a very satisfying role as teacher as well as healer and that there is a remarkable honesty between doctor and patient". If we are dissatisfied with the peer group trends noted above, perhaps the time is ripe for some serious group introspection. Fanning also commented: In the Tibetan system, health is defined as a state of balance in the body. The doctor first develops this balance in him or herself. This is maintained by proper diet and work and by a mindfulness of one's actions. The doctor's own state of balance and health is integral to his or her practice of medicine. G.H. GROwE, MD Division of hematology Vancouver General Hospital 855 W 12th Ave. Vancouver, BC
Reference 1. VINCE DJ: The hidden agenda of medical education. Musings Q 1 (3): 19, 1975
Cervical cancer screening programs To the editor: I have several comments to make after reading the report by the task force on cervical cancer screening programs (Can Med Assoc J 114: 1003, 1976). Although the report is accurate scientifically, it was obviously written by people who have little experience of primary care medicine: it shows the complete lack of understanding by the academic medical community regarding the practice of medicine at the grass-roots level, and some of the dangers of such a report being made public via the media. For many years the clinic in which I practise has successfully used the Pap smear as a carrot to convince women to come in for annual check-ups. The idea of a Pap smear as a check for cancer has caught on in Canada and many patients who would otherwise not come to a doctor's office do come because they think that a Pap smear gives them some protection against cancer. This has been welcomed by physicians because it enables us to see, talk to and examine many more women than in previous years. At this time the physician can also examine his patients for unrelated conditions. I consequently feel justified in disputing the area in the report that states there is no evidence that a cervical cytologic screening program will reduce mortality from other gynecologic or medical conditions. It is for this and other reasons that I take exception to some of the statements in the report that, when taken out of context, could be misconstrued. The report leaves the impression that only women of the high-risk group
(those with an early onset of sexual activity, especially with multiple male partners) should have Pap smears annually. I fear that such an impression, if gained by the general public, could well decrease the number of women who have formerly had the courage to request thorough physical examinations, simply because of the insinuation that they have been promiscuous from an early age. To say that women considered to be of the low- or at-risk groups should be discouraged from having smears more frequently than recommended - that is, more than once every 3 years after their two liiitial visits - can again lead to a misinterpretation. Women may feel that to comply with this recommendation is to avoid seeing their physicians more often than once every 3 years for a general check-up. The report states that provisions for taking cytologic smears in women of the high-risk group should be made at several types of clinics, but fails to mention that all women should have a family physician who is equally capable of making these examinations. Although I agree with many of the points discussed in the report, I wish that it had not been made public and certainly wish that it had not had such a push by the media because I feel there will be a decrease in the number of patients who have, in the past, presented themselves for preventive medical check-ups. J.D. BROWN, MB, B CH, BAO, OPH
Avon Medical Center Avonhurst & Albert Regina, Sask.
To the editor: There were two reasons for distribution of the report by the lay news media to the general public. First, it would appear that a significant number of women in the high-risk group in this country are not taking advantage of the screening facilities currently available. It is hoped that by our having defined the type of individual who is at high risk, such a woman will identify herself to herself and enter a screening program - for example, through a family physician s office. The task force recommendations do not imply in any sense that Dr. Brown's office or any other physicians s office should be ignored as a participant in a screening program, but does recognize that in our society there is more than one entrance to the health care system. A substantial yield of high-risk individuals and abnormal cytologic smears will be found in family planning clinics, student health clinics, youth clinics, venereal disease clinics, prenatal clinics and penal institutions. Second, for years Dr. Brown, I and probably most Canadian physicians have taken the position that advising
1078 CMA JOURNAL/DECEMBER 4, 1976/VOL. 115
a patient to have an annual Pap smear was sound. I think the task force has shown clearly, and Dr. Brown appears to agree, that in most instances this is unnecessary. If the profession is going to reverse its position and follow these recommendations, then its credibility with the informed patient population will be supported by publication of this report. It will not always be easy to dissuade a concerned well individual that she now needs a Pap smear once every 3 to 5 years instead of annually, but publication of statements from this report in the lay news media will help convince her. Dr. Brown states that by adopting a policy of less-than-annual cervical screening one removes the "carrot" that brings women to the office for "preventive medical check-ups". The concept of the annual examination has recently been the subject of critical review1 and the final word is still to be heard. As explained in the report, it is very difficult to link a cervical screening program with a preventive program for other malignant diseases, including carcinoma of the endometrium, carcinoma of the ovary and carcinoma of the breast. I suggest that if Dr. Brown believes that there is an argument to be made for parading every woman in his practice, regardless of age, into his clinic on a regular basis, then this argument must be made on its own merits and not on concepts that have now been shown to be incorrect. Besides, in Canada in this day of the informed consumer, frightening the patient with a carrot concept surely is no longer acceptable. JOHN A. CARMICHAEL, MD, CM, FRC5[C], FACOG Department of obstetrics and gynecology Hotel Dieu Hospital Kingston, Ont.
Reference 1. The annual rip-off? Time, July 26, 1976. p40
Laboratory investigation of cholera To the editor: The reports in the Sept. 4, 1976 issue of the Journal on the case of cholera imported to Canada in 1974 are very interesting and well presented. The paper by Lewis and colleagues, "Laboratory investigation and infection control of cholera in Kingston, Ont." (page 397), was of particular interest to me as a clinical microbiologist who has been responsible for laboratories in Canadian veterans hospitals since 1945. The return of prisoners of war from the Far East, military personnel from the Korean War and United Nations peace-keeping duty, and members of
Reference 1. VINCE DJ: The hidden agenda of medical education. Musings Q 1 (3): 19, 1975
Cervical cancer screening programs To the editor: I have several comments to make after reading the report by the task force on cervical cancer screening programs (Can Med Assoc J 114: 1003, 1976). Although the report is accurate scientifically, it was obviously written by people who have little experience of primary care medicine: it shows the complete lack of understanding by the academic medical community regarding the practice of medicine at the grass-roots level, and some of the dangers of such a report being made public via the media. For many years the clinic in which I practise has successfully used the Pap smear as a carrot to convince women to come in for annual check-ups. The idea of a Pap smear as a check for cancer has caught on in Canada and many patients who would otherwise not come to a doctor's office do come because they think that a Pap smear gives them some protection against cancer. This has been welcomed by physicians because it enables us to see, talk to and examine many more women than in previous years. At this time the physician can also examine his patients for unrelated conditions. I consequently feel justified in disputing the area in the report that states there is no evidence that a cervical cytologic screening program will reduce mortality from other gynecologic or medical conditions. It is for this and other reasons that I take exception to some of the statements in the report that, when taken out of context, could be misconstrued. The report leaves the impression that only women of the high-risk group
(those with an early onset of sexual activity, especially with multiple male partners) should have Pap smears annually. I fear that such an impression, if gained by the general public, could well decrease the number of women who have formerly had the courage to request thorough physical examinations, simply because of the insinuation that they have been promiscuous from an early age. To say that women considered to be of the low- or at-risk groups should be discouraged from having smears more frequently than recommended - that is, more than once every 3 years after their two liiitial visits - can again lead to a misinterpretation. Women may feel that to comply with this recommendation is to avoid seeing their physicians more often than once every 3 years for a general check-up. The report states that provisions for taking cytologic smears in women of the high-risk group should be made at several types of clinics, but fails to mention that all women should have a family physician who is equally capable of making these examinations. Although I agree with many of the points discussed in the report, I wish that it had not been made public and certainly wish that it had not had such a push by the media because I feel there will be a decrease in the number of patients who have, in the past, presented themselves for preventive medical check-ups. J.D. BROWN, MB, B CH, BAO, OPH
Avon Medical Center Avonhurst & Albert Regina, Sask.
To the editor: There were two reasons for distribution of the report by the lay news media to the general public. First, it would appear that a significant number of women in the high-risk group in this country are not taking advantage of the screening facilities currently available. It is hoped that by our having defined the type of individual who is at high risk, such a woman will identify herself to herself and enter a screening program - for example, through a family physician s office. The task force recommendations do not imply in any sense that Dr. Brown's office or any other physicians s office should be ignored as a participant in a screening program, but does recognize that in our society there is more than one entrance to the health care system. A substantial yield of high-risk individuals and abnormal cytologic smears will be found in family planning clinics, student health clinics, youth clinics, venereal disease clinics, prenatal clinics and penal institutions. Second, for years Dr. Brown, I and probably most Canadian physicians have taken the position that advising
1078 CMA JOURNAL/DECEMBER 4, 1976/VOL. 115
a patient to have an annual Pap smear was sound. I think the task force has shown clearly, and Dr. Brown appears to agree, that in most instances this is unnecessary. If the profession is going to reverse its position and follow these recommendations, then its credibility with the informed patient population will be supported by publication of this report. It will not always be easy to dissuade a concerned well individual that she now needs a Pap smear once every 3 to 5 years instead of annually, but publication of statements from this report in the lay news media will help convince her. Dr. Brown states that by adopting a policy of less-than-annual cervical screening one removes the "carrot" that brings women to the office for "preventive medical check-ups". The concept of the annual examination has recently been the subject of critical review1 and the final word is still to be heard. As explained in the report, it is very difficult to link a cervical screening program with a preventive program for other malignant diseases, including carcinoma of the endometrium, carcinoma of the ovary and carcinoma of the breast. I suggest that if Dr. Brown believes that there is an argument to be made for parading every woman in his practice, regardless of age, into his clinic on a regular basis, then this argument must be made on its own merits and not on concepts that have now been shown to be incorrect. Besides, in Canada in this day of the informed consumer, frightening the patient with a carrot concept surely is no longer acceptable. JOHN A. CARMICHAEL, MD, CM, FRC5[C], FACOG Department of obstetrics and gynecology Hotel Dieu Hospital Kingston, Ont.
Reference 1. The annual rip-off? Time, July 26, 1976. p40
Laboratory investigation of cholera To the editor: The reports in the Sept. 4, 1976 issue of the Journal on the case of cholera imported to Canada in 1974 are very interesting and well presented. The paper by Lewis and colleagues, "Laboratory investigation and infection control of cholera in Kingston, Ont." (page 397), was of particular interest to me as a clinical microbiologist who has been responsible for laboratories in Canadian veterans hospitals since 1945. The return of prisoners of war from the Far East, military personnel from the Korean War and United Nations peace-keeping duty, and members of
