prove the image of nursing. Articles identifying the positive aspects of the profession should begin to appear in nursing and other health care journals. Nurses should independently identify the aspects of nursing they like and begin to value themselves as members of an intellectually, emotionally and physically demanding profession. They must voice their concerns directly, assertively and in a business-like fashion so that they will be heard. Nurses must begin to support nurses and nursing. Articles such as Cohen's in a medical journal do not improve the image of nursing in the eyes of physicians. Leanne P. Poirier, RN 216-1615 Belmont Ave. Victoria, BC
Medical journals and the 6 o'clock news ecently it was announced tthat the Journal of the American Medical Association would be released 2 days earlier (on Wednesdays) than had been the practice for many years (Winnipeg Free Press, Feb. 27, 1990: 35). The editor offered a rationale, which appeared to be that this move would allow the journal to "scoop" the New England Journal of Medicine, which publishes on Thursdays. R
Unfortunately, one must expect that the less admirable machinations of the free enterprise system will rear their heads from time to time, even in society's most respected profession. Nevertheless, it ought to be recognized, despite the headlong rush for media attention (and presumably research funds, a laudable goal), that there are many physicians, including me, who find media posturing about important studies and discoveries before scientific discussion not only distasteful but tacky. 922
CAN MED ASSOC J 1990; 142 (9)
More important, one wonders if researchers know how we "grunts" in the trenches feel when we have to get the information, which dozens if not hundreds of people immediately call us about, from the 6 o'clock news. The journals won't arrive for another several days, and by then the "news" is stale. Having to say "Well, I haven't actually seen the article" leaves one feeling rather silly. The situation has descended to the level that I now require all my residents to become "news junkies", so that when some happy panel of researchers holds its news conference on a Wednesday evening, at least we will have some idea of what to say to local media and citizens on Thursday. A "new" cure for AIDS? Great! But guess who is going to have to interpret the findings to desperate people? We who await our journals. If a publisher feels an article worthy of widespread media attention, both our duty as physicians and common courtesy dictate that affected practitioners be advised first. Happily, this is not a problem that has afflicted Canadian journals. It is definitely one practice of other countries that ought not to be imported. Douglas G. Luckhurst, MD Deputy medical health officer Citv of Winnipeg Health Department Winnipeg, Man.
Patient choice and medical treatment I commend Drs. Jeffrey A. Nisker and Ronald J. Benzie for their courage in pointing out the poor logic of those who support patient choice regarding the place of childbirth (Can Med Assoc J 1989; 141: 765). In a recent study of factors determining rates of child abuse we found no difference between children
born in hospital and those born at home; the amounts of bonding, mother-infant contact and patient satisfaction were not significantly different. ' To make an informed choice patients need all the facts. They should have at least as much knowledge on the subject as the doctor who is being asked to provide the service. This ridiculous situation highlights the tendency of physicians to try to maintain a demand for their services and patient cooperation by being popular rather than credible. Credibility depends on the provision of good treatment based on both a knowledge of the patient and scientific data rather than on the patient's choice. The difference between responding to a person's desire to be treated as he or she wishes and providing professionally recommended treatment is the difference between being a technician and being a medical professional. Professional responses fall into three wide categories. * Patient choice: If the patient chooses, then the treatment provided is elective, optional. It doesn't require professional judgement but some kind of technical expertise. It is not a medical procedure and should not be funded as such. An example is induced abortion. * Physician recommended: The treatment is provided with the patient's consent, but the doctor makes a strong recommendation. It may be elective but necessary, in which case the doctor may wait for the patient to make up his or her mind. It may be essential and urgent, in which case the doctor may have to accept the patient's being discharged against his or her advice or reluctantly suggest that the patient seek treatment elsewhere. An example is major surgery. * Physician determined: The doctor makes the decision, sometimes with and sometimes without
the patient's consent, but, often there isn't time to inform the patient, as when a life-saving procedure is required but the patient is unconscious, confused or irrational. An example is treatment for toxic psychosis. About 95% of induced abortions are being provided not because of medical indications but because patients so choose. By recommending or performing an abortion only because it is a woman's choice, physicians are demeaning themselves and their profession. If physicians deliver babies or destroy them in utero when and how patients choose, the patient becomes a customer and the physician a salesperson or a mechanic. Philip G. Ney, MD 1958 Fort St. Victoria, BC
Reference 1. Ney PG, Wickett AR: Mental health
and abortion: review and analysis. PsY'chiatr J Univ Ottawa 1989; 14: 506-516
Resuscitation of the terminally ill T | ahe articles and letters on this topic recently published in CMAJ are put into perspective by the case pending in Cincinnati, Ohio, in which an 84-year-old man is suing a hospital for resuscitating him against his specific directives to the contrary (Toronto Star, Mar. 19, 1990: 2). Although the hospital claims that the event and the outcome were "an act of God", it appears that the man's case is very strong legally. More important, he has made a point about the "right to die" in a humane and gentle manner. Medical technology is being misused especially for cardiopulmonary resuscitation in people with terminal illnesses and in frail 924
CAN MED ASSOC J 1990: 142 (9)
aged people requiring institutional care because of multiple complex and debilitating medical problems. The fact that the technology is available should not mean that it is used indiscriminately, which at present seems to be the rule rather than the exception. Michael Gordon, MD, FRCPC Medical director Baycrest Centre for Geriatric Care North York, Ont.
Making hockey safer I have one objection to the recommendations of the Canadian Academy of Sport Medicine (CASM) in their Position Statement on Violence and Injuries in Ice Hockey, as reported by Patrick Sullivan in his timely and excellent article "Sports MDs seek CMA support in bid to make hockey safer" (Can Med Assoc J 1990; 142: 157-159). I do not agree that body checking should be banned at the peewee level (ages 12 and 13) and below. I believe that elite players (such as those on all-star teams), who account for perhaps 15% or 20% of all players, should be
taught body checking techniques from the day they begin to play elite hockey. All other players, those taking part in what I call recreational hockey, should not be allowed to body check from the time they first play hockey through all levels into old-timers" hockey. We know from the statistics so well reported by Dr. Charles Tator and colleagues' that catastrophic hockey injuries occur at an average age of 17 years and an average weight of 77 kg. Waiting to introduce body checking at age 14 or, as Dr. James Sproule, chairman of the CASM's Hockey Safety Committee, suggests, 16 or 17 years is hazardous. Suddenly elite players entering the age bracket in which spinal cord inju-
ries occur are asked to change their style of play. Would it not be wiser for these players to have been taught proper body-checking techniques from the start? I was a dissenter when the body-checking policy was being formulated at the CASM meeting in Banff in March 1989, and I still am. I suggest that the CMA speak to Murray Costello, president of the Canadian Amateur Hockey Association, and John Gardner, president of the Metropolitan Toronto Hockey League, before supporting this one clause in the otherwise excellent CASM proposal. Thomas J. Pashby, MD, CRCSC 215-20 Wynford Dr. Don Mills, Ont.
Reference I.Tator CH, Edmonds VE, Duncan EG et al: Danger upstream: catastrophic sports and recreational injury in Ontario. Ont Med Rev 1988; 55: 7-12
Antibiotic therapy for acute otitis media T n he validity of the study reported by Dr. William Feldman, Ms. Theresa Sutcliffe and Dr. Corinne Dulberg (Can Med Assoc J 1990; 142: 115118) in their article "Twice-daily antibiotics in the treatment of acute otitis media: trimethoprimsulfamethoxazole versus amoxicillin-clavulanate" is questionable since no bacteriologic specimens were taken. It is very difficult to prove the efficacy of antibiotic therapy without culture results. The article is vague as to how the diagnosis of otitis media was made. Also, the reliability of the nurse's examination is questionable since the accuracy of the diagnosis was not measured by, for example, comparing tympanometry or reflectometry results with tympanocentesis results. The 95% rate of agreement be-
Medical journals and the 6 o'clock news ecently it was announced tthat the Journal of the American Medical Association would be released 2 days earlier (on Wednesdays) than had been the practice for many years (Winnipeg Free Press, Feb. 27, 1990: 35). The editor offered a rationale, which appeared to be that this move would allow the journal to "scoop" the New England Journal of Medicine, which publishes on Thursdays. R
Unfortunately, one must expect that the less admirable machinations of the free enterprise system will rear their heads from time to time, even in society's most respected profession. Nevertheless, it ought to be recognized, despite the headlong rush for media attention (and presumably research funds, a laudable goal), that there are many physicians, including me, who find media posturing about important studies and discoveries before scientific discussion not only distasteful but tacky. 922
CAN MED ASSOC J 1990; 142 (9)
More important, one wonders if researchers know how we "grunts" in the trenches feel when we have to get the information, which dozens if not hundreds of people immediately call us about, from the 6 o'clock news. The journals won't arrive for another several days, and by then the "news" is stale. Having to say "Well, I haven't actually seen the article" leaves one feeling rather silly. The situation has descended to the level that I now require all my residents to become "news junkies", so that when some happy panel of researchers holds its news conference on a Wednesday evening, at least we will have some idea of what to say to local media and citizens on Thursday. A "new" cure for AIDS? Great! But guess who is going to have to interpret the findings to desperate people? We who await our journals. If a publisher feels an article worthy of widespread media attention, both our duty as physicians and common courtesy dictate that affected practitioners be advised first. Happily, this is not a problem that has afflicted Canadian journals. It is definitely one practice of other countries that ought not to be imported. Douglas G. Luckhurst, MD Deputy medical health officer Citv of Winnipeg Health Department Winnipeg, Man.
Patient choice and medical treatment I commend Drs. Jeffrey A. Nisker and Ronald J. Benzie for their courage in pointing out the poor logic of those who support patient choice regarding the place of childbirth (Can Med Assoc J 1989; 141: 765). In a recent study of factors determining rates of child abuse we found no difference between children
born in hospital and those born at home; the amounts of bonding, mother-infant contact and patient satisfaction were not significantly different. ' To make an informed choice patients need all the facts. They should have at least as much knowledge on the subject as the doctor who is being asked to provide the service. This ridiculous situation highlights the tendency of physicians to try to maintain a demand for their services and patient cooperation by being popular rather than credible. Credibility depends on the provision of good treatment based on both a knowledge of the patient and scientific data rather than on the patient's choice. The difference between responding to a person's desire to be treated as he or she wishes and providing professionally recommended treatment is the difference between being a technician and being a medical professional. Professional responses fall into three wide categories. * Patient choice: If the patient chooses, then the treatment provided is elective, optional. It doesn't require professional judgement but some kind of technical expertise. It is not a medical procedure and should not be funded as such. An example is induced abortion. * Physician recommended: The treatment is provided with the patient's consent, but the doctor makes a strong recommendation. It may be elective but necessary, in which case the doctor may wait for the patient to make up his or her mind. It may be essential and urgent, in which case the doctor may have to accept the patient's being discharged against his or her advice or reluctantly suggest that the patient seek treatment elsewhere. An example is major surgery. * Physician determined: The doctor makes the decision, sometimes with and sometimes without
the patient's consent, but, often there isn't time to inform the patient, as when a life-saving procedure is required but the patient is unconscious, confused or irrational. An example is treatment for toxic psychosis. About 95% of induced abortions are being provided not because of medical indications but because patients so choose. By recommending or performing an abortion only because it is a woman's choice, physicians are demeaning themselves and their profession. If physicians deliver babies or destroy them in utero when and how patients choose, the patient becomes a customer and the physician a salesperson or a mechanic. Philip G. Ney, MD 1958 Fort St. Victoria, BC
Reference 1. Ney PG, Wickett AR: Mental health
and abortion: review and analysis. PsY'chiatr J Univ Ottawa 1989; 14: 506-516
Resuscitation of the terminally ill T | ahe articles and letters on this topic recently published in CMAJ are put into perspective by the case pending in Cincinnati, Ohio, in which an 84-year-old man is suing a hospital for resuscitating him against his specific directives to the contrary (Toronto Star, Mar. 19, 1990: 2). Although the hospital claims that the event and the outcome were "an act of God", it appears that the man's case is very strong legally. More important, he has made a point about the "right to die" in a humane and gentle manner. Medical technology is being misused especially for cardiopulmonary resuscitation in people with terminal illnesses and in frail 924
CAN MED ASSOC J 1990: 142 (9)
aged people requiring institutional care because of multiple complex and debilitating medical problems. The fact that the technology is available should not mean that it is used indiscriminately, which at present seems to be the rule rather than the exception. Michael Gordon, MD, FRCPC Medical director Baycrest Centre for Geriatric Care North York, Ont.
Making hockey safer I have one objection to the recommendations of the Canadian Academy of Sport Medicine (CASM) in their Position Statement on Violence and Injuries in Ice Hockey, as reported by Patrick Sullivan in his timely and excellent article "Sports MDs seek CMA support in bid to make hockey safer" (Can Med Assoc J 1990; 142: 157-159). I do not agree that body checking should be banned at the peewee level (ages 12 and 13) and below. I believe that elite players (such as those on all-star teams), who account for perhaps 15% or 20% of all players, should be
taught body checking techniques from the day they begin to play elite hockey. All other players, those taking part in what I call recreational hockey, should not be allowed to body check from the time they first play hockey through all levels into old-timers" hockey. We know from the statistics so well reported by Dr. Charles Tator and colleagues' that catastrophic hockey injuries occur at an average age of 17 years and an average weight of 77 kg. Waiting to introduce body checking at age 14 or, as Dr. James Sproule, chairman of the CASM's Hockey Safety Committee, suggests, 16 or 17 years is hazardous. Suddenly elite players entering the age bracket in which spinal cord inju-
ries occur are asked to change their style of play. Would it not be wiser for these players to have been taught proper body-checking techniques from the start? I was a dissenter when the body-checking policy was being formulated at the CASM meeting in Banff in March 1989, and I still am. I suggest that the CMA speak to Murray Costello, president of the Canadian Amateur Hockey Association, and John Gardner, president of the Metropolitan Toronto Hockey League, before supporting this one clause in the otherwise excellent CASM proposal. Thomas J. Pashby, MD, CRCSC 215-20 Wynford Dr. Don Mills, Ont.
Reference I.Tator CH, Edmonds VE, Duncan EG et al: Danger upstream: catastrophic sports and recreational injury in Ontario. Ont Med Rev 1988; 55: 7-12
Antibiotic therapy for acute otitis media T n he validity of the study reported by Dr. William Feldman, Ms. Theresa Sutcliffe and Dr. Corinne Dulberg (Can Med Assoc J 1990; 142: 115118) in their article "Twice-daily antibiotics in the treatment of acute otitis media: trimethoprimsulfamethoxazole versus amoxicillin-clavulanate" is questionable since no bacteriologic specimens were taken. It is very difficult to prove the efficacy of antibiotic therapy without culture results. The article is vague as to how the diagnosis of otitis media was made. Also, the reliability of the nurse's examination is questionable since the accuracy of the diagnosis was not measured by, for example, comparing tympanometry or reflectometry results with tympanocentesis results. The 95% rate of agreement be-
