haviour" frown on "whistle-blowered as being unbecoming to the [Dr. Kluge replies.: profession" (Can Med Assoc J ing". Clause 27 of the CMA's Dr. Shepherd's letter highlights an code of ethics really has no teeth. 1989; 141: 1080-1081). It is germane to Kluge's argu- essential difference in the ap- So physicians who are in need of ment that one professional body proach taken to physician impair- help don't get it, and the patients has moved the obligation to re- ment in Canada and the United suffer. port an impaired colleague from States. A quick check of relevant As I tried to point out in my the ethical to the legal sphere. The Canadian provincial regulations article, a physician has an ethical agency that grants medical li- and regulatory agencies has re- obligation to take appropriate cences in the state of Oregon is vealed that most provinces do not steps when he or she becomes the Board of Medical Examiners. have a reporting law like Ore- aware of a colleague's impairOne section of the laws governing gon's. British Columbia is one of ment. I am not sure that it is the practice of medicine in Ore- the few exceptions. Its Medical always necessary to enshrine ethgon (the Medical Practice Act), Practitioners Act, section 55, ical obligations in law. However, entitled "Duty to report violations states the following: physicians do find themselves in a or suspected violations", reads as special fiduciary position toward Every registered member shall report patients in virtue of what they do, follows. to the registrar the condition of any a fact that is recognized in the BC person registered under this Act statute. Perhaps it is time to exAny physician licenced by the Board whom he, on reasonable and probable amine publicly the whole issue. ... shall ... report to the Board any information such physician . . . may have which appears to show that a physician is or may be guilty of unprofessional or dishonorable conduct or is or may be mentally or physically unable to engage in the practice of medicine [ORS 677.415]. No person who has made a complaint as to the conduct of a licensee of the Board or who has given information or testimony relative to a proposed or pending proceeding for misconduct against the licensee of the Board, shall be answerable for any such act in any proceeding except for perjury committed by him [ORS 677.335].
Before being granted a licence in Oregon a physician must demonstrate familiarity with the Medical Practice Act. If the case Kluge outlines had occurred in Oregon Dr. W would not have been in a quandary. ORS 677.415 could be interpreted such that she would be legally obligated to report her concerns to the Board of Medical Examiners, which in turn might have investigated the evidence and taken action. Has this solution to Dr. W's quandary been implemented by any Canadian licensing agency? Robert Shepherd, MD 37 Beechmont Cres. Gloucester, Ont.
grounds, believes to be suffering from a physical or mental ailment, emotional disturbance or addiction to alcohol or drugs that, in his opinion, if the person continues to practise medicine or surgery, might constitute a danger to the public or be contrary to the public interest.
The need and indeed appropriateness of such formal reporting requirements are a matter of some debate in the Canadian medical scene. One side maintains that such requirements are counterproductive: they establish a confrontational framework that is not conducive to dealing with the problem in any except legal terms. Furthermore - so the argument goes - whether it is subsequently substantiated or not, the fact that a complaint is laid under such requirements threatens the personal and professional position of the physician in an irreparable fashion. The emphasis should be on prevention and help, not formal procedures. The other side maintains that, like any other profession, medicine is notoriously blind toward the shortcomings of its own members. As long as there is no formal reporting requirement there will be little actual reporting, because the canons of medical "good taste" and "collegial be-
Eike-Henner W. Kluge, PhD Director Ethics and Legal Affairs Canadian Medical Association
Geriatricians and the frail elderly rs. Roy Alan Fox, Avram Mark Clarfield and David Bryan Hogan recently outlined the "Competencies required for the practice of geriatric medicine as a consultant physician" (Can Med Assoc J 1989; 141: 1045-1048). In his editorial "Geriatrics - consolidating the specialty" (ibid: 1039) Dr. Bruce P. Squires said that more attention should have been paid to what geriatricians do as compared with what they know. Neither paper, in my view, dealt sufficiently with who the geriatricians know about and do things to, and this is important. It is not a matter of, in Squires' terms, "limiting their practice to old people" any more than cardiologists "limit" their practice to people with hearts. The geriatrician's constituency is the 10% to 15% of the elderly population who, in addition to their multiple CAN MED ASSOC J 1990; 142 (4)
283
medical problems, are functionally dependent. These are the frail elderly, and the effectiveness of, for example, geriatric assessment units can only be demonstrated when such "technology"' is limited to the frail.2 Although in the United States there is active pursuit of primary care by geriatricians, in Canada, as Fox and colleagues point out, "there is no support . . . for the specialty's becoming a primary care service for elderly people". Nor, on the basis of the available evidence, should there be. Kenneth Rockwood, MD Division of Geriatric Medicine Camp Hill Medical Centre Halifax, NS
References 1. Epstein AM, Hall JA, Besdine R et al: The emergence of geriatric assessment units: the 'new technology' of geriatrics. Ann Intern Med 1987; 106: 299-303 2. Rubenstein LZ: Geriatric assessment: an overview of its impacts. Clin Geriatr Med 1987; 3: 1-17
[Dr. Fox and colleagues reply.] The letter from Dr. Rockwood and the editorial by Dr. Squires point out that much more remains to be written and debated concerning geriatric medicine. Those of us practising the specialty know what we do, where and to whom. In our paper we looked only at defining the knowledge, attitudes and skills required by the geriatrician, to aid our training programs. At the same time we are hoping that others, particularly those involved in core training in internal medicine, will consider the relevance of these "competencies" for their own trainees. Once consensus is achieved, then more specific goals can be set and the means of attainment (i.e., training time and location) more accurately defined. We agree that the role of geriatricians is in the care of a subset of elderly Canadians. Our efforts need to be targeted toward For prescribing information see page 317
the frail elderly, who Rockwood points out comprise 10% to 15% of those over 65 years old. We have attempted to define the competencies required for the care of these people, who have functional impairment and multiple interacting problems. We are sorry to disappoint, but more effort will be needed to measure the performance of individual physicians and may be the subject of future studies. We believe, unlike Squires, that geriatricians and the specialty are easily distinguishable, perhaps more so than in other specialties. The competencies of the specialist and the target population are being clearly defined. Can we say the same for general internal medicine and rehabilitation, hematology etc.? Roy Alan Fox, MD, FRCPC, FRCP Head Division of Geriatric Medicine Dalhousie University Halifax, NS Avram Mark Clarfield, MD, CCFP, CSPQ, FRCPC Director Division of Geriatrics Sir Mortimer B. Davis
Jewish General Hospital McGill University Montreal, PQ David Bryan Hogan, MD, FRCPC, FACP Assistant professor of medicine Division of Geriatric Medicine Dalhousie University Halifax, NS
Reducing deaths from breast cancer in Canada xW rith reference to the report of the Workshop Group (Can Med Assoc J 1989; 141: 199-201) a few observations seem to be in order. Although physical examination and breast self-examination make valuable contributions to the detection of breast carcinoma, it is generally recognized that
mammography is the uniquely effective and most sensitive modality for the detection of nonpalpable early tumours. Mammography has been improved and meaningfully practised by dedicated radiologists for the past several decades. Seminal studies'-4 by such practitioners of the art in Sweden, Britain and the United States form the basis of breast screening programs in several countries, including Canada. Only one radiologist with vast experience in mammography, Dr. Guy Hebert, of Montreal, was included in the Workshop Group, undoubtedly all of whom had excellent credentials. Hebert's voice was nevertheless extinguished by those in the group with little or no experience in breast imaging. We submit that the studies cited in the report were conducted by experts in mammography that is, radiologists. Neglect for radiologists in some if not most provincial plans for breast screening is not new, these plans being heavy with blueprints as well as with organizational and statistical personnel. Whatever political considerations have brought this situation about, such should not have been the case in such an important workshop. The report places much emphasis on the presumed lack of benefit of screening women in the age group 40 to 49 years. In fact, one-third of breast carcinoma occurs in women under the age of 50.5 Arguments against the inclusion of these women do not stand up. With the tremendous advances in equipment and technique, as well as our considerable experience, there is no reason to assume significant difficulties in demonstrating early carcinomas in women between 40 and 49 years of age. The fact that the benefit of screening in these women shows up only after several years of delay6-8 should not diminish its significance for the CAN MED ASSOC J 1990; 142 (4)
285
Before being granted a licence in Oregon a physician must demonstrate familiarity with the Medical Practice Act. If the case Kluge outlines had occurred in Oregon Dr. W would not have been in a quandary. ORS 677.415 could be interpreted such that she would be legally obligated to report her concerns to the Board of Medical Examiners, which in turn might have investigated the evidence and taken action. Has this solution to Dr. W's quandary been implemented by any Canadian licensing agency? Robert Shepherd, MD 37 Beechmont Cres. Gloucester, Ont.
grounds, believes to be suffering from a physical or mental ailment, emotional disturbance or addiction to alcohol or drugs that, in his opinion, if the person continues to practise medicine or surgery, might constitute a danger to the public or be contrary to the public interest.
The need and indeed appropriateness of such formal reporting requirements are a matter of some debate in the Canadian medical scene. One side maintains that such requirements are counterproductive: they establish a confrontational framework that is not conducive to dealing with the problem in any except legal terms. Furthermore - so the argument goes - whether it is subsequently substantiated or not, the fact that a complaint is laid under such requirements threatens the personal and professional position of the physician in an irreparable fashion. The emphasis should be on prevention and help, not formal procedures. The other side maintains that, like any other profession, medicine is notoriously blind toward the shortcomings of its own members. As long as there is no formal reporting requirement there will be little actual reporting, because the canons of medical "good taste" and "collegial be-
Eike-Henner W. Kluge, PhD Director Ethics and Legal Affairs Canadian Medical Association
Geriatricians and the frail elderly rs. Roy Alan Fox, Avram Mark Clarfield and David Bryan Hogan recently outlined the "Competencies required for the practice of geriatric medicine as a consultant physician" (Can Med Assoc J 1989; 141: 1045-1048). In his editorial "Geriatrics - consolidating the specialty" (ibid: 1039) Dr. Bruce P. Squires said that more attention should have been paid to what geriatricians do as compared with what they know. Neither paper, in my view, dealt sufficiently with who the geriatricians know about and do things to, and this is important. It is not a matter of, in Squires' terms, "limiting their practice to old people" any more than cardiologists "limit" their practice to people with hearts. The geriatrician's constituency is the 10% to 15% of the elderly population who, in addition to their multiple CAN MED ASSOC J 1990; 142 (4)
283
medical problems, are functionally dependent. These are the frail elderly, and the effectiveness of, for example, geriatric assessment units can only be demonstrated when such "technology"' is limited to the frail.2 Although in the United States there is active pursuit of primary care by geriatricians, in Canada, as Fox and colleagues point out, "there is no support . . . for the specialty's becoming a primary care service for elderly people". Nor, on the basis of the available evidence, should there be. Kenneth Rockwood, MD Division of Geriatric Medicine Camp Hill Medical Centre Halifax, NS
References 1. Epstein AM, Hall JA, Besdine R et al: The emergence of geriatric assessment units: the 'new technology' of geriatrics. Ann Intern Med 1987; 106: 299-303 2. Rubenstein LZ: Geriatric assessment: an overview of its impacts. Clin Geriatr Med 1987; 3: 1-17
[Dr. Fox and colleagues reply.] The letter from Dr. Rockwood and the editorial by Dr. Squires point out that much more remains to be written and debated concerning geriatric medicine. Those of us practising the specialty know what we do, where and to whom. In our paper we looked only at defining the knowledge, attitudes and skills required by the geriatrician, to aid our training programs. At the same time we are hoping that others, particularly those involved in core training in internal medicine, will consider the relevance of these "competencies" for their own trainees. Once consensus is achieved, then more specific goals can be set and the means of attainment (i.e., training time and location) more accurately defined. We agree that the role of geriatricians is in the care of a subset of elderly Canadians. Our efforts need to be targeted toward For prescribing information see page 317
the frail elderly, who Rockwood points out comprise 10% to 15% of those over 65 years old. We have attempted to define the competencies required for the care of these people, who have functional impairment and multiple interacting problems. We are sorry to disappoint, but more effort will be needed to measure the performance of individual physicians and may be the subject of future studies. We believe, unlike Squires, that geriatricians and the specialty are easily distinguishable, perhaps more so than in other specialties. The competencies of the specialist and the target population are being clearly defined. Can we say the same for general internal medicine and rehabilitation, hematology etc.? Roy Alan Fox, MD, FRCPC, FRCP Head Division of Geriatric Medicine Dalhousie University Halifax, NS Avram Mark Clarfield, MD, CCFP, CSPQ, FRCPC Director Division of Geriatrics Sir Mortimer B. Davis
Jewish General Hospital McGill University Montreal, PQ David Bryan Hogan, MD, FRCPC, FACP Assistant professor of medicine Division of Geriatric Medicine Dalhousie University Halifax, NS
Reducing deaths from breast cancer in Canada xW rith reference to the report of the Workshop Group (Can Med Assoc J 1989; 141: 199-201) a few observations seem to be in order. Although physical examination and breast self-examination make valuable contributions to the detection of breast carcinoma, it is generally recognized that
mammography is the uniquely effective and most sensitive modality for the detection of nonpalpable early tumours. Mammography has been improved and meaningfully practised by dedicated radiologists for the past several decades. Seminal studies'-4 by such practitioners of the art in Sweden, Britain and the United States form the basis of breast screening programs in several countries, including Canada. Only one radiologist with vast experience in mammography, Dr. Guy Hebert, of Montreal, was included in the Workshop Group, undoubtedly all of whom had excellent credentials. Hebert's voice was nevertheless extinguished by those in the group with little or no experience in breast imaging. We submit that the studies cited in the report were conducted by experts in mammography that is, radiologists. Neglect for radiologists in some if not most provincial plans for breast screening is not new, these plans being heavy with blueprints as well as with organizational and statistical personnel. Whatever political considerations have brought this situation about, such should not have been the case in such an important workshop. The report places much emphasis on the presumed lack of benefit of screening women in the age group 40 to 49 years. In fact, one-third of breast carcinoma occurs in women under the age of 50.5 Arguments against the inclusion of these women do not stand up. With the tremendous advances in equipment and technique, as well as our considerable experience, there is no reason to assume significant difficulties in demonstrating early carcinomas in women between 40 and 49 years of age. The fact that the benefit of screening in these women shows up only after several years of delay6-8 should not diminish its significance for the CAN MED ASSOC J 1990; 142 (4)
285
