full-time emergency physicians in our hospital. Dr. Collyer found a high prevalence of emotional illness in his practice and I believe a similar figure would be found in practices in this community. However, in spite of this, I believe that the tendency to put undue emphasis on psychotherapy, family therapy and group counselling in family practice training programs is regrettable because there is a danger of organic illnesses receiving insufficient attention. To the family physician the importance of both organic and emotional illnesses must be stressed. I hope Dr. Collyer's remarks concerning remuneration for the procedure-oriented physician as opposed to the total-care physician are taken seriously. A restructuring of the philosophy of payment in family medicine is overdue. D.P.C. O'CONNOR, MB
180 Ross St. St. Thomas, ON
To the editor: Dr. O'Connor is not alone in his concern about the possibility of emotional illnesses being overemphasized in the training of family physicians. It is my belief, however, that family physicians as a group should study the kind of work they do and provide training programs accordingly. Studies indicate that the psychological component in family practice is of major importance and I believe that training programs should reflect this. I hope that fee schedules will come to reflect this also. Of all branches of medicine, I believe family medicine is the one in which the physician should concentrate on the person who is ill and try to evaluate all the processes that are functioning abnormally. With this in mind it becomes irrelevant to consider one aspect of the person as more important than another. The importance lies in returning the patient to a state of health. JAMES A. COLLYER, MD
310 Piccadilly St. London, ON
Selection of medical students To the editor: In his article "How one Canadian medical school seeks those who will practise art and science" (Can Med Assoc J 113: 230, 1975) Dr. J.D. Wallace wonders "whether those young people with a genius intelligence rating" would be sufficiently challenged to enjoy a career in primary care. He decides that they would probably not. Hence, it is reasoned, other factors in addition to academic achievement should be assessed when considering applications for medical school admission. No argument here. I am con-
cerned, however, about what appears to be a major theme underlying Dr. Wallace's support of McMaster's admission procedures - that the field of primary care is likely to be unchallenging to the intellectually or academically gifted student. I feel strongly that the reasoning behind current alterations in medical school admission policies may be highly fallacious. There seems to be a widespread belief, shared by many medical educators, government officials and apparently Dr. Wallace, that one must be less academically qualified to be happy and challenged as a primary care physician. Coincident with this view is the assumption that the quality of "people-orientation.. varies inversely with academic qualifications or intelligence ratings or both. Many medical educators tend to react with dismay when top students opt for careers in primary care, in the belief that such students are misguided and wasting their talents. The reason for this reaction is that primary care (general practice, family medicine) is seen by many to be unchallenging, unrewarding and basically simple - in short, the end of the medical line, a medical dumping ground, as it were. It is apparent, however, that careers in primary care are becoming increasingly appealing to students with high academic standing. Contrary to Dr. Wallace's doubts, such students seem challenged by the many unanswered questions and unexplored areas in what they perceive to be a demanding, interesting and potentially satisfying life work. Another implication in Dr. Wallace's viewpoint is that academically gifted students may not be as people-oriented and community-minded as students of lesser academic ability - a concept which, to my knowledge, has never been validated. My experience with undergraduate and postgraduate students over the past 4 years would not support this assumption. The fortunate combination of high academic ability and people-orientation produces an excellent primary care physician. In my view, it seems a tenuous proposition to set up arbitrary criteria whereby a student with unquestioned academic qualification might be denied admission to medical school because an admission board supposed he or she appeared to lack a degree of compassion or empathy for people, as judged by interviews, reference letters or autobiographic sketches. I believe that such methods of assessment should be used with extreme caution and primarily to screen out blatantly unsuitable applicants, providing valid criteria can be agreed upon.
712 CMA JOURNAL/OCTOBER 18, 1975/VOL. 113
COMPOSITION: Each uncoated, scored, light tan tablet contains spironolactone, 25 mg. Aldactone offers an entirely new approach to the treatment of essential hypertension, edema and ascites, including resistant states. Aldactone specifically blocks the effects on the kidneys of mineralocorticoids and antagonizes the sodium retaining and water retaining effects of aldosterone which is important in the production of edema. INDICATIONS: Aldactone is indicated in the treatment of edema and ascites of congestive heart failure, hepatic cirrhosis, the nephrotic syndrome, and idiopathic edema as well as that due to malignant effusions especially if not responding well to conventional diuretics. Aldactone is also indicated for lowering blood pressure in essential hypertension, correcting hypokalemic alkalosis in severe hypertension and in the treatment of myasthenia gravis. DOSAGE: Edema-the initial recommended adult dose is one 25 mg tablet four times daily. Rarely a patient may require up to 300 mg per day and others as little as 75 mg per day. If adequate diuresis with Aldactone is not obtained within five days, Aldactizide should be substituted in its usual dosage to obtain the synergistic effect of the spironolactone and the thiazide components. In an occasional patient with severe, resistant edema, it may be necessary to add a glucocorticoid to this combined therapy. In children a dosage providing 1.5 mg of Aldactone per pound of body weight should be employed. Essential hypertension-One tablet four times a day, treatment should be continued at least two weeks. PRECAUTIONS: Other than acute renal insufficiency there are no known contraindications to Aldactone. It should be used judiciously in patients with hyponatremia or hyperkalemia. SIDE EFFECTS: Side effects are mild and infrequent; drowsiness, mental confusion and maculopapular or erythematous eruptions have occurred rarely, subsiding within forty-eight hours on discontinuation of the drug. Gynecomastia and mild androgenic manifestations have also been reported in a few patients. TOXICITY: No reports of fatal overdosage in man. No adverse effects from high dosage in chronic animal studies. Symptoms of Overdosage-True toxicity has not been reported; drowsiness, mental confusion or a maculopapular or erythematous rash has occurred rarely. These manifestations disappear promptly on discontinuance of medication. Hyperkalemia may be exacerbated. Treatment-No specific antidote. No true toxicity has occurred or is expected. Appearance of effects described above require only discontinuance of the drug. For hyperkalemia, reduce potassium intake, administer potassiu m-excreting diuretics, intravenous glucose with regular insulin or oral ion exchange resins. SUPPLY: Bottles of 100, 1,000 and 2,500 tablets. Complete prescribing information available on request.
AIdactone. (S.RONOLACTONE)
the only specific, competitive aldosterone antagonist for gradual, sustained diuresis with minimal possibility of potassium loss.. .especially indicated for the digitalized patient. Sea,le Pharmaceuticals Oakville, Ontario
I think a great deal of caution should be exercised in assessing the need for radical alterations in medical school admission policies, and that boldly innovative policies such as McMaster's should be regarded as experimental and unproved. If changes are to be made that de-emphasize academic achievement, let them be made for reasons other than the hopeful hunch that more and better primary care physicians will somehow result. It is entirely likely that many, if not most, students admitted with lesser academic qualifications may choose to become specialists in any number of fields. What is needed more than major alterations in medical school admission policies is a change in the thinking processes of all concerned, which would be reflected in the enthusiastic promotion and endorsement of careers in primary care to all students, including the most gifted, most of whom seem to be people-oriented as well as of high academic standing. Primary care is downgraded and made less appealing when it is suggested or implied that students of high academic standing may find the field unrewarding and unchallenging. JOHN BIEHN, MD
Director,
Centre London, ON
To the editor: As one who has contributed to the admission procedures of the University of Saskatchewan over the past 5 years, I would like to say in response to Dr. Wallace's article that we in the West are at least as progressive as any school in the East, if not more so. All applicants to the college of medicine are interviewed, not just those with the highest grades. For 5 years a medical student has been sitting on the interviewing panels, and two medical students are members of the admission committee. For 3 years members of the community have also taken part in interviewing, and there have been on the admission committee two community representatives, who play a large part in the selection of the community members of the interviewing panels; the members are truly representative of the community and are not medical or paramedical personnel. Each interviewing panel consists of four members, representing five points of view: a medical student, a physician, a faculty member and a member of the community; one of the four is a woman. We believe, therefore, that at least one other medical school is well advanced in its selection procedure and is finding, presumably like McMaster, that the procedure is working very sa-
tisfactorily for all concerned - the applicant, the currently enrolled medical student, the faculty and the community. L.J. CLEIN, MB, FRC5[C]
Head, department of neurosurgery University of Saskatchewan Saskatoon, 5K
Comparison of earnings To the editor: From my experiences as British Medical Association representative, and in general and later specialist practice in the United Kingdom's National Health Service up to 1971 when I came to Canada, I am prompted to comment on Dr. Bloomfield's letter "Fee schedules and workloads" (Can Med Assoc 1 112: 1290, 1975). I believe Dr. Bloomfield's penultimate paragraph to be the most important, and I would like to embellish it with data from the United States reported by Wamsley in the May 12, 1975 issue of Medical Economics (pages 78-9). The figures are comparable to those released in Canada last year, although they may now be out of date in view of some of the recent increases for such items as union plumbing work. I have set out the data a little differently to facilitate comparison with the figures in my additional columns, calculated from the data in the original report. The final column is fundamental because, owing to progressive taxation, as the gross pay increases it bears an increasingly distant relation to real, usable pay. The data reveal that the average general practitioner in the United States is paid at a smaller after-tax hourly rate than a crane driver, and his rate is even further below those of the other professional groups represented. I am not suggesting that the job of crane driving is necessarily worth any less per hour than practising medicine. However, the figures clearly and totally refute the notion that physicians are overpaid. The figures simply indicate that, as a group, physicians work harder than most others. It may be difficult
for some to understand the reason for this but I suspect that at least some of the willingness to work hard results from the desire to benefit the patient even at one's inconvenience, and is not prompted merely by the wish to improve one's own lifestyle. Even if it were the latter, is it better for society that one does it for one's self or that the state does it for you? Some readers may find these statistics arresting, but there is worse to come. To illustrate this I would like to take further Dr. Bloomfield's idea of lifetime earnings. It is sometimes forgotten that the crane driver is earning to capacity many years before the physician. If the cumulative earnings of the two are graphed from the time the skilled labourer begins earning, say at 18 years of age, and the deficit of cost of medical training is included in the physician's lifetime earnings, then, based upon a constant dollar in a noninflationary economy, the total lifetime earnings of the two do not become equal until approximately the age of 45 years. Unless the physician persistently works much harder than the skilled artisan the lifetime earnings of the former will never approach those of the latter. In an inflationary economy the point of equality rapidly approaches infinity and can only be brought forward in time by relatively massive differentials in after-tax pay. Furthermore, by the age of 45 the higher death rate among physicians has begun to take its toll, so that a proportion of medical practitioners die without ever having achieved equality of lifetime earnings. Such circumstances of employment, if sustained in medicine, would seem likely to attract into the profession an increasing number of people with unduly prominent characteristics of masochism or irresponsible idealism. Is this really what the profession and the public want or need? THOMAS J. MUCKLE, MD, FRCP[C]
Department of pathology McMaster University Medical Centre Hamilton, ON
Table I-Comparison of earnings derived from different types of work in the United States in 1974
$ per annum Weeks* Hours of work after expenses $ per hour worked per Per Per Before After Before After annum week annum* taxt tax* tax tax* Lawyer 49 40 1960 30000 18200 15.30 9.6 Crane driver 50 37 1850 25 000 15700 13.44 8.5 Army major general 48 55 2640 37 000 21 600 13.98 8.2 Chief executive 48 58 2800 48 000 26700 17.24 9.5 Preclinical professor 39 55 2150 32000 19200 15.15 8.9 Practising MD 48 60 2876 39 000 22 600 13.58 7.9 *Calculated from original 1975 data of Wamsley. .Figures are rounded to the second digit. .Figures derived by applying 1974 rates for Ontario residents, without personal deductions. 716 CMA JOURNAL/O.2TOBER 18, 1975/VOL. 113
180 Ross St. St. Thomas, ON
To the editor: Dr. O'Connor is not alone in his concern about the possibility of emotional illnesses being overemphasized in the training of family physicians. It is my belief, however, that family physicians as a group should study the kind of work they do and provide training programs accordingly. Studies indicate that the psychological component in family practice is of major importance and I believe that training programs should reflect this. I hope that fee schedules will come to reflect this also. Of all branches of medicine, I believe family medicine is the one in which the physician should concentrate on the person who is ill and try to evaluate all the processes that are functioning abnormally. With this in mind it becomes irrelevant to consider one aspect of the person as more important than another. The importance lies in returning the patient to a state of health. JAMES A. COLLYER, MD
310 Piccadilly St. London, ON
Selection of medical students To the editor: In his article "How one Canadian medical school seeks those who will practise art and science" (Can Med Assoc J 113: 230, 1975) Dr. J.D. Wallace wonders "whether those young people with a genius intelligence rating" would be sufficiently challenged to enjoy a career in primary care. He decides that they would probably not. Hence, it is reasoned, other factors in addition to academic achievement should be assessed when considering applications for medical school admission. No argument here. I am con-
cerned, however, about what appears to be a major theme underlying Dr. Wallace's support of McMaster's admission procedures - that the field of primary care is likely to be unchallenging to the intellectually or academically gifted student. I feel strongly that the reasoning behind current alterations in medical school admission policies may be highly fallacious. There seems to be a widespread belief, shared by many medical educators, government officials and apparently Dr. Wallace, that one must be less academically qualified to be happy and challenged as a primary care physician. Coincident with this view is the assumption that the quality of "people-orientation.. varies inversely with academic qualifications or intelligence ratings or both. Many medical educators tend to react with dismay when top students opt for careers in primary care, in the belief that such students are misguided and wasting their talents. The reason for this reaction is that primary care (general practice, family medicine) is seen by many to be unchallenging, unrewarding and basically simple - in short, the end of the medical line, a medical dumping ground, as it were. It is apparent, however, that careers in primary care are becoming increasingly appealing to students with high academic standing. Contrary to Dr. Wallace's doubts, such students seem challenged by the many unanswered questions and unexplored areas in what they perceive to be a demanding, interesting and potentially satisfying life work. Another implication in Dr. Wallace's viewpoint is that academically gifted students may not be as people-oriented and community-minded as students of lesser academic ability - a concept which, to my knowledge, has never been validated. My experience with undergraduate and postgraduate students over the past 4 years would not support this assumption. The fortunate combination of high academic ability and people-orientation produces an excellent primary care physician. In my view, it seems a tenuous proposition to set up arbitrary criteria whereby a student with unquestioned academic qualification might be denied admission to medical school because an admission board supposed he or she appeared to lack a degree of compassion or empathy for people, as judged by interviews, reference letters or autobiographic sketches. I believe that such methods of assessment should be used with extreme caution and primarily to screen out blatantly unsuitable applicants, providing valid criteria can be agreed upon.
712 CMA JOURNAL/OCTOBER 18, 1975/VOL. 113
COMPOSITION: Each uncoated, scored, light tan tablet contains spironolactone, 25 mg. Aldactone offers an entirely new approach to the treatment of essential hypertension, edema and ascites, including resistant states. Aldactone specifically blocks the effects on the kidneys of mineralocorticoids and antagonizes the sodium retaining and water retaining effects of aldosterone which is important in the production of edema. INDICATIONS: Aldactone is indicated in the treatment of edema and ascites of congestive heart failure, hepatic cirrhosis, the nephrotic syndrome, and idiopathic edema as well as that due to malignant effusions especially if not responding well to conventional diuretics. Aldactone is also indicated for lowering blood pressure in essential hypertension, correcting hypokalemic alkalosis in severe hypertension and in the treatment of myasthenia gravis. DOSAGE: Edema-the initial recommended adult dose is one 25 mg tablet four times daily. Rarely a patient may require up to 300 mg per day and others as little as 75 mg per day. If adequate diuresis with Aldactone is not obtained within five days, Aldactizide should be substituted in its usual dosage to obtain the synergistic effect of the spironolactone and the thiazide components. In an occasional patient with severe, resistant edema, it may be necessary to add a glucocorticoid to this combined therapy. In children a dosage providing 1.5 mg of Aldactone per pound of body weight should be employed. Essential hypertension-One tablet four times a day, treatment should be continued at least two weeks. PRECAUTIONS: Other than acute renal insufficiency there are no known contraindications to Aldactone. It should be used judiciously in patients with hyponatremia or hyperkalemia. SIDE EFFECTS: Side effects are mild and infrequent; drowsiness, mental confusion and maculopapular or erythematous eruptions have occurred rarely, subsiding within forty-eight hours on discontinuation of the drug. Gynecomastia and mild androgenic manifestations have also been reported in a few patients. TOXICITY: No reports of fatal overdosage in man. No adverse effects from high dosage in chronic animal studies. Symptoms of Overdosage-True toxicity has not been reported; drowsiness, mental confusion or a maculopapular or erythematous rash has occurred rarely. These manifestations disappear promptly on discontinuance of medication. Hyperkalemia may be exacerbated. Treatment-No specific antidote. No true toxicity has occurred or is expected. Appearance of effects described above require only discontinuance of the drug. For hyperkalemia, reduce potassium intake, administer potassiu m-excreting diuretics, intravenous glucose with regular insulin or oral ion exchange resins. SUPPLY: Bottles of 100, 1,000 and 2,500 tablets. Complete prescribing information available on request.
AIdactone. (S.RONOLACTONE)
the only specific, competitive aldosterone antagonist for gradual, sustained diuresis with minimal possibility of potassium loss.. .especially indicated for the digitalized patient. Sea,le Pharmaceuticals Oakville, Ontario
I think a great deal of caution should be exercised in assessing the need for radical alterations in medical school admission policies, and that boldly innovative policies such as McMaster's should be regarded as experimental and unproved. If changes are to be made that de-emphasize academic achievement, let them be made for reasons other than the hopeful hunch that more and better primary care physicians will somehow result. It is entirely likely that many, if not most, students admitted with lesser academic qualifications may choose to become specialists in any number of fields. What is needed more than major alterations in medical school admission policies is a change in the thinking processes of all concerned, which would be reflected in the enthusiastic promotion and endorsement of careers in primary care to all students, including the most gifted, most of whom seem to be people-oriented as well as of high academic standing. Primary care is downgraded and made less appealing when it is suggested or implied that students of high academic standing may find the field unrewarding and unchallenging. JOHN BIEHN, MD
Director,
Centre London, ON
To the editor: As one who has contributed to the admission procedures of the University of Saskatchewan over the past 5 years, I would like to say in response to Dr. Wallace's article that we in the West are at least as progressive as any school in the East, if not more so. All applicants to the college of medicine are interviewed, not just those with the highest grades. For 5 years a medical student has been sitting on the interviewing panels, and two medical students are members of the admission committee. For 3 years members of the community have also taken part in interviewing, and there have been on the admission committee two community representatives, who play a large part in the selection of the community members of the interviewing panels; the members are truly representative of the community and are not medical or paramedical personnel. Each interviewing panel consists of four members, representing five points of view: a medical student, a physician, a faculty member and a member of the community; one of the four is a woman. We believe, therefore, that at least one other medical school is well advanced in its selection procedure and is finding, presumably like McMaster, that the procedure is working very sa-
tisfactorily for all concerned - the applicant, the currently enrolled medical student, the faculty and the community. L.J. CLEIN, MB, FRC5[C]
Head, department of neurosurgery University of Saskatchewan Saskatoon, 5K
Comparison of earnings To the editor: From my experiences as British Medical Association representative, and in general and later specialist practice in the United Kingdom's National Health Service up to 1971 when I came to Canada, I am prompted to comment on Dr. Bloomfield's letter "Fee schedules and workloads" (Can Med Assoc 1 112: 1290, 1975). I believe Dr. Bloomfield's penultimate paragraph to be the most important, and I would like to embellish it with data from the United States reported by Wamsley in the May 12, 1975 issue of Medical Economics (pages 78-9). The figures are comparable to those released in Canada last year, although they may now be out of date in view of some of the recent increases for such items as union plumbing work. I have set out the data a little differently to facilitate comparison with the figures in my additional columns, calculated from the data in the original report. The final column is fundamental because, owing to progressive taxation, as the gross pay increases it bears an increasingly distant relation to real, usable pay. The data reveal that the average general practitioner in the United States is paid at a smaller after-tax hourly rate than a crane driver, and his rate is even further below those of the other professional groups represented. I am not suggesting that the job of crane driving is necessarily worth any less per hour than practising medicine. However, the figures clearly and totally refute the notion that physicians are overpaid. The figures simply indicate that, as a group, physicians work harder than most others. It may be difficult
for some to understand the reason for this but I suspect that at least some of the willingness to work hard results from the desire to benefit the patient even at one's inconvenience, and is not prompted merely by the wish to improve one's own lifestyle. Even if it were the latter, is it better for society that one does it for one's self or that the state does it for you? Some readers may find these statistics arresting, but there is worse to come. To illustrate this I would like to take further Dr. Bloomfield's idea of lifetime earnings. It is sometimes forgotten that the crane driver is earning to capacity many years before the physician. If the cumulative earnings of the two are graphed from the time the skilled labourer begins earning, say at 18 years of age, and the deficit of cost of medical training is included in the physician's lifetime earnings, then, based upon a constant dollar in a noninflationary economy, the total lifetime earnings of the two do not become equal until approximately the age of 45 years. Unless the physician persistently works much harder than the skilled artisan the lifetime earnings of the former will never approach those of the latter. In an inflationary economy the point of equality rapidly approaches infinity and can only be brought forward in time by relatively massive differentials in after-tax pay. Furthermore, by the age of 45 the higher death rate among physicians has begun to take its toll, so that a proportion of medical practitioners die without ever having achieved equality of lifetime earnings. Such circumstances of employment, if sustained in medicine, would seem likely to attract into the profession an increasing number of people with unduly prominent characteristics of masochism or irresponsible idealism. Is this really what the profession and the public want or need? THOMAS J. MUCKLE, MD, FRCP[C]
Department of pathology McMaster University Medical Centre Hamilton, ON
Table I-Comparison of earnings derived from different types of work in the United States in 1974
$ per annum Weeks* Hours of work after expenses $ per hour worked per Per Per Before After Before After annum week annum* taxt tax* tax tax* Lawyer 49 40 1960 30000 18200 15.30 9.6 Crane driver 50 37 1850 25 000 15700 13.44 8.5 Army major general 48 55 2640 37 000 21 600 13.98 8.2 Chief executive 48 58 2800 48 000 26700 17.24 9.5 Preclinical professor 39 55 2150 32000 19200 15.15 8.9 Practising MD 48 60 2876 39 000 22 600 13.58 7.9 *Calculated from original 1975 data of Wamsley. .Figures are rounded to the second digit. .Figures derived by applying 1974 rates for Ontario residents, without personal deductions. 716 CMA JOURNAL/O.2TOBER 18, 1975/VOL. 113
