dency director at Dalhousie University and the longest serving psychiatry residency director in Canada I have had ample experience of the disruption to proper study when postgraduates face the annual May examination to become a licentiate of the MCC (LMCC). Since virtually all Canadian graduates succeed in this examination either in the final year of undergraduate study or during the first postgraduate year this problem has, up to now, been one entirely affecting the progress of foreign medical graduates. Last year and this year in my small psychiatry program I saw residents distracted from their proper fields of study because of the LMCC examination. With the introduction of the new, part II examination all postgraduates will be distracted well into the second postgraduate year. One might assume that planners in both the family practice and the specialty streams would have ensured a fairly broad range of experience for residents in the first postgraduate year. However, for reasons of convenience and logistics the MCC is planning to hold its second LMCC examination in November of the second postgraduate year. Thus, specialty training program directors can expect their trainees to be distracted from their chosen field of study from some time in the middle of the first postgraduate year until almost halfway through the second. Whenever I review the new licensing requirements and the changes overall in postgraduate education I echo Maurice Chevalier, who used to sing "I'm glad I'm not young any more."
in prelicensure training rules leaving sour taste in medical students' mouths," by Simon Kirby (ibid: 1617-1619), then president of the Canadian Federation of Medical Students (CFMS). Kirby's main points are as follows: first, although a portable licence was a major goal of the new system, it may not be achieved; second, the new, part II qualifying examination is costly to students and entirely unnecessary if they are also to be evaluated by a college; and, third, the new system provides considerably less flexibility in career choice and route to licensure and may coerce students into choosing a specialty too early. As a final-year medical student I wish to comment on the lack of communication by the licensing bodies and on the significant decrease in flexibility in routes to licensure. After I had completed my first year of medical school I was appalled to discover that my class would be the first to be required to complete the 2-year internship. I think that the licensing bodies have a lot of gall to make decisions about our futures without telling us before we enter our career program. It is one thing to start a course of training knowing what is in store so that it can be planned for and quite another to have the requirements changed in midflight. Why was this not in my application package? Worse, 2 years later none of us is completely sure what those final requirement possibilities are, only months before our applications to the Canadian Intern and Resident Matching Service are due. Who's running the show here? It certainly appears as if this whole process has been extremely poorly orgaWilliam 0. McCormick, MB, FRCP nized. Medical/clinical director In the next few months we and director of postgraduate must come to grips with a choice psychiatric education of training propostgraduate Dalhousie University Halifax, NS grams. Many of us can choose between family medicine and speI was interested to read "Changes cialty training. However, it is not
1744
CAN MED ASSOC J 1992; 147 (12)
true that most graduating students know which specialty they will choose. In the past many general licensees have spent time practising before deciding on a specialty. Can we go to Africa and work for a year or two? Can we work in northern Ontario for a year or two? Can we join Medecins sans frontieres and work where there is a need? The answer is Not immediately, despite the fact that now (when most of us do not have family commitments) is the best
time. To get a licence we must now also be certified by a college. The shortest route is through 2 years of family medicine training. We know that the Ontario government may restrict billing numbers in the near future. It is not surprising that the Professional Association of Internes and Residents of Ontario in its May 1992 open letter to third-year and fourthyear medical students advised us to get our licences in the shortest time possible, obtain a billing number and start working. Undoubtedly family medicine is unprepared and in the long run will be unwilling to take in all those graduates who do not wish to do specialty training immediately. Although, in general, medical students are flexible and could enjoy practising in various types of medicine, many will be forced into something they do not want to do. This is reduced flexibility. It will not be surprising if students choose family medicine to obtain their licence quickly, work for a couple of years (perhaps in underserviced areas in the North or in underprivileged areas of the world) to pay off debts and gain clinical experience and then return for more training. Michael D. Hill Class of 1993 University of Ottawa Ottawa, Ont.
Three cheers for Mr. Kirby's valiant attempt to describe the plight LE 15 DECEMBRE 1992
of medical students faced with the current changes to licensure. As a fellow medical student I wholeheartedly agree with many of the concerns he has raised. Not only is there no proven need for another examination, but it is also difficult to understand why the MCC has prematurely embraced the notion of administering an examination (at a cost of $1000 to each poor medical student) that achieves nothing for students: it does not lead to licensure or even to a guarantee of portability. The College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada should be left to determine whether their applicants fulfil the necessary criteria (which can be modified in conjunction with the MCC and other relevant bodies) and demonstrate the appropriate skills and attitudes to become licensed physicians. I am even more frustrated that, as a medical student, there is so little that I seem to be able to say or do when the powers that be decide my fate. I have written two letters to the MCC outlining my concerns about the part II examination, but to date I have received only one (totally unsatisfactory) response that did not address any of my concerns. I sympathize with and appreciate the efforts of the CFMS, but I wonder if the time has come for medical students across the country to unite in solidarity and refuse to write the MCC part II examination. Is this now our only effective voice? Shabbir M.H. Alibhai Richmond Hill, Ont.
Physicians of Canada when the part II examination was first proposed. Maudsley's account of the sequence of events is accurate. His arguments for moving the part II examination back to the end of undergraduate training are logical and thoughtful, and they should be supported. Reg L. Perkin, MD Executive director College of Family Physicians of Canada Mississauga, Ont.
Ethics and the physician W ith regard to the correspondence on this topic in the Sept. 1, 1992, issue of CMAJ (147: 575-581), by Dr. Eike-Henner Kluge and others, I have these comments. Bid adieu to the days when physicians Were believed to have knowledge and skills With conundrums of choices and duties and rights As opposed to their scalpels and pills.
Say farewell to that part of caring That allowed us to guide and assist. Untutored, inadequate, now we are saved By the "Expert Witness Ethicist."
Rejoice, for it offers solutions To the questions of good versus ill. Open minds may be closed as the answers come down From the perch on the ethical hill. How unique to be blessed with such wisdom To know just how others should think, And insist they adopt that perspective As they skate on the ethical rink.
I wish to support the position taken by Dr. Robert F. Maudsley To a few this might seem to be in his editorial "Timing of the arrogant, Medical Council of Canada clin- But, of course, then who are they ical examination" (Can Med Assoc to judge, J 1992; 147: 995-997). His views Unrecognized as they are by Canadian courts? are congruent with the position taken by the College of Family But ";law is not ethics." Oh, fudge! 1746
CAN MED ASSOCJ 1992; 147 (12)
Perspectives might vary with cultures and time, As will people and medical platitudes. Will ethicists change as the paradigms shift Or be frozen in time by their
attitudes? Philip F. Hall, MD, BScMed, FRCSC Professor and head Department of Obstetrics, Gynaecology and Reproductive Sciences St-Boniface General Hospital Winnipeg, Man.
[Dr. Kluge responds:] Happy day! Here is a physician Who seems to have seen the light, Who has recognized that mere tradition May mislead as to wrong and to right, Who has seen - alas it is painful, But the truth must out, t'would appear That the ethics of good old Percival No longer have society's ear, Who has seen - though he's loath to admit it That the courts have broken the mould. There's a new approach to ethical practice: The paternalism of old Must give way to new manners of treating.
"Informed consent" and "objective standard of disclosure" Have become de rigueur in the land. Of course there are those i'the profession Who rebel and who rant and rave, Even try their hand at doggerel, But nothing their practice can save From the lawsuits that seem to follow Their patterns of practice so bold, When they ignore Malette v. Shulman Or Mclnerny v. Macdonald. I'm told That the tide of their fear is rising: Hippocrates is no longer a shield. Doctors actually have to learn ethics! They no longer control the field Of patient decision-making! "Best interests" is no longer enough, Unless the patient defines it. The life of a doctor's become tough. The old and well-worn approaches"'Tis in your best interest, my dear," Or "Doctor knows best, Mrs. Murphy, So do it! Go on! Never fear!LE 15
DECEMBRE 1992
in prelicensure training rules leaving sour taste in medical students' mouths," by Simon Kirby (ibid: 1617-1619), then president of the Canadian Federation of Medical Students (CFMS). Kirby's main points are as follows: first, although a portable licence was a major goal of the new system, it may not be achieved; second, the new, part II qualifying examination is costly to students and entirely unnecessary if they are also to be evaluated by a college; and, third, the new system provides considerably less flexibility in career choice and route to licensure and may coerce students into choosing a specialty too early. As a final-year medical student I wish to comment on the lack of communication by the licensing bodies and on the significant decrease in flexibility in routes to licensure. After I had completed my first year of medical school I was appalled to discover that my class would be the first to be required to complete the 2-year internship. I think that the licensing bodies have a lot of gall to make decisions about our futures without telling us before we enter our career program. It is one thing to start a course of training knowing what is in store so that it can be planned for and quite another to have the requirements changed in midflight. Why was this not in my application package? Worse, 2 years later none of us is completely sure what those final requirement possibilities are, only months before our applications to the Canadian Intern and Resident Matching Service are due. Who's running the show here? It certainly appears as if this whole process has been extremely poorly orgaWilliam 0. McCormick, MB, FRCP nized. Medical/clinical director In the next few months we and director of postgraduate must come to grips with a choice psychiatric education of training propostgraduate Dalhousie University Halifax, NS grams. Many of us can choose between family medicine and speI was interested to read "Changes cialty training. However, it is not
1744
CAN MED ASSOC J 1992; 147 (12)
true that most graduating students know which specialty they will choose. In the past many general licensees have spent time practising before deciding on a specialty. Can we go to Africa and work for a year or two? Can we work in northern Ontario for a year or two? Can we join Medecins sans frontieres and work where there is a need? The answer is Not immediately, despite the fact that now (when most of us do not have family commitments) is the best
time. To get a licence we must now also be certified by a college. The shortest route is through 2 years of family medicine training. We know that the Ontario government may restrict billing numbers in the near future. It is not surprising that the Professional Association of Internes and Residents of Ontario in its May 1992 open letter to third-year and fourthyear medical students advised us to get our licences in the shortest time possible, obtain a billing number and start working. Undoubtedly family medicine is unprepared and in the long run will be unwilling to take in all those graduates who do not wish to do specialty training immediately. Although, in general, medical students are flexible and could enjoy practising in various types of medicine, many will be forced into something they do not want to do. This is reduced flexibility. It will not be surprising if students choose family medicine to obtain their licence quickly, work for a couple of years (perhaps in underserviced areas in the North or in underprivileged areas of the world) to pay off debts and gain clinical experience and then return for more training. Michael D. Hill Class of 1993 University of Ottawa Ottawa, Ont.
Three cheers for Mr. Kirby's valiant attempt to describe the plight LE 15 DECEMBRE 1992
of medical students faced with the current changes to licensure. As a fellow medical student I wholeheartedly agree with many of the concerns he has raised. Not only is there no proven need for another examination, but it is also difficult to understand why the MCC has prematurely embraced the notion of administering an examination (at a cost of $1000 to each poor medical student) that achieves nothing for students: it does not lead to licensure or even to a guarantee of portability. The College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada should be left to determine whether their applicants fulfil the necessary criteria (which can be modified in conjunction with the MCC and other relevant bodies) and demonstrate the appropriate skills and attitudes to become licensed physicians. I am even more frustrated that, as a medical student, there is so little that I seem to be able to say or do when the powers that be decide my fate. I have written two letters to the MCC outlining my concerns about the part II examination, but to date I have received only one (totally unsatisfactory) response that did not address any of my concerns. I sympathize with and appreciate the efforts of the CFMS, but I wonder if the time has come for medical students across the country to unite in solidarity and refuse to write the MCC part II examination. Is this now our only effective voice? Shabbir M.H. Alibhai Richmond Hill, Ont.
Physicians of Canada when the part II examination was first proposed. Maudsley's account of the sequence of events is accurate. His arguments for moving the part II examination back to the end of undergraduate training are logical and thoughtful, and they should be supported. Reg L. Perkin, MD Executive director College of Family Physicians of Canada Mississauga, Ont.
Ethics and the physician W ith regard to the correspondence on this topic in the Sept. 1, 1992, issue of CMAJ (147: 575-581), by Dr. Eike-Henner Kluge and others, I have these comments. Bid adieu to the days when physicians Were believed to have knowledge and skills With conundrums of choices and duties and rights As opposed to their scalpels and pills.
Say farewell to that part of caring That allowed us to guide and assist. Untutored, inadequate, now we are saved By the "Expert Witness Ethicist."
Rejoice, for it offers solutions To the questions of good versus ill. Open minds may be closed as the answers come down From the perch on the ethical hill. How unique to be blessed with such wisdom To know just how others should think, And insist they adopt that perspective As they skate on the ethical rink.
I wish to support the position taken by Dr. Robert F. Maudsley To a few this might seem to be in his editorial "Timing of the arrogant, Medical Council of Canada clin- But, of course, then who are they ical examination" (Can Med Assoc to judge, J 1992; 147: 995-997). His views Unrecognized as they are by Canadian courts? are congruent with the position taken by the College of Family But ";law is not ethics." Oh, fudge! 1746
CAN MED ASSOCJ 1992; 147 (12)
Perspectives might vary with cultures and time, As will people and medical platitudes. Will ethicists change as the paradigms shift Or be frozen in time by their
attitudes? Philip F. Hall, MD, BScMed, FRCSC Professor and head Department of Obstetrics, Gynaecology and Reproductive Sciences St-Boniface General Hospital Winnipeg, Man.
[Dr. Kluge responds:] Happy day! Here is a physician Who seems to have seen the light, Who has recognized that mere tradition May mislead as to wrong and to right, Who has seen - alas it is painful, But the truth must out, t'would appear That the ethics of good old Percival No longer have society's ear, Who has seen - though he's loath to admit it That the courts have broken the mould. There's a new approach to ethical practice: The paternalism of old Must give way to new manners of treating.
"Informed consent" and "objective standard of disclosure" Have become de rigueur in the land. Of course there are those i'the profession Who rebel and who rant and rave, Even try their hand at doggerel, But nothing their practice can save From the lawsuits that seem to follow Their patterns of practice so bold, When they ignore Malette v. Shulman Or Mclnerny v. Macdonald. I'm told That the tide of their fear is rising: Hippocrates is no longer a shield. Doctors actually have to learn ethics! They no longer control the field Of patient decision-making! "Best interests" is no longer enough, Unless the patient defines it. The life of a doctor's become tough. The old and well-worn approaches"'Tis in your best interest, my dear," Or "Doctor knows best, Mrs. Murphy, So do it! Go on! Never fear!LE 15
DECEMBRE 1992
