchewan. Of the 1516 graduates active in Canada in 1995-96, 878 (57.9%) were in general practice/family medicine, and only 638 (42.1%) were practising or training in a specialty. INTERPRETATION: The "yield" of the Class of 1989 for Canada''s physician workforce is insufficient to meet annual physician inflows from Canadian sources to serve population growth and to replace retiring or emigrating physicians. As output from Canada''s medical schools drops even further, the gap between requirements and supply will grow even wider.     

A fundamental problem of consent.

A consultant anaesthetist gave a diclofenac suppository for postoperative pain to a patient having four teeth extracted under general anaesthesia in the dental surgery. He did not seek the patient''s specific consent preoperatively for use of the suppository but told her afterwards what he had done. Charged before the professional conduct committee of the General Medical Council with failure to obtain informed consent and assault, the anaesthetist was found guilty of serious professional misconduct and admonished. This decision has far reaching implications and has caused great concern.     

The costs of human locomotion: Maternal investment in child transport

This article investigates maternal investment in child carrying and presents a method for determining when it is energetically advantageous for a mother to carry her child rather than force her child to walk independently. I calculate maternal and child energy consumption while walking and develop correction factors to facilitate making these energy calculations for young children. In addition, I investigate the effect of maternal burdens in addition to the child and of external nutritional support on energy consumption. Since maternal energy is a finite resource, the “decision” to carry a child or force it to walk independently is especially important. This decision can be predicted from the body mass of the mother and child and the child's age. If the mother provides all of the child's nutrition, then the mother should choose to carry her child only when the energy usage of the mother carrying the child is less than the sum of the energy used when the mother and child walk independently. The critical velocity, when the two expenditures are equal, can then be determined. Several general hypotheses are also addressed. The critical velocity of a 60 kg mother with a 4-year-old child approximately equals the average walking speed of adult humans. For a lighter mother, the critical velocity is reached when her child is 3 years old, while for heavier mother this point is not reached until her child is 6 years old. The effect of burdens in addition to the child's mass is minimal. Nutritional support of the child by agencies other than the mother decreases the age at which the mother should force the child to walk independently. In some cases, especially for the lightest mothers, it is never in the mother's best energetic interest to carry her child. Am J Phys Anthropol 107:71–85, 1998. © 1998 Wiley-Liss, Inc.     

How strategy environment and wealth shape altruistic behaviour: cooperation rules affecting wealth distribution in dynamic networks

Societies rely on individual contributions to sustain public goods that benefit the entire community. Several mechanisms, that specify how individuals change their decisions based on past experiences, have been proposed to explain how altruists are not outcompeted by selfish counterparts. A key aspect of such strategy updates involves a comparison of an individual''s latest payoff with that of a random neighbour. In reality, both the economic and social milieu often shapes cooperative behaviour. We propose a new decision heuristic, where the propensity of an individual to cooperate depends on the local strategy environment in which she is embedded as well as her wealth relative to that of her neighbours. Our decision-making model allows cooperation to be sustained and also explains the results of recent experiments on social dilemmas in dynamic networks. Final cooperation levels depend only on the extent to which the strategy environment influences altruistic behaviour but are largely unaffected by network restructuring. However, the extent of wealth inequality in the community is affected by a subtle interplay between the environmental influence on a person''s decision to contribute and the likelihood of reshaping social ties, with wealth-inequality levels rising with increasing likelihood of network restructuring in some situations.     

ACMC: past,present and future.

In this article, the president of the Association of Canadian Medical Colleges (ACMC) and its director of research review the issues that have confronted ACMC since its inception: the founding of ACMC; development of the clinical teaching unit; creation of the Medical Research Council and expansion of the research mission; the Royal Commission on Health Services and the founding of new faculties of medicine; ACMC''s in-house research program; accreditation and ACMC''s links with medical education in the United States; and French-language medical education in Canada. The review points out the perennial nature of many of these issues, and how often perceived solutions to the problems later become problems themselves. It ends on the optimistic note that ACMC can successfully meet the challenges of the future.     

Young Children's Probability of Dying Before and After Their Mother's Death: A Rural South African Population-Based Surveillance Study

Background

There is evidence that a young child''s risk of dying increases following the mother''s death, but little is known about the risk when the mother becomes very ill prior to her death. We hypothesized that children would be more likely to die during the period several months before their mother''s death, as well as for several months after her death. Therefore we investigated the relationship between young children''s likelihood of dying and the timing of their mother''s death and, in particular, the existence of a critical period of increased risk.

Methods and Findings

Data from a health and socio-demographic surveillance system in rural South Africa were collected on children 0–5 y of age from 1 January 1994 to 31 December 2008. Discrete time survival analysis was used to estimate children''s probability of dying before and after their mother''s death, accounting for moderators. 1,244 children (3% of sample) died from 1994 to 2008. The probability of child death began to rise 6–11 mo prior to the mother''s death and increased markedly during the 2 mo immediately before the month of her death (odds ratio [OR] 7.1 [95% CI 3.9–12.7]), in the month of her death (OR 12.6 [6.2–25.3]), and during the 2 mo following her death (OR 7.0 [3.2–15.6]). This increase in the probability of dying was more pronounced for children whose mothers died of AIDS or tuberculosis compared to other causes of death, but the pattern remained for causes unrelated to AIDS/tuberculosis. Infants aged 0–6 mo at the time of their mother''s death were nine times more likely to die than children aged 2–5 y. The limitations of the study included the lack of knowledge about precisely when a very ill mother will die, a lack of information about child nutrition and care, and the diagnosis of AIDS deaths by verbal autopsy rather than serostatus.

Conclusions

Young children in lower income settings are more likely to die not only after their mother''s death but also in the months before, when she is seriously ill. Interventions are urgently needed to support families both when the mother becomes very ill and after her death. Please see later in the article for the Editors'' Summary     

Causes of mortality in a subarctic settlement (York Factory,Man.), 1714-1946.

A 250-year retrospective mortality study of York Factory, on the shores of Hudson Bay, was undertaken. The daily journals of the Hudson''s Bay Company and the records of the Anglican Church of Canada were the principal sources examined. From 1714 to 1801 the death rate among the Europeans was 0.015 per year, about 10 times today''s level but in line with American figures of the period. The high mobility of the population during the 19th century precluded statistical assessment. In the first half of the 20th century the Europeans left; among the Cree Indians who stayed 316 out of 401 deaths were caused by infection. As in the preceding eras, tuberculosis and influenza, sometimes in epidemic form, were the most commonly diagnosed diseases. The settlement''s overall mortality rate in those last 45 years was 0.03 per year, triple that for the rest of Canada in 1932.