LETTERS * CORRESPONDANCE
We will consider for publication only letters submitted in duplicate, printed in letterquality type without proportional spacing and not exceeding 450 words. All the authors must sign a covering letter transferring copyright. Letters must not duplicate material being submitted elsewhere or already published. We routinely correspond only with authors of accepted letters. Rejected letters are destroyed. Accepted letters are subject to editing and abridgement. Seules peuvent etre retenues pour publications les lettres recues en double dont la longueur n'excede pas 450 mots. Elles doivent etre mecanographiees en qualite "correspondance" sans espacement proportionnel. Tous les auteurs doivent signer une lettre d'accompagnement portant cession du copyright. Les lettres ne doivent rien contenir qui ait ete presente ailleurs pour publication ou deja paru. En principe, la redaction correspond uniquement avec les auteurs des lettres retenues pour publication. Les lettres refusees sont detruites. Les lettres retenues peuvent etre abregies ou faire l'objet de modifications d'ordre redactionnel.
Screening for cancer of the cervix T n he report of the National Workshop on Screening for Cancer of the Cervix, which appears as a special supplement to this issue of CMAJ, presents a series of recommendations that revise and update those of the 1982 and 1976 task force. The workshop was attended by many
stakeholders, including consumers and providers. The recommendations are based on the need for laboratory services of high quality and an information management system that allows compliance and the frequency of screening to be monitored. The undersigned societies, as significant providers of health care to women, have reviewed the -
For prescribing information see page 1384
report and collaboratively prepared this response. The development of formal screening programs in Canada is appropriate to reduce the incidence and rate of death from cancer of the cervix and is strongly supported as a primary goal. It is essential that the recommendations of the workshop be considered as a whole and not be implemented in part until such comprehensive programs exist within each province. This is clearly stated as the primary recommendation of the report; since it is the basis on which the other recommendations are made the importance of this first step cannot be overstated. The screening interval of every 3 years after satisfactory results from two Papanicolaou smears was selected after a detailed analysis of the available data; it can only be justified if a mechanism is in place to ensure strict patient compliance and optimal laboratory services. However, there is still a concern that this prolonged window may allo'v a slight increase in the cumulative risk of more aggressive malignant disease developing in individual
patients.
rather than colposcopic examination. The recommendations of the national workshop are supported as a whole. National and provincial health care agencies should be strongly encouraged to review the report and ensure that they have high-quality laboratory services and patient information systems. Until such facilities are in place routine screening at annual intervals should be a continued standard of practice in all women who have been sexually active. Gavin C.E. Stuart, MD Chair, Oncology Committee Society of Obstetricians and Gynaecologists of Canada Greg O'Connell, MD Secretary-treasurer Gynaecologic Oncologists of Canada Alex Ferenczy, MD President Society of Canadian Colposcopists
Physical inactivity among physicians I t is not at all surprising that Paul H. Gaertner and Drs. Whitmer B. Firor and Lindsay Edouard (Can Med Assoc J 1991; 144: 1253-1256) found physicians to be less physically active than the general population, despite their awareness of the importance of exercise. The authors hypothesized that the high demands and time constraints placed on medical students contribute to their inability to take part in recreational activities. I suggest that the lack of encouragement for pursuing physical fitness during medical training also contributes to physician
The practice of recommending repeat smear tests without colposcopy for patients showing lowgrade squamous intraepithelial lesions (the first grade of cervical intraepithelial neoplasia [CIN I]) is subject to question, since there are conflicting data about the natural history of this abnormality and the risk of progression to invasive carcinoma. Also of concern are the anxieties that this approach engenders among patients and the uncertain economic inactivity. Students at McMaster Uniimpact of repeat cytologic tests CAN MED ASSOC J 1991; 145 (10)
1195
versity, Hamilton, Ont., are fortunate that peer evaluation is a major component of the evaluation process. Students are encouraged by their colleagues to keep their interests and activities varied and balanced. However, such pursuits become more difficult as the clinical component of the educational experience increases. Would it be unreasonable to replace or combine educational teaching sessions with physical activities? I do not believe that the educational experience would be jeopardized by replacing events such as "drug lunches" with opportunities to engage in physical fitness pursuits. In the long run doctors would not only be healthier but also be more credible role models for their patients. As long as medical programs do not recognize the importance of the physical well-being of their students, the physical inactivity of many physicians will continue. Marianne Talman, MSc Clinical clerk McMaster University Hamilton, Ont.
One possible explanation for the lesser physical activity of physicians versus the general population could be related to interpretation of the literature. It is well documented that physical activity reduces blood pressure and the levels of cholesterol and glucose. Such activity also imparts a sense of well-being. However, I am unaware of any single documentation in the literature that physical activity in itself, without consideration of its effects on other risk factors, has clear-cut beneficial primary preventive effects in terms of cardiovascular disease. In other words, if the blood pressure and the levels of cholesterol and glucose are good, what additional effect would physical activity have? Or, if these values are elevated, what effect would physical activity have other than lowering them? Can I 1196
CAN MED ASSOC J 1991; 145 (10)
not control my risk factors equally well, with less time involvement, by means other than physical activity? I still believe that the literature puts the onus on those physicians or scientists who advocate physical activity for the sake of reducing these risk factors to show, through at least one wellcontrolled, prospective study in which blood pressure and levels of cholesterol and glucose have been equalized, that physical activity is of benefit in reducing the risk of cardiovascular disease. Thomas Baitz, MD, FRCPC 1 13-820 McConnell Ave. Cornwall, Ont.
[The authors respond.] We thank Ms. Talman for her observations and the additional insights they offer. We agree wholeheartedly with all that she says, including the notion that providing opportunities for physical activity in medical students' schedules would be worth while. Dr. Baitz raises a number of interesting points, but we are puzzled that he has chosen to focus upon the prevention of coronary heart disease, since this was not the topic of our article. He is correct that physical activity exerts its beneficial effects on health through a variety of metabolic, hemodynamic and physiologic effects, a few of which he has mentioned. We are not aware of any other single intervention with such a wide variety of favourable health influences. Baitz seems to believe that relying upon good genes and good luck for these effects is sufficient. We do not agree that this is a sound strategy for achieving physiologic hygiene. The purpose of our study was to examine the matter of physicians as role models for their patients. We view physical activity as a form of preventive mainte-
nance, a positive step toward the promotion and maintenance of health. The long-term physiologic benefits of exercise can be achieved and maintained with only a modest input of time. Baitz seems to believe the time input to be excessive and would prefer a quicker fix. We believe that the physician who encourages patients to spend as little time as possible at health promotion, either by word or by example, serves them ill. Paul H. Gaertner, MD Intern St. Paul's Hospital Whitmer B. Firor, MD Department of Medicine Lindsay Edouard, MB, MFCM Department of Community Health and Epidemiology University of Saskatchewan Saskatoon, Sask.
HIV infection among Quebec women giving birth to live infants I apologize to Dr. Catherine A. Hankins for suggesting in my
earlier letter (Can Med Assoc J 1991; 145: 198-199) no prior knowledge of the study by Blanche and associates and the HIV [human immunodeficiency virus] Infection in Newborns French Collaborative Study Group. ' I caution her, however, regarding the use of absolute or universal statements.
In her reply (ibid: 199) Hankins suggests that I had not read the discussion in that report. I most certainly did read it. The authors considered the relation of breast-feeding to HIV infection important enough to include it in the abstract of their paper. Indeed, in their discussion they state: "Despite the small number of infants observed this difference is significant and tends to suggest that breast feeding may have a role in the transmission of the virus from mother to infant." The LE 15 NOVEMBRE 1991
We will consider for publication only letters submitted in duplicate, printed in letterquality type without proportional spacing and not exceeding 450 words. All the authors must sign a covering letter transferring copyright. Letters must not duplicate material being submitted elsewhere or already published. We routinely correspond only with authors of accepted letters. Rejected letters are destroyed. Accepted letters are subject to editing and abridgement. Seules peuvent etre retenues pour publications les lettres recues en double dont la longueur n'excede pas 450 mots. Elles doivent etre mecanographiees en qualite "correspondance" sans espacement proportionnel. Tous les auteurs doivent signer une lettre d'accompagnement portant cession du copyright. Les lettres ne doivent rien contenir qui ait ete presente ailleurs pour publication ou deja paru. En principe, la redaction correspond uniquement avec les auteurs des lettres retenues pour publication. Les lettres refusees sont detruites. Les lettres retenues peuvent etre abregies ou faire l'objet de modifications d'ordre redactionnel.
Screening for cancer of the cervix T n he report of the National Workshop on Screening for Cancer of the Cervix, which appears as a special supplement to this issue of CMAJ, presents a series of recommendations that revise and update those of the 1982 and 1976 task force. The workshop was attended by many
stakeholders, including consumers and providers. The recommendations are based on the need for laboratory services of high quality and an information management system that allows compliance and the frequency of screening to be monitored. The undersigned societies, as significant providers of health care to women, have reviewed the -
For prescribing information see page 1384
report and collaboratively prepared this response. The development of formal screening programs in Canada is appropriate to reduce the incidence and rate of death from cancer of the cervix and is strongly supported as a primary goal. It is essential that the recommendations of the workshop be considered as a whole and not be implemented in part until such comprehensive programs exist within each province. This is clearly stated as the primary recommendation of the report; since it is the basis on which the other recommendations are made the importance of this first step cannot be overstated. The screening interval of every 3 years after satisfactory results from two Papanicolaou smears was selected after a detailed analysis of the available data; it can only be justified if a mechanism is in place to ensure strict patient compliance and optimal laboratory services. However, there is still a concern that this prolonged window may allo'v a slight increase in the cumulative risk of more aggressive malignant disease developing in individual
patients.
rather than colposcopic examination. The recommendations of the national workshop are supported as a whole. National and provincial health care agencies should be strongly encouraged to review the report and ensure that they have high-quality laboratory services and patient information systems. Until such facilities are in place routine screening at annual intervals should be a continued standard of practice in all women who have been sexually active. Gavin C.E. Stuart, MD Chair, Oncology Committee Society of Obstetricians and Gynaecologists of Canada Greg O'Connell, MD Secretary-treasurer Gynaecologic Oncologists of Canada Alex Ferenczy, MD President Society of Canadian Colposcopists
Physical inactivity among physicians I t is not at all surprising that Paul H. Gaertner and Drs. Whitmer B. Firor and Lindsay Edouard (Can Med Assoc J 1991; 144: 1253-1256) found physicians to be less physically active than the general population, despite their awareness of the importance of exercise. The authors hypothesized that the high demands and time constraints placed on medical students contribute to their inability to take part in recreational activities. I suggest that the lack of encouragement for pursuing physical fitness during medical training also contributes to physician
The practice of recommending repeat smear tests without colposcopy for patients showing lowgrade squamous intraepithelial lesions (the first grade of cervical intraepithelial neoplasia [CIN I]) is subject to question, since there are conflicting data about the natural history of this abnormality and the risk of progression to invasive carcinoma. Also of concern are the anxieties that this approach engenders among patients and the uncertain economic inactivity. Students at McMaster Uniimpact of repeat cytologic tests CAN MED ASSOC J 1991; 145 (10)
1195
versity, Hamilton, Ont., are fortunate that peer evaluation is a major component of the evaluation process. Students are encouraged by their colleagues to keep their interests and activities varied and balanced. However, such pursuits become more difficult as the clinical component of the educational experience increases. Would it be unreasonable to replace or combine educational teaching sessions with physical activities? I do not believe that the educational experience would be jeopardized by replacing events such as "drug lunches" with opportunities to engage in physical fitness pursuits. In the long run doctors would not only be healthier but also be more credible role models for their patients. As long as medical programs do not recognize the importance of the physical well-being of their students, the physical inactivity of many physicians will continue. Marianne Talman, MSc Clinical clerk McMaster University Hamilton, Ont.
One possible explanation for the lesser physical activity of physicians versus the general population could be related to interpretation of the literature. It is well documented that physical activity reduces blood pressure and the levels of cholesterol and glucose. Such activity also imparts a sense of well-being. However, I am unaware of any single documentation in the literature that physical activity in itself, without consideration of its effects on other risk factors, has clear-cut beneficial primary preventive effects in terms of cardiovascular disease. In other words, if the blood pressure and the levels of cholesterol and glucose are good, what additional effect would physical activity have? Or, if these values are elevated, what effect would physical activity have other than lowering them? Can I 1196
CAN MED ASSOC J 1991; 145 (10)
not control my risk factors equally well, with less time involvement, by means other than physical activity? I still believe that the literature puts the onus on those physicians or scientists who advocate physical activity for the sake of reducing these risk factors to show, through at least one wellcontrolled, prospective study in which blood pressure and levels of cholesterol and glucose have been equalized, that physical activity is of benefit in reducing the risk of cardiovascular disease. Thomas Baitz, MD, FRCPC 1 13-820 McConnell Ave. Cornwall, Ont.
[The authors respond.] We thank Ms. Talman for her observations and the additional insights they offer. We agree wholeheartedly with all that she says, including the notion that providing opportunities for physical activity in medical students' schedules would be worth while. Dr. Baitz raises a number of interesting points, but we are puzzled that he has chosen to focus upon the prevention of coronary heart disease, since this was not the topic of our article. He is correct that physical activity exerts its beneficial effects on health through a variety of metabolic, hemodynamic and physiologic effects, a few of which he has mentioned. We are not aware of any other single intervention with such a wide variety of favourable health influences. Baitz seems to believe that relying upon good genes and good luck for these effects is sufficient. We do not agree that this is a sound strategy for achieving physiologic hygiene. The purpose of our study was to examine the matter of physicians as role models for their patients. We view physical activity as a form of preventive mainte-
nance, a positive step toward the promotion and maintenance of health. The long-term physiologic benefits of exercise can be achieved and maintained with only a modest input of time. Baitz seems to believe the time input to be excessive and would prefer a quicker fix. We believe that the physician who encourages patients to spend as little time as possible at health promotion, either by word or by example, serves them ill. Paul H. Gaertner, MD Intern St. Paul's Hospital Whitmer B. Firor, MD Department of Medicine Lindsay Edouard, MB, MFCM Department of Community Health and Epidemiology University of Saskatchewan Saskatoon, Sask.
HIV infection among Quebec women giving birth to live infants I apologize to Dr. Catherine A. Hankins for suggesting in my
earlier letter (Can Med Assoc J 1991; 145: 198-199) no prior knowledge of the study by Blanche and associates and the HIV [human immunodeficiency virus] Infection in Newborns French Collaborative Study Group. ' I caution her, however, regarding the use of absolute or universal statements.
In her reply (ibid: 199) Hankins suggests that I had not read the discussion in that report. I most certainly did read it. The authors considered the relation of breast-feeding to HIV infection important enough to include it in the abstract of their paper. Indeed, in their discussion they state: "Despite the small number of infants observed this difference is significant and tends to suggest that breast feeding may have a role in the transmission of the virus from mother to infant." The LE 15 NOVEMBRE 1991
