macrodant.n (nitrofurantoin macrocrystals) References: 1. From thefull data base of PMRBacteriologicReports, 1971 to 1976: results of susceptibility tests were provided by a panel of approximately 200 hospitals of 100 beds or more in 1974 through 1976, and of 108 hospitals in 1971 and 1973. The Kirby-Bauer methodology for fast-growing organisms was used. Specimen source: urine. While standard testing methods were used, it is recognized that in such surveys, consideration must be given to methodology variations as possible sources of error. Thus, these figures are not absolute. In addition, selection of therapeutic drugs should not necessarily be based on laboratory results alone, but consideration must be given to clinical pictureand potential toxicity of the therapeutic choice. However, this is a national survey of urinary pathogens, and the extreme care in data collection and tabulation does permit generally acceptable conclusions that the figures are significant. 2. Goddard OW: Conn HF(ed): Current Therapy 1975, Philadelphia, W.B. Saunders Company, 1975, pp 470-473. 3. Kalowski 5, Radlord N, Kincaid-Smith P: NEnglJMed 290: 385-387, 1974. 4. Shirley SW, Ozog IS: Urology Digest 9:8-10, 1970.
Action: The large crystal size of Macrodantin (nitrofurantoin macrocrystals) provides the proven clinical efficacy of Furadantin (nitrofurantoin) but with increased gastrointestinal tolerance. In a comparative clinical study the incidence of nausea and/or emesis was appreciably less with Macrodantin than with Furadantin. Patients unable to tolerate Furadantin reported good tolerance of Macrodantin. Indications: Macrodantin is indicated for the treatment of pyelonephritis, pyelitis and cystitis caused by sensitive organisms. Contraindicatlons: Anuria, oliguria or extensive impairment of renal function. Infants under one month. Warnings: Haemolytic anaemia, which disappears on cessation of drug therapy has been reported in sensitive individuals. Usually defined as the 10% of negroes and lower percentages of people of Mediterranean and near Eastern origin who exhibit glucose-6---phosphate dehydrogenase deficiency of the red blood cells. Safety during pregnancy and lactation has not been established. Precautions: Peripheral neuropathy has been reported with nitrofurantoin. This may become severe and irreversible and one fatality has been reported. Therapy should be discontinued if numbness and tingling occur. Macrodantin should not be co-prescribed with drugs which impair renal function. Adverse Reactions: Nausea, emesis, and less frequently, diarrhea may occur; reduction in dosage may alleviate these symptoms. Sensitization appearing as an erythematous, maculopapular cutaneous eruption, urticaria, eczematoid eruption or pruritus has occurred. Hypersensitivity reactions resulting in nonfatal anaphylaxis, angloedenia, pulmonary infiltration with pleural effusion and eosinophilia have been reported. Other possible reactions are chills, lever, jaundice, asthmatic symptoms, and hypotension. Occasional minor reactlons such as headache, dizziness, nystagmus, vertigo, drowsiness, malaise, and muscular aches have occurred Transient alopecia has been reported. Leukopenia, including granulocytopenia has been reported rarely. Return of the blood picture to normal has followed cessation of therapy. As with other antimicrobial agents, superintections by resistant organisms may occur. With Macrodantin, however, these are limited to the genitourinary tract because suppression of normal bacterial flora elsewhere in the body does not occur. Administration and Dosage: Dosage: Adult: 5010100 milligrams four times a day. Children: Should be calculated on the basis of 5 to 7 milligrams per kilogram (2.2 to 3.2mg per Ib) of body weight per 24 hours, to be given in divided doses four times a day (contraindicated under one month of age.) Administration: Macrodantin (nitrofurantoin macrocrystals) may be given with food or milk to further minimize gastric upset. Therapy should be continued for at least one week and for at least3 days after sterility of the urine is obtained. Continued infection indicates the need for re-evaluation. If the drug is to be used for long-term suppressive therapy, a reduction of dosage should be considered. How Suppiied: Macrodantin is available in opaque white imprinted capsules ol 25 mg (Eaton 007) in bottles of 30, l00and 500 capsules; opaque yellow/white imprinted capsules 0150mg (Eaton 008) in bottles of 30,100 and 500 capsules; opaque .eHowjmpnntedcapsules ol 100mg (Eaton 009) in bottles of 500 capsules. Product monograph avaiiabie on request. Originators and Developers of the Nitrofurans ! EATON LABORATORIES Division of Norwich Pharmacai Company Ltd. EMA-812.E Paris, Ontario
try to attract research industries to the province. The government also is offering awards to postdoctoral researchers through a program in cooperation with local industries. The government will pay $12 000 to a doctoral graduate from BC during his first year if he is working in research for a BC industry. As well, the government now is offering graduate research, educational and technical (GREAT) awards for projects approved by a local industry and now is trying to extend these awards for undergraduate levels as well. It is amazing to watch the change that comes over McGeer whenever conversation shifts from his political role to his medical role. When he discusses politics, even the sticky moments, he throws himself into his wing chair, occasionally sprawling comfortably, and invariably smiling and affable. Switch the topic to medicine and he immediately becomes serious. When pressed for information about his current work, he often rises and paces the floor like an Oxford don, head down, hands behind his back, and he hovers over his statements in an effort to be precise and completely understood. In Wilmington, he met Dr. Edith Graef, a fellow PhD in chemistry, and within months had married her. The couple returned to Vancouver, where Pat McGeer went back to medical school, then into brain research. Both now are with the Kinsman laboratory of neurological research in the department of psychiatry at UBC. Although Pat McGeer is officially on leave, he often supervises doctoral research and participates in some clinical trials. He
continues to publish papers and each year accepts about 10 of some 50 invitations to participate in international conferences. He is currently completing two medical texts that probably will be released later this year. The first is a basic text, "Neurobiology of the brain", coauthored with his wife and Sir John Eccles, winner of a Nobel prize for his work in neurophysiology. The second book, "Kainic acid as a neurological tool", is edited by the two McGeers and will contain the latest papers related to this analog of glutamic acid. Kainic acid, explains McGeer, is derived from seaweed and destroys neurons that have a high concentration of glutamate receptors and therefore is a relatively selective neurotoxic material. For example, when injected into the basal ganglia, it has effects on the behavioural sequelae in Huntington's chorea. "Most of the work I do now and have always done is basic research. It lends itself frequently to clinical trials based on research findings in the laboratory. For example, if we uncover biochemical defects in Huntington's chorea, as we have done in the last 3 to 4 years, then clinical trials are indicated." His almost passionate responses to his medical work seem to contrast to his easygoing approach to his political role. Yet there also seems a certain similarity in the approach of both politician and brain researcher. In both he seems to be single-mindedly working toward some distant goal and is undeterred by a few failures in current experiments because he is supremely confident of the eventual outcome. U
Physician migration: Beware the easy way GEOFFREY GOLDSMITH, MD
Most organizations - hospital corporations or multistate nonprofit placement agencies - that recruit Canadian physicians for posts in the US are honest and reliable agents. In this I agree with the articles of Korcok (CMAJ 118: 980 and 1156, 1978). There are, however, a small number of companies with which an
individual may come into contact that take advantage of the Canadian physician. My experience is that there are unscrupulous groups that cause Canadian physicians first to move to the US and then to have to relocate because of problems with employers. A Canadian acquaintance of mine
- call him Dr. Brown - finished his family practice residency several years ago. Becoming less and less enchanted with the role of the government in his practice, he was anxious to leave Canada for practice in the United States. He contacted a Canadian-based recruiting firm (call it X), which put him in contact with an American company that had several practice sites available in California, Nevada and Arizona. Dr. Brown was told by X that, even if he did not agree to accept any of the practices, he would be paid half of his expenses for a week-long visit. It seemed to Dr. Brown that he could not lose in this arrangement. It would, he felt, provide him with an inexpensive way to view a number of practice settings and learn more about groups. To ensure this, X's representatives literally shadowed Dr. Brown day and night. He did escape for one evening and contacted me to ask my opinion about the opportunities they offered him. Briefly, he was being offered $34 000 a year to start, with guarantees for much higher earnings in the next 2 or 3 years, although the contract was strikingly vague about the details of this future guarantee. Oncall coverage was also unclear within the contract but the recruiter assured him that it would be easy to contact other doctors in the community to cover calls. Specialist consultation was the major concern of Dr. Brown and he was reassured that many consultants were "easily available in the nearby town." Only 2 weeks of vacation were allowed during the 1st year. Two additional weeks of educational leave were to be paid. The recruiter assured him this was the very best offer he could get within the particular community and that the company would be assuming all the financial risks and taking care of all the paper work. All he had to do was practise medicine. (Beware of this line; it sometimes contains a big hidden hook.) X's contract also had a curious provision, which restricted Dr. Brown's right to practise not only within the same city, but even within the same county, if he chose to leave the company's practice. He would have been required to pay a large penalty to the corporation in the event that he were to set up his own practice in the same location. It is doubtful
whether this provision is enforceable and I suspect the main purpose of this company was pure intimidation. It is highly unusual for any employment contract between physician and employer to contain a penalty clause. There were a number of other questionable items in this contract, but the outstanding feature was that Dr. Brown had very little awareness of what other practices were offering in the community and what an appropriate employment contract in the United States should contain. He had bought into Company X's line "We'll take care of business, all you have to concern yourself with is practising medicine." Now Dr. Brown was about to feel the hook on the end of the line. Specialty back-up poor
I made several telephone calls to colleagues in the area and found out that the specialty back-up in the area was quite poor, and it was nearly impossible for new family physicians to arrange for on-call coverage. The family physician in the closest town was earning approximately $60 000 per year and having approximately 6 weeks off for vacation. This family physician was offering a new partner a 1st year guarantee of $45 000 per year and the specialty back-up, hospital and quality of this town were superior to that of X. After Dr. Brown and I had a brief discussion about employment contracts and opportunities available within California, he decided to call the corporation and tell them he would pay for his own trip. At that point, Dr. Brown's prospects began to look up. Our family practice residency program receives many inquiries from rural and semi-rural physicians desperately looking for partners. This is true at residencies throughout the United States. Dr. Brown and 1 sorted through these job offers, and he found several in areas that interested him. After several calls to these physicians he set off, map in Dr. Goldsmith is a gradtiate of McMaster University and the family practice residency program at Sunnybrook Hospital, University of Toronto. He is now coordinator of practice management programs and acting director of the undergraduate program in family practice at the school of medicine, University of California at Davis, CA 95616.
hand, to seek his own opportunities. He made remarkably rapid progress. Within 3 days he had met a compatible family physician who made him a partnership offer. He was amazed at the improvement in earnings, working conditions and fringe benefits in this practice versus that offered by X. Having once been burned, he checked out several other positions available in the community. He came back and chatted with me for another half hour about this practice. I gave him some basic articles that outline some specific questions he needed to ask himself and his prospective partner before he signed any contract. I recommended that he get in touch with a practice management consultant or an attorney specifically involved with medical contracts to assist him with his partnership agreement. There are many resources for this type of information; most residency programs are able to identify practice opportunities, direct you to areas of physician shortage and point you to a practice management consultant or attorney. Immigration and medical licensure concerned Dr. Brown, and this was one of the factors that originally drove him toward the hospital corporation and professional recruiter. Dr. Brown's prospective partner (Dr. "Smith") was so excited about having located a new partner that he went out of his way to assist. He put Brown in direct contact with the licensing board and also assisted in the immigration procedure which, due to new laws, have made it easier for Canadian-trained physicians to immigrate. This made economic sense to Dr. Smith, in that recruiters were currently asking for $4000 to $6000 per MD applicant they referred. Dr. Smith identified a local immigration attorney, who told him that Dr. Brown would be able to handle the immigration protocol himself. If any problem occurred, the attorney would be available. As it turned out, no legal help was required. Even if a situation arose that warranted the attorney's assistance, the legal fees would have been significantly less
than the recruiter's fees. The next phase was contacting the local hospital administrator regarding privileges for Dr. Brown. The hospital administrator was excited about having a new practitioner
CMA JOURNAL/OCTOBER 7, 1978/VOL. 119 785
in town, for it meant additional use of his hospital. Joining the hospital staff was equally easy; securing privileges after Dr. Smith's recommendation and evidence of Dr. Brown's educational background was no problem at all. One problem, did occur - the immigration status of Dr. Brown was delayed slightly. The recruiting physician called his local congressman and explained the situation. The congressman assisted in expediting the matter. In the United States, the medical profession still has a very powerful influence on its local representatives. The congressman, of course, was acting out of his own self-interest in that his name was associated with finding a new physician for this underserved community within his district. Several other Canadian physicians that I worked with have had no problem with immigration. Licensure in California was no problem as Dr. Brown had passed his Flex examinations one year previously. This is only one example of a physician who was able to find an excellent practice opportunity without the use of a large corporation, multistate non-profit placement corporation or professional recruiter. I have assisted others in this way and
they have also had few problems. * In any visit to the United As far as academic family practice States, elicit a number of offers, some is concerned, most programs are of which might come from a hospital happy to assist in finding or recom- corporation, a partnership or a premending physicians for underserved paid health plan. Do not accept any areas. Most state medical associa- offer which pays transportation yet tions also keep a list of practice op- restricts the freedom to assess the portunities available. There are alter- job market. If recruited by a primary natives to using a physician recruiter care group or hospital corporation, or large non-profit prepaid health talk to physicians already employed plan - for example the Kaiser by that corporation about whether it Foundation in California, and Group lives up to the letter of the contract. Health in Washington. Or the pros* Talk to other doctors within pective migrant could locate a small the same community about the hosprimary care group or emergency pital corporation or partner who has room group that has 5 to 10 practices within one state and is locally offered a position. Is the doctor recontrolled. Such a group will set up spected? How many associates has a practice, handle billing and hiring this doctor had in the practice who and assist in all the practice manage- have left? Is this physician a rement details in exchange for a per- spected member of the hospital staff? centage of the billing. Once again, I * Ask for an conwould not ask these' groups to pay tract that specificallyemployment spells out rights transportation if this in any way and obligations during compromises ability to visit other of practice and makesthea 1st year practice sites. I would also hesitate in statement about what will takedefinite accepting a position without guar- during the 2nd and 3rd yearsplace of antees about future partnership. practice. It is essential to show this I urge the migrant physician not document to an unbiased adviser beto join a practice that simply "takes fore signing. care of all the management details." I have seen too many physicians * A common reason physicians leave this arrangement after a short leave a practice is because of their period. I recommend four steps that spouse's unhappiness with the locawill maximize the opportunity to find tion. The move should be fully disthe best practice: cussed with the spouse.E
Salt and sugar in the diet D.J.R. ROWE You might call me a salt freak. Give me a pizza, for instance, that is already loaded with highly spiced goodies, and before even tasting it, I'm likely to be picking up the salt cellar. So it was with more than mild interest that I read a recent article (MORGAN T ET AL:
Hypertension
treated by salt restriction. Lancet 1: 227: 1978) calling for efforts to reduce salt consumption. This led to an investigation into per-capita consumption, official attitudes and regulatory machinery, and it ultimately branched off into a brief look at other foods that, like salt, are pleasant and sometimes even necessary items of diet in moderation, but may be dangerous taken in excess. But what is excess? A 1976 report
by a Department of National Health and Welfare sponsored committee, chaired by Dr. Fraser Mustard, had this to say: Although the evidence relating salt and hypertension remains controversial, it would appear prudent to reduce the present excessive consumption of salt in our society. There is good evidence that the modest salt restriction which might be achieved would not be associated with any harmful effects to adults nor would it interfere with growth or development in children (Dahl, 1958). Especially pertinent would be a change in the current practice of substituting cow's milk for breast milk (cow's milk contains roughly twice as much sodium as breast milk). Morgan studied 31 Australian patients with diastolic blood pressures
786 CMA JOURNAL/OCTOBER 7, 1978/VOL. 119
of 95 to 109 mm Hg over 2 years. Salt restriction reduced the diastolic blood pressure by 7.3 ± 1.6 mm Hg, "a result similar to that in patients treated with antihypertensive drugs." The authors conclude: "Our findings have wider implications, and taken with other evidence suggest that if the mean sodium intake of the Australian population were reduced from 190 mmol/d to 100 mmol/d then the epidemic of hypertension would be prevented. This statement does not imply that excessive sodiumchloride intake is the underlying cause in every case of hypertension. but emphasizes that many of its causes do not operate if the sodium intake is low." However, added the Australians, the high sodium content of many
Action: The large crystal size of Macrodantin (nitrofurantoin macrocrystals) provides the proven clinical efficacy of Furadantin (nitrofurantoin) but with increased gastrointestinal tolerance. In a comparative clinical study the incidence of nausea and/or emesis was appreciably less with Macrodantin than with Furadantin. Patients unable to tolerate Furadantin reported good tolerance of Macrodantin. Indications: Macrodantin is indicated for the treatment of pyelonephritis, pyelitis and cystitis caused by sensitive organisms. Contraindicatlons: Anuria, oliguria or extensive impairment of renal function. Infants under one month. Warnings: Haemolytic anaemia, which disappears on cessation of drug therapy has been reported in sensitive individuals. Usually defined as the 10% of negroes and lower percentages of people of Mediterranean and near Eastern origin who exhibit glucose-6---phosphate dehydrogenase deficiency of the red blood cells. Safety during pregnancy and lactation has not been established. Precautions: Peripheral neuropathy has been reported with nitrofurantoin. This may become severe and irreversible and one fatality has been reported. Therapy should be discontinued if numbness and tingling occur. Macrodantin should not be co-prescribed with drugs which impair renal function. Adverse Reactions: Nausea, emesis, and less frequently, diarrhea may occur; reduction in dosage may alleviate these symptoms. Sensitization appearing as an erythematous, maculopapular cutaneous eruption, urticaria, eczematoid eruption or pruritus has occurred. Hypersensitivity reactions resulting in nonfatal anaphylaxis, angloedenia, pulmonary infiltration with pleural effusion and eosinophilia have been reported. Other possible reactions are chills, lever, jaundice, asthmatic symptoms, and hypotension. Occasional minor reactlons such as headache, dizziness, nystagmus, vertigo, drowsiness, malaise, and muscular aches have occurred Transient alopecia has been reported. Leukopenia, including granulocytopenia has been reported rarely. Return of the blood picture to normal has followed cessation of therapy. As with other antimicrobial agents, superintections by resistant organisms may occur. With Macrodantin, however, these are limited to the genitourinary tract because suppression of normal bacterial flora elsewhere in the body does not occur. Administration and Dosage: Dosage: Adult: 5010100 milligrams four times a day. Children: Should be calculated on the basis of 5 to 7 milligrams per kilogram (2.2 to 3.2mg per Ib) of body weight per 24 hours, to be given in divided doses four times a day (contraindicated under one month of age.) Administration: Macrodantin (nitrofurantoin macrocrystals) may be given with food or milk to further minimize gastric upset. Therapy should be continued for at least one week and for at least3 days after sterility of the urine is obtained. Continued infection indicates the need for re-evaluation. If the drug is to be used for long-term suppressive therapy, a reduction of dosage should be considered. How Suppiied: Macrodantin is available in opaque white imprinted capsules ol 25 mg (Eaton 007) in bottles of 30, l00and 500 capsules; opaque yellow/white imprinted capsules 0150mg (Eaton 008) in bottles of 30,100 and 500 capsules; opaque .eHowjmpnntedcapsules ol 100mg (Eaton 009) in bottles of 500 capsules. Product monograph avaiiabie on request. Originators and Developers of the Nitrofurans ! EATON LABORATORIES Division of Norwich Pharmacai Company Ltd. EMA-812.E Paris, Ontario
try to attract research industries to the province. The government also is offering awards to postdoctoral researchers through a program in cooperation with local industries. The government will pay $12 000 to a doctoral graduate from BC during his first year if he is working in research for a BC industry. As well, the government now is offering graduate research, educational and technical (GREAT) awards for projects approved by a local industry and now is trying to extend these awards for undergraduate levels as well. It is amazing to watch the change that comes over McGeer whenever conversation shifts from his political role to his medical role. When he discusses politics, even the sticky moments, he throws himself into his wing chair, occasionally sprawling comfortably, and invariably smiling and affable. Switch the topic to medicine and he immediately becomes serious. When pressed for information about his current work, he often rises and paces the floor like an Oxford don, head down, hands behind his back, and he hovers over his statements in an effort to be precise and completely understood. In Wilmington, he met Dr. Edith Graef, a fellow PhD in chemistry, and within months had married her. The couple returned to Vancouver, where Pat McGeer went back to medical school, then into brain research. Both now are with the Kinsman laboratory of neurological research in the department of psychiatry at UBC. Although Pat McGeer is officially on leave, he often supervises doctoral research and participates in some clinical trials. He
continues to publish papers and each year accepts about 10 of some 50 invitations to participate in international conferences. He is currently completing two medical texts that probably will be released later this year. The first is a basic text, "Neurobiology of the brain", coauthored with his wife and Sir John Eccles, winner of a Nobel prize for his work in neurophysiology. The second book, "Kainic acid as a neurological tool", is edited by the two McGeers and will contain the latest papers related to this analog of glutamic acid. Kainic acid, explains McGeer, is derived from seaweed and destroys neurons that have a high concentration of glutamate receptors and therefore is a relatively selective neurotoxic material. For example, when injected into the basal ganglia, it has effects on the behavioural sequelae in Huntington's chorea. "Most of the work I do now and have always done is basic research. It lends itself frequently to clinical trials based on research findings in the laboratory. For example, if we uncover biochemical defects in Huntington's chorea, as we have done in the last 3 to 4 years, then clinical trials are indicated." His almost passionate responses to his medical work seem to contrast to his easygoing approach to his political role. Yet there also seems a certain similarity in the approach of both politician and brain researcher. In both he seems to be single-mindedly working toward some distant goal and is undeterred by a few failures in current experiments because he is supremely confident of the eventual outcome. U
Physician migration: Beware the easy way GEOFFREY GOLDSMITH, MD
Most organizations - hospital corporations or multistate nonprofit placement agencies - that recruit Canadian physicians for posts in the US are honest and reliable agents. In this I agree with the articles of Korcok (CMAJ 118: 980 and 1156, 1978). There are, however, a small number of companies with which an
individual may come into contact that take advantage of the Canadian physician. My experience is that there are unscrupulous groups that cause Canadian physicians first to move to the US and then to have to relocate because of problems with employers. A Canadian acquaintance of mine
- call him Dr. Brown - finished his family practice residency several years ago. Becoming less and less enchanted with the role of the government in his practice, he was anxious to leave Canada for practice in the United States. He contacted a Canadian-based recruiting firm (call it X), which put him in contact with an American company that had several practice sites available in California, Nevada and Arizona. Dr. Brown was told by X that, even if he did not agree to accept any of the practices, he would be paid half of his expenses for a week-long visit. It seemed to Dr. Brown that he could not lose in this arrangement. It would, he felt, provide him with an inexpensive way to view a number of practice settings and learn more about groups. To ensure this, X's representatives literally shadowed Dr. Brown day and night. He did escape for one evening and contacted me to ask my opinion about the opportunities they offered him. Briefly, he was being offered $34 000 a year to start, with guarantees for much higher earnings in the next 2 or 3 years, although the contract was strikingly vague about the details of this future guarantee. Oncall coverage was also unclear within the contract but the recruiter assured him that it would be easy to contact other doctors in the community to cover calls. Specialist consultation was the major concern of Dr. Brown and he was reassured that many consultants were "easily available in the nearby town." Only 2 weeks of vacation were allowed during the 1st year. Two additional weeks of educational leave were to be paid. The recruiter assured him this was the very best offer he could get within the particular community and that the company would be assuming all the financial risks and taking care of all the paper work. All he had to do was practise medicine. (Beware of this line; it sometimes contains a big hidden hook.) X's contract also had a curious provision, which restricted Dr. Brown's right to practise not only within the same city, but even within the same county, if he chose to leave the company's practice. He would have been required to pay a large penalty to the corporation in the event that he were to set up his own practice in the same location. It is doubtful
whether this provision is enforceable and I suspect the main purpose of this company was pure intimidation. It is highly unusual for any employment contract between physician and employer to contain a penalty clause. There were a number of other questionable items in this contract, but the outstanding feature was that Dr. Brown had very little awareness of what other practices were offering in the community and what an appropriate employment contract in the United States should contain. He had bought into Company X's line "We'll take care of business, all you have to concern yourself with is practising medicine." Now Dr. Brown was about to feel the hook on the end of the line. Specialty back-up poor
I made several telephone calls to colleagues in the area and found out that the specialty back-up in the area was quite poor, and it was nearly impossible for new family physicians to arrange for on-call coverage. The family physician in the closest town was earning approximately $60 000 per year and having approximately 6 weeks off for vacation. This family physician was offering a new partner a 1st year guarantee of $45 000 per year and the specialty back-up, hospital and quality of this town were superior to that of X. After Dr. Brown and I had a brief discussion about employment contracts and opportunities available within California, he decided to call the corporation and tell them he would pay for his own trip. At that point, Dr. Brown's prospects began to look up. Our family practice residency program receives many inquiries from rural and semi-rural physicians desperately looking for partners. This is true at residencies throughout the United States. Dr. Brown and 1 sorted through these job offers, and he found several in areas that interested him. After several calls to these physicians he set off, map in Dr. Goldsmith is a gradtiate of McMaster University and the family practice residency program at Sunnybrook Hospital, University of Toronto. He is now coordinator of practice management programs and acting director of the undergraduate program in family practice at the school of medicine, University of California at Davis, CA 95616.
hand, to seek his own opportunities. He made remarkably rapid progress. Within 3 days he had met a compatible family physician who made him a partnership offer. He was amazed at the improvement in earnings, working conditions and fringe benefits in this practice versus that offered by X. Having once been burned, he checked out several other positions available in the community. He came back and chatted with me for another half hour about this practice. I gave him some basic articles that outline some specific questions he needed to ask himself and his prospective partner before he signed any contract. I recommended that he get in touch with a practice management consultant or an attorney specifically involved with medical contracts to assist him with his partnership agreement. There are many resources for this type of information; most residency programs are able to identify practice opportunities, direct you to areas of physician shortage and point you to a practice management consultant or attorney. Immigration and medical licensure concerned Dr. Brown, and this was one of the factors that originally drove him toward the hospital corporation and professional recruiter. Dr. Brown's prospective partner (Dr. "Smith") was so excited about having located a new partner that he went out of his way to assist. He put Brown in direct contact with the licensing board and also assisted in the immigration procedure which, due to new laws, have made it easier for Canadian-trained physicians to immigrate. This made economic sense to Dr. Smith, in that recruiters were currently asking for $4000 to $6000 per MD applicant they referred. Dr. Smith identified a local immigration attorney, who told him that Dr. Brown would be able to handle the immigration protocol himself. If any problem occurred, the attorney would be available. As it turned out, no legal help was required. Even if a situation arose that warranted the attorney's assistance, the legal fees would have been significantly less
than the recruiter's fees. The next phase was contacting the local hospital administrator regarding privileges for Dr. Brown. The hospital administrator was excited about having a new practitioner
CMA JOURNAL/OCTOBER 7, 1978/VOL. 119 785
in town, for it meant additional use of his hospital. Joining the hospital staff was equally easy; securing privileges after Dr. Smith's recommendation and evidence of Dr. Brown's educational background was no problem at all. One problem, did occur - the immigration status of Dr. Brown was delayed slightly. The recruiting physician called his local congressman and explained the situation. The congressman assisted in expediting the matter. In the United States, the medical profession still has a very powerful influence on its local representatives. The congressman, of course, was acting out of his own self-interest in that his name was associated with finding a new physician for this underserved community within his district. Several other Canadian physicians that I worked with have had no problem with immigration. Licensure in California was no problem as Dr. Brown had passed his Flex examinations one year previously. This is only one example of a physician who was able to find an excellent practice opportunity without the use of a large corporation, multistate non-profit placement corporation or professional recruiter. I have assisted others in this way and
they have also had few problems. * In any visit to the United As far as academic family practice States, elicit a number of offers, some is concerned, most programs are of which might come from a hospital happy to assist in finding or recom- corporation, a partnership or a premending physicians for underserved paid health plan. Do not accept any areas. Most state medical associa- offer which pays transportation yet tions also keep a list of practice op- restricts the freedom to assess the portunities available. There are alter- job market. If recruited by a primary natives to using a physician recruiter care group or hospital corporation, or large non-profit prepaid health talk to physicians already employed plan - for example the Kaiser by that corporation about whether it Foundation in California, and Group lives up to the letter of the contract. Health in Washington. Or the pros* Talk to other doctors within pective migrant could locate a small the same community about the hosprimary care group or emergency pital corporation or partner who has room group that has 5 to 10 practices within one state and is locally offered a position. Is the doctor recontrolled. Such a group will set up spected? How many associates has a practice, handle billing and hiring this doctor had in the practice who and assist in all the practice manage- have left? Is this physician a rement details in exchange for a per- spected member of the hospital staff? centage of the billing. Once again, I * Ask for an conwould not ask these' groups to pay tract that specificallyemployment spells out rights transportation if this in any way and obligations during compromises ability to visit other of practice and makesthea 1st year practice sites. I would also hesitate in statement about what will takedefinite accepting a position without guar- during the 2nd and 3rd yearsplace of antees about future partnership. practice. It is essential to show this I urge the migrant physician not document to an unbiased adviser beto join a practice that simply "takes fore signing. care of all the management details." I have seen too many physicians * A common reason physicians leave this arrangement after a short leave a practice is because of their period. I recommend four steps that spouse's unhappiness with the locawill maximize the opportunity to find tion. The move should be fully disthe best practice: cussed with the spouse.E
Salt and sugar in the diet D.J.R. ROWE You might call me a salt freak. Give me a pizza, for instance, that is already loaded with highly spiced goodies, and before even tasting it, I'm likely to be picking up the salt cellar. So it was with more than mild interest that I read a recent article (MORGAN T ET AL:
Hypertension
treated by salt restriction. Lancet 1: 227: 1978) calling for efforts to reduce salt consumption. This led to an investigation into per-capita consumption, official attitudes and regulatory machinery, and it ultimately branched off into a brief look at other foods that, like salt, are pleasant and sometimes even necessary items of diet in moderation, but may be dangerous taken in excess. But what is excess? A 1976 report
by a Department of National Health and Welfare sponsored committee, chaired by Dr. Fraser Mustard, had this to say: Although the evidence relating salt and hypertension remains controversial, it would appear prudent to reduce the present excessive consumption of salt in our society. There is good evidence that the modest salt restriction which might be achieved would not be associated with any harmful effects to adults nor would it interfere with growth or development in children (Dahl, 1958). Especially pertinent would be a change in the current practice of substituting cow's milk for breast milk (cow's milk contains roughly twice as much sodium as breast milk). Morgan studied 31 Australian patients with diastolic blood pressures
786 CMA JOURNAL/OCTOBER 7, 1978/VOL. 119
of 95 to 109 mm Hg over 2 years. Salt restriction reduced the diastolic blood pressure by 7.3 ± 1.6 mm Hg, "a result similar to that in patients treated with antihypertensive drugs." The authors conclude: "Our findings have wider implications, and taken with other evidence suggest that if the mean sodium intake of the Australian population were reduced from 190 mmol/d to 100 mmol/d then the epidemic of hypertension would be prevented. This statement does not imply that excessive sodiumchloride intake is the underlying cause in every case of hypertension. but emphasizes that many of its causes do not operate if the sodium intake is low." However, added the Australians, the high sodium content of many
