[The author responds:] I thank Drs. Ross and Donoff and Dr. Perkin for their supportive comments. It is true that the national colleges were not originally conceived as proxies for licensing bodies. However, for many years most, if not all, licensing bodies in Canada have accepted CFPC and RCPSC certification as suitable qualifications for licence in lieu of the LMCC. Dr. McKendry misses my point about the inappropriateness of licensing all physicians for "practice in general". A strengthened and more relevant MCC examination held at the end of the undergraduate medical program should ensure competence in the knowledge, skills and attitudes expected of all physicians. Certified specialists holding a general licence currently practise within their area of competence; I assume this would continue to be the case. The argument as to whether training in family medicine is the only suitable preparation for general practice will no doubt continue. I suspect similar arguments were voiced decades ago regarding the suitability of RCPSC programs for the preparation of spe-
cialists. With respect to a minimum acceptable standard I emphasized that Canadian medicine is now at a stage in its evolution at which the highest possible standard should be the goal of licensure, a standard within the reach of most Canadian physicians. Although fewer than 5% of North American graduates in medicine fail to achieve RCPSC certification after specialty training it is true that some prove not to be suitable for independent practice as judged by certification standards. A system in which achievement of the standard is virtually guaranteed serves
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neither the public nor the profession. The RCPSC assesses large numbers of foreign graduates as to training and eligibility for certification examinations; this need not change with my proposal. The CFPC might feel a greater impact from foreign physicians seeking certification. The numbers quoted by McKendry would not overwhelm the capacities of either college. I agree that portability of licensure is a desirable objective. The point of my proposal is that it is not the only objective. The PMCs' varying requirements as to what constitutes satisfactory postgraduate training has been the major impediment to portability of licensure rather than the rigour or relevance of the MCC qualifying examination. If the PMCs want to use more stringent standards to assess the clinical competence of those wishing to enter independent practice such standards are already in place at the national colleges. Furthermore, accepting the training requirements of the colleges would eliminate the barriers now imposed by the various training requirements of the PMCs. Perhaps the CFPC and the RCPSC should be more accountable to the public - the colleges might welcome the opportunity. They have broad representation from Canadian medical schools, whereas only 3 of the 39 MCC members are appointed by the Governor in Council. I suggested that the PMCs, through the Federation of Medical Licensing Authorities of Canada, be more involved in the accreditation and certification processes of the colleges. The PMCs should and would remain accountable to the public, both generally and specifically through the provincial legislatures. The PMCs would choose to use the certification process of
the colleges and justify their choice to the public, as they presumably now do in choosing the MCC examinations. I agree with Dr. Kendel that the public expects, demands and deserves a high level of accountability on the part of the profession. That is why I proposed adoption of the highest possible standards for medical licensure. Robert F. Maudsley, MD, FRCSC Vice-Dean Faculty of Medicine Queen's University Kingston, Ont.
Assisting suicide he subject of the letter in the Aug. 1, 1990, issue of ..LCMAJ (143: 168) by Dr. Gerry Craigen, Dr. Neil Lazar and Margaret Keatings really bothers me. As a psychiatrist I am keenly aware of the difficulty of dealing with people who express a wish to die, especially those with Alzheimer's disease, which is still diagnosed largely at autopsy. How did Dr. Jack Kevorkian know that the woman he "helped" was not suffering from serious depression rather than Alzheimer's disease? It is extremely dangerous for us, as physicians, to in any way assist people to kill themselves. Most of us are aware of the many causes of depression, especially those related to drugs such as reserpine. The premise that the patient's wish should be accepted uncritically puts us on very dangerous ground. I agree with Craigen and his coauthors that Kevorkian should be severely criticized and reprimanded by state and national medical associations. Willi D. Gutowski, MD 101-9181 Main St. Chilliwack, BC
cialists. With respect to a minimum acceptable standard I emphasized that Canadian medicine is now at a stage in its evolution at which the highest possible standard should be the goal of licensure, a standard within the reach of most Canadian physicians. Although fewer than 5% of North American graduates in medicine fail to achieve RCPSC certification after specialty training it is true that some prove not to be suitable for independent practice as judged by certification standards. A system in which achievement of the standard is virtually guaranteed serves
836
CAN MED ASSOC J 1990; 143 (9)
neither the public nor the profession. The RCPSC assesses large numbers of foreign graduates as to training and eligibility for certification examinations; this need not change with my proposal. The CFPC might feel a greater impact from foreign physicians seeking certification. The numbers quoted by McKendry would not overwhelm the capacities of either college. I agree that portability of licensure is a desirable objective. The point of my proposal is that it is not the only objective. The PMCs' varying requirements as to what constitutes satisfactory postgraduate training has been the major impediment to portability of licensure rather than the rigour or relevance of the MCC qualifying examination. If the PMCs want to use more stringent standards to assess the clinical competence of those wishing to enter independent practice such standards are already in place at the national colleges. Furthermore, accepting the training requirements of the colleges would eliminate the barriers now imposed by the various training requirements of the PMCs. Perhaps the CFPC and the RCPSC should be more accountable to the public - the colleges might welcome the opportunity. They have broad representation from Canadian medical schools, whereas only 3 of the 39 MCC members are appointed by the Governor in Council. I suggested that the PMCs, through the Federation of Medical Licensing Authorities of Canada, be more involved in the accreditation and certification processes of the colleges. The PMCs should and would remain accountable to the public, both generally and specifically through the provincial legislatures. The PMCs would choose to use the certification process of
the colleges and justify their choice to the public, as they presumably now do in choosing the MCC examinations. I agree with Dr. Kendel that the public expects, demands and deserves a high level of accountability on the part of the profession. That is why I proposed adoption of the highest possible standards for medical licensure. Robert F. Maudsley, MD, FRCSC Vice-Dean Faculty of Medicine Queen's University Kingston, Ont.
Assisting suicide he subject of the letter in the Aug. 1, 1990, issue of ..LCMAJ (143: 168) by Dr. Gerry Craigen, Dr. Neil Lazar and Margaret Keatings really bothers me. As a psychiatrist I am keenly aware of the difficulty of dealing with people who express a wish to die, especially those with Alzheimer's disease, which is still diagnosed largely at autopsy. How did Dr. Jack Kevorkian know that the woman he "helped" was not suffering from serious depression rather than Alzheimer's disease? It is extremely dangerous for us, as physicians, to in any way assist people to kill themselves. Most of us are aware of the many causes of depression, especially those related to drugs such as reserpine. The premise that the patient's wish should be accepted uncritically puts us on very dangerous ground. I agree with Craigen and his coauthors that Kevorkian should be severely criticized and reprimanded by state and national medical associations. Willi D. Gutowski, MD 101-9181 Main St. Chilliwack, BC
