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.     

Use of personal medical records for research purposes.

The established practice of doctors using medical records for research purposes is threatened by the recent proposed guidelines from the Department of Health, the BMA, and the European Commission. The European Commission has proposed that explicit consent should be obtained from each patient before his or her medical records can be used; the proposals from the Department of Health and the BMA would require all research that needs access to personal medical records to be submitted to an ethics committee. We believe that these proposals would seriously impair an entire category of research and suggest therefore that another set of guidelines, proposed by a Royal College of Physicians'' working group, should be used to modify the proposals. The guidelines of the working group encourage the use of medical records for research and ensure that such use can be made in a confidential manner without causing harm.     

The road to Wisconsin

In this article Lynne Sears Williams of Calgary describes her family''s decision to leave for the US, where her husband, Dr. Jim Williams, will pursue his career in family medicine. The decision was not made easily, she writes, but eventually a love for Canada was outweighed by her husband''s desire to practise medicine without the financial and other constraints facing physicians in Canada.     

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.     

The ethics of learning from patients

Is it ethical for medicine to use patients as learning tools for medical students if these patients have not been given a chance to provide truly informed consent? Dr. Caroline Shooner raises this question in the following article, which claimed second prize in CMAJ''s 1996 Logie Medical Ethics Essay Contest. She considers the case of a patient whose trust was shaken when a medical student performed a chest-tube insertion. Shooner concludes that psychologic harm could have been avoided had the patient''s right to informed consent been respected. She also argues that few patients will turn down a chance to help students learn if the request is made properly and openly.     

An international basic science and clinical research summer program for medical students

An important part of training the next generation of physicians is ensuring that they are exposed to the integral role that research plays in improving medical treatment. However, medical students often do not have sufficient time to be trained to carry out any projects in biomedical and clinical research. Many medical students also fail to understand and grasp translational research as an important concept today. In addition, since medical training is often an international affair whereby a medical student/resident/fellow will likely train in many different countries during his/her early training years, it is important to provide a learning environment whereby a young medical student experiences the unique challenges and value of an international educational experience. This article describes a program that bridges the gap between the basic and clinical research concepts in a unique international educational experience. After completing two semester curricula at Alfaisal University in Riyadh, Kingdom of Saudi Arabia, six medical students undertook a summer program at St. Boniface Hospital Research Centre, in Winnipeg, MB, Canada. The program lasted for 2 mo and addressed advanced training in basic science research topics in medicine such as cell isolation, functional assessment, and molecular techniques of analysis and manipulation as well as sessions on the conduct of clinical research trials, ethics, and intellectual property management. Programs such as these are essential to provide a base from which medical students can decide if research is an attractive career choice for them during their clinical practice in subsequent years. An innovative international summer research course for medical students is necessary to cater to the needs of the medical students in the 21st century.     

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.     

Alternative allergy and the General Medical Council.

In July 1992 Dr Keith Mumby, a clinical ecologist, appeared before the professional conduct committee of the General Medical Council on five charges to do with his practice of clinical ecology. He was found guilty of two of the charges--touting for publicity and failing to give a patient adequate medical attention--and admonished. The GMC failed, however, to address the issue of the nature of Mumby''s treatments--clinical ecology itself. This is based on the idea that some patients are unusually susceptible to their environment, the diagnosis and treatment are based on an unstandardised provocation-neutralisation test. A variety of medical bodies have failed to find scientific foundation for the technique. The GMC''s policy on advertising services to patients is inconsistent, and in this case it has shown a regrettable reluctance to deal with the issue of treatments that are not scientifically validated.     

The Need for Continuing Medical Education

Continuing medical education is an essential feature of the practice of modern medicine since it furnishes the means to maintain the doctor''s ability to provide quality patient care.To ensure that continuing medical education is provided efficiently and in the best quality, and utilized fully, it is necessary that: (1) the medical faculty inculcate in the student the concept of lifelong learning; (2) the practitioner adopt less time-consuming patterns of practice, to free more of his time for learning; (3) community hospital-based clinical teaching be provided universally; and (4) research be conducted to determine the best of current teaching methods and develop better ones. Conflicting efforts to meet these needs by practitioners (whose primary responsibility it is) and by organized medicine, specialty societies, voluntary health agencies and others have led to inefficient use of medical faculty teachers. The key parties in continuing medical education—practitioner and teacher—can learn best in medical school-administered programs, which need be supported by all other interested organizations.     

Requirements of British universities for higher medical degrees.

OBJECTIVE--To examine the requirements and opportunities for obtaining a doctor of medicine or master of surgery degree from a university in the United Kingdom other than the graduate''s own, particularly in the case of foreign graduates. DESIGN--Review of regulations governing the award of doctor of medicine and master of surgery degrees in British universities. SETTING--All 19 universities in the United Kingdom offering clinical courses. MAIN OUTCOME MEASURE--Availability of degrees to graduates of other universities. RESULTS--Opportunities for obtaining a degree differed widely among the medical schools, one university (Edinburgh) not admitting graduates of other universities in any circumstance. Of the remaining universities, none would consider a graduate who had not worked in the area where the medical school was located. CONCLUSION--The wide differences in opportunity among the medical schools may put some foreign graduates at a disadvantage compared with other graduates. This problem may become more severe as the number of graduates from the European Community who settle in Britain increases.     

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.     

The Oslerian Tradition and Changing Medical Education: A Reappraisal

Although only 21 of Sir William Osler''s 45 years in academic medicine were spent in US medical schools (1884 to 1905), he played a major role in shaping modern medical education in this country. The integration of scholarship with patient care, together with the science and art of medicine, was central to Osler''s teaching and writing throughout his career. A classic generalist and a charismatic clinical teacher, he taught by example and was as concerned with the ideals of medicine as with its science and knowledge.Many changes have reshaped the content, process and concerns of American medical education since Osler''s time. Subspecialization and balkanization of medical education and practice have become dominant. Many of the important issues in medicine today do not fit neatly into the domain of any of the established specialties or medical organizations. There is now an urgent need to promote generalist attitudes in medicine, and the Oslerian tradition has much to offer in approaching today''s problems in medical education and practice.     

McMaster's pioneer in evidence-based medicine now spreading his message in England.

Dr. David Sackett, formerly of McMaster University and now at Oxford University in England, is considered one of the pioneers of the evidence-based medicine movement. This article looks at his colleagues'' assessment of Sackett''s contributions to medicine and at Sackett''s own views on his lengthy career.     

Doctors' use of electronic medical records systems in hospitals: cross sectional survey

ObjectivesTo compare the use of three electronic medical records systems by doctors in Norwegian hospitals for general clinical tasks.DesignCross sectional questionnaire survey. Semistructured telephone interviews with key staff in information technology in each hospital for details of local implementation of the systems.Setting32 hospital units in 19 Norwegian hospitals with electronic medical records systems.Participants227 (72%) of 314 hospital doctors responded, equally distributed between the three electronic medical records systems.ResultsMost tasks listed in the questionnaire (15/23) were generally covered with implemented functions in the electronic medical records systems. However, the systems were used for only 2-7 of the tasks, mainly associated with reading patient data. Respondents showed significant differences in frequency of use of the different systems for four tasks for which the systems offered equivalent functionality. The respondents scored highly in computer literacy (72.2/100), and computer use showed no correlation with respondents'' age, sex, or work position. User satisfaction scores were generally positive (67.2/100), with some difference between the systems.ConclusionsDoctors used electronic medical records systems for far fewer tasks than the systems supported.

What is already known on this topic

Electronic information systems in health care have not undergone systematic evaluation, and few comparisons between electronic medical records systems have been madeGiven the information intensive nature of clinical work, electronic medical records systems should be of help to doctors for most clinical tasks

What this study adds

Doctors in Norwegian hospitals reported a low level of use of all electronic medical records systemsThe systems were mainly used for reading patient data, and doctors used the systems for less than half of the tasks for which the systems were functionalAnalyses of actual use of electronic medical records provide more information than user satisfaction or functionality of such records systems     

Medical Education and Research: The Foundations of Quality Health Care

In May 1964 the Royal Commission on Health Services declared that “health research is essential to health progress”. However, since that time the means of providing adequate health care have received far less attention than have methods of payment for physicians'' services. Because medical education and research is the source from which all other health benefits flow, urgent attention must be paid to the adequate support of teacher-scientists, as set forth in the Woods, Gordon (Gundy) report. It is the numbers and quality of these men and women, more than any other factor, that will determine the shape of medical science and, hence, medical practice in Canada in the future. Expensive as it is, Canadian medicine and Canadian medical scientists must have generous support if medical care in this country is to be of high quality.     

An American's view of Canadian medical education.

Undergraduate medical education in Canada and the United States is remarkably similar, except for the fact that Canadian medical schools are supported by their provincial governments. However, the systems diverge sharply at the postgraduate level. In Canada, the number and specialty mix of residents are negotiated by medical schools in response to educational and social needs; in the United States, these factors are largely determined by hospital service needs. The Canadian systems of accreditation, certification and payment for medical education after graduation are much simpler than those of the United States, and the accreditation and certification systems are more objective. In addition, the US system promotes subspecialization and a costly specialty imbalance, whereas Canada''s system has achieved an appropriate balance of specialists and generalists. In general, Canadian medical education appears to be simpler, more accountable and more socially responsive.     

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.