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					                                              Letters ❖ Correspondance

Initiative.”1 Baby-friendly is the trade-               College of Family Physicians of Canada’s           nor dwelling on them inappropriately.
mark term to describe the formal recog-                 Task Force on Child Health. Can Fam                The Information Letter also indicates
nition bestowed on those hospitals that                 Physician 1997;43:1585-9(Eng), 1590-4(Fr).         some areas that have been considered
fully conform with the assessment crite-                                                                   by patients, cour ts, and licensing
ria. It is a global effort to encourage and                                                                authorities to be sexually abusive.
recognize hospitals that have estab-                  Don’t shoot the                                      Included in these areas are such
lished and adopted optimal lactation
management for mothers and babies.
                                                      messenger                                            things as criticizing a patient’s sexual
                                                                                                           orientation, comments about potential
                                                        n his editorial, 1 Dr Maurice takes
    Many physicians have expressed
concerns similar to those of Dr Kents
about the terminology, because, if their
                                                      I direct aim at the messenger. The
                                                      editorial demonstrates some lack
                                                                                                           sexual per formance “except clinical
                                                                                                           comments where the patient’s purpose
                                                                                                           in seeking the consultation was to dis-
hospital does not conform to the                      of understanding of the role of                      cuss sexual issues,” requesting sexual
assessment criteria, it might be implied              the Canadian Medical Protective                      history “when not clinically indicated,”
that they are not friendly to babies.                 Association (CMPA). The CMPA does                    or discussing a physician’s own sexual-
However, the terminology applies to                   not “make policy.” Rather, it has a                  ity. Note that clinically indicated ques-
the global program designed to protect,               twofold role: to defend members who                  tions and comments are always
promote, and support breastfeeding,                   face medicolegal allegations and to                  appropriate but must be expressed in a
not to the relationship doctors might                 educate members about ways to avoid                  sensitive manner.
have with their newborn patients.                     medicolegal risks.                                       A recent review of cases dealt with
    This terminology was intentionally                   In order to fulfil the latter func-                by the CMPA reveals that, in the 10
adopted in 1997 by the College of                     tion, the CMPA assesses medicolegal                  years ending December 31, 1999,
Family Physicians of Canada’s Task                    risks based on experience through                    there were 379 cases in which
Force on Child Health as a means to                   judgments of courts and findings of                   patients alleged sexual impropriety on
encourage and honour best breastfeed-                 disciplinar y bodies, such as                        the part of their doctors. This is a sig-
ing practices in family doctors’ offices.2             Provincial/Ter ritorial Colleges of                  nificant number, considering that it
Baby-friendly is therefore the formal                 Physicians and Surgeons. The courts                  does not include more serious allega-
recognition bestowed on an office that                 and the disciplinar y bodies rely on                 tions, such as inappropriate touching
met the assessment criteria. Dr Kents                 clinical experts, such as Dr Maurice                 or sexual intercourse or allegations of
should be commended on his obvious                    or other practising physicians, and on               lack of privacy in disrobing or drap-
dedication and commitment to infants.                 position statements from medical                     ing. In 69 of the 379 cases (both disci-
He and his office staff might be very                  organizations, such as the College of                plinar y and legal), it was clear that
friendly toward babies, but unfor tu-                 Family Physicians of Canada, the                     communication was a severe prob-
nately, if Dr Kents’ office does not con-              Canadian Medical Association, and                    lem, because in more than a third of
form with these criteria, it would not be             the Society of Obstetricians and                     those 69 cases it was alleged that
designated as a “baby-friendly office.”                Gynaecologists of Canada. Based on                   inappropriate sexual questions were
          —Cheryl Levitt, MB BCH, CCFP, FCFP          these opinions and policies as well as               asked. In other cases, the nature of
                 —Fahrin Shariff, MD, CCFP            other evidence, and taken in context                 the examination was not communicat-
                 —Janusz Kaczorowski, PHD             of the overall evidence presented, a                 ed, and in yet others, inappropriate
          —Jacqui Wakefield, MD, CCFP, FCFP            physician’s practice is judged as                    comments were alleged to have been
               —Debbie Sheehan, BSCN, MSW             being either within or outside the                   made by the doctor.
               —John Sellors, MD, CCFP, FCFP          boundaries of acceptable practice.                       Dr Maurice gives as an example a
                     —Hiltrude Dawson, RN             The CMPA then attempts to aler t                     case where a physician was clearly
                              Hamilton, Ont           physicians to the implications of these              judged by both the cour t and the
                                                      judicial and disciplinary rulings.                   College as having fallen below the
References                                               Dr Maurice might also have misin-                 required standard by failing to make
1. World Health Organization, United Nations          terpreted some of the comments in the                appropriate and clinically indicated
  Children’s Emergency Fund. Innocenti dec-           CMPA’s Information Letter.2 The arti-                inquiries. In fact the specific case was
  laration on the protection, promotion and           cle clearly states that “the physician               complicated and had many more ram-
  support of breast feeding. Florence, Italy:         must always consider first the well-                  ifications, but it was cer tainly
  WHO; 1990.                                          being of the patient.” This does, of                 brought to the attention of the mem-
2. Levitt C, Doyle-MacIsaac M, Grava-Gubins           course, require the physician to take                bers of the CMPA in its annual report
  I, Ramsay G, Rosser W. Our strength for             an adequate histor y, in accordance                  for the year 1993. 3 A more recent
  tomorrow: valuing our children. Part 2:             with accepted medical practice, nei-                 case repor ted in Ontario illustrates
  Unborn and newborn babies. Report to the            ther neglecting relevant sexual issues               how a communication problem led to

1738   Canadian Family Physician • Le Médecin de famille canadien ❖ VOL 46:   SEPTEMBER • SEPTEMBRE 2000
                                           Letters ❖ Correspondance

allegations of sexual impropriety
against a doctor. 4 In this case the
                                                  Tips from a retired
complainant alleged that the doctor’s             family physician
sexual history and physical examina-
tion were inappropriate in the context
of her presenting complaint.
    Dr Maurice clearly believes that the
                                                  I retired from general practice 2 years
                                                    ago, and I do not think I have ever
                                                  had anything published in a medical
reasons for conducting a sexual history           magazine. However, during my career
are much more inclusive than they were            of 45 years, I believe I picked up (or
a few years ago. Not all clinicians agree         invented) two little helpers that could
that a sexual histor y is necessar y in           be passed on to your readers.
every doctor-patient encounter, and most             First, looking down the throat of
patients will not likely expect a sexual          someone who gags can be a simple
history to be taken during all visits. The        matter. It is impossible to gag and hold
CMPA, therefore, must continue to                 your breath. Tr y it! Explain this to
advise doctors to consider carefully              your patients, and, if necessary, allow
under which circumstances a sexual his-           them to put the tongue depressor
tory is required. It is beyond the scope of       down their own throats. Then, ask
the CMPA’s medicolegal advice to sug-             them to take a deep breath and hold it,
gest when such a history would be con-            and you have plenty of time to do a
sidered essential or non-essential. That          gag-free examination.
falls more appropriately in the purview of           Second, I know a foolproof method
the “medical educators and public health          for making friends with little patients.
officials” to whom Dr Maurice refers.              To examine their throats or ears,
    In addition, knowing that patients            approach them with the auriscope
might not be aware that such a history            turned off. Then explain that the light
is appropriate in the context of today’s          is magic and goes on only if someone
medicine, physicians might wish to                blows on it. Then, invite your little
inform patients that sensitive ques-              patients to give it a puff and simultane-
tions will be asked and tell them the             ously tur n the light on—smiles all
medical relevance of these questions.             around while you peek into the ear or
    The law and its interpretation                throat. But remember to then get
changes in accordance with new knowl-             them to blow the light off when the
edge and new cases. The CMPA will                 examination is finished. Each time
continue to keep its members informed             these patients come to see you, they
of the implications of new develop-               will actually look for the magic light
ments and interpretations as they arise.          and will be most upset if you do not
                  —John E Gray, MD, CCFP          use it. When your patients get to be 10
                              Ottawa, Ont         or 11, however, forget about it—the
                                    by mail       magic has gone by then.
                                                                        —Mike Tibbetts, MD
References                                                                     Victoria, BC
1. Maurice WL. Talking about sexual matters                                        by e-mail
  with patients. Time to re-examine the                                …
  CMPA’s policy [editorial]. Can Fam
  Physician 2000;46:1553-4 (Eng), 1558-60 (Fr).
2. Information letter. Ottawa, Ont: Canadian
  Medical Protective Association; 1992;7:2.
3. Evans KG. Ninety-third annual report.
  Ottawa, Ont: Canadian Medical Protective
  Association; 1994. p. 23-6.
4. Member’s dialogue. Toronto, Ont: College of
  Physicians and Surgeons of Ontario;

                                                  VOL 46: SEPTEMBER • SEPTEMBRE 2000 ❖ Canadian   Family Physician • Le Médecin de famille canadien   1739