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 historical per pective by Hans Marquardt, Meds '94, introduces one to Western Medical School and it illu triou past. This is ue explores some area of new technology at Western, wi th an article by Dr. j . Denstedt on the addition of Ontario' econd renal lithotripter a t St. joseph' Ho pita!. In conjunction with the OMSW symposium on the Royal Commi ion on ew Reproductive Technologies, a comprehensive overview on the legal i ues involved with 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 have been included , courtesy of Dr. W. Weston and Dave Hackam, Med '92. With

War! Repo rts of it filling the new each night. For many of u in fourth year the new that we were at wa r with Iraq ca me in the midst of the traditional London Academy of Medicine dinner. It immediately superceded all other topics of conversation.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 were pounding Baghdad and the threat of retalia tion against Israel was immi­nent. It is now 10 days into the war as I wri te this. It has truly become a media event. The U.S. milita ry, their experience honed on the cutting edge of the Vietnam War, have become the masters of military propaganda . They con­trol the military briefings that the journalists receive, which colours our perception of the wa r.

I, like many others, have m ixed feelings abou t the wa r. One comment was made on television that this was "war by Nintendo". In reflecting, that s tatement ha a g rea t deal of validi ty. We ee videos of a ircraft targeting ites and relea ing bombs, much in the same

way "galactic wa rriors" do in video ga mes. 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 the SCUD bombing of Tel Aviv I'm certai n only touche the surface. And what of the other ide, th e civ ilian po pulatio 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 going on in Iraq. Peter Arnett, C , the lone We tern journalis t remaining in Baghdad, i getting a much propagand a as is the other 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

page 2

the continual changes in medical training and the declining medical housestaff workforce, Dr. R. Alessa ndr ini clarifies th e objectives of PAIRO (the Professional Association of Interns and Residents of Ontario), and how this orga­nization acts to protect doctors.

.... on a more globa l level, the Gulf wa r i uppermost in everyone'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 fear. It seem ironic that thi i sue of the jour­nal includes an ad from the Canadian Armed Forces Medical Officer Traini ng Program, showing a soli tary U. . tank ascending a sa nd dune in the desert. Who would ha ve ever 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

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 gulf region. Howeve r, the need fo r trauma surgeons is undoubtably great, a many Canadian military physicians in recent years have had more expe­rience in the capacity of family physicians than under the conditions in a field hospitaL Of course, I can o nly peculate, but given the desert condition , water will undoubtably be at a premium, including for aseptic OR condi­tion , especially with the recent news that the Saudi water desalinators may have to cease operation due to the oil contamination in the gul f. Wound contamination and d ysentry are likely to become major problems. I can' t help but think of our colleagues who chose the mili­tary option in medical school, and I wish them welL

Rumour has it that everal surgeons, cur­rently and formerly associated with Western ha ve headed to the gulf region to assist in whatever way that they can. They and all oth­ers who volunteer to go must be commended for putting their skill to use where they a re desperately needed, even though substantial personal sacri fice i involved . Many urgical advances came about through techniques pio­neered in wartime, so perhaps something may be salvaged from thi war. i:::J

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 own peace efforts within the Ba ltic s ta tes. At the sa m e time, Romania attempts its slow recovery from a tota litarian government which, among other things, enforced archaic 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 protruding ea rs, the wrong sex, or low birth weights, became the victims of orphan asy­lums a nd guinea pigs for human experimentation .... 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 issur of thr Mrdi cal Jo ur·n11l is •Mrdicinr: Past and Prnntr. n.r cot~rr, drawn by Km Alanrn, M rds '94 drpicts Snlf*rtll mrdica l milrs tonrs. Slrown "" thr Jarvik·7 artificial heart, to nnv pninilltll trchnology, w hich nrablrs 17 wrrk old prrmaturr b11birs to survivr, to thr '"Vatson·Crick DNA doublt' ht lix, t o Frrdfflck Banting- olHILAurra t~ fo r thr co-discovny of ins ulin, and finally, t o 11n illustr11tion driiWif 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.adline for next issue: March 4, 1991

UWO Medical Journal 60 (2) February 1991

UWO Medical School: A look back

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 Univer-ity, 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

by Hans Marquardt, Meds '94

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-1 at 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

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-time 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.)

UWO Medical Journal 60 (2) February 1991 page 3

In Vitro Fertilization: An examination of the legal issues by Constance Nasello Paterson, Meds '91

In recent years, the rapid advances in medi­cal technology appear to have outstripped the ability of the law to respond to the resulting legal issues. In no area is this more evident than in the development of reproductive tech­nol ogy. Clinicians a nd resea rche rs have developed techniques to artificially a sist con­ception in couples who have been identified as infertile. The most recent technique , 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 concerns to which the law must respond . In a report com­missioned by the Ministry of the Attorney General in 1985, the Onta rio Law Refo rm Commission (OLRC) commented that "the law in this area is astigmatic in the main, ignoring or inadvertently applying to the various legal issues arising from the growth of artificial con­ception services" (1 ).

Other cou ntries are s tru ggling, or 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 Brown, the first baby conceived throug h in vi tro fertilization, was born in Engla nd . While this was applauded as a technique to finally allevia te infe rtilit y, many qu esti o ns we re raised about the implications of this event (2). Tha t same year, 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 destroyed by the hospital's chief of obstet­rics and gy necology, w ho claimed tha t the 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 par­ents (5). In 19 3, in Au tral ia, the Rios case focus ed atten tion on the status of the fetus. The Rios couple had undergone in vitro fe rtil­ization a t a clinic in Me lbourne, Aus tralia. 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 millionaire , 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 other debates in the health sciences. Central amongst these issues are the tatu of the fe tus a nd the definition of life.

Ancillary to these are the question of owner­ship of embryos a nd donated games, legal

page 4

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parenthood of donor-fertilized embryos, the employment of surrogate mothers, informed consent, and experimentation on embryos. At the present time few countries where in vitro fertilization i performed have addres 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 whether the individ ual has a right to procre­ate, and if so, whether the individual has the right to use arti ficial methods to achieve that end . Article 10 of the Universal Declaration of Human Rights, which was ratified by Canada s ta tes "The wides t possibl e protection and assistance should be accorded to the family .. .in particular for its establishment." Article 15 of the sa me document recog nizes the right of everyone to enjoy the be nefi ts of scien tific progress and its applica tion (1) . Thus is would appea r that Canada, at leas t internationally, supports the right to procrea te, and to use sci­entific mea ns to do so. To whom is that right ex tended in actual fac t? The OLRC recom­me nd ed that "s table" s ing le women and

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Artwork by Cath<riM Cagiarrrros, M<ds '92

"s table" men and women in "stable" marital or nonmarita l relations be considered el igible to participate in artificial conception programs (1).

The status of the embryo

The legal problem o f th e s tatu s of th e embryo has implications for all o ther issues arisi ng out of IVF. This would appear to hinge o n w hen the definition of human life can apply to the fe tus. In the United States, an Illi ­nois s tatute specifical ly pe rtaining to IV F requires that any person causing the external fertilization of a human oocyte by a human sperm hall assume the "ca re and cu tody" of the child, with penalties under the child abuse legislation (7). This intimates that, a t least in Illinois, life is considt>red to begin at fertiliza ­tion . However, the statute also sta tes tha t it "shall not be cons tru ed to a ttach penalty to lawful pregnancy te rmina ti on" (7) . Thus, damage to an embryo is considered punish­a bl e by law only when th e e mbryo is conceived outside the uterus. This appears to be incongruous, 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 uses 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 caused 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 trans­species fertilization , provided that the resulting embryo was allowed to progress no further than the two-cell stage. Victoria, Aus­tralia , however, has made this manipulation 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 should 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 experimentation 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 constituents, 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 reliably frozen, so the concept of oocyte banks, in the nature of present sperm banks, i still distant. However, oocytes may 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 gametes and embryos is closely tied to the issue of informed consent and ownership. A question that arises with respect to donation of gametes is whether a donor can withdraw consent for gamete use. This can depend on whether the process is considered as the sale of goods o r the sale of service. If it is considered 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 body parts, however, donors may be paid for their services and inconve­nience. Thus, the donor retains ownership of hi or her gametes, and may specify uses for them, or may withdraw consent for their use.

UWO Medical Journal 60 (2) February 1991

The ability to decide disposition of gametes ends, 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 that when urplus 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 Warnock 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 possession of the embryo (1 ,2). The OLRC also recommended that embryos should only 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 embryo 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 couple be destroyed. This was rejected, and subsequently a recommendation was made to donate the embryos for IVF (13).

Status of Children

The s tatus of children conceived by IVF where the gametes come from husband and wife is the same under the law a children con­ceived normally. However, when the gametes come from one or more donors, the legal situa­tion 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 develop­ment 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 or 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 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 results 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 sperm, and pre­sumably posthumous implantation of frozen embryo , the resulting child should be recog­nized as the legal child of both parents, and should 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 (Amendment) 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

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 trictions 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 possible in IVF, with either one or both gametes donated , or by transfer of an embryo conceived in vitro from the contracting couple's sperm 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 woman 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

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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 desi re a child without the bother of a pregnancy hire a surrogate to carry their genetic child .

Interna tionally, mos t jurisdictions have argued against surrogacy. The Warnock Com­mission recommended that the recruitment of surrogates should be illegal. that professionals involved in the establishment of a surrogate pregnancy should 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 such 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

Continued on page 7

page 6 UWO Medical Journal 60 (2) February 1991

IVF continued

legisla ti on fo r the contro l of surrogacy a nd included that a ll urrogacy agreement must be approved by the court prior to conception, and upervised b y the court until the ch ild was

given up to the socia l parents. This propo al denies lega l s ta tu s to the b irth mother a nd requ ires tha t any payment to the surroga te be approved by the court.

Summary

The i s ues involved with IVF a re highly complex and are grounded both in conventional legal p rinci ples and ethics. The field of IVF is developing rapidly, and requires guidelines fo r both the professionals involved in the clinica l applica tion and research areas as well as fo r the patients who desi re to be involved . The legal s ta tus of the children who are born through use of IVF p ro·cedures mu s t a lso be cla r ified . Change within the lega l system is excrucia ting­ly slow. The Ontario La w Reform Commission gave its report 5 years ago, but definitive legis­lation has not been drawn up. Currently the Royal Commission on Reprod uctive Technolo­gy is holding hearings across Ca nad a w ith a report expected in la te 1991 or early 1992. In the mea ntime, a hand ful of physicians a re the ga tekeepers to a mys te rious a nd poten tially d ehumanizing technology that some view akin to crea tion . Small wonder rep roductive tech-

nologies are either p raised or bashed by the publ ic. :::J

(The author would like to tha11k Dr. Stall Brou'll for acti11g as guest editor.)

REFERENCES 1. Ontario Law Reform Commission; Report

on human arti ficial re production and related matters, Ministry of the Attorney General, 19 5.

2. United Kingdom, Depa rtment of Hea lth and Social Security; Report of the com­mittee o f inqu iry into human fertili sat ion an d e mb ryology, Da m e Mary Warnock, Chairman, Her Majesty's Stationary Office, London, 1984.

3. Flannery, D. M., et .al.; Tes t tube babies: Lega l issues raised by in vitro fertiliza­tion. Georgetown Law J. 67:1295, 1979.

4. Cohen, M.E.; The "brave new baby" and the law: Fashioning remed ies for the vic­tims of in vitro fertilization. J. Law Med. 4(3):319, 197 .

5. Long, L. L. ; Artificially assis ted concep­tion. Health Law in Canada 5(4):89, 19 5.

6. Dr. S. Brown, UWO, Personal communi­ca tion.

7.

9.

10.

11.

12.

13.

14.

15.

Annas, G.j ., El ias, S.; In vitro fertil iza tion and embryo transfer: Medicolegal aspects of a new techniq ue to create a fa m ily. Family Law Quarterly 17(2):199, 19 3.

Criminal Code of Ca nada R.S.C.1 970 c. C-34, s.206.

Br iti sh Medi ca l Assoc ia t io n Wo rk ing Group on IVF; Interim report on human in vitro fertilisa tion and embryo replace­ment a nd tran fer. Br.Med .J. 286:1594, 1983.

Roya l C o ll ege o f Obs tetri c ia ns a nd Gynaecologis ts; Report of the RCOG Ethics Committee on In Vitro Fertilisa­ti on and Embryo Replacement or Transfer, Chameleon Press Ltd ., London, 19 3.

Un ited Sta tes Ethi cs Ad v iso ry Boa rd ; Report o f HEW Suppo rt o f Huma n In Vi tro Fertiliza tion and Embryo Transfer. Federal Register 44(1 ):35033, 1979.

Victoria, Australia; Infertility (Medical Procedures) Act 1984, o. 10163.

Thomson, C.; Australia: In vitro fertil iza­tion and more . Hasting Center Report 14(12):14, 1984.

Victo ria, Aus tralia: Status of Children (Amendment) Act 1984, No. 10069.

London Free Press; "Law outla ws surro­ga te motherhood", Oct.25/ 90.

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UWO Medical Journal 60 (2) February 1991 page 7

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

SEE YOUR C. HE£

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

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 respected 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 within the universities in 1974. Establishment 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 teaching hospi tals. In addition to remuneration, the contract contains information on membership 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

received an award from the Board of Arbitra­tion concerning houses taff remuneration . Unfortunately, this 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 PAIRO 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 PAIRO and its functions. Most of this information can be found in the PAIRO handbook, which is available to all interns or residents.

£RENT LIGHT Get the facts about the challenge and opportunity of the Canadian Forces Medical Officer Training

Plan. Your new career could include a peacekeeping tour. Here's how it works.

As a student of medicine - male or female - under the Medical Officer Training Plan, you may have your medi­cal studies subsidized for up to three years at medical school. And a maxi­mum of two years internship training. You will attend a Canadian civilian universitY, your textbooks and neces­sary equipment will be supptied and you will be paid while you learn.

Following graduation, you will com­bine your medical training with that of an officer in the Canadian Forces.

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-invasive method for the trea tment of renal and ureteral tones. The contact-free destruc­tion of kidney stones by high-t!nergy shock waves was made possible by basic resea rch in acoustic physics. The first experimental efforts at using extracorporeally induced shock waves to d isinte­grate human kidney stones were done in Munich, West Germany 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 and tissue -two surfaces of d iffering acoustical impedance. After in-vitro testing had proved d isintegration of stones was feasible, an animal stone model was used to demonstrate that hock waves genera ted outside the body could noninvasively disintegra te

Fig·ure 1: Dorni~r M FL· 5000 Litllo trip trr

kidney stones to a size allowing their spontaneous passage. In February 1980 extracorporea l shock wave Hthotripsy was introduced cHnicaUy a t the Department of Urology, University of Munich. In a short time the efficacy, safety and reHability of the method was proved, dramatica lly 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, Europe a nd Asia . Currently m ore tha n 500 li tho tripters are operational world wid e (1 2 in Canada) and more than 2 miUion treatments have been performed.

PHYSICAL PRINCIPLES The underlying physical principles of shock

wave treatment of calculi in the human urinary tract are generation of shock waves outside the body, focusing of the shock wave onto an area dis­tant from the generation s ite, coupling of the

page 10

shock wave into the body and localization and positioning of the trea tment ta rge t in to the treatment focus. The basic technical principles of shock waves a re often confused wi th those of ultrasound waves. Although both shock waves and ultrasonic waves are governed by the same laws of acoustics, they are fundamentally d iffer­ent. Ultrasound consists of a sinusoidal wave of defined wave length with alternating positive and negative deflections. Shock waves consist of a sin­gle positive-pressure front of multiple frequencies with a steep onset and gradual decline. Shock waves undergo substantia lly lower a ttenua tion than ultrasound waves when propagated through water or body tissue. Thus, shock waves can be transmitted through water and into the bod y without major loss of energy or damage to tissue.

The physical phenomenon that governs the fragmenta tion of calculi is the rapid build-up of a pressure g radient w hen focussed shock waves encounter materia ls of different acoustic proper­tics. The acoustic properties of a Auid (water) 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 rapid build­up of pressure occurs creating strong tensile forces which, when exceeding the cohesive strength of the stone, causes fragmentation.

CURRENT STATE OF CUNICAL USE OF EXTRACORPOREALLY

INDUCED SHOCK WAVES Indica tions: Although the fi rst clinical experi­

ence with ESWL only dates back a few years, the method has a lready become a routine procedure with well-established indications. Approximately 80% of kidney stone patients are eHgible for ESWL monotherapy. This includes single and multiple stones in the kidney 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 disease requ iring o the r fo rms of intervention. Large (>2.5 em) renal stones a re most effectively managed w ith percu ta neous nephrolithotripsy a lone or in combination with ESWL. Controversy exists 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 patients are excluded from ESWL treatment due to the presence of the following contraindica­tions: uncorrected bleeding d isorder, pregnancy, uretera l obstruction and aortic or renal a rtery aneurysm.

CLINICAL RESULTS WITH ESWL The initial results of the Munich group for the

first 3 yea rs when ESWL was used in Munich alone revealed a success rate of over 90%. This early group of pa tients however represented a

highly selected popula tion with small (<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 ureter 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 rendered free of stones following ESWL. Large s tones, multiple s tones a nd ca lculi located 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, ureteral obstruction and subcap­sular or perinephric hematoma. When multiple fragments line the ureter the line or aggrega te of calculi is known as steinstrasse (stone street). This will o ften clear spontaneously but may requi re

Patient Positioning

Figure 2.: Pat irnt positio11i"g fo r ESWL

percu taneous or u reteroscopic intervention. An indwelling ureteric stent is often placed prior to ESWL to prevent renal colk or steinstrassc. The incidence of significant perinephric or subcapsu­lar hematoma following ESWL is approximately 1 in SOD patients.

BIOLOGIC EFFECTS OF SHOCK WAVES

Recent discussion has focussed on the rele­va nce of s hort te rm s hock wa ve induced alterations on renal morphology and the possibili­ty of to da te unapprecia ted long term ad verse effects. With the advent of more sensitive imaging technology, immediate changes in renal morphol­ogy fo llowing shock wa ve trea tment 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

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

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 prospective studies or controlled for alternate therapies.

OTHER USES FOR SHOCK WAVES 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 calculi . 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 Domier 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

Biochemistry, Hematology, Microbiology, Cytology,

Blood Grouping

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 original electrohydraulic ( park plug)

Figure 4: Fragmt'ntation of calculus following shol'k wavr drlivt'ry. lnti"~WIIing 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

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page 11

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 ··

"Not bad. You ktrow, we're still doilrg that group interactio11 tilillg."

/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 st ill have11't reaclred the sta,~e where we takr our clothes off."

As our chat progressed , 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 curriculum. 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 fact 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 blazing battlefields of such heated dia­logue that maked one wonder whether medicine is being discus ed or s pontaneous thermonuclear fu sio n is being proven to occur. 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 scope 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 reality is that while PBL is a potentially vital part of Western's Medical program, it is currently meeting with a degree of opposition that perhaps it doesn' t deserve, yet nonetheless makes it lightly more popular than the Federal Tories, yet slightly less popular than Syrup of Ipecac on an empty stomach.

Fundamentally, while PBL is a good idea, the above issues must be

page 12

A Student's

1'~

~~?eYt

? ·,\).L.

by Dave Hackam, Meds '92

~ Y OUf - ~OU.

w o ,.,~-t!.r w\,~>.T

~eans - 1 r>

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 minimize 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 students, to acquire a class that is most suitable for this learning method . I believe that McMaster owes the success of 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 evaluation, 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 conclusion, 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 leaders 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 the 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 educa 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 speak or wri te most persuasively and may succumb 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 well than to skim an enormous collection of fac ts. But teachers have trouble determining which ideas should stay in the curriculum and which can be left out. When the curriculum is parcelled out to departments,a nd there is no strong central curriculum committee, these deci­sions may be made on political grounds ra ther than educational ones. Also, it may be difficult for individual departments to select those 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 rricu la should be bette r integrated.

Problem-based learning offers two advan­tages. First, i t brings faculty from all departments into dialogue w ith each other. Through a discus ion of cases, they are better able to identify the core objectives. Second, mindful of how much time it requires for tu­dents to identify the learning issues, find appropriate resources and then discuss what they have learned, faculty realize they must not be too ambitious. As we gain experience with problem-based lea rn ing, a nd trus 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 members, 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 desire 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 method , 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 Har­

vard 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 and s tudents to switch gears. Some tutors have reported that it is "the hardest teach­ing I ha ve ever 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 efficiently

and effectively; • to challenge assumptions; • to back up opinions with appropriate ref­

erences; • to integrate knowledge from several disci­

plines; • to improve skills in communication with

other group members (a skill essential for all physicians);

• to develop 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 "learning 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 involved 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 has 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

curriculum; most of the rest of the time i spent in lectun'-bascd cou rses. We expect gradua l evolution in many of these cou rses too. For example, the case method wa used to teach one component of the eu rosciences cou rse in Yea r II during the Fall of 1990.

Other cou rses may usc a variety of approaches to involve students more actively in thei r own lea rning. Idea lly, each cou rse should select the teaching methods w hich best ma tch the lea rning objectives o f the course and the resou rces ava ilable. There is no such thing as a perfect curricu­lum. Continual renewal is essential to mainta in faculty enthusiasm a nd to ensu re currency. Western's curriculum is in ongoing evolution-content will need continual revision; the evalua tion system is changing to provide better feedback to students and to place more emphasis on the asscssment of skills and problem solving. communication, critica l a ppraisa l and team­work; the clinical clerkship i currently under review and w ill be cha nging in 1992; the Curriculum Improvement Committee is reviewing fourth yea r and will soon suggest changes fo r implementation in 1993.

When Abraham Rexner vis ited Western in 1909, he recommendl'<l that the school be closed. If he could see us now, I hope he would have second thoughts.

REFERENCES 1. isbet, J. Innova tion: Band wagon or Hearse? in Harris, A. et a l (ed.)

Curriculum Innovation. London: Croom-Helm, 1978.

2. O xman, A.D. and G uya tt, G .H. "Guide lines fo r reading litera ture reviews". CMAJ 138, April 15, 1988, 697-703.

3. Rogers, D.E., 1982, Spring. "Some musings o n med ical educa 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 edition 1972 (original edition 191 0).

5. Cannon, Walter B. 'The case method of teaching systematic medicine". Boston Medical and Surgical Joumal 142 (1 900: 31-36).

ESWL continued from page 11

Over 90% of a ll patients are trea ted on an outpatient basis without general or regional anesthesia. The majori ty of the patients are able to return to their reg­ula r activities within 2 to 3 days of treatment.

CONCLUSION During the short period since the ad vent of ESWL the ma nagement of

urinary stone d isease has changed completely. ESWL has almost complete­ly s u ppla nted o pe n urgica l a nd to a lesser ex te nt e nd o u rol ogica l approaches to renal stone d isease. Experience ha hown that approximately 80% of pa tients can benefi t from ESWL monotherapy. The 20-25o/, of cases tha t require combined endoumlogic ma nagement are technica lly demand­ing complex cases and should be reserved for stone centres with extensive experience in aU alternative techniques of urinary stone treatment. Finally the ad vancement in lowered morbidity and costs offered by ESWL does not lessen the importance of metabolic factors involved in nephroli thiasi . A significant percentage of patients will be left with small amoun ts of residual stone material in the upper u rinary tract. The fa te of these fragments is unclear at this time but w ill no d oubt be influenced by the adequacy of a ttention to metabolic evaluation of these patients.

REFERENCES 1. Chaussy, C. et al: First clinica l experience with extracorporeally induced

destruction of kidney stones by shock waves. J. Urol., 127., 127:41 7, 1982. 2. Chaussy, C.G. and Fuchs, G.j .: Current tate and fu tu re developments of

noninvasive trea tment o f human urina ry s to nes with extracorporea l shock wave li thotripsy. J. Urol., 141 :728, 1989.

3. Drach, G.W. et al: Report of the Uni ted States cooperative stud y of extra­corporeal shock wave li thotripsy. J. Urol., 135:1127, 1986.

4. Graff, J. et al.: Long term fo llowup in 1,003 extracorporca l shock wave lithotripsy patients. J. Urol., 140: 479, 1988.

UWO Medical Journal 60 (2) February 1991

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