OUT WITH THE OLD
I'm writing in regards to your article "Trying... and trying... to get my CCFP" (Vol 2 No 1). Many docs are against this examination. There's no objective evidence to show that it's better than the old system. The test itself doesn't mean very much — it's exam based not performance based. In Australia they do an office-based assessment where doctors are observed in their environment or they can send in a videotaped submission. This would be a much better system for Canada.

This doctor would prefer to remain anonymous
Toronto, ON

CAUSE AND EFFECT
It's interesting comparing the article "Trying... and trying... to get my CCFP" (Vol 2 No 1) with "Family doctors just aren't what they used to be" (Vol 2 No 1) in your last issue. I'm a recycled GP (I practised for 30 years) and am now a hospitalist having done office, hospital, obstetrics work as well as assisting. Like Dr Watts, I would not pass Dr Paul Rainsberry's — director of education at the CFPC — "patient-centered" exam, whatever that is. Perhaps Dr Rainsberry, PhD, should ask himself if there could be any relevance between the two issues.

Dr R A Green
Barrie, ON

DRUG ALPHABET SOUP
Your article "CCB plus ACE is a winning combination for hypertension" (Vol 2 No 1) details the ASCOT trial, which appears to show that the combination of CCB and ACE inhibitor trumps the combination of diuretic and beta blocker in reducing vascular incidents in hypertension treatment. But angiotension II receptor blockers, the fifth most commonly used class of drugs, weren't studied.

In actual practice, anything goes, because over time most patients will have an adverse reaction to one or several classes of drugs. These may be the very common ACE cough, CCB edema, diuretic electrolyte disturbance or beta blocker fatigue. We are at times left shaking our heads as to what to try next, groping for alpha blockers and other old drugs.

A mathematician friend told me that there are 31 possible combinations of the commonly used five classes, some quite bizarre, a virtual alphabet soup of A, B, C and D. I have patients on most of these drugs.

Dr David Rapoport
Downsview, ON

LIVING UP TO THE CHALLENGE
Sleep deprivation affects our tolerance and patience. We are all human. Doctors are no different. Being conscious of our body rhythm alerts us to our potential temperament and moods when we are sleepy, hungry etc. This understanding would help medical students to go through their years of torturous, long shifts.

Todd Suende, author of Diary of a Doctor in Training (Vol 1 No 23), has done a great job in fixing things for his psych patient. In a way, his rural patient Karen is no different. Sometimes, the most effective action to fix a problem is inaction. Some patients just need a listener. Some just want someone to sit there, be quiet and keep company until they're ready to talk. Understandably, this isn't practical for today's doctors with heavy workloads and busy schedules. Todd Suende has the temperament and sensitivity needed for this profession. I believe he will continue to enjoy his discovery of this most honorable and challenging human profession of "comforting and healing".

You'd make a good doctor, Dr Suende.

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