CORRESPON DENCE
family physician's office have nonsurgical problems of the musculoskeletal system, for which there is To the editor: I read with interest often an easy diagnostic and therathe report by Charlotte Gray about peutic modality available.1 As these the problem of paramedics trying to modalities 'are not taught in medical do more and more in the medical school, they are virtually unknown field (Can Med Assoc 1 119: 370, to most family physicians. Therefore, 1978). patients with these problems must I am very sympathetic with the seek help from lay manipulators. plight of physiotherapists who are D.M. FRASER, MD well trained and capable in the diag145 Queenston St., Ste. B7 nosis of lesions of the musculoskelSt. Gatharines, Ont. etal system, perhaps more so than many of our family physicians and References orthopedic surgeons. One article 1. CYRIAX J: Personal view. Br Med J written by Dr. James Cyriax,1 an 4: 292, 1972 orthopedic physician, aptly expresses 2. Idem: Textbook of Orthopaedic Medicine, vol 1, Diagnosis of Soft Lethe problem in the diagnosis and sions, 6th ed, Williams & Wilkins, treatment of musculoskeletal disBaltimore, 1975 orders today. Indeed, he has proposed that the only way we can avoid To the editor: I find it interesting treatment by lay manipulators (e.g., that Dr. John Bennett, as the director chiropractors, osteopaths and foot- of professional affairs of the Canaball trainers) is to have an adequate dian Medical Association, has done body of trained family physicians so little research into the training of who are able to recognize and diag- podiatrists. Dr. Bennett and many nose the lesions and then, if they other physicians refer to podiatrists cannot give the necessary treatment, as a "nonmedical professional health refer the patients to physiotherapists group [demanding] to be allowed to who are equally well trained. Simi- practise primary health care". larly, all medical students learn to I invite Dr. Bennett to visit one recognize the signs and symptoms of of the colleges of podiatric medicine acute appendicitis, yet few family in the United States; he would disphysicians perform appendectomies. cover that the students there are The dilemma, however, is that taught to "generalize before specialthere are very few trained orthopedic izing." Schools of podiatric medicine physicians, but Cyriax gives 8 to 10 are graduating doctors who, in fact, courses per year in the United States are trained as physicians specialized and occasionally in Canada. If in treating disorders of the feet and courses in orthopedic medicine could related structures by medical and be given at medical schools or to surgical means. Reference to podifamily physicians as part of their atrists as a nonmedical group is erfamily practice internships, the prob- roneous. A comparison of podiatric lem would be solved within a genera- and general medical education demtion. It has been shown clearly that onstrates this fact. 20% of all patients who come to a Besides taking the same Medical
Role and training of paramedical groups
122 CMA JOURNAL/JANUARY 20, 1979/VOL. 120
College Admission Test as medical students, podiatry students undergo a basic medical sciences program that is practically identical to that found in major medical schools. The questions on the national board exams of the two groups reflect this. Pharmacology and therapeutics are no exception, contrary to the thinking of Dr. Robert Clark, executive director of the Alberta Medical Association. Since the foot cannot be divorced from the rest of the body, the clinical years at the colleges of podiatric medicine provide general medical training to "diagnose for the whole body". Included are courses in neurology, anesthesiology, general and vascular surgery, traumatology and emergency medicine, that, once again, are practically identical to those given to general medical students. Additional courses in podiatric surgery and biomechanics are taught so that early specialization is possible. The California College of Podiatric Medicine has an exchange program with the University of California Medical Center in San Francisco, whereby 3rd- and 4th-year podiatry students rotate through the various medical clinics at the University of California hospitals and vice versa. Podiatry students participate in other clinics across the United States from Stanford Medical Center in Palo Alto, California to the John F. Kennedy Memorial Hospital in Stratford, New Jersey. Following graduation, most doctors of podiatric medicine take a 1-, 2- or 3-year residency program. (Presently the Vancouver General Hospital is the only hospital in Canada that has a podiatry residency program.) Is it really "a threat to patients' welfare" when they see a podiatrist,
as some physicians think, or is it a blow to the ego of these physicians to admit that there are others more qualified than they to treat a particular foot problem? To categorize podiatrists and their training on the same level as physiotherapists and laboratory technicians is indicative of narrow-minded and antiquated thinking by the government and many physicians in Canada. Perhaps this is why this much-needed specialized area of health care delivery in Canada is years behind the United States as far as legislation and recognition are concerned. A closer look at podiatric medicine in the United States should result in better health care delivery for Canadians. LLOYD I. Nnsnrrr, DPM Executive secretary Canadian Podiatric Sports Medicine Academy Toronto, Ont.
It is apparent from the reaction to Charlotte Gray's article that there is much confusion over who is (legally) allowed to do what to whom. If the present trends continue, can we expect to have specialized optometrists who treat left eyes only or podiatrists who specialize in the care of big toes? This may be a case of reductic ad absurdum, but Parkinson's law is still operative. In conclusion, I find nothing in Dr. Nesbitt's letter to make me change my views about the proliferation of health professionals all wanting "to get into the act". J.S. BENNETT, FACOG, FRCS[C]
Director of professional affairs Canadian Medical Association Reference 1. Proceedings of the 110th Annual Meeting Including the Transactions of the General Council, Quebec City, Quebec, June 20, 21, 22, 1977, Can
Med Assoc, Ottawa, 1977, p 173
To the editor: In commenting on the letter by Dr. Nesbitt, I am reminded of a well known saying by Jimmy Durante: "Everybody wants to get into the act." I can only confess amazement that "the clinical years at the colleges of podiatric medicine provide general medical training to 'diagnose for the whole body' ". Inasmuch as similar claims are made for their training by optometrists and chiropractors, I am beginning to wonder why so many people take the time and the trouble and undertake the financial outlay to go to recognized schools of medicine to become physicians. At the 1977 General Council of the Canadian Medical Association the following motion was debated: "That the medical schools and departments of continuing medical education inquire into teaching that is presently being carried out with a view to improving the treatment of foot problems."1 The motion was not approved, but it was made very clear during the debate that physicians were remiss in their treatment of certain ailments and, by such omission, patients went to others for assistance. A similar debate on chiropraxis took place at the 1972 General Council, and the activities of chiropractors and optometrists have been the subject of ongoing debate in spheres of organized medicine for many years.
Behaviour modification To the editor: In his paper on the use of behaviour modification for decreasing the stress of hospitalization and surgery (Can Med Assoc J 119: 45, 1978) Dr. Malcolm A. Marshall lucidly describes a simple method for reducing anxiety and altering perception of the hospital surroundings and personnel. He points out that such a procedure produces many satisfying changes in patient behaviour and comfort. The suggestion of systematic relaxation, because of its acceptability, catches and holds a patient's attention and directs it in ways in which the operator wishes. It is an effective hypnotic induction procedure (all hypnosis is an active" procedure in that the patient's cooperation and participation are involved in an ongoing communication process directed by the operator). Patients who are being taught systematic relaxation, though they may not be said to be hypnotized, are more ready to accept other suggestions from the operator simply because they have already learned that by doing so they will be more comfortable (i.e., their anxiety will be reduced). The patients are therefore ready to respond to both verbal and nonverbal suggestions, many of which may be inadvertent. It is therefore important that nursing personnel who are
124 CMA JOURNAL/JANUARY 20, 1979/VOL. 120
DERMOVATE (clobetasol propionate 0.05%)
TOPICAL CORTICOSTEROID
Rapid relief can mean an early return to normal living. INDICATIONS Thpical therapy of recalcitrant corticosteroidresponsive dermatoses, including severe cases of psoriasis and eczematous dermatitis. CONTRAINDICATIONS Infected skin lesions if no anti-infective agent is used simultaneously; fungal and viral infections of the skin, including herpes simplex. vaccinia and varicella; pregnancy and lactation; hypersensitivity to any of the ingredients. ¶Ibpical corticosteroids are also contraindicated in tuberculous lesions of the skin. WARNINGS Dermovate should not be used in the eye. When used over extensive areas for prolonged periods, it is possible that sufficient absorption may take place to give rise to systemic effects. It is advisable, therefore, to use Dermovate for brief periods only, and to discontinue its use as soon as the lesion has cleared up. Do not use more than fifty grains of Dermovate per week. Patients should be advised to inform subsequent physicians of the prior use of corticosteroids. PRECAUTIONS ¶Ibpical corticosteroids should be used with caution on lesions close to the eye. Posterior subcapsular cataracts have been reported following systemic use of corticosteroids. Although hypersensitivity reactions are rare with topically applied steroids, the drug should be discontinued and appropriate therapy initiated if there are signs of hypersensitivity. In cases of bacterial infections of the skin, appropriate antibacterial agents should be used as primary therapy. If it is considered necessary, the topical corticosteroid may be used as an adjunct to control inflammation, erythema and itching. If a symptomatic response is not noted within a few days to a week, the local application of corticosteroid should be discontinued until the infection is brought under control. Significant systemic absorption may occur when steroids are applied over large areas of the body, especially under occlusive dressings. Because the degree of absorption of clobetasol 17-propionate when applied under occlusive dreasing has not been measured, its use in this fashion is not recommended. Because the safety and effectiveness of Dermovate has been established in children, its use in children is not recommended. ADVERSE REACTIONS Local burning, irritation, itching, skin atrophy, striae, change in pigmentation, secondary ininfection, hypertrichosis and adrenal suppression have been observed following topical corticosteroid therapy. DOSAGE AND ADMINISTRATION Dermovate Cream and Dermovate Ointment are applied thiniy to cover the affected area, and gently rubbed into the skin. Frequency of application is two to three times daily, according to the severity of the condition. The total dose of Dermovate applied weekiy should not exceed fifty grams. Therapy should be discontinued if no response is noted after a week or as soon as the lesion heals. It is advisable to use Dermovate for brief periods oniy. Note: If malntenance therapy is required, a lower strength topical steroid, such as Betnovate, is indicated. DOSAGE FORMS Dermovate Cream and Dermovate Ointment are available in 15 and 60 g tubes, and in lOOg jars. Product monograph available on request. REFERENCE: 1. Floden, C.H. et al., Current Med. Research and Opimon, 3 875-877,1975
V..ij7GIaxoLahomtories
family physician's office have nonsurgical problems of the musculoskeletal system, for which there is To the editor: I read with interest often an easy diagnostic and therathe report by Charlotte Gray about peutic modality available.1 As these the problem of paramedics trying to modalities 'are not taught in medical do more and more in the medical school, they are virtually unknown field (Can Med Assoc 1 119: 370, to most family physicians. Therefore, 1978). patients with these problems must I am very sympathetic with the seek help from lay manipulators. plight of physiotherapists who are D.M. FRASER, MD well trained and capable in the diag145 Queenston St., Ste. B7 nosis of lesions of the musculoskelSt. Gatharines, Ont. etal system, perhaps more so than many of our family physicians and References orthopedic surgeons. One article 1. CYRIAX J: Personal view. Br Med J written by Dr. James Cyriax,1 an 4: 292, 1972 orthopedic physician, aptly expresses 2. Idem: Textbook of Orthopaedic Medicine, vol 1, Diagnosis of Soft Lethe problem in the diagnosis and sions, 6th ed, Williams & Wilkins, treatment of musculoskeletal disBaltimore, 1975 orders today. Indeed, he has proposed that the only way we can avoid To the editor: I find it interesting treatment by lay manipulators (e.g., that Dr. John Bennett, as the director chiropractors, osteopaths and foot- of professional affairs of the Canaball trainers) is to have an adequate dian Medical Association, has done body of trained family physicians so little research into the training of who are able to recognize and diag- podiatrists. Dr. Bennett and many nose the lesions and then, if they other physicians refer to podiatrists cannot give the necessary treatment, as a "nonmedical professional health refer the patients to physiotherapists group [demanding] to be allowed to who are equally well trained. Simi- practise primary health care". larly, all medical students learn to I invite Dr. Bennett to visit one recognize the signs and symptoms of of the colleges of podiatric medicine acute appendicitis, yet few family in the United States; he would disphysicians perform appendectomies. cover that the students there are The dilemma, however, is that taught to "generalize before specialthere are very few trained orthopedic izing." Schools of podiatric medicine physicians, but Cyriax gives 8 to 10 are graduating doctors who, in fact, courses per year in the United States are trained as physicians specialized and occasionally in Canada. If in treating disorders of the feet and courses in orthopedic medicine could related structures by medical and be given at medical schools or to surgical means. Reference to podifamily physicians as part of their atrists as a nonmedical group is erfamily practice internships, the prob- roneous. A comparison of podiatric lem would be solved within a genera- and general medical education demtion. It has been shown clearly that onstrates this fact. 20% of all patients who come to a Besides taking the same Medical
Role and training of paramedical groups
122 CMA JOURNAL/JANUARY 20, 1979/VOL. 120
College Admission Test as medical students, podiatry students undergo a basic medical sciences program that is practically identical to that found in major medical schools. The questions on the national board exams of the two groups reflect this. Pharmacology and therapeutics are no exception, contrary to the thinking of Dr. Robert Clark, executive director of the Alberta Medical Association. Since the foot cannot be divorced from the rest of the body, the clinical years at the colleges of podiatric medicine provide general medical training to "diagnose for the whole body". Included are courses in neurology, anesthesiology, general and vascular surgery, traumatology and emergency medicine, that, once again, are practically identical to those given to general medical students. Additional courses in podiatric surgery and biomechanics are taught so that early specialization is possible. The California College of Podiatric Medicine has an exchange program with the University of California Medical Center in San Francisco, whereby 3rd- and 4th-year podiatry students rotate through the various medical clinics at the University of California hospitals and vice versa. Podiatry students participate in other clinics across the United States from Stanford Medical Center in Palo Alto, California to the John F. Kennedy Memorial Hospital in Stratford, New Jersey. Following graduation, most doctors of podiatric medicine take a 1-, 2- or 3-year residency program. (Presently the Vancouver General Hospital is the only hospital in Canada that has a podiatry residency program.) Is it really "a threat to patients' welfare" when they see a podiatrist,
as some physicians think, or is it a blow to the ego of these physicians to admit that there are others more qualified than they to treat a particular foot problem? To categorize podiatrists and their training on the same level as physiotherapists and laboratory technicians is indicative of narrow-minded and antiquated thinking by the government and many physicians in Canada. Perhaps this is why this much-needed specialized area of health care delivery in Canada is years behind the United States as far as legislation and recognition are concerned. A closer look at podiatric medicine in the United States should result in better health care delivery for Canadians. LLOYD I. Nnsnrrr, DPM Executive secretary Canadian Podiatric Sports Medicine Academy Toronto, Ont.
It is apparent from the reaction to Charlotte Gray's article that there is much confusion over who is (legally) allowed to do what to whom. If the present trends continue, can we expect to have specialized optometrists who treat left eyes only or podiatrists who specialize in the care of big toes? This may be a case of reductic ad absurdum, but Parkinson's law is still operative. In conclusion, I find nothing in Dr. Nesbitt's letter to make me change my views about the proliferation of health professionals all wanting "to get into the act". J.S. BENNETT, FACOG, FRCS[C]
Director of professional affairs Canadian Medical Association Reference 1. Proceedings of the 110th Annual Meeting Including the Transactions of the General Council, Quebec City, Quebec, June 20, 21, 22, 1977, Can
Med Assoc, Ottawa, 1977, p 173
To the editor: In commenting on the letter by Dr. Nesbitt, I am reminded of a well known saying by Jimmy Durante: "Everybody wants to get into the act." I can only confess amazement that "the clinical years at the colleges of podiatric medicine provide general medical training to 'diagnose for the whole body' ". Inasmuch as similar claims are made for their training by optometrists and chiropractors, I am beginning to wonder why so many people take the time and the trouble and undertake the financial outlay to go to recognized schools of medicine to become physicians. At the 1977 General Council of the Canadian Medical Association the following motion was debated: "That the medical schools and departments of continuing medical education inquire into teaching that is presently being carried out with a view to improving the treatment of foot problems."1 The motion was not approved, but it was made very clear during the debate that physicians were remiss in their treatment of certain ailments and, by such omission, patients went to others for assistance. A similar debate on chiropraxis took place at the 1972 General Council, and the activities of chiropractors and optometrists have been the subject of ongoing debate in spheres of organized medicine for many years.
Behaviour modification To the editor: In his paper on the use of behaviour modification for decreasing the stress of hospitalization and surgery (Can Med Assoc J 119: 45, 1978) Dr. Malcolm A. Marshall lucidly describes a simple method for reducing anxiety and altering perception of the hospital surroundings and personnel. He points out that such a procedure produces many satisfying changes in patient behaviour and comfort. The suggestion of systematic relaxation, because of its acceptability, catches and holds a patient's attention and directs it in ways in which the operator wishes. It is an effective hypnotic induction procedure (all hypnosis is an active" procedure in that the patient's cooperation and participation are involved in an ongoing communication process directed by the operator). Patients who are being taught systematic relaxation, though they may not be said to be hypnotized, are more ready to accept other suggestions from the operator simply because they have already learned that by doing so they will be more comfortable (i.e., their anxiety will be reduced). The patients are therefore ready to respond to both verbal and nonverbal suggestions, many of which may be inadvertent. It is therefore important that nursing personnel who are
124 CMA JOURNAL/JANUARY 20, 1979/VOL. 120
DERMOVATE (clobetasol propionate 0.05%)
TOPICAL CORTICOSTEROID
Rapid relief can mean an early return to normal living. INDICATIONS Thpical therapy of recalcitrant corticosteroidresponsive dermatoses, including severe cases of psoriasis and eczematous dermatitis. CONTRAINDICATIONS Infected skin lesions if no anti-infective agent is used simultaneously; fungal and viral infections of the skin, including herpes simplex. vaccinia and varicella; pregnancy and lactation; hypersensitivity to any of the ingredients. ¶Ibpical corticosteroids are also contraindicated in tuberculous lesions of the skin. WARNINGS Dermovate should not be used in the eye. When used over extensive areas for prolonged periods, it is possible that sufficient absorption may take place to give rise to systemic effects. It is advisable, therefore, to use Dermovate for brief periods only, and to discontinue its use as soon as the lesion has cleared up. Do not use more than fifty grains of Dermovate per week. Patients should be advised to inform subsequent physicians of the prior use of corticosteroids. PRECAUTIONS ¶Ibpical corticosteroids should be used with caution on lesions close to the eye. Posterior subcapsular cataracts have been reported following systemic use of corticosteroids. Although hypersensitivity reactions are rare with topically applied steroids, the drug should be discontinued and appropriate therapy initiated if there are signs of hypersensitivity. In cases of bacterial infections of the skin, appropriate antibacterial agents should be used as primary therapy. If it is considered necessary, the topical corticosteroid may be used as an adjunct to control inflammation, erythema and itching. If a symptomatic response is not noted within a few days to a week, the local application of corticosteroid should be discontinued until the infection is brought under control. Significant systemic absorption may occur when steroids are applied over large areas of the body, especially under occlusive dressings. Because the degree of absorption of clobetasol 17-propionate when applied under occlusive dreasing has not been measured, its use in this fashion is not recommended. Because the safety and effectiveness of Dermovate has been established in children, its use in children is not recommended. ADVERSE REACTIONS Local burning, irritation, itching, skin atrophy, striae, change in pigmentation, secondary ininfection, hypertrichosis and adrenal suppression have been observed following topical corticosteroid therapy. DOSAGE AND ADMINISTRATION Dermovate Cream and Dermovate Ointment are applied thiniy to cover the affected area, and gently rubbed into the skin. Frequency of application is two to three times daily, according to the severity of the condition. The total dose of Dermovate applied weekiy should not exceed fifty grams. Therapy should be discontinued if no response is noted after a week or as soon as the lesion heals. It is advisable to use Dermovate for brief periods oniy. Note: If malntenance therapy is required, a lower strength topical steroid, such as Betnovate, is indicated. DOSAGE FORMS Dermovate Cream and Dermovate Ointment are available in 15 and 60 g tubes, and in lOOg jars. Product monograph available on request. REFERENCE: 1. Floden, C.H. et al., Current Med. Research and Opimon, 3 875-877,1975
V..ij7GIaxoLahomtories
