LJDEX (fluocinonide) ABRIDGED PRESCRIBING INFORMATION* Indications: for topical use in management of corticosteroid responsive dermatoses.
Contraindications: tuberculous, fungal and most viral lesions of the skin - in individuals with a history of hypersensitivity to its components. Not for ophthalmic use. Precautions: should sensitivity occur, the agent should be discontinued. In the presence of infection, the use of an appropriate antifungal or antibacterial agent should be instituted. Not presently recommended for occlusive therapy. Should not be used extensively on pregnant patients, in large amounts, or for prolonged periods of time.
Adverse reactions: on rare occasions,
some local burning, irritation or itching.
Dosage: a small amount applied two to four times daily. Presentation: Lidex (fluocinonide 0.05% in FAPG base) - 15g, 45g and 120g tubes. Lidex Mild (fluocinonide 0.01 % in FAPG base) - 20g and 60g tubes and 454g jars. Lidex Ointment (fluocinonide 0.05% in a specially formulated base) - 1 5g and 45g tubes. Lidex Ointment Mild (fluocinonide 0.01 % in a specially formulated base) -20g and 60g tubes. * Monograph on request. BIBLIOGRAPHY McKenzie, A. W. and Stoughton, R. B.: Method for Comparing Percutaneous Absorption of Steroids. Arch. Derm. 86, 608-61 0, 1962. McKenzie, A. W.: Percutaneous Absorption of Steroids. Arch. Derm. 86, 611-614, 1962. Stoughton, R. B.: Vasoconstrictor Activity and Percutaneous Absorption of GlucoCorticoids. Arch. Derm. 99, 753-756,1969. Place, V. A. et at: Precise Evaluation of Topically Applied Corticosteroid Potency. Arch. Derm. 101, 531 -537, 1970. Scholtz, J. R. and Nelson, D. H.: Some Quantitative Factors in Topical Corticosteroid Therapy. Olin. Pharmacol. Ther. 6, 498-509, 1965. March, C. et al: Adrenal Function After Topical Steroid Therapy. Olin. Pharmacol. Ther. 6, 43-49, 1965. Scoggins, R. B. and Kliman, B.: Percutaneous Absorption of Corticosteroids. New Eng. J. Med. 273, 831 -840, 1965.
S.NTEX Syntex Ltd. Montreal, Quebec
EEEJ
will rise; when the demand decreases, average incomes will fall. Other methods of comparing incomes of sections must be devised if equity is ever to be achieved. I believe that in the process optimum workloads must be considered. For each section there must be an optimum workload that would allow the practitioner sufficient time to give his patients care of good quality and sufficient time to keep up to date and still have enough rest and recreation. It should also be possible to reach a consensus of what the optimum workload for each section should be in terms of 10 or 20 of the most commonly performed procedures. I believe that the work of all physicians is of equal value because all are dependent upon one another. The physician who diagnoses appendicitis does as much for the patient as the surgeon who removes the offending organ. Surgeons would not have patients to operate on if other physicians had not made a diagnosis or at least made a decision to refer them. Fee schedules should therefore be arranged so that the lifetime incomes ot all physicians who are carrying an optimum workload are the same. The income derived from this should be sufficient to maintain a lifestyle appropriate to the training, skill and responsibility required of physicians. Although physicians are interdependent, some are subject to more stress than others. Allowances should be made for this factor in determining the optimum workload. For a neurosurgeon the optimum would be less than that for a general practitioner but the lifetime income derived from performing the workload would be the same. If, however, the number of neurosurgeons were to increase and the workload decrease below the optimum, then the incomes of neurosurgeons would fall and this would not be used as an argument for increasing fees for neurosurgical procedures. In response to changes in the cost of living, physicians' fees should be increased to maintain the purchasing power of the net income derived from performing the optimum workload. The average incomes of physicians have risen considerably over the last 15 or 20 years as a result of a very modest increase in fees, a considerable increase in workloads and a virtual elimination of bad debts. These factors have affected different sections to varying degrees but I believe that in most cases the major factor causing the increase in incomes has been the increase in workloads. Outside the profession little attention has been paid to this, but the net income of almost any phy-
sician carrying the same workload today as he did 15 or 20 years ago is considerably less than it was then. The physician must work harder today to maintain the same lifestyle he enjoyed then. This is quite the opposite to what has happened to most other groups in society, who are getting paid more for doing less. Fees must be increased sufficiently to maintain the purchasing power of the income generated by performing an optimum workload so that workloads need not be increased to maintain lifestyles. M.A. BLOOMFIELD, MD 111 Waterloo St. London, Ont.
Self-inoculation with milk
To the editor: Psychiatry has been included in medical education for at least a generation, and it is acknowledged without question that the patient must be considered as a whole - body, mind and milieu. How then is it possible that an article like "Self-inoculation with milk as a cause of recurrent cellulitis" by Steinman, Mendelson and Portnoy (Can Med Assoc J 112: 605, 1975) can be written and accepted for publication with no more than a few words regarding the patient's state of mind? Three authors (no psychiatrist), six admissions, "many physicians", three columns of physical findings but no mention that anyone talked to her, quietly and alone. ELLIOrr EMANUEL, MD 352 Dorval Ave. Dorval, QuE.
To the editor: It would appear that Dr. Emanuel has missed the essential point we were trying to make in our article. We were attempting to alert physicians to the possibility of selfinflicted injury presenting as cellulitis; it was not our aim to elaborate on the psychodynamics involved. The possibility that, the condition was being selfperpetuated was considered after the third admission, and many physicians, including her family physician, approached her (quietly and alone) with the facts that suggested such a possibility, but she flatly denied it. Her husband would not accept that the condition might be self-inflicted and we really did not know how she was doing it, if in fact she was. After the discovery of the evidence at home, the patient admitted to what she was doing and psychiatric help was sought. The patient has been under psychiatric care ever since. JACK MENDELSON, MD, FRCP[C] JOSEPH PORTNOY, MD, FRCP[C] ROBERT STEINMAN. MD Jewish General Hospital MontrEal, Qu6.
CMA JOURNAL/JUNE 7, 1975/VOL. 112 1293
Contraindications: tuberculous, fungal and most viral lesions of the skin - in individuals with a history of hypersensitivity to its components. Not for ophthalmic use. Precautions: should sensitivity occur, the agent should be discontinued. In the presence of infection, the use of an appropriate antifungal or antibacterial agent should be instituted. Not presently recommended for occlusive therapy. Should not be used extensively on pregnant patients, in large amounts, or for prolonged periods of time.
Adverse reactions: on rare occasions,
some local burning, irritation or itching.
Dosage: a small amount applied two to four times daily. Presentation: Lidex (fluocinonide 0.05% in FAPG base) - 15g, 45g and 120g tubes. Lidex Mild (fluocinonide 0.01 % in FAPG base) - 20g and 60g tubes and 454g jars. Lidex Ointment (fluocinonide 0.05% in a specially formulated base) - 1 5g and 45g tubes. Lidex Ointment Mild (fluocinonide 0.01 % in a specially formulated base) -20g and 60g tubes. * Monograph on request. BIBLIOGRAPHY McKenzie, A. W. and Stoughton, R. B.: Method for Comparing Percutaneous Absorption of Steroids. Arch. Derm. 86, 608-61 0, 1962. McKenzie, A. W.: Percutaneous Absorption of Steroids. Arch. Derm. 86, 611-614, 1962. Stoughton, R. B.: Vasoconstrictor Activity and Percutaneous Absorption of GlucoCorticoids. Arch. Derm. 99, 753-756,1969. Place, V. A. et at: Precise Evaluation of Topically Applied Corticosteroid Potency. Arch. Derm. 101, 531 -537, 1970. Scholtz, J. R. and Nelson, D. H.: Some Quantitative Factors in Topical Corticosteroid Therapy. Olin. Pharmacol. Ther. 6, 498-509, 1965. March, C. et al: Adrenal Function After Topical Steroid Therapy. Olin. Pharmacol. Ther. 6, 43-49, 1965. Scoggins, R. B. and Kliman, B.: Percutaneous Absorption of Corticosteroids. New Eng. J. Med. 273, 831 -840, 1965.
S.NTEX Syntex Ltd. Montreal, Quebec
EEEJ
will rise; when the demand decreases, average incomes will fall. Other methods of comparing incomes of sections must be devised if equity is ever to be achieved. I believe that in the process optimum workloads must be considered. For each section there must be an optimum workload that would allow the practitioner sufficient time to give his patients care of good quality and sufficient time to keep up to date and still have enough rest and recreation. It should also be possible to reach a consensus of what the optimum workload for each section should be in terms of 10 or 20 of the most commonly performed procedures. I believe that the work of all physicians is of equal value because all are dependent upon one another. The physician who diagnoses appendicitis does as much for the patient as the surgeon who removes the offending organ. Surgeons would not have patients to operate on if other physicians had not made a diagnosis or at least made a decision to refer them. Fee schedules should therefore be arranged so that the lifetime incomes ot all physicians who are carrying an optimum workload are the same. The income derived from this should be sufficient to maintain a lifestyle appropriate to the training, skill and responsibility required of physicians. Although physicians are interdependent, some are subject to more stress than others. Allowances should be made for this factor in determining the optimum workload. For a neurosurgeon the optimum would be less than that for a general practitioner but the lifetime income derived from performing the workload would be the same. If, however, the number of neurosurgeons were to increase and the workload decrease below the optimum, then the incomes of neurosurgeons would fall and this would not be used as an argument for increasing fees for neurosurgical procedures. In response to changes in the cost of living, physicians' fees should be increased to maintain the purchasing power of the net income derived from performing the optimum workload. The average incomes of physicians have risen considerably over the last 15 or 20 years as a result of a very modest increase in fees, a considerable increase in workloads and a virtual elimination of bad debts. These factors have affected different sections to varying degrees but I believe that in most cases the major factor causing the increase in incomes has been the increase in workloads. Outside the profession little attention has been paid to this, but the net income of almost any phy-
sician carrying the same workload today as he did 15 or 20 years ago is considerably less than it was then. The physician must work harder today to maintain the same lifestyle he enjoyed then. This is quite the opposite to what has happened to most other groups in society, who are getting paid more for doing less. Fees must be increased sufficiently to maintain the purchasing power of the income generated by performing an optimum workload so that workloads need not be increased to maintain lifestyles. M.A. BLOOMFIELD, MD 111 Waterloo St. London, Ont.
Self-inoculation with milk
To the editor: Psychiatry has been included in medical education for at least a generation, and it is acknowledged without question that the patient must be considered as a whole - body, mind and milieu. How then is it possible that an article like "Self-inoculation with milk as a cause of recurrent cellulitis" by Steinman, Mendelson and Portnoy (Can Med Assoc J 112: 605, 1975) can be written and accepted for publication with no more than a few words regarding the patient's state of mind? Three authors (no psychiatrist), six admissions, "many physicians", three columns of physical findings but no mention that anyone talked to her, quietly and alone. ELLIOrr EMANUEL, MD 352 Dorval Ave. Dorval, QuE.
To the editor: It would appear that Dr. Emanuel has missed the essential point we were trying to make in our article. We were attempting to alert physicians to the possibility of selfinflicted injury presenting as cellulitis; it was not our aim to elaborate on the psychodynamics involved. The possibility that, the condition was being selfperpetuated was considered after the third admission, and many physicians, including her family physician, approached her (quietly and alone) with the facts that suggested such a possibility, but she flatly denied it. Her husband would not accept that the condition might be self-inflicted and we really did not know how she was doing it, if in fact she was. After the discovery of the evidence at home, the patient admitted to what she was doing and psychiatric help was sought. The patient has been under psychiatric care ever since. JACK MENDELSON, MD, FRCP[C] JOSEPH PORTNOY, MD, FRCP[C] ROBERT STEINMAN. MD Jewish General Hospital MontrEal, Qu6.
CMA JOURNAL/JUNE 7, 1975/VOL. 112 1293
