that the stomach will not be empty for well over S hours. On the other hand, patients having elective surgery who are not in pain or unduly apprehensive are likely to empty the stomach in the physiologic time. They are, of course, precisely the group of patients whose oral intake is most easily controlled and who are not really much of a problem. Fluids are more rapidly absorbed than solids; hence, we are probably safe in assuming the stomach to be empty in 3 hours after intake of fluids and 4 hours after intake of solids. Others might be prepared, in certain circumstances, to reduce these margins even further, but I would argue that extending them is of dubious help. Furthermore, I believe that patients, especially the very old and the very young, who are booked for elective surgery late in the day do better if they have something by mouth early in the morning. The traditional "NPO after midnight" is all very well for those coming to operation before noon, but is quite otherwise for those coming later. I have no quarrel with the anesthetist who decides, in a specific case, that surgery should be postponed 5 (or 25) hours. However, the mindless and perhaps ill-judged insistence on a 5-hour delay in all cases, no matter what the circumstances, seems to me just as irresponsible as does reckless and too premature intervention. JOHN H. HARLAND, MB
Park Medical Building Kelowna. BC
[The following is the opinion of the Canadian Anaesthetists' Society. - Ed.] To the editor: I am grateful to Dr. Harland for expressing his opinions and reservations concerning one of our guidelines for minimal standards of practice of anesthesia. Controversy and discussion are the vital ingredients of the academic process. I offer the following comments in reply to his letter. The guidelines,1 which have been widely circulated since their approval by the council of the Canadian Anaesthetists' Society in February 1975, were developed to assist all physicians who practise anesthesia in Canada to meet a minimum standard of patient care. It was realized that the guidelines for safe practice would have to be applicable in every conceivable circumstance, regardless of where the anesthetic was administered and regardless of the training and skills of the anesthetist. However, it was also evident that if we were to attempt to cover all circumstances and all aspects of the practice of anesthesia we would end up writing a complete textbook in anesthesia. We compromised by making the guidelines as brief, specific and easily understood as possible.
The guideline concerning the minimum time of delay from the last oral intake of food or drink to the induction of anesthesia reads as follows: A policy should be followed concerning the minimum delay from the time of the last oral intake to the induction of anaesthesia for elective surgery. While a complete emptying of the stomach can never be guaranteed, a minimum time of five hours in the absence of pain, trauma, apprehension, narcotics, gastrointestinal disorders, or medications is suggested except under emergency conditions. The same rules should apply for regional anaesthesia. Emergency surgery should be undertaken taking into consideration the risks of delaying surgery versus the risks of aspiration should anaesthesia be induced.1 This guideline was formulated after a great deal of discussion by six specialists in anesthesia representing five major teaching centres in Canada. Although it is impossible to abolish the risk of aspiration of gastric contents in the anesthetized patient, the intent of the policy was to minimize the risk as much as possible. In all properly managed anesthetic procedures, the risk to the patient should be minimal. The only relevant event that can spoil a well conducted anesthetic procedure is aspiration of gastric contents. Therefore, it seems prudent to minimize this risk by restricting food and fluid intake prior to any anesthetic procedure. The guideline clearly indicates that the 5-hour rule is for elective surgery only, allowing for flexibility and judgement of the individual anesthetist in nonelective procedures. All the anesthetists who participated in the formulation of the guideline believed that a 5-hour delay was safer for the patient than a 4-hour delay. Dr. Harland suggests that there may be medicolegal repercussions if the anesthetist fails to follow the guideline and aspiration occurs. The law requires simply that reasonable care and judgement be used. If surgical intervention is urgently required, the anesthetist is obliged to proceed with the induction of anesthesia with a knowledge of the problems involved and to take appropriate precautions to prevent regurgitation and aspiration. The guidelines were perused by representatives of the Canadian Medical Protective Association before they were released for circulation to members of the Canadian Anaesthetists' Society. In my department we follow the 5hour rule as outlined in the guideline. There has been little inconvenience to the patients, the surgeons or the anesthetists. If the patient is kept "NPO after midnight" the 5-hour period is often exceeded. It is permissible to order a liquid breakfast at 7 am if the
patient is scheduled for a procedure that will commence after 1 pm. JOHN H. FEINDEL, MD, CM, FICPEC]
Head, department of anesthesia
N and vice-president Canadian Ansesthetists' Society
References 1. Guidelines for the Minimal Standards of Practice of Anaesthesia, Canadian Anaesthetists' Society, Feb 1975 2. Draft Guidelines for the Practice of Anaesthesia in British Columbia, BC College of Physicians and Surgeons, Feb 1976
Outlawing the snowmobile To the editor: It is to be regretted that the paper by Letts and Cleary (Can Med Assoc J 113: 1061, 1975), citing the large number of serious snowmobile injuries incurred by children, recommended for minimizing this problem only modification of the structure of the machine, an education program, and so on. The opportunity might have been seized to make the only sensible and totally effective recommendation - namely, the total elimination by law of the recreational use of snowmobiles. Besides severe fractures, health hazards of the snowmobile include impairment of hearing in a high proportion of frequent users, and psychological damage, with emotional disturbance, impairment of concentration and elimination of peace and quiet for those who must listen to the machines near and far. Though not directly healthrelated, the harm to flora and fauna, the esthetic damage to the beauty of nature in winter, and many other reasons can be given to support legislation for the permanent outlawing of the motorized winter toy of the juvenile and adult. This has been done in countries in Europe and in a number of communities in the United States. VRS (Vermonters for the Restriction of Snowmobiles) has worked toward this end in Vermont. GEORGE A. SCHUMACHER, MD
Department of neurology Medical Center Hospital of Vermont Burlington, VT
The causes and treatment of non-disease To the editor: I should like to dispute certain points in W.C. Watson's editorial, "The causes and treatment of non-disease" (Can Med Assoc J 114: 402, 1976). It seems to me that, with the best of intentions, Dr. Watson has failed to distinguish "non-disease" caused by laboratory error or misinformed interpretation of valid laboratory test results from plainly false diagnosis made on the basis of inadequate clinical findings
CMA JOURNAL/JUNE 5, 1976/VOL. 114 989
- 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
Park Medical Building Kelowna. BC
[The following is the opinion of the Canadian Anaesthetists' Society. - Ed.] To the editor: I am grateful to Dr. Harland for expressing his opinions and reservations concerning one of our guidelines for minimal standards of practice of anesthesia. Controversy and discussion are the vital ingredients of the academic process. I offer the following comments in reply to his letter. The guidelines,1 which have been widely circulated since their approval by the council of the Canadian Anaesthetists' Society in February 1975, were developed to assist all physicians who practise anesthesia in Canada to meet a minimum standard of patient care. It was realized that the guidelines for safe practice would have to be applicable in every conceivable circumstance, regardless of where the anesthetic was administered and regardless of the training and skills of the anesthetist. However, it was also evident that if we were to attempt to cover all circumstances and all aspects of the practice of anesthesia we would end up writing a complete textbook in anesthesia. We compromised by making the guidelines as brief, specific and easily understood as possible.
The guideline concerning the minimum time of delay from the last oral intake of food or drink to the induction of anesthesia reads as follows: A policy should be followed concerning the minimum delay from the time of the last oral intake to the induction of anaesthesia for elective surgery. While a complete emptying of the stomach can never be guaranteed, a minimum time of five hours in the absence of pain, trauma, apprehension, narcotics, gastrointestinal disorders, or medications is suggested except under emergency conditions. The same rules should apply for regional anaesthesia. Emergency surgery should be undertaken taking into consideration the risks of delaying surgery versus the risks of aspiration should anaesthesia be induced.1 This guideline was formulated after a great deal of discussion by six specialists in anesthesia representing five major teaching centres in Canada. Although it is impossible to abolish the risk of aspiration of gastric contents in the anesthetized patient, the intent of the policy was to minimize the risk as much as possible. In all properly managed anesthetic procedures, the risk to the patient should be minimal. The only relevant event that can spoil a well conducted anesthetic procedure is aspiration of gastric contents. Therefore, it seems prudent to minimize this risk by restricting food and fluid intake prior to any anesthetic procedure. The guideline clearly indicates that the 5-hour rule is for elective surgery only, allowing for flexibility and judgement of the individual anesthetist in nonelective procedures. All the anesthetists who participated in the formulation of the guideline believed that a 5-hour delay was safer for the patient than a 4-hour delay. Dr. Harland suggests that there may be medicolegal repercussions if the anesthetist fails to follow the guideline and aspiration occurs. The law requires simply that reasonable care and judgement be used. If surgical intervention is urgently required, the anesthetist is obliged to proceed with the induction of anesthesia with a knowledge of the problems involved and to take appropriate precautions to prevent regurgitation and aspiration. The guidelines were perused by representatives of the Canadian Medical Protective Association before they were released for circulation to members of the Canadian Anaesthetists' Society. In my department we follow the 5hour rule as outlined in the guideline. There has been little inconvenience to the patients, the surgeons or the anesthetists. If the patient is kept "NPO after midnight" the 5-hour period is often exceeded. It is permissible to order a liquid breakfast at 7 am if the
patient is scheduled for a procedure that will commence after 1 pm. JOHN H. FEINDEL, MD, CM, FICPEC]
Head, department of anesthesia
N and vice-president Canadian Ansesthetists' Society
References 1. Guidelines for the Minimal Standards of Practice of Anaesthesia, Canadian Anaesthetists' Society, Feb 1975 2. Draft Guidelines for the Practice of Anaesthesia in British Columbia, BC College of Physicians and Surgeons, Feb 1976
Outlawing the snowmobile To the editor: It is to be regretted that the paper by Letts and Cleary (Can Med Assoc J 113: 1061, 1975), citing the large number of serious snowmobile injuries incurred by children, recommended for minimizing this problem only modification of the structure of the machine, an education program, and so on. The opportunity might have been seized to make the only sensible and totally effective recommendation - namely, the total elimination by law of the recreational use of snowmobiles. Besides severe fractures, health hazards of the snowmobile include impairment of hearing in a high proportion of frequent users, and psychological damage, with emotional disturbance, impairment of concentration and elimination of peace and quiet for those who must listen to the machines near and far. Though not directly healthrelated, the harm to flora and fauna, the esthetic damage to the beauty of nature in winter, and many other reasons can be given to support legislation for the permanent outlawing of the motorized winter toy of the juvenile and adult. This has been done in countries in Europe and in a number of communities in the United States. VRS (Vermonters for the Restriction of Snowmobiles) has worked toward this end in Vermont. GEORGE A. SCHUMACHER, MD
Department of neurology Medical Center Hospital of Vermont Burlington, VT
The causes and treatment of non-disease To the editor: I should like to dispute certain points in W.C. Watson's editorial, "The causes and treatment of non-disease" (Can Med Assoc J 114: 402, 1976). It seems to me that, with the best of intentions, Dr. Watson has failed to distinguish "non-disease" caused by laboratory error or misinformed interpretation of valid laboratory test results from plainly false diagnosis made on the basis of inadequate clinical findings
CMA JOURNAL/JUNE 5, 1976/VOL. 114 989
- 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
