trials immunization of im- combination; this is as true in law munocompetent elderly people in as in medicine. I would interpret Hu's article institutions is recommended. as an admission of an unrealistic Elaine Wang, MD, FRCPC expectation of the system that was Assistant professor more than likely based on bad Department of Pediatrics advice. The system, of course, Faculty of Medicine means the awful "b" word University of Toronto Toronto, Ont. bureaucracy. I suggest that there is a common thread to indifference, References incompetence and surliness that transcends national borders. It ex1. Sims RV, Steinmann WC, McConville JH et al: The clinical effectiveness of tends to bureaucracies of all types pneumococcal vaccine in the elderly. both north and south of the 49th Ann Intern Med 1988; 108: 653-657 parallel. However, to conclude 2. Shapiro ED, Clemens JD: A controlled that Hu's frustration justifies an evaluation of the protective efficacy of pneumococcal vaccine for patients at invigorated nationalistic feeling high risk of serious pneumococcal in- about practising medicine in Canfections. Ann Intern Med 1984; 101: ada may be to throw out the baby 325-330 with the bathwater. 3. Kaufman P: Pneumonia in ald age. Present restrictions on acActive immunization against pneumoquiring graduate medical training nia with pneumococcus polysaccharide: results of a six-year study. Arch Intern in the United States limit most Med 1947; 79: 518-531 applicants to accepting an ex4. Gaillat J, Zmirou D, Mallaret MR et visitor visa, a category change al: Essai clinique du vaccin antisymbolized by the abbreviation pneumococcique chez des personnes agees vivant en institution. Rev Epide- J-1. The disadvantage of J-ls is miol Sante Publique 1985; 33: 437-444 the obligation to return home for 2 years following their expiration. Waivers of the 2-year foreign resiMedical training dence rule are available but are in the United States nearly impossible to obtain in practice, no matter how much D ~r. Richard Hu's article money is spent on legal fees. "Training in US benefiAnother category mentioned cial but foreign trainees is the H- 1 visa, now changed to face many roadblocks" (Can Med H- 1 B, for physicians and other Assoc J 1991; 144: 592-593) cau- foreign professionals. Hu contions those accepting graduate cludes that he could have expeditmedical training in the United ed his immigration process if he States to remember the costs. had sought an H instead of a J Presumably Hu means the ag- visa. Present laws restrict H-lB gravation, frustration and attor- visas for graduate medical trainneys' fees. He does not go as far as ing to foreign physicians who Shakespeare did in his condemna- have graduated from US medical tion of attorneys, but his com- schools or are of national or interments clearly indicate a disap- national renown. The most typical pointment with the "happy talk" H-lB physician in the United he may have received from the States is a teacher or researcher legal community. Since the details for a public or nonprofit organizaare missing there is no way to tion. adequately respond to those isAll the grumbling about the sues. However, physicians should system and the law may be anticlinot forget that the treatment of mactic. The Immigration Act of choice does not always produce 1990 presents a whole new ball the desired result. Flexibility and game with fresh possibilities and patience are usually the winning categories of immigration. This is 204

CAN MED ASSOC J 1991; 145 (3)

not to suggest that you will now be able to dance through the bureaucratic minefield but, rather, indicates that the clearest common denominator of success is good legal advice. William Newell Siebert, JD William Newell Siebert and associates 915-307 North Michigan Ave. Chicago, Ill.

Mnemonic serves as diagnostic tool rimary care physicians are often faced with the problem of identifying the cause of a known or suspected infectious disease. Given the wide range of pathogens and their equally diverse sources a complete exposure history may serve as an extremely important diagnostic tool. To this end a memory device that uses the word COASTED is proposed. Contacts (e.g., family, friends, coworkers) Oral ingestion (e.g., of seafood, Chinese food) Animal exposure (e.g., to pets, wild animals) Sexual history (e.g., sexual orientation, number of partners, use of prostitutes) Travel history (e.g., recent foreign trips) Employment exposure (e.g., to animals, insects, fumes) Drug history (e.g., over-thecounter medications, illegal drugs, needle sharing) Although the list may not be all-inclusive it does give the physician a good basis for obtaining an extensive exposure history. Combined with such other information as that obtained from physical examination and diagnostic tests it should prove helpful in the diagnosis of difficult cases. James F. Gettler, MD Department of Medicine North General Hospital New York, NY LE 1Cr AOUT 1991