Montreal, we read with interest the article by Fran Lowry entitled "Many Quebec MDs search for greener pastures as morale of province's doctors nosedives" (Can Med Assoc J 1991; 145: 329332). We must, however, take exception to the implication of the paragraph dealing with our program. Although it is true that we no longer have a long list of the "cream"l of medical students from across the country, in 1988 we expanded our residency program to twice its previous size as a result of government decree.' This alone has profoundly changed the competition for residency positions. We are not, however, struggling along with a group of disgruntled underachievers, as the article implies. Many students from McGill University have taken the opportunity to leave the province when they finish medical school, but only a small portion of these students choose family medicine. This is not surprising considering the specialty orientation of McGill's undergraduate curriculum and the political situation outlined in the article. A significant number of applicants are attracted to McGill and to our training program in particular. We are still able to recruit highly desirable residents, many from out of the province, through a combination of a highquality teaching program and the romance and excitement of life in Montreal. Moreover, we have not seen any overall diminution in the quality of our residents. We have this year an exceptionally bright, eager and hard-working group. Although there are always some problems, this year there are no more than usual. Perhaps this should cause us to look with scepticism at the selection process for residency and at our own biases.2 In spite of the cycles of political discomfort, we McGill family medicine teachers who remain in the province enjoy and thrive on 100
CAN MED ASSOC J 1992; 146 (2)
Montreal's multicultural milieu and McGill's academic environment, which facilitates our growth as clinicians and teachers. We stay for the joy we take in our work and the commitment we have made to maintaining the excellence of our program. Perle Feldman, MD Cheryl Levitt, MD Ronald Wilson, MD Roland Grad, MD Howard Goldstein, MD John Kirk, MD Morrie Golden, PhD Michael Malus, MD Herzl Family Practice Centre Sir Mortimer B. Davis-Jewish General Hospital Montreal, Que.
References 1. Levitt CA, Klein MC: The demise of the rotating internship and family practice program expansion: view from the trenches. Can Fam Physician 1991; 37: 604-610, 742 2. Levitt CA: Expansion and recruitment - a survey of medical students interviewed for family medicine residencies. Can Fam Physician (in press)
Comparison of search strategies on CD Plus/MEDLINE I n the introduction to their article (Can Med Assoc J 1991; 145: 457-464) Leslie C. Wright and associates state that GRATEFUL MED and other enduser software products "tended to be used by librarians because of complexities of *searching and
system, a much more powerful and flexible approach for those skilled in its use. I draw attention to this point in case the article leads readers to conclude that GRATEFUL MED is too complicated for the practising physician to use in his or her office or home. Nothing could be further from the truth: as part of a project of the Department of Continuing Medical Education at the University of British Columbia more than 150 physicians have purchased and been briefly trained in the use of GRATEFUL MED so that they can search MEDLINE from their offices and homes. I am also concerned that the authors' description of two distinct search strategies and their concluding comments may create the impression that a search is done one way or the other. One of the most effective methods is to do a fairly broad search using medical subject heading (MeSH) terms, if possible, to identify a few relevant articles and 'then, using the MeSH terms from those articles, to repeat the search. The articles of greatest interest are therefore found by means of a combination of the two strategies the authors describe. There are many different ways to "skin a cat," depending on the needs of the searcher. However, a study of MEDLINE searching (including the 'use of GRATEFUL MED) prepared for the US National Library of Medicine revealed that one of the main reasons why searches did not produce the desired result was failure to use interactive searching: the searchers tried to hit the target on the first shot rather than stalking it step by step.' With the latest version (5.05) of GRATEFUL MED interactive searching is not "cumbersome and time-consum-
equipment requirements." I know of no librarians in the Woodward Library at the University of British Columbia or in the library of the College of Physicians and Surgeons of British Columbia who use GRATEFUL MED or any of the other products mentioned as a search aid. All the ing." librarians with whom I have Although there can be little worked search MEDLINE directly doubt about the advantages of in the command language of the
digital disc technology for the acaLE 15 JANVIER 1992
demic institution, hospital or others advance their searching and, indeed, it remains only that - a suggestion. large medical clinic, I suspect that skills. for some time to come end-user Russell Springate, MD software, such as GRATEFUL John I. Jackson Women's College Hospital MED, will remain the most effec- Senior technician Toronto, Ont. Library Institute Cancer Ontario tive method of keeping up to date Toronto, Ont. for the single-handed or small[Dr. Skvorc-Ranko responds:] group practitioner. R. Patrick Gannon, MB, ChB, MIS 6-4411 Williams Rd. Richmond, BC
Reference 1. Wilson SR, Starr-Schneidkraut N, Cooper MD: Use ofthe Critical Incident Technique to Evaluate the Impact of MEDLINE (NTIS PB90-142522), American Institutes for Research in the Behavioral Sciences, Palo Alto, Calif, 1989
[One of the authors responds.] Dr. Gannon is correct in stating that most library professionals who search MEDLINE do so directly, on line, using the ELHILL command lexicon. As we stated, GRATEFUL MED reduces the complexity of manipulating that system. Our experience has been that some physicians have required substantial support from library staff when they begin to use GRATEFUL MED. We note that GRATEFUL MED has been continually improved, and we agree that for individuals or small clinics it remains 'the end-user program of choice for searching MEDLINE. CD-ROM technology, as we implied, is appropriate for larger institutions. The focus of our paper was not, however, a comparison of end-user products but measurement of the relative efficacy of two distinct search strategies on one system. For our purpose it was desirable to test each strategy by itself. Gannon's suggested interactive strategy or a combination of elements from each of our strategies would be the approach of an experienced searcher. We hope our observations will help JANUARY 15, 1992
Intrauterine diagnosis of cytomegalovirus and rubella infections by amniocentesis I n the study by Dr. Ranko Skvorc-Ranko and associates (Can Med Assoc J 1991; 145: 649-654) the evidence given for the value of amniocentesis and virus culture in determining fetal infection is not as clear-cut as might first be thought. In the cases of primary
cytomegalovirus (CMV) infection the results of culture of the amniotic fluid were no better than those of serologic studies in predicting infection of the fetus. Nor were they more predictive of a neurologic deficit in the infected babies. With the recognition that CMV cultures of amniotic fluid may fail to yield a truly positive result, carrying out this procedure would not necessarily add to a diagnosis, and it might, in fact, be insufficient if it were relied on as the sole means of diagnosing intrauterine infection. The results are different in the rubella studies. Only three cases were investigated, and it was not possible to tell from the serologic test results which babies were infected. However, the one infected baby was identified from the results of culture of the amniotic fluid. Although there was a strong correlation between the isolation of CMV or rubella virus from the amniotic fluid and the presence of congenital infection the suggestion that amniocentesis is a useful method for the diagnosis of fetal infection applies only to rubella,
I disagree with Dr. Springate's comment that in the case of CMV infection the results of amniocentesis are no better than those of serologic studies in predicting infection of the fetus. First of all, prospective studies (including complement fixation, enzyme-linked immunosorbent assay and indirect immunofluorescence for IgM) of the maternal serum only may fail to reveal a high-risk pregnancy.' In such serologically negative cases amniocentesis and culture have been found to be useful in the diagnosis of a fetal infection.2-7 Second, in serologically positive cases of primary infection a negative result of 'viral culture of the amniotic fluid has been correlated with the absence of fetal infection.7-'0 Finally, as we pointed out, assessment of the risk to the fetus and a complete virologic examination rather than serologic studies only are important when counselling a pregnant woman with suspected CMV infection. Further research is required to determine whether prenatal diagnosis will allow identification of the parameters (for example, the stage at which the amniotic fluid becomes infected and the duration of infection) that discriminate between fetuses that are infected but do not have the congenital syndrome and those with severe sequelae. Ranko Skvorc-Rauko, MD Virology Research Centre Institut Armand-Frappier Laval, Que.
References 1. Ahlfors K, Harris S, Ivarsson S et al: CAN MED ASSOC J
1992; 146 (2)
101
CAN MED ASSOC J 1992; 146 (2)
Montreal's multicultural milieu and McGill's academic environment, which facilitates our growth as clinicians and teachers. We stay for the joy we take in our work and the commitment we have made to maintaining the excellence of our program. Perle Feldman, MD Cheryl Levitt, MD Ronald Wilson, MD Roland Grad, MD Howard Goldstein, MD John Kirk, MD Morrie Golden, PhD Michael Malus, MD Herzl Family Practice Centre Sir Mortimer B. Davis-Jewish General Hospital Montreal, Que.
References 1. Levitt CA, Klein MC: The demise of the rotating internship and family practice program expansion: view from the trenches. Can Fam Physician 1991; 37: 604-610, 742 2. Levitt CA: Expansion and recruitment - a survey of medical students interviewed for family medicine residencies. Can Fam Physician (in press)
Comparison of search strategies on CD Plus/MEDLINE I n the introduction to their article (Can Med Assoc J 1991; 145: 457-464) Leslie C. Wright and associates state that GRATEFUL MED and other enduser software products "tended to be used by librarians because of complexities of *searching and
system, a much more powerful and flexible approach for those skilled in its use. I draw attention to this point in case the article leads readers to conclude that GRATEFUL MED is too complicated for the practising physician to use in his or her office or home. Nothing could be further from the truth: as part of a project of the Department of Continuing Medical Education at the University of British Columbia more than 150 physicians have purchased and been briefly trained in the use of GRATEFUL MED so that they can search MEDLINE from their offices and homes. I am also concerned that the authors' description of two distinct search strategies and their concluding comments may create the impression that a search is done one way or the other. One of the most effective methods is to do a fairly broad search using medical subject heading (MeSH) terms, if possible, to identify a few relevant articles and 'then, using the MeSH terms from those articles, to repeat the search. The articles of greatest interest are therefore found by means of a combination of the two strategies the authors describe. There are many different ways to "skin a cat," depending on the needs of the searcher. However, a study of MEDLINE searching (including the 'use of GRATEFUL MED) prepared for the US National Library of Medicine revealed that one of the main reasons why searches did not produce the desired result was failure to use interactive searching: the searchers tried to hit the target on the first shot rather than stalking it step by step.' With the latest version (5.05) of GRATEFUL MED interactive searching is not "cumbersome and time-consum-
equipment requirements." I know of no librarians in the Woodward Library at the University of British Columbia or in the library of the College of Physicians and Surgeons of British Columbia who use GRATEFUL MED or any of the other products mentioned as a search aid. All the ing." librarians with whom I have Although there can be little worked search MEDLINE directly doubt about the advantages of in the command language of the
digital disc technology for the acaLE 15 JANVIER 1992
demic institution, hospital or others advance their searching and, indeed, it remains only that - a suggestion. large medical clinic, I suspect that skills. for some time to come end-user Russell Springate, MD software, such as GRATEFUL John I. Jackson Women's College Hospital MED, will remain the most effec- Senior technician Toronto, Ont. Library Institute Cancer Ontario tive method of keeping up to date Toronto, Ont. for the single-handed or small[Dr. Skvorc-Ranko responds:] group practitioner. R. Patrick Gannon, MB, ChB, MIS 6-4411 Williams Rd. Richmond, BC
Reference 1. Wilson SR, Starr-Schneidkraut N, Cooper MD: Use ofthe Critical Incident Technique to Evaluate the Impact of MEDLINE (NTIS PB90-142522), American Institutes for Research in the Behavioral Sciences, Palo Alto, Calif, 1989
[One of the authors responds.] Dr. Gannon is correct in stating that most library professionals who search MEDLINE do so directly, on line, using the ELHILL command lexicon. As we stated, GRATEFUL MED reduces the complexity of manipulating that system. Our experience has been that some physicians have required substantial support from library staff when they begin to use GRATEFUL MED. We note that GRATEFUL MED has been continually improved, and we agree that for individuals or small clinics it remains 'the end-user program of choice for searching MEDLINE. CD-ROM technology, as we implied, is appropriate for larger institutions. The focus of our paper was not, however, a comparison of end-user products but measurement of the relative efficacy of two distinct search strategies on one system. For our purpose it was desirable to test each strategy by itself. Gannon's suggested interactive strategy or a combination of elements from each of our strategies would be the approach of an experienced searcher. We hope our observations will help JANUARY 15, 1992
Intrauterine diagnosis of cytomegalovirus and rubella infections by amniocentesis I n the study by Dr. Ranko Skvorc-Ranko and associates (Can Med Assoc J 1991; 145: 649-654) the evidence given for the value of amniocentesis and virus culture in determining fetal infection is not as clear-cut as might first be thought. In the cases of primary
cytomegalovirus (CMV) infection the results of culture of the amniotic fluid were no better than those of serologic studies in predicting infection of the fetus. Nor were they more predictive of a neurologic deficit in the infected babies. With the recognition that CMV cultures of amniotic fluid may fail to yield a truly positive result, carrying out this procedure would not necessarily add to a diagnosis, and it might, in fact, be insufficient if it were relied on as the sole means of diagnosing intrauterine infection. The results are different in the rubella studies. Only three cases were investigated, and it was not possible to tell from the serologic test results which babies were infected. However, the one infected baby was identified from the results of culture of the amniotic fluid. Although there was a strong correlation between the isolation of CMV or rubella virus from the amniotic fluid and the presence of congenital infection the suggestion that amniocentesis is a useful method for the diagnosis of fetal infection applies only to rubella,
I disagree with Dr. Springate's comment that in the case of CMV infection the results of amniocentesis are no better than those of serologic studies in predicting infection of the fetus. First of all, prospective studies (including complement fixation, enzyme-linked immunosorbent assay and indirect immunofluorescence for IgM) of the maternal serum only may fail to reveal a high-risk pregnancy.' In such serologically negative cases amniocentesis and culture have been found to be useful in the diagnosis of a fetal infection.2-7 Second, in serologically positive cases of primary infection a negative result of 'viral culture of the amniotic fluid has been correlated with the absence of fetal infection.7-'0 Finally, as we pointed out, assessment of the risk to the fetus and a complete virologic examination rather than serologic studies only are important when counselling a pregnant woman with suspected CMV infection. Further research is required to determine whether prenatal diagnosis will allow identification of the parameters (for example, the stage at which the amniotic fluid becomes infected and the duration of infection) that discriminate between fetuses that are infected but do not have the congenital syndrome and those with severe sequelae. Ranko Skvorc-Rauko, MD Virology Research Centre Institut Armand-Frappier Laval, Que.
References 1. Ahlfors K, Harris S, Ivarsson S et al: CAN MED ASSOC J
1992; 146 (2)
101
