What makes Martin Barkin run? A t the end of yet another 75-hour work week I sat down to get caught up on my reading and came across the article on Martin Barkin (Can Med Assoc J 1990; 142: 628-631, 633-634, 636-637). I had often wondered what it was that made me different from Dr. Barkin aside from his intelligence and brilliant career as a clinician and administrator. The answer was revealed in the article: he is the ultimate pragmatist ("When government makes it illegal, it is illegal. When the law changed, I changed"). However, there is a difference between legal and moral or ethical. It was presumably legal to put political dissidents in mental institutions in the Soviet Union until recently, and it was probably legal to deport Jews from Nazi Germany. That did not make it right. There is a very fine line between being the ultimate pragmatist and being a quisling. I will leave it to CMAJ readers to decide on which side of that line Barkin
falls. W.L. Gilbert Hopson, MD 946 Queen St. E Sault Ste. Marie, Ont.
Suicide among teenagers T he suicide rate among teenagers is now higher in Canada than in the United States' and in fact has increased 280% since 1960, probably because of the apparently neverending socialistic universal programs that are helping people (and thus their children) into "learned helplessness".2 The fact that the rate in the province of Quebec is the highest in the world' has to be accounted for; it is probably due 1362
CAN MED ASSOC J 1990; 142 (12)
four times more often than girls (probably because girls "get into" their feelings better) and that approximately 50% of depressed teenagers become substance abusers.' I consider it significant that Anthony Burgess's tale of violent "anomie",9 crafted three decades ago,'0 is now a sold-out play (A Clockwork Orange 2004) in London, England, the reason being manizing modern society is doing that real life is now as bad as, if to our teenagers. More than 25 not worse than, the play. years ago both men forecast an escalating suicide rate among US Ray Holland, MD, FRCPC 458 teenagers because of this sense of Box 80 Fraser St. lack of meaning and responsibili- Port Colborne, Ont. ty, but I don't think anyone expected the rate in Canada to ex- References ceed that of the United States. The breakdown of the tradi- 1. Sutherland R: Teen suicide. Med Post 1990; 26 (10): 11 tional family has left many young 2. Seligman MEP: Learned helplessness. people with too much adult-like Annu Rev Med 1972; 23: 407-412 freedom, and the lack of a value 3. Erikson E: Childhood and Society, Norton, New York, 1950 system in the home is aided and abetted by the school systems, 4. Frankl V: Man's Search for Meaning, Bks, New York, 1963 with their lack of standards and 5. Pocket Bettelheim B: Love is Not Enough, the irrelevance of subjects.6 In adFree Pr, New York, 1950 dition, teenagers are worried 6. Radwanski G: Ontario Study of the Relevance of Education and the Issue about their future more than ever of Dropout, Ontario Ministry of Eduas the computer revolution (which cation, Queen's Printer, Toronto, is making the industrial revolu1987 tion look anemic) gallops forward. 7. McLuhan M: Understanding Media, Signet Bks, New York, 1946 As well, teenagers are overin8. Ayd FJ (ed): Underdiagnosis of deformed by the media, which have pression. Int Drug Ther Newsl 1988; transformed the world into the 23(2): 11-12 "'global village" of Marshall 9. Durkheim E: Suicide: a Study of Sociology, Free Pr, New York, 1951 McLuhan.7 10. Burgess A: A Clockwork Orange, NorIf depression (with which suiton, New York/London, 1967 cide is associated) is the most missed medical diagnosis among adults,8 the situation is even worse with regard to teenagers,' in whom depression is more difficult Metronidazole to diagnose (requiring psychologi- and fungating tumours cal testing within the clinical context). I saw more depression in I n "A medical potpourri" (Can Med Assoc J 1990; 142: 866teenagers as a general practitioner than I do now as a psychiatrist; 867) Dr. Patrick J. Taylor 97% of youngsters referred to me comments on the use of methave behaviour problems ("The ronidazole gel to reduce odour squeaky wheel gets the grease"). from fungating neoplastic lesions. In 1978, while a senior regisMeanwhile, where are those with trar at Guy's Hospital, London, depression? Family physicians should re- England, I was presented with a member that boys commit suicide similar problem. At the time, met-
to the identity crisis the province is going through, which in turn will aggravate the identity crisis that teenagers go through.3 Drs. Viktor Frankl4 and Bruno Bettelheim5 were both incarcerated in Nazi concentration camps, and both observed that the guards tried to break down the prisoners' identity and sense of value, meaning and responsibility, which is precisely what the dehu-
ronidazole was still considered the new wonder drug, and by extrapolation I advised oral metronidazole therapy. The effect was dramatic, with a major change in the level of care from family and professionals. However, the inevitable outcome was unchanged. In the intervening years I have from time to time suggested and used the same approach, with variable success. The gel formula-, tion should, if it works at the same rate as the oral or parenteral formulation, continue to provide excellent relief for caregivers and
patients. Maurice T. Dalton, MB, FRCPC Director of clinical bacteriology Victoria General Hospital Halifax, NS
Preventive care and practice funding A ccording to their paper "Do health service organizations [HSOs] and community health centres have higher disease prevention and health promotion levels than fee-for-service practices?" (Can Med Assoc J 1990; 142: 575-581) Julia Abelson and Jonathan Lomas were unable to demonstrate much difference in the approach to disease prevention in differently funded types of practice in Ontario. Although it is assumed that there are differences in the philosophy of care between HSOs and fee-for-service practices there is no mandate for this in the contract with the Ontario Ministry of Health. Since physicians are exposed to much the same training before entering any particular practice setting it is probably not surprising that they offer much the same service to patients. Some of the preventive approaches studied by Abelson and Lomas are billable under the fee-for-service system, so that an incentive is
provided, and it would not be surprising if physicians working under other funding arrangements were less inclined to use approaches of questionable efficacy. Abelson and Lomas fail to give sufficient emphasis to the approach to prevention that is distinctive to HSOs and has attracted many physicians to them. With their enrolled population being well defined and identified on a computer database HSOs allow a unique opportunity for a community-based approach to epidemiology. Rather than resulting in routinized disease prevention services, capitation funding in Ontario provides a strong incentive to move toward the "anticipatory care" advocated by Tudor Hart.' Robert Frankford, MD 166 Main St. Toronto, Ont.
Reference 1. Tudor Hart J: A New Kind of Doctor, Merlin, London, 1988
"Health care security"? Not in Alberta either
temporarily elected politicians but those that will show the true state of affairs in the health care system. Amirali Nanji, MD 240 Adolphus St. Cornwall, Ont.
Abbs. in Js I enjoyed Dr. William G. Green's witty letter (Can Med Assoc J 1990; 142: 287, 290). For those of us who love literature but must write articles in the language of science, I offer a semilimerick that addresses the problem. Since ancient times we've loved the language flow: Words upon words, newly fashioned aeons ago. Wond'rous words, whate'er the source, Spring with meaning clear, to course Along, a fresh and warming glow. In any accent, clipped or brogue, Peasant, philosopher, judge or rogue, For objects material Use words ethereal, Archaic words or words in vogue.
However,
I read Dr. Brian A. Shamess's letter about the waiting lists for cardiac surgery in Ontario (Can Med Assoc J 1990; 142: 798) with great interest. If Dr. Ronald Gregg, president of the Alberta Medical Association, is trying to mislead the Americans he should look in his own backyard. My father, who lives in Edmonton, had three-vessel coronary artery disease; all three vessels were more than 80% stenosed. He was told that the minimum wait for coronary artery bypass surgery in Edmonton was 1 year and in Calgary 6 months. He elected to go to Calgary, where he waited 8 months. Please, Dr. Gregg, present the facts -not those that please the
The tongue to science is brevity, we opine, And turgid pleonasm we eradicate or redefine. Reviewers we entice By showing we're precise, With acronyms filtered out, as anodyne. We cut "in close proximity" to "near", Change "females" to "women" to make it clear. We avoid review decision By writing with precision In language succinct, spartan and sincere. Frank I. Jackson, MB, ChB Cross Cancer Institute Edmonton, Alta. CAN MED ASSOC .J 1990; 142 (12)
1363
falls. W.L. Gilbert Hopson, MD 946 Queen St. E Sault Ste. Marie, Ont.
Suicide among teenagers T he suicide rate among teenagers is now higher in Canada than in the United States' and in fact has increased 280% since 1960, probably because of the apparently neverending socialistic universal programs that are helping people (and thus their children) into "learned helplessness".2 The fact that the rate in the province of Quebec is the highest in the world' has to be accounted for; it is probably due 1362
CAN MED ASSOC J 1990; 142 (12)
four times more often than girls (probably because girls "get into" their feelings better) and that approximately 50% of depressed teenagers become substance abusers.' I consider it significant that Anthony Burgess's tale of violent "anomie",9 crafted three decades ago,'0 is now a sold-out play (A Clockwork Orange 2004) in London, England, the reason being manizing modern society is doing that real life is now as bad as, if to our teenagers. More than 25 not worse than, the play. years ago both men forecast an escalating suicide rate among US Ray Holland, MD, FRCPC 458 teenagers because of this sense of Box 80 Fraser St. lack of meaning and responsibili- Port Colborne, Ont. ty, but I don't think anyone expected the rate in Canada to ex- References ceed that of the United States. The breakdown of the tradi- 1. Sutherland R: Teen suicide. Med Post 1990; 26 (10): 11 tional family has left many young 2. Seligman MEP: Learned helplessness. people with too much adult-like Annu Rev Med 1972; 23: 407-412 freedom, and the lack of a value 3. Erikson E: Childhood and Society, Norton, New York, 1950 system in the home is aided and abetted by the school systems, 4. Frankl V: Man's Search for Meaning, Bks, New York, 1963 with their lack of standards and 5. Pocket Bettelheim B: Love is Not Enough, the irrelevance of subjects.6 In adFree Pr, New York, 1950 dition, teenagers are worried 6. Radwanski G: Ontario Study of the Relevance of Education and the Issue about their future more than ever of Dropout, Ontario Ministry of Eduas the computer revolution (which cation, Queen's Printer, Toronto, is making the industrial revolu1987 tion look anemic) gallops forward. 7. McLuhan M: Understanding Media, Signet Bks, New York, 1946 As well, teenagers are overin8. Ayd FJ (ed): Underdiagnosis of deformed by the media, which have pression. Int Drug Ther Newsl 1988; transformed the world into the 23(2): 11-12 "'global village" of Marshall 9. Durkheim E: Suicide: a Study of Sociology, Free Pr, New York, 1951 McLuhan.7 10. Burgess A: A Clockwork Orange, NorIf depression (with which suiton, New York/London, 1967 cide is associated) is the most missed medical diagnosis among adults,8 the situation is even worse with regard to teenagers,' in whom depression is more difficult Metronidazole to diagnose (requiring psychologi- and fungating tumours cal testing within the clinical context). I saw more depression in I n "A medical potpourri" (Can Med Assoc J 1990; 142: 866teenagers as a general practitioner than I do now as a psychiatrist; 867) Dr. Patrick J. Taylor 97% of youngsters referred to me comments on the use of methave behaviour problems ("The ronidazole gel to reduce odour squeaky wheel gets the grease"). from fungating neoplastic lesions. In 1978, while a senior regisMeanwhile, where are those with trar at Guy's Hospital, London, depression? Family physicians should re- England, I was presented with a member that boys commit suicide similar problem. At the time, met-
to the identity crisis the province is going through, which in turn will aggravate the identity crisis that teenagers go through.3 Drs. Viktor Frankl4 and Bruno Bettelheim5 were both incarcerated in Nazi concentration camps, and both observed that the guards tried to break down the prisoners' identity and sense of value, meaning and responsibility, which is precisely what the dehu-
ronidazole was still considered the new wonder drug, and by extrapolation I advised oral metronidazole therapy. The effect was dramatic, with a major change in the level of care from family and professionals. However, the inevitable outcome was unchanged. In the intervening years I have from time to time suggested and used the same approach, with variable success. The gel formula-, tion should, if it works at the same rate as the oral or parenteral formulation, continue to provide excellent relief for caregivers and
patients. Maurice T. Dalton, MB, FRCPC Director of clinical bacteriology Victoria General Hospital Halifax, NS
Preventive care and practice funding A ccording to their paper "Do health service organizations [HSOs] and community health centres have higher disease prevention and health promotion levels than fee-for-service practices?" (Can Med Assoc J 1990; 142: 575-581) Julia Abelson and Jonathan Lomas were unable to demonstrate much difference in the approach to disease prevention in differently funded types of practice in Ontario. Although it is assumed that there are differences in the philosophy of care between HSOs and fee-for-service practices there is no mandate for this in the contract with the Ontario Ministry of Health. Since physicians are exposed to much the same training before entering any particular practice setting it is probably not surprising that they offer much the same service to patients. Some of the preventive approaches studied by Abelson and Lomas are billable under the fee-for-service system, so that an incentive is
provided, and it would not be surprising if physicians working under other funding arrangements were less inclined to use approaches of questionable efficacy. Abelson and Lomas fail to give sufficient emphasis to the approach to prevention that is distinctive to HSOs and has attracted many physicians to them. With their enrolled population being well defined and identified on a computer database HSOs allow a unique opportunity for a community-based approach to epidemiology. Rather than resulting in routinized disease prevention services, capitation funding in Ontario provides a strong incentive to move toward the "anticipatory care" advocated by Tudor Hart.' Robert Frankford, MD 166 Main St. Toronto, Ont.
Reference 1. Tudor Hart J: A New Kind of Doctor, Merlin, London, 1988
"Health care security"? Not in Alberta either
temporarily elected politicians but those that will show the true state of affairs in the health care system. Amirali Nanji, MD 240 Adolphus St. Cornwall, Ont.
Abbs. in Js I enjoyed Dr. William G. Green's witty letter (Can Med Assoc J 1990; 142: 287, 290). For those of us who love literature but must write articles in the language of science, I offer a semilimerick that addresses the problem. Since ancient times we've loved the language flow: Words upon words, newly fashioned aeons ago. Wond'rous words, whate'er the source, Spring with meaning clear, to course Along, a fresh and warming glow. In any accent, clipped or brogue, Peasant, philosopher, judge or rogue, For objects material Use words ethereal, Archaic words or words in vogue.
However,
I read Dr. Brian A. Shamess's letter about the waiting lists for cardiac surgery in Ontario (Can Med Assoc J 1990; 142: 798) with great interest. If Dr. Ronald Gregg, president of the Alberta Medical Association, is trying to mislead the Americans he should look in his own backyard. My father, who lives in Edmonton, had three-vessel coronary artery disease; all three vessels were more than 80% stenosed. He was told that the minimum wait for coronary artery bypass surgery in Edmonton was 1 year and in Calgary 6 months. He elected to go to Calgary, where he waited 8 months. Please, Dr. Gregg, present the facts -not those that please the
The tongue to science is brevity, we opine, And turgid pleonasm we eradicate or redefine. Reviewers we entice By showing we're precise, With acronyms filtered out, as anodyne. We cut "in close proximity" to "near", Change "females" to "women" to make it clear. We avoid review decision By writing with precision In language succinct, spartan and sincere. Frank I. Jackson, MB, ChB Cross Cancer Institute Edmonton, Alta. CAN MED ASSOC .J 1990; 142 (12)
1363
