We were certainly proud to have Iempathize with the difficulties by csgirla



ical services for rural and isolated        family physicians because our waiting     to believe otherwise is naïve. The
communities.                                lists are still too long and our work-    competing programs to which a stu-
   There is more to the formula for         loads still threaten our commitment to    dent applies are none of the program
developing a good retention pro-            a fulfilling northern lifestyle.          director’s business.
gram, but Marathon has the basics               Incidentally, Dr. Rupa Patel is a        Where does the solution lie? Stu-
right. Let’s make sure they get the         graduate of the Queen’s Rural Fam-        dents must not be expected to dis-
support to keep it that way.                ily Medicine Program and not the          close dealings with rival programs.
                                            Northwestern Ontario Medical Pro-         The interviewer’s sensitivity and
Peter Newbery, MDiv, MD                     gram, as stated in the article.           common sense will prevent students
Director                                        We feel that herculean recruiting     from being placed in awkward posi-
United Church Health Services
                                            efforts and serendipity in finding the    tions that evoke either deceit or
Hazelton, BC
                                            right individuals are insufficient to                          o
                                                                                      damning silence. T ease pressure on
                                            address the problems of recruitment       students, the flexibility to change

W       e were certainly proud to have
        been featured on the cover of
the June 1 issue of CMAJ and to pro-
                                            and retention. Only by combining
                                            these with a sustainable group philos-
                                            ophy will rural communities have a
                                                                                      programs midstream and a common
                                                                                      postgraduate year 1 must be built
                                                                                      into our present system. This will re-
vide evidence that all is not doom and      realistic chance of finding a solution.   duce uncertainty and the pressure to
gloom when it comes to rural recruit-                                                 choose a specialty prematurely.
ment. OReilly’s article did a good job      Gordon Hollway, MD
of outlining the recent events in           Ruby Klassen, MD                          David Omahen, BSc
                                            Steve Klassen, MD                         Class of ’99
Marathon. We feel, however, that
                                            Sarah Newbery, MD                         University of Ottawa
one aspect that did not receive the at-     Eliseo Orrantia, MD                       Ottawa, Ont.
tention it deserved was the central         Rupa Patel, MD
role of our group’s philosophy toward       Mike Sylvester, MD
recruitment and retention.                  Marathon, Ont.
   Early in the recruitment phase,
                                                                                      Error corrected, conclusions
our group met to devise a philosophy                                                  the same
that was instrumental in cementing          Making career choices
the recruitment. It incorporated
group practice, consensus-based deci-
                                                                                      I  n the article “Recent trends in in-
                                                                                         fant mortality rates and propor-
sion-making, emphasis on quality of
patient care and lifestyle, use of alter-
native health care providers, a com-
                                            I   empathize with the difficulties Dr.
                                                Chris Feindel faces in choosing fu-
                                            ture residents (“Know your residency
                                                                                      tions of low-birth-weight live births
                                                                                      in Canada” (Can Med Assoc J
                                                                                      1997;157:535-41), Drs. K.S. Joseph
mitment to continuing education,            applicants well” [letter], Can Med As-    and Michael S. Kramer identify a
and sustainability. We realized that        soc J 1997;156:977-8). However, if        possible error in the birth weight data
sustainability might not always mean        students who have not spent elective      from Ontario for 1993 and 1994.
that our group consisted of the same        time in a program are excluded from       The error was traced to improper
faces, but would mean that it would         consideration (or “placed at a disad-     keying (data capture) of a small num-
continue to share the same philoso-         vantage,” as Feindel phrased it), qual-   ber of records. For birth weights re-
phy. Ironically, we included the con-       ified candidates will be overlooked.      ported in pounds and ounces, the sec-
cept of ease of exit as a means to sus-         Students face financial constraints   ond digit of the ounces was omitted,
tainability. Our reasoning was that, in     and limited amounts of elective time.     e.g., 5 pounds 10 ounces became 5
a group that allowed physicians to          Because career choices must be made       pounds 1 ounce.
leave to pursue other life goals, those     at an early stage, students must ex-         Since we were made aware of this
physicians would be likely to assist in     plore as many avenues as possible. It     problem, the data have been rekeyed
recruiting their replacements.              is shortsighted and unreasonable to       to correct the error for 1993 and
   We are not satisfied with our cur-       believe all interested students will      1994. As well, 1995 data are now
rent arrangement. We still hope to ne-      spend elective time with a given pro-     available. Finally, to validate the vital
gotiate a fair means to free ourselves      gram. The wise director realizes that     statistics data, they were compared
from fee-for-service payment (we have       the student with exposure to several      with birth weight data from hospital
not already negotiated an alternative       areas will make a better informed         discharge abstracts, which are avail-
payment plan, as the article implied).      choice. Students will apply to many       able up to 1994. The same statistical
We are recruiting an additional 1 or 2      programs in several specialty areas —     tests used by Joseph and Kramer

646                      CAN MED ASSOC J • 15 SEPT. 1997; 157 (6)

were conducted on the revised data                                 borns of low birth weight was 5.78%                                     desks. The information could also be
to determine whether there was a sig-                              in 1995, up from 5.44% in 1992.                                         placed in the national press so that
nificant increase in the proportion of                                                                                                     patients could participate in decision-
low-birth-weight babies born in On-                                Indira Singh                                                            making.
tario between 1987 and 1995.                                       Deputy Registrar General
                                                                   Ontario Ministry of Consumer and                                        David C.F. Muir
    The corrections to the data re-
                                                                   Commercial Relations                                                    Director
duced the percentage of low-birth-                                 Toronto, Ont.                                                           Occupational Health Program
weight babies from 6.06% to 5.87%                                  Janet Hagey                                                             McMaster University
in 1993 and from 6.54% to 5.93% in                                 Director                                                                Hamilton, Ont.
1994 (Table 1). The 1995 percentage                                Health Statistics Division
is 5.98%. The 1994–95 to 1987 ratio                                Statistics Canada
is, therefore, 1.11. But, despite the re-                          Ottawa, Ont.
                                                                                                                                           Residents and suicide:
duction in the 1993 and 1994 per-
centages, the statistical tests show
                                                                                                                                           Lessons to be learned?
                                                                   Bringing guidelines to the
that the increase in the proportion of
low-birth-weight babies from 1987 to
1995 is still statistically significant.
                                                                   people                                                                  I  read with much sadness the article
                                                                                                                                              “Manitoba suicides force consid-
                                                                                                                                           eration of stresses facing medical
The hospital discharge data also indi-
cate a statistically significant trend.
    The differences in the proportion
                                                                   D      r. Nuala P. Kenny’s article
                                                                          “Does good science make good
                                                                   medicine” (Can Med Assoc J 1997;157:
                                                                                                                                           residents” (Can Med Assoc J
                                                                                                                                           1997;156:1599-602), by Lynne Sears
                                                                                                                                           Williams. It discussed 3 recent sui-
of low-birth-weight babies between                                 33-6) commented on the distance                                         cides involving residents at the Uni-
the vital statistics and the hospital dis-                         separating health care knowledge and                                    versity of Manitoba.
charge data can be explained by 2 fac-                             individual clinical practice. Perhaps                                      Having recently completed resi-
tors: (1) vital statistics include all                             the selling of clinical guidelines is no                                dency and fellowship training, I can
births among Ontario residents,                                    different from selling widgets. Suc-                                    appreciate the comments expressed
whereas hospital discharge data in-                                cessful entrepreneurs already know                                      about stresses and anxieties faced by
clude only hospital births and only                                that a good idea is not a guarantee of                                  residents in the 1990s. These
births among Ontario residents oc-                                 commercial success: it must be sup-                                     stresses are not specific to one area,
curring within Ontario; (2) in the vi-                             ported by an effective distribution                                     although this recent rash of suicides
tal statistics, birth weights are re-                              and sales campaign.                                                     happened at the University of Mani-
ported by the mothers, whereas those                                  With this in mind, perhaps it is                                     toba. Once is happenstance, twice is
in hospital discharge data are re-                                 time for CMAJ to have a page that                                       a coincidence, but thrice is enemy
ported by the attending physicians.                                summarizes selected current guide-                                      action. We have yet to identify the
    Joseph and Kramer showed a sig-                                lines. It should be designed by an ad-                                  specific enemy in these cases.
nificant increase in low-birth-weight                              vertising expert so that it has instant                                    It will not be easy to ascertain
babies in Ontario, but the results                                 appeal. Names, doses and costs of ap-                                   whether there are training-program
were somewhat constrained by the                                   propriate medications should be pro-                                    flaws that precipitated these tragedies.
incorrect data. The corrected data,                                vided, together with essential investi-                                 Residents are unlikely to express con-
however, still indicate a significant in-                          gations. Each topic should be                                           cerns about their programs for fear of
crease. The trend is confirmed by the                              repeated at frequent intervals. CMAJ                                    jeopardizing future references and
hospital discharge data. At the na-                                could also provide convenient plastic                                   employment. Attending physicians
tional level, the percentage of new-                               cards that we could keep on our                                         may be reluctant to investigate and

  Table 1: Percentage of newborns of low birth weight,* by data source, Ontario, 1987 to 1995
                                                                                                                                                Ratio 1994–95
                                                      Year; % of newborns with low birth weight                                                                  1987 to 1994–95
                                                                                                                                                   to 1987
 Data source                1987         1988         1989         1990         1991        1992         1993         1994          1995        (and 95% CI†)    χ2‡      p value
 Vital                                                                                                                                               1.11
 statistics                 5.36         5.46         5.29         5.35         5.55         5.52         5.87         5.93         5.98         (1.08–1.15)    124.7        < 0.01
 Hospital data              5.21         5.40         5.32         5.31         5.48         5.44         5.66         5.76           –          (1.07–1.14)     53.1        < 0.01
 *Live births of infants weighing 500 to 2499 g as a proportion of all live births of infants with stated birth weight of 500 g or more.
 †CI = confidence interval.
 ‡χ2 (1 degree of freedom) for linear trend in proportions.

                                                                                                      CAN MED ASSOC J • SEPT. 15, 1997; 157 (6)                                   647

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