Letters · Correspondance

CMAJ 1999;160:1695-9

• College-generated lawsuits R.G. Holmes; response: T.F. Handley
• Antibiotic resistance: the agricultural connection J.F. Prescott; response: G.G. Khachatourians
• Barometer falling I. Buckingham
• Update on the new virus in Malaysia C.E. Caplan
• New method for prostate exam N. Hotte
• Alternative views on alternative therapies S.M. Sagar; response: D.W. Warr, I.F. Tannock
• Lifestyle modifications to prevent and control hypertension: 5. Recommendations on dietary salt [Correction]
• The Internet and chiropractic [Correction]

My heart went out to Drs. Arlene Rosenbloom and Gary Viner after I read your recent article about their experience with a lawsuit [full text].¹ In spite of what they were advised to do by the Canadian Medical Protective Association (CMPA), it would have been just and therapeutic for those physicians to have discussed the case with colleagues, friends and families.

Let me tell you about the only lawsuit I faced in 40 years of practice, most of which was spent in remote and underdoctored areas engaged in the whole spectrum of general practice. It began when a complaint was laid against me regarding my management of a patient with major medical problems who eventually died of cardiac arrest. The complaint was made by the patient's spouse in a letter to the College of Physicians and Surgeons of British Columbia. The college called me to attend an interview with the Quality of Medical Practice Committee, which at the time was chaired by a Vancouver gynecologist.

The meeting was a farce. None of the committee members had worked in an isolated hospital and none had practised without the benefit of having an internist or radiologist on staff. Certainly, none of them was accustomed to working 24-hour shifts in an emergency department. And yet this committee quite easily found itself ready to condemn and criticize a 60-year-old physician who toiled under these conditions.

The college sent a letter to the complainant that was critical of my management, and this proved just the ammunition required to launch a lawsuit. The spouse wrote to the CMPA's legal representative in Vancouver, demanding a $75 000 settlement in lieu of a malpractice suit that would be supported by the college's letter. This demand was vigorously denied by the CMPA, and the action against me was eventually dropped.

What have I learned from this? Trust the CMPA, not your college. Probably the most disturbing aspect of my experience is that there is no representation from rural and isolated communities on college peer-review committees, and this is unlikely to change under present rules concerning college elections.

I feel fortunate to have fulfilled 40 years of medical practice with only a single lawsuit against me, but it still irks me that the college played so great a role in its generation.

Robert G. Holmes, MB
Merritt, BC

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1. Cohen L. Code of silence hardest part of being sued, FPs say. CMAJ 1999;160(1):97-8.

  See also: Doubts about the college

Dr. Holmes' assertion about lack of representation in college peer reviews is incorrect. He was interviewed by a committee that included practitioners thoroughly familiar with the conditions of practice in remote areas; one had been a GP in Fort St. James, BC, for several years. Also, the deputy registrar who conducted preliminary registration of the complaint had been a GP in Prince George, BC, for 24 years and remains fully cognizant of the practice problems encountered in the surrounding northern, isolated communities. Committee members were sympathetic to Dr. Holmes' heavy workload and resultant stress but, in addition to advising him on that, certain criticisms were expressed. Notifying the complainant of the committee's opinion is a statutory requirement. Professional self-governance is a privilege granted by the legislature and, in order to maintain public trust, there has to be accountability.

I must disagree when Dr. Holmes advises physicians not to trust their college, apparently because the complainant took the committee's conclusions as sufficient evidence to attempt a malpractice suit. The test should be whether the conclusions of peers were impartial, fair and objectively stated. In the end, any malpractice suit is determined on its own legal merits, not by college opinion, as became evident in this case. I do not take issue with Dr. Holmes' advice that the CMPA can be the physician's greatest ally in facing a complaint — the college is frequently the first to give that advice.

Investigation and adjudication of complaints is complex and difficult. More often than not, one or both of the parties are dissatisfied with the outcome.

Thomas F. Handley, MB ChB
Registrar
College of Physicians and Surgeons of British Columbia
Vancouver, BC

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Dr. George G. Khachatourians' article [text / résumé]¹ on the agricultural use of antibiotics and the transfer of resistant bacteria and resistance genes is a timely and reasonable summary of this topic. However, there are some factual errors. One is the statement that the use of antibiotics in agricultural animals is "100 to 1000 times that in the human population" (although he corrects this later to the more generally accepted "half of all antibiotics"). Another is the statement that "to improve the growth of swine, 2­500 g of [10 different, named antibiotics] is added to each ton of feed." No feed mill in Canada would make up such an illegal and bizarre mix. More serious than these errors is the lack of balance in the article. There is no recognition of the fact that almost all resistance in human bacterial pathogens results from the use (including misuse and overuse) of antibiotics in medicine.

This lack of balance might not matter were it not for the carefully timed press releases on this review that somehow turned the article's mundane title into the National Post's front-page headline, "Antibiotics in food spawn deadly superbugs." Agriculture cannot be made a scapegoat for the problems of antibiotic resistance in medicine. In 1971 Health Canada and the Canadian Infectious Diseases Society convened a meeting in Montreal on antimicrobial resistance. Participants recognized that control of antibiotic resistance could only result from the partnership of all users. CMAJ should have taken care to inform readers of the very serious and dramatic way in which the agricultural antibiotic connection is being addressed in Europe and the US as well as (though more slowly) in Canada. The journal could have provided balance. Good public policy is made by thoughtful and balanced analysis, not by the manipulation by dubious headlines.

John F. Prescott, VetMB, PhD
Department of Pathobiology
University of Guelph
Guelph, Ont.

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1. Khachatourians GG. Agricultural use of antibiotics and the evolution and transfer of antibiotic-resistant bacteria. CMAJ 1999;159(9):1129-36.

The emergence of certain human pathogens resistant to antibiotics has come from the use of antibiotics in animals and not the other way around. Drug-resistant Salmonella infections in humans originated with antimicrobial drug use on farms. This conclusion came from studies in the 1980s, which are in fact cited in Antimicrobial Therapy in Veterinary Medicine, a book co-edited by Dr. Prescott.¹ Likewise, new evidence from Asia, 7 European countries and North America supports the assertion that the primary transmission of antibiotic-resistant Escherichia coli, Enterobacter and Enterococcus is from animals to humans.^2,3 Further, vancomycin-resistant enterococci have been isolated only from gastrointestinal tracts of meat-eating but not vegetarian people.⁴ Until molecular and epidemiological studies prove otherwise, nonhuman reservoirs can be as suspect as human reservoirs. In the meantime, an increasing number of reports point to animals.

The example of an agricultural use of antibiotics that is 1000 times greater than in human populations is that of vancomycin and avoparcin in 1994 in Denmark: 24 kg of vancomycin in the human population and 24 117 kg of avoparcin in animals.⁵ The figure of 2­500 g of antibiotics per ton of feed is in accord with the Canadian Compendium of Veterinary Pharmaceuticals, Biologicals and Specialities⁶ and, from a regulatory perspective, with the Compendium of Medicating Ingredient Brochures (CMIB).⁷ The CMIB also lists the following combinations (and sometimes with other therapeutic agents) as acceptable in feeds: bacitracin and penicillin; lincomycin and spectinomycin; oxytetracycline and neomycin; sulfamethazine and tylosin; sulfamethazine and chlortetracycline; sulfamethazine and penicillin and chlortetracycline. As all medicated feed manufactured, used or sold in Canada must adhere to and comply with the Feeds Regulations Act, we are already and legitimately using combinations of 2­3 different types of antimicrobials from 7 of the 10 listed in my article. Thus, there is nothing "illegal and bizarre" about this practice.

I do agree, however, that we need to re-examine public policy on the overall use of antibiotics. Should we get there, I have one last hope that the media will not generate more dubious headlines that misinterpret the message.

George G. Khachatourians, MA, PhD
Department of Applied Microbiology and Food Science
University of Saskatchewan
Saskatoon, Sask.

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1. Prescott JF, Baggot JD, editors. Antimicrobial therapy in veterinary medicine. 2nd ed. Ames (IA): Iowa State University Press; 1993.
2. Jensen LB. Differences in the occurrence of two base pair variants of Tn1546 from vancomycin-resistant enterococci from humans, pigs, and poultry [letter]. Antimicrob Agents Chemother 1998;42(9):2463-4.
3. Woodford N, Adebiyi AM, Palepou MF, Cookson BD. Diversity of VanA glycopeptide resistance elements in enterococci from humans and nonhuman sources. Antimicrob Agents Chemother 1998;42(3):502-8.
4. Schouten MA, Voss A, Hoogkamp-Korstanje JA. VRE and meat [letter]. Lancet 1997;349:1258.
5. Wegner HC. Historical yearly usage of glycopeptides for animals and humans: the American­European paradox revisited. Antimicrob Agents Chemother 1998;42(11):3049-50.
6. Canadian Animal Health Institute. Canadian
   compendium of veterinary pharmaceuticals, biologicals and specialities. 5th ed. Hensall (ON): North American Compendiums; 1997.
7. Compendium of medicating ingredient brochures. 7th ed. Ottawa: Canada Communications Group; 1994.

With regard to Patrick Sullivan's article on the military physician staffing crisis [full text],¹ the Canadian Forces have access to a large pool of retired, well trained and experienced physicians whom they could employ as civilians on bases located in Canadian cities. This would free up military physicians to serve overseas.

Incidentally, the 3 flight surgeons pictured as experiencing the symptoms of hypoxia are located in a decompression or hypobaric chamber, not a hyperbaric chamber. By creating a vacuum in the chamber the effects of altitude are simulated. Conversely, by increasing the pressure in a recompression or hyperbaric chamber the effects of increased pressure as experienced by divers may also be reproduced.

Commander Ian Buckingham (Ret.), MB BS, MMM, CD
Victoria, BC

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1. Sullivan P. Military set to offer large signing bonuses, higher pay in face of unprecedented MD staffing crisis. CMAJ 1999;160(6):889-91.

A CMAJ public health article recently described the emergence of a new morbillivirus causing febrile encephalitis among pig farmers and abattoir workers in Malaysia [full text].¹ As of Apr. 27, 1999, 257 cases have been reported. Almost half of those affected died. Several cases were also reported in Singapore among workers handling pigs imported from Malaysia. The virus, formerly known as Hendra-like virus because of its similarity to an equine morbillivirus identified in Australia in 1994, is now called Nipah virus.² Most human cases continue to be connected to exposure to pigs. In an effort to control the outbreak, approximately 890 000 pigs have been killed in Malaysia, transport of pigs within the country has been banned, and education has been provided about contact with pigs and use of protective equipment. The incidence of infection in humans has been decreasing, from a peak of 46 cases between Mar. 13 and 19 to 4 cases between Apr. 10 and 16. Nipah virus infection has been confirmed in a necropsied dog. No human-to-human transmission has been reported to date.

Caralee E. Caplan, MD
Editorial Fellow, CMAJ

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1. Caplan CE. New virus emerges in Malaysia. CMAJ 1999;160(11):1607.
2. Update: Outbreak of Nipah virus — Malaysia and Singapore, 1999. MMWR 1999;48(16):335-7.

I would like to propose an alternative to the conventional way of performing the digital rectal examination for palpation of the prostate. I believe this method is more comfortable for the examiner and thus may facilitate the detection of abnormalities. A search of the literature has shown no prior reference to this method.

Conventionally, examination of the prostate is performed with the patient in the left lateral or left lateral prone position (Sim's position).^1,2 To palpate the prostate adequately, the examiner must have the palmar surface of his or her hand facing the ventral prostate gland. The examiner must therefore pronate his or her arm maximally and may even need to turn his or her body away from the patient to feel the area. This position is unnecessarily awkward and makes it especially difficult to reach the prostate and the right rectal wall.

I suggest that the patient be placed instead in a right lateral or right lateral semi-prone position. Using this method, the examiner need not pronate his or her hand to the same degree. In this more natural position, the examination can be performed more easily, comfortably and reliably. Of course, the posterior rectal wall may be more difficult to palpate in the proposed position, but the emphasis of the technique is on palpation of the prostate. Once the patient's hips and knees are flexed, the examiner should stand below the level of the hips to visualize the perineum, the anal orifice and the buttocks. The remainder of the exam is then performed in the usual manner.

Nancy Hotte
Class of 2001
Faculty of Medicine
McGill University
Montreal, Que.
hotte01@med.mcgill.ca

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1. Bates B. A guide to physical examination and history taking. Philadelphia: Lippincott Williams & Wilkins; 1995.
2. Swartz MH. Textbook of physical diagnosis: history and examination. Philadelphia: WB Saunders; 1998.

Although I can understand Drs. Ian F. Tannock and David G. Warr's frustration with limited research funding [full text],¹ I find that their article belittles the qualities of science, which are to seek evidence and truth, wherever that search may lead. The accusation that the CMAJ series on unconventional therapies represents a "low point for both CMAJ and the Canadian Cancer Society" is an unwarranted insult, one that may be viewed as unsympathetic to the educational needs of both health care professionals and patients with cancer. Nowhere is an endorsement of these therapies implied and, quite frankly, the information provided may persuade open-minded, but sceptical, readers that evidence for their efficacy is limited.

I agree that many inappropriate quasi­scientific therapies are touted for the alternative treatment of cancer. These should be distinguished from alternative paradigms of health care, for example traditional Chinese medicine and ayurvedic medicine, which operate within a very different cultural philosophy.² The strength of these paradigms is that they convey a humanistic and holistic approach to health care by integrating the body, mind and spirit into their diagnostic and treatment systems. The therapeutic tools used within these systems are currently being evaluated.³ Many oriental herbs have been shown to be active as biological response modifiers when tested in the laboratory. They may be useful as adjunctive therapies for both the treatment of cancer and the reduction of side effects from chemotherapy and radiotherapy.⁴ Acupuncture has been shown to modulate neurophysiologic responses and neuropeptide levels and may be useful for both symptom control and manipulation of endocrine status, cykotine production and immunocompetence.⁵ The science of psychoneuroimmunology is revealing that psychological techniques, such as meditation, can modulate the immune system and levels of hormones such as melatonin (which can inhibit the division of prostate and breast cancer cells in vitro and in vivo).⁶ I believe that the scientific evaluation of these alternative health care systems, including their interaction at the molecular level, is a challenge and a responsibility that should be met with enthusiasm and not shunned by physicians.⁷

To use Drs. Tannock and Warr's metaphor, patients with cancer do see the earth as flat, their perception clouded by the immediacy of their impending death. A holistic approach to their care is more likely to persuade them that the earth is round.

Stephen M. Sagar, MB BS
Board member
Complementary Medicine Section Ontario Medical Association
Hamilton, Ont.

Competing interests: None declared.

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1. Tannock IF, Warr DG. Unconventional therapies for cancer: A refuge from the rules of evidence? CMAJ 1998;159(7):801-2.
2. Eskinazi DP. Factors that shape alternative medicine. JAMA 1998;280:1621-3.
3. Alterations are ahead at the OAM [editorial]. JAMA 1998;280:1553-4.
4. Guo ZX, Wei MC, De XQ, Jie HY, Xue LW, Hong XZ, et al. Chinese herb "destagnation" series I. Combination of radiation with destagnation in the treatment of nasopharyngeal carcinoma (NPC): a prospective randomized trial on 188 cases. Int J Radiat Oncol Biol Phys 1989;16:297-300.
5. Filshie J, White A. Medical acupuncture: a Western scientific approach. Edinburgh: Churchill Livingstone; 1998.
6. Massion AO, Teas J, Hebert JR, Wertheimer MD, Kabat-Zinn J. Meditation, melatonin and breast/prostate cancer: hypothesis and preliminary data. Med Hypotheses 1995;44:39-46.
7. Sagar SM. Unproven cancer therapies. Ann R Coll Physicians Surg Can 1998;31(3):160.

    See letter: Unconventional therapies and cancer

Dr. Sagar is concerned that our editorial may be viewed as "unsympathetic to the educational needs of both health care professionals and patients with cancer." This criticism is ill-founded — our concluding paragraph stated that the series provided useful background information for physicians [full text].¹ Education, however, should be based on facts. Although the series gave the appearance of an evidence-based review, it did not use conventional rules for ranking evidence. In the case of hydrazine sulfate, the highest quality data consisted of 3 negative double-blind randomized trials published in a peer-reviewed journal [full text].² If this was an antineoplastic drug developed along traditional lines, there would be only one reasonable verdict: ineffective. Dr. Elizabeth Kaegi, however, concluded that the effects of hydrazine sulfate on tumour shrinkage and survival were "uncertain" and that more trials are necessary. Ill-founded conclusions considerably weaken the educational value of any article, especially one also intended for the lay public.

Patients use alternative cancer therapies to improve their chance of survival. Life-prolonging anticancer therapies developed by nontraditional means could exist. However, we lack a logical framework for deciding which of the endless alternative approaches should be evaluated. The evaluation of interventions that receive vocal support (laetrile, vitamin C, hydrazine sulfate) has yielded entirely negative results, yet their use persists. How will we answer the inevitable comments on trial design when the intervention is a "holistic approach" with enormous variability in delivery? The expected 1 in 20 false-positive studies will be forever touted as evidence of efficacy and subsequent negative trials will be attributed to inadequate methodology.

The scientific community has a responsibility to use wisely the money generously donated by the Canadian public to the Canadian Cancer Society.

David G. Warr, MD
Ian F. Tannock, MD, PhD
Department of Medicine
Princess Margaret Hospital and University of Toronto
Toronto, Ont.

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1. Tannock IF, Warr DG. Unconventional therapies for cancer: A refuge from the rules of evidence? CMAJ 1998;159(7):801-2.
2. Kaegi E, on behalf of the Task Force on Alternative Therapies of the Canadian Breast Cancer Research Initiative. Unconventional therapies for cancer: 4. Hydrazine sulfate. CMAJ 1998;158(10):1327-30.

A recent CMAJ supplement¹ contained an incorrect statement of competing interests for Dr. George Fodor. The statement should have read: "Dr. Fodor has received educational grants and speaker's fees from various pharmaceutical companies."

[Contents]

1. Fodor JG, Whitmore B, Leenen F, Larochelle P. Lifestyle modifications to prevent and control hypertension: 5. Recommendations on dietary salt. CMAJ 1999;160(9 Suppl):S29-S34.

A recent letter by Dr. Terry Polevoy¹ contained an error. It was a young woman from the Saskatoon area, not Regina, who died.

The online version is correct.

[Contents]

1. Polevoy T. The Internet and chiropractic. CMAJ 1999;160(9):1288.