Atromid.S* (clofi brate) to lower blood lipids safely and effectively Indications ATROMID-S is indicated where reduction of blood lipids is desirable; e.g., patients with hypercholesterolemia and/ or hypertriglyceridemia. Contralndicatlons While teratogenic studies have not demonstrated any effect attributable to ATROMID-S, its use in nonpregnant women of childbearing age should only be undertaken in patients using strict birth control measures. If these patients then plan to become pregnant, the drug should be withdrawn several months before conception. The drug should not be given to lactating women. ATROMID-S is not recommended in children since, to date, an insufficient number of cases have been treated. ATROMID-S is not recommended for patients with impaired renal or hepatic function. Warning Caution should be exercised when anticoagulants are given in conjunction with ATROMID-S. The dosage of the anticoagulant should be reduced by one-third to one-half (depending on the individual case) to maintain the prothrombin time at the desired level to prevent bleeding complications. Frequent prothrombin determinations are advisable until it has been definitely determined that the levels have been stabilized. For PRECAUTIONS and ADVERSE REACTIONS, see scientific brochure. Dosage and Administration For adults only: One capsule (500 mg) four times daily. Availability No. 3243 Each capsule contains 500 mg clofibrate N.F. in bottles of 100 and 360. Further information, references, and scientific brochure available on request.
.
. 0
0 -
AYERST LABORATORIES, division of Ayerst, McKenna & Harrison Limited, Montreal, Canada Made in Caneda by arrangement with IMPERIAL CHEMICAL INDUSTRIES LTD. Regd.
Psychiatrists and medical education A systematic, planned training for psychiatry residents, documented by a logbook for each student, was urged by Dr. Myre Sim, Ottawa. "Psychiatry is an important branch of medicine with serious responsibilities, very often involving life and death or the risk of chronic and total disability," he told the meeting. "If there is competence to be learned, it should be defined and taught, and it would be negligence to let a psychiatrist loose in the community if he had failed to acquire the desired level of competence." Dr. Sim refuted the criticism that a logbook system is too rigid and does not allow the resident sufficient freedom to indulge his interests and grow as an individual. "The notion that psychiatry is vague and indefinite, that formal psychiatric training is irrelevent and that anybody who likes working with people can do just as well can only be dispelled by turning out competent psychiatrists," he said. "Would one consider a policy of laissez-faire in the training of airline pilots or - to bring the lesson nearer home - surgeons?" He proposed that a logbook form a continuous record of a resident's activities, complete with attendance records at lectures, seminars, discussion groups and journal clubs. Also it should record the resident's clinical experience. Performance could be marked in four grades. Dr. Sim said a study of the logbook would indicate deficiencies that need to be remedied. This would require additional paperwork by the tutor, Dr. Sim acknowledged. But in fact, "the actual documentation is very simple and not time-consuming." The dividend of better assessment, better checks on the curriculum and a better product outweighs any inconvenience, he declared. A paper by Drs. Judith Gold and Charles David of Dalhousie drew attention to the changes in emphasis in psychiatry to a more biologic approach and discussed the implications of these changes in the training of residents. A survey of full- and part-time staff of the university's department of psychiatry showed a unanimous opinion that present training in psychotherapy is not satisfactory. Reasons given for this varied from poor staff motivation to poor selection of residents to a lack of departmental emphasis on psychotherapy and psychodynamics to improper use of supervisory time. "All the staff felt that the most
important factor in their own training was long-term supervised psychotherapy with suitable patients," the authors reported. Staff members commented that they are (some of them) disinterested in teaching, the quality of their supervision is inadequate, they require instruction to be supervisors and often do not demand process notes or recordings of interviews. The department has set up a committee to ensure that "the teaching of psychotherapeutic skills and theories will be an essential part of the residents' training," added Gold and David. Three years ago the University of Western Ontario introduced a new curriculum, which cut out one of the preclerkship years. Thus the 3rd year became the clinical clerkship and the 4th year became an elective experience. This in turn meant that the last of the old curriculum students and the first of the new curriculum students were doing their psychiatric clerkships at the same time. Drs. J.E. Bishop and E.M. Waring reported on a study of the two groups, each of about 100 students, to assess the results of their training. The authors studied examination results, applied the Shepherd physician attitude scale, had the students write an essay and assessed clinical performance through a rating by the supervisors and by the students themselves. "Overall the 3rd-year students were just as good as, and on some scales better than, the 4th-year students," reported Bishop and Waring. The 3rdyear students scored better on the psychiatry part of the neurosciences and the mind examination, on the supervisors' rating, on one subsection of the Shepherd scale and on the essay. They showed a significantly more negative attitude toward psychiatrists and psychiatric referral at the beginning of their rotation; by the end, however, there was no difference in this respect between the two groups. The authors plan to continue study of the two groups through LMCC results, choice of future training, career choice and use of skills in their practices. Dr. Robert Krell of Vancouver suggested psychiatric trainees be subject to a selection procedure at the end of their 1st year of residency. It is not possible, he said, to determine clinical competence by interviews before training commences. This comes to light only with involvement with patients, staff and supervisors. "Adequate performance with patients, peers and
CMA JOURNAL/OCTOBER 23, 1976/VOL. 115 791
VermOXi.abets (mebendazole) One tablet, 950/o effective against pinworm *No dosage calculation. sWill not stain. eMinimal absorption. * Broad-Spectrum Efficacy. INDICATIONS & CLINICAL USES: VERMOX has a broad-spectrum of anthelmintic activity and is effective in the treatment of single or mixed helminthic infestations. Clinical studies have shown it effective in the treatment of Enterobius vermicularis (pinworm); Ascaris lumbricoides (roundworm); Trichuris trichiura (whipworm); Ancylostoma duodenale and Necator americanus (hookworm). It has also been used to treat infections due to Taenia solium (large tapeworms). CONTRAINDICATIONS: Animal trials conducted in a wide range of species revealed an embryotoxic and teratogenic effect in the rat. Also, the safety of use in pregnant women has not been established. Therefore, VERMOX should not be administered during pregnancy, particularly in the first trimester, unless the potential benefit to the patient outweighs the possible risk to the fetus. PRECAUTIONS: As with all new drugs, every patient should be carefully checked to detect any alteration in blood studies or hepatic or renal function tests following treatment with VERMOX. Special attention should be given to patients with intestinal pathology (e.g. Crohns Ileitis, ulcerative colitis). Since VERMOX has not been extensively studied in infants under two years of age, its use in such individuals should only be implemented in cases where the potential therapeutic effects outweigh the possible hazard to the patient. DOSAGE AND ADMINISTRATION: The same dosage applies to children (above two years of age) and adults. Pinworm Enterobiasis -One tablet Whipworm Trichuriasis -' RoundwormAscarias,s -One tablet bid. for Hookworm Necatoriasis, 3 consecutive days Ancylostomiasis -' If the patient is not cured three weeks after treatment, a second course of therapy is advised. No special procedures, such as fasting or purging are required. PACKAGING: VERMOX is available as tablets, each containing 100 mg. of mebendazole, in bottles of twelve (12) tablets. EFFICACY: Efficacy varies in function of such factors as preexisting diarrhea and gastrointestinal transit time, degree of infection and helminth strains. Efficacy rates derived from various studies are shown in the table below. _______ Whipworm Roundworm Hookworm Pinworm Cure rates mean 68% 98% 96% 95% (range) (61-75%) (91.100%) (90-100% egg reduction mean 93% 99.7% 99.9% (range) (70-99%) (99.5-100%) -Product Monograph Avallabloto Physicians and Phaimaclats on RequosL
PHARMACEUliCAL .(CANALY) LID-DON MILLSONTARIC
*Tredem.
© ORTHO 1976
others early in training might serve as a reasonable predictor to the second objective of demonstrating knowledge and skills under exam conditions," he said. Dr. Krell noted the many colleagues who have finished training but are unable to pass the royal college exams. "A fairly typical sequence appears. to be one where a resident finishes 1 year of psychiatry with dubious distinction. Is it fair to pass such a person to 2nd year knowing that the critique of his or her work is such as to seriously place in question the issue of eventual success?" He cited two cases where residents in their 1st year showed unsuitability for psychiatry. They nevertheless rejected criticism and continued in their programs. Both were "bright, challenging and reasonable candidates on first sight it was relatively easy for each to become a 1st-year resident on the basis of minimal information. "It proved almost impossible not to advance them to 2nd year when in fact there was now much information, most of which suggested promotion to be inadvisable." Dr. Roger Boutin of Ottawa favoured emphasis on self-evaluation. He called for immersion "from the beginning" into an experience of intensive psychotherapy where nothing else takes precedence over it. "There is no shame in not being a psychotherapist, but there is in pretending to be," he told the meeting. "We all have an obligation to recognize what we are not able, not trained or not free to do (or to teach)." His ideal training program would have residents beginning with the sickest patients - including at least one schizophrenic patient - at a provincial type of hospital. "Outpatients and neLirotics seem a better choice after the 1st year and children after the 2nd or
3rd year," he added. He proposed a weekly session with a different supervisor for each patient followed in the 1st year, with supervision in small groups in later years. He urged provision for training in group and family therapy. Dr. Boutin pointed out that residents tend to imitate their teachers, who accordingly "need to keep a sharp eye on themselves." He concluded: "We can also feel an obligation to promote these very types of treatment that may be effective in depth, over many generations even, and not only the easy, popular measures that may give transient relief but no long-term gains (and possibly some long-term losses). In our age of technology we are not threatened so much by the dehumanization of machines as by the dehumanization of humans... In the discussions on the medical education of psychiatrists, there was little dispute over the objective - to produce, as Dr. Michael Thompson of London stated, "safe, sound, knowledgeable specialist clinicians". But the methods for arriving at this elusive goal, he added, are both legion and everchanging. How then to test the results? Dr. Thompson described a program audit he has developed and used at the University of Western Ontario. This consists of forms to be filled in by members of the postgraduate education committee and residents at UWO, evaluating structure, process and outcome of the program. This is achieved by a single list of questions. Dr. Thompson said the evaluation technique could obtain fairly precise judgements about structure of the program and subjective, but usable, judgements on the process. Outcome and cost-benefits could only be assessed on a very broad subjective basis, however.
Psychiatrists and children The inadequacies of the judicial system in dealing with children in divorce situations were dealt with by a panel of four Vancouver psychiatrists, all of whom had an involvement with the family courts there. British Columbia has been making a re-examination of its treatment of such children through a royal commission, and one result of this has been the drafting of new statutes and guidelines, although these have not yet become law. The psychiatric consultant to the commission was Dr. Susan Stephenson, who was leadoff speaker for the symposium. Existing law on divorce, Dr. Ste-
phenson said, is based mainly on outdated British concepts that stem from the UK's 1857 Matrimonial Causes Act. That act was passed as an expression of Victorian morals, sentiment and economics. In the mid-l9th century marriage was seen as an answer to women's economic problems and a man was required to provide for his wife unless fault could be shown. Thus the concept of matrimonial fault has entered the divorce court, dragging with it the adversary system. This tends to escalate the bitterness and hostility of the proceedings; the dissolving partners are given a motive for public recriminations. Dr. Stephenson saw an
CMA JOURNAL/OCTOBER 23, 1976/VOL. 115
793
.
. 0
0 -
AYERST LABORATORIES, division of Ayerst, McKenna & Harrison Limited, Montreal, Canada Made in Caneda by arrangement with IMPERIAL CHEMICAL INDUSTRIES LTD. Regd.
Psychiatrists and medical education A systematic, planned training for psychiatry residents, documented by a logbook for each student, was urged by Dr. Myre Sim, Ottawa. "Psychiatry is an important branch of medicine with serious responsibilities, very often involving life and death or the risk of chronic and total disability," he told the meeting. "If there is competence to be learned, it should be defined and taught, and it would be negligence to let a psychiatrist loose in the community if he had failed to acquire the desired level of competence." Dr. Sim refuted the criticism that a logbook system is too rigid and does not allow the resident sufficient freedom to indulge his interests and grow as an individual. "The notion that psychiatry is vague and indefinite, that formal psychiatric training is irrelevent and that anybody who likes working with people can do just as well can only be dispelled by turning out competent psychiatrists," he said. "Would one consider a policy of laissez-faire in the training of airline pilots or - to bring the lesson nearer home - surgeons?" He proposed that a logbook form a continuous record of a resident's activities, complete with attendance records at lectures, seminars, discussion groups and journal clubs. Also it should record the resident's clinical experience. Performance could be marked in four grades. Dr. Sim said a study of the logbook would indicate deficiencies that need to be remedied. This would require additional paperwork by the tutor, Dr. Sim acknowledged. But in fact, "the actual documentation is very simple and not time-consuming." The dividend of better assessment, better checks on the curriculum and a better product outweighs any inconvenience, he declared. A paper by Drs. Judith Gold and Charles David of Dalhousie drew attention to the changes in emphasis in psychiatry to a more biologic approach and discussed the implications of these changes in the training of residents. A survey of full- and part-time staff of the university's department of psychiatry showed a unanimous opinion that present training in psychotherapy is not satisfactory. Reasons given for this varied from poor staff motivation to poor selection of residents to a lack of departmental emphasis on psychotherapy and psychodynamics to improper use of supervisory time. "All the staff felt that the most
important factor in their own training was long-term supervised psychotherapy with suitable patients," the authors reported. Staff members commented that they are (some of them) disinterested in teaching, the quality of their supervision is inadequate, they require instruction to be supervisors and often do not demand process notes or recordings of interviews. The department has set up a committee to ensure that "the teaching of psychotherapeutic skills and theories will be an essential part of the residents' training," added Gold and David. Three years ago the University of Western Ontario introduced a new curriculum, which cut out one of the preclerkship years. Thus the 3rd year became the clinical clerkship and the 4th year became an elective experience. This in turn meant that the last of the old curriculum students and the first of the new curriculum students were doing their psychiatric clerkships at the same time. Drs. J.E. Bishop and E.M. Waring reported on a study of the two groups, each of about 100 students, to assess the results of their training. The authors studied examination results, applied the Shepherd physician attitude scale, had the students write an essay and assessed clinical performance through a rating by the supervisors and by the students themselves. "Overall the 3rd-year students were just as good as, and on some scales better than, the 4th-year students," reported Bishop and Waring. The 3rdyear students scored better on the psychiatry part of the neurosciences and the mind examination, on the supervisors' rating, on one subsection of the Shepherd scale and on the essay. They showed a significantly more negative attitude toward psychiatrists and psychiatric referral at the beginning of their rotation; by the end, however, there was no difference in this respect between the two groups. The authors plan to continue study of the two groups through LMCC results, choice of future training, career choice and use of skills in their practices. Dr. Robert Krell of Vancouver suggested psychiatric trainees be subject to a selection procedure at the end of their 1st year of residency. It is not possible, he said, to determine clinical competence by interviews before training commences. This comes to light only with involvement with patients, staff and supervisors. "Adequate performance with patients, peers and
CMA JOURNAL/OCTOBER 23, 1976/VOL. 115 791
VermOXi.abets (mebendazole) One tablet, 950/o effective against pinworm *No dosage calculation. sWill not stain. eMinimal absorption. * Broad-Spectrum Efficacy. INDICATIONS & CLINICAL USES: VERMOX has a broad-spectrum of anthelmintic activity and is effective in the treatment of single or mixed helminthic infestations. Clinical studies have shown it effective in the treatment of Enterobius vermicularis (pinworm); Ascaris lumbricoides (roundworm); Trichuris trichiura (whipworm); Ancylostoma duodenale and Necator americanus (hookworm). It has also been used to treat infections due to Taenia solium (large tapeworms). CONTRAINDICATIONS: Animal trials conducted in a wide range of species revealed an embryotoxic and teratogenic effect in the rat. Also, the safety of use in pregnant women has not been established. Therefore, VERMOX should not be administered during pregnancy, particularly in the first trimester, unless the potential benefit to the patient outweighs the possible risk to the fetus. PRECAUTIONS: As with all new drugs, every patient should be carefully checked to detect any alteration in blood studies or hepatic or renal function tests following treatment with VERMOX. Special attention should be given to patients with intestinal pathology (e.g. Crohns Ileitis, ulcerative colitis). Since VERMOX has not been extensively studied in infants under two years of age, its use in such individuals should only be implemented in cases where the potential therapeutic effects outweigh the possible hazard to the patient. DOSAGE AND ADMINISTRATION: The same dosage applies to children (above two years of age) and adults. Pinworm Enterobiasis -One tablet Whipworm Trichuriasis -' RoundwormAscarias,s -One tablet bid. for Hookworm Necatoriasis, 3 consecutive days Ancylostomiasis -' If the patient is not cured three weeks after treatment, a second course of therapy is advised. No special procedures, such as fasting or purging are required. PACKAGING: VERMOX is available as tablets, each containing 100 mg. of mebendazole, in bottles of twelve (12) tablets. EFFICACY: Efficacy varies in function of such factors as preexisting diarrhea and gastrointestinal transit time, degree of infection and helminth strains. Efficacy rates derived from various studies are shown in the table below. _______ Whipworm Roundworm Hookworm Pinworm Cure rates mean 68% 98% 96% 95% (range) (61-75%) (91.100%) (90-100% egg reduction mean 93% 99.7% 99.9% (range) (70-99%) (99.5-100%) -Product Monograph Avallabloto Physicians and Phaimaclats on RequosL
PHARMACEUliCAL .(CANALY) LID-DON MILLSONTARIC
*Tredem.
© ORTHO 1976
others early in training might serve as a reasonable predictor to the second objective of demonstrating knowledge and skills under exam conditions," he said. Dr. Krell noted the many colleagues who have finished training but are unable to pass the royal college exams. "A fairly typical sequence appears. to be one where a resident finishes 1 year of psychiatry with dubious distinction. Is it fair to pass such a person to 2nd year knowing that the critique of his or her work is such as to seriously place in question the issue of eventual success?" He cited two cases where residents in their 1st year showed unsuitability for psychiatry. They nevertheless rejected criticism and continued in their programs. Both were "bright, challenging and reasonable candidates on first sight it was relatively easy for each to become a 1st-year resident on the basis of minimal information. "It proved almost impossible not to advance them to 2nd year when in fact there was now much information, most of which suggested promotion to be inadvisable." Dr. Roger Boutin of Ottawa favoured emphasis on self-evaluation. He called for immersion "from the beginning" into an experience of intensive psychotherapy where nothing else takes precedence over it. "There is no shame in not being a psychotherapist, but there is in pretending to be," he told the meeting. "We all have an obligation to recognize what we are not able, not trained or not free to do (or to teach)." His ideal training program would have residents beginning with the sickest patients - including at least one schizophrenic patient - at a provincial type of hospital. "Outpatients and neLirotics seem a better choice after the 1st year and children after the 2nd or
3rd year," he added. He proposed a weekly session with a different supervisor for each patient followed in the 1st year, with supervision in small groups in later years. He urged provision for training in group and family therapy. Dr. Boutin pointed out that residents tend to imitate their teachers, who accordingly "need to keep a sharp eye on themselves." He concluded: "We can also feel an obligation to promote these very types of treatment that may be effective in depth, over many generations even, and not only the easy, popular measures that may give transient relief but no long-term gains (and possibly some long-term losses). In our age of technology we are not threatened so much by the dehumanization of machines as by the dehumanization of humans... In the discussions on the medical education of psychiatrists, there was little dispute over the objective - to produce, as Dr. Michael Thompson of London stated, "safe, sound, knowledgeable specialist clinicians". But the methods for arriving at this elusive goal, he added, are both legion and everchanging. How then to test the results? Dr. Thompson described a program audit he has developed and used at the University of Western Ontario. This consists of forms to be filled in by members of the postgraduate education committee and residents at UWO, evaluating structure, process and outcome of the program. This is achieved by a single list of questions. Dr. Thompson said the evaluation technique could obtain fairly precise judgements about structure of the program and subjective, but usable, judgements on the process. Outcome and cost-benefits could only be assessed on a very broad subjective basis, however.
Psychiatrists and children The inadequacies of the judicial system in dealing with children in divorce situations were dealt with by a panel of four Vancouver psychiatrists, all of whom had an involvement with the family courts there. British Columbia has been making a re-examination of its treatment of such children through a royal commission, and one result of this has been the drafting of new statutes and guidelines, although these have not yet become law. The psychiatric consultant to the commission was Dr. Susan Stephenson, who was leadoff speaker for the symposium. Existing law on divorce, Dr. Ste-
phenson said, is based mainly on outdated British concepts that stem from the UK's 1857 Matrimonial Causes Act. That act was passed as an expression of Victorian morals, sentiment and economics. In the mid-l9th century marriage was seen as an answer to women's economic problems and a man was required to provide for his wife unless fault could be shown. Thus the concept of matrimonial fault has entered the divorce court, dragging with it the adversary system. This tends to escalate the bitterness and hostility of the proceedings; the dissolving partners are given a motive for public recriminations. Dr. Stephenson saw an
CMA JOURNAL/OCTOBER 23, 1976/VOL. 115
793
