Splashback and vaginitis To the editor: Dr. Berberian (Can Med Assoc J 114: 188, 1976) seems to have gone to a great deal of trouble to prove what any female over the age of 3 is aware of: urination with normal bladder pressure at the wrong angle results in splashback, noted subjectively by the sensation of coldness as the water from the toilet bowl hits the vulva. Whether or not this phenomenon transmits vaginitis, it is certainly Unesthetic, and the prophylaxis is readily (and cheaply) available: a couple of sheets of toilet paper floated on top of the water prevents any splashback from either micturition or defecation. ANNE C. LowE Lambton St. W Durham, ON
Anencephaly associated with megavitamin therapy To the editor: Recently in this hospital a healthy 28-year-old mother of one normal child was discovered to be pregnant with a 17-week anencephalic conceptus, fortunately detected by ultrasound. During the first 10 weeks of pregnancy she had been undergoing psychiatric treatment with "megavitamins", including large doses of ascorbic acid, thiamine, folic acid, pyridoxine, brewer's yeast and other nonspecified nutrients. I was unable to find any reports of the association of anencephaly and megavitamin therapy, but maternal diet has long been incriminated in neural tube defects.1. In experiments with animals, vitamin deficiency as well as vitamin excess (notably excess of vitamin A) have been used to produce anencephaly, with consistent results.' P. AVERBACK, MD Department of pathology Royal Victoria Hospital Montreal, PQ
References 1. KNOX EG: Anencephalus and dietary intakes. Br J Prey Soc Med 26: 219, 1972 2. FEDRIcK J: Anencephalus and maternal tea drinking; evidence for a possible association. Proc R Soc Med 67: 356, 1974 3. wARKANY J: Congenital Malformations, Chicago, Year Bk Med, 1971, p 189
Seat belt legislation To the editor: I object to the comment inserted in the recent paper by Dr. D.F. Bray, "A concept and strategies for health protection" (Can Med Assoc J 114: 461, 1976). The editor added that "Dr. Bray's observation was written before Ontario enacted compulsory wearing of seat belts. Residents of the province will have noted the ludicrous lack of enforcement of this new law." This comment seems tinged with emotion and the use of the word ludicrous is unnecessary.
The object of the seat belt legislation is to increase the wearing of seat belts in the province. Persons who do not comply may never be caught, just as a driver who habitually breaks the speed limit may never be caught. However, the risk does exist. Introduction of a new law is sufficient "enforcement" to make people aware of the need to follow it. But although people may be aware it exists, the wearing rate may drop after the initial high compliance. If such a decline is apparent, then increased enforcement may be necessary. Although I have not yet seen any studies on the effect of the legislation, the Globe and Mail reported a decrease in numbers of deaths and injuries for the first 2 months of this year. I. HAUSER, MD
Director Health division Statistics Canada Ottawa, ON
CMARSP withdrawals To the editor: I recently decided to transfer my CMARSP to a selected financial institution with a better performance. I received a letter from MD Management Ltd. telling me that the insured annuity fund portion will be transferred over a 5-year period at the rate of 20% of the account value each year with the first instalment to be made 1 year from this month-end. I have looked at CMARSP literature and nowhere is this restrictive clause spelled out. I feel that the CMA has a responsibility to ensure its members are not exposed to this type of business practice in an association-sponsored retirement plan. w. BRYSON, MD
Schomberg, ON
Student selection and internship To the editor: I have just read the article "Council on Medical Education looks at student selection, 2-year internship, lab surveys" (Can Med Assoc J 114: 357, 1976) and it caused me grave concern. The statement is made that there is little concrete evidence for what constitutes a good family practitioner. This is followed by remarks indicating that the patient-practitioner relationship will never be what it was 20 years ago. I suggest that the general public has a very good idea of what it considers a good family physician and that a public survey of concerned, intelligent lay persons would give you an excellent account. And I have evidence that government officials at high levels are concerned with this problem. The present medical school curricula have been set largely by people who graduated in the SOs and 60s, when
general practice was on the way out. In 1955 only 6 of 118 McGill graduates went into general practice; it was considered a dying situation. The people planning medical school curricula today are possibly 20 years out of date. The suggestion is made that a 2-year internship is not necessary to produce adequate family practitioners. It is now possible for a person "streaming" an internship - for example, doing a straight internship such as dermatology, then a year of specialist internship to set up in practice as a licensed family practitioner, a title that implies a basic knowledge of surgery, obstetrics, public health and psychiatry and a broad general knowledge of all specialties. I suggest that even a 2-year internship in this situation is absolutely ridiculous. The only possible solution is a family practice residency program. Under the subheading "Empathy" the statement is made that, according to researchers studying the human brain, all people of apparently normal mental health are born with a capacity for empathy. One wonders how mental health can be determined without some form of interview. The suggestion is made that selection for medical school be based on marks and a lottery. Any criminologist will tell you a psychopath has an anatomically normal brain and often an aboveaverage IQ. Selection on this basis would ensure that medical schools accept the best academic cheats, the most avaricious and the most clever sociopaths. Having been involved with the Ontario preceptorship program since its initiation and having spoken to 3rd- and 4th-year students at the University of Western Ontario over the past 5 years about the current selection methods, I would say there is some evidence that this is already happening. Certainly it has been suggested by some public officials in the United States. If we do not wish to perpetuate the recent private laboratory kickback type of scandal in the medical profession, we would be wise to continue to keep character evaluation a part of the selection process. Selection boards may use many man hours but this time is far from wasted and is necessary. I suggest that perhaps criteria for being on a selection board should be examined in order to meet the accusation of bias. Perhaps there should be significant lay representation on such boards. I find the trend that the CMA Council on Medical Education is taking frightening. J.G.L. SLATER, B SC, MD, CM, CcFP
Chief, medical staff Lady Minto Hospital at Cochrane Cochrane, ON
CMA JOURNAL/JUNE 5, 1976/VOL 114 995
Anencephaly associated with megavitamin therapy To the editor: Recently in this hospital a healthy 28-year-old mother of one normal child was discovered to be pregnant with a 17-week anencephalic conceptus, fortunately detected by ultrasound. During the first 10 weeks of pregnancy she had been undergoing psychiatric treatment with "megavitamins", including large doses of ascorbic acid, thiamine, folic acid, pyridoxine, brewer's yeast and other nonspecified nutrients. I was unable to find any reports of the association of anencephaly and megavitamin therapy, but maternal diet has long been incriminated in neural tube defects.1. In experiments with animals, vitamin deficiency as well as vitamin excess (notably excess of vitamin A) have been used to produce anencephaly, with consistent results.' P. AVERBACK, MD Department of pathology Royal Victoria Hospital Montreal, PQ
References 1. KNOX EG: Anencephalus and dietary intakes. Br J Prey Soc Med 26: 219, 1972 2. FEDRIcK J: Anencephalus and maternal tea drinking; evidence for a possible association. Proc R Soc Med 67: 356, 1974 3. wARKANY J: Congenital Malformations, Chicago, Year Bk Med, 1971, p 189
Seat belt legislation To the editor: I object to the comment inserted in the recent paper by Dr. D.F. Bray, "A concept and strategies for health protection" (Can Med Assoc J 114: 461, 1976). The editor added that "Dr. Bray's observation was written before Ontario enacted compulsory wearing of seat belts. Residents of the province will have noted the ludicrous lack of enforcement of this new law." This comment seems tinged with emotion and the use of the word ludicrous is unnecessary.
The object of the seat belt legislation is to increase the wearing of seat belts in the province. Persons who do not comply may never be caught, just as a driver who habitually breaks the speed limit may never be caught. However, the risk does exist. Introduction of a new law is sufficient "enforcement" to make people aware of the need to follow it. But although people may be aware it exists, the wearing rate may drop after the initial high compliance. If such a decline is apparent, then increased enforcement may be necessary. Although I have not yet seen any studies on the effect of the legislation, the Globe and Mail reported a decrease in numbers of deaths and injuries for the first 2 months of this year. I. HAUSER, MD
Director Health division Statistics Canada Ottawa, ON
CMARSP withdrawals To the editor: I recently decided to transfer my CMARSP to a selected financial institution with a better performance. I received a letter from MD Management Ltd. telling me that the insured annuity fund portion will be transferred over a 5-year period at the rate of 20% of the account value each year with the first instalment to be made 1 year from this month-end. I have looked at CMARSP literature and nowhere is this restrictive clause spelled out. I feel that the CMA has a responsibility to ensure its members are not exposed to this type of business practice in an association-sponsored retirement plan. w. BRYSON, MD
Schomberg, ON
Student selection and internship To the editor: I have just read the article "Council on Medical Education looks at student selection, 2-year internship, lab surveys" (Can Med Assoc J 114: 357, 1976) and it caused me grave concern. The statement is made that there is little concrete evidence for what constitutes a good family practitioner. This is followed by remarks indicating that the patient-practitioner relationship will never be what it was 20 years ago. I suggest that the general public has a very good idea of what it considers a good family physician and that a public survey of concerned, intelligent lay persons would give you an excellent account. And I have evidence that government officials at high levels are concerned with this problem. The present medical school curricula have been set largely by people who graduated in the SOs and 60s, when
general practice was on the way out. In 1955 only 6 of 118 McGill graduates went into general practice; it was considered a dying situation. The people planning medical school curricula today are possibly 20 years out of date. The suggestion is made that a 2-year internship is not necessary to produce adequate family practitioners. It is now possible for a person "streaming" an internship - for example, doing a straight internship such as dermatology, then a year of specialist internship to set up in practice as a licensed family practitioner, a title that implies a basic knowledge of surgery, obstetrics, public health and psychiatry and a broad general knowledge of all specialties. I suggest that even a 2-year internship in this situation is absolutely ridiculous. The only possible solution is a family practice residency program. Under the subheading "Empathy" the statement is made that, according to researchers studying the human brain, all people of apparently normal mental health are born with a capacity for empathy. One wonders how mental health can be determined without some form of interview. The suggestion is made that selection for medical school be based on marks and a lottery. Any criminologist will tell you a psychopath has an anatomically normal brain and often an aboveaverage IQ. Selection on this basis would ensure that medical schools accept the best academic cheats, the most avaricious and the most clever sociopaths. Having been involved with the Ontario preceptorship program since its initiation and having spoken to 3rd- and 4th-year students at the University of Western Ontario over the past 5 years about the current selection methods, I would say there is some evidence that this is already happening. Certainly it has been suggested by some public officials in the United States. If we do not wish to perpetuate the recent private laboratory kickback type of scandal in the medical profession, we would be wise to continue to keep character evaluation a part of the selection process. Selection boards may use many man hours but this time is far from wasted and is necessary. I suggest that perhaps criteria for being on a selection board should be examined in order to meet the accusation of bias. Perhaps there should be significant lay representation on such boards. I find the trend that the CMA Council on Medical Education is taking frightening. J.G.L. SLATER, B SC, MD, CM, CcFP
Chief, medical staff Lady Minto Hospital at Cochrane Cochrane, ON
CMA JOURNAL/JUNE 5, 1976/VOL 114 995
