From the Editors' Desk As students from across Ontario ga ther at Western for the annual OMSW, the UWO Medical Journal is proud to present a glimp e of Medicine at Western. A histo rical per pective by Hans Marquardt, Meds '94, introduces one to Western Medical School and it illu triou past. This is ue explo res some area of new technology at Western, wi th an article by Dr. j. Denstedt o n the addition of Ontario' econd renal lithotripter a t St. joseph' Ho pita!. In conj uncti o n with the OMSW symposium on the Roya l Com mi io n on ew Reproductive Technologies, a comprehensive ove rview o n the legal i ues involved w ith in vitro fertilization has been included . At the undergraduate curriculum level, in ightful articles on the continuing controversy over PBL (Problem Based Learning) from both tutor and tu dent perspectives ha ve been included , courtesy of Dr. W. Weston and Dave Hackam, Med '92. With
the continual changes in medical training and the declining medical housestaff workforce, Dr. R. Al essa ndr ini clarifies th e o bjectives of PA IRO (the Professional Association of Interns and Residents of Ontario), and how this organization acts to protect doctors. .... o n a more globa l level, the Gulf wa r i uppermost in eve ryone's mind . While some have quipped it a the "war miniseries" on TV, for those of u with friend in the military or abroad, it takes on a greater importance and fea r. It seem ironic that thi i sue of the journal includ es an ad from the Ca nadian Armed Forces Medical Officer Traini ng Program , showing a soli tary U. . tank ascending a sa nd dune in th e de sert. Who wo uld ha ve eve r thought that reality could so closely mirror this photo-advertisement? It also seem somewhat paradoxical that Gorbachev, who was a recent recipient of the obel Peace Prize, now faces
War! Repo rts of it filling th e new each night. For many of u in fourth yea r the new that we were at wa r with Iraq ca me in th e midst of the traditional Lond o n Academy of Medicine dinner. It immediatel y superceded all other topics of conversation. We were also in the middle of the ACLS cou r e, which somehow had lost its importance while bombs and missiles we re pounding Baghdad and the threat of retalia tion against Israel was immi nent. It is now 10 da ys into the war as I wri te this. It has trul y become a media event. The U.S. milita ry, th eir experience honed on the cutting edge of the Vietnam War, have become the ma sters of military propaganda . They control the military briefi ngs that the journalists receive, which colours our perception of th e wa r. I, like man y others, have m ixed feelings abou t the wa r. One comm ent was made on television that this was "war by Nintendo". In reflecting, that statement ha a g rea t deal of validi ty. We ee videos of a ircraft targeting ites and relea ing bo mbs, much in the sa me way "galactic wa rrio rs" do in video ga m es. We don' t, however, see anything of theca ualtie of war .. . th e injured, th e dead, the homeles . Film howi ng the re ults of th e SCUD bombing of Tel Aviv I'm certai n only touche the surfa ce. And what of the ot her ide, th e civ ilian p o pulati o n of Iraq and Kuwait? Today, the totals read 20,000 sorties flown (read bombing raids - military sani tization?). Yet we ha ve no real idea of what is , the lone going on in Iraq. Peter Arnett, C We tern journalis t remaining in Baghdad, i getting a much pro pagand a as is the ot her ide di pensing. nfortunately, it i the member of the medical community world-wide that will be picking up the pieces long after thi "limited engagement" is over. Canada has sent over a
field hospitaL The Red Cros has a lso made an appeal for heal th care workers to volunteer to set up a nd staff ho pita! in the g ulf region . Howeve r, the need fo r trauma surgeo ns is undoubtably great, a many Ca nadian military physicians in recent years have had more experience in the capacity of family physicians than under th e conditions in a field hos pitaL Of co urse, I can o nl y peculate, but given th e d esert condition , water will undoubtably be at a premium, including for aseptic OR conditio n , especially with the recent news that the Saudi water desalinators may have to cease operation due to the oil conta mination in the gul f. Wound contamination and d ysentry are likel y to become major problems. I can' t help but think of our colleagues who chose the military option in medi cal school, and I wish them welL Rumour ha s it that everal surgeons, currentl y and formerly associated with Western ha ve headed to the gulf region to assist in w hatever way that they can. They and all others who volunteer to go must be commended for putting their skill to use w here they a re desperately needed, even though substantial personal sacri fice i involved . Many urgica l advances ca me about through techniques pioneered in wartime, so perhaps something may i:::J be salvaged from thi war.
page 2
Connie Nasello PateJSon, Meds '91
Correction A cartoon in the previous edition suggested that the new clerkship would begin in 1993. It will in fact begin in 1992.
the very destruction of his ow n peace efforts within the Ba ltic sta tes. At the sa m e tim e, Romania attempts its slow recove ry from a tota litarian government which, amo ng other things, enforced archa ic reproductive demands which ou tlawed the use of birth control for any women under 45 or with fewer than five children . Child ren with "defects" a minor a protrudi ng ea rs, the wrong sex, or low birth weights, became the victims of orphan asylums a nd g uin ea pi gs for human experi mentation .... and in spite of it all, life in medical school goes on, vi rtually oblivious to it all It's a crazy world we live in, isn' t it?
Shirley Lee, Meds '92
Thr thrmr of this is sur of th r Mrdi cal Jo ur·n11l is • Mrdicinr: Past and Prnntr. n.r cot~rr, drawn by Km Alanrn, M rds '94 drpicts Snlf*rtll m rdica l milrs tonrs. Slrown "" thr Jarvik·7 artificial heart, to nnv pninilltll trchnology, w hich nrablrs 17 wrrk old prrmaturr b11birs t o survivr, to thr '"Vatson·Crick DNA doublt' ht lix, t o Frrdfflck Banting- olHILAurra t~ fo r thr co-discovny of in s ulin, and fi nally, t o 11n illustr11tion drii Wif from Andrr11s Vt>sa lius' Bodt> dt>, Hum11ni fabrica - ont> of thr firs t 11natomy ta ts.
The University of Western Ontario Medical )ollll\al is published 4- times per year by the students of the U .W.O . Medical School. Established in 1930. Articles, letters, photographs and drawings welcome from the London medical community. Submi sions should be typewritten and double spaced, or submitted on computer diskette. Correspondence should be directed to U.W.O. Medical Journal, Health Sciences Centre, U.W.O., London, Ontario, 6A5Cl . Editon: Connie asello Paterson, Med '91 Shirley Lee, Meds '92 Associate Editor: Barry Love, Meds '93
Advertising: Caroline Meyer, Meds '92 Jollll\al Reps: Allan Garbutt Meds '91 Joan Lipa, Med '92 Barry Love, Meds '93 Justin Amann. Meds '94 Jeff Politsky, Meds '94 faculty LWsoll: Dr. Martin Inwood De.a dline for next issue: March 4, 1991
UWO Medical Journal 60 (2) February 1991
UWO Medical School: A look back by Hans Marquardt, Meds '94 Try to imagine a time when all 'qualified ' applicants were accepted to U.W.O Medical School. To qualify, one needed high school Junior Matriculation, a requirement which was often not enforced. So it was during the early years of U.W.O Medical School. The marked changes in the entrance requirements from the first days to present reflect equally momentous changes which transformed the Western University Medical Department, as it was originally called, into the University of Western Ontario Medical School of today, considered on par with the best medical schools in orth America. Two individuals were responsible for events which preceded the founding of Western Univerity, both were representatives of the Church of England, Dr. Benjamin Cronyn and Dr. Isaac Hellmuth. It was Dr. Cronyn's idea to found Huron College, to be used for the training of Anglican clergy. Dr. Hellmuth was instrumental in establishing Huron College and later in the founding of Western University. Dr. Hellmuth took over as Bishop of Huron in 1871 after the death of Bishop Cronyn. Dr. Benjamin Cronyn was born and educated in Ireland. He emigrated to Canada at the age of 31 years with his wife and two small children. The year was 1832 and London was a pioneer community of roughly 500 inhabitants, referred to by many as the Fork of the Thames. Dr. Isaac Hellmuth had a particularly interesting background . He was born in 1820 near Warsaw. Hellmuth's father, an orthodox rabbi, wished his son to follow in the rabbinate. Instead, young Isaac became involved with a missionary belonging to the Society for the Conversion of the Jews. Upon informing his father that he wished to convert to Christianity he was obliged to sever aU connections with his family. He assumed his mother's maiden name and became Isaac Hellmuth instead of Isaac Kirchmann. After studying and teaching in England at the Institute for Enquiring Jews, he joined the Church of England. He emigrated to Canada in 1844 and became involved with Dr. Cronyn's work in 1861. Bishop Hellmuth applied to the Provincial Government for incorporation of a college with university powers, in connection with the Church of England. After some tumult, the bill passed and received royal assent on March 7, 1878, the official date for the founding of Western University. The act of incorporation placed control of the University with its Senate. The Huron College Alumni Association purchased the property of Hellmuth' s Boy' s College, until recently a preparatory school, founded by Dr. Hellmuth. In May, 1881, Huron College transferred its income and resources to the University. Official opening of Western University occurred on October 6, 1881. Classes started the next day in two Faculties, Arts and Divinity. The Western University Act made provisions for further Faculties; Arts, Sciences, Literature, Law, Medicine, and Engineering. It is not known whether the impetus for the formation of the Medical School came from Dr. Hellmuth or others, but the increasing population of Western Ontario indicated the need for a medical school in the area. Only two meetings, two days apart in
1881 , were needed to agree on the founding of a Medical School. Dr. Charles G. Moore was chosen as the first Dean. The Arts and Divinity College occupied aU available pace in the main building and so a modest five room cottage on the property, the home of Rev. Charles B. Guillemont of the Divinity faculty, was used for medical classes. Dr. William E. Waugh arrived at the cottage by horse and carriage punctually at eight, on the morning of October 1, 1882, to deliver the first lecture, which was on anatomy. The first class had sixteen students. The faculty were all part-time teachers who had large practices or other responsibilities. There were no separate departments, as there are today, for thirty years. Three subjects or chairs that late.r formed part of the premedical training were Botany and Zoology, Theoretical Chemistry, and Practical Chemistry. The ba ic medical chairs were Anatomy, Physiology, and ormal and Pathological
UWO Medical sm-1at York and -uloo d Jal900. ~..w. ,..,.,....,..
Histology. The clinical chairs were the Principles and Practise of Surgery, Clinical Surgery, Obstetrics and Diseases of Women and Children, ervous and Mental Diseases, Sanitary Science, Therapeutics, Materia Medica, Medical Jurisprudence, and Toxicology. ln 1885 Huron College withdrew from Western University. The Medical Faculty alone continued to function from 1885 to 1895 during which time the University was reorganized. In 1888 the Medical School moved to a building erected at York and Waterloo streets, at the site of the present day fire hall, where it remained until 1921. Prior to 1913 the Medical School was owned and operated by the professors. ln the summer of 1913 the Medical Faculty became a responsibility of the Board of Governors of Westem University. The existence of the Medical School was strongly challenged when the Report on Medical Education in the United States and Canada, by Abraham Flexner was published in 1910. The report gave Western University and many other schools a very poor rating. Following publication
UWO Medical Journal 60 (2) February 1991
of the report, the Council on Medical Education of the American Medical Association introduced a grading system for Medical Schools. Class A was acceptable, Class B was acceptable with present organization, provided that certain improvements were made, and Class C signified the need for complete reorganization. eedless to say, Western Medical School received a Cia s C rating. Among the shortcomings were insufficient education in premedical subjects, too few full-tim e professors, meagre financial resources, inadequate laboratory and library facilities, and limited access to public ward patients at Victoria Hospital. The Flexner Report had a profound effect on medical education in orth America . The criticism, although quite disturbing, was justified and led to important improvements. Laboratory and clinical facilities were improved, entrance requirements became more stringent, and they were enforced. New highly respected full-time faculty members were hired and standards we.re raised. An average mark of 60% was now needed for a pass, up from the 40-50% level. Fewer supplemental examinations were allowed and public ward patients were aU made available for teaching. ln 1917 the Medical School received a Class B rating, and in 1926 a Class A rating was achieved, five years after moving into a new building on Ottaway Avenue (renamed South Street in 1947), across the street from Victoria Hospital. The rating system was discontinued in 1928. Henceforth Medical Schools meeting the required standards, as Western has continued to do, were recorded as approved. Several significant events took place over a period of a few years. In 1918 an executive committee passed a resolution that " women be admitted as students in the Faculty of Medicine on the same basis as men". Western's first woman medical student enrolled in 1919; her name was Kathleen Braithwaite. Furthermore, the fir t women faculty members were appointed jus t prior to the 1921 move to Ottaway Ave. ln addition, in 1920 Dr. Frederick G. Banting came up with the idea which led to the discovery of insulin while he was a junior member of the Medical Faculty of Western University. Relocation of the Medical Faculty from South Street to the main University campu took place in 1965, where it remains today. At this time the Kresge School of Nursing and the Cancer Research Laboratory were already in place; the former was completed in 1960 and the latter was established in 1961 . The Dental Science Building and the University Hospital opened in 1968 and 1972 respectively. Additions to the Health Sciences Centre took place in 1968 and 1975, incorporating the Collip Reading Room and the Health Sciences Addition, in that order. And so, from the five room cottage used during the first years, to the extensive facilities of today, the Medical School of Western Ontario has been transformed from a somewhat obscure and uncertain venture into the respected institution of today, of which Bishop Hellmuth would certainly beproud . D (Material for this article was obtained from A Century of Medicine at Western by Dr. Murray L. Barr, published in 1978.)
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In Vitro Fertilization: An examination of the legal issues by Constance Nasello Paterson, Meds '91 In recent years, the rapid advances in medical technology a ppear to have outstripped the ability of the law to respond to the resulting legal issues. In no area is this more evid ent than in the development of reproductive technol ogy. Clinicians a nd resea rche rs h ave developed techniques to artificially a sist conception in couples w ho have been identified as infertile. The mos t rece nt tec hniqu e , a nd those most strongly questioned, are the developments of in vitro fertilization and embryo transfer. Intervention in the area of conception gene rates bo th e thical a nd mora l co n ce rn s to which the law must respond . In a report commissio ned by the Ministry of th e Attorney General in 1985, the Onta ri o Law Refo rm Commission (OLRC) commented that "the law in this area is astigmatic in the main, ignoring or inad vertently applying to the various legal issues arisi ng from the growth of artificial conception services" (1 ). Other cou ntri es are s tru gg ling, o r have struggled with the legal issues affiliated with in vitro fertilization . This has been precipitated by a series of events which have occurred over the past 12 yea rs. In July, 1978, Louise Brow n, th e first baby conceived thro ug h in vi tro fertilization, was born in Engla nd . While this was applauded as a technique to finally allevia te infe rtilit y, man y qu es ti o ns we re raised about the implications of this event (2). Tha t sa me yea r, the first lawsuit was brought involving in vi tro fertilization before the courts in the United States. In Del Zio vs. Presbyteria n Hospita l, an in vitro fertili za tion culture was d estroyed by the hospital's chief of obstetri cs a nd gy necology, w ho claimed tha t th e experiment was too risky, and had not been approved by the hospital. The jury awarded the prospective parents $50,000 for pain and suffering (3,4,5). This suit raised the issues of "sanctity of life" a nd of whether the embryo could be considered the property of the paren ts (5). In 19 3, in Au tral ia, the Rios case focus ed atten tion on the statu s of the fetus. The Rios couple had undergone in vitro fe rtilization a t a clinic in Me lbo urn e, Aus trali a. Two embryos were frozen for implantation at a later date. However, prior to implantation, the Rio es were killed in an accident, leaving no will. The couple were millio naire , a nd the legal problem was to determine w hether the frozen embryos could be considered legi timate heirs (5). In vitro fertilization involves many issues that are common to o ther debates in the health sciences. Central amongst these issues are the tatu of the fe tu s a nd the definition of life. Ancillary to these are the question of owners hip of embryos a nd donated games, legal
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parenthood of dono r-fertilized embryos, the empl oyment of surrogate mo thers, informed consent, and experimentation on embryos. At the present time few countries where in vitro fertilization i perfo rmed have add res ed the legal problems by establishing specific legislation.
The Right to Procreate The legal issues ari ing out of the IVF procedure center around a number of issues. One of the first thi ng tha t mu s t be decided is w hether the individ ual has a right to procreate, and if so, whether the individual has the rig ht to use arti ficial methods to achieve that end . Article 10 of the Universal Declaration of Human Rig hts, w hich was ratified by Canada s ta tes "The wides t p ossi bl e pro tection and assistance should be accorded to the family...in particular for its establishment." Article 15 of th e sa me document recog ni zes the right of everyone to enjoy th e be nefi ts of scien tific progress and its applica tion (1) . Thus is would a ppea r that Canada, at leas t internationally, supports the righ t to procrea te, and to use scientific mea ns to do so. To w hom is that right ex tend ed in actual fac t? The OLRC reco mm e nd ed that "s table" s in g le wome n and
"sta ble" men and women in "stable" marital or nonmarita l relations be considered eligible to partici pate in artificial conception programs (1).
The status of the embryo The legal problem o f th e s tatu s of th e embryo ha s implications for all o ther issues arisi ng out of IVF. This would a ppear to hinge o n w hen th e definition of human life can apply to the fe tus. In the United States, an Illinois s tatute specifical ly pe rtainin g to IV F requires that any person ca using the ex ternal fertilization of a human oocy te by a human sperm hall assume the "ca re and cu tody" of the child, w ith penalties under the child abuse legislation (7). This intimates that, at least in Illinois, life is considt>red to begi n at fertiliza tion . However, th e statute also sta tes tha t it "shall no t be cons tru ed to a ttach penalty to lawful pregnancy te rmin a ti o n " (7) . Thus, damage to an emb ryo is co nsidered punisha bl e by law only when th e e mbr yo is conceived outside the uterus. This appears to be incong ruous, and the statute has been challenged in the courts (7). In Canada, the Criminal Code section 206
Continued on page 5
UWO Medical Journal 60 (2) February 1991
IVF continued states (1) "A child becomes a human being when it has completely proceeded, in a living state, from the body of its mother," and (2) "A person commits homicide when he ca u ses injury to a child before or during its birth, as a result of which the child dies after becoming a human being ."(8) Under the present law, embryo deaths would not therefore constitute homicide, since the embryo has not resided within the mother's body, and thus has no status as a human being. However, in Borowski vs. Attorney General for Canada, in the question of whether there is a right to life, the judge found that " ... foetal life .. .is an existence separate and apart from the pregnant woman, even although the foetal life may not be maintainable, during the early stages of pregnancy, independently of the pregnant woman" (5). He held, however, that it was the responsibility of Parliament to legislate to protect the fetus. To date, Parliament has not taken up that challenge. Such legislation would have far reaching implications and would undoubtedly create more problems than it would solve. In the !VF programs, the embryo could thus be considered independent human life. It would , however, be difficult to determine whether a physician ca used the death of an embryo, or whether such embryo death would have been inevitable under any circumstance.
Use of Embryos in Research Also affected by the definition of human life would be use of human embryos for experimentation. Internationally, it is generally agreed that to be successful and to maximize effectiveness and minimize the risks involved in IVF, embryo experimentation must occur. However, it is also agreed, and recommendations have been made, that it be unlawful for any physician to implant any embryo that has undergone experimentation (1,2,9,10,11). In Australia, this has also been encompassed in legislation covering !VF (12). Experimentation in fVF ranges from identifying new techniques for preparation and implantation of embryos, to improving techniques for freezing and thawing of embryos, to determination of sex or identification of genetic abnormalities. Other ancillary research including abortifacents, contraception , cancer theory, genetic manipulation, identification of abnormal genes and transplantation are also performed o n embryonic tissue (6). The Warnock Commission, in the Uni ted Kingdom, recommended that facilities performing research on embryos be licensed, to control unauthorized or illegal experimentation (2). Among the research that they considered shou ld be allowed wa s tran sspecies fertilization , provided that the resulting embryo was allowed to progress no further than the two-cell stage. Victoria, Australia , however, has made this manipulati on illegal under its legislation. They included as illegal experimentation implantation of human embryos into other animal species, cloning
experimentation and the use of embryos to test toxic substances (2,12). While the OLRC considered these issues, it made no recommendation that research be restricted in its scope. It did , however, recommend that resea rch and experimentation s hould not be licensed , but that it s hould be restricted to approved research centres (1 ). Most study group have recommended that it be illegal to continue ex perimentation on the embryo beyond 14 days of development. This does not include any time that the embryo has been frozen . It is at this time that early neural development begins. While most embryos in vitro rarely survive that long, any remaining must be destroyed (6). Most groups also have agreed that urplus embryos hould be available for research purposes. However, they have also agreed that embryos should not be created strictly for the purpose of research (1,2,9,10,11).
Donation of Gametes and Embryos The Human Tissue Gift Act states that to donate human tissue, the individual must be of the age of majority and be competent to give a free and informed con ent. This does not include skin, bone, blood or blood cons tituents, or tissue which is normally replaced by nature. In this respect, oocytes would be covered by the Act, as they are not normall y replaceable . The woman is also required to undergo a medical or s urgi cal procedure to obtain oocytes, which would require informed consent. At present, oocytes cannot be reliabl y frozen, so the concept of oocyte banks, in the nature of present sperm banks, i still distant. However, oocytes ma y be donated by women undergoing tubal ligation, by relatives, or even excess oocytes retrieved via IVF which could be donated for immediate use. Sperm, in contra s t, are under continual production and sperm donations would consequently not be covered by the Act, and technically, would not require an informed consent (1 ). This issue of donation o f game tes and embryos is closely tied to the issue of informed consent and ownership. A question that arises with respect to donation o f gametes is whether a donor can withdraw consent for ga mete use. This can depend on whether the process is considered as the sa le of goods o r the sale of service. If it is cons idered to be the sale of goods, then on completion of the sale, the owner forfeits his interest in the property. If considered a sa le of services, then the owner retains his interest, and may withdraw his consent. The Human Tissue Gift Act prohibits the sale of blood or bod y parts, however, donors may be paid for their services and inconvenience. Thus, the donor retains ownership of hi or her gametes, and ma y s pecify uses for them, or may withdraw consent for their use.
UWO Medical Journal 60 (2) February 1991
The ability to decide disposition of gametes end s, however, when the gametes are used. The OLRC recommended that all gamete donors be required to give their informed consent prior to donation (1). Similarly, the OLRC recommended th at when urplu s embryo are available for donation to a third party, or when they have been frozen, the parent couple retains the right to decide the uses or disposition of the embryos. Where donor gametes have been used , the donor has no recognized right over the resulting embryo (1 ) . However, the Warno c k Commission recommended that there is no right of ownership of a human embryo (2). Instead, the parents act as guardians of the embryos. In either case, when one of the couple dies, the legal control of a frozen embryo passes to the survivor. If both die, control of the embryo should pass to the facility that has actual possess ion of the embryo (1 ,2). The OLRC also recommended that embryos should o nl y be s tored for a maximum of 10 years, after which time they should be destroyed (1 ). The Victoria legislation, in contrast, specific that should the woman be incapable of receiving the embryo for implantation, or should both parents die, then the e mbryo shall be made available for donation for another IVF procedure (12). This was in direct respon e to the Rio ca e. Initially, a committee of the legislature recommended that the frozen embryos of the Rios co uple be destroyed. This was rejected , and subsequently a recommendation was mad e to donate the embryos for IVF (13).
Status of Children The s tatu s of children conceived by IVF where the gametes come from hu sband and wife is the same under the law a children conceived normally. However, when the gametes come from one or more donors, the legal situati on becomes more complex. Ultimately, a child could have 5 parents: a genetic mother, a gestational mother, a social mother, a genetic father, or a social father. Prior to the d evelopment of IVF, there was no problem in identifying the mother, it was always the birth mother. ow, a third party ma y donate an oocyte for fertilization by either the husband's sperm or donor sperm . This rai es the is ue of legal parenthood , which has implications as far as requirement to support children conceived b y IVF, and of inheritance ri ghts. Legislation to date has defined parent as "the father or mother of a child" (1 ). This makes no reference to biological parenthood, it assumes it. The OLRC made a number of recommendations in this area. First, it recommended that donors of gametes shall have no legal right or obligation to any children o r embryos conceived by artificial means. If a couple utilizes one donor gamete in IVF, then they shall legally be considered the parents of a child born by this procedure. Similarly, if donor gametes are
Continued on page 6 page 5
IVF Continued from
to bear a child for another couple, and to give up that child upon birth. It often requires artificial insemination by the contracting male partner and may involve agreement to lifestyle res triction s on the part of the surrogate, in order to ensure a healthy child . The exchange of money is u ually involved , and although this is argued to be payment for services and expenses, it is difficult to separate from the notion of baby-selling. Surrogacy is al o poss ible in IVF, with either one or both gametes donated , or by transfer of an embryo conceived in vitro from the contracting couple's s perm and oocytes. Similarly, in vivo fertilization and lavage might also be employed . Surrogacy might be the answer in situations where fertilization is possible in a wo man who suffers habitual abortion and is unable to carry a pregnancy to term . Alternately, it ma y be used where a woman lacks a functional uterus. There are several problems inherent in the issue of surrogacy. First, it involves the concept of ' rental ' of a uterus . Thi s may be considered distasteful and also raises the is ue of whether the urrogate is indeed being paid an adequate fee for her ervices. The second problem is that of parenthood . Even though a couple may be the genetic parents, under the recommendation of the OLRC the surrogate, and if married, her husband , would be considered the legal parents of such a child . Thus, the question of adoption is involved, which may
page 5
used to create an embryo, or an embryo is donated by another couple, which is sub equently transferred to a woman , then the child which res ults is to be considered the lega l child of the gestational mother and her partner. Thus, in all cases, the birth mother and her partner would be considered the legal parents of children produced by any method of conception (1 ). The Commission also recommended that children conceived through artificial mean should acquire inheritance right to the estates of those persons recognized as their legal parents. On the matter of posthumous conception using the husband ' s s tored s perm, and presumably posthumous implantation of frozen embryo , the resulting child should be recognized as the legal child of both parents, and s hould be recognized as a legitimate heir (1). In general, these recommendations concur with recommendations made by the Warnock Commission in the U.K. (2), and tho e in Victoria , Australia , the Status of Children (A mendment) Act 1984 (14). Germany, however, recently pa sed legisla tion banning such practices (15).
Surrogacy The iss ue of employment of surrogate mother is on that has evoked very strong responses. It involves a contract for a woman
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result in detailed study by outside agencies to determine whether the genetic pa rents are suitable candidates to adopt their own genetic offspring. The Child Welfare Act, as an additional complicating factor prohibits payments in connection with adoption (1 ). There is also the issue of misuse of surrogacy, should a couple de si re a child without the bother of a pregnanc y hire a surrogate to carry their genetic child . Intern a tionally, mos t jurisdictions have argued against surrogacy. The Warnock Commission recommended that the recruitment of surrogates s hould be illegal. that professionals involved in the establishment of a surrogate pregnancy s hould be liable for criminal prosecution, and that all surrogacy agreements s hould be illegal and unenforceable by the courts. The Australian legislation recommended that anyone contracting for a surrogate, o r any person giving or receiving payment for s uch a purpose shall be liable for imprisonment of up to two years (12). Germany recently passed legislation banning surrogacy (15). In the United States, while the American Fertility Society approved surrogacy in principle, only a few sta tes have considered the legal problems associated wi th it. In general, the courts are deciding the issue (7). In Ontario , the OLRC also decided to approve the concept of su r rogacy. In thi s regard , it made 34 recommendations regarding
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UWO Medical Journal 60 (2) February 1991
IVF continued legisla ti o n fo r th e co ntro l of s urrogacy a nd included tha t all urrogacy agreement must be approved by the court prior to conceptio n, a nd upe rvised b y th e court until th e ch ild was given up to the socia l pa rents. Th is propo al denies lega l s ta tu s to th e b irth mothe r a nd requ ires tha t a ny payment to the surroga te be a pproved by the court.
no log ies are eith e r p raised or bashed by the publ ic. :::J
(The author would like to tha11k Dr. Stall Brou'll for acti11g as guest editor.)
T he i s ues invo lved with IVF a re hig hl y complex a nd a re g rounded both in conventional legal p ri nci ples and ethics. The field of IVF is developing rapidly, a nd requires guideli nes fo r both the professionals invo lved in the cli nica l applica tion a nd resea rch areas as well as fo r the patien ts w ho desi re to be in volved . The legal s ta tus of the children w ho a re born through use of IVF p ro路cedures mu s t a lso b e cla r ified . Cha nge within the lega l system is excrucia tingly slow. The Onta rio La w Reform Comm ission gave its report 5 years ago, but definitive legislation has no t been drawn up. C urrently the Royal Commission on Reprod ucti ve Technology is ho lding hearings across Ca nad a w ith a repo rt expected in la te 1991 or early 1992. In the mea ntime, a ha nd ful of physicians a re the ga te kee pe rs to a m ys te ri ou s a nd po ten tially d ehumanizing technology tha t some view a ki n to crea ti on . Small wond er rep roductive tech-
2.
Ontario Law Reform Commission; Report on human arti ficial re production and related matters, Ministry of the Attorney General, 19 5. United Kingdom, Depa rtment of Hea lth a nd Social Security; Re port of the committee o f in qu iry i nto human fertili s at ion an d e mb ry olog y, Da m e Mary Warnock, Chairman, Her Majesty's Stationary Office, London, 1984.
3.
Flann e ry, D. M., et.al.; Tes t tube ba bies: Lega l issues raised by in vitro fertilization. Georgetown Law J. 67:1295, 1979.
4.
Cohen, M.E.; The "brave new ba by" a nd the law: Fashioning remed ies for the victims of in vitro fertilizatio n. J. Law Med. 4(3):319, 197 .
Annas, G .j., El ias, S.; In vitro fertil iza tion and embryo tra nsfer: Medicolegal aspects of a new tec hniq u e to creat e a fa m ily. Family Law Quarterly 17(2):199, 19 3. Criminal Code of Ca nada R.S.C.1 970 c. C34, s.206.
9.
Br iti sh Medi ca l Assoc ia t io n Wo rk ing Grou p o n IVF; Inte rim report o n human in vitro fertilisa tion and embryo replaceme nt a nd tra n fe r. Br.Med .J. 286:1594, 1983.
10.
Roya l C o ll ege o f Ob s tetri c ia n s a n d Gy naeco logis ts; Report of the RCOG Ethics Committee on In Vitro Fertilisati on and Embryo Replacement or Transfer, Cha meleon Press Ltd ., Lond on, 19 3.
11.
Un ited Sta tes Ethi cs Ad v iso ry Boa rd ; Re p o rt o f HEW Suppo rt o f Huma n In Vi tro Fertiliza tio n a nd Embryo Transfer. Federal Register 44(1 ):35033, 1979.
12.
Victoria, Aus tralia; Infertility (Medical Procedures) Act 1984, o. 10163.
13.
Thomson, C.; Australia: In vitro fe rtil izati o n a nd m o re . Hasting Center Report 14(12):14, 1984.
REFERENCES 1.
Summary
7.
5.
Lo ng, L. L.; Artificially assis ted conce ption. Health La w in Ca nada 5(4):89, 19 5.
14.
Victo ria, Aus trali a: Stat us of Children (Amendment) Act 1984, No. 10069.
6.
Dr. S. Brow n, UWO, Personal communi ca tio n.
15.
Lond on Free Press; "Law outla ws surroga te motherhood", Oct.25/ 90.
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PAIRO- Protecting our future by Renato Alessandrini, M.D. '89 PAIRO stands for The Professional Association of Interns and Residents of Ontario . PAIRO was created officially in 1968 by a group of interested housestaff. The goals of the organization are to pursue improvements in matters of training, communication and remuneration for all interns and residents. PAIRO is not a union, but functions similarly to one. PAIRO is a non-profit organization that continues to be run by interested interns and residents. All interns and residents are members of PAIRO. There are three major levels for participation in PAIRO: the executive level , the general council level and the general membership level. As an intern or resident you are involved at the general membership level unless you choose not to belong. All members at any level pay a small membership fee which is calculated as a percentage of their wage. General council members are actually the hospital representatives. They are elected at the beginning of each training year by the housestaff at each hospital. Being a general council member is a perfect way to become more involved with PAIRO. That's how I originally
became involved . It's easy, interesting and even fun at times . The hospital representatives, together with the executive, constitute the General Council of PAIRO. We meet on a regular basis, about once per month, to conduct the affairs of the Association. All PAIRO members may attend meetings of the General Council. The executive membership, including two additional Board of Directors, are elected from the General Council membership. The executive also meets to conduct the affairs of PAJRO about once per month in addition to the meetings of the General Council. The decisions of the executive are under the scrutiny of the general council and indirectly through the general membership. The primary function of PAJRO is to represent its member as a whole, a group or an individual. We are involved in numerous activities, including contractual negotiations , advisory rol es for individual members of groups of members, development of various committees, such as the Physician at Risk Committee, administration of membership Long-Term Disability Plans, participation on
other important committees such as the Postgraduate Education Committee of the Council of Ontario Faculties of Medicine (COFM) and the OMA, communication with the Government of Ontario and The College of Physicians and Surgeons of Ontario, just to name a few. PAIRO also encourages excellence in postgraduate teaching of housestaff by the creation of the Excellence in Clinical Teaching Awards which are presented yearly to outstanding clinical teachers at each university center. In addition, PAIRO plays a very active role in CAIR, the Canadians Association of Interns and Residents. CAJR is the national organization of housestaff. CAJR and PAIRO share the same office which is situated in Toronto. Its Board of Directors is composed of an elected executive and representatives from each of the provincial housestaff organizations across the country. CAIR's primary focus is to make sure that housestaff are well represented with respect to those issues that have a bearing on their life as an intern or resident as well as those issues that may have an effect on their future professional
SEE YOUR C. HEÂŁ IN A' O/J
PAIRO continued career. CAIR has formal correspondence with many national organizations including the Royal College of Physicians and Surgeons, the College of Family Physicians of Canada, the Federation of Provincial Licen ing Authorities, the Canadian Federation of Provincial Licensing Authorities, the Canadian Medical Association, the Canadian Medical Protective Association, and the Association of Canadian Medical Colleges to name just a few. CAIR has an excellent track record and is a respect ed national association. For example, CAIR was instrumental in defeating the Government of British Columbia 1984 legislation at the Supreme Court of Canada, which attempted to prevent new doctors from being able to practice in the province. In addition, CAIR is involved in ensuring that the medical licencing requirement changes are ca r ried out in a logical fashion. There are many more function s of CAIR that I haven't space to mention, but if you wish to know more about either of these associations, I encourage you to read a PAIRO Manual. Since 1968 PAIRO has come a long way in improving the working conditions and opportunities for its members. The following arc a few of the achievements tha t have been attained over the past years. Recognition of the dual tatus of housestaff as both employees of teaching
hospital and as postgraduate s tudent w ithin the universities in 1974. Es tablishment of the Medical Postgraduate Consultation Committee, designed to help resolve differences between the Ontario Council of Teaching Hospitals (OCOTH) and PAIRO in 1976. Substantial wage increase to improve housestaff salary towards a satisfactory level in 1979. Independent compulsory binding arbi tration so that future strikes would not be necessary in 1980. Participation on COFM and postgraduate education committees in each of the five Ontario medical schools in 1982. Elimination of the unfair practice of some housestaff who were funded by sources other than the Mini try of Health not receiving equal pay for equal work in 1986. Mechanisms to review excessive housestaff workload problems in hospitals in 1988. One of PAIRO's major functions is to negotiate the Agreement with OCOTH. This Agreement covers terms and conditions of employment at most tea ching hos pi tals. In addition to remuneration, the contract contains information on members hip benefits such as OHIP. Life Insurance, Sick Leave, Long-Term Disability, Extended Health Care, Vision Care, Dental Plan, Out of Hospital Insurance, Vacations, Maternity and Paternity Leave, Statutory Holidays, Professiona l and Compassionate Leave. In 1980, housestaff gave up the right to strike in favour of binding arbitration. Recently, in December 1990, PAIRO and OCOTH
ÂŁRENT LIGHT
received an award from the Board of Arbitration concerning houses taff remuneration . Unfortunately, thi s new contract expires on March 31, 1991 , and as a result, PAI RO must begin to plan for upcoming negotiations. The initial steps of this process involve the Contract Committee, of which I am the chairperson. My objectives are to collect, discuss and summarize information regarding the PAIRO contract from the general membership and present it to the PAIRO General Council and Executive. Finally, it is important to realize that PA IRO is available to advise its members who require assistance, be it in a professional or personal capacity. If a member has a problem, the local hospital representative is there to help. Also, the PAIRO office is available to give advice and support. One of the most active committees of PAIRO is the Physician at Risk Committee. This committee' s goals are to increase awareness of the alarming incidence of drug, alcohol and marital problems caused by the pressures of housestaff lifestyle, to lobby for the provision of therapy to physicians who need help and to focus on preventative measures. There is a hoiline service for any housestaff needing help that is operated by this important committee. I hope that this summary has helped to introduce you to PA IRO and its functions. Most of this information can be found in the PAIRO handbook, which is available to all interns or residents.
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page 9
Treatment of Renal Calculi with Extra Corporeal Shock Wave Lithotripsy by Dr. John Denstedt, M.D. Urology, Dept. of Surgery, U. W .0.
Extracorporeal shock wave Hthotripsy (ESWL) is a non-in vasive method for the trea tment of renal and ureteral tones. The contact-free d estruction of kidney stones by high-t!nergy shock waves was made possible by basic resea rch in acoustic physics. The first experimenta l efforts at using extracorporeally induced shock waves to d isintegrate human kidney stones were d one in Munich, West Germa ny in 1972. It was realized during aerospace studies that shock waves had an action at the interface of two surfaces of differing acoustic impedance. Engineers at Domier Aerospace hypothesized that if shock waves acted on surfaces of differing acoustical impedance, they could act at the junction of kidney stones a nd tissue two surfaces o f d iffering acoustica l impedance. After in-vitro testing had proved d isintegration of stones was feasible, an a nimal stone model was used to d emonstrate that hock waves genera ted outside the body could noninvasively disintegra te
shock wave into the body and localization and pos iti o nin g of the trea tm e nt ta rg e t in to the treatment focus. The basic technical principles of shock waves a re o ft en confused wi th those of ultrasound waves. Althoug h both shock waves and ultrasonic waves are governed by the same laws of acoustics, they are fund amentally d ifferent. Ultrasound consists of a sinusoidal wave of defined wave length with alternating positive and negative d eflections. Shock waves consist of a single positive-pressure front of multiple freq uencies with a steep onset and gradual d ecline. Shock waves und ergo substa ntia lly lower a ttenua tion than ultrasound waves when propagated through wa ter or body tissue. Thus, shock waves can be tra nsmitted throug h wa te r a nd into th e bod y without major loss of energy or damage to tissue. The physica l phenomenon that governs the fragmenta tion of calculi is the rapid build-up of a p ressure g radient w hen focussed shock waves encounter materials of different acoustic p ropertics. The acoustic properties of a Auid (wa ter) and most body tissues are simila r, therefore the shock wave traverses these media with minimal loss of energy. When a focussed shock wave encounters a stone it interprets the junction of stone and tissue or the interface between stone and Auid as a alteration in acoustic impedance. A ra pid buildup of pressure occurs creating strong tensile forces which, when exceed ing the cohesive strength of the stone, causes fragmentation.
high ly selected popula tion with sma ll (<2 em.) primarily rena l pelvic stones. With the increase in range of ind ica tions to include larger stones and stones located in the calyces or u reter a decrease in the ultimate rate free of stones has been apprecia ted. Data from a variety of authors now suggest that in an unselccted patient popula tion approximately 7()..75% of patients may be expected to be rend ered free o f stones following ESWL. Large s tones, multiple s tones a nd ca lculi loca ted in lower pole calyces have all been associated with a decrease in the fina l success rate.
COMPliCATIONS OF ESWL There are three major complications of ESWL trea tment: pain, uretera l obstruction and subcapsular or perinephric hematoma. When multiple fragments line the ureter the line or aggrega te of ca lculi is known as steinstrasse (stone street). This will o ften clea r spontaneous ly but may requi re
Patient Positioning
CURRENT STATE OF CUNICAL USE OF EXTRACORPOREALLY INDUCED SHOCK WAVES
Fig路u re 1: D o rn i~r M FL路 5000 Litllo trip tr r
kidney stones to a size allowing their spontaneous passage. In February 1980 extracorporea l shock wave Hthotripsy was introduced cHnica Uy a t the Department of Urology, University of Munich. In a short time the efficacy, safety and reHability of the method was proved, dramatica ll y changing the management of upper urinary stones. In 1983 further d istribution of the Hthotripter tarted first in West Germany and in 1984 in orth America, Euro pe a nd Asia . Curre ntl y m o re tha n 500 li tho tripters are operationa l wo rld wid e (1 2 in Canada) and more than 2 miUion treatments have been performed.
Indica tions: Although the fi rst clinical experience with ESWL only dates back a few years, the method has a lready become a routine p roced ure with well-established indications. Approximately 80% of kidney stone patients are eHgible for ESWL monotherapy. This includes single and multiple stones in the kid ney of an added stone mass of up to 2.5 em. and ureteral stones above the iliac crest. The remaining patients present with more complex s to ne di sease requ irin g o th e r fo rm s o f intervention. La rge (>2.5 em) rena l sto nes a re most effectively managed w ith pe rcu ta neous nephrolithotripsy a lone or in combination with ESWL. Controve rsy ex ists regarding management of distal ureteral stones (ureteroscopy vs. ESWU. Open surgery for stones is now indicated in <5% of all stone patients. Less than 5% of a ll stone patien ts are excluded from ESWL treatment due to the presence of the following contraindications: uncorrected bleeding d isorder, pregna ncy, uretera l obstruction a nd aortic or rena l a rtery aneurysm.
PHYSICAL PRINCIPLES The underlying physical principles of shock wa ve treatment of calculi in the human urinary tract are generation of shock waves outsid e the bod y, focusing of the shock wave onto an area distant from the gene ratio n s ite, coupling o f the
page 10
CLINICAL RESULTS WITH ESWL The initial results of the Munich group for the first 3 yea rs when ESWL was used in Munich alone revea led a success rate of over 90%. This ea rly group o f pa tients however represented a
Figure 2.: Pat irnt positio11i"g fo r ESWL
percu ta neous or u reteroscopic intervention. An ind welling ureteric stent is often placed prior to ESWL to prevent renal colk or steinstrassc. The incid ence of significant perinephric or subcapsular hematoma following ESWL is approximately 1 in SOD patients.
BIOLOGIC EFFECTS OF SHOCK WAVES Recent discussion has focussed o n the releva nce of s ho rt te rm s hoc k w a ve indu ced alterations on renal morphology and the possibility of to da te una pprecia ted lo ng term ad verse effects. With the ad vent of more sensitive imaging technology, immediate cha nges in renal morphology fo llo win g s hock wa ve trea tm e nt such as subcapsular bleeding. perirenal Auid collections and loss of corticomedullary differentiation have
Continued on page 11
UWO Medical Journal 60 (2) February 1991
ESWL continued been described in as many as 63% of patients. Animal studies have revealed renal injury secondary to shock wave energy including disruption of renal vessels, damage to tubular
transient. Clinically no long term adverse effects had been reported until recently when various retrospective studies suggested an incidence of new onset hypertension in up to 8% of ESWL treated patients. These figures however have not been reproduced in prospecti ve studies or controlled for alternate therapies.
lithotripter, the Domier MFL-5000, was selected for use from amongst over a dozen manufacturers now in the marketplace. The device is a fluoroscopically guided, bath free lithotripter which uses the origi nal electrohydraulic ( park plug)
OTHER USES FOR SHOCK WAVES
Figure 3: lArgt' right rr11al calculus prr-ESWL
epithelium and eventual formation of focal and segmental interstitial fibrosis. These studies have identified the amount of energy used as the common denominator of damage and unless exceedingly high levels of energy were used the shock wave induced changes were found to be
The use of shock waves to fragment urinary calculi is the first use of shock waves in a biologic system . Work is currently in progress using ultrasound as the imaging modality to allow shock waves to fragment biliary calcu li. Further research is being done by Fair and Chaussy on the effect of shock waves on in-vitro tumors and cell cultures. It appears that the shock wave has a greater effect on rapidly dividing cells than on normal cells. This finding may have some usefulness for some aspects of tumor treatment. Although there is considerable industrial secrecy about the possible uses for shock waves, it is rumored that more than 200 different uses for shock waves in medicine have been contemplated by the Domie r Company. It is likely that what we are seeing is the initial use of shock waves as a treatm e nt modality in clinical medicine.
WESTERN ONTARIO LITHOTRIPSY PROGRAM In August 1990 the second renallithotripter in Ontario was installed at St. Joseph's Health Centre, London. A multi-functional third generation
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Figure 4: Fragmt'ntation of calculus following shol'k wavr drlivt'ry. lnti"~W IIing urrtrral strnt in position.
focu ed high-energy shock wave to fragment renal calculi. The Western Ontario Lithotripsy Program began treating patients in August 1990 and is able to treat over 2,000 patients annually.
Continued on page 14
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UWO Medical Journal 60 (2) February 1991
G/BXO canada Inc. page 11
A Student's
Education isn't Oat Bran Perspective on PBL "Ri11g, ring" Tile telephone shrieks to awake11me from my blissful slumber. "Hello?" "Dave! Dave, mate, llow are you? " The crackle 011 the li11e a11d the reso11a11t mice, ide11tify tile caller as Mike, a frielld studyi11g medici11e at McMaster U11iversity. "Good thanks! How are tlri11gs with you7 路路 "Not bad. You ktrow, we're still doilrg that group interactio11 tilillg."
by Dave Hackam, Meds '92
1'~ ~~?eYt
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w o ,.,~-t!.r w\,~>.T ~eans -
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/laughed at Iris assessme11t of Mac 's wrriwlum . "Good stuff...althouglr you're maki11g it sou11d like a11 orgy or sometili11g. " "I wish it was," laughed Mike, "but after orre a11d a Ira If years, we still have11't reaclred the sta,~e where we takr our clothes off."
As our chat prog ressed , I was reminded of the sharp contrasts between Western's curriculum and that of McMaster, and was impressed at how our school appeared in comparison. In truth, however, our program of study is undergoing major modifications, and is showing igns of taking a form that departs from the present traditional format to become more "modern", orne would even say "more Mac-like". A clear sign of this "U.W.O. Perestroika" is the addition of Problem Based Learning (PBL) to our cu rriculum. This form of teaching. in which groups of students analyze and research a clinical problem and thus, under a tutor's direction, elucidate a set of learning objectives, has replaced some thirty lecture hours in second year medicine. While PBL is in essence a brilliant idea, it has met up with some sharp criticism from many student . Since PBL promises to be a future focus of Western's curriculum, I thought it deserved orne comments from a tudent's perspecti ve comments which I hope, will alert our educators to the current student opinion of Western's "Big Mac-attack". I intend to describe what appear to be the three commonest complaints made about PBL, followed by three suggestions for ameliorating these current problems. The first attack made by students about PBL stem from the fa ct that few students ee the point of rummaging through the library for course material that could apparently be just as easily presented in the form of pre-brought notes, a done in every other course. Even fewer enjoy leafing through journal , despite the advice from clinicians that no matter how unpleasant it seems to be now, all this will be good for us in the long run. Education, after all, is not oat bran. Additional complaints centre around the discussion format as a key to learning. Stories abound about PBL sessions varying from only cursory, delicate discussions about different ubject areas to cannon bla zing battlefields of such heated dia logue that maked one wonder whether medicine is being discus ed or s pontaneous thermonuclear fu sio n is being proven to occ ur. This explains the common usage of the term "P.B.Hell". Finally, many are baffled as to how PBL, which is by definition general in its sco pe and variable in its content, can be tested in the multiple choice format, which by nature examines our ability to differentiate subtleties and details about a given subject. Thus, the rea lity is that while PBL is a potentially vital part of Western's Medical program, it is currentl y meeting with a degree of oppos ition that perhaps it does n' t deserve, yet nonetheless makes it lightly more popular than the Federal Tories, yet slightl y less popular than Syrup of Ipecac on an empty stomach. Fundamentally, while PBL is a good idea, the above issues must be
page 12
addressed. Firstly, to aid the overburdened Med student in his or her seemingly endless trek through the library, it is suggested that the titles of relevant references be given to the students. This would give us the opportunity to see what "textbook research" is really like, yet minimi ze the extraneous time constraints imposed by the new method of teaching. Secondly, to en ure group dialogue is useful and sufficient, PBL tutors must be trained as to how to mo t effectively facilitate group discussion. In addition, if PBL is to be a mainstay of our curriculum, it may be recommended that UWO changes its selection criteria for medical stud e nts, to acquire a class that is most suitable for this learning method . I believe that McMaster owes the success o f its PBL type format in part to a combination of these two fa cto rs. Finally, for effective evaluation of the student's knowledge gained from PBL, perhaps an oral examination format would be more appropriate. This could be given by each group's tutor in a somewhat group-individualized manner. This would not only provide for more adequate e valuation, but would also give the student the opportunity to be exposed to the oral examination, which seems to be such a common, often feared , exam format in our profession. In conclus ion, Western 's addition of PBL to its curriculum represents a bold move on the part of its educators. In order for the student to benefit from this new approach to learning, it must be realized that there arc various difficulties with its present format. The correction of these difficulties, perhaps along the lines of I have suggested , will help further the pursuit of excellence in education a t Western that our academic lead ers seem to have accepted as a goal. It is encouraging to see that modernization and revamping of a curriculum is indeed a priority at Western; let us hope that the student is remembered in the process. "1
UWO Medical Journal 60 (2) February 1991
Curriculum Evolution at Western An Overview by w. Wayne Weston, M.D., Director OHSED 'There is 11othi11g more difficult to carry out, 11or more doubtful of success, nor more dangerous to handle, than to i11itiate a 11ew order of thi11gs. For the refonner has enemies i11 all who profit by the old order, a11d only lukewann defenders i11 all those who would profit by the new order. This lukewonnness arises ... partly from th e i11credulity of mankind who do not truly believe in anything new until they have had actual experience of it." (MachiavelJj, 1513) One vital spin-off of curriculum change is increased attention to medical edu ca tion; it encourages both faculty and students to reconsider the ultimate purpose of the students' four years in medical school. Unfortunately, curricula often change for the sake of change-to keep up wi th the academic joneses. Hackam suggests that the popularity of PBL may be no better substantiated than the popularity of oat bran and he challenges the tutors to improve their skills in small group teaching and confronts the faculty with the problems of evaluating learning in PBL. Despite these difficulties in changing the way we learn and teach and despite the lack of hard evidence that PBL offers significant advantages, there are reasonable arguments for including PBL in our new curriculum. (We should remember that there is no hard evidence that any particular method of teaching in medical school is better than any other.) The most compelling argument relates to the need for our medical graduates to be able to take charge of their own learning. Science is messy; truth, elusive; conclusions, tentative. Physicians are daily bombarded with conflicting claims about the merits of one drug or another. Even the "experts" can' t agree. For example, there are at least five different expert opinions about how best to manage borderline hypertension (2). The physician who has not learned how to evaluate evidence and opinion will be at the mercy of those who spea k or wri te most persuasively and ma y succu mb to each new therapeutic fad . Medical curriada around the world a re so crammed with facts that learning medicine has been likened to "trying to drink water from a firehose" (3). This problem is not new. Aexner, in 1910, decried the excessive use of lectures and too many facts to be learned (4). Most educators would agree that it is better to learn a few ideas we ll than to s kim an enormous collection of fac ts. But teachers have trouble d etermining which ideas should stay in the curriculum and which ca n be left out. When the curriculum is parcelled out to departments,a nd the re is no strong central curriculum committee, these d ecisions may be made on political grounds ra ther than educational ones. Also, it may be difficult for individual departments to select th ose aspects of their disciplines most relevant to the education of medical students. This problem has
recently led the Committee on Accreditation of Canadian Medical Schools to suggest that undergraduate medical cu rri cu la s hould be bette r integrated. Problem-based learning offers two advantages. First, it brings faculty from all department s into dialogue w ith eac h other. Through a discus ion of cases, they are better able to identify the core objecti ves. Second, mindful of how much time it requires for tudents to identify th e learning issues, find appropriate resources and then discu ss what they have learned, faculty realize they must not be too ambitious. As we gain experience with problem-based lea rn ing, a nd tru s t that our students will learn what matters, we should be able to reduce the duplication of content in PBL and other courses. With continuing discussion among faculty me mbers, we will define our objectives more clearly, and realistically, and thus produce a better integra ted curriculum. Problem-based learning is not new and did not originate at McMaster. It is the form of learning used by most adults faced with a problem and a serious des ire to understand it. The McMaster founding fathers modelled their curriculum afte.r their own experiences as graduate students. PBL is very similar to the case method used in the law school at Harvard over one hundred years ago . Wal te r Cannon was so impressed with the met h od , when he was a medical student at Harvard, that he persuaded one of his teachers to use it in a course in eurology. Of this experience he wrote,
"with a good le der...a11d the habit of careful thought established amo11g students, the underlying pathological co11dition, the disturbed physiology, the therapeutic action of the drugs employed, could constantly be brought fo rth to give the cases n rational explanation and to teach the students the deeper insight which vision through general principles affords." (5) This small experiment died quickly and Harvard retained its traditional curriculum until three years ago when it made a major change to incorporate problem-based learning. Dozens of medical schools around the world have adopted PBL and Ottawa, Queen's and Toronto are planning major changes in their curricula to include PBL. Faculty development is a key to the introduction of PBL. Our faculty members have spent more time learning about PBL and preparing themselves to be tutors than they have in preparation for any other teaching responsibility. In the past two years Western has mounted eight 1 and 1/ 2 day Introductory Workshops and seven "Booster'' Workshops involving almost 100 faculty members. ln addition, all faculty members attended a one day Trimester Introduction Workshop just prior to beginning their tutoring. We plan additional workshops for new tutors, video peer review workshops and advanced work-
UWO Medical Journal 60 (2) February 1991
shops for experienced teachers. There have been growing pains. It is hard for faculty a nd s tudents to sw itch gears. Some tutors have reported that it is "the hardest teaching I ha ve eve r done" . It does not come naturally for most teachers and requires much practice to get it right. Evaluation is one of the most difficult aspects of PBL. It is important to evaluate, not only the students' learning skill but a lso to assess the content learned . It is important to focus on the students' learning of genera l concepts and their ability to use these concepts to explain the phenomena of disease. We expect our students to develop a scholarly approach to knowledge and learn how: • to identify key issues in clinical problems; • to set priorities and use time efficientl y and effectively; • to challenge assumptions; • to back up opinions with appropriate references; • to integrate knowledge from several disciplines; • to improve skills in communication with other group members (a skill essential for all physicians); • to d evelop a set of useful notes on core issues and a personal filing system for easy access to references; • to improve skills in critical appraisal of evidence without becoming nihilistic. A common misconception of PBL i that it focusses entirely on these "lea rning skills" and ignores factual knowledge. ot so! We expect our students to learn a large number of facts and concepts. But there is no value in memorizing a catalogue of discrete facts which are rapidly forgotten. Students need time to struggle with ideas, to integrate them with what they already know. Sometimes they may need to change some of their prior convictions; this can be a difficult and threatening process. All of this takes time and effort and an effective curriculum provides time for discussion with other students and with teachers. It is also important to have time alone for wondering and thinking and for reading more than one expert's opinions about a subject. Skimming and cramming are common survival strategies used by students to cope with volume overload but it is the antithesis of a liberal education. This curriculum change has invol ved hundreds of hours of extra work by faculty to plan the new curriculum, train tutors and develop cases. ln addition, dozens of students assisted in the tutor training workshops. All of this ha s been undertaken in the sincere belief that our previous curriculum relied too much on lectures and that we needed to use teaching methods that would promote more active involvement of tudents in their own learning . In the new curriculum, PBL represents 20% of scheduled learning activities in the preclinical phases of the
Continued on page 14
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Curriculum continued from page 13
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curriculum; most of the rest of the time i s pent in lectu n'-bascd cou rses. We expect gradua l evolutio n in ma ny of these cou rses too. Fo r exa m ple, the case method wa used to teach one compone nt of the eu rosciences cou rse in Yea r II during the Fall of 1990. Othe r cou rses may usc a variety of a pproaches to involve students more actively in thei r own lea rning. Idea lly, each cou rse sho uld select the teaching methods w hich best ma tch the lea rning objectives o f the course a nd the resou rces ava ila ble. There is no such thing as a perfect cu rriculum. Continual renewa l is essential to mainta in faculty enthusiasm a nd to ensu re currency. Weste rn's cu rriculum is in o ngoing evolutio n-conte nt will need continual revision; the eva lua tion system is cha ngin g to provid e bette r feedback to stude nts a nd to place mo re emphasis on the asscssment of skills and proble m solving. communicatio n, critica l a ppraisa l a nd tea mwork; the clinical cler kship i cu rrently unde r review a nd w ill be cha ngi ng in 1992; the C urriculum Improvement Co mmittee is reviewing fo urth yea r a nd will soon suggest changes fo r imple menta tio n in 1993. Whe n Abraha m Rexner vis ited Western in 1909, he recomme ndl'<l that the school be closed. If he could see us now, I hope he would have second thoughts.
REFERENCES 1.
isbet, J. Innova tio n: Band wagon o r Hearse? in Harris, A. et a l (ed.) C urriculum Innovation. Londo n: Croom-Helm, 1978.
2. O xman, A.D. and G uya tt, G .H . "G uid e lines fo r reading lite ra ture reviews". CMAJ 138, April 15, 1988, 697-703. 3. Rogers, D.E., 1982, Spring. "Some musings o n med ica l ed uca tion". Pharos, 45 (2) 11 -14. 4. Rexner, A. Medical education in the United States and Canada - A report to the Carnegie Foundation for the advancement of teaching. ew York: Arno Press a nd the ew York limes, reprint ed ition 1972 (original edition 1910). 5. Ca nnon, Walte r B. 'The case method of teaching systematic medici ne". Boston Medical and Surgical Joumal 142 (1 900: 31-36).
ESWL continued from page 11 Over 90% of all patients are trea ted on a n outpatient basis without general or regional anesthesia. The majority of the patients are able to return to their regula r activities within 2 to 3 days of treatment.
CONCLUSION
Peter Regier, BA, CA Partner
L J. Sandy Wetstein, BA, CA Partner
During the sho rt period since the ad vent of ESWL the ma nageme nt of urinary stone d isease has cha nged completely. ESWL has almost completely s u pp la nt ed o p e n urgi ca l a nd to a lesser ex te nt e n d o u rol ogica l a pproaches to renal sto ne d isease. Experience ha hown that a pproxima tely 80% of pa tients can benefi t from ESWL mo nothe rapy. The 20-25o/, of cases tha t require combined endoumlogic ma nagement a re technica lly de ma nding complex cases a nd should be reserved for stone centres with extensive experience in a U alternative techniques of urina ry stone treatment. Finally the ad vancement in lowered mo rbidity a nd costs offered by ESWL does no t lessen the importance of metabolic fa ctors involved in nephroli thiasi . A significant percentage of patients will be left with small amoun ts of residual sto ne mate rial in the upper u rinary tract. The fa te of these fra g ments is unclear at this time but w ill no d oubt be influenced by the adequacy of a ttentio n to metabolic evaluation of these patients.
REFERENCES
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1. Chaussy, C. et al: First clinica l experience with extracorporeally induced destruction of kidney stones by shock wa ves. J. Urol., 127., 127:41 7, 1982. 2. Chaussy, C.G. and Fuchs, G.j .: Current tate a nd fu tu re developments of no ninvasive trea tment o f huma n urina ry sto nes with extracorporea l shock wave lithotripsy. J. Urol., 141 :728, 1989. 3. Drach, G.W. et al: Report of the Uni ted States cooperative stud y of extracorporeal shock wave lithotripsy. J. Urol., 135:1127, 1986. 4. Graff, J. et al.: Long term fo llowup in 1,003 extracorporca l shock wa ve lithotripsy patients. J. Urol., 140: 479, 1988.
UWO Medical Journal 60 (2) February 1991
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UWO Medical Journal 60 (2) February 1991
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