EDITORIAL * EDITORIAL
Licences, examinations and more examinations W. Dale Dauphinee, MD, FRCPC
T he creation of the Medical Council of Canada is an amazing story of the persistence and foresight of one man: Sir Thomas Roddick. Born in Newfoundland Sir Thomas was a distinguished professor of surgery and dean of medicine at McGill University. His achievements were such that he was knighted in 1915; in 1925 his widow and McGill University had gates erected at the entrance to the main campus in his honour. The Roddick Gates stand as a magnificent testimony to his many accomplishments but particularly to his role in bringing order and standards to the licensure of physicians in Canada. Because he was unable to interest the politicians in the licensure problem Sir Thomas ran for Parliament, was elected in 1896 and spent 16 years shepherding his solution through Parliament and the provincial legislatures. Before 1911 the licensing mechanisms had been fragmented and arbitrary, as he observed in a speech before the House of Commons in support of his bill to establish the medical council. If a student begins to study medicine in one province by complying with the provincial enactment in reference to matriculation, he may be debarred forever from getting into another province, so absurd are the refutations today. These barriers exist in no other country under the sun, and it is the object of the Bill to break them down.'
Passed initially in 1902 as a private member's bill the Canada Medical Act finally received approval from all provinces and was promulgated in 1912. The history of the council's origins and development are well documented.'-4 Subsequent changes in the
council's examinations in the late 1970s and early 1980s were the subject of a commentary in 1981.5 Recently, the winds of change have swept the medical council again. Acting on the concerns of members of the Canadian licensing community about an increasingly fragmented system of licensure the council created the Task Force on Future Directions in 1988.6 This task force was widely representative of the council's two primary constituents: the medical schools and the provincial licensing authorities. (The council comprises two delegates from each of the 10 provincial licensing authorities, one delegate from each of the 16 medical schools and three members selected by the Governor in Council. It can be viewed as a national medical parliament on matters of standards for licensure.) The task force met regularly for 18 months; it submitted a preliminary report at the annual meeting of the medical council in September 1988 recommending a new direction in the council's evaluation process and a final report in September 1989 recommending several changes in how the council functions.7 The recommendations for changes in the evaluation system have attracted the most attention. In the current debate the intent of the council's new directions has frequently been submerged by a preoccupation with medical territoriality and misunderstandings of the fundamental issues at stake. The real issue is: What is to be the nature of a national medical qualification that will permit portability? The proposed changes in the qualification process are as follows. The current multiple-choice examinations (Q 1, Q2 and Q3) would continue to be taken at the completion of the MD program but would be updated in keeping with the council's recently developed evaluation objectives, which de-
Dr. Dauphinee is professor and chair, Department ofMedicine, and director, Centre for Medical Education, McGill University, Montreal,
Que. Reprint requests to: Dr. W. Dale Dauphinee, Centre for Medical Education, McGill University, 529-3655 Drummond St., Montreal, PQ H3G I Y6 APRIL 15, 1991
CAN MED ASSOC J 1991; 144 (8)
967
fine the knowledge and skills required for the provision of general health care. A new sampling grid would be used to make the examination representative of the "real world."7 Also to be taken at this time would be a new Q4 examination developed in Canada and considered to be an important innovation.8 This would replace the current patient management problems, which have fallen into disrepute.9 Controversy has been sparked off by the decision to implement a new examination of clinical skills, including communication and counselling skills. This examination would be taken after completion of the first postgraduate year, although the timing is still a topic of discussion.6 An expert committee is currently working on its development and field testing. The new examination attempts to address one main concern: the need to evaluate basic clinical skills (not measurable by pencil and paper methods) as outlined in the council's new objectives, given the national consensus that the licensing bodies and the profession support the concept of general licensure. The recent developments in evaluation methods make the new clinical examination a feasible alternative to the current "soft" and perfunctory in-training evaluation reports.10 However, there is confusion about the implications and the decisions that would follow if the concept of general licensure were
accepted. Our current dilemma is that the Licentiate of the Medical Council of Canada has meant different things to different licensing authorities, and there is no national portability. If one supports Roddick's concept of portability and the notion of general licensure, as has the council, a good argument can be made for a clinical examination after the first postgraduate year. The present certificate of internship suffers from the shortcomings of global rating scales.1 1-13 What are the alternatives? Why not have everyone certified by either the College of Family Physicians of Canada after 2 years or the Royal College of Physicians and Surgeons of Canada after completion of specialty training?14 This would automatically define two types of practitioner but is not in keeping with the current views of the licensing authorities, which support the concept of general licensure. Without their agreement a change to two tracks will not occur.
training to take the family medicine examination after 2 years. This does not make pedagogic sense. Furthermore, if specialty trainees were to pass, the family medicine training program would be compromised. In fact, this sequence is highly unlikely. Last, some might argue that a national qualification for licensure is unnecessary. Although at first glance attractive, not having such a qualification would lead to further balkanization of licensure and no national standard for portability unless we borrow from the US examination system. Interestingly, the National Board of Medical Examiners and the state licensing bodies in the United States are now committed to a new national standard consisting of a two-part comprehensive examination and a test of clinical skills at the end of the first postgraduate year. Sound familiar? Given the current consensus on the desirability of general licensure or until we can agree on a two-track licensure system the currently proposed evaluation process is feasible and appropriate. Surely we owe it to the public and each other that our graduates should pass an independently administered evaluation of general clinical skills before being licensable in all provinces. The irony is that the proposed clinical test represents a return to the pre-1970 examination era when everyone had to pass a clinical oral examination before being licensed. In reality, nothing is new, and one could argue that the aberrancy of our national evaluation system is not the council's proposal for the 1990s but, rather, our failure to use a clinical, patient-based examination in the 1970s and 1980s. The period of preoccupation with examination reliability and multiple-choice tests has given way to more valid and equally reliable assessment tools. Given our long-standing national obsession with political unanimity and the 16 years it took Sir Thomas Roddick to obtain support for his bill, we cannot expect to speedily achieve unanimity on licensure. However, there is a national consensus on the need for an improved qualification for general licensure that would also provide the basis of portability; that consensus leads one to conclude that the medical council is following a reasonable and prudent course in overhauling its evaluation system in keeping with the standards of the day.
Why not have everyone take the examination References for certification in family medicine after 2 years of Kerr RB: The actual beginning, 1894-1912: the Roddick Bill. postgraduate education? Everyone would have to 1. In History ofthe Medical Council of Canada, Medical Council undergo training in family medicine before choosing of Canada, Ottawa, 1979: 14-23 a specialty. This is not feasible, because training 2. Barr JWB: The Medical Council of Canada. Part I: Portability of qualifications rejected, resurrected. Can Med Assoc J posts and resources are limited; moreover, an extra 1974; 111: 185, 193 year for specialty training would be educationally 3. Idem: Medical Council of Canada. Part II: More about the inefficient. Another option would be for those in specialty
968
CAN MED ASSOC J
1991; 144 (8)
origins of the council. Ibid: 267 4. Idem: Medical Council of Canada. Part III: The story from its LE 15 AVRIL 1991
origin to the present. Ibid: 353, 361 5. Dauphinee WD: Role of examinations of the Medical Council of Canada in improving medical standards. Can Med Assoc J 1981; 124: 1425-1427 6. Federation of Medical Licensing Authorities of Canada: A position paper with respect to the enhanced L.M.C.C. as a passport to portability of medical licensure in Canada. ACMC Forum 1990; 23 (4): 1-3 7. Annual Report, Medical Council of Canada, Ottawa, 1989 8. Bordage G, Page G: An alternative approach to PMPs: the "key features" concept. In Hart I, Harden R (eds): Further Developments in Assessing Clinical Competence, Heal Publ, Montreal, 1987: 59-75 9. Norcini JJ, Swanson DB, Grosso UJ et al: A comparison of several methods for scoring PMPs. Proc Annu Conf Res Med
Educ 1983; 22: 41-46 10. Dauphinee WD, Stillman P, Tamblyn R et al: Multiple station examinations for licensure: issues and solutions. Proc Annu ConfRes Med Educ 1989; 28: 211-214 11. Dauphinee WD, Norman G, Stillman P et al: Residency directors' role in assessment of clinical competence. Ann R Coll Physicians Surg Can 1988; 21: 35-40 12. Littlefield JH, Ellis RE, Cohen PA et al: Licensing and score distribution differences among clerical raters. Proc Annu Conf Res Med Educ 1984; 23: 199-204 13. Marienfeld RD, Reid JC: Six-year documentation of the easy grader in the medical clerkship setting. J Med Educ 1984; 59: 589-591 14. Maudsley RF: Medical licensure: Let's not lose sight of the objective. Can Med Assoc J 1990; 143: 98- 100
Conferences
May 24, 1991: Hormone Replacement Therapy (HRT) in the 1990s: Why, How and When Block Amphitheatre, Sir Mortimer B. Davis-Jewish General Hospital, Montreal BioVision Inc., 7816 Bodinier, Anjou, PQ H1K 4C5, (514) 354-4277; or Dr. Alex Ferenczy, (514) 340-7526, fax (514) 340-7510
continuedfrom page 965 May 17, 1991: 16th Annual Medical Clinic Day Intergeneration Interface: What's New for the Old Joseph E. and Minnie Wagman Centre, North York, Ont. Education Department, Baycrest Centre for Geriatric Care, 3560 Bathurst St., North York, ON M6A 2E1 May 18-21, 1991: National Conference on Medical Management Harbour Castle Westin, Toronto Jill Roote, American College of Physician Executives, 200-4890 W Kennedy Blvd., Tampa, FL 33609-2575; fax (813) 287-8993 May 22-24, 1991: 4th Annual Health Policy Conference Health Care and the Public: Roles, Expectations and
Contributions Sheraton Hamilton Hotel, Hamilton, Ont. Lynda Marsh, conference administrator, Centre for Health Economics and Policy Analysis, Rm. 3H1, McMaster University, 1200 Main St. W, Hamilton, ON L8N 3Z5; (416) 525-9140, ext. 2135, fax (416) 546-5211 May 22-24, 1991: Society for Scholarly Publishing Annual Meeting Hershey Hotel, Philadelphia Society for Scholarly Publishing, Ste. 304, 10200 W 44 Ave., Wheat Ridge, CO 80033; (303) 422-3914, fax (303) 422-8894
May 22-25, 1991: North American Primary Care Research Group 19th Annual Meeting Chateau Frontenac, Quebec Dr. Michel Labrecque, chairman, Organizing Committee, NAPCRG-9 1, Continuing Medical Education Office, Faculty of Medicine, Ferdinand-Vandry Pavilion, Laval University, Quebec, PQ GIK 7P4; (418) 656-5958, fax (418) 656-3442
May 23-24, 1991: 2nd Canadian Epidemiology Research Conference University of Alberta, Edmonton Dr. Colin Soskolne, conference convenor, 13-103 Clinical Sciences Bldg., University of Alberta, Edmonton, AB T6G 2G3; (403) 492-6013, fax (403) 492-0364 APRIL 15, 1991
Du 24 au 26 mai 1991: Epilepsie vers l'an 2000 (en collaboration avec les assemblees annuelles d'Epilepsie Canada, la Ligue de l'epilepsie du Quebec et d'Epilepsie Montreal) L'H6tel Meridien, Montreal Viviane Bergua, Ligue de l'epilepsie du Quebec, 3175, C6te Sainte-Catherine, Montreal, QC H3T 1C5; (514) 733-9929, fax (514) 345-4800 May 31-June 2, 1991: Human-Animal Bond Association of Canada (HABAC) Annual Conference (prelude to the 6th International Conference on Human-Animal Interactions, July 21-25, 1992, Montreal) Bessborough Hotel, Saskatoon Taylor and Associates, 676 Shefford Ct., Gloucester, ON KIJ 6X3; (613) 747-0262 June 2-5, 1991: Canadian Long Term Care Association Annual Conference (cosponsored by the Associated Homes for Special Care, Nova Scotia) Halifax Hilton Canadian Long Term Care Association, 302-260 St. Patrick St., Ottawa, ON KIN 5K5, (613) 237-9837, fax (613) 237-6592; or Associated Homes for Special Care, Nova Scotia, (902) 469-1730 June 2-6, 1991: Joint Annual Scientific Meeting of the Canadian Society of Clinical Chemists, la Societe quebecoise de biochimie clinique and the Canadian Association of Medical Biochemists Hilton Bonaventure, Montreal Ms. Elizabeth Hooper, congress coordinator, PO Box 1570, 190 Railway St., Kingston, ON K7L 5C8; (613) 531-9210, fax (613) 531-0626
continued on page 1010 CAN MED ASSOC J 1991; 144 (8)
969
Licences, examinations and more examinations W. Dale Dauphinee, MD, FRCPC
T he creation of the Medical Council of Canada is an amazing story of the persistence and foresight of one man: Sir Thomas Roddick. Born in Newfoundland Sir Thomas was a distinguished professor of surgery and dean of medicine at McGill University. His achievements were such that he was knighted in 1915; in 1925 his widow and McGill University had gates erected at the entrance to the main campus in his honour. The Roddick Gates stand as a magnificent testimony to his many accomplishments but particularly to his role in bringing order and standards to the licensure of physicians in Canada. Because he was unable to interest the politicians in the licensure problem Sir Thomas ran for Parliament, was elected in 1896 and spent 16 years shepherding his solution through Parliament and the provincial legislatures. Before 1911 the licensing mechanisms had been fragmented and arbitrary, as he observed in a speech before the House of Commons in support of his bill to establish the medical council. If a student begins to study medicine in one province by complying with the provincial enactment in reference to matriculation, he may be debarred forever from getting into another province, so absurd are the refutations today. These barriers exist in no other country under the sun, and it is the object of the Bill to break them down.'
Passed initially in 1902 as a private member's bill the Canada Medical Act finally received approval from all provinces and was promulgated in 1912. The history of the council's origins and development are well documented.'-4 Subsequent changes in the
council's examinations in the late 1970s and early 1980s were the subject of a commentary in 1981.5 Recently, the winds of change have swept the medical council again. Acting on the concerns of members of the Canadian licensing community about an increasingly fragmented system of licensure the council created the Task Force on Future Directions in 1988.6 This task force was widely representative of the council's two primary constituents: the medical schools and the provincial licensing authorities. (The council comprises two delegates from each of the 10 provincial licensing authorities, one delegate from each of the 16 medical schools and three members selected by the Governor in Council. It can be viewed as a national medical parliament on matters of standards for licensure.) The task force met regularly for 18 months; it submitted a preliminary report at the annual meeting of the medical council in September 1988 recommending a new direction in the council's evaluation process and a final report in September 1989 recommending several changes in how the council functions.7 The recommendations for changes in the evaluation system have attracted the most attention. In the current debate the intent of the council's new directions has frequently been submerged by a preoccupation with medical territoriality and misunderstandings of the fundamental issues at stake. The real issue is: What is to be the nature of a national medical qualification that will permit portability? The proposed changes in the qualification process are as follows. The current multiple-choice examinations (Q 1, Q2 and Q3) would continue to be taken at the completion of the MD program but would be updated in keeping with the council's recently developed evaluation objectives, which de-
Dr. Dauphinee is professor and chair, Department ofMedicine, and director, Centre for Medical Education, McGill University, Montreal,
Que. Reprint requests to: Dr. W. Dale Dauphinee, Centre for Medical Education, McGill University, 529-3655 Drummond St., Montreal, PQ H3G I Y6 APRIL 15, 1991
CAN MED ASSOC J 1991; 144 (8)
967
fine the knowledge and skills required for the provision of general health care. A new sampling grid would be used to make the examination representative of the "real world."7 Also to be taken at this time would be a new Q4 examination developed in Canada and considered to be an important innovation.8 This would replace the current patient management problems, which have fallen into disrepute.9 Controversy has been sparked off by the decision to implement a new examination of clinical skills, including communication and counselling skills. This examination would be taken after completion of the first postgraduate year, although the timing is still a topic of discussion.6 An expert committee is currently working on its development and field testing. The new examination attempts to address one main concern: the need to evaluate basic clinical skills (not measurable by pencil and paper methods) as outlined in the council's new objectives, given the national consensus that the licensing bodies and the profession support the concept of general licensure. The recent developments in evaluation methods make the new clinical examination a feasible alternative to the current "soft" and perfunctory in-training evaluation reports.10 However, there is confusion about the implications and the decisions that would follow if the concept of general licensure were
accepted. Our current dilemma is that the Licentiate of the Medical Council of Canada has meant different things to different licensing authorities, and there is no national portability. If one supports Roddick's concept of portability and the notion of general licensure, as has the council, a good argument can be made for a clinical examination after the first postgraduate year. The present certificate of internship suffers from the shortcomings of global rating scales.1 1-13 What are the alternatives? Why not have everyone certified by either the College of Family Physicians of Canada after 2 years or the Royal College of Physicians and Surgeons of Canada after completion of specialty training?14 This would automatically define two types of practitioner but is not in keeping with the current views of the licensing authorities, which support the concept of general licensure. Without their agreement a change to two tracks will not occur.
training to take the family medicine examination after 2 years. This does not make pedagogic sense. Furthermore, if specialty trainees were to pass, the family medicine training program would be compromised. In fact, this sequence is highly unlikely. Last, some might argue that a national qualification for licensure is unnecessary. Although at first glance attractive, not having such a qualification would lead to further balkanization of licensure and no national standard for portability unless we borrow from the US examination system. Interestingly, the National Board of Medical Examiners and the state licensing bodies in the United States are now committed to a new national standard consisting of a two-part comprehensive examination and a test of clinical skills at the end of the first postgraduate year. Sound familiar? Given the current consensus on the desirability of general licensure or until we can agree on a two-track licensure system the currently proposed evaluation process is feasible and appropriate. Surely we owe it to the public and each other that our graduates should pass an independently administered evaluation of general clinical skills before being licensable in all provinces. The irony is that the proposed clinical test represents a return to the pre-1970 examination era when everyone had to pass a clinical oral examination before being licensed. In reality, nothing is new, and one could argue that the aberrancy of our national evaluation system is not the council's proposal for the 1990s but, rather, our failure to use a clinical, patient-based examination in the 1970s and 1980s. The period of preoccupation with examination reliability and multiple-choice tests has given way to more valid and equally reliable assessment tools. Given our long-standing national obsession with political unanimity and the 16 years it took Sir Thomas Roddick to obtain support for his bill, we cannot expect to speedily achieve unanimity on licensure. However, there is a national consensus on the need for an improved qualification for general licensure that would also provide the basis of portability; that consensus leads one to conclude that the medical council is following a reasonable and prudent course in overhauling its evaluation system in keeping with the standards of the day.
Why not have everyone take the examination References for certification in family medicine after 2 years of Kerr RB: The actual beginning, 1894-1912: the Roddick Bill. postgraduate education? Everyone would have to 1. In History ofthe Medical Council of Canada, Medical Council undergo training in family medicine before choosing of Canada, Ottawa, 1979: 14-23 a specialty. This is not feasible, because training 2. Barr JWB: The Medical Council of Canada. Part I: Portability of qualifications rejected, resurrected. Can Med Assoc J posts and resources are limited; moreover, an extra 1974; 111: 185, 193 year for specialty training would be educationally 3. Idem: Medical Council of Canada. Part II: More about the inefficient. Another option would be for those in specialty
968
CAN MED ASSOC J
1991; 144 (8)
origins of the council. Ibid: 267 4. Idem: Medical Council of Canada. Part III: The story from its LE 15 AVRIL 1991
origin to the present. Ibid: 353, 361 5. Dauphinee WD: Role of examinations of the Medical Council of Canada in improving medical standards. Can Med Assoc J 1981; 124: 1425-1427 6. Federation of Medical Licensing Authorities of Canada: A position paper with respect to the enhanced L.M.C.C. as a passport to portability of medical licensure in Canada. ACMC Forum 1990; 23 (4): 1-3 7. Annual Report, Medical Council of Canada, Ottawa, 1989 8. Bordage G, Page G: An alternative approach to PMPs: the "key features" concept. In Hart I, Harden R (eds): Further Developments in Assessing Clinical Competence, Heal Publ, Montreal, 1987: 59-75 9. Norcini JJ, Swanson DB, Grosso UJ et al: A comparison of several methods for scoring PMPs. Proc Annu Conf Res Med
Educ 1983; 22: 41-46 10. Dauphinee WD, Stillman P, Tamblyn R et al: Multiple station examinations for licensure: issues and solutions. Proc Annu ConfRes Med Educ 1989; 28: 211-214 11. Dauphinee WD, Norman G, Stillman P et al: Residency directors' role in assessment of clinical competence. Ann R Coll Physicians Surg Can 1988; 21: 35-40 12. Littlefield JH, Ellis RE, Cohen PA et al: Licensing and score distribution differences among clerical raters. Proc Annu Conf Res Med Educ 1984; 23: 199-204 13. Marienfeld RD, Reid JC: Six-year documentation of the easy grader in the medical clerkship setting. J Med Educ 1984; 59: 589-591 14. Maudsley RF: Medical licensure: Let's not lose sight of the objective. Can Med Assoc J 1990; 143: 98- 100
Conferences
May 24, 1991: Hormone Replacement Therapy (HRT) in the 1990s: Why, How and When Block Amphitheatre, Sir Mortimer B. Davis-Jewish General Hospital, Montreal BioVision Inc., 7816 Bodinier, Anjou, PQ H1K 4C5, (514) 354-4277; or Dr. Alex Ferenczy, (514) 340-7526, fax (514) 340-7510
continuedfrom page 965 May 17, 1991: 16th Annual Medical Clinic Day Intergeneration Interface: What's New for the Old Joseph E. and Minnie Wagman Centre, North York, Ont. Education Department, Baycrest Centre for Geriatric Care, 3560 Bathurst St., North York, ON M6A 2E1 May 18-21, 1991: National Conference on Medical Management Harbour Castle Westin, Toronto Jill Roote, American College of Physician Executives, 200-4890 W Kennedy Blvd., Tampa, FL 33609-2575; fax (813) 287-8993 May 22-24, 1991: 4th Annual Health Policy Conference Health Care and the Public: Roles, Expectations and
Contributions Sheraton Hamilton Hotel, Hamilton, Ont. Lynda Marsh, conference administrator, Centre for Health Economics and Policy Analysis, Rm. 3H1, McMaster University, 1200 Main St. W, Hamilton, ON L8N 3Z5; (416) 525-9140, ext. 2135, fax (416) 546-5211 May 22-24, 1991: Society for Scholarly Publishing Annual Meeting Hershey Hotel, Philadelphia Society for Scholarly Publishing, Ste. 304, 10200 W 44 Ave., Wheat Ridge, CO 80033; (303) 422-3914, fax (303) 422-8894
May 22-25, 1991: North American Primary Care Research Group 19th Annual Meeting Chateau Frontenac, Quebec Dr. Michel Labrecque, chairman, Organizing Committee, NAPCRG-9 1, Continuing Medical Education Office, Faculty of Medicine, Ferdinand-Vandry Pavilion, Laval University, Quebec, PQ GIK 7P4; (418) 656-5958, fax (418) 656-3442
May 23-24, 1991: 2nd Canadian Epidemiology Research Conference University of Alberta, Edmonton Dr. Colin Soskolne, conference convenor, 13-103 Clinical Sciences Bldg., University of Alberta, Edmonton, AB T6G 2G3; (403) 492-6013, fax (403) 492-0364 APRIL 15, 1991
Du 24 au 26 mai 1991: Epilepsie vers l'an 2000 (en collaboration avec les assemblees annuelles d'Epilepsie Canada, la Ligue de l'epilepsie du Quebec et d'Epilepsie Montreal) L'H6tel Meridien, Montreal Viviane Bergua, Ligue de l'epilepsie du Quebec, 3175, C6te Sainte-Catherine, Montreal, QC H3T 1C5; (514) 733-9929, fax (514) 345-4800 May 31-June 2, 1991: Human-Animal Bond Association of Canada (HABAC) Annual Conference (prelude to the 6th International Conference on Human-Animal Interactions, July 21-25, 1992, Montreal) Bessborough Hotel, Saskatoon Taylor and Associates, 676 Shefford Ct., Gloucester, ON KIJ 6X3; (613) 747-0262 June 2-5, 1991: Canadian Long Term Care Association Annual Conference (cosponsored by the Associated Homes for Special Care, Nova Scotia) Halifax Hilton Canadian Long Term Care Association, 302-260 St. Patrick St., Ottawa, ON KIN 5K5, (613) 237-9837, fax (613) 237-6592; or Associated Homes for Special Care, Nova Scotia, (902) 469-1730 June 2-6, 1991: Joint Annual Scientific Meeting of the Canadian Society of Clinical Chemists, la Societe quebecoise de biochimie clinique and the Canadian Association of Medical Biochemists Hilton Bonaventure, Montreal Ms. Elizabeth Hooper, congress coordinator, PO Box 1570, 190 Railway St., Kingston, ON K7L 5C8; (613) 531-9210, fax (613) 531-0626
continued on page 1010 CAN MED ASSOC J 1991; 144 (8)
969
