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VOL 49: APRIL • AVRIL 2003 Canadian Family Physician Le Médecin de famille canadien 421

Letters Correspondance Letters Correspondance

Understanding “beings”

is the challenge

I

enjoyed reading “Individualized medicine”1 by Dr Judith Hall in the January issue of Canadian Family Physician. It is good, however, to remind readers that we are all “human beings.”

The discovery of the genetic map and the fact that we are all 99.9%

similar has opened the door to under- stand the easiest part: the human part.

The being part is the most difficult to explore. It needs a lot of talent, many years of experience, and sometimes an artistic look to understand a human being.

This challenge cannot be met with a 10-minute, genetic card, office-based test. Any progress in science should be combined with its practicality. Before asking readers to listen up and tune into a “genetic bazaar,” let us measure our expectations carefully. Medicine is a valuable heritage, and the transmis- sion of our findings to the next genera- tion must be done with extreme care.

—Ali Ahmadizadeh, MD

Hoboken, NJ by e-mail Reference

1. Hall JG. Individualized medicine. What the genetic revolu- tion will bring to health care in the 21st century [editorial].

Can Fam Physician 2003;49:12-3 (Eng), 15-7 (Fr).

Who is that woman?

W

ho is the woman on the cover of the February 2003 issue of Canadian Family Physician? Is she a physician, glum at having to read so much and think so hard about whether to prescribe daily medication to a

group of patients for the rest of their lives? Is she a patient, sad to think that a large group of physicians believe that she might require “replacement”

of hormones, which naturally are not present at her stage of life?

In 1994, Dr Lorie Smith and I orga- nized the first multidisciplinary con- tinuing medical education course about menopause in North America (as far as we know ours was the first;

such courses later became common- place). Our working title for the project was “Choices for Women in Their Sixth Decade.” We were told that it was the most heavily attended CME course at the University of British Columbia in 1994. The course was repeated for sev-

eral years afterward.

We invited endocrinologists, a psy- chiatrist, a cardiologist, a radiologist, gynecologists, a breast surgeon, a urologist, and an alternative medicine

specialist. In formal debate style, rep- resentatives of two subspecialties considered the question: hormone therapy prevents heart disease, yes or no? Many of our presenters had never been asked to speak specifically about menopausal women before. When we invited them to speak, some were non- plussed at first, but all came up with thought-provoking, evidence-based talks and participated in enthusiastic discussions with each other and the audience. The overall conclusion was:

clinicians must inform their patients well, so that together prescriber and patient can make intelligent decisions about health care in a woman’s sixth decade.

One comment during the debate stood out in my mind. The psychia- trist spoke of an article that compared mood assessments among age cohorts and found that fewer women in their sixth decade reported depression than women in any other decade of life. It is not accidental that women in post- menopausal hormone therapy adver- tisements look happy. Is it significant that the woman on the cover of the February issue does not?

The term hormone replacement therapy conveys the idea that our 50- year-old female patients require exog- enous hormones, although medical evidence suggests that such therapy is rarely needed and might be danger- ous. How much of the impetus for pre- scribing hormones to postmenopausal women comes from social prejudice fueled by drug company pressures?

How much of our attitude to this kind of treatment comes from subliminal messages, such as erroneous names for drug regimens and pictures of older women looking unhappy when auto- matic prescribing of drugs is called into question? Administering exogenous hormones to postmenopausal women

Make your views known!

Contact us by e-mail at letters.editor@cfpc.ca

on the College’s website at www.cfpc.ca by fax to the Scientific Editor at (905) 629-0893 or by mail to Canadian Family Physician

College of Family Physicians of Canada 2630 Skymark Ave

Mississauga, ON L4W 5A4

Faites-vous entendre!

Communiquez avec nous par courier électronique:

letters.editor@cfpc.ca

au site web du Collège:www.cfpc.ca par télécopieur au Rédacteur scientifique (905) 629-0893 ou par la poste

Le Médecin de famille canadien Collège des médecins de famille du Canada

2630 avenue Skymark Mississauga, ON L4W 5A4

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422 Canadian Family Physician Le Médecin de famille canadien VOL 49: APRIL • AVRIL 2003

is not “replacement” of anything. And, according to at least one psychiatric survey, the 50s are the happiest decade of a woman’s life!

—Georgia Hunt, MD

Vancouver, BC by e-mail

Jumping off the

hormone bandwagon

E

vidence changes….”1 This is the lesson learned from the Critical Appraisal article1 on hormone replace- ment therapy (HRT). I have heard cred- ible experts use the same line at several continuing medical education activities.

No guilt. That is what the literature said then, but this is what it says now.

Patients (women) will just have to adapt to today’s version of reality.

But the literature had never justified the widespread prescription of ovarian hormones for primary prevention. If it had, the Women’s Health Initiative (WHI) would never have made it past the ethics committee! The WHI came about because American women’s groups, concerned about the call for quasiuniversal long-term use of HRT, lobbied for a randomized trial with a non-clinical, multiethnic sample popu- lation. The rest, as they say, is history.

I have rarely seen an issue politicize CME and clinical practice as HRT has.

Some specialists laid a guilt trip on family physicians who did not jump on the hormone bandwagon, accus- ing them of depriving their patients of important health benefits. Comments about overmedicalization or sex bias were dismissed as unscientific. Some of these same experts are now equally dogmatic about avoiding hormones.

Guilt is not the issue; our credibility is. There should be room for a critical analysis that goes beyond statistics and looks at the larger issues deter- mining clinical practice. Indeed, there are lots of lessons: no free lunch and

the pharmaceutical industry’s influ- ence on continuing medical education to name a few.2 Maybe we will be a bit more critical when the next magic pill comes along,3 particularly for primary prevention.

—Donna Cherniak, MD, FCFP

Sherbrooke, Que by e-mail References

1. Muraca MF, Evans MF. Hormone replacement therapy: the final frontier. Can Fam Physician 2003;49:157-9.

2. Fugh-Berman A, Pearson C. The overselling of hormone replacement therapy. Pharmacotherapy 2002;22(9):1205-8.

3. Batt S. Preventing disease. Are pills the answer? Women and Health Protection [webpage]. Montreal, Que: 2003 Jan 16.

Available from: www.whp-apsf.ca. Accessed 2003 Mar 3.

...

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