- for example, his "touch of pneumonia". I strongly disagree with his statement that "physicians. . are less likely to be wrong if they attribute a little of some disease to people who are not feeling perfect to start with." On the contrary, physicians are always wrong when they draw the wrong conclusions. Ironically, Dr. Watson seems to disagree with himself when he asks rhetorically, "Which of us is [feeling perfect]?" The answer is, of course, No one. But does Dr. Watson ever wonder why some patients, merely because they are not feeling perfect, nevertheless seek help? The problem of misdiagnosis lies in a misconception of disease that has its roots in the earliest days of our medical training. We are led to believe that, because the diseases we read about in medical textbooks are characterized by certain symptoms and signs, all symptoms and signs indicate significant organic disease. It is not so. We must recognize that such factors as the emotional state of the patient and his expectations about health have a major bearing on his decision to seek treatment.1" There should be nothing hard about telling a patient that his condition is normal, if it is normal. Saying this is not treating the patient "with nothing", but is giving the patient full value of a medical judgement refined over years of experience in medical school and in practice, something infinitely more precious than a tablet or injection. The danger lies in how the message is communicated. If the doctor says something like, "I am glad to be able to tell you that those pains (or nausea, or dizziness, etc.) you were telling me about are not indications of anything serious", he can be therapeutically reassuring. However, as is so often the case, the doctor may communicate to the patient one way or another "There is nothing wrong with you", despite the fact that the patient still has his symptoms. The result is that the patient leaves the office believing that the doctor thinks he is faking or crazy, or he concludes that the doctor is stupid or incompetent and that he should consult another doctor. If physicians define treatment simply as dispensing or prescribing medicine, they are not only ignoring an impressive amount of evidence indicating the therapeutic efficacy of the doctorpatient relationship and of meeting the patient's expectations (the so-called placebo effect), but they are also providing ammunition for those critics of medicine who say that doctors have contributed to the common misconception that for every problem there must be a pill. Lastly, I cannot accept with equani-
mity Dr. Watson's suggestion that we should not be outraged if some physicians are more concerned with making money than with practising perfect medicine. No patient should expect his doctor to be "a saint" or to practise "perfect medicine". In the real world no such things exist. In practice we all make mistakes but, one hopes, we learn from them. However, surely patients can hope that physiciaqs' errors are made in good faith and not because an interest in making money is given priority over the welfare of the patient. P.C.S. HOAKEN, MD, PacP[c]
Department of psychiatry Hotel Dieu Hospital Kingston, ON
References 1. MECHANIC D: Social psychological factors affecting the presentation of bodily complaints. N Engi I Med 286: 1132, 1972 2. HOAKEN PCS: Psychosocial aspects of physical complaints. Mod Med Can 29: 745, 1974
Record-keeping in family practice
To the editor: In the article by Dr. J. Brandejs and colleagues, "Information systems. Part VII: problem-oriented medical records for family practice" (Can Med Assoc J 114: 371, 1976), it is stated that "the application of the principle outside of a very few demonstration models and research centres has been minimal." In fact, the concepts of record-keeping have been implemented in a number of areas in Canada with considerable success, and no one with whom I have discussed the matter has rejected the problem-oriented approach to record-keeping because he thought it required the presence of a computer. The article shows a fair understanding of the problem-oriented concepts of record-keeping but a poor understanding of family practice. Family physicians seem to reject such concepts first, because change is difficult and anxiety-provoking, and second, because there are real constraints of time and money in family practice, which may seem to rule out any new approach. The implementation of the full system as described in Dr. Brandejs' article is, in my opinion and that of many persons with whom I have communicated over the past 2 years, generally inappropriate for family practice. The concepts a family physician can take from the system, those which will provide him with satisfaction and early returns, are the problem list, the medication list and the structured progress note.
To the editor: My aim in my editorial was to tackle the problem of nondisease deftly. Dr. Hoaken comes at me with a bludgeon. Just as I do not expect the preacher to give me the whole of religion in one sermon, I hope Dr. Hoaken will credit me with not purveying the whole of my medical philosophy in one brief editorial. I feel he has missed some of the nuances. As a gastroenterologist no one is more aware than I am of the importance of emotional factors not only in the causation of disease but also in the experience of its manifestations. But my editorial was not on emotional factors and disease. There are many ways one can get one's non-disease. I have illustrated only some of them. Of course one can make a semantic quibble between the state of having a non-disease and that of having a wrong diagnosis, but the poor patient who has been labelled with the wrong diagnosis is still about to get treatment for a disease he does not have, and it is no consolation to him to know that there is a better way of describing the error. To stay with the example given, what the patient now has is non-pneumonia. Dr. Hoaken completely misses the gentle irony of the words "physicians do not like to be wrong, and they are less likely to be wrong if they attribute a little of some disease to people who are not feeling perfect to start with." My intention was to make a point and have people smile a little. I suspect that Dr. Hoaken's objective would be to have us ache all over.
It is a shame that Dr. Brandejs and his colleagues did not take the time to look around in Canada for their examples; they would have found many excellent ones and many differences as well as similarities between them. The problem-oriented system was developed initially for use in the hospital, and much trial and error remains to be done before it is fully adapted for use in family practice. Canada is certainly one of the leaders in this endeavour.
W.C. WATSON, MD Director of gastroenterology Victoria Hospital London, O.
Chairman Special committee of the medical record College of Family Physicians of Canada
990 CMA JOURNAL/JUNE 5, 1976/VOL. 114
The College of Family Physicians of Canada has a committee that is currently reaching some conclusions and making recommendations in the area of record-keeping in family practice. I hope CMAJ will give prominence to its recommendations, since they will be made for the benefit of all family physicians in the country and will be based on a thorough consideration of the problem-oriented concept and the realities of family practice in Canada.
J. PAUL NEWELL, MD
mity Dr. Watson's suggestion that we should not be outraged if some physicians are more concerned with making money than with practising perfect medicine. No patient should expect his doctor to be "a saint" or to practise "perfect medicine". In the real world no such things exist. In practice we all make mistakes but, one hopes, we learn from them. However, surely patients can hope that physiciaqs' errors are made in good faith and not because an interest in making money is given priority over the welfare of the patient. P.C.S. HOAKEN, MD, PacP[c]
Department of psychiatry Hotel Dieu Hospital Kingston, ON
References 1. MECHANIC D: Social psychological factors affecting the presentation of bodily complaints. N Engi I Med 286: 1132, 1972 2. HOAKEN PCS: Psychosocial aspects of physical complaints. Mod Med Can 29: 745, 1974
Record-keeping in family practice
To the editor: In the article by Dr. J. Brandejs and colleagues, "Information systems. Part VII: problem-oriented medical records for family practice" (Can Med Assoc J 114: 371, 1976), it is stated that "the application of the principle outside of a very few demonstration models and research centres has been minimal." In fact, the concepts of record-keeping have been implemented in a number of areas in Canada with considerable success, and no one with whom I have discussed the matter has rejected the problem-oriented approach to record-keeping because he thought it required the presence of a computer. The article shows a fair understanding of the problem-oriented concepts of record-keeping but a poor understanding of family practice. Family physicians seem to reject such concepts first, because change is difficult and anxiety-provoking, and second, because there are real constraints of time and money in family practice, which may seem to rule out any new approach. The implementation of the full system as described in Dr. Brandejs' article is, in my opinion and that of many persons with whom I have communicated over the past 2 years, generally inappropriate for family practice. The concepts a family physician can take from the system, those which will provide him with satisfaction and early returns, are the problem list, the medication list and the structured progress note.
To the editor: My aim in my editorial was to tackle the problem of nondisease deftly. Dr. Hoaken comes at me with a bludgeon. Just as I do not expect the preacher to give me the whole of religion in one sermon, I hope Dr. Hoaken will credit me with not purveying the whole of my medical philosophy in one brief editorial. I feel he has missed some of the nuances. As a gastroenterologist no one is more aware than I am of the importance of emotional factors not only in the causation of disease but also in the experience of its manifestations. But my editorial was not on emotional factors and disease. There are many ways one can get one's non-disease. I have illustrated only some of them. Of course one can make a semantic quibble between the state of having a non-disease and that of having a wrong diagnosis, but the poor patient who has been labelled with the wrong diagnosis is still about to get treatment for a disease he does not have, and it is no consolation to him to know that there is a better way of describing the error. To stay with the example given, what the patient now has is non-pneumonia. Dr. Hoaken completely misses the gentle irony of the words "physicians do not like to be wrong, and they are less likely to be wrong if they attribute a little of some disease to people who are not feeling perfect to start with." My intention was to make a point and have people smile a little. I suspect that Dr. Hoaken's objective would be to have us ache all over.
It is a shame that Dr. Brandejs and his colleagues did not take the time to look around in Canada for their examples; they would have found many excellent ones and many differences as well as similarities between them. The problem-oriented system was developed initially for use in the hospital, and much trial and error remains to be done before it is fully adapted for use in family practice. Canada is certainly one of the leaders in this endeavour.
W.C. WATSON, MD Director of gastroenterology Victoria Hospital London, O.
Chairman Special committee of the medical record College of Family Physicians of Canada
990 CMA JOURNAL/JUNE 5, 1976/VOL. 114
The College of Family Physicians of Canada has a committee that is currently reaching some conclusions and making recommendations in the area of record-keeping in family practice. I hope CMAJ will give prominence to its recommendations, since they will be made for the benefit of all family physicians in the country and will be based on a thorough consideration of the problem-oriented concept and the realities of family practice in Canada.
J. PAUL NEWELL, MD
